An integrated sociocultural curriculum f

Sm. SC;. Med. Vol. 23, No. 7. pp. 673-682, 1986

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AN INTEGRATED
SOCIOCULTURAL
FOR COMMUNITY MEDICINE
INDONESIA

% 1986 Pergamon Journals Lrd

CURRICULUM
IN BALI,

LINDA H. CONNOR’ and NICK HIGGINBOTT-IA$
‘Department of Sociology, University of Newcastle, Newcastle, N.S.W. 2308, Australia and
*Social Sciences Division, University of Hawaii at Hilo, 1400 Kapiolani Street, Hilo, HI 96720, U.S.A.

Abstract-Since
1983, social scientists have collaborated with teaching staff at the Faculty of Medicine,
Udayana University, Bali, Indonesia, to develop an integrated sociocultural curriculum for undergraduate
students in community health. The Udayana curriculum is discussed in the context of an international
commitment over the last two decades to appropriate education for primary health care and community
health in developing countries. The authors describe their work as consultants with Udayana staff.
Participants formulated a five-stage project of curriculum development and community health research
that could be continued as part of an ongoing community medicine teaching program. Recommendations
for integrating social science perspectives within medical domains are outlined, based on the project
experience. The paper also discusses the undertaking as a ‘development project’ suggesting that many of

the issues and problems that arose are common to bureaucratic institutions in Third World countries when
development projects are initiated.
Key words--Indonesia,

community medicine, curriculum

IMPLICATIONSOF THE PROJECT

few examples exist for health science students of
either social scientists with strong clinical interests or
Recent collaboration between social scientists and
clinicians trained in social sciences. As a consequence,
teaching staff at the medical school in Bali, Indonesia
the clinician’s image of social science is one of an
atheoretical technology to be narrowly applied to
produced a curriculum that addresses the basic question of how social science concepts can contribute to questions of methodology and statistics. It is evident
medical education. In November, 1983, anthropology
to social scientists, however, that medical students
denied the opportunity for exposure to discourse on
and medical faculty of Udayana University together
with the authors, met for the first time to develop a
basic conceptual questions in social science will not
sociocultural curriculum integrated with the commube able to think critically about social issues or
nity medicine component of medical instruction. By achieve a reflexive view of their own work.
George Foster has challenged social scientists to
situating instruction in community settings, this curriculum has the potential to reformulate medical
apply their research efforts in medicine and in international health programs in order to help find solustudent education, equipping the students to comprehend village health issues with the broad undertions to pressing health problems. Foster argues that
standing of a medical ethnographer. In practical

health bureaucracies should occupy a large part of
the social science research effort. Because Third
terms, the curriculum seeks to generate educational
experiences that develop young medical graduates’
World governments typically channel considerable
abilities to better survive the hardships of their
resources through these institutions, it is necessary to
mandatory rural polyclinic service, while at the same
understand the ways in which health bureaucracies
time preparing them to offer a quality of care more
function, as well as the selection, training and work
appropriate to rural populations.
situation of health service personnel [2]. Social
At a more genera1 level, the collaboration
of
scientists can help improve health education by
anthropologists and physicians set in motion a test of
demonstrating to educators exactly how a knowledge
the relevance of the social science perspective zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGF
in and

of prevailing health beliefs and practices must be
ofmedicine. Recent reviewers of social science within
the starting point in planning and health education
medical education and health delivery have issued
campaigns [2, p. 8521. Foster urges social scientists to
sobering judgements of past failures and future chalwork as participant observers within interdisciplinary
lenges. For example, Arthur Kleinman has analyzed
health teams. Thus the researcher will acquire
reasons for the marginality of social sciences in
knowledge of two sociocultural systems: the client
medicine despite their obvious relevance [ 11. Primary
community and health care services.
among these is that medical practitioners are socialAnother issue raised by this curriculum developized into a cultural epistemology based upon molment endeavour is the effect of initiating a developecular biology and reductionism which dismisses as
ment project, where there is a temporary injection
of funds and personnel into a preexisting system of
irrelevant the social and psychological sources and
consequences of disease. Kleinman points out that
institutional relationships. What changes does a de673

674

LSD& H. COSSORand NICK HIGGINBOTHAM

velopment project set in motion. and do the beneficial
effects outweigh the more deleterious? !vlany of the
problems encountered in implementation
of the
Udayana project bear on this issue.

