Technical ReportPDF Available

Revitalization of Family Planning in Indonesia

February 2009
The Government of Indonesia and
United Nations Population Fund
Revitalization of Family
Planning in Indonesia
Principal contributors:
Professor Terence H. Hull
Australian National University
Professor Henry Mosley
Johns Hopkins University
Revitalization of Family Planning in Indonesia
The Indonesian Family Planning Programme has been recognized as one of the successful
programme in the world. During 1970 to 2006, the contraceptive prevalence rate had
greatly increased, and the total fertility rate had significantly reduced. Since then, there
have been phenomena of flat trend in several indicators of the achievements on family
planning programme. There is a need to analyse the existing situation and formulate
realistic policy and strategy to improve and accelerate the achievement of Family Planning
Programme in Indonesia.
The recommendation addressed in this document is revitalization of family planning. This
recommendation is based on assessment on the past, present, and projection of family
planning, reproductive health, and demographic situation in Indonesia in association
with change of the governmental system from centralization to decentralization. This
transformation of governmental system has also implicated on the policies and strategies
on the implementation of family planning programme. Therefore, there is an urgency to
reformulate the family planning programme in respond to current dynamic situation in
this country. Important role of local government to meet the needs of their community
and better management on the family planning services has been emphasized on this
consultation document.
On behalf of the Government of Indonesia and UNFPA, we convey our thanks and
gratitude to the Consultant Team: Professor Terence H. Hull and Professor Henry Mosley
for their excellent work. We hope that this publication will contribute to the revitalization
of family planning programme in Indonesia and development of the Indonesian Medium-
Term Development Plan 2010-2014.
Jakarta, February 2009
Nina Sardjunani, MA Dr. Sugiri Syarief, MPA Dr. Zahidul Huque
Deputy Minister for Chairperson of BKKBN Representative, UNFPA
Human Resources and Indonesia
Cultural Affaris
Revitalization of Family Planning in Indonesia
of Content
EXECUTIVE SUMMARY ............................. vii
THE DEMOGRAPHIC PICTURE ................................... 1
Fertility Levels and Trends .............................................. 1
Trends in the Total Number of Births .............................. 7
Unmarried Women – a Growing Need for
Contraception and Family Planning Services .................. 10
FAMILY PLANNING PROGRAM TRENDS .................... 13
Trends in Contraceptive Prevalence Rates (CPR) .............. 13
Source of Supply of Contraceptives for Current Users ..... 15
The Changing Profile of Family Planning Service
Providers ....................................................................... 18
Problems of Contraceptive Method Mix ........................ 20
BKKBN Procurement versus DHS Estimates of CPR ......... 22
FOR WOMEN ............................................................ 25
A Rising Unmet Need for Contraception ........................ 25
“Met Need”: the Disconnect Between Fertility
Preferences and Method Choice .................................... 26
Revitalization of Family Planning in Indonesia
Unintended pregnancies and resulting unintended
births and abortions ..................................................... 30
Clarifying Adolescent Family Planning and Reproductive
Health Needs ................................................................ 33
Past Operational Structure of the Family Planning
Program ........................................................................ 35
Changes with the New Government and
Decentralization ............................................................ 36
Developing a New Vision, Mission and Values ................ 38
A Future Agenda for a Revitalized Family
Planning Program ......................................................... 46
Adjusting DHS Fertility for Missing Single Women. ......... 55
Contraceptive Prevalence Rates by Method, DHS,
1976–2007 ................................................................... 63
Family Planning and Health Services Synergies in
the Benefits, and Complementarities in Program
Operations ................................................................... 65
Executive Summary
Revitalization of Family Planning in Indonesia
The Indonesia national family planning program, led by
BKKBN, has been recognized as one of the world’s greatest
demographic success stories of the 20th century. In a period
of 30 years from the late 1960s until the turn of the century,
contraceptive prevalence increased from under 5 percent to
over 50 percent and the total fertility rate (TFR) was cut in half.
Furthermore, over this period, the family planning program
successfully implemented a policy to move most of the service
provision from the public sector to private providers.
Presently, national TFR trends indicate that the two child
family has essentially become the norm, and there is
no demographic justification for the continuation of an
aggressive promotion of fertility reduction. It seems clear
that married women have a desire to control their fertility
as manifest in the fact that half of currently married women
want no more children, and of those who do intend to have
more, half want to delay the next birth for at least two years.
This means that three quarters of women have an immediate
need for safe and effective contraception. Unfortunately they
often face obstacles in gaining access to methods of birth
control appropriate to their personal preferences and needs.
Disturbing trends in the family planning picture have
emerged since the mid-1990s pointing to an urgent need
to revitalize the family planning program to more effectively
(and efficiently) meet the reproductive needs of women and
men across the nation. Among these are the following:
1. A flat trend in contraceptive prevalence in recent years,
with evidence of decay in practice among the least
educated women and a reversal of decades of decline in
the measure of unmet need in the latest IDHS.
2. Narrowing of the contraceptive method mix to temporary
hormonal methods (primarily injectables) due to major
Revitalization of Family Planning in Indonesia
declines in the promotion of longer acting implants
and IUDs and the failure of the program to support and
extend surgical sterilization for people wishing to have a
permanent end to childbearing.
3. High rates of unintended pregnancy among both married
and unmarried women manifested by: the reported high
number of induced abortions among both groups and
the fact that one in six mothers report that their last birth
was not wanted at the time it occurred.
4. Persistent regional disparities in contraceptive availability
with many poor provinces and districts lagging behind
their richer counterparts, and isolated regions suffering
from shortages of staff and materials for family planning
These trends are in part due to –
1. The success of the Blue Circle and Gold Circle Campaigns
since the 1980s to shift services from public to private
providers (principally village midwives in the rural areas),
resulting in a private provider driven program that primarily
promotes the use of injections and pills irrespective of
clients’ needs
2. Policy and budgeting decisions to reduce government
support for surgical sterilization since 1995
3. Budgeting decisions since 1999 to reduce BKKBN
procurement, distribution and training for the
contraceptive implant program
4. Lack of collaborative efforts by the Department of
Health and the BKKBN to develop policies, strategies
and programs to ensure that private providers have the
competencies, resources and incentives to provide high
quality family planning services
5. Explicit policies that ignore the contraceptive needs of
unmarried women (and men).
Revitalization of Family Planning in Indonesia
6. An ambiguous abortion law promulgated in 1992, and
lack of clear policies and programs to ensure that women
have access to safe abortions and to post-abortion family
planning services
7. Policies and practices leading to the diversion of
government contraceptive commodities into the growing
private market (potentially reducing access by the poor)
Most of these actions and the worrisome trends they
produced began before decentralization. Decentralization,
however, has resulted in less emphasis on family planning
in many districts/municipalities and so has aggravated these
adverse trends.
Yet, the family planning program still has considerable
momentum based on BKKBN service statistics since 2000
collected from the districts/municipalities indicating that
contraceptives continue to be distributed at the usual levels,
often because of the loyalty and strong training endowments
of the former BKKBN staff at the district level.
Decentralization, however, does impact on the political
instruments and operational strategies available to the
central government agencies to revitalize the family
planning program when these departments and agencies
no longer have line authority, staff or budgets to direct
field operations. This report identifies the challenges BKKBN
faces in this new environment, and develops the following
Revitalization of Family Planning in Indonesia
1. To revitalize family planning the Government should
first reformulate the Vision, Mission and Values to
respond to the new realities of decentralized government
and achievement of the goal of replacement level fertility.
This could possibly involve the creation of a new
identity for the BKKBN, perhaps involving a change
of name.
2. The central government needs to take the lead in
the process of building core analytical and technical
competencies related to family planning at all levels of
government and in both the public and private spheres.
There should be a central agency charged with revitalizing
the family planning.
3. Develop a senior leadership advisory structure to guide
the central agency.
4. Initiate leadership capacity building for reproductive
health and family planning in the districts/municipalities
5. Strengthen the role and functions of the new district
level Offices/Boards of Family Planning and Women and
6. Promote initiatives nationally and locally to increase the
availability and accessibility of long acting contraceptives
– IUD, implants and male and female sterilization – to all
7. Formulate program policies and develop operational
strategies in collaboration with the Ministry of Health to
meet critical service delivery needs including:
Revitalization of Family Planning in Indonesia
a. Reaching disadvantaged women including all
women with an unmet need for contraception with
information and services
b. Engaging the private sector with training, technical
assistance and incentives to ensure that all women
can choose the contraceptive method best for their
life stage
c. Assuring that women are not forced to undergo
unsafe abortions, and that all women terminating a
pregnancy are provided with contraception.
8. Develop and promote national communication strategies
focusing on the major unmet needs and unreached
9. A central agency charged with responsibility for family
planning and reproductive health should place a high
priority on monitoring public and private program
performance (from service statistics and surveys)
with interpretation and rapid feedback to districts/
10. The agency should also test and introduce innovations,
primarily through grants to universities, private
organizations and NGOs as appropriate.
11. The agency should encourage districts to innovate and
take other actions to strengthen the program, primarily
through “block grants”.
12. The agency should conduct advocacy, nationally and
internationally, based on critically analysed data.
Revitalization of Family Planning in Indonesia
The Demographic Picture
Fertility Levels and Trends in
Over the last four decades Indonesia, like most countries in
Asia, has undergone a major transition from high to low
fertility. Where women up to the 1970s had long borne
an average of over five children, the pace of childbearing
has slowed since then through a combination of delayed
marriage and the increased use of contraception to prolong
the time between births and ultimately end childbearing with
fewer children. Underlying this major behavioural change
was a national family planning program that promoted free
contraceptives, small family values, and enhanced family
welfare. This, along with rapid increases in school enrolments
and steady reductions in the rates of poverty and rises in
formal workforce participation meant that women could
entertain ambitions beyond motherhood and families could
invest more in the quality of their children rather than simply
the quantity of family size.
The transformation in behaviours surrounding family
formation is reflected in the sequence of blue diamonds in
Figure 1. This gives us a long term ‘macroscopic’ view of
fertility trends from the beginning of the family planning
program through the most recent national surveys. Each blue
Revitalization of Family Planning in Indonesia
1965 1975
1985 1995 2005
Census, Supas, Susenas
CPS and DHS pre-2000
DHS 2002-3 Retro
DHS 2007 Retro
diamond is an estimate of fertility spanning a three to five year
period centred on the point. This calculation is drawn from a
comparison of the number of children between the ages of
0 to 3 or 4 enumerated in the population, and the number
of women of childbearing ages (the Own Child method). The
line is not linear but falls continuously through the turn of the
century, at which point the decline slowed near the so-called
replacement level of 2.1 children per woman.
The fertility calculations of the more detailed Contraceptive
Prevalence Survey and the Demographic and Health Surveys
(CPS and DHS) since the late 1980s do not follow the
census trend lines. In early years they were below the own
child estimates. Since 1995 the DHS total fertility rates have
increasingly exceeded the levels found in the census-type
national surveys. Since the year 2000 the published DHS
estimates of current fertility (three years prior to the survey)
have been stagnant at 2.6 children per woman, well above
replacement level and nearly half a child higher than the
census estimates.
Figure 1. Indonesian fertility trends, 1965-2007
Revitalization of Family Planning in Indonesia
DHS enumerators collect detailed data from ever-married
women between the ages of 15 and 49, including complete
histories of pregnancies and births. The total number of births
in discrete periods of time prior to the survey is obtained
from these histories. Thus in Figure 1 the two most recent
DHS produced estimates of fertility both for the three year
period immediately prior to the survey and five to nine years
retrospectively. In each case they show declining fertility in
same survey retrospective trend but comparison of current
fertility between the two surveys shows no decline.
In the DHS it is assumed that single women are not sexually
active and have not produced any children. However, to
calculate fertility rates the survey needs to record all women
in the population irrespective of their marital status. This
number is obtained from the household census compiled
by interviewers when they first arrive at selected sample
households. The DHS census listing is the tool used to collect
the estimate of the total population of women and men in the
sample households. Table 1 reveals that the DHS household
listings consistently show lower proportions of single women
compared to Census, SUPAS or SUSENAS enumerations taken
at around the same time, particularly for the ages from 20
through 29.
What explains the apparent lack of single women in the DHS
listings? In part it appears that there is a major difference
in the type of household covered by DHS and census type
surveys. Essentially, the DHS interviewers are on the lookout
for ever married women and given the nature of the survey
they are particularly attuned to households with families.
