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MCA-Indonesia Social And Gender Integration Plan (SGIP) Implementation

in Community-Based Health And Nutrition to Reduce Stunting Project:

Lessons Learned

APRIL 2018

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This document is written with the support from the People of the United States of America through Millennium

Challenge Corporation. Information, opinion and recommendations stated in in this document do not represent the

position of Millennium Challenge Corporation or the Government of the United States of America.

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Contents Social and Gender Integration in Community-Based Health and Nutrition to Reduce Stunting (CBHN)

Project............................................................................................................................................................... 4

1.Background ............................................................................................................................................... 4

Community Projects Activity (Demand Side) ........................................................................................... 5

Supply-side Intervention Activity ............................................................................................................. 5

Communications, Project Management and Evaluation Activity ............................................................. 5

2. Key Social and Gender Issues in CBHN Project ....................................................................................... 6

1. Men and women needs and access to user-friendly information on health and nutrition ........ 6

2. Women capacity for decision making in the family and community .......................................... 8

3. Implementation of SGIP and Key Social and Gender Results in CBHN Project................................... 10

3.1. Support Project Commitment to Gender Equality and Social Inclusion ................................... 10

3.2. Increased Advocacy for Gender Equality and Social Inclusion in National Nutrition

Communication and Campaign ................................................................................................ 14

3.3. Knowledge Production for Better Strategy and Tools for Advocacy ......................................... 17

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Social and Gender Integration in Community-Based Health and Nutrition to Reduce Stunting (CBHN) Project

Background

Indonesia has made progress in reducing poverty. However, malnutrition in children

remains a problem. Indonesia has around 37% (almost 9 million) stunted children1 and the

fifth highest number of stunted children in the world – more than 7.6 million.2 Nutritional

deprivation in a child’s early life leads to higher infant and child mortality, increased

susceptibility to infection and illness, reduced adult physical stature, and impaired

cognitive abilities, all of which results in long-term economic losses to individuals and to

Indonesian society. Intervening within the first 1,000 days of a child’s life is crucial for the

prevention of the long-term impacts of stunting resulting from nutritional deprivation.

Therefore, the government of Indonesia has set a policy to prevent stunting. This is as

outlined in the National Medium Term Development Plan 2010-2014 which states that one

purpose of development is to reduce the prevalence of stunting to a maximum of 32% in

2014. In the long term, Indonesia is committed to reducing the prevalence of stunting by

40% by 2025.To accelerate efforts to reduce the prevalence of stunting, the government

issued Presidential Decree No. 42 of 2013 on the National Movement on the acceleration

of improved Nutrition with a focus on the first 1,000 days of life. The National Movement

is a joint effort between the government and community to work together to reduce the

prevalence of stunting to meet the basic needs of pregnant women and children aged 0-2

years.

The Community-Based Health and Nutrition to Reduce Stunting (CBHN) Project aimed to

support the Government of Indonesia in reducing and preventing childhood under-

nutrition. The objective of the project was to reduce and prevent low birth weight,

childhood stunting and malnourishment of children in project areas. In the long term, the

project is expected to increase household income through healthcare cost savings and

increased productivity.

To achieve these objectives, CBHN project undertook several activities oriented towards

improving the nutritional status of pregnant women and children through increased

community participation, improved nutrition, and reduction of diarrhea cases, increase the

availability of affordable nutritious food and improve the awareness of parents,

communities, local leaders and other stakeholders on child under-nutrition. In particular,

1 TNP2K (2017), “100 Kabupaten/Kota Prioritas untuk Intervensi Anak Kerdil (Stunting)”, Cetakan pertama Agustus, Jakarta: TNP2K. 2 UNICEF (2013), “Improving Child Nutrition: The Achievable Imperative for Global Progress”

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CBHN supported PNPM Generasi to conduct community activities to reduce childhood

stunting. CBHN has three interlinked components:

Community Projects Activity (Demand Side)

This component builds on the existing community-driven intervention, called Healthy and

Smart Generation Program/ Program Generasi Sehat dan Cerdas-GSC (previously called

PNPM Generasi) which has supported community efforts to improve health, nutrition and

education indicators. The objective of this activity is to develop sustainable community

awareness and demand for nutrition and health services. The activity includes providing

community facilitators, capacity building of Kaders on nutrition and health, participatory

planning, and provision of community block grants. This activity is implemented in

partnership with PNPM Support Facility (PSF) and initially with Ministry of Home Affairs

(MoHA) and in 2015 the responsibility was transferred to the Ministry of Villages,

Disadvantaged Regions and Transmigration.3

Supply-side Intervention Activity

The Supply Side activity aimed to strengthen capacities of health service providers to be

able to provide better quality and coverage of health and nutrition services. This activity

includes two main areas of focus: (i) training and advocacy sub-activity that were given to

healthcare and sanitation service providers, sanitation and hygiene activities, expanding

an existing GOI program and approach; and (ii) private sector response sub-activity that

provided grant(s) for the purpose of leveraging private sector responses to community and

family needs for improved sanitation, hygiene and/or safe water using market driven and

sustainable solutions. This activity is implemented in partnership with the Ministry of

Health.