A MODEL FOR INTEGRATING
SOCIAL SCIENCE AND
MEDICINE IN CO~IML’ZIITY HEALTH TEACHING,
RESEARCH AND DEI’ELOPMEST

The project grew out of a desire by the authors to
implement a general educational model that addressed issues of rural health needs. For almost two
decades, international planners have promoted primary health care and community health as the means
by which poor, isolated and hitherto neglected rural
populations could be provided with more equitable
forms of health care. Themes of what became known

as the primary health care and community health
‘movements’ include cultural sensitivity to local community problems and concerns, a more equitable
distribution of health resources. and an emphasis on
active participation of rural populations in the health
care process, as well as the integration of health care
with other arenas of community development.
As attempts to realize some of the ideals of the
‘new’ health care have foundered or failed, a body of
literature critical of extant practices in implementing
the new approach has emerged. Problems have
emerged in every area of planning and implementation, not least being the difficulty of shifting the
orientation of health care providers who are dominated by concepts of clinical professionalism and the
mastery of narrowly defined technical skills. Considerable effort and expense has been expended on the
training of health ‘auxiliaries’ who are seen as the
linchpin of the system. Much less attention has been
lavished on the education of physicians whose vocations will be transformed if the new health care ideals
are realized. In a recent survey of health educators in
south and southeast Asia, one WHO consultant
observed that:
many health educators believed that villagers had false

health notions, and that their task was to impart true and
scientific knowledge to “ignorant villagers”
. Many health
educators and other kinds of personnel.
were surprised
when the Consultant mentioned that it was necessary for the
health educators to be “educated” in the health beliefs of the
people he is expected to serve. The idea that the health
beliefs of the people may be rational and oftentimes practically sensible was not favorably received
Very few
attempted to use the existing health beliefs in a creative
manner, to subtly change what was obviously and readily
harmful to health, and encourage the more positive aspects
of popular health beliefs and nutrition [3].

What is missing in these circumstances is the
concept of education as a ‘dialogic process:’ a creative
horizontal exchange of ideas and practices between
all parties involved [4]. The precepts of professionalism encourage the view that there should be a oneway transmission of skills from the expert to the
layperson. Training for health professionals such as

doctors and nurses is usually constituted so that there
is minimum opportunity for dialogic contact with the
culture of the potential patient population. The widespread ignorance of and intolerance about indigenous
health beliefs and practices does not bode well for the

hoped-for promotion of community participation
that policymakers, administrators and professionals
endorse.
The fieldwork experiences of the authors, as
anthropologist and community psychologist respectively, bore out other accounts of the problems village
residents experience in their dealings with formal
health care systems. Generally, delivery of health
programs is shaped by the exigencies of professional
and administrative bureaucracies, as well as national
political and economic pressures, rather than by the
concerns of local residents. Dissatisfaction and wariness of villagers toward formal care is associated with
the absence of ‘culture accommodation:’ services are
insensitive to the culturally patterned meaning of
illness, its remediation, and health management
within families and villages [j].

Connor observed during fieldwork in Bali (1976
1978) that representatives of the health bureaucracy,
such as researchers and medical students, periodically
attempted to obtain information from village residents. The aim for researchers was to promote more
effective primary health care and community participation, while the students’ aim was to learn from
direct field experience about rural health problems.
However, the formal surveys they used posed enormous difficulties for respondents and led to inaccurate portrayals of actual health conditions. It was
evident that the whole spectrum of health-care related
encounters could be facilitated by various forms of
collaboration with social scientists who could obtain
information about social relations and cultural processes within the community. Social science fieldwork
could thereby provide technically-oriented outsiders
with the ability to see for themselves what their
treatments and data collecting activities meant to
the villagers and interpret more meaningfully the
information taken away.
The authors have attempted to translate these
fieldwork insights into a general model for health
professional education in rural areas [6]. Our approach argues for an educational curriculum for
doctors and other health professionals that would

enable them to: (a) experience the sociocultural perspective of the community research scientist; (b)
understand the resource potential of local health
systems; and, (c) amplify the strengths of indigenous
healing systems or create new health resources that
are culturally acceptable and within the control of
community constituents.
The understanding
and
skills that would ideally be developed through such a
curriculum
are those that underpin the process of
social science research, including a theoretical perspective on holistic health, knowledge
of research
design methods, as well as the ability to function in
a community
and interpret research findings.