Since the 1980s Indonesia has undergone a remarkable
change in the roles young women perform in society. They
are increasingly likely to pursue education to higher levels, to
work in expanding industrial and service occupations, or join
the over four million Indonesian workers who are employed
overseas sending remittances home. Single women often
Revitalization of Family Planning in Indonesia
live in institutional settings – dormitories, industrial barracks,
and boarding houses. Anecdotal evidence from interviewers
indicates that these places are often passed over in the DHS
canvassing because fieldworkers concentrate on households
that are more likely to yield eligible respondents. In contrast
the decennial census enumeration includes all households,
and the intercensal survey (SUPAS) makes special efforts to
cover both family and non-family households, often with
particular interest in workers and students.
Table 1.
Marital status distributions for women of reproductive ages in
successive national surveys in Indonesia
Percentage of women in the age group who are single
15-19 85.7 82.1 89.3 89.7 85.4 90.8 86.9
20-24 40.1 36.1 43.1 47.0 41.2 51.4 38.3
25-29 15.2 14.1 16.7 16.3 13.8 19.7 15.4
30-34 5.5 5.3 6.9 6.5 5.9 8.1 7.0
35-39 2.8 2.4 3.5 2.9 3.0 4.3 3.6
40-44 2.1 2.9 2.4 2.1 2.1 2.6 2.6
45-49 1.9 1.7 2.0 1.4 2.0 2.0 1.9
All WRA 27.7 25.3 28.7 27.6 25.0 28.8 23.7
Percentage of women in the age group who are ever-married
15-19 14.3 18.0 10.7 10.3 14.6 9.2 13.1
20-24 59.9 63.9 56.9 53.0 58.8 48.6 61.7
25-29 84.8 85.9 83.3 83.7 86.2 80.3 84.6
30-34 94.5 94.7 93.1 93.5 94.1 91.9 93.0
35-39 97.2 97.7 96.5 97.1 97.0 95.7 96.4
40-44 97.9 97.1 97.6 97.9 98.0 97.4 97.4
45-49 98.1 98.4 98.0 98.6 98.0 98.0 98.1
All WRA 72.3 74.7 71.3 72.4 75.0 71.2 76.3
*Calculated from the Measure DHS STATCompiler: and 2007 DHS data provided by Statistics Indonesia.
Revitalization of Family Planning in Indonesia
The adjustment of DHS fertility rates is a two step process.
First the data in Table 1 can be used to estimate the number
of single women missing from the DHS sample compared
to the expected number if the DHS had the same marriage
status patterns as recent census or intercensal survey results.
Second, once those single women are added to the total
number of women in the DHS households the fertility rates
can be recalculated with new denominators. Both these
calculations are described in ANNEX 1, producing a pair of
adjusted fertility rates for the two most recent DHS.
Figure 2 takes a ‘microscopic’ view of the fertility estimates.
The adjusted DHS results are just above the census-type
survey trend line. While they indicate a slow rate of decline,
they are substantially below the unadjusted DHS levels and
on track to reach replacement level fertility within a few
Figure 2. Unadjusted trend lines from 2002-3 and
2007 DHS and three census type surveys compared
with adjusted fertility estimates for 2002-3
and 2007 DHS and the latest published UNFPA
estimates from State of the World’s Population
1995 1997 1999 2001 2003 2005 2007 2009
2000, Census, 2003-
04-05 SUSENAS,
2005 SUPAS
DHS 2002-3 retro
estimate for 1995-2000
DHS 2007 retro
estimate for 1995-2006
Adjusted estimate
for DHS 2002-2003
current fertility
Adjusted estimate for
2007 DHS current
UNFPA State of World
Population 2008
Revitalization of Family Planning in Indonesia
years, assuming there is no reversal in mean age at marriage
or levels of effective contraceptive use in the population. It
is notable that the UN Population Division calculations used
in the UNFPA State of the World’s Population 2008 tables
is on line with the census and adjusted DHS figures, and
substantially below the published DHS results.
This is an important finding for two reasons. First, the
higher DHS results have been used to fuel criticisms of the
Indonesian family planning program and raise alarms about
possibilities of a baby boom or population explosion related
to the implementation of a decentralized system of health and
family planning service delivery since 2000. The adjustments
show that fertility is falling, and is on track to meet planning
targets, and there is certainly no baby boom on the horizon.
Second, the failure of the DHS to account for all women is
not a problem unique to Indonesia. It has also been found
in Bangladesh, where young women are flocking to jobs in
textile factories and staying in school for longer periods of
time as a result of positive government policies. DHS type
surveys are likely to encounter difficulties accounting for single
women wherever the roles of women are subject to rapid
change, and households are in a state of flux. It serves as a
wakeup call to national statisticians who will need to develop
new ways to ensure that the sample designs encompass
non-standard households. Adopting de facto definitions of
residence rather than reliance on de jure listings of registered
household members will go a long way to addressing this
We can conclude that there are serious problems with the
methods used to estimate fertility in Indonesia. The own-child
method of fertility calculation used in the decennial census
and the annual SUSENAS produces a steady downward trend
of fertility from the 1970s through to the present day. In
contrast the pregnancy history techniques used by the DHS
Revitalization of Family Planning in Indonesia
yielded lower fertility than the census prior to 2000, and
higher levels since then. The discrepancy appears to be caused
by the failure of the DHS sample and interview methods to
capture a true profile of all women of reproductive ages and
in particular failure to record a substantial number of single
women. Once adjusted for these missing women the fertility
rates for the three years prior to the 2002-03 and 2007 DHS
are around 2.3, slightly above the long term BKKBN goal of
replacement level fertility but well below the levels assumed
by many government planners.
Trends in Total Number of Births
The challenge of assessing fertility trends in Indonesia is not
just a puzzle for demographers, but also a tangle of challenges
for health and family planning managers. If the fertility rates
implied by the DHS are correct, there are in excess of 4.6
million births annually in Indonesia, and future numbers will
moderate only as smaller cohorts of mothers work their way
into the reproductive ages.
If the lower and slightly falling fertility rates calculated from
the Census, SUPAS and annual Socio-Economic Surveys are
correct, then there are currently 4.3 million births annually,
and these numbers will drift lower to 4.2 million in around
8 to ten years from now. Figure 3 shows the trend in births
embedded in the most recent population projections
commissioned by BAPPENAS and carried out by BPS.
Interestingly the assumed fertility rates are slightly lower than
the census and adjusted DHS fertility points in Figure 2. They
show estimates of TFR of 2.23 for 2005 falling very gradually
to reach 2.15 in 2010, when the BKKBN target calls for 2.10,
and going on to reach 2.10 in 2016. Demographically there is
no reason to criticize the assumptions, but politically they raise
Revitalization of Family Planning in Indonesia
questions about the degree to which government intends to
invest resources to improve reproductive health and in the
process speed the pace of fertility decline. A revitalisation of
family planning would lead to a quicker decline in fertility
which would translate into a smaller number of births in
future than the numbers shown in Figure 3.
Figure 3. Estimated and Projected Annual Number
of Births Indonesia, 2000-2015
2000 2002 2004 2006 2008 2010 2012 2014
Number of Birth
2000, Census Based
2000, Census Based
According to the BAPPENAS/BPS population projections
the number of women of reproductive age will continue to
climb in coming decades, but at a diminishing rate of growth
(Figure 4). There are currently just over 64 million women
between the ages of 15 and 49. In 2015, the target year
to achieve the MDGs, there will be over 68 million women
demanding services to deal with a full range of reproductive
health issues.
An increasing proportion of these women will be in the later
reproductive age groups of 35-49, a time at which they will
have two, three or more children, but are still potentially
fertile. The vast majority of women in this group want no
more children. These are the people who need long term
Revitalization of Family Planning in Indonesia
contraceptives like the implant or surgical sterilization. At
the turn of the century this group represented 32 percent of
all women of reproductive potential and today they are 37
percent. By 2015 they will be over 40 percent of the clientele
for contraception and will number nearly 28 million women.
Translating that into estimates of the need for permanent
contraception is a challenge for policy makers and health
planners. Certainly the most cost-effective and practical
option is the promotion of male sterilization using no-
scalpel vasectomy techniques in primary health care facilities.
However despite substantial investments in the 1980s and
1990s the Indonesian vasectomy program has never reached
a point of self sustaining take-off, and in recent years the
numbers of men having vasectomies has waned.
Figure 4. Estimated and Projected Number of
Women of Reproductive Ages in Indonesia,
2000 – 2015
Women 15-34
Women 35-49
2000 2005 2010 2015
Number of Women
Revitalization of Family Planning in Indonesia
Unmarried Women – a Growing
Need for Contraception and
Family Planning Services
Indonesia’s national family planning program explicitly
excludes unmarried women (and men), therefore these
women receive little attention in the usual DHS surveys.
This policy may have been rational 40 years ago when the
family planning program began and most women, with no
opportunity for education, married and began childbearing
early. But with development and urbanization, times have
changed dramatically, as has the demographic picture and
sexual behaviour of unmarried women, yet the old policies
There has been a steady change in marital status of young
women since the inception of the national family planning
program. (Figure 5). In 1971, just over 60 percent of women
15-19 years of age were unmarried; by 2005, 91 percent of
this group were single. More strikingly, in the 20-24 year age
group, the proportion single increased from 19 percent to
51 percent. Overall, there are currently 24 million unmarried
women in the reproductive age group of whom just over 9
million are in the teenage years of 15-19. Less well recognized
is the fact that over 11 million young adult women (age 20-
34) are single.
Revitalization of Family Planning in Indonesia
Figure 5. The growing numbers of single
(never married) women in the reproductive age
population of women
Number of Woman
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Source: BAPPENAS/BPS Projections 2008
Even in the absence of any survey, it is safe to assume that
essentially 100 percent of these young women (and men)
want to delay their first birth until marriage. Many may be
practicing abstinence, but many others, as they leave school,
become employed and mature both physically and socially,
may be sexually active, thus running the risk of an unintended
However, since these women are often ignored by the IDHS
questions on sexual behaviour, the nation has no idea at
Revitalization of Family Planning in Indonesia
all of the contraceptive options being taken up by sexually
active but unmarried women. Since the consequence of an
untended pregnancy can mean termination from school or
employment, many (if not most) of unintended pregnancies
are illegally aborted by untrained practitioners with adverse
consequences for the woman, and for society at large. (See
the discussion of abortion below.)
Revitalization of Family Planning in Indonesia
Family Planning Program Data
Trends in Contraceptive
Prevalence Rates (CPR)
The credibility gap surrounding fertility data is also found
in the data on prevalence of contraceptive use by currently
married women, but here the implications are reversed.
The CPR on the annual socioeconomic household survey is
consistently lower than those found in the occasional DHS,
and the gap has been widening over time (Figure 6). This is
not surprising since the respondents for the two surveys are
different – the DHS interviewers must talk to the woman,
while the SUSENAS interviewer may meet with the male head
of household or another responsible household member.
In the complex extended family units sometimes found in
Indonesia it is quite possible that the SUSENAS respondent
would not know about the method of contraceptives used
by a married in-law, child, niece, or visitor. A few percentage
points difference is not a matter of concern.
Revitalization of Family Planning in Indonesia
Figure 6. Contraceptive prevalence in Indonesia,
Percentage of Married Women using Contraceptive
Susenas Estimates
DHS Estimates
1991 1994 1997 2000 2003 2006
Both types of survey, and especially the SUSENAS, do reveal
lethargy in the rate of growth of CPR since the mid 1990s.
Many commentators talk of “continuing multiple crises”
in Indonesia from 1997 to the present. A wide range of
social data shows that Indonesia has experience substantial
development in the decade since the Asian Financial Crisis
of 1997-99. Education levels have been rising steadily,
particularly among women. The age at marriage has
continued to increase, and the average age at first birth is
higher than ever. Women have entered the formal workforce
in unprecedented numbers, and a growing number of
married women are in salaried employment that takes them
away from their homes. All these social changes point to
Revitalization of Family Planning in Indonesia
the growth of demand for contraceptives among women
who increasingly want to space or limit births. But almost in
defiance of these trends the CPR measured by the last seven
annual SUSENAS remained stuck at just over half of married
women of reproductive ages.
This picture is likely an indicative of a relaxation in family
planning program effort in this decade and is consistent with
the fact that since decentralization in 1999 many districts
have placed a lower priority on family planning programs.