Communications, Project Management and Evaluation Activity

This activity included work to develop and implement a National Nutrition

Communications Campaign (NNCC), a national effort aimed at increasing awareness about

childhood stunting, its causes, its consequences, and its prevention, including a focus on

healthy families that emphasizes shared decision making between women and men within

the household. This activity was implemented in partnership with the Ministry of Health.

3 Previously, the key government agency in charge of PNPM was the Ministry of Home Affairs. But since 2014, PNPM management has been moved to the Ministry of Villages, Disadvantaged Regions and Transmigration, and change the program name to GenerasiSehatdanCerdas (GSC).

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Key Social and Gender Issues in CBHN Project

Childhood stunting is a chronic under nutrition problem caused by long-term insufficient

nutrient intake and frequent infections of pregnant women and infants. The causes of

malnutrition are numerous and multifaceted. These causes are intertwined with each

other and are hierarchically related. The most immediate determinants are poor diet and

disease which are themselves caused by a set of underlying factors; household food

security, maternal/child caring practices and access to health services, access to safe water

and sanitation, safe hygienic practices and healthy environment. These factors themselves

are influenced by the underlying factors; gender based discrimination, traditional/cultural

practices, and socio-economic conditions.4

Gender based discrimination is one of the underlying causes of malnutrition and child

stunting. Relations of power between men and women affect household dynamics, control

over decision-making and resource allocations (including food). Within household and

community, child health is considered a female domain, and men, even though they are

fathers, usually do not concern themselves about it. Main social and gender issues in CBHN

project are as follow:

1. Men and women needs and access to user-friendly information on health and nutrition

Men and women access information on health and nutrition differently. Women access

the information from various sources such as from midwives, community health

volunteers/Posyandu Cadres, and woman community leaders and peers. At the household

level, the main source of the information is from mother or mother in law.5 Men access

the information from peers, village elders and religious leaders. Friends and older,

respected men are most frequently the ones who provide advice to men. Religious

institutions also play an important advisory role. However, information provided by health

center, such as posyandu, is not popular amongst men, as the activity is assumed to be

specifically for women. At the household level, men get information from their mother and

in some rare cases from their wives. Besides, low health seeking behavior amongst men is,

to some extent, attributed to the minimal participation of men in accessing the provided

health service.

It is interesting to note that although there is a different pattern of information source between women and men, however, the main nutrition information channeled to parents is through mother (or mother in law), and community or adat leaders. Grandmother’s role

4 Black RE, Allen LH, Bhutta ZA, Caulfield LE, Onis M, Ezzati M, Mathers C, Rivera J. (2008), “Maternal and child under nutrition: global and regional exposures and health consequences”, Lancet. 2008, 371 (9608): 243-260. 5Stunting in Indonesian communities, Summary of formative study report, IMA Word Health – Indonesia, September, 2015.

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(or mother in law) is quite influential, not only in matters related to infant and young child feeding but also in the health and overall well-being of their grandchildren. This become evident during group discussions undertaken by MCA-Indonesia with grandmothers in GSC sites. Rather similar, a report of a formative assessment in Eastern and Western Kenya on infant and young child feeding and maternal nutrition indicated that men listen to and believe the counsel of their mothers (grandmothers) more than their wives because they believe the grandmothers are more experienced and knowledgeable in childcare.6 The result from Formative Research to inform CBHN Project’s NNNC Strategy also shows similar findings. Finalized in April 2015, with regards to childcare and childrearing practices, the NNNC Formative Research concluded that the role of grandmother was important in childcare. There were two patterns, first is the grandmothers’ role to provide advice/suggestions to the mother about child care practices. The second is the role of grandmother as caregiver, in lieu of the mother’s absence, usually because the mother is working outside the home. The study also confirms that the role of husband/father in childcare and feeding was not so prominent. The wives and grandmothers did not entirely trust husbands to take care of the children, because they perceived that husbands were not careful enough. 7

Although their strong influencer in maternal and child health, grandmothers appear to

have traditional and inadequate knowledge on child health and nutrition related issues

and can have negative impact on maternal and child health. In almost all part of Indonesia,

for instances, grandmothers believe that breast milk alone is not adequate to satisfy a baby

and promote gaining weight for the first six months and fuel early supplementation of

other liquid and solid food such as porridge, and water.