APPLICATION
OF THE SOCIOCULTCRU
EDUCATION

MODEL TO COMMUNITY
MEDImE
TRAINING
AT UDAYANA UNIVERSIn.
BALI

Connor’s fieldwork in Bali and her association
with Balinese health professionals led her to identify
Udayana University as a potential site for a pilot
project implementing
the sociocultural education
model. Udayana University, with a student body of

Community medicine in Bali, Indonesia

675

about 15,000, is the only government university in
Saturday mornings during the academic y-ear are
the province of Bali. The medical faculty has 170 nominally allotted to UCHP activities. Prior to 1984,
academic staff members, and about 5.50 students.
the classroom component was not part of a strucSince 1972 the faculty of medicine has carried out the
tured, cumulative learning sequence, nor was it inteUdayana Community Health Program or UCHP for
grated with the field activities of the students. Rather
all undergraduate medical students [7]. The staff of
it consisted of a series of occasional lectures on topics
Udayana University’s community health program
that were considered to be of broad relevance to
expressed interest in the project as a way to improve
community, psychological, ethical and cultural conthe overall quality of the program. The program is
cerns. Three field activities are included. First, the
rated highly among similar programs in Indonesia,
Foster Family Program, which runs for 12 semesters
but in 1983 staff morale and involvement were low.
and which requires each student to visit regularly
The previous year UNICEF had sponsored an evaluwith a selected family in one of the training villages.
ation of the Udayana program, but there had been no
Second, community action, which comprises events
revision of program activities based on the evaluation
organized to promote the students’ integration into
report. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
their host community and as reciprocity for community hospitality (e.g. free medical treatment or immuUdayana Community Health Program
nization, sports events and entertainment). Third, the
Indonesia, like many other developing countries in
pre-graduate course, a month long field experience
the 1960s and 1970s was drawn into the plans of
undertaken after the students’ final examination at
international agencies for a new era of health care.
the end of semester 12.
Highly placed officials in the ministry of health who
In 1982, UNICEF funded an evaluation of UCHP
also functioned as senior faculty and administrators
as part of the organization’s efforts to foster better
in the universities became part of policy-making
community health-oriented education in Indonesia.
elites, chiefly under the auspices of agencies such as
The evaluation, carried out by an in-country consulWHO, UNICEF and USAID, that formulated the
tant, was based on interviews and questionnaires
new directions for Third World health care. Intercompleted by UCHP supervisors, students. alumni
national aid programs have heavily funded programs
and the employers of alumni [8]. Positive aspects of
in high priority areas such as population growth
the program were noted along with recommendations
control, maternal and child health and the training of
for strengthening the efforts of all involved. A majorprimary health care workers. Universities have been
ity of medical faculty recorded the opinion that the
affected in many ways by these policies and proUCHP was not operating to its full potential. The
grams. Staff career trajectories have been transbiggest problem area as seen by both students and
formed by the opportunities to gain research experistaff was supervision of the students’ field experience, administrative
skills and extra income on
ences. Supervisors expressed the need for clearer
development projects initiated by foreign aid funding.
instructions in their work with students, and for more
University staff have become part.of an international
training as field teachers. Other problems included a
poor grasp of the program’s objectives, insufficient
network of researchers and development program
administrators.
means for evaluating students’ field performance, no
In many countries, it appears that the new health
involvement of teachers from other faculties and low
care concerns have had a negligible impact on the
awareness of other development programs in the
education of physicians except at a rhetorical level.
villages in which the students worked.
Training in primary health care is reserved for the
The problems highlighted by the evaluation are not
various types of village and district level workers,
surprising considering the way in which community
conceived of as the front line of the battle. Newly
health has been promoted within the university.
trained physicians are expected to take their places as
Although since the early 1980s ‘Community-Oriented
‘leader of the health team’ in rural polyclinics for a
Medical Education’ (COME) has been endorsed by
number of years after they graduate. But many
the national medical curriculum advisory body as the
aspects of their training do not adequately equip
foundation of medical curricula in Indonesia, medical
them for the tasks they are expected to undertake,
faculty teachers have never been given any training in
and for many the period of service in the polyclinic
what their role as proponents of COME actually
is regarded as a hardship.
entails. Nor has there been any nationally sponsored
program of training in community health for the staff
One initiative taken by Indonesian medical faculwho now have the responsibility of supervising comties was the development of community health as part
munity health programs in medical faculties. Preof the student curriculum. Departments of public
sumably, such training programs have been assigned
health within medical faculties also grew in influence
a low priority because of other demands on faculty
and numbers during the 1960s and 1970s. UCHP was
time, such as clinical practice and teaching. Lack of
part of this trend, with a program that has evolved
educators with appropriate experience is another
over the last 14 years, and at present consists of a
limiting factor.
variety of classroom and field activities. Day-today work of coordinating UCHP is performed by
Project proposal for revising UCHP
members of the Department of Public Health within
During October and November of 1983, the
the medical faculty. All medical faculty staff are
supposed to take turns at supervising students in
authors worked closely with staff at Udayana
University to formulate a project outline suitable to
the program in association with polyclinic staff,
employees of the provincial Department of Health, in
the needs of the institution, based on the ideas of the
sociocultural
education model. The faculty’s highest
a rural training area 18 km from the campus.