Other evidence for this is the fact that while overall modern
method CPR rose slightly between the 2002-03 DHS and the
2007 DHS, it actually declined from 45 to 44 percent among
women with no education. Concurrently, knowledge about
modern methods declined in this group as well.
Sources of Contraceptives for
Current Users
One of the most successful policy initiatives of the family
planning program over the last two decades is the shift of
the program from one of universal free access to a user pays
system with subsidies built in to ensure access by the poor.
This was implemented through a three pronged approach.
The Blue Circle set prices for contraceptives which
encouraged clients to seek out their own providers, either
public or private, with a heavy emphasis on marketing in ways
to create a notion of differentiated brands reflecting quality.
Poor clients were still given free contraceptives (though
there were often charges for registration at clinics or other
small fees), but private providers sold contraceptive services
at subsidized prices to clients able to pay. The Gold Circle
services were not subsidized, but promised a high quality
product from a highly skilled provider. Market segmentation
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was promoted with an emphasis on quality for all, but better
quality for those who could pay more.
The challenge of poverty and isolation of large parts of the
country was met by a Village Midwife program, which
trained and placed tens of thousands of young women to
provide birthing and family planning assistance in every
village. Though initiated by the BKKBN this idea was quickly
adopted by the Ministry of Health along with a system of
short term contract employment for doctors, midwives and
nurses, to ensure staff availability in disadvantaged regions.
Finally a mixture of Poverty Alleviation measures has been
implemented to ensure access to medical services including
family planning. Sometimes based on cards promising free
services, insurance schemes paying for service, or subventions
to institutions coupled with requirements that they serve
the poor, these schemes are generally based around public
facilities, but they sometimes include the private sector.
The scissors shaped lines on the graph in Figure 7 demonstrate
the substantial transformation of the family planning service
delivery from a public to a private sector dominated system
over the two decades between 1987 and 2007. The data on
the graph are somewhat different from those shown in DHS
reports because the survey categorized village Pos KB (family
planning posts) or Posyandu (health post) as “other private”
sector, but they are actually organized by government
officials. Even with these minor changes, it is clear that
family planning in Indonesia is now heavily dependent on
private institutions and practitioners, with all the implications
this has for the possibility of government policy to shape,
influence and direct.
In short, not only has control of programmatic initiatives
shifted from central to district government authorities, the
routine decisions about how women are treated has shifted
Revitalization of Family Planning in Indonesia
from government to private agents. It is thus more important
than ever to consider what incentives health professionals
have to provide family planning services as well as what
‘demands’ consumers may have.
Figure 7. Source of supply for modern
contraceptive methods, Indonesia, 1987-2007
Note: Posyandu and Pos KB desa are shown as “public” in this graph, though they are categorized as “other private”
in DHS survey coding.
Source: Contraceptive Prevalence Survey, 1987 and Demographic and Health Surveys, 1991, 1994, 1997, 2002-3,
Percentage of Currently Married Women by Source
of Modern Contraceptive Supply
1987 1991 1994 1997 2003 2007
Revitalization of Family Planning in Indonesia
The Changing Profile of Family
Planning Service Providers
Today family planning providers can be seen either as
individual professionals, like doctors, midwives, nurses, or
pharmacists, or as institutions, like PUSKESMAS (Community
Health Clinic), hospitals, Polindes (Village Birthing Post),
surgeries, or drug stores. In the 1970s, 1980s and 1990s the
program trained an army of volunteers and large numbers
of fieldworkers to promote acceptance of family planning
and distribute pills and condoms directly to the hamlets
where women lived and worked. In recent years government
regulations have inhibited the effectiveness of such workers
as service agents.
Obviously the institutions are largely dependent on individual
professionals to have direct contact with the clients, but the
organization of that contact can vary enormously depending
on the size and location of the institution. Nurses in a large
urban teaching hospital may have day to day responsibility
for delivering service under the general supervision of a
physician, and there would be a network of professionals
overseeing policy and standards for the service. In contrast a
midwife running a private practice out of her home would be
making decisions to give the injection or distribute the pills
that the clients want with little or no oversight by the broader
Revitalization of Family Planning in Indonesia
Over the time of decentralization the number of institutions
registered as part of the BKKBN network of family planning
service points has remained fairly steady but the number of
private practitioners, both doctors and midwives, has grown
overall. The total number of service points is now just on
80,000, compared with around 62,000 just eight years ago
(Figure 8). Of course some of the private practices represent
government workers who supplement their incomes and
serve their communities by running a clinic in the evening.
It is unclear how decentralization has affected these
numbers, but the one clear dynamic is the large shift of
Figure 8. Numbers of Registered Family Planning
Service Points
Source: BKKBN Service Statistics, 2000-2008.
FP Public Clinics
Private FP Clinics
Registered Private
Registered Private
2000* 2001* 2002* 2003* 2004* 2005* 2006* 2007* 2008**
Revitalization of Family Planning in Indonesia
contract midwives (bidan PTT) to the private sector as their
limited term contracts expire. It is estimated that of a total of
67,000 midwives trained under the village midwife programs
around 40,000 remain under contract as of September 2008.
It is worth noting that there are around 44,000 midwives
registered as private practitioners in the BKKBN data system.
A portion of these are former contract midwives, some are
government workers with after hours practice and some are
graduates from private midwifery schools who have never
worked for the government.
Problems of Contraceptive
Method Mix
One of the strongest manifestations of a privatized family
planning program is found in the transformation of the mix
of contraceptives used by women and men over the last
fifteen years. The Indonesian program had long offered the
widest choice of contraceptives in the developing world, and
in most cases the supplies were free. The result was a real
‘cafeteria’ with couples and providers having good access to
very inexpensive methods like pills as well as more expensive
methods like implants and sterilization. Among the choices
were a wide range of different dosages, allowing the provider
to ensure that women with particular biological conditions
(like breastfeeding, sensitivity to hormones, or anxiety about
gynaecological exams) would have options.
While there was no doubt that Indonesian women did show
some preference for injectable contraceptives, many studies
also showed that there were large numbers who preferred
implants and both men and women were attracted to the
benefits of sterilization as methods appropriate to people
who have completed their childbearing and not wanting to
Revitalization of Family Planning in Indonesia
continue taking hormones for the rest of their reproductive
The annual National Social and Economic Survey (SUSENAS)
shows the relative decline of all forms of contraception except
the injectable (Figure 9). (Similar data from the DHS surveys are
presented in ANNEX 2.) This occurred coincidentally with the
shift from public to private providers. The majority of private
providers are not doctors, but rather the village midwives
who were recruited, trained and for a brief time contracted
by the government to provide services to villagers. When
their contracts expired, many of these women transformed
themselves into general health providers, offering routine
medical care for their neighbours, and relying on a steady
stream of clients for their income. The injectables, once a
three monthly treatment, but more recently a monthly shot,
were an ideal way for the private practitioner to lock in a
flow of payments – particularly in contrast to implants which
involve only five yearly visits and male and female sterilization
which provide a lifetime of protection if properly carried out.
Revitalization of Family Planning in Indonesia
Figure 9. Contraceptive Mix, Indonesia,
Source: SUSENAS data sets 1992-2007.
Percentage of current users
1992 1994 1996 1998 2000 2002 2004 2006
Others Method
BKKBN Procurement versus DHS
Estimates of CPR
Another issue related to the source of contraceptives is the
ultimate source of method procurement. It is important for
the central family planning authority to monitor the volume
of contraceptives distributed through government channels
(whether central or local), private sales via doctors, and
private sales direct to users.
Revitalization of Family Planning in Indonesia
In Table 2 a simple comparison is made. Of the nearly 43
million women in the population in 2007, over 20 million
were using hormonal methods of contraception, including
the pill, injectables and implants. Two thirds of the pill and
implant users or about 4.5 million married women, obtained
their supplies from the BKKBN. Only one third of injectable
users were served by the BKKBN supplies, meaning that
8.4 million users were paying full price through the private
Table 2.
Comparison of DHS based estimate of number of current users
of hormonal contraceptives and reported BKKBN procurement of
supplies in 2007.
Source: Calculated from DHS and BKKBN data
2007 DHS
Estimate of
Current Users
2007 BKKBN
Procurement in
Person Years of
from BKKBN
Pill 5,624,634 3,725,263 66.2
Injectables 13,550,254 5,164,175 38.1
Implant 1,193,104 786,248 65.9
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Reproductive Health
Consequences for Women
A Rising Unmet Need for
As noted earlier, the overall increase in CPR has almost
halted and a significant decline has been observed among
uneducated women since 2002-03. Coupled with this has
been a disturbing trend in the unmet need for contraception.
Between 1991 and 2002-03, the trend in unmet need
was favourable, declining from 13 percent to 8.6 percent,
but the 2007 DHS showed increase to 8.8 percent for the
regions comparable to the 2002-03 survey. It is not surprising
that there is a correspondence between the trends in CPR,
method mix and unmet need, which together are indicative
of a decline in family planning program effort while demand
for fertility control is increasing. One consequence of this can
be an increase in abortions, as women seek other means to
avoid an unwanted birth. This is discussed below.
Revitalization of Family Planning in Indonesia
“Met Need” and the Disconnect
Between Fertility Preferences and
Method Choice
While we do not have data whether or not women are
receiving their method of choice, depending on where they
are in their reproductive life cycle, it is reasonable to assume
that when women decide that they want no more children,
the majority are likely to choose a long acting method like
sterilization, IUDs or implants if these methods are readily
available at low cost. The alternative is having injections
monthly or tri-monthly or taking pills daily for over ten years
or more, an option that will be burdensome for women
and costly for the program if the contraceptives and costs
of provision must be subsidized for the poor. Furthermore,
these short-term methods have a higher likelihood of failure
compared with the long term methods. This question can
be examined indirectly by looking at the fertility preferences
of women according to number of living children, and then
comparing these findings to the level of contraceptive use
and methods mix by parity. These data from the 2007 IDHS
are shown in Figures 10 and 11.
Figure 10 shows the rapid decline in the desire for an additional
birth as family size increases. Sixty percent of women with
two children want to stop childbearing. This rises to around
75 percent for those with 3 or 4 children and over 80 percent
for those with larger families. Very few women have either
been declared infecund or have had themselves or their
partner sterilized. This indicates a very substantial demand
for ongoing contraceptive services.
Revitalization of Family Planning in Indonesia
Figure 10. Percentages of Currently Married
Women Wanting No More Children, According to
their Current Family Size
Source: IDHS 2007: Preliminary Report, Table 7.
0 123456+
Number of Living Children
Declared infecund
Self or partner
Wants no more
This pattern of high potential demand for fertility control
services according to the family size is not new. As Figure 11
shows, from 1987 to the present, the percentage of women
with three or more children who say they want no more
pregnancies has consistently been a majority, and over the
years the line has pushed higher. This is consistent with an
emerging two child family norm. Looking specifically at Parity
2 we can see a major change with just over 40 percent of
mothers with two living children saying they wanted to stop
childbearing in 1987, and 60 percent, or fifty percent more,
Revitalization of Family Planning in Indonesia
displaying that preference in 2007. Though not shown in the
graph, it is notable that the percentage of currently married
women with two living children was only 21 percent in 1987,
but had risen to almost one third in 2007. This is one area
where women’s preferences have been changing, and they
have changed their actions in concert.
Figure 11. Percentages of Women Who Do
Not Want Any More Children, According to the
Number of Children They Currently Have.
Number of Living Children
0 123456+
DHS 2007
DHS 2002-3
DHS 1997
DHS 1994
DHS 1991
DHS 1987
The data on contraceptive use by family size in Figure 12
shows a favourable picture for women with 1 to 2 children
– over 65 percent are using contraception, with the vast
majority using injectables and pills. This same high level of
use is seen for women with 3 to 4 children, but the method
mix has hardly changed – injectables and pills still dominate.
Revitalization of Family Planning in Indonesia
Figure 12. Contraceptive Method Used by
Currently Married Women 15-49, by Number of
Children Still Living
Source: 2007 IDHS Preliminary Report, Table 5.
Number of Living Children
Female Sterilization
Male Sterilization
Among older women with the largest families injectables and
pills still dominate despite the fact that they overwhelmingly
do not want to have further pregnancies. The failure
of providers to promote and provide methods that are
appropriate to the clients’ age, parity and desire for an end
to child bearing is perhaps the most striking shortcoming of
the program today.