The provision of the information from health facility also is not user friendly, especially for

rural young parents with limited education and knowledge. Health promotion provided by

health center, for example, is still conducted centralized at puskesmas (Sub-district level)

or posyandu (Village). In fact, due to financial hardship, double burden and distance, only

few women can access these centralized health services. The finding from field visit to GSC

sites confirmed this gap. Besides, the information provided by health staffs (midwives and

posyandu cadres), may not be well-presented or easily understood by parents due to

unfamiliar terms.. Due to gender stereotypes that put women as the primary caregiver of

children and the family, information sharing on child health and nutrition is not designed

to encourage men to access the services.

Lack of access and limited availability of user-friendly information should be taken into

consideration to strategically engage both men and women to seek information on health

and nutrition.

6 Formative Assessment on Infant and Young Child Feeding Practices at The Community Level , November 2010 7 IMA World Health (Commissioned by MCA-Indonesia), Final Report of Formative Research: Phase I of National Nutrition Communication and Campaign, April 2015.

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2. Women capacity for decision making in the family and community

2.1. Decision-making at household level

A key issue for improving family nutrition is a woman’s control over decision-making in the

household, including time use and allocation of resources (including food) and access to

services. Unequal allocation of household resources puts women at greater risk of food

insecurity because they are more likely to reduce food intake during times of scarcity and

this increases their risk of under-nutrition and anemia which impacts infants’ health and

nutrition. In Indonesia, like most parts of the developing world, men and women use their

money differently. This affects what the family eats and the services it uses. Women’s

income is predominantly spent on food, education, health, capital and savings. Men’s

income is used mostly to purchase assets and for personal use, including cigarettes. While

men and women, share decision making about use of household finances, women’s

bargaining power and control over assets and decision making is constrained because their

contribution to the household economy (largely unpaid) is invisible, and any money they

do earn is seen as “supplementary”.

The baseline study of Mathematica conducted in three provinces8 shows that women have

agency to make decision that affect themselves and their children health (such as decision

making on: health care, amount of money to spend on food, type of food to eat at home).

However, this is not in line with the fact that there are still high cases of anemia and low

weight among pregnant women, although they consume variety of food. This contradiction

indicates that women lack knowledge on nutrition and balanced diet, which caused anemia

and low weight babies. In this regards, health service providers should take this critical

finding into their consideration.

Gender division of labor is also exacerbated by time used by women to deal with their

family’s nutrition. Most women work longer hours, multi-tasking to manage multiple

domestic and productive responsibilities. When women are overworked they lack time and

energy to prepare nutritious food, and ensure children are consuming balanced meals. In

addition to that, children are often fed with unhealthy food due to lack of knowledge on

healthy and nutritious foods. Hygienic practices on using safe water, hand washing and

sanitation are also inadequate, especially among poor households.

2.2. Decision-Making in the Community

Despite greater attention to women’s participation and decision-making, men continue to be

treated as “head of household” and the main decision makers. Women are keen to participate in

public meetings – although more to get information than to express their demands – as they are

8 The baseline research conducted in three provinces: West and Central Kalimantan and South Sumatera, covering 190 sub districts and 760 villages.

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not yet aware of their rights or how such processes work. In practice, they normally attend

meetings because they are sent by husbands or are specifically invited, project rules require their

attendance or they are the target group of the project. Even so, participants tend to be elite or

better-off rather than poor women, with the same people involved in most public activities.

Such limited participation means that most women at the village level have little knowledge and

access to participate in about village planning processes, such as five year planning (RPJMDes),

annual village planning (Musrenbangdes) or annual budgeting (Alokasi Dana Desa). They also have

few opportunities to develop the confidence and skills to express their needs and interest in public

meetings. Consequently, women’s priorities such as improved health, education, water and

sanitation are not well considered in the final decision-making in village planning and budgeting.9

Overall, women’s participation in decision-making in household and community is lacking. In fact,

several studies found that improvements in women’s power relative to men within the household

and community strongly influence their own and children’s nutritional status as they have greater

ability to make decisions regarding their own and their children’s’ care and nutrition. Therefore

women’s lack of participation in decision making should be increased by ensuring that women are

involved in any development planning activity and they are able to express their interests and

needs. Additionally, women’s lack of knowledge on nutrition, maternal and child health should be

addressed by health service providers through the provision of appropriate approaches and user-

friendly services.

2.3. Men’s active participation in maternal and child health

Men’s role as head of the household, is a critical factor when addressing maternal-child health and

nutrition issues. Traditional gender roles assign women primary responsibility for child health and

the domestic sphere. This gender role segregation has negatively affected men’s’ role and

responsibility for maternal and child health. The culturally defined roles of fathers entail providing

for the family, such as food, clothing, shelter, money for health care, security in the home. While

childcare is regarded as a shared responsibility, the roles of men and women are distinctly

different. Men are not involved in direct care and nurturing of children younger than 2 years in the

community because culturally, it is considered women’s work.

