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One of the efforts, which has been carried out to empower the elderly in Indonesia, is building posyandu (The Integrated Service unit) for the elderly in four general hospitals in Central Java through community-based development project over the elderly in Parakan-Semarang-Klampok (PPLM-PSK). This project is a community-based pilot project intended to empower the elderly and its goal is to improve the life quality thoroughly. The project is expected to run for 3 years and at the present it already reaches the end of the third year. The four general hospitals, which are then known as centers and serve the public concerning with consultation, supervision, facilities providers and coordination and building posyandu for elderly are as follows:
(1) Ngesti Waluyo Hospital, Parakan
(2) Panti Wilasa Dr. Cipto Hospital, Semarang
(3) BKK Taman Brantas clinic, Semarang
(4) Emanuel Hospital, Klampok
In the succeeding parts of this feature, the existence of PPLM-PSK since the beginning up to the present will be elaborated with the following orders; the first parts will deal with the brief explanation of PPLM-PSK’s success. The second part discusses the idealization context of community groups or the perception of primary and secondary groups. The third part explains the activities, which are intended to promote people’s participation in the activities held by PPLM-PSK. Then the fourth part elaborates the social exclusion – which is differently interpreted especially on how social exclusion is carried out. The fifth part covers PPLM-PSK in personal context – even though it is only a little – in more meaningful life context.
(1)
On the whole PPLM-PSK has managed to build 35 posyandu for the elderly and 8 posyandu out of project initiation (35 posyandu in the previous evaluation) in which those posyandu hire at least 85 cadres (only 70 cadres in the previous evaluation) taken from the people around posyandu to run the activities. In their day to day operation, posyandu runs the activities such as providing medical services (blood pressure test, medication), providing food supplements, other activities intended to improve the elderly people’s economic condition and also providing aids. The last two activities have not been carried out by all posyandu yet. Posyandu Dewi Kunti (BKK Taman Brantas Clinic) already provides aids while the activities to improve the elderly people’s economic condition such as envelope making which is carried out by Posyandu Dewi Srikandi (BKK Taman Brantas Clinic) has already stopped. Posyandu Mawar and Posyandu Ngudi Waras I (both are under Ngesti Waluyo Hospital which serves as a center) also run economic activities such as raising goats. However, the activity of raising goats in Posyandu Ngudi Waras I has already stopped due to the fact that this activity is not suitable with the culture and the needs of community.
If viewed from the perspective of life quality, there is a quite positive correlation between activities carried out by posyandu for the elderly and the life quality of the elderly who become the project’s participants. The results of quantitative evaluation shows that most of the elderly who become the project’s participants feel that their lives are more enjoyable, they enjoy the life better, and their lives are more meaningful either for themselves or for others. Besides, most of them still have the ability to concentrate, have opportunities to have funs, feel satisfied with their daily lives, gain supports and families and also have stamina to do the activities.
However, if viewed from the medical aspects there are some facts, which need further intervention. Most of them suffer from pains in which the pains may disturb their daily activities. Besides, a lot of elderly people have a great dependence on drugs, do not enjoy their sleeps and tend to have bad feelings such as anxiety, sadness and bad mood.
The result of process evaluation shows the following points. Firstly, the elderly people’s participants in posyandu is quite high. At the beginning, the high participants of the elderly indicate a good starting point for the process of empowerment in the future in a wider perspective. Secondly, the service of posyandu for the elderly can be carried out at the continued routine level, meaning that the supports from the cadres’ work performance and centers towards the service activities at posyandu for the elderly in community give positive contribution. Thirdly, the service activities in posyandu still tend to be dominated or perceived with medical services. This tendency leaves the doctors’roles very significant and places the centers in a strong position. In this case, the position of cadres (which indirectly represents the community) is conditioned in the position, which is dependent upon doctors and centers. Fourthly, the socialization tends to be carried out at the beginning of the project and has not become a part of empowerment aspect in a wider context; in the process to improve the life quality of the community. Fifthly, the coordination and communication among stakeholders in order to draw social supports to ensure the continuity of the program in the community have not been carried out optimally. Sixthly, the organization of posyandu for the elderly in the community seems to be weak. On the other words it does not have a strong organizational structure yet in the community level. Seventhly, the supervision, coordination, and evaluation between the centers and the program executors in the community level already works even though it tends to be informal and has not used good instruments of supervision and evaluation yet.