To summarize, we have the situation where fully 50 percent
of all married women do not want another child yet the great
majority do not have effective access to the most secure
methods of fertility control. This is a huge “hidden unmet
need” for the method of their choice to avoid another birth
Revitalization of Family Planning in Indonesia
over the remaining decade or more of their reproductive life.
Yet because of a program failure to meet this need, these
women will be contributing to the majority of unintended
pregnancies, many of which will be terminated by unsafe
Unintended Pregnancies
Leading to Unintended Births
and Abortions
The most obvious evidence of unmet needs for fertility
control among women of reproductive age is the number
of unintended pregnancies leading to unintended births and
abortions. While there are significant problems in measuring
both of these events, there are some estimates of the
magnitude of these problems.
In the 2002-03 DHS, married women of reproductive age
reported that 17 percent of their births were unwanted or
mistimed. This represents about 720,000 unintended births
among 4.3 million births occurring annually and implying an
even higher number of unintended pregnancies.
It is difficult to gauge exactly how many pregnancies are
unintended in any given year. If a woman becomes pregnant
by accident or misadventure she may react in a variety of
ways, depending on her situation. Many women will accept
the pregnancy as a welcome surprise, and will make plans to
have the baby. Others will begrudgingly accept the birth as an
unwelcome but unavoidable “fate”, in the process accepting
all the implications this has for her relationships and her life
prospect. Many will reject the birth, opting instead to take
measures to terminate the pregnancy through the use of a
variety of problematic traditional measures, or by recourse to
safe professional medical interventions. In making decisions
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among these options each woman will be heavily influenced
by the cultural, legal, religious and personal dimensions of
her life and upbringing, but in the end these influences will
not necessarily determine a particular outcome, either in
terms of what the woman decides or what impact it has on
her own life or the fate of the pregnancy. Chance and risk
play a crucial role in pregnancy. In fact, for a fifth to a third
of pregnancies a spontaneous abortion or miscarriage will
intervene, often well before a woman is even aware that a
conception has occurred.
It is very difficult to estimate the number of women who
opt to purposefully terminate their pregnancies through
induced abortion. In Indonesia various attempts have been
made to estimate the numbers through analysis of the most
common sources of supply of effective abortion services.
While Indonesian women are very familiar with the widely
distributed forms of traditional herbal methods of provoking a
delay menses (jamu terlambat bulan) there is no evidence that
these are effective in terminating pregnancy. Hull, Widyantoro
and Sarwono (1993) took reports of numbers of potential
abortion service workers (traditional midwives, midwives,
nurses, doctors and specialist OBGYN) and attributed rough
average numbers of abortions per provider to estimate
that Indonesia had over 700,000 abortions per year. Later
Budi Utomo refined this approach by conducting a sample
survey of providers in selected abortion “service delivery
points” done in 10 cities and 6 districts across Indonesia in
2000. This provided a national estimate of almost 2 million
abortions annually, including both spontaneous and induced
terminations (Utomo et al. 2001:21). Two-thirds of the
women admitted their abortions were induced; this would
translate to about 1.3 million induced abortions annually, or
nearly 30 induced abortions for every 100 live births.
Considering the estimates of unintended pregnancies and
abortions together with the total births, this would mean
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that among 6.3 million pregnancies, 1.3 million were aborted
purposefully, and 0.7 million were spontaneously aborted or
miscarried. This leaves 4.3 million live births among which
0.7 million were unintended. From both a health and socio-
economic perspective, the problem of at least 2 million
unintended pregnancies (the total of induced abortions
and unintended births) poses major challenges for mothers,
families and society as a whole.
The abortion study cited above was revealing in other ways,
One-third of the abortion clients were unmarried; this
was consistent with the fact that about 36 percent of
women said they were aborting their first pregnancy.
Fifty percent of the women had never used contraception;
no doubt the vast majority of these were unmarried
These data reinforce the necessity of addressing the
contraceptive needs of sexually active unmarried women (and
One final point; in the rural areas the vast majority (77 percent)
of induced abortions were done by unqualified providers
(dukun bayi or traditional birth attendants), posing a great
risk to the women. Noteworthy, in the urban areas, the single
largest provider of induced abortions were family planning
clinics, accounting for 47 percent of reported procedures.
This is an interesting observation, considering that abortion
is not officially condoned by the national family program,
but it reflects the fact that family planning NGOs, university
supported specialist family planning clinics, and some private
providers are known to offer abortion services, though with
a minimum of publicity.
We can reasonably assume that most if not all abortions
done by unqualified providers did not receive post-abortion
Revitalization of Family Planning in Indonesia
care including family planning services to prevent subsequent
pregnancy. But since even abortions done by qualified
providers in family planning clinics are not officially monitored,
there is no way of knowing if their clients received post-
abortion contraception, or if they were counselled on ways of
protecting themselves from sexually transmitted infections.
The confused legal status of abortion, and the widespread
concern amongst Indonesia’s moral guardians implies that
this would be a difficult issue to tackle directly, but if it is not
addressed the nation will continue to deal with thousands of
deaths and untold morbidity caused by unsafe abortions.
Clarifying Adolescent Family
Planning and Reproductive Health
Indonesia has long carried out projects and activities targeting
adolescents. However, unlike the situation in many African
and Latin American countries, these interventions have not
addressed the realities of young adult sexual behaviour, and
contraceptive services have been restricted to adolescent
women who are legally married.
In Table-3 the first row shows how the number of married
adolescents in the DHS has declined over the last decade
and a half even as the total sample size of women listed in
the household has increased from 38,000 to 45,000. If the
DHS captured all women of reproductive age in the sample,
they would have likely recorded around 9000 adolescent (15-
19) women in recent surveys. However, because they missed
between 2400 and 2900 women in the last two surveys,
representing one third of all single adolescents, the picture
that emerges on unmet reproductive health service needs is
very skewed.
Revitalization of Family Planning in Indonesia
The published figures of unmet need among 15-19 year
olds fell from 13.7 in 1994 to 6.8 percent in 2002-3, before
rising to 9.8 percent in 2007. However these numbers only
refer to the dwindling number of married adolescents. If the
program were to address the reproductive health service
needs of single adolescents the total number of potential
adolescent clients would grow enormously. Essentially today
92.4 percent of this group is unserved by the system, and this
represents a large “unmet need”. Until some way of ensuring
that all women of reproductive age have the same rights
to information, services and supplies, the twin problems
of unwanted pregnancy and untreated reproductive tract
infections will continue to grow.
Table 3.
Family Planning Services and DHS Sample
for 15-19 Year Old Women
Indonesian DHS
1994 1997 2002-3 2007
Married women aged 15-19 in
DHS Sample
1291 1246 912 814
Using contraception (%) 36.4 44.5 47.3 46.8
to space 34.7 43.6 43.5 41.8
to limit 1.7 0.9 3.8 5.1
Unmet Need (%) 13.7 9.1 6.8 9.8
to space 12.7 9.0 6.4 7.3
to limit 1.0 0.1 0.4 2.5
Total demand met and unmet 51.3 54.1 54.3 56.6
Singles aged 15-19 eligible for
DHS household listing
na na 8000 8885
Included in sample 6216 5992 5577 5949
Missing from sample na na 2423 2936
Percent missing na na 30.3% 33.0%
Revitalization of Family Planning in Indonesia
The Family Planning Program –
Past, Present and Future
Past Operational Structure of the
Family Planning Program
The Indonesian national family planning program began
with the establishment of National Family Planning Institute
(LKBN) in 1968 that changed to the National Family Planning
Coordinating Board (BKKBN) in 1970. Key elements of the
national family planning program in the period prior to
decentralization included:
1. A strong central agency (BKKBN) with direct access to,
and strong support by the President
2. Strategic, financial and technical support from the
international donor community
3. Highly qualified professional staff at the centre – oriented
to introducing innovations in a “learning by doing”
4. A mandate to coordinate all government agencies and
private groups to support the national family planning
program – with a budget to support this mandate
5. An ability to organize vertical programs from the central
level to the village, with lines of control and structures for
implementation of actions
6. A working relationship with the Ministry of Health to
provide the technical services for the contraceptive
program in hospitals, clinics and outreach facilities
Revitalization of Family Planning in Indonesia
7. A growing structure of field operations, ultimately with
37 regional training centres, 25,000 trained and salaried
family planning field workers (PLKB) and over 100,000
local family planning volunteers (PPKBD), 40,000 of
whom re-supplied pills and condoms from their homes.
8. Funds and a national distribution system to provide
contraceptive commodities and related supplies and
equipment for the national program.
In addition to building a large public sector family planning
program, in the early 1980s BKKBN began a strategy to
develop private sector services – first in the urban areas with
the Blue Circle (Lingkaran Biru) and then more broadly with
the concept that family planning clients should be self-reliant
(KB Mandiri) and pay something for services (public and
private). Following this was a program to greatly expand the
availability of midwives in the rural areas to provide services
to private sector clients. This led to a great expansion of
village midwives (Bidan Desa) to upwards of 75,000 by the
late 1990s who became the major providers of services in the
rural areas.
Changes with the New Government
and Decentralization
The intrinsic vitality of the national family planning program
by the late 1990s was evident by the fact that during the
economic crisis of 1997-2000, there was no measurable
diminution in contraceptive use. The crisis and related political
events led to the resignation of President Soeharto in 1998.
This was followed by a series of political and administrative
changes that had a major impact on the operations of BKKBN.
These included:
1. Professor Haryono Suyono, who had been a key leader in
BKKBN since its inception was elevated to Coordinating
Revitalization of Family Planning in Indonesia
Minister for People’s Welfare in 1998 in the Cabinet
under President Habibie
2. The government passed decentralization legislation in
1999 and major ministries (e.g., Health and Education)
began to implement regulations to divest themselves of
centralized implementation duties in 2001
3. BKKBN was granted a waiver and so did not decentralize
until January 2004. With decentralization, the BKKBN
district offices were moved in most cases. In some
districts the responsibility for family planning came under
the office of Health, or Population, or Civil Registration,
or Women’s Empowerment or some combination of
these. The PLKB (Family Planning fieldworkers) were also
shifted to other offices, and some no longer worked
in contraceptive delivery or community promotion
4. At the time of decentralization in 2004, BKKBN, with
the Ministry of Health and the Ministry of Home Affairs
established minimum standards for maintaining the
quality of the family planning services at the district level
and developed a guide book for managers that explained
the responsibilities and regulations
5. In 2003, USAID, a major donor, decided to phase out
technical support on the grounds that Indonesia had
“graduated” from the need for bilateral assistance. This
was completed in 2006.
6. Indonesia’s Medium Term Development Plan (MTDP)
2004-09 recognized the importance of Family Planning
services for “reducing the total fertility rate.”
7. Government Regulation (PP) 38/2007 stipulated that
Population and Family Planning are among 31 obligatory
functions at Central/Provincial and District/Municipal
levels, along with, but separate to health.
8. Government Regulation (PP) 41/2007 stipulated that
Population, grouped with Civil Registration should be
structured at the level of an Institution (Lembaga), and that
Family Planning, grouped with Women’s Empowerment
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should be structured at the level of a Board (Badan) or an
Office (Kantor) level. Health was to continue in the form
of an Office (Dinas) and would be responsible for clinical
BKKBN’s loss of central control of family planning with
decentralization did weaken program effort as is evident from
the data on contraceptive method mix, prevalence and unmet
need presented earlier. The emphasis on family planning
in the MTDP and the subsequent Government Regulations
promulgated in 2007 are designed to strengthen the Family
Planning program, though there has not be sufficient time to
observe the effects of these directives. However, it is already
clear that strong national leadership with a new agenda will
be required to address the emerging problems that have
been identified in the analyses above.
The decentralized government structure does present
challenges for a central agency interested in promoting family
planning programs and population policies. BKKBN must
find new ways to engage the district/municipal authorities,
relevant ministries (especially Health) and private providers to
ensure that every woman has the information, contraceptive
methods and related fertility control services she needs to
meet her reproductive goals at every stage in her life cycle.
Developing a New Vision,
Mission and Values
The transformation of the authorities and operations of
the agencies of Government of Indonesia accomplished
by the decentralization over the past nine years requires a
corresponding transformation in the “ways of getting things
done” by those persons at the central level who formerly
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operated with direct administrative powers over operations at
the provincial and district levels. This requires a deep change
in mindset from “command and control” to an approach
1) engages others in a shared vision of a future that all will
commit to work for;
2) creates an environment characterized by teamwork, trust,
open-mindedness; transparency and shared accountability
for all outcomes; and
3) encourages mutual learning drawing on the perspectives
and experiences of a diverse group of stakeholders, through
an ongoing critical analysis of program performance.