On the other hand, men may feel discouraged to attend health facilities with young children, as

communities and the facilities themselves often view maternal and child health care as a purely

‘female’ domain. As the Formative Research illustrates, lacking trust from their wives and mothers’

husband’s (father’s) role in childcare and feeding and nurturing practice is not prominent. The

involvement of fathers is usually for accompanying their pregnant wives to healthcare facilities for

the Antenatal Care (ANC) visits, as this involves travelling and aligns with their role as family

protector. However, in most cases, men do not follow up the outcome of this clinic visit to know

information on his child’s health. This stereotype influences the low participation of man

/husband/father in child and maternal health. The findings from the field visit to Generasi sites

confirmed on this. In most of the targeted sites of intervention, field visits revealed that spousal

counseling is hardly ever conducted. For example, from 8 villages visited in 3 sub districts of Sangihe

9 IDEA, Pattiro, International Budget Partnership, et al, 2011, “Show Me the Money: Budget advocacy in Indonesia”.

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district, North Sulawesi, none of the villages conducted couples counseling on health and nutrition.

According to GSC consultant, this is partly because IYCF training has not yet been conducted in the

district, so health staffs or Posyandu cadres are not aware on this mandatory training. The head of

the Puskemas of Tabukan Tengah admitted that it is hard to do couples counseling because

husbands are reluctant to be involved as this is influenced by value and norm in communities,

assuming that domestic tasks, including childcare, is women’s responsibility, as such man is not

supposed to participate in those domestic or women’s sphere and activities.

Despite those gaps, there is, actually, opportunity to engage men in CBHN Project. The Formative

Study also found out that both women and men respondents (81%) expressed their disagreement

that nutrition and health problems is the sole business of women / mothers. Interestingly, the data

indicates that the disagreement is more widely shown by male respondents (84 % male, 77%

female).10 This figure obviously shows that the community had been aware that the health of

children is a shared responsibility between husband and wife and this certainly disprove the gender

notion that family nutrition and health is primarily mothers’ responsibility. Therefore, there is an

opportunity to engage men to boost their interest in sharing responsibilities of child rearing and in

the health and nutrition status of the family.

3. Implementation of SGIP and Key Social and Gender Results inCBHN Project

Gender and Social Integration in CBHN aimed to increase husband/fathers’ involvement in

maternal and child health improvement to reduce childhood stunting. It also aimed to build

capacity of traditional midwives in modern health services to reduce stunting in ethnic

communities, especially to perform their roles in transmitting messages nutrition for pregnant

women and infant. There were three areas of intervention:

1. Support project commitment to gender equality and social inclusion

2. Increased advocacy for social inclusion in behavior change campaign

3. Knowledge Production for better strategy and tools for advocacy

3.1. Support Project Commitment to Gender Equality and Social Inclusion

A. Infant and Young Children Feeding (IYCF)

There were 9,457 villages awarded community grants to finance 80,163 different activities in

health, education and stunting, resulting from participatory planning processes carried out in the

community. A gender module, which developed by MCC/MCA, was used to train GSC community

facilitator (KF). This module was shared with PNPM Generasi and the Ministry of Home Affairs

(MoHA) and included in the PNPM Generasi Training Manual. As of January-March 2016, there

were 547 Generasi facilitators (165 females, 382 males) trained on stunting and gender.

The project conducted several trainings for national trainers (Master Trainers) at the national level,

health workers (at provincial, district, sub district level), and cadres. There are three different types

10 IMA World Health (Commissioned by MCA-Indonesia), ibid.

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of training activities being carried out: training on Infant and Young Child Feeding (IYCF), Growth

Monitoring (GM) training, and sanitation triggering training.

The IYCF training aimed at improving the capacity of health workers, midwives, and posyandu

cadres in providing counseling regarding the provision of meal for pregnant women and children.

At community level, this training aimed to improve the skill and knowledge on feeding for pregnant

women, as well as to encourage involvement of men and fathers in ensuring healthy behavior in

households. The target participants were district health staff, puskesmas health workers, village

midwives, and posyandu cadres. There were total 17,328 health workers trained in IYCF training.11

To sensitize master trainers on social and gender issues that affect health and stunting in children,

MCA-Indonesia developed a gender module that provided clear example on how to engage men

to improve nutrition and reduce stunting. The IYCF module was also reviewed. It was identified

that the component of men’s engagement was lacking and the session on maternal health was

limited.