LISDA H. CONNOR
and zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONM
NICK HIGGISBOTHAM
676 zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA

priority, spurred on by the UNICEF evaluation, was
to improve the UCHP curriculum of undergraduate
instruction.
They envisaged a curriculum development project that involved cooperation between
the medical faculty, the Department of Anthropology
and the provincial Department of Health.
One of the first tasks was to facilitate communication between the anthropologists and medical
instructors. Several members of the Anthropology
Department were enthusiastic about serving as CUFriculum advisers, fieldwork supervisors and, possibly,
as researchers. Numerous meetings were held both
within and between departments to explain the rationale of a sociocultural approach within community
health education, and to facilitate discussion of how
the ideas could be adapted to the needs of Udayan
students.
At this stage, staff members expressed two main
concerns. They wished to develop a project that
was tailored to the needs of their institution and
their students, and to that end spent a lot of time
explaining the administration
of Udayana as an
educational institution and the specific curricula the
medical students were required to complete. Second,
the senior staff were adamant that the enterprise
should not degenerate into what they called ‘project
disease’, whereby foreign experts full of enthusiasm
offer advice and funding for a particular project that
could not be supported locally after the external
funding expired. Senior staff recounted experiences
where they had participated in short-lived projects
‘with high-paid foreign consultants who then departed
leaving no ongoing support for their ambitious ideas.
They felt that the most significant result of these
projects often was the destruction of preexisting
activities, with no suitable replacement.
After a series of meetings held over 2 months,
Udayana participants and the consultants drafted a
proposal for a five-stage project. Project proposals
were submitted to several international agencies in
Jakarta with a request for funding. The Udayana
project would consist of a 24 month cycle of curriculum development and community health research
that could be continued by members of the medical
faculty and anthropology department as part of the
ongoing program. The new curriculum would begin
with semester I students-approx.
100 enrollees who
had just finished high school, and were about 19 years
of age-and
be advanced with them for two subsequent semesters. This comprised the premedical
segment of the students’ 12 semester education. Content of the curriculum was intended to prepare students for later semesters of UCHP, when they are
encouraged to work with village residents on specific
community development projects. Using an interdisciplinary team approach and more focused field
participation, it was hoped to overcome many of the
problems of student supervision, field involvement,
inter-faculty cooperation and the lack of sociocultural research skills on the part of both students
and staff.
IM PLEM ENTATION
OF THE FIVE-STAGE
CURRICULUM
PROJECT

