COLLABORATION OF NGO AND PRIVATE SECTOR IN …ngobiz.org/picture/File/Improving_0.pdf · Habibie, Abdurrachman Wahid and Megawati Sukarnoputri. In 2004, Indonesia will have its In

BANCO INTERAMERICANO DE DESARROLLOBANCO INTERAMERICANO DE DESENVOLVIMENTO

INTER-AMERICAN DEVELOPMENT BANK BANQUE INTERAMERICAINE DE DEVELOPPMENT

INDES – Japan Program

Workshop on

Corporate Social Responsibility in the Promotion of Social Development: Experiences from Latin America and Asia

Tokyo, Japan – Okinawa, Japan ● July 12–16, 2004

Ngo and Private Sector Collaboration in Improving the Health of Primary School Children in Jakarta, Indonesia

by Adi Sasongko – Yayasan Kusuma Buana (YKB)

Workshop Draft

03 June 2004

1. Background/Context General situation: With more than 10,000 islands, Indonesia is the largest archipelago in the world and the home of 210 million people, making the country the fourth most populated country in the world. The country is now experiencing a double-burden health problem. Infectious diseases such as tuberculosis, malaria and intestinal worm infection are not yet under control while non-infectious or degenerative diseases such as cancer and heart diseases are on the rise. This situation becomes more difficult due to the current socio-economic situation. Since proclaiming its independence in 1945, Indonesia has experienced several political changes. Up until the end of 1949, when the Dutch renounced control over Indonesia, there were disputes against the ruling democratic republic. From 1950 to 1959, Indonesia faced several political problems and rebellious uprisings due to ideological, ethnic and racial differences. In 1965, the communist party initiated an aborted coup and since 1996 President Suharto began the New Order Government. After more than 30 years under the New Order Government, Indonesia has made substantial progress, particularly in stabilizing political and economic conditions. A period of great economic growth was experienced from 1968 to 1986 when per capita income increased sharply from US $ 50 to US $ 385. This increase was primarily the result of the international oil boom of the early 1980s from which more than 60% of the country’s foreign exchange came. The drop in the prices of crude oil and natural gas in 1985 forced the government to look for alternative sources of income such as manufacturing, international trade and service industries. With these efforts, per capita income increased to approximately US $ 1,124 in 1996 and the economic growth was nearly five percent. These successes ended in mid-1997 when the Asian economy collapsed. The value of the currency decreased, prices rose and unemployment dramatically increased. In 1998, Indonesia went through its worst economic crisis when the economic growth rate dropped to negative 13 percent. At the same time, the political situation became unstable. President Suharto was ousted from office and was quickly replaced by his Vice President B.J. Habibie. This was the beginning of the reformation era. Since 1998, Indonesia has had three presidents, B.J. Habibie, Abdurrachman Wahid and Megawati Sukarnoputri. In 2004, Indonesia will have its general election and in July will vote for the new president. During the New Order Government, President Suharto used his power to mobilize private companies to help in the financing of a number of foundations such as the Yayasan (foundation) Dharmasis, Dakap, Super Semar dan Amal Bakti Muslim Pancasila. In 1995, he established another foundation (Yayasan Dana Sejahtera Mandiri) by asking large companies with a net profit of over 100 million rupiahs to donate 2 percent of their net annual profit to this foundation (Rp. 8500/US $1). This foundation was established by a Presidential Decree and was able to accumulate a fortune. In 1998, it was reported that all of his foundations have accumulated funds of over 2500 billion rupiahs. It was very clear that during New Order Government, companies were asked by the government to donate funds in the name of helping social causes. The problem was the use of the money was not accountable by the public and there were indications that it was used to also strengthen the political power of the president and the ruling party of Golkar.

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CSR practices in Indonesia Traditionally, various large companies have the custom to contribute to the society by donating to needy groups during times of need, such as during natural disasters like earthquakes, floods etc, or in terms of providing scholarships to poor students or renovating school buildings. The companies initiate these charitable acts. Private foundation such as the Yayasan Jantung Sehat (the Foundation for Healthy Hearts), also works closely with a number of companies to obtain financial support for heart surgeries for people from poor families and in need of heart surgery. Another private foundation Yayasan Kesejahteraan Anak (Foundation for the Welfare of the Children) also finds support from a number of companies for the benefit of needy children. Pfizer CSR Activities: In Indonesia, the Pfizer Corporation plays a key role in CSR. The Pfizer’s CEO, in his Performance Report in 2003, stated that his company measures Pfizer’s success not only from their financial performance but also from their ability to provide access to medicine and their performance as corporate citizens. As part of performing their role as good corporate citizens in Indonesia, Pfizer has made donations to various activities. In its 25th anniversary in 1994, Pfizer announced its Pfizer Health Education Forum to provide scholarships for continuing medical education, research etc. In 1997, Pfizer was also reported contributing 190 million rupiahs to help the poor families through Yayasan Dana Sejahtera Mandiri. General Health Conditions in Indonesia: The Human Development Index in 2003 showed that Indonesia ranked number 112 out of 175 countries in the world. One of the reasons for this low ranking is the health condition of the primary school children. Many primary school children in Indonesia still suffer from health problems caused by infectious diseases (including intestinal worm infections) and malnutrition. These two conditions decrease the learning ability and contribute to the low quality and low productivity of human resources in Indonesia. Data from TIMSS (Trends in International Mathematics and Science Study, 1999) revealed that the Indonesian primary school children ranked number 32 and 34 out of 38 countries tested in 1999 and ranked number 26 out of 27 countries tested in reading literacy study. The common health problem in Indonesia is still dominated by infectious diseases and malnutrition meanwhile degenerative diseases such as diabetes mellitus, cancer, and heart diseases are also on the rise. The nine most common diseases among outpatients in Indonesian public hospitals are:

1. Diarrhea and other intestinal tract infections 2. Upper respiratory tract infections 3. Skin diseases 4. Gastritis 5. Acute pharyngitis (throat infections) 6. Hypertension 7. Dental infections 8. Influenza 9. Conjunctivitis (eye infection) (Min. of Health 2000).

The nine most common diseases among inpatients in Indonesian public hospitals are:

1. Diarrhea and other intestinal tract infections 2. Typhoid infections 3. Gastritis

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4. Dengue hemorrhagic fever 5. Upper respiratory tract infections 6. Pneumonia 7. Malaria 8. Tuberculosis 9. Hypertension (Min. of Health, 2000).

Considering the health problems in Indonesia, the resources available to overcome the challenges are also limited. Table 1 shows the health budget per capita of Indonesia in comparison with other Asian countries and Japan. The data showed that the health budget of Indonesia is among the lowest compared with other Asian countries. Table 1: Health budget per capita and percentage to GDP of Indonesia and other Asian countries and Japan:

Country Health Budget /capita (US $)

Percentage to GDP

1. Brunei 490 3,1% 2. Cambodia 19 8,1% 3. Indonesia 19 2,7% 4. Laos 11 3,4% 5. Malaysia 101 2,5% 6. Philippines 33 3,4% 7. Singapore 814 3,5% 8. Thailand 71 3,7% 9. Vietnam 21 5,2% 10. Japan 2908 7,8% (The World Health Report, 2002). With the limited budget available for the health sector, priority is given to infectious and fatal diseases such as diarrhea, tuberculosis, malaria, dengue hemorrhagic fever, which dominate the infectious pattern in Indonesia. Non-fatal diseases such as intestinal worm infections are not given priority and since 1984 were not part of the government program. As a result, the prevalence rate of intestinal worms is continues to be high. Surveys conducted by the Ministry of Health and parasitologists from all over the country found that the average prevalence rate among primary school children is 60 – 80 percent. Table 2: The estimated prevalence rate of intestinal worms in Indonesia (1992): Types of worms Estimated Prevalence rate • Round worm (Ascaris lumbricoides) 70 – 90% • Whip worm (Trichris trichiura) 80 – 90% • Hookworm (Necator americanus and Ankylostoma

duodenale) 30 – 59%

(Indonesian Association for Parasite Control, 1992) Table 3: Prevalence rate of intestinal worms in various provinces in Indonesia during the period of 1970 – 1980: Province Round worm Whip worm Hookworm North Sumatera 75,0% 87,0% 58,0%

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West Sumatera 71,0% 28,0% 66,0% West Kalimantan 76,0% 90,0% 60,0% South Kalimantan 79,0% 83,0% 65,0% Central Sulawesi 52,0% 38,0% 55,0% Papua 77,4% 72,9% 73,4% West Java 90,0% 91,0% 67,0% Central java 73,1% 45,1% 23,2% Jogjakarta 84,6% 90,8% 52,1% Bali 91,3% 89,9% 54,8% NTB 92,0% 84,0% 25,0% (Margono, 1989). Table 4: The prevalence rate of intestinal worms in school children reported during the period of 1987 – 1999: Authors & Year Total Round worm Whip worm Hookworm Sasongko et al (1987) from 7.879 Primary School Children in Jakarta