The MCA SGA team provided inputs to increase men’s participation in infant feeding and nutrition

in the family to be incorporated in the module. As a result, the IYCF module showed more gender-

balance pictures and statement that portray fathers actively involved in health and nutrition of

their family. 12

In order to support capacity building on gender integration, especially male/father’s participation

and women’s empowerment in GSC training module, SGA unit reviewed the GSC module and

updated the gender training for Community Facilitator and cadres. Field visit was also conducted

to supervise GSC training and counseling activities. SGA unit provided technical advisory support

especially in male/father’s participation and women’s empowerment to GSC project

implementation.

To capture knowledge and document lessons learned for impact evaluation, SGA unit incorporated

a specific gender focus into the PNPM Generasi. Inputs were provided on gender-based evaluation

strategy and designs to ensure all social groups, including women, men and marginalized groups

were able to participate in evaluation. Gender specific evaluation questions and components in the

TORs were also integrated.

B. National Nutrition Communication Campaign (NNCC)

The NNCC was launched successfully on December, 2015. It continued with campaign

implementation phase using various media, such as mass media (television and print

advertisements, talk shows and news coverage). The media campaign has reached significant

target audiences, as of the end of February 2016, the television campaign reached 85.4% of the

NNCC’s primary target audience, and around 70% of its secondary target audience. This means that

around 567,153 grandmothers and 355,831 fathers have seen one NNCC spot at least one time.

NNCC also intensified its district campaign in the three focus districts, OKI, Kapuas and Landak,

through various activities such as public discussions, journalist trainings, religious and community

leader trainings, interpersonal communication (IPC) trainings and district quarterly coordination

meetings.

11 Final Report, 22 February 2018 12 See IYCF Module.

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Despite its progress, there are social inclusion and gender issues in NNCC activities that need to be

improved. For example, from the document review of interpersonal communication (IPC) plan, it

was identified that male participation is not well defined and identified in the document and no

specific approaches developed to increase men’s participation. In this regard, SGA unit provided

inputs and recommendations for increasing male participation in the IPC activity plan by reviewing

and developing IPC materials such as guideline, module for mother groups, father discussion

groups and of social inclusion in IPC strategy and material, especially module for Bidan and

Posyandu cadres. The SGA team also conducted field visit to supervise IPC activities.

Social inclusion issues were also identified during NNCC activity implementation. For example, in

Central Kalimantan, it was identified that Dayak, one of the ethnic communities, faced exclusion

over resource utilization, and their access and participation in the local development process was

limited. However, limited efforts have been taken to integrate inclusion of marginalized groups

such as ethnic minorities into campaign tools and materials, including IPC material.

For this reason, effort made to integrate social inclusion and gender dimensions into campaign

tools and materials, such as the incorporation of health and nutrition messages into Karungut, a

Malay poetic form and bidan lewu pocket book, as discussed below.

C. Sanitation and Hygiene

Gender integration in sanitation and hygiene was carried out by incorporating gender into the

ongoing design of triggering event activities. SGA unit provided inputs to ensure equal opportunity

for women, men and marginalized groups in the management and implementation arrangements

of Community Led Total Sanitation (CLTS) activities. Female Headed Household was also included

in social mapping as a new variable of targeted Open Defecation Free (ODF). In addition SGA unit

reviewed and integrated gender and social inclusion into sanitation modules, ensuring that women

and girls had equal opportunity as men to participate in all activities.

D. Private Sector Response Activity (PSRA)

A Call for Proposal (CfP) was launched on early May 2016 to select partners and develop innovative

partnerships under the CHNP that catalyze greater private sector investment and support

development of public private partnerships that will address the CHNP objective of reducing

stunting by addressing constraints and opportunities in sanitation, safe water and hygiene at the

community level (Community Sanitation Partnerships). The deadline for proposal submission is

August 31st, 2016. A pre-bidding meeting was held on June 9, 2016 to provide an overview of the

Call for Proposal (CfP) and, to provide the opportunity to discuss queries related to the proposal

requirements.

To strengthen the CfP, SGA Unit included specific requirements on gender and social inclusion to

ensure access, participation and benefit of women and vulnerable groups over the project, by

ensuring men, women and vulnerable groups have equal access, opportunity to participate and

avail benefits from the proposed project. In project management structure, gender balance was

considered in the formulation and designation of personnel and team. In project budget, the

programmatic cost accommodated the different needs and priorities of men, women and

vulnerable groups that identified during the preliminary social and gender assessment conducted.

M&E monitored and evaluated access, participation, and benefits among women, men and

vulnerable groups, as such project impacts were tracked to assess if the project equally benefited

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the beneficiaries and if required, incorporated remedial action that redressed any social and

gender inequalities in project implementation.