Stage one: faculty

priorities for the curriculum

The first step was to invite the participation

of all

interested faculty in setting priorities for the sociocultural curriculum. A major faculty concern was the
lack of suitable materials in Indonesian for students
and supervisors to use. A 3-month period was allotted for a curriculum development workshop at the
East-West Center in Hawaii, where participants
could write new materials. It was vital to foster a
consensus on the agenda that the faculty representatives would take with them to Hawaii to guide their
construction of new materials. Meetings were conducted in Bali between UCHP coordinators from the
Public Health Department, other medical faculty and
the Udayana anthropologists,
during December
through March, 1984. All staff agreed that the
East-West Center workshop should produce a supervisors’ handbook and students’ workbook for the
first three semesters of UCHP. Concern was expressed that the curriculum materials should not be
too theoretical in fields of social science beyond the
expertise of medical staff supervisors, and that they
should be relevant to the practical problems facing
medical students. Udayana medical faculty selected
one member of the Public Health Department (the
project coordinator) to participate in the Hawaii
workshop together with a member of the Department
of Anthropology,
who had expressed interest in
designing his graduate degree research proposal as
part of the UCHP integrated research project.
Stage two: curriculum

development

workshop

The second stage comprised a 3-month workshop
(April-June,
1984) at the East-West Center. The
working group’s [9] first task was to review a wide
variety of relevant materials [lo] and evaluate
possible curriculum models. Before work on the
handbooks could begin, it was necessary that the
East-West
Center (EWC) coordinators
be acquainted in detail with the nature of teaching activities in UCHP and with the resources (time, equipment, routine funds, staffing, classroom space) that
would determine the sort of curriculum changes that
could be made. Udayana faculty were prepared to
consider any modifications to the three semester
curriculum as long as such modifications remained
roughly within the existing resource parameters. The
faculty preferred that any extramural funds should
be used for non-routine expenses (e.g. a research
project), so as not to jeopardize continuation of the
new curriculum after the end of the project period.
They also required that the new curriculum be within
the present capabilities of medical faculty staff, augmented by the anthropologists and the benefits of a
faculty development workshop.
The major challenge of the workshop was to design
a cumulative set of readings, discussion questions and
field exercises that were simple, practical and relevant
to the students’ needs, bearing in mind that they had
just graduated from high school in an educational
system that does not encourage independent initiative
in the learning process. The students had no experience of fieldwork, research or social science concepts.
Initially, it was difficult for the EWC coordinators to
conceptualize the level of demand that the curriculum
could make on students. Udayana participants scrutinized all suggestions and written material with
regard to its appropriateness
and adaptability. It

Community medicine in Bali, Indonesia

soon became apparent that there were no reading
materials that would be suitable for the students
without being completely rewritten. They were all
too complex, too long or too ethnocentric (North
American) in their tone and specific examples.
The first few weeks produced a list of possible
topics and a curriculum structure spanning three
semesters. The teaching format involved a recurring
cycle: lecture, readings, field preparation, field exercise, reflection upon field experience through group
discussion, and then another iteration of this cycle
with a new topic. Daily workshop sessions were
devoted to fleshing out the details of each teaching
unit. It became obvious that general guidelines about
goals, themes and exercises were not enough. To be
successful we needed to produce, in Indonesian, all of
the specific materials that: (a) the lecturers and
supervisors needed for making presentations and
facilitating classroom discussions; (b) the supervisors
needed for guiding and evaluating the students’ contact with villagers; and, (c) the students needed to
complete the classroom and field assignments: readings, interview questions, discussion points, etc. The
most time consuming tasks were the creation of
reading materials, and the translation of Englishlanguage materials into Indonesian.
The lectures and field exercises written for semester I students’ and supervisors’ handbooks focused
on the theme of ‘Understanding the Family in the
Community.’ The topics covered in the first semester
include sociocultural aspects of family systems in
Indonesia, household economics, community organization and religion. In addition to these substantive
topics, the curriculum addresses: the student’s role
in developing a good working relationship with the
foster family that each student is assigned and principles of communication necessary for rapport and
data-gathering. The major written assignment for
semester I, as of semesters II and III, is a report based
on field data.
As originally conceived, the 16 units of semester II
were organized around the theme of family health
beliefs and practices. Among the instructional objectives are: principles of community-oriented medicine;
the social context of lay health beliefs; family
decision-making about health concerns; and, changes
in the student’s role within the Foster Family as he
or she begins to examine family health practices. At
the beginning of this semester, students and supervisors organize a meeting with leaders and members
of the host hamlets to allow students an opportunity
to explain their field activities and obtain feedback
from community members.
The original 14 units outlined for semester III
moved to a higher level of specificity on the theme of
family expectations of health services and validation
of a formal questionnaire evaluating local maternal
and child health resources. A second objective was to
have the students understand lay concepts by eliciting
specific terms and metaphors used to describe health
problems. Following this the students were to gain
experience in translating across professional and folk
concepts of health. Time restrictions prevented the
full development and review of semester III units at
the workshop. As a result, the UCHP supervisors
were unable to implement these materials because