Sociologically PPLM-PSK is a product of modern community that places a group of the elderly into a direct targeting group of the development activities. One of sociological maxims says that if the members of the community are tied up in a quay with common assumptions about the world where they live, the moral unity will surely be reformed through it. Without this kind of quay, any kind of community – be it modern or primitive - will lead to decadence and damage, since the community will be trapped into an unprotected existential crisis. At least it begins with the weakest aspects of the community.
If the maxim is true in the level of operational context of empowering the elderly, consequently Indonesian community as a transitional community should start to build that paradigmatic assumption. Our community benefits from the fact that several members of the community are called – a term which sounds prophetic – to be pioneers and to start running the activities which are considered new among the people in the community. The initial idea of PPLM-PSK is initiated by two doctors, Timotius Widyanto and Oei Kiem Hien, and then followed up by a strategic group, which begins to run that great job. PPLM-PSK is initiated by this kind of group in which it then turns to be the so called a center. PPLM-PSK is evaluated on how far it manages to develop itself and focuses on the community-based activities. The answers can be simply positive or negative statements. We will view it as a variation from both opposites through the description on how PPLM-PSK meets the levels as the community-based project. It will show how far the activities to empower the elderly are socially functioned.
Folded Corner: Has PPLM-PSK been initiated by considering the needs and the interests of all parties?
Those who get involved since the beginning of PPLM-PSK will surely understand how far this project is initiated by considering the needs of the community. The project executors are of course not the ones who merely create new needs for the community as the same manner as, for instance, certain industrial exponents create new products to sell and distribute. The empowering efforts require substantial needs of community which are latent and actual and those needs are to be brought into reality in order to improve the life quality and the quality of community’s work.
In the efforts to improve the community’s life quality and work, empowering the elderly seems logical – it is also supported by personal consideration, that is to make the life more meaningful. The problem rest on how far the awareness among community is promoted by the project executors before and during the project.
In several posyandu there is a tendency that the needs of community are perceived in a limited meaning and simply indicates an economic aspect. Hence, several posyandu run economic activities for the elderly, aiming at adding an-sich income. As manpower which has reducing productivity, the elderly who work in certain economic activities (such as making envelopes and raising goats) are certainly against efficiency principles. Those kinds of economic activities will only be significant if they are not intended to add an-sich income, but to improve the meanings of life instead. The chance to bring it into reality is still open considering the fact that the elderly are the ones who posses a lot of experiences in life. Those experiences can serve as a means, for instance, to get involved in the societal activities.
The most crucial and best activity to promote awareness among people in the community is by socializing the essence of PPLM-PSK, in which it is to empower the elderly. While the most effective way of socializing it is by proving that this project is really able to empower the elderly.
Folded Corner: Have the benefits of the work among groups in PPLM-PSK exceeded its cost?This calculation is necessarily applied even though all organizers work voluntarily and what they usually do is attending meetings, having interviews or doing other activities without gaining financial compensation. The advantage measured is not always an economic benefit (savings, increase on productivity, income and the saved time to do certain activities) but also political benefits (a bigger access in decision making, less possibility of conflicts, addition on responsibility and rights) or instrumental benefits (the ability to solve the problems together, increase on the knowledge and skill capacity) or psychological benefits (the increase on meaningful life, meaningfulness), a sense of belonging, enthusiasm to help each other and sense of brotherhood).
Even, the economic benefit seems to be more trivial if compared to other benefits mentioned above. It, however, turns out to be a significant point: for the elderly, economic consideration is viewed as a “finished” activity. Therefore if viewed from the philosophy of PPLM-PSK, the economic activities in several posyandu can be contra-productive.