78,6% 62,2% 48,1% 0,72%

Ministry of Health (1995) from Primary School Children in North Sumatera

NA 60,2% 53,8% 6,7%

Sri Margono et al (1999) from Primary School Children in Lombok

NA 76,7% 62,7% NA

Sasongko et al (1999) from Primary School Children in Seribu Islands

95,1% 65,4% 86,2% 0%

Sasongko et al (1999) from Junior High School Students in Seribu Islands

89,8% 57,1% 68,4% 0%

Sasongko et al (1999) from High School Students in Seribu Islands

80,5% 47,1% 64,4% 0%

NA: not available Although intestinal parasite control is not a priority, there have been short-term, sporadic and minor efforts to decrease the prevalence rate. Most of the efforts were conducted at the community level using a blanket approach in which all of the targets of the project were simply given treatment without any prior stool examination. In Indonesia, the government implements mandatory education through nine years (until the junior high school level). To accommodate for the mandatory schooling many schools were established however the focus was on building adequate quantity of schools rather than on the quality of education. In Jakarta, there are 2500 primary schools with 625,000 students. It is estimated that 60% of these schools (1500 schools with 375,000 students) are at risk of intestinal worms infection due to the lack of sanitation and poor environmental condition. According to the data from the Jakarta Health Authority, the main health problems of school children in Jakarta are Upper Respiratory Tract Infections, Gastro-enteritis (including diarrhea), Dengue Hemorrhagic Fever, tooth caries, malnutrition, anemia, etc. Intestinal worm infections are not included as the main health problems,

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because the government health center does not perform stool examinations to identify worm infections. 2. Description/Process: The Establishment of School-based Intestinal Parasite Control Program: The YKB is a non-profit health organization and established in 1980. In 1981, the YKB started a clinic for the middle-lower income families living in the densely populated areas of Jakarta. The service provided by the clinic was maternal and child health (including family planning) in relation to one of the principle health problems of the country: high prevalence rate of maternal and infant death. This clinic was one of the NGO clinics initiating fee-charging family planning in Indonesia, which was later adopted by the government as the Self-reliant Family Planning program in 1993. The clinic was successful and was followed by the development of other clinics. Currently the YKB manages a total of six clinics. Table 5: YKB clinics and their year of establishment: Name of Clinic Year of Establishment 1. Pisangan Baru 1981 2. Palbatu 1983 3. Tanjung Priok 1983 4. Kebon Jeruk 1983 5. Hayam Wuruk 2000 6. Bintara 2003

Figure 1: YKB’s clinic utilization (1981-2004)

YKB CLINIC UTILIZATION 1981 - 2003

-

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

FP MCH Total

The middle-lower income families targeted by the YKB cJakarta with poor sanitation and environmental conditiointestinal worm (or parasite infection) was very high. A sthat the prevalence rate of parasite infection in one primas high as 82.5 percent. The findings of this survey werand education authorities. In 1987, based on the findinschool-based intestinal parasite control program. As a NGO focused on family planning in Indonesia, the Yfamily planning/health NGOs from various countries. OnYKB is a Japanese NGO namely JOICFP (Japan OrganizaPlanning). From this collaboration, the YKB learned thaprinciple threat in Japan after the Second World War. Th

Figure 2: Financial balance of YKB clinics (1981 – 2003)

FINANCIAL BALANCE OF YKB CLINICS 1981 - 2003

t

(500.000.000)

-

500.000.000

1.000.000.000

1.500.000.000

2.000.000.000

1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

INCOME EXPENDITURE BALANCE

linics live in the densely populated areas of ns. As a result, the prevalence rate of urvey conducted by the YKB in 1986 found ary school located near the YKB clinic was

e then reported to the government health gs of the survey it was decided to start a

KB also collaborated with a number of e of the foreign NGOs that worked with the tion for International Cooperation in Family intestinal parasite infections were also a e founder of JOICFP (Mr. Chojiro Kunii)

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established a school-based intestinal parasite control program and has successfully overcome the problem. Based on the successful model implemented in Japan, in 1987 the YKB then established a school-based intestinal parasite control program. The previous efforts to control intestinal parasite infections were conducted as community-based programs and not as school-based programs. Therefore the YKB’s program was the first school-based intestinal parasite control program initiated in Indonesia. In collaboration with JOICFP, the YKB received technical and financial assistance from JAPC (Japan Association of Parasite Control, a sister organization of JOICFP) during the period of 1987-1991.

The school implemented program emphasized the importance of using educational approaches such as health education activities for the students, teachers and parents to explain the problem of parasite infections, the impact on the health, nutritional status and learning ability of the children and the importance of personal hygiene and sanitation to prevent such infections. These educational activities were then followed by regular stool examinations conducted twice a year to identify students infected by intestinal worms, using the Kato technique recommended by WHO. After the laboratory examinations, students infected by worms were subsequently treated. Twice-a-year stool examinations are still conducted due to the high re-infection rate of parasite infection. This way re-infection is regularly detected before the infection worsens. To enable this regular stool examination, YKB gradually established a mass stool examination laboratory with the assistance from JAPC. Realizing that intestinal parasite control pcould not be implemented in a short-term periodsince the start of the program the YKB collectedparents’ contributions. For each student, the

parents contributed Rp. 1000/year (in 1987 it was equal to US$ 0.60) to cover the stool examinations and treatment.