SGA unit incorporated gender and social inclusion into project’s key document by developing a

checklist that was used as a reference by grantees to incorporate gender into project design,

implementation and M&E.

The Project Social and Gender Integration Plan (PSGIP) was developed, emphasizing required

measures to mainstream gender into project activities. Social and gender issues in PSRA were

identified. Key issues to guide the PSRA Grantees are based on women’s and vulnerable groups’

(poor households) participation in project activities, their needs and access to benefit from the

project. A set of questions were asked during the training for grantees to develop the PSGIPs, as

follows:

Can poor households and women headed household afford? Do they have access to

financing?

Do they have low knowledge on health risks associated with poor sanitation?

Do women have access to become sanitation entrepreneurs?

Can cost be reduced to increase affordability of sanitation facility/healthy latrines?

Do poor households/women headed household have access to after sales maintenance

service for latrines and/or water treatment facility?

Grantees were required to follow the project logic that consists of issue identification, assessment,

planning, implementation, evaluation and reporting. SGA unit provided inputs for grantees to

ensure incorporation of gender analysis and included strategies for enabling women’s active

participation in the projects. Field visit for monitoring and supervision of grantee’s project

implementation was also conducted.

Box. 1. Story from the Field: Gender and Social Inclusion in Aksansi Project Activities One of the grantees, Aksansi (Asosiasi Kelompok Swadaya Masyarakat Sanitasi Seluruh Indonesia), followed specific requirements specified by SGA unit. The project was to provide water sources, toilets, and waste water treatment facilities for village communities in Desa Blayu, Malang District, East Java Province. Aksansi conducted pre-test and post-test of health and sanitation training to its beneficiaries to map level of knowledge of the community on this issues. Using sex-disaggregated data, it concluded that women have better understanding on sanitation issues after the training. The training also stressed women’s roles in sanitation. Although men outnumbered women in almost all activities, Aksansi gave equal opportunity and participation to both gender, especially young women. In result, five female community members participated in Operational and Maintenance (OM) training for water supply, while twenty four female community members participate in OM training for Waste Water Treatment Plant (WWTP). Four Community Based Organization (CBO) committees in Malang Regency were female. There was also one female construction worker in Malang for soil excavation during construction of water supply pipeline. To accommodate the needs of vulnerable people, constructed healthy toilet were equipped with handle bar for elderly and disabled.

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Aksansi involved both men and women in assessing the land availability, social and technical mapping (healthy toilet location). Trainings and meetings (especially health and sanitation training) always involved both gender, especially woman and young girls. After the training, community understanding on the importance of sanitation in households improved. As the health survey showed, 56 % of the community members in Desa Blayu were willing to pay for the user fee.

Box. 2. Story from the Field: Gender and Social Inclusion in Terima Bersih Project Activities Terima Bersih, also incorporated gender strategies into its project. The project was a joint initiative of Indonesian Sanitation Entrepreneurs Association (APPSANI), an umbrella association of sanitation entrepreneurs, and Garden Impact, a Singapore-based social impact investor. It aimed at providing training for East Java sanitation entrepreneurs in creating ‘one stop shop’ business training model to promote, sell, and install latrine molds to households. Facts from the field, women have lower level of confidence in their business abilities prior to starting business, though those managing active business have the same level of skill and confidence as the male entrepreneurs. Terima Bersih, thus, conducted some activities, including retraining APPSANI members and facilitating a meeting with sales agents and retailers, as well as providing coaching services. These events have increased women confidence and skill to be successful in this business. As a consequence, there were 11 female trained as sanitation entrepreneurs, 176 as promoters, and 6 retailers. Among 365 units constructed, most used women sales agents. In order to create an enabling environment, Terima Bersih also provided all recruited sales agents and entrepreneurs with access to IT platform system and facilitated them to engage in the community. This was supported by local government through the provision of assignment letter and business areas.

3.2. Increased Advocacy for Gender Equality and Social Inclusion in National Nutrition Communication and Campaign

A. Traditional Dayak Midwife (Bidan Lewu)

Several activities conducted to involve traditional birth attendants (bidan kampung/bidan lewu) in

stunting prevention. Started with field visit in November 2016 to some villages in Kapuas Hulu Sub-

district, Kapuas, Central Kalimantan. It aimed to identify local practices related to bidan lewu’s roles

in providing information on health and nutrition to pregnant women and children under two, by

interviewing and focus group discussion. This activity facilitated by a local NGO, Lembaga Dayak

Panarung (LDP) and attended by local staff of government institution, such as local health agency,

members of PKK, Posyandu, bidan lewu and local community.