Folded Corner: Have the activities of PPLM-PSK been integrated into the social structure in the community?
The basic idea behind this point rests on the consideration of the continuity of the activities after the project is over. If the project is only measured by the period of supervision or facilities providing from the centers and then freed without institutionalising it to the community, the activities then will fade away in a short time. The efforts to put the paradigmatic principles as elaborated above will also fade away.
The problem rests on the fact that the institutions and social structure in the community are possibly unclear, and/or putting women and the poor away from taking part in the activities. During the project of PPLM-PSK, it may be already institutionalized so the first possibility may not happen but the second and the third possibilities should be taken into account carefully.
The new ways to get the women (and the poor) involved in the activities should be found in the community, either from the elderly (for the members of community) or for the elderly (from the members of community). One of the ways which is so far not promoted yet in PPLM-PSK – even though medical aspect is already dominant in the activities of posyandu for the elderly – is “women to women services” towards the children and parents’ health. It is called “women to women services” but it is not intended to overlook the men at all but to make women’s roles more focused, considering that the women are also the agents of change and not merely the recipients of benefits of any development activity.
Folded Corner: Have those groups had rules, which should be obeyed by the members of the community?The most important point here is the existence of rules on how the community’s participation is managed, regulated and promoted. The rules are not the ones pushed by the power from outside but the members of community should formulate the rules themselves. It is to ensure the sense of belonging and also serve as a kind of a learning process.
Folded Corner: Have the groups in Posyandu for the elderly already had capacity, leadership, knowledge and skills to solve the problems?This item is also one of the requirements to lead to success and continuity of the activities after the project is over. Observers may not feel worried about the existence of PPLM-PSK in the future, if this point is the only matter, considering the fact that this fifth item is only instrumental as long as the preceding items are completed.
(3)
From its name, PPLM-PSK is designed to be owned by the community in which it is indicated by real participation from the community.*
PPLM-PSK faces a problem since this project is initiated by the ones who pioneer it; the people who are called to do so and then they introduce it to the community as a package from outside. And of course it covers charity content, which is inherent to it. It goes with saying since the vision and mission and hopes to build a hospital and clinics as social service centers in which their work is intended to serve community.
Directly or indirectly the project design has tried to use the strategy to “promote participation of the community”in the implementation of PPLM-PSK, as problems elaborated below.
Stakeholders’ Involvement
The participation can be varied in forms such as workshop or discussion before the implementation of the project, coordination with government officials from central and local offices, non-government organization (NGO), profession organization including IDI (Indonesian Doctor Association), universities and the related community’s representatives. The quality of stakeholders’ participation in community-based project actually depends on how far the community’s representatives are involved. Having a characteristic as a prepared project outside the community, PPLM-PSK has not done optimally to get the community’s representatives involved.
Consultative Activities
It is, of course, impossible to get all people involved in the decision making process in a certain project such as PPLM-PSK. If that is unavoidable, the principle to “promote the participation of the community” suggests that the plan of the project should use a survey method, estimation of benefit takers, and consultative meetings with all prospective clients. The problem rests on the fact that the surveys and assessments tend to be more project-oriented than client-oriented due to some factors – especially because they are analytical (they are not carried out in the field) in which it publishes what is called by external expert stand. PPLM-PSK will surely be difficult to be free from those things.
Structured Learning
This item is directly related to what is going on in the field (in posyandu for the elderly). The opportunity for learning is open as long as the members of the community is actively involved in learning by doing, experimentation on various models of problem solving and conducting monitoring and evaluation. The quality of the learning depends on how far the opportunity for learning is open for the people, including doing controlled trials and errors-especially for non-medical activities. Otherwise, the malpractice may happen. PPLM-PSK has done it quite well and it is expected to be implemented better in the future.
Pilot Project Implementation
PPLM-PSK is actually a pilot project. Therefore it should collect inputs optimally – especially in posyandu for the “advanced” elderly. That as a project, PPLM-PSK is (nearly) over is an unquestionable fact. In the future PPLM-PSK will face a real challenge: Will PPLM-PSK be able to develop continuously after collecting inputs and learning from the past experiences in posyandu for the elderly? Or posyandu for the elderly will collapse or will not be able to develop?