rograms ,

In implementing this program, a three-partite collaboration was also established between the YKB as a NGO, academics (parasitologists) from the Medical School of University of Indonesia and the Jakarta Health and Education authorities. The parasitologists provided basic training and technical assistance to the YKB staff and have the access to make use of the data generated from this program to publish scientific papers. During the first four years of this program, financial support was given by JOICFP, including the budget to buy anthelmintics. In 1991, the support was terminated and the YKB has since sustained the program until today. In 1992, the partnership with Pfizer was established. Pfizer was aware of the activities of this program from media publicity. The marketing manager of Pfizer contacted the YKB and proposed to work with the YKB. In this collaboration, Pfizer give a discounted price for the anthelmintics1

1 Anthelmintic is the drug uses to cure worm infection.

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needed by the YKB, provided the plastic containers and envelopes necessary for stool collection and the financial support to conduct health promotion activities such as school competitions, drawing and essay writing competitions, etc. The total amount of financial support from Pfizer (excluding the discounted price of the anthelmintics) for the period of 1992 – 2003 is more than one billion rupiahs (Rp. 1.096.300.500 or equivalent of US$ 128.976 with the exchange value of Rp. 8500/US $). Pfizer financial support to YKB:

Year Pfizer support (Rupiahs) 1992 17.000.000 1993 17.000.000 1994 28.500.000 1995 79.796.000 1996 81.349.500 1997 103.475.000 1998 138.600.000 1999 46.250.000 2000 86.460.000 2001 129.792.500 2002 123.740.000 2003 244.337.500 Note: including the rupiahs value of IEC materials 3. Results of the program:

With the support from the Jakarta health and education authorities, the program was able to gradually increase its coverage. Starting with 34 schools in 1987, in 2003 it covered 657 schools with 175,000 students. Since 1997, the program has been expanding its activities to serve a number of primary schools in the fishing community at Seribu Island located in the bay of North Jakarta.

Inline with the increased coverage, the program gradually decreased the prevalence rate of the intestinal worms. In the beginning (1987) the prevalence rate was 78.6% and gradually it has decreased to 8.4% (in 2003). In the meantime, reports from the Ministry of Health showed that the average of intestinal worm infections among school children in Indonesia is between 60 – 80%.

DECLINING PREVALENCE OF INTESTINAL WORM INFECTION 1987-2003

0%

20%

40%

60%

80%

100%

TAHUN/SIKLUS PEMERIKSAAN

PR

EV

ALE

NS

Series1 78.6 70.9 68.5 64.2 67.7 68.5 69.7 61.5 67.0 56.1 56.3 40.7 42.8 31.2 35.9 26.8 25.8 21.1 24.4 18.2 20.2 13.8 14.7 11.7 14.1 8.0% 13.5 14.0 10.8 8.4% 8.4%

87/88

88/89

89/90

90/91

91/92

92/93

93/94

94/95

95/96

96/97

97/98

98/99

99/00

00/01

01/02

02/03

Figure 3: Declining prevalence rate of intestinal worm infection among primary school children in Jakarta (1987 – 2003)

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The parents’ contribution was not enough to cover all of the program expenses. The value of the contribution has also decreased with the fall in value of the Indonesian rupiah to the US dollar. For example, in 1987 the parent’s contribution of Rp. 1000/student/year was equal to 60 cents US dollar. In 2003 (with an exchange rate of Rp. 8500 = 1 US dollar) the value has decreased to 12 cents US dollar. Until 2003, the government did not provide financial support to the program thus making the support from Pfizer crucial to sustain the program. From 2002 - 2005, the YKB receives and will continue to receive three-years of support from JICA to expand its coverage in Jakarta and replicate it to other cities (Jogjakarta and Denpasar). Combined with the support from Pfizer, the YKB decided to expand to Semarang. This expansion is conducted in collaboration with the local health NGOs in those three cities. The selection of these three cities was according to the availability of strong NGOs and medical schools to support its activities. In these three cities, the same program has also been implemented in the local primary schools. Advocacy to government has consistently been conducted throughout the duration of the program. Unfortunately, until 2002 the government did not provide financial support to this program. According to the government one of the principal reasons behind its decision to not support the YKB’s efforts was the government health center was implementing a similar activity. Unfortunately, the government program was well managed and skilled technicians did not conduct and manage the mass stool examination laboratory. Therefore the government program on school-based parasite control was discontinued in 1998. In 2003/2004, the health authority in North Jakarta decided to officially assign the YKB the job of conducting the intestinal parasite control program in 100 schools. The program was successfully implemented and the continuation of this program is being discussed. In 2004, the Government of Jakarta finally recognized this program. The YKB was invited to submit a proposal to attain government assistance to expand its activities in Jakarta. The proposal has been submitted and in the review process for additional laboratory equipment (such as binocular microscopes, freezer, etc.), educational equipment (such as LCD projectors and sound systems) and transportation facilities (such as van and motorbikes). 4. Problems encountered: During the regime of the New Order Government of Suharto, the country experienced an authoritarian government in which many NGOs were considered to be opposition to the government. Political stability was very important and critical voices and opinions by NGOs were considered to threaten political stability. During this period, many government officials openly refused or did not recognize the role of NGOs accusing NGOs to be the “public enemy”. With this systematic stigmatization, working in a NGO was quite difficult. Continuous efforts and strong determination to work effectively were needed to gain the confidence from the community. Not only was there a general fear of the work of NGOs but also attention to the effects of worm infections were given low priority due to their non-fatal nature. The priority and the budget were allocated to diseases such as malaria, tuberculosis and dengue hemorrhagic fever due to their fatal nature. Parasite infections were considered important (causing the eventual depletion of human quality) but not urgent Students infected with intestinal worms were still able to attend school, however the infections did cause hemorrhages, fever and long-term bodily degeneration among other challenges. It was with this background situation and the omnipresence of other governmentally researched fatal disease that the YKB initiated a school-based intestinal parasite control program in 1987. The different approaches implemented by the YKB and the government caused another problem for the YKB program. The YKB implemented a screening-based approach (based on successful