In September 2017, a qualitative study on bidan lewu’s knowledge, perception, attitudes and roles

related to health and nutrition, was conducted. This study tried to find communication tools which

would be used for delivering health and nutrition messages to the community. It showed that

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karungut/pantun--a Malay poetic form, and guidance books for bidan lewu considered effective to

deliver key health messages. Karungut is a Dayak ethnic’s ancient form of art, containing advice,

social criticism, and suggestion for society. It is usually sung by the elderly followed by traditional

music instruments such as kecapi, kendang and little gong. Bidan lewu promoted good nutrition

through karungut. The rhymes were modified by health and nutrition messages, including good

eating habit and vitamin intake for pregnant women, the importance of breast milk for newborn

and nutritious food for baby after six month, and advice for parents to take their little children to

local health clinics. Two preliminary tests for bidan lewu were carried out. The first pre-test was to

test the effectiveness of the karungut and the second test was to test the bidan lewu’s guidance

book and also to train bidan lewu how to use the book.

Facilitated and supported by LDP and local facilitators, the pre-test of guidance book located in

three remote villages in Kapuas Hulu sub district, Sei Hanyo village, Bulau Ngandung, and Supang.

In total, there were thirteen participants of bidan lewu, consisted of eleven female and two male

bidan lewu. During the training, all participants received Bidan Lewu Guidance Book and were

trained how to deliver the messages. The guidance book was full of colored pictures, and came in

two forms. One book was accompanied by written dialog, while other without dialog. The book

contains information on health and nutrition for the first one thousand days of a child’s life (1000

Hari Pertama Kehidupan/HPK). The book also stressed good hygiene and sanitation, such as regular

hand wash with soap before feeding and after using toilets. The book is in Dayak Ngaju, the

language used by majority people of Kapuas Hulu. After the training, the participants were asked

to practice their understanding of the book by providing counselling session to pregnant women

and mothers with toddlers.13

Box 3. Capacity building of Traditional Midwives “Bidan Lewu” in Stunting Prevention In Kapuas Hulu sub-district, travel to nearest health facility in Provincial Capital of Palangka Raya, at the heart of Borneo, usually takes minimum 6 hours by car. It is the farthest sub-district in Kapuas District. Bidan Lewu, as the name will usually called by locals for traditional birth attendant, is more than just midwives. They are esteemed elders in the community and well respected for preparing pregnant women and assisting them during child delivery. In addition to assisting child delivery, they provides care for pregnant mother and infant, they perform traditional rites and rituals, considered as important for Dayak community. They’re the one who are usually consulted and called for during pregnancy and child birth and nurturing. The training of Bidan Lewu in Kapuas Hulu Sub-District is important in a close-knit traditional community in remote areas where health facilities are not easily accessible and trained health providers are limited. MCA partnered with local NGOs, capacity building of traditional midwives in modern child health and nutrition knowledge added value to the approach that CBHN Project is embracing through linkage of supply (health service providers) and demand (community empowerment) side to strengthen the communication strategy in transmitting message about stunting using local context.

13 Risang R (IMA World Health), Report Result of Bidan Lewu Guidance Book--Kecamatan Sei Hanyo, Kabupaten Kapuas 12-15 Desember 2017.

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B. Male/Father Involvement in Health and Nutrition

Lack of male/father active participation in family health and nutrition has been considered as one

of influencing factors of poor child rearing that leads to stunting prevalence. Therefore, SGA unit

sought to document global and local good practices for developing policy recommendation on

gender equality as well as to increase male participation in health and nutrition. As part of HN SGIP

implementation, MCA SGA team undertaken various actions were taken, including social and

gender assessment of child health/nutrition services, strategy development to increase

male/husband/fathers’ participation in maternal and child health and nutrition programs,

enhanced commitment of village local government, leaders/elders, and women’s empowerment

offices towards reducing childhood stunting, carried out workshop and meetings with stakeholders

to gain inputs and validate the strategy, with Ministry of Women’s Empowerment and Child

Protection (MoWECP).

In addition, SGA unit integrated fathers involving measures into MoWECP’s Family Learning Center

(Puspaga) activities. Several consultation sessions with relevant stakeholders were conducted. In

September 2017, socialization event on the importance of father active roles in 1000 HPK was

carried out to about 100 Puspaga counsellors throughout Indonesia. Followed by module

development of father involvement in family health and nutrition and the integration of father

involving measures into Puspaga’s Guidance Book. In February 2018, a workshop was held to

obtain constructive inputs from relevant stakeholders on the module. In March 2018, a pilot test

of the module was conducted to 50 mixed participants of Puspaga counsellors, academics, and

local government officers.