(4)
As what is going on in developed countries, the elderly –due to their natural condition which is unavoidable –belongs to sub-population which offers problems along with the increasing figure of life expectation and public health. The one which needs a particular attention is the continued social impact due to the decreasing productivity and generative aspect of the elderly; the so-called social exclusion.
The fact shows that the social exclusion is predominantly related to poverty. This is the first economic aspect of four aspects of social exclusion. Even though in some situations social exclusion is a cause, in general social exclusion is an effect of poverty. Those who are unemployed and whose income is decreasing due to the old age are usually excluded from the main economic activities and even in some cases they do not have any access anymore to get financial credits and possessions. Then what happen to the elderly who are so poor and unemployed or who do not have take-home pay such as a pensionary salary?
The next aspect is a social aspect. Those who are unemployed (due to old age) not only have less income (or no income at all) but also experience decreasing social status, which may have happened slowly for a long time year by year. Another problem rests on the fact that the people in the community still have fresh memory about the condition when those people (the elderly) were in their productive age. As a result there will be a drastic fall in terms of productivity, life standard or life styles (psychologically it is called post-power syndrome).
The third aspect is political in which it is related to the discrimination over the population structure, especially when the description mentioned above is for the “minority”situation which covers women (sexually minority), ethnic, race or religious groups. What will happen to the elderly from that minority domain?
The next aspect is related to what is called by a paradox of “continued development pattern”where the social activities and development are only intended to compromise with things related to generation perseverance and also things which are suitable and profitable and may last for a long time under the development measurement. The aspects out of this, including the elderly who do not meet this requirement, will be easily neglected.
(5)
The aspect of social context is proved to be in line with the individual clients of PPLM-PSK and the clients are the elderly. When the client experiences social-exclusion, he or she will surely loose the life meaningfulness. It will be a tragic when social exclusion occurs due to some aspects together: old women who are poor, uneducated and have no relatives and suffer from illness and have a minority religion amid the people in the community.
In this evaluation the life meaningfulness, due to various factors, is analyzed in a limited scope even though there are some quite accurate general conclusions about the clients’condition of PPLM-PSK. The evaluation finds out that:
C 20% of client respondents feel that their lives are very enjoyable,
C 3% of them feel that their lives are terrible.
At the other time, using a quite different test tool, it is found out that:
C 35.9% of respondents feel that they can enjoy their lives,
C 12.5% of them state that they do not enjoy the lives much.
It is reasonable that 35.9% of respondents who enjoy the life are parts of those who feel that their lives are enjoyable (20% of respondents). On the contrary, nearly 12.5% of respondents who do not enjoy the lives much overlaps with 3% of respondents who feel that their lives are terrible. These two categories reflect the level of life meaningfulness experienced by the respondents if we assume that there is a positive correlation between the enjoyable life and the meaningful life.
If viewed from the achievement of life meaningfulness by the respondents, PPLM-PSK has not managed that optimally. Or in the other words, only 25% of respondents state that they have achieved the life meaningfulness. At the same time, it should be realized that those who manage to achieve the life meaningfulness is not always the results of PPLM-PSK’s roles. It is believed that some of the elderly manage to achieve the life meaningfulness after they go through other processes and ways including through art, societal, religious activities – eventually they realize that those ways are roads to go closer to God.
* Participation is a term, which needs to be clarified to make it more operational. Hence, the following definition taken from OECD-CSOPP, Empowering People A guide to Participation (mimeograph) should be used:
1. By considering the development in the villages…participation covers people’s involvement in making decisions, in implementing the programs, in their roles in the benefits of development programs and in their involvement in evaluating those programs (Cohen & Uphoff 1977);
2. Community participation is an active process from which the benefit takers or client groups affect the direction and decision making of the development project in the efforts to improve their life condition in terms of income, self-development, self-confidence or other values they believe (Paul 1987)
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