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experience in Japan). The government, however, used a blanket approach. The reasoning behind the governments’ preference for such an approach was due to the high prevalence rate of worm infection and it was much easier to conduct blanket treatments instead of selective treatments. Using the blanket approach, the school children were given anthelmintics without any stool examinations prior to the treatment. The YKB does not agree with this approach since it is not beneficial to provide treatment blanketly. For a long-term program, a blanket approach is more expensive because anthelmintics are distributed to all students regardless of their infection status. In a screening-based approach, drugs are given only to infected cases therefore the use of anthelmintics lowers according to the decrease of prevalence rate. In Jakarta, the government health authority is supporting the approach used by the YKB despite the Ministry of Health’s policy to use the blanket approach. In a national-scale project directed by the central government (PMT-AS Project), since 1996, anthelmintics were given twice a year to nearly 10 million school children throughout the country. A number of schools in Jakarta were also included in this project. This kind of situation created confusion between schools working under the YKB approach and the schools applying the government’s approach. There has not been regular health examinations systematically programmed by the government thus causing difficulties for the YKB program. The curative approach is widely practiced in many health programs under the government’s project. Unlike many developed countries (such as Japan) in which school children are accustomed to have regular health checkups, the Indonesian school children are not accustomed to such examinations. These situations explain the difficulties faced by the YKB in promoting regular stool examinations for school children. 5. Beyond parasite control: Working regularly with school communities increases the contacts between the YKB staff and the teachers. During the visits to the school, some teachers asked questions about Pap smears. Many teachers had heard about Pap smears but they did not understand the process. They inquired about the examinations and the YKB decided to respond to their inquiries and provide health education on Pap smears for teachers offering Pap smear examinations directly after the health education sessions. Besides promoting Pap smears for the school faculty, the YKB clinics have been promoting them to the community in the surrounding areas of the clinics. The YKB clinic staff in conjunction with the local women organizations conducted meetings at the mosque, the house of the local community leader and the office of the village leader. During the meetings (at school or in community buildings), the YKB clinic staff brought portable overhead projectors, showing slides on cervical cancer and showing the anatomical displays of reproductive organs to explain the importance of Pap smears.

In comparison with the YKB efforts to promote Pap smears to the women’s organization, the teachers responded more positively to the education on Pap smears. Organizing education and examination on Pap smears for teachers was easier than working with the women’s organization. The explanation is very simple. The teachers were well educated and easily understood the importance of health checkups. They earned their own income enabling them to make decisions about their health. A

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NUMBER OF PAP SMEAR EXAMINATION 1987 - 2003

0

500

1000

1500

2000

2500

3000

3500

Series1 24 358 440 398 668 1.355 1.408 1.215 1.046 977 995 1.155 1.524 2.247 1.990 2.226 2.977

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Figure 4: Number of Pap smear examination at YKB clinics in Jakarta (1987 – 2003)

housewife, traditionally, has to tell her husband and ask for money from the husband to pay the cost of the Pap smear. The housewife runs the risk of the husband not understanding the importance of the Pap smear or not place priority on such an examination. Through regular contacts with the teachers, the YKB identified that the teachers needed to improve their knowledge and understanding on certain health issues. After discussing with the teachers, the YKB proposed to conduct regular one-day seminars for teachers to discuss health and education issues. The teachers quickly supported the idea. Since 1993 the YKB has been able to organize 30 one-day seminars. These seminars were conducted with the support from the teachers by paying seminar fees to attend the seminar. Topics on education and teaching methodology and current health issues were discussed by inviting prominent resource persons. The seminar was found to be very useful and an average of 250 teachers participated in each seminar.