Box. 4. The Time is Ripe: Riding the Momentum of National Stunting Strategy Husband/Father’s active participation in family health and nutrition is an unknown approach. Recently launched in 2017, Puspaga’s core services are heavy with outreach and psychoeducation counselling for family issues. Health and nutrition is considerably new content for Puspaga, as prevention of domestic violence through gender equitable parenting is their key objective. In 2017 Study by National Team for Poverty Alleviation (Tim Nasional Percepatan Pengentasan Kemiskinan – TNP2K) under Vice President’s office, parenting is identified as one of the non- health related factors (sensitive factors) in stunting. The paper, and the strategies proposed in it provided role and responsibility for MOWECP to act, since cohesive coordination among ministries and the understanding that Stunting prevention is not only the responsibility of Ministry of Health, but MOWECP recognized coordination with MoH is important to reach the national goal to reduce stunting. It is noteworthy, measures to involve husband/father in family health and nutrition in Puspaga activities were hampered by limited number of male counsellors. Puspaga needs a sufficient number of male counsellors, so this measure can be implemented effectively. By having male counsellors, Puspaga will serve as a male-friendly family learning center, as male clients (husbands/fathers) usually feel more comfortable having a consultation session with male counsellors than with female counsellors.

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3.3. Knowledge Production for Better Strategy and Tools for Advocacy

Knowledge production is one of strategies for promoting sustainable development. Various

knowledge products were developed, aiming at capturing and documenting lesson learned and

best practices of social and gender integration activities. A knowledge management consultant

was, hence, recruited to conduct these tasks and develop a knowledge dissemination plan. The

plan aimed at highlighting themes to be distributed, type of knowledge products, general summary

and its objective, target audience, the source of information, and medium of dissemination. Some

themes included 1) Husband/father’s involvement in health and nutrition in Generasi; 2). Gender

equality and social inclusion in NCCC activities; 3). Women’s empowerment on community

sanitation partnership and community led total sanitation; 4). Nutrition education and impact on

children in family. Discussion and consultation sessions with the consultant and relevant

stakeholders were carried out and resulted in six knowledge product drafts and one audiovisual

script draft.

There were three factsheets published with the topic on husband/father’s roles in health and

nutrition and another two on sanitation, namely: 1) “Father’s active participation in health and

nutrition”, 2) “Gain Profit from Latrine Business: The Success Story of a Female Sanitation

Entrepreneur”, 3) “Latrine’s Heroines from Mesuji Makmur”. An issue brief on traditional birth

attendant, “Involving Bidan Kampung in Reducing Stunting” was also developed, highlighting the

importance of traditional birth attendants’ roles in providing correct information on health and

nutrition to the community, especially pregnant women and parents with children under two year

olds. A success story of the Bidan Kampung Training was documented in an article attached later

in this report. It highlights how the training has contributed positively to the traditional midwives

as the participants, local healthcare staff, and the community.

An animated video called “Ayah, Waktumu Sedikit! (Daddy, you don’t have much time!)” was

circulated on youtube, https://www.youtube.com/watch?v=EgJmGa8pqWY&t=1s. It portrays how

fathers can play active roles in the first one thousand days of a child’s life.

Moreover, three knowledge products were developed to support the MoWECP’s program of

Family Learning Center (Puspaga). They are: 1) Module on Fathers involvement in stunting

prevention and improving family nutrition. 2) A Handbook: A Prosperous and Equal Family for

Child’s growth, Fathers’ Involvement and Financial Literacy for Family Nutrition. 3) KIE

development framework for Puspaga in stunting prevention and improving family nutrition. The

first two documents targeted Puspaga counsellors who would facilitate a small group session in

the community on fathers’ participation in improving family nutrition and the KIE served as

complementary tools of the module.

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Table 1. Knowledge Products on Community-Based Health and Nutrition

No. Aspects of Health and

Nutrition Knowledge products

1 Men’s involvement in Family’s Health and Nutrition

1. Factsheet on the importance of fathers’ active participation infamily’s health and nutrition

2. Module of father’s involvement in health and nutrition for theMoWECP’s Family Learning Center (Puspaga) Counsellors

3. Animated video on Father’s roles in the first 1000 days of achild’s life

4. Handbook: A Prosperous and Equal Family for Child’s growth,Fathers’ Involvement and Financial Literacy for Family Nutrition

5. KIE development framework for Puspaga in preventing stuntingand improving family nutrition

2 Gender equality and social inclusion in NBCC activities

1. Issue Brief: Involving Traditional Birth Attendants (Bidan Kampung) for Behavior Change to Reduce Stunting

2. Story of Change: Involving Traditional Birth Attendants (Bidan Kampung) for Behavior Change to Reduce Stunting

3 Women’s empowerment on community sanitation partnership and community led total sanitation

1. Story of Change: “Gain Profit from Latrine Business: The Success Story of a Female Sanitation Entrepreneur”

2. Factsheet “Latrine’s Heroines from Mesuji Makmur”.

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