Basically, this requires the development of leadership skills to
engage people who do not work for you to ensure that they
work with you to reach mutually held goals.
The first step in organizational transformation to meet new
challenges in a changing environment is to re-examine the
Vision, Mission and Values.
The Vision is a concrete picture of the future that the
organization seeks to create. It should make clear what
is important for the organization and what is not. Most
importantly, it should inspire people to take action, and
create new levels of energy.
The Mission statement provides the focus for the
organization’s efforts. This is essential since every
organization has limited resources and cannot do
everything necessary to reach the Vision. Focus demands
sacrifice; this means giving careful consideration not only
to new activities, but also to current activities that the
organization should no longer be doing.
Revitalization of Family Planning in Indonesia
The Values are the foundation of all the organization’s
efforts. These will guide the organization, especially when
confronting social and cultural barriers. In the case of
family planning, the bases for these values come from
international conventions that Indonesia has signed
including the International Convention of Human Rights
and the Cairo Declaration in 1994 among others.
BKKBN has articulated a Philosophy, Vision, Mission and
Values in recent years, but these must be re-examined to see
their relevance to the current situation. The current version is
as follows:
Philosophy Encourage the participation of the
community in family planning
Vision The whole family supports family planning
Mission To create small prosperous and happy
Values Smart: Acts quick, precise, effective and
Tough: Able to survive and recover
immediately in difficult condition.
Partnerships: To build networks and work
out cooperation by mutually advantageous
These operating principles have served BKKBN in the past,
however given that there has been a fundamental change
in the government structure and that disturbing new
demographic and contraceptive trends are emerging, serious
consideration needs to be given to totally revising these
A critical first step in organizational transformation is to
engage everyone in a process of reformulating the Vision,
Mission and Values that will provide the basis for everything
that they do. Because this process and the outcome must
Revitalization of Family Planning in Indonesia
be “owned” by the members of the organization itself, we
are only presenting an outline of some of the key issues that
should be considered.
A. Vision What is the future we want to create? The focus
here must be on the specific elements of prosperous
Indonesia in the future where BKKBN can make a
Based on the data provided above, it seems clear that the
long term goal for the future needs to move away from
the current policy of restricting family planning services
to married couples towards reaching every sexually active
person both men and women. In particular, every woman
of childbearing age, - married or unmarried, rich or poor
- must have the knowledge and full access to method(s)
of her choice to control her fertility and protect herself
from sexually transmitted diseases at every stage of life.
Related elements of this Vision should include a society
where all family members and community and national
organizations, public and private, secular and religious,
are committed to this goal and are taking actions to ensure
that equity and access are promoted for all citizens.
B. Mission – Why do we need a central organization
working on family planning and reproductive justice in a
decentralized system? The Mission identifies the essential
purposes (objectives) of a restructured and reinvigorated
The proposal here diverges from the current Mission
statement of BKKBN. The reason is that the current
statement could more appropriately be defined as
the Mission of the entire government of Indonesia.
An organization’s Mission statement must have focus
and specificity in order to justify the reasons for the
organization’s existence. The process of formulating the
Revitalization of Family Planning in Indonesia
Mission statement will provide the foundation defining
the critical functions of the transformed organization.
Key tasks that can only be done centrally involve such
things as:
a. Collaboration - Working with other Ministries at the
national level to ensure that policies, strategies and
standards are developed and coordinated and that
funds are appropriated as required
b. Data analysis for informed action including:
i. Monitoring and analysing data covering critical
program activities at the provincial and district/
municipal levels from service statistics and other
sources to get a national picture of the progress
of the program and areas requiring interventions,
and providing rapid feedback
ii. Analysing relevant national data from other
agencies that are consequential for reaching the
family planning goal
iii. Generating original data from surveys, focus groups
and other sources to gain a deeper understanding
of the social, economic and cultural underpinning
of the family planning program
c. International networking - Learning about international
trends and innovations in family planning that can be
adapted to the local context
d. Communication and behaviour change – Designing
communication strategies that are to be applied
nationally to improve program performance
e. Training and technical assistance to build local skills in
program leadership including planning, management
and evaluation
f. Research – to develop a deeper understanding about
provider and client behaviour and to introduce
Revitalization of Family Planning in Indonesia
g. Advocacy - Being a voice for the program at national
and international levels
Consideration must also be given to tasks that should
no longer be done at the central level, since these
divert attention and resources from the core Mission.
For example, because the central organization will not
have any direct operational control over field operations,
it should not be doing tasks related to program
implementation, for example, management of field staff
and distribution of commodities. Since these tasks have
already been devolved to the districts and municipalities,
the new challenge is to develop standards and procedures
to ensure that the program will perform satisfactorily
under local control. In fact, in all matters related to service
delivery, close collaboration with the Ministry of Health
will be essential (see ANNEX 3).
A revitalized family planning program central agency’s
Mission is complicated by the multiple levels of
government it will deal with, and the multiplicity of
agencies concerned with reproductive health and rights
at each level, and the wide range of professional skills
required to carry out the mandate.
We have struggled to gain a clear understanding of
training and finances in the current Family Planning
Program. Consider Table 4:
Revitalization of Family Planning in Indonesia
Table 4.
Training carried out by BKKBN, 2004-2007
Source: BKKBN offices.
Type of training 2004 2005 2006 2007 Total
Leadership 1208 790 465 1401 3864
Management 3623 5528 8895 9806 27852
Research and Policy 640 1810 1868 903 5221
Medical technique 376 965 1650 1690 4681
IPCC IEC 3045 2957 3130 1806 10938
Fieldworker (LDU) 5850 5592 8424 3148 23014
Total 14742 17642 24432 18754 75570
Ideally we would like to see the numbers of trainees
each year according to type of training and level of
government – central, provincial, district and below
district. Such breakdowns are not centrally available for
a comprehensive monitoring of training related to the
Family Planning Program.
Instead it is necessary to contact a range of different units
to obtain figures for the training they carry out under their
various budget lines, including: PULAP, PULIN, PUSJA,
BIKPA, BIBEK. While we tried to compile this information,
it seems clear that there is no standard metric used by all
units, and many groups have lost or have never collected
any detailed data on the training they funded. As might
be imagined each unit has different ways of recording
and reporting the data, and for many units training is not
a central concern, so they do not pay much attention to
monitoring who is being trained.
Revitalization of Family Planning in Indonesia
There is no central BKKBN effort to monitor the training of
medical personnel in contraceptive technologies. Instead
it is assumed that the professional associations such as IBI,
POGI and IDI will have such information. Unfortunately
they do not. There is no way for central planners to know
how many provincial and district doctors are certified
to do vasectomies, how many midwives are up to date
with training on implants and injectables, or how many
surgeons are available to do tubectomies. The central
agency needs new methods to ensure that such complex
information is collected, analysed and maintained in a
systematic way.
Similarly, financial analysis is very complex, and
decentralization makes it all the more so. A true accounting
of the family planning program would necessarily include
funds from the central budget (APBN) for the BKKBN and
parts of the Department of Health; provincial and district
budgets (APBD); Direct transfers for Special Purposes
(Block Grants or DAK), fees paid by clients to government
service providers, and fees paid for private services. A
study by the World Bank and BAPPENAS (2008) revealed
the complexity of financial analysis of the health service
sector, and could well serve as a model for a study of
family planning and reproductive health, and a guide for
the creation of a system of monitoring and analysis.
C. Values How are we going to carry out our mission?
Here the discussion must centre on formulating the basic
principles that will underpin how the organization will
go about achieving its objectives. The core value is to
put the welfare and choices of women in the forefront
of every operational decision. For example, there may be
competing “professional” values such as restrictions on
non-medical people providing oral contraceptives that
will need to be confronted if these medical barriers limit
Revitalization of Family Planning in Indonesia
access to services, particularly among the poor. Another
challenge will be from cultural and religious traditions
that may restrict fertility control options - such as
providing family planning services to unmarried women
and men and assuring safe pregnancy terminations and
post-abortion care. Ultimately these will need to be
addressed, since failing to do so may wreck a woman’s
future or even threaten her life. Here is where research
clearly documenting the consequences of failing to meet
these needs will be an essential foundation for addressing
these issues.
The BKKBN’s current statement of Values mentions
partnerships almost as an afterthought. A new statement
would make working in partnerships a central value in
the new, decentralized environment. There must be the
commitment to collaboration with a wide variety of
stakeholders with different interests.
Another Value must be openness to listening to the voices
of people at every level in society – not just the leaders, but
ordinary people, especially the poor and disadvantaged
women who are, in fact, the most important stakeholders
of all.
A Future Agenda for a Revitalized
Family Planning Program
The main thrusts and accomplishments of the family planning
program in the last century up to the present have been
summarized above. An agenda for the future in a decentralized
government, taking into consideration the challenges evident
from recent trends in the survey data and program statistics,
must include building mutually productive relationships with
key stakeholders. Among these stakeholders are:
Revitalization of Family Planning in Indonesia
a. Local political leadership and family planning and
health services program managers in the districts
and municipalities
b. Ministry of Health, Ministry of Women and
Development, and Ministry of Home Affairs
officials, among others
c. NGOs, particularly professional groups such as IBI,
POGI, PKMI, PKBI, religious groups and women’s
d. Private sector enterprises
e. National political leaders from all parties
These relationships should all be designed to achieve the
following goals:
a. assuring that the family planning program has
expanding resources and qualified personnel to
provide for the needs of a growing population of
women of childbearing age
b. identifying and serving all childbearing women
with an unmet need for contraception, especially
in more deprived districts
c. promoting policies and developing program
strategies to ensure that long acting contraceptive
methods, especially IUDs and sterilization, are
readily available to the population
d. meeting the information needs of adolescents,
both male and female, who are not yet sexually
e. developing policies and programs to ensure
that contraceptive information and services are
provided for all sexually active unmarried women
and men, including adolescents
f. directly addressing the problem of abortion
Revitalization of Family Planning in Indonesia
1. disseminating information about emergency
contraception and increasing the availability of
these products
2. generating support for high quality post-
abortion care that assures that all women get
appropriate contraception
3. developing the data to support advocacy for
policies to ensure the availability safe abortions
and to reduce unsafe abortions
g. developing policies in collaboration with the
MOH, relevant professional organizations and the
district authorities to monitor and improve the
performance of private sector providers
h. initiating a staff development program that builds
the leadership, management, service delivery,
analytical and communication skills in the districts/
municipalities and the provinces to the level
required for the family planning program to
accomplish its objectives
Revitalization of Family Planning in Indonesia
1. Reformulate the Vision, Mission and Values
This is an essential first step in organizational
transformation, since it sets the course for everything
that follows. This process should be supported by data
and involve a wide range of staff in the organization as
well as outside stakeholders with vital interests in the
reproductive welfare of women. The process should
not be rushed, and should not be looked on as a forum
where various parties can justify their own interests. (An
outside facilitator can be helpful in this process.) Through
this process a new identity will be created for the BKKBN,
and it is likely that a change of name and structure will
emerge, though that is an issue beyond this consultancy.
2. Begin the process of building the core analytical
and technical competencies related to family
planning in the decentralized and mixed public
private system of governance that has emerged
since 1998.
The central government needs to take the lead in
promoting core competencies at all levels of government
and in both the public and private spheres. In particular
a central agency concerned with revitalizing
FP will need to harness the social and behavioural
sciences including disciplines such as demography,
sociology, anthropology, economics, political science,
communication and management (financial, personnel,
Revitalization of Family Planning in Indonesia
policy formulation, etc.). These skills are required to
analyse and interpret data being regularly generated by
a wide variety of external sources (including BPS, DEPKES,
BAPPENAS, DIKNAS, and Home Ministry) as well reports
from district/municipal and provincial level activities. These
analytical skills are crucial for development of strategies,
setting standards, monitoring program performance,
identifying program constraints, improving provider
performance, understanding how to effectively reach and
serve women and men with an unmet need for FP, and,
most importantly, for advocacy. The BKKBN has some
nascent skills in these areas, but lacks the breadth, depth
and focus to achieve the quantity and quality of work
3. Develop a senior leadership advisory structure
In order to gain the commitment of key stakeholders and
maintain a central agency charged with revitalizing the
family planning, reproductive health, and population
program on course, key stakeholders should be recruited
to advise on all major policy and programmatic decisions.