During 2000 – 2003, the YKB collaborated with Ajinomoto Inc. (Tokyo) to develop a model for solving the problem of anemia and under nutrition among primary school children in Jakarta. The blood examinations taken from over 15,000 samples conducted during this project activity revealed the high prevalence of anemia among school children. Studies have shown that anemia affected the physical and learning performance of the students. This project has been able to develop a cost-effective model for controlling anemia and improving the nutritional status of the

primary school children. Advocacy works are on going now to create awareness on this problem and the need to have a school-based program to overcome the problem of anemia and under nutrition. The Ajinomoto Inc. (Tokyo) learned about the YKB activities with the primary school children from information provided by JOICFP, which had worked with the YKB in establishing primary school-based parasite control programs. The Ajinomoto assistance to the YKB was provided as part of the global corporate social responsibility program of this company. After examining the positive results of this project in relation to the vision and mission of the Ajinomoto Food Company, the company is researching a possible extension of this

innovative project.

DECREASING PREVALENCE RATE OF ANEMIA

0

10

20

30

40

50

60

PREPOST

PRE 35.1 49.5

POST 4.4 6.3

YEAR1 (10 SCHOOLS) YEAR2 (13 SCHOOLS)

Figure 5: Decreasing prevalence rate of anemia in two groups of primary schools in Jakarta (2000 – 2002)

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The support from the Ajinomoto was used by the YKB to develop a model to improve the nutrition and anemia conditions of the school children. Previously there had not been systematic and sustainable program to overcome these challenges. The collaborative work between the YKB and the Ajinomoto in this field is the first effort in using primary schools to control anemia and to improve the nutritional status in Indonesia. The result has been very encouraging. In 10 pilot schools with 2864 students in Jakarta, the prevalence rate of anemia decreased from 35.1% to 4.4%. In another 13 pilot schools with 3160 students, the prevalence rate of anemia decreased from 49.5% to 6.3%. The YKB has also been working with many private companies in conducting activities to prevent HIV/AIDS in the workplace settings. Statistics from the Ministry of Health showed that more than 80% of HIV/AIDS cases in Indonesia belong to the productive age of 20-49 years age. The first case of HIV/AIDS in Indonesia was reported in 1987 and since then, HIV/AIDS has spread throughout the country. Despite the availability of risk factors for HIV/AIDS epidemic such as the sex industry, injecting drug use and low condom use, the reported number of HIV/AIDS cases is still low. This low number makes many people unaware of this potential problem, particularly among business communities unaware that most of the HIV/AIDS cases belong to working age people: the backbone of the business activities.

HIV/AIDS CASES BASED ON AGE GROUPS UP TO DECEMBER CUMULATIVE NUMBER OF HIV/AIDS CASES 1987 - 2003

0

500

1000

1500

2000

2500

3000

3500

4000

4500

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998* 1999 2000 2001 2002 2003

Source: Ministry of Health (2004) To create awareness on this issue, since 1993 the YKcompanies to provide education and training on HIV/of this program, the YKB worked with companies sucNational/Panasonic Gobel and Matsushita Gobel (elecompany), Nike (shoe company) in conducting traininmanagers and workers. The initial support was providTechnologies on Health). Collaboration with the Indoestablished to facilitate the activities with the businethe YKB was the only NGO working on this issue due business community. To foster more awareness among the business commcollaboration with the Indonesian Employers AssociaAIDS Award to companies that have activities to prov

Figure 6: Cumulative number of HIV/AIDS cases in Indonesia 1987 - 2003

BAIh cge

nessto

utioid

Figure 7: HIV/AIDS cases based on age groups in Indonesia up to December 2003

2003

4 17 4

78

596

411

151

4112

0

100

200

300

400

500

600

700

< 1 1 - 4 5 - 14 15 - 19 20 - 29 30 - 39 40 - 49 50 - 59 > 60

has been working with a number of DS prevention in the workplace. At the start as Unitex (textile company), tronic companies), Levi Straus (jeans and education on AIDS prevention for their d by PATH (Program for Appropriate sian Employers Association was also community. In the beginning of this effort, the low AIDS awareness among NGOs and

nity in Indonesia, in 1997 the YKB in n (Apindo) took the initiative to provide the e their workers with training and education

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on AIDS prevention. In the year 2000, this activity started to receive support from UNAIDS Indonesia. In 2002, the YKB gained assistance from the USAID-support project on AIDS (Aksi Stop AIDS/ASA) to expand the activities throughout the business community and to train other NGOs. In 2003, the ILO Indonesia started their new program in promoting AIDS prevention in the working community and started to collaborate with the YKB and the ASA to create awareness among the business community in Indonesia. The YKB has reached nearly 200 companies (with an estimated 250,000 employees) in Indonesia with training and education activities on AIDS prevention. Until 2004, 30 companies had received the award including large companies such as Freeport (mining company), Krakatau Steel (steel company), Gajah Tunggal (tire company), and Standard Chartered Bank etc. In establishing these activities in 1993, the YKB started this program by using its own resources without support from funding agencies. The first support was provided by PATH in 1995, which received grants from the Gates Foundation. UNAIDS started to provide its support in 2000 and USAID in 2002. With this support, the YKB provides training and education to companies free of charge and in return the participating companies contribute their time and facilities that they provided to conduct the training and its follow-up activities. With regard to sustaining these activities, the YKB has initiated fee charging in providing its services to companies. Gillette was the first company (in 1994), which paid the YKB a fee to conduct the training for their managers and workers. Other companies have gradually followed this plan, such as Krakatau Steel (in 2003/2004) and Panasonic Manufacturing Indonesia (in 2004).