677

they were far too complex. Instead, the UCHP
coordinator improvised units and extended activities
from semester II. zyxwvutsrqponmlkjihgfedcbaZYXWVU
Stage three: curriculum implementation and faculty
development workshops

Most UCHP supervisors were willing to implement
the new curriculum materials. A few voiced reservations about the complexity and density of some of
the materials and several units of semester I were
simplified. It is noteworthy that the medical faculty
were committed to implementing the new curriculum
for semester I students even though outside funding
did not materialize until midway through semester I.
A core of enthusiastic medical faculty supervisors and
anthropology department members were resourceful in overcoming many of the logistical problems
that arose during the early period of curriculum
implementation.
Connor made a second trip to Bali during the
months of September and October 1984 to assist with
curriculum implementation and faculty development
workshops. Udayana staff were particularly anxious
to have more background on the curriculum content
rationale as well as key concepts and methods of
small group discussion that would help them improve
their performance as supervisors. Faculty workshop
topics included educational principles underlying the
new curriculum, explanation of its content and analysis of the supervisors’ new functions. Also examined
were teaching techniques of small group discussion,
the role of the anthropologists and use of the handbooks. At these sessions and other informal meetings, all of which were conducted in Indonesian, the
organizers sought feedback from the supervisors
about their experiences with the new curriculum
which had been running for several weeks.
Subsequently, Connor and the UCHP coordinators from the Public Health Department drew up
a series of recommendations based on the results of
the workshops, interviews and observations of curriculum activities. This document was discussed at a
general meeting of medical and anthropology faculty
in early November, which provided the starting point
for an ongoing process of evaluation and revision.
Impetus was given to the organizers’ efforts when in
October 1984 Ford Foundation, Jakarta, agreed to
fund the project.
On the basis of feedback about semester I, the
contents of semesters II and III were considerably
modified. However, it was not until 14 months later
at a second EWC workshop that the substantial
problems with semesters II and III were resolved
through a comprehensive revision of unit themes and
activities.
Stage four: rural community health research

Although the fourth stage of the project was
intended to run concurrently with curriculum implementation, research design did not begin until late
1985. There were funding delays, and the early stages
of curriculum implementation were very demanding
on Udayana faculty involved in the project, allowing
no time to initiate the research. The level of demand
of a project having both curriculum and research
components, relative to available time and resources,

678

LISDA H. COSSOR and NICK HIGGI? ;BOTHAM
zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA

was not fully appreciated at the onset by the consultants, or by Udayana staff. Research project planning
became part of the second workshop at the
East-West Center.