These stakeholders would be organized in practical
working groups and could include selected representatives
from: the central government including the Ministry of
Health, Ministry of Women and Development, Home
Ministry, BAPPENAS, and legislative branch members;
representatives from a number of local governments
representing a variety of cultural and economic conditions;
NGOs like IBI, POGI, PKBI, IDI; major research universities;
religious organizations; major representative private
enterprises (ideally led by women); and from the wider
society, e.g., the press.
4. Initiate leadership capacity building for
reproductive health and family planning in the
This must be a collaborative effort with the Home
Revitalization of Family Planning in Indonesia
Ministry, the Ministry of Health and the State Ministry of
Women’s Empowerment. This will ensure cooperation
with the Bupati and Walikota. Working together
through a network of training centres, coherent courses
in leadership and management should be developed
to teach the significance of family planning to overall
development goals, best practice methods to ensure
financial adequacy for service systems, and the techniques
for ensuring quality of care.
5. Strengthen the role and functions of the new
Offices/Boards of Family Planning and Women and
Development that have superseded the previous
BKKBN offices
In collaboration with the Ministry of Health, build the
planning, managerial and data analysis skills by providing
training, on-going technical assistance and routine two
way communication.
6. Promote initiatives to increase nationally and locally
the availability and accessibility of long acting
contraceptives – IUD, implants and sterilization –
to all couples.
The current program of contraceptive delivery gives
too many provider incentives for the use of injectables,
and too little support for vasectomy, implants and
tubectomy. Appropriate interventions to support long
acting contraceptives will require strong policies at the
central level, and effective financing and cooperation at
the local level. In particular attention will have to be paid
to health insurance schemes to ensure they cover long
acting contraceptives in their policies.
7. Formulate program policies and develop operational
strategies in collaboration with the Ministry of
Health to meet the critical service delivery needs
Revitalization of Family Planning in Indonesia
a. Reaching disadvantaged women including women
with an unmet need for contraception with
information and services
b. Engaging the private sector with training, technical
assistance and incentives to ensure that all women
can choose the contraceptive method best for their
life stage
c. Assuring that women are not forced to undergo
unsafe abortions, and that all women terminating a
pregnancy are provided with contraception.
Since this involves private as well as public service
delivery, this must be done in close collaboration with the
Ministry of Health, engaging professional associations,
government and private health insurance agencies and
the pharmaceutical industry (See ANNEX 3 regarding
the rationale for close collaboration with the Ministry of
Health.) Because this will no doubt require investments in
a major restructuring of provider incentives, any changes
should involve cost-effectiveness and cost-benefit studies
before being implemented on a wide scale.
8. A central agency charged with responsibility for
family planning and reproductive health should
place a high priority on monitoring public and
private program performance (from service
statistics and surveys) with interpretation and
rapid feedback to districts/municipalities.
9. Develop and promote national communication
strategies focusing on the major unmet needs and
unreached groups.
10. The agency should also test and introduce
innovations, primarily through grants to
universities, private organizations and NGOs as
Revitalization of Family Planning in Indonesia
This activity needs to be closely coordinated with the
Ministry of Health.
11. The agency should encourage districts/municipalities
to innovate and take other actions to strengthen
the program, primarily through “block grants”.
These grants must be based on action plans and budgets
that may be developed with technical assistance from the
centre and provinces.
12. The agency should conduct advocacy, nationally
and internationally, based on critically analysed
This will not only be for increased support for all
components of the family planning program, but also
for new policies to ensure that unmarried women and
women seeking to terminate a pregnancy can get safe,
confidential services without stigma.
Adjusting DHS Fertility for the Missing Single Women
Revitalization of Family Planning in Indonesia
When looking into the algebraic source for an adjustment it
is possible to achieve the same result in two distinct ways.
First we can solve for the missing single women, represented
in Table A1 as x.
Start with the basic entity that the proportion single in the
DHS (ds) in each age group can be represented as Ds/Dw
(Single women in the DHS divided by all women in the DHS),
for each age group. Then the proportion single in the DHS
population if all the single women were restored to both
the numerator and the denominator to achieve the same
proportion single as found in the recent census enumeration
(cs) gives us:
cs = (Ds+x)/(Dw+x)
Ds+x = (cs * Dw)+ (cs*x)
x-(cs*x) = cs*Dw – Ds
x(1 – cs) = cs*Dw – Ds
x = [(cs * Dw) – Ds]/(1-cs)
This calculation is shown for the two most recent DHS in
Table A1.
Revitalization of Family Planning in Indonesia
Table A1. Estimation of total number of women if reflecting recent census
based marriage patterns -- solving for missing single women:
2002-03 DHS Estimate
2007 DHS Estimate
by age
DHS single
by age
single in
age group
single in
age group
total DHS
Dw Ds ds cs x D'
15-19 6715 5735 0.8540 0.8927 2423 9138
20-24 6738 2776 0.4120 0.4312 227 6965
25-29 6302 870 0.1380 0.1667 217 6519
30-34 5844 345 0.0590 0.0695 66 5910
35-39 5349 160 0.0300 0.0349 27 5376
40-44 4704 99 0.0210 0.0241 15 4719
45-49 4170 83 0.0200 0.0198 -1 4169
All WRA 39822 10068 0.2500 0.2870 2974 42796
2007 DHS
by age
2007 DHS
by age
2007 DHS
single in
age group
single in
age group
2007 DHS
Dw Ds ds cs x D'
15-19 6849 5949 0.8686 0.9080 2936 9786
20-24 7040 2693 0.3825 0.5142 1908 8948
25-29 7156 1099 0.1535 0.1974 391 7548
30-34 6730 468 0.0695 0.0810 84 6814
35-39 6473 235 0.0364 0.0431 45 6518
40-44 5722 148 0.0259 0.0255 -2 5720
45-49 5127 96 0.0188 0.0197 5 5132
All WRA 45098 10689 0.2370 0.2879 5368 50466
Revitalization of Family Planning in Indonesia
An alternative approach suggested by Professor Peter
McDonald solves for the adjusted total population of women
in each age group rather than the number of missing women.
The numbers missing can be derived from the difference
between the recorded and the adjusted populations (Dw’ –
The basis of the calculation is the ratio of the percentage
ever married in the each age group of DHS population and
the percentage ever married in the census population. The
ratio of the absolute size of the recorded and adjusted
populations (Dw’/Dw) is assumed to be the same as the
ratio of percentages ever married: de/ce. To solve for Dw’ we
calculate Dw*(de/ce) as shown here:
2007 DHS
by age
2007 DHS
ever mar-
ried in age
2005 SUPAS
ever married
in age group
total 2007
DHS women
of missing
Dw de ce Dw' x
15-19 6849 13.1 9.2 9786 2936
20-24 7040 61.7 48.6 8948 1908
25-29 7156 84.6 80.3 7548 391
30-34 6730 93.0 91.9 6814 84
35-39 6473 96.4 95.7 6518 45
40-44 5722 97.4 97.4 5720 -2
45-49 5127 98.1 98.0 5132 5
All WRA 45098 76.3 71.2 50466 5368
Table A2. Estimation of total number of women if reflecting recent census
based marriage patterns -- solving for missing single women:
Dw’ =Dw*(de/ce)
Revitalization of Family Planning in Indonesia
Comparison with the bottom panel of Table A1 shows that
the same result is obtained for both the estimate of missing
women and the adjusted total number of women for the
2007 DHS.
Adjusting the fertility rates for
missing single women
The census based estimate of missing women allows the
reconstruction of age specific and total fertility rates for
the 2002-3 DHS. In the Main Report the method used for
calculating fertility rates indicates that:
Numerators of the ASFRs are calculated by summing the
number of live births that occurred in the period 1 to 36
months preceding the survey (determined by the date of
interview and the date of birth of the child) and classifying
them by the age (in five-year groups) of the mother at the
time of birth (determined by the mother’s date of birth).
The denominators of the rates are the number of woman-
years lived in each of the specified five-year groups during
the 1 to 36 months preceding the survey. Since only
women who had ever married were interviewed in the
IDHS, the numbers of women in the denominators
of the rates were inflated by factors calculated
from information in the Household Questionnaire
on populations ever married in order to produce
a count of all women. Never-married women are
presumed not to have given birth. (IDHS Main
Report, 2003:43)
In Table A3 the published age specific fertility rates and the
calculated numbers of women recorded in the Household
Questionnaire are used to estimate the annual number of
Revitalization of Family Planning in Indonesia
births for all women in 2002, assuming no decline in fertility
over the period 2000-2002. Then the annual fertility rates
are recalculated using the adjusted numbers of women who
should have been listed in the DHS Household Questionnaire
if the 2000 Census marriage patterns had prevailed for the
2002-03 DHS.
Where the 2002-03 DHS Main Report showed a TFR of 2.57,
adjusting the fertility rate for missing single women produces
a TFR of 2.35 for the three year period 2000-2002 (centred
on 2001). This is slightly below the trend line for census-type
own-child calculations of fertility.
A similar adjustment applied to the 2007 DHS using the
marital status distribution from the 2005 SUPAS produces a
TFR of 2.33 for the period from 2005-2007 centred on the
point estimate for 2006.
Revitalization of Family Planning in Indonesia
Table A2. Adjustment of ASFR and Total Fertility Rate for the 2002-3 DHS
and the 2007 DHS
Adjustment of 2002-03 DHS ASFR and Total Fertility Rates
Age of
Fertility rates
of 2002-3
DHS Final
recorded in
2002-3 DHS
Annual births
implied by
fertility rates
and number
of women in
adjusted for
2000 Census
marital status
2002-03 DHS
Fertility Rates
using 2000
Census based
estimate of
15-19 51 6845 349 9138 38
20-24 131 6422 841 6965 121
25-29 143 6134 877 6519 135
30-34 99 5484 543 5910 92
35-39 66 5127 338 5376 63
40-44 19 4361 83 4719 18
45-49 4 3500 14 4169 3
Total 37873 3046 42796
2.57 2.35
Adjustment of 2007 DHS ASFR and Total Fertility Rates --
Age of
Fertility rates
of 2007 DHS
Final Report
recorded in
2007 DHS
Annual births
implied by
fertility rates
and number
of women in
2007 DHS
adjusted for
2005 SUPAS
marital status
Fertility Rates
with 2005
SUPAS based
estimate of
15-19 51 6849 349 9786 36
20-24 135 7040 950 8948 106
25-29 134 7156 959 7548 127
30-34 108 6730 727 6814 107
35-39 65 6473 421 6518 65
40-44 19 5722 109 5720 19
45-49 6 5127 31 5132 6
Total 45098 3546 50466
2.59 2.33
2002-03 DHS Estimate
2007 DHS Estimate
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Contraceptive Prevalence Rates by Method,
WFS, CPS and DHS, 1976 - 2007
Revitalization of Family Planning in Indonesia
Official Program Methods 17.2 40.7 43.7 48.4 51.3 52.4 54.0
IUD 4.1 13.2 13.3 10.3 8.1 6.2 4.9
Pill 11.6 16.1 14.8 17.1 15.4 13.2 13.2
Injectable - 9.4 11.7 15.2 21.1 27.8 31.8
Implant - 0.4 3.1 4.9 6.0 4.3 2.8
Condom 1.5 1.6 0.8 0.9 0.7 0.9 1.3
Program Promoted but
Non-official Methods*
0.1 3.3 3.3 3.8 3.4 4.1 3.2
Female Sterilisation 0.1 3.1 2.7 3.1 3.0 3.7 3.0
Male Sterilisation 0.0 0.2 0.6 0.7 0.4 0.4 0.2
Traditional and Folkloric
1.0 6.0 2.7 2.7 2.7 3.6 4.0
Rhythm 0.8 1.2 1.1 1.1 1.1 1.6 1.5
Withdrawal 0.1 1.3 0.7 0.8 0.8 1.5 2.1
Traditional (Herbs or massage)
and other
0.1 3.5 0.9 0.8 0.8 0.5 0.4
Reported Use of Any
18.3 49.8 49.7 54.7 57.4 60.3 61.4
No Method 81.7 52.3 50.3 45.3 42.6 39.7 38.6
2007 DHS Estimate
Revitalization of Family Planning in Indonesia
Family Planning and Health Services – Synergies in the
Benefits, and Complementarities in Program Operations
Revitalization of Family Planning in Indonesia
A new agency concerned with revitalizing the Family
Planning program should not have direct responsibilities for
the managerial or technical aspects of contraceptive service
delivery, or more broadly, for women’s health. These rightly
rest under the jurisdiction of the Ministry of Health.