After advocating the issue of AIDS prevention in the workplace for many years and with strong support from funding agencies such as USAID, ILO and AusAID, in April 2004 the Ministry of Manpower finally issued a decree on AIDS prevention in the workplace. In this decree, companies in Indonesia have to establish activities in their workplace to prevent the spread of AIDS and are forbidden to discriminate workers with HIV/AIDS. This decree is a strategic milestone in the efforts of AIDS prevention in Indonesia and it is expected that more companies will be actively involved in the prevention of AIDS in Indonesia.

6. Lessons Learned The lessons learned from the varying CSR interventions have revealed many lessons in their development. The first program, school-based health programs to treat school children with worm infections, proved to be one of the first non-communities based approaches. Most of the health programs in Indonesia were using community-based approaches and few used school-based approaches. Officially, the school health program existed but it had not been properly managed and implemented. In the case of the intestinal parasite control program, and despite the successful experience from Japan, previous efforts conducted by the government used community-based approaches and in some cases were using factory-based approaches (in a mining company in West Sumatera and rubber and a tea plantation in West Java). Through this program, the YKB has been able to conduct regular stool examinations and educate the community to use anthelmintics selectively (only for infected children). By conducting regular laboratory examinations, data on the prevalence rate of intestinal worm infections has been regularly generated. The data was also used by the academicians to publish scientific paper in conferences in Indonesia and in other international meetings. From analyzing the data, new and better understanding of the intestinal worm infections and ways to control it have been shared with

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academicians and experts on parasite control in Indonesia and throughout the international community. Starting with the parasite control program, the school community then realized the importance of other health conditions such as Pap smears, anemia and nutrition. The presence of the YKB activity in a vast network of primary schools was utilized to initiate a school-based Pap smears program (for female teachers) and anemia control and nutrition improvement program for the school children. This unique development is related to the fact that school is an institution where the future generation is educated to be the future leaders of the country. That is why the value of progress and innovation is embedded in the school institution. It is because of these values that explain why innovative efforts to develop school-based health program were easily accepted by the school community. A long-term collaboration between NGO and private company may not be a common example. The common examples are a practice of CSR in sporadic, short-term activities such as providing fellowships, donations or renovating school buildings. Many of these examples are more PR-oriented activities conducted as part of the anniversary celebration of the company or during outbreaks or natural disasters such as floods or earthquakes. In the case of the YKB-Pfizer collaboration, a win-win solution has been the foundation of its long-term collaboration. By putting the name of its product on the envelope of the stool container distributed biannually to the students, Pfizer has the access to promote its product (Combantrin) to the school community including the parents of the students and the teachers. When the students bring the plastic container home for stool collection, the family members will see it and be exposed to the product’s name printed on the container’s envelope. Many of the teachers are also community leaders and through the exposure to Pfizer products at school, they are aware of the availability of Pfizer’s medicine: Combantrin. The fact that the YKB, as the collaborating partner of Pfizer, has been able to sustain the program for an extended period has added to Pfizer’s benefits. Through long-term exposure to the Pfizer product, the brand awareness and brand loyalty have been established. For most of the parents and the teachers, the term anthelmintic is the same as Combantrin. For the YKB, the support from Pfizer is very important in helping to sustain the program because the parents’ contributions were not enough to cover the costs of the program that lacks support from the government. At the same time, the YKB does not market nor promote Combantrin. Since the start of this program, the treatment is not provided blanketly. It is provided only to infected children. In this program, the YKB is promoting regular stool examinations -and not promoting blanket treatments- and educating the school community to use the drug rationally. This example shows a win-win partnership is attained since both of the parties have been able to achieve their objectives. Pfizer has been able to create brand awareness and brand loyalty for its product (Combantrin) and the YKB has been able to sustain a control program to decrease the prevalence rate of intestinal worm infection. A win-win partnership like this one should be the basis to sustain corporate social responsibility programs. From the corporate social responsibility point of view, the collaboration with Pfizer is inline with their policy of how Pfizer is doing their business. As stated by Dr. Hank McKinell, the Pfizer CEO, Pfizer measures their business by three key standards: financial performance, ability to increase access to health care and corporate citizenship. Through the school-based parasite control program in Jakarta, Pfizer has consistently and successfully implemented two key standards of their business philosophy: increasing access to health care to primary school children in Jakarta and a good practice of corporate citizenship. The YKB working with Ajinomoto Inc. (Tokyo) is also an example of how Ajinomoto helps the school children to improve their health and nutritional status. The vision and mission of Ajinomoto as a food company is inline with the nutrition-related activities program conducted to improve the health of the school children.