analysis of home remedies and content analysis of
advertising. This combination of field activities and
methods maximizes collaboration
between social
scientists, their UCHP colleagues (coordinators,
supervisors, students), village residents and district
Stage five: zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
second East-West Center workshop
medical officers.
The fifth stage of the project was a 2-month
follow-up workshop at the East-West Center early in
RECOZ lM EN DAT I ON S FOR I N T EGRAT I N G
1986. It involved the participants from the first EWC
SOCI AL SCI EN CE AN D COM ~1 LN lT Y
workshop plus two additional
Udayana
Public
M EDI CI N E
Health Department faculty active in UCHP [l 11. As
originally conceived, this workshop would complete
This section discusses some principles for intean internal review of the project-assess
the sociograting social science perspectives within medical
cultural education model, and disseminate project
domains based on participants’ experiences with the
outcomes. Instead, the workshop was devoted to curriculum development project for Balinese medical
review and revision of materials for semesters I-III,
students.
construction of curriculum structure and materials
A recurrent concern is the ‘project’ status of the
for semesters IV-VIII, and design of the project’s
endeavour. There are a set of problems common to
community health research component.
many different types of institutions in developing
Review and revision of semesters I-III materials
countries when aid projects are undertaken. A few
was based on the teaching experience of the previous
preliminary generalizations will allow the reader to
2 years. Most revision occurred in semester III
place the following examples in the broader perspecthemes which were altered to include analysis of tive of the impact of aid projects on the bureaucratic
specific family illness episodes and their relationship
institutions of recipient countries.
to family decision making about treatment resources
Projects engender a variety of competitive re(e.g. home remedies, folk and cosmopolitan health
lationships between and within the institutions and
providers). A student-centered curriculum evaluation
groups involved, from the international agencies to
scale was developed for semester I and III students.
the host-country organizations and finally to the
The scale consists of 16 items pertaining to lecture,
target populations. Aid agency officers vie for recogfieldwork, supervision, assessment, small group dis- nition as initiators and administrators of successful
cussion and foster family relationship facets of the
programs and projects and promotion prospects are
curriculum. It was sent to Bali and was returned for
influenced by such results. These people strive to
analysis in the final week of the workshop.
develop networks of in-country personnel to impleTeaching units for semesters IV-VIII were also
ment projects. In-country institutions, in turn, comoutlined based upon the ‘problem solving cycle,’ a pete for participation in development projects, alconceptual model familiar to public health faculty in though to some extent competition is reduced by the
Indonesia. The problem solving cycle comprises a tendency for most funding to go to institutions
sequence of evaluation research and intervention
closest to centres of power. Within host-country
stages employed to initiate, monitor and assess public
institutions such as universities, departments compete
health action. Although creation of semester IV-VIII
for funds, and individual staff vie to participate on
units was not an original objective of the project, and
the best projects. The factor of competition is mitisignificantly added to the workload, extending the gated somewhat within institutions because project
new curriculum into all 12 semesters was encouraged
organization conforms to a preexisting hierarchy.
by senior medical school administrators at Udayana.
Each project, with different goals, schedule and fundAll project participants deem it important to maining, requires the participation of administrative and
tain a high standard of curriculum materials for the technical personnel, often with rewards commenstudents as they advance rather than abandon them
surate with seniority in the institution rather than
at the end of semester III.
active participation in the task at hand. Some staff
Finally, the second workshop
designed the may be involved in several projects concurrently.
project’s community health research component, a Large, well-funded projects (usually on a national
study of the use of self-administered medications by scale) generally take priority over smaller projects,
rural Balinese. Participants drafted fieldwork instrueven though the latter may have been initiated
ments and an action plan for implementing the multifirst and participants may have a higher degree of
control over their activities compared with projects
disciplinary study during 19861987. The project’s
research component aims to: (a) increase UCHP
orchestrated by the larger international agencies.
supervisors’ community experience and their skills in
The situation can become quite anarchic for junior
using methods specific to field rather than laboratory
staff who may have to carry out the time-consuming
or other clinical settings; and (b) gather information
tasks on several projects, but who have little influence
about community health problems (e.g. child surover higher-level politicking about project budgets,
vival), that can be applied to UCHP teaching, and to
schedules, priorities and so on. Although in-country
programs of community health development. To
participants usually recognize that they need to weigh
broaden field experiences, the research component
the advantages of any particular project against its
divisive or disorganizing
effects, the short-term
poses a spectrum of research questions and applies
benefits of project participation often override these
diverse methods. Included are household surveys,
clinical case studies, village surveys, analysis of comconsiderations. The Udayana project has avoided
some of the worst pitfalls of the ‘project process,’
mercial drug distribution networks, pharmacological