It would be appropriate to change the name of BKKBN along
with the change in mission, vision and activities.
Nonetheless there are powerful synergies of benefits to be
gained if women have full access to the resources of both
of these programs. There are clear areas where the two
organizations might intersect operationally. Therefore it is
essential that at the national, provincial and district/municipal
levels the health and family planning programs work in
harmony and close collaboration to maximize the benefits
for women and their families.
The rationale for this may be summarized in the following
key points:
1. A woman’s ability to control her fertility will have major
direct and indirect health benefits:
Direct benefits -
i. To her in preventing unintended pregnancies with
the health risks to her of an added childbirth or
even abortion
ii. To her child by avoiding births when she is too
young or too old, or when the interval is too short
or when there are other health contraindications
for a pregnancy.
Indirect benefits –
i. To her entire family if there are economic
constraints such that an additional child would
add a significant burden, threatening the nutrition
and health of other members
Revitalization of Family Planning in Indonesia
2. Conceptually, all preventive health services (e.g.,
immunizations, pre-natal care, maternity care, ORT,
nutrition, school health and dentistry, sex education,
hygiene) including family planning are fundamentally
social interventions supported by technologies – and
therefore all face fundamental demand and supply
constraints. Demand creation and quality of services
are equally important in reaching all preventive health
objectives. Like family planning, there is an “unmet need”,
since many mothers will not come for these services, even
when they are free. From this perspective, there should
be close collaboration among the staff of the health
and family planning programs, since their efforts will be
mutually reinforcing in serving the hard-to-reach clients.
3. Operationally, there are areas where the health and
family planning programs can be mutually supportive to
the benefit of the health and welfare of the mother and
her child. Using 2007 IDHS data, some of these areas
Antenatal care: 93 percent of women receive antenatal
care from a health professional. Asking these women
if this pregnancy was planned for this time (or if the
desire was for a later pregnancy or none at all, and if
so was there a contraceptive failure) would not only
be directly helpful to the provider in knowing how to
counsel the mother, but these data would also be a
powerful monitor of the effectiveness (or failure) of
the FP program.
Childhood immunizations: 85 percent of newborns
receive BCG vaccine and 81 percent receive Hepatitis
BA vaccine, 89 percent receive a first dose of polio at
around 6 weeks and 76 percent receive measles vaccine
at around 6 months. Since the post-partum mother is
present at these times, these can be critical periods to
Revitalization of Family Planning in Indonesia
discuss her need for birth spacing or limitation. At the
same time, children missing these vital immunizations
should be reached together by health and FP workers,
since these will likely represent much of the unmet
need for FP as well as health services, and thus are
more likely to have an unintended pregnancy.
Post-abortion care: This is a vitally important entry point
for BKKBN. Many women experiencing a complication
of an abortion (spontaneous or induced) will appear
in the health system for care. All of these women need
special counselling, and contraceptive services are
critical to prevent repeated induced abortions with all
the risks to women’s health and lives if this abortion
is the consequence of an untended pregnancy. The
MOH and BKKBN need to work together: first, to
develop and introduce standards and procedures for
post-abortion management; and second, to set up
a routine registration and reporting system so that
the magnitude of the problem, its underlying causes
and the consequences for the woman and the health
system are documented..
Contraceptive service statistics: BKKBN has a system
for routinely gathering statistics on the provision of
contraceptive services, but it is recognized to be very
incomplete. With decentralization, BKKBN has no
direct power to improve the situation. The MOH also
has an interest in collecting routine service statistics
on preventive services like ante-natal care, deliveries,
immunizations, etc. Since both of these systems need
improvement, and both agencies will need to work
through the decentralized system, it will be more
effective if they work together – and more efficient
for the provider who will not need to be completing
multiple reporting forms for different agencies.
Revitalization of Family Planning in Indonesia
Procurement and distribution of contraceptives: BKKBN
currently controls procurement of about 20 percent
of the national requirement for contraceptives –
ostensibly for the poor - and manages their delivery to
provincial warehouses. However, with decentralization
control of the distribution within the districts has
been lost. Since these “medical” commodities are
required by the service delivery programs, they are
technically under the control of the District Office of
Health and this Office is accountable to the Ministry
of Health. The Ministry of Health also has a much
larger logistics system in place to distribute preventive
health products (vitamins and vaccines to pregnant
women, immunizations and micronutrients to infants
and children) to essentially the same target group
of childbearing women. Given these realities, a new
operational system should be established in close
collaboration with the Ministry of Health. It will be
in the interest of both agencies to ensure complete
coverage, maintain quality of services and complete
reporting, and both agencies will need to learn how
to achieve this is a decentralized system. There will
be FP client groups that will not be reached by this
system – e.g., unmarried women, women who have
stopped childbearing, and most men. BKKBN will need
to develop innovative systems in collaboration with
districts to meet these needs, but the task will not
be any easier if BKKBN is “burdened” with a logistics
system that is really does not control at the district
Inclusion of all contraceptive services in health
insurance coverage. With the major shift of family
planning service from public to private sources it is
important to monitor the coverage of family planning
services by public and private health insurance policies.
It appears that some schemes do not underwrite the
Revitalization of Family Planning in Indonesia
costs of more expensive contraceptive options like
implants and sterilization. This is an issue requiring
collaboration between the central agency for family
planning and the Ministry of Health.
Revitalization of Family Planning in Indonesia
Thanks to the many individuals who generously gave their
time and shared their experiences
BKKBN for facilitation
UNFPA for support
BAPPENAS for collaboration
ANU for providing institutional collaboration and allowing
Professor Hull to join in the activity
Pak Eddy and Ibu Sonya, who shouldered the burdens of
and Suggested
Revitalization of Family Planning in Indonesia
Entwisle, Barbara (1989) Measuring the components of family planning program effort.
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... 14 Skewed contraceptive method mix and unequal access are still a problem in poor and developing countries. 13,15,16 A study in 2006 showed that 34 of the 96 countries studied had a mixed type of contraception that deviated (skewed). 17 A similar study by Bertrand et al. in 2014 indicated that 33 of the 109 countries had a skewed method mix. ...
... 3 This skewness, however, is thought to be the result of several factors, including lack of knowledge among acceptors about the method used, provider preferences for specific methods because the incentives received by providers for using the injection method are too high, and support and promotion for the use of vasectomy and implants. Moreover, tubectomy lacks 15 and limited access, make acceptors choose only available and affordable methods. ...
... 26 The deviation proportion of the contraception mix is the result of several factors, including acceptors' lack of knowledge about the method used, providers' preference for specific methods because the incentives for using injection methods are high, and support and promotion for the use of vasectomy, implants, and much less tubectomy. 15 The shift towards injection methods and the reduction in use of other methods, especially the IUD, had an unexpected impact because the injection failure rate was relatively high. 27 The IUD is the most effective method after tubectomy and vasectomy (Stephen Searle, 2014). ...
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Background: Indonesia's decentralization policy adopted in 1999 had implications for the programs of national ministries and agencies, including the family planning program. Since 1999, there has been a "relaxation in family planning program effort" since many districts have a low commitment to family planning. The trend of contraceptive mix in Indonesia leading to hormonal methods, especially injections, has occurred since 2007. This study aimed to describe the mixed conditions of contraception in Indonesia from 1997 to 2012 and explore the link between the availability of facilities and infrastructure with this plan. Methods: The quantitative research used was a cross-sectional design using secondary data from the Indonesian Demographic and Health Survey (IDHS), and In-depth interviews were employed as the qualitative approach in this study. It was found based on the results of the quantitative analysis that the trend of contraceptive mix tilted to the injection method. Results: The qualitative study results indicate that the contraceptive mix is affected by infrastructure as the main factor. Conclusion: In conclusion, there is a close relationship between the decentralization policy and the condition of the contraceptive mix. Thus, it is recommended that the central and local governments re-prioritize family planning programs and assure the availability of supporting facilities and infrastructure.
... In Indonesia, with the increasing proportion of women aged 35-49 and an increasing number of contraceptive prevalence rates (CPR), the estimate of female sterilization needs is around 28 million women. 2 However, in some patients who previously underwent female sterilization, due to several reasons they want to have children again. Accordingly, tubal reanastomosis is one possible way to conceive for women desiring fertility who previously underwent tubal sterilization. ...
... This method may be preferred especially in low-resource settings or in developing countries because of its cost-effectiveness and feasibility. 2 Tubal reanastomosis is a microsurgical technique to recanalize fallopian tubes after previous sterilization. This procedure involves a loupe or microscope for magnifying the tubes during reanastomosis procedure. ...
... In other words, the concept of family planning was reduced to birth control and, in turn, contraception. This view was reflected in the three broad objectives of BKKBN, i.e., (a) to expand the coverage of contraception following the targets of the government, (b) to promote continued use of contraception, and (c) to institutionalize family planning and small family norm concepts by shifting the responsibility for decisions about practicing family planning to the individual, the family, and the community (Hull and Mosley 2009). ...
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This article portrays how the Catholic Church in Indonesia in the 1980s faced some legal civil decrees that were contrary to Catholic beliefs, but they nonetheless responded in a wise manner. Since the Second Vatican Council, the Catholic Church has had a new outlook on the relationship between Church and State. As stated in canon 22 of the 1983 Code of Canon Law, the Church is willing to accept and observe civil law, as long as it is “not contrary to divine law and unless canon law provides otherwise”. There were three instances in which the Catholic Church in Indonesia had to deal with such controverting matters. The first was the divorce issue and the second was the enforcement of family planning. In both cases, the Catholic Church strongly opposes them. The third issue was the law on inter-religious marriage, which the State strongly prohibits, although the Catholic Church provides dispensation. The observation of the Indonesian Bishops’ Conference’s opinions shows that the Catholic Church were able to maintain good relations with the State because the bishops could apply the Catholic teachings in the Indonesian context and better distinguish the rights of being Catholic from the rights of being an Indonesian citizen.
... A possible explanation for these findings is that the decentralization of the FP program, as reported in Government Regulation No. 38/2007, resulted in various implementations in the provinces. The National Population and FP Board lost its jurisdiction over the provinces' FP program due to this regulation [27]. As a result, many regions are still unconcerned about FP programs. ...
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Background: Modern contraceptives are proven as the most effective birth control methods. However, it was a change in the pattern of modern method use in Indonesia to traditional. Objectives: This study investigated the pattern of contraceptive use and its determinant in Indonesia between 2007 and 2017. Methods: The study employed data from the Indonesian Demographic and Health Survey (IDHS) 2007, 2012, and 2017. Eligible participants included all women aged 15–49 who were married/living together with a partner. The dependent variable was contraceptive method use categorized as long-term, short-term, and traditional. Weighted pooled logistic regression analysis was applied to determine the shifting patterns of the independent variables related to contraceptive use over time. Results: The trend of contraceptive use in Indonesia has shifted over the three periods of the IDHS. During the three survey periods, contraceptive use was still dominated by short-term contraception, although over the last five years, the proportion has shown a decline of around 9%. Traditional contraceptive adoption followed the same patterns as long-acting reversible contraception (LARC), although having a smaller prevalence. Education level was significantly unassociated with the use of the traditional method at the beginning of the observation. However, more educated and knowledgeable women about contraceptive methods were more likely to use traditional contraceptives, switched from long-acting use following the next five and ten years. Long-term methods were no longer significantly more common among women in Java and Bali after five and ten years; the likelihood of using traditional methods in Java and Bali was growing. Conclusion: This study showed that contraceptive use and determinants were always dynamic over time. Therefore, family planning strategies and policies should adapt accordingly. Giving an understanding of contraceptive methods' benefits and risks through adequate method information is encouraged to prevent contraceptive dropout or switch to less-effective methods.
... The success and the declining quality of family planning in Indonesia The Indonesian family planning program has been considered successful in reducing fertility and maternal mortality. Within three decades of its initiation, from the early 1970s to early 2000s, the program brought the contraceptive prevalence rate from 5% to over 50%, and brought down the total fertility rate from 5.0 to 2.3 (Hull and Mosley, 2009). The program's success was related in part to international support and the government's strong commitment to family planning. ...