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Besides the collaboration with Pfizer in school-based parasite control programs and with Ajinomoto for nutrition improvement programs, the YKB has been working with various companies on AIDS prevention in the workplace. Starting as a small initiative by the YKB in 1993, this program has since become a national program in Indonesia after the Ministry of Manpower officially issued a decree to promote AIDS prevention in the workplace. Funding organizations such as USAID and AusAIDS and other international agencies such as UNAIDS and ILO have also supported the YKB’s initiatives. The YKB’s continuous work with companies shows that collaboration between NGOs and the private sector is feasible and potentially sustainable. Being as a NGO, the YKB has the expertise in working for social causes with the approach of “educating people how to fish instead of only supplying fish”. Companies have resources to help the community but may not have the expertise to properly and continuously facilitate the development of the community. Collaboration between NGOs and the private sector will foster partnerships to help the community help themselves. Being a professional NGO, the YKB exemplifies a NGO that functions as a professional provider to companies in strengthening their human resources to protect themselves from the AIDS epidemic, a facilitator focused on the health essentials of school aged children and an organization that responds to the needs of the educational professionals.

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BIBLIOGRAPHY Adhyatma (1997) Berbagai model pemberantasan cacingan di Indonesia. (Different models of STH control in Indonesia) Presented at the Seminar on One Decade of STH Control in Jakarta, organized by Faculty of Public Health University of Indonesia and Yayasan Kusuma Buana, 21 October 1997. Hara, T (1985) Promotion of parasite control programme as the trigger for community health development. In: Notes for APCO Integrated Project Training Course. Bangkok, Faculty of Tropical Medicine, Mahidol University. Kunii C (1992) It all started from worms. The 45-year record of Japan’s post-World War II national health and family planning movement. Tokyo, Hoken kaikan Foundation. Margono Sri S. Ismid IS (1998) Mass treatment of STH in schoolchildren in Indonesia. Presented at IX International Congress of Parasitology, 24-28 August, 1998, Chiba, Japan Mayun Pudja (personal communication) (2004). The practice of corporate social responsibility in Indonesia. Ministry of Health (1995) Laporan hasil survey prevalensi dan intensitas cacingan pada anak sekolah di Sumatera Utara. (Report on the the results of prevalence and intensity of infection of Soil-transmitted helminthes among primary schoolchildren in North Sumatera Province). Jakarta, Ministry of Health, Directorate General of Communicable Diseases Control. Ministry of Health (2004) Reports on the surveillance of HIV/AIDS in Indonesia. Jakarta, Directorat General of Communicable Diseases Control. Perkumpulan Pemberantasan Penyakit Parasit Indonesia (P4I/Indonesian Parasite Control Association) (1992) Menyambut harijadi P4I (Celebrating the anniversary of P4I). Jakarta, P4I Perkumpulan Pemberantasan Penyakit Parasit Indonesia (Indonesian parasite Control Association) (1992). Memperingati Harijadi P4I Tahun 1992 (Celebrating the Anniversary of IPCA 1992). Jakarta, P4I. Pfizer (2004) Corporate Social Responsibility Program (www.pfizer.com) Sasongko A, Mahaswiati M, Lubis F (1997) Hasil pemberantasan cacingan di sekolah-sekolah dasar DKI Jakarta 1987-1997 (The results of STH control in primary schools of Jakarta 1987-1997) Presented at the Seminar on One Decade of STH Control in Jakarta, organized by Faculty of Public Health University of Indonesia and Yayasan Kusuma Buana, 21 October 1997. Sasongko A, (1999) Duabelas tahun pelaksanaan program pemberantasan cacingan di sekolah dasar DKI Jakarta (1987-1999) (Twelve years’ implementation of primary school-based parasite control in Jakarta (1987-1999). Presented at the VIIth National Congress of Indonesian Parasite Control Association, Makassar, 18-21 Nopember 1999. Sasongko A, Ratnawulan D, Lubis F (1999) Laporan hasil pemberantasan cacingan di Kep. Seribu, Jakarta Utara. (Report on the results of STH control in Seribu Island, North Jakarta) Presented to the Vice-Governor of Jakarta province. Sasongko A, Lubis F, Mahaswiati M, Ratnawulan D (2003) Practical experience from the primary school-based STH control programme in Jakarta (1987 – 1999). In: Controlling disease due to helminth infection. Geneve, World Health Organization. WHO (1991) Basic laboratory methods in medical parasitology. Geneva, World health Organization.

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