Community medicine in Bali, Indonesia

chieflv because of the small scale on which it was
concAved, flexible funding policies on the part of
Ford Foundation (a relatively small donor in the area
of health and education in Indonesia), and a critical
and sensitive approach to project management by
Udayana University administrators.
Equit)

The Udayana project has shown that the principle
of equity must govern resource exchanges at all
levels-inter-personal,
inter-departmental
and interinstitutional. If social science and medicine are to be
successfully integrated, members of each domain
must perceive benefits in the relationship.
Clearly, many of the medical faculty appreciated
the general premise that social science concepts and
methods could enhance the competence of medical
students as well as their own research and teaching
skills. However, in order to adopt the new curriculum
and enter into a relationship with social scientists
toward that end, the major costs and benefits of such
an enterprise had to be weighed. First, what benefits
to Udayana would accrue from cooperation with
outside institutions and social science consultants?
Many developing country universities have had
negative experiences with staff who have travelled
overseas for further training at a site where they were
in a minority and the curriculum content was inappropriate. In the project under discussion, the
overseas workshop was designed jointly with the
Indonesian participants to meet their needs, and was
carried out in local languages.
An important resource that the overseas institution
offered Udayana faculty was the opportunity to work
full time on planning and writing. As in many
developing countries, academic careers in Indonesia
are structured so that it is difficult for staff to find
large blocks of time to write thorough curriculum
materials or attend intensive workshops. Udayana
staff members reported that they benefited from the
curriculum development workshop at the East-West
Center through their exposure to new colleagues and
to a different educational system. Equally important,
the workshop provided an opportunity to spend 3
months in uninterrupted preparation of curriculum
materials. In addition, Udayana administrators were
hopeful that the workshop would have sequels in
Indonesia and at overseas institutions. Udayana staff
complained that many projects in which they have
previously participated have not had built into them
adequate provisions for long-term continuity of the
relationship, with opportunities for project evaluation, and further revision as well as dissemination of
project achievements. They view these long-term
commitments as having fundamental importance in
improving the quality of their institutions.
The principle of equity also governs the relationship between the Anthropology Department
and Faculty of Medicine at Udayana. For the anthropologists, their active participation in community
medicine teaching is a welcomed innovation. Moreover, an honorary teaching position within the medical faculty is a source of some prestige. The new
arrangements are not unproblematic however. There
are some administrative obstacles to the easy flow of
staff members between faculties. It is easier to coordi-

679

nate commitments within faculties than between
them, and there are pressures to give higher priority
to home faculty commitments. Problems exist about
how to devise a research project that is truly collaborative, given the diverging perspectives of social
scientists and medically trained personnel. zyxwvutsrqponmlkj
Another issue that arose during the faculty
development meetings was how much autonomy the
medical instructors were prepared to assign to the
anthropologists, in teaching medical students. This
can only be resolved over a long period of time, as
the anthropologists find more ways to deploy their
skills in community health teaching. At present, the
anthropologists are not assigned their own student
groups, but are asked to perform as advisers for all
the groups, when needed. This arrangement was
working satisfactorily in 1984. Moreover, by the end
of 1984 there had been an increase in the interdisciplinary participation at UCHP-related meetings,
as compared to a year before, and some collaboration
had begun in projects unrelated to UCHP.
Finally, it is essential that the individual social and
health scientists view their inter-personal partnerships as mutually advantageous. The project’s goal is
to facilitate and strengthen collegiality by structuring
teaching and research opportunities
where each
participant can realize the advantages of contributing
his or her perspective and seeking out the other’s
perspective. For example, the UCHP research component was designed to draw together anthropologists and UCHP coordinators, supervisors and
students around diverse field methods that are best
executed through collaboration [ 121.
Small- scale networks

The second principle concerns the intertwined
issues of personal knowledge and the use of personal
and professional networks as a framework in which
to attempt an integration of social science and medicine. The mechanism for initiating the sociocultural
curriculum project was a network of associates at
Udayana and the East-West Center. The advantage
of social scientists using personal knowledge and
social networks to initiate collaboration with health
scientists is that they can more easily conceptualize
projects that are relevant to their colleagues’ needs
and interests and that can be accomplished with