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The still stubbornly high maternal mortality ratio challenges Indonesia to improve health program strategies to achieve the Sustainable Development Goal 3.1 target of a maternal mortality ratio below 70 per 100,000 live births by 2030. Indonesia has already adopted maternal-neonatal health experts’ recommendation of four core program strategies to reduce maternal mortality: (1) family planning with related reproductive health services; (2) skilled care during pregnancy and childbirth; (3) timely emergency obstetric care; and (4) immediate postnatal care (WHO, 1996). These four core strategies would reduce maternal mortality through reduced high-risk births. To be effective, however, these four core program strategies require continued strong quality assurance and central and local government support to ensure program effectiveness yielded towards widely accessible, sustained, quality family planning and maternal and neonatal emergency services. This paper provides evidence for the importance of family planning to help health program strategies to accelerate maternal mortality reduction.
... Doctors, nurses, and midwives placed at the local level are encouraged to open their own private practices in the areas where they work. The KB village is expected to become an icon of the population, family planning, and family development (KKBPK) program and reach 14,838 current 11,22 . ...
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Background: The family planning program in some countries have not been successful yet because the population is growing rapidly. Currently, all the government is trying to provide family planning access in health facilities through the national health insurance program Aim: To compare the role of universal health coverage in supporting national family planning programs Method: This literature study had been made by data reviewing in four different countries which have large population: China, India, the USA and Indonesia. Using the indicator of involvement of UHC in family planning in several countries, there are advocacy and policy, health service, health financing and governance. It was compared the support of contraceptive policy and highlighted the program as a strategy for developing family planning in the national health insurance era Results: Policies related to the use of national health insurance for supporting family planning in several different countries produced different results. In addition to the aspect of finance, the policy on the number of children, the private and public service systems, the priority of contraception choice and family involvement also played a role in the success of the program Conclusion: The correct target program must be immediately determined by the government so it is important for policymakers to self-introspection related to family planning in this country by using the indicator of involvement of UHC.
... Muhammadiyah is thus contributing to the disproportionate increase in hormonal injections in overall contraceptive use in Indonesia caused by the ongoing privatization of family planning services and private providers' preference for one-and three-monthly injections as "an ideal way to lock in a flow of payments". 25 ...
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A case study of Muhammadiyah's Islamic charitable health services in the islands of Java and Sumatra, Indonesia, was undertaken in 2008, to assess the impact of privatization of health care on this socially-oriented service provider, especially in terms of access for the poor. Findings presented here relate primarily to the effects on Muhammadiyah's maternal and child health and contraceptive services. In order to survive and thrive amidst private and public competitors, Muhammadiyah's primary care units, mostly consisting of maternal and child health centres and maternity clinics, when not closed altogether, have been directed toward providing curative hospital services, and more expensive and sometimes unnecessary treatment. A shift in the patient population away from the poor has also occurred, as market pressures transform this charitable enterprise into a commercial one, prejudicing reproductive health care and reducing access for those most in need. An improved stewardship role by government is needed to regulate the private sector, along with serious thinking about the future of primary and preventive care and health promotion, including for comprehensive reproductive health care. The neglect of these core primary care elements in Indonesia may worsen as privatization proceeds and profit considerations become more pressing with increased competition. Résumé Une étude de cas des services de santé caritatifs islamiques de Muhammadiyah sur les îles de Java et Sumatra, Indonésie, a évalué en 2008 l'impact de la privatisation des soins de santé sur ce prestataire de services à vocation sociale, en particulier du point de vue de l'accès des pauvres. Les conclusions présentées ici concernent principalement les retombées sur les services contraceptifs et de santé maternelle et infantile de Muhammadiyah. Afin de survivre face à des concurrents privés, les unités de soins primaires de Muhammadiyah, consistant essentiellement en centres de santé maternelle et infantile et en maternités, quand ils n'ont pas été tout simplement fermés, assurent désormais des services hospitaliers curatifs, et un traitement plus onéreux et parfois superflu. La population de patients a aussi changé pour compter moins de pauvres, alors que les pressions du marché transforment cette łuvre caritative en entreprise commerciale, nuisant aux soins de santé génésique et réduisant l'accès des personnes qui en ont le plus besoin. Les pouvoirs publics doivent mieux jouer leur rôle d'administrateur afin de réguler le secteur privé; il convient aussi de réfléchir sérieusement à l'avenir des soins de santé primaires et préventifs et de la promotion de la santé, notamment pour des soins génésiques complets. Le désintérêt pour ces éléments centraux des soins de santé primaires en Indonésie pourrait s'aggraver avec la poursuite de la privatisation et la recherche plus pressante du profit face à une concurrence accrue. Resumen En el año 2008 se realizó un estudio de caso de los servicios sanitarios benéficos de Muhammadiyah Islámico en las islas de Java y Sumatra, en Indonesia, con el fin de evaluar el impacto de la privatización de los servicios de salud en este prestador de servicios con conciencia social, especialmente con relación al acceso para las personas pobres. Los hallazgos presentados aquí están relacionados principalmente con los efectos en los servicios de salud materno-infantil y anticonceptivos de Muhammadiyah. A fin de sobrevivir y prosperar entre competidores privados, las unidades de atención sanitaria primaria de Muhammadiyah, la mayoría centros de salud materno-infantil y clínicas de maternidad, cuando no son cerradas, han sido dirigidas hacia proporcionar servicios curativos hospitalarios, así como tratamiento más costoso y a veces innecesario. Además, la población de pacientes se ha desviado de las personas pobres, a medida que las presiones del mercado transforman a esta empresa benéfica en una comercial, perjudicando los servicios de salud reproductiva y reduciendo el acceso para las personas más necesitadas. Es necesario que el gobierno desempeñe un mejor papel administrativo para regular al sector privado y que piense seriamente en el futuro de la atención primaria y preventiva y la promoción de la salud, incluso para los servicios de atención integral a la salud reproductiva. El descuido de estos importantes elementos de la atención primaria en Indonesia podría empeorar a medida que continúa la privatización y que las consideraciones de ganancias se vuelven cada vez más apremiantes según va aumentando la competencia.
With massive support from international organisations, Indonesia has been one of the fastest-growing countries with the highest enrolment increase in Early Childhood Education (ECE). The rapid scaling up is known to be primarily supported by women. Unfortunately, the impacts of ECE on women remain under-recognized. On the community side, the early learning approach perpetuates the governmentalization of women and stigmatizes child-rearing done by low-income mothers. Meanwhile, on the side of policy, the ECE expansion program has mobilized and recruited women to serve as teachers and managers with meagre earnings and low-quality work conditions. At a glance, these practices may appear to be rooted in local social norms, disconnected from international organizations’ roles. However, In this article, I argue that, by turning a blind eye, international organizations have thus contributed to the re-traditionalization of women’s care work as unpaid labour and instrumentalization of middle-class caring values that turn poor women’s mothering into the practices of “Others”.
Preliminary results from a study of family planning program effort in 93 developing countries indicate that family planning programs can contribute substantially to increased contraceptive usage and declines in fertility. Questionnaires were used to rate countries on 30 items grouped into 4 components: policy and stage-setting activities service and service-related activities recordkeeping and evaluation and availability and accessibility of services. The countries with the highest program effort scores out of a possible 120 for 1982 were China (101) Republic of Korea (96.9) Singapore (95.3) Taiwan (92.6) Indonesia (87.1) Colombia (85.3) Mauritius (84.6) Hong Kong (82.6) and Sri Lanka (81.6). 4 countries--Kampuchea Laos Libya and Mongolia--had scores of 0. Unweighted mean program effort scores by region were 55 for South and East Asia 46 for Latin America 24 for the Middle East and North Africa and 18 for Sub-Saharan Africa. Of the 9 countries that improved their program effort scores by 25% or more in 1972-82 7 are in South and East Asia or Latin America. 18 countries (including Brazil China Colombia Indonesia Thailand and Turkey) had declines in their crude birth rates of at least 25% in the 1965-80 period and an additional 16% had declines of 10% or more. However no significant fertility declines occurred in Sub-Saharan Africa or in most of the Arab and Muslim countries. Contraceptive prevalence in the 74 countries for which data were available ranged from 0-80% with an average of 26% of married women of reproductive age. The birth rate declines and contraceptive prevalence increases in an orderly manner as program effort and socioeconomic setting improve. The article concludes with case studies of countries representing each of 3 program effort categories: Colombia (strong) Malaysia (moderate) and Kenya (weak). It is suggested that the collection and analysis of program information can help program administrators government and private sector policy makers and donor agencies to improve program perforance. Final study results will be available in a forthcoming World Bank monograph. (summaries in ENG SPA FRE)
The Indonesian family planning program has attained field success through implementation strategies centering on communities and clients. It seeks to make communities favorably disposed to family planning, persuade clients, provide adequate medical support, and maintain strong pressure for results. Quantitative data from 48 villages show that such strategies have been effective means of promoting and maintaining contraceptive use. The program now has problems in developing quantitative measures of its success, in balancing external influences on clients with free choice, in deciding how much pressure to exert on other government agencies, and in maintaining the commitment of local implementers. A question for the future is whether Indonesia will maintain the strong support it has shown for this program since 1970.
The Indonesian Fertility Survey (IFS) was conducted in the 5 provinces of Java and the province of Bali in 1976 as a part of the World Fertility Survey. The IFS results compared with results from the 1971 population census and the 1973 Fertility-Mortality Survey provide the means for assessing changes in fertility and contraceptive use as well as program impact from the late 1960s to 1976. The decline in the crude birthrate using the IFS results is about 11% between the late 1960s and 1976 (from 38 to 34) again with the largest drop in Bali and no decline in Yogyakarta. More than 1/2 of the decline in the birthrate (and more than 3/4 of the decline in Bali and Jakarta) occurred after 1972-1973. Marital fertility over the 1960-1976 period declined for women in each age-group over 25 while increasing among younger women. The decline among older women is consistent with patterns of fertility decline found in other developing countries. For the sample as a whole the family size at which a majority want to stop childbearing is 3.4 children. There was a substantial increase in knowledge of contraception over the 1973-1976 period. In 1976 75% of of ever-married women knew of a method dispensed by the national family planning program (oral contraceptive IUD condom). 54% of currently married respondents to the 1976 IFS indicated that they knew of at least one place or person they could visit to obtain contraceptives. Among currently married women aged 15-44 there was a tripling or near tripling between 1973 and 1976 in ever-use of contraception (from 12% to 39%) in current use (from 11% to 28%) and in use of modern methods (from 9% to 23%). The use of OCs IUDs and condoms offered by the program more than doubled (from 9% to 21%).
This report surveys fertility trends in Asia since the mid-1960s, focusing on 24 countries that together account for 3.1 billion, or 56% of the world's population. Asian fertility has declined overall by 39% or 62% of the decline necessary for reaching the population-replacement level of 2.1 children per woman, and contraceptive use has risen sharply throughout much of the region. By 1990 nine out of 10 Asians were living in countries where fertility had fallen by at least 25%. Although fertility rates and contraceptive use vary widely within the region, three out of four Asians today live in six countries where fertility rates range from 4.5 to 2.1 children per woman and nearly two-thirds of married couples, on average, practice contraception. The report considers three factors usually believed to account for these astonishingly rapid changes in reproductive behavior: mortality decline, broad social and economic development, and effective national family planning programs. An assessment follows of the current demographic situation, the role of those three factors and of alternative plausible pathways for reducing fertility, and likely future fertility levels in individual countries and subregions. -from Author
About this series... This series is produced by the Health, Nutrition, and Population Family (HNP) of the World Bank's Human Development Network. The papers in this series aim to provide a vehicle for publishing preliminary and unpolished results on HNP topics to encourage discussion and debate. The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations or to members of its Board of Executive Directors or the countries they represent. Citation and the use of material presented in this series should take into account this provisional character. For free copies of papers in this series please contact the individual authors whose name appears on the paper. Enquiries about the series and submissions should be made directly to the Editor in Chief Alexander S. Preker ( or HNP Advisory Service (, tel 202 473-2256, fax 202 522-3234). For more information, see also
Fertility trends in Indonesia for the period 1967-1985 are analyzed. Data are from the Indonesian censuses of 1971 and 1980 and from the 1985 Intercensal Survey (SUPAS 85); they concern fertility rates by province, marital status, and for the general population. An overview of the sociocultural factors that affect data reliability and a discussion of the effectiveness of the date of last birth method are included. The authors conclude that the evidence "has confirmed the existence of a major fertility decline throughout Indonesia. The pace of the decline has been faster in 1980-85 than during the 70s. On present trends, it should be possible to reach the ambitious target of halving fertility between 1979 and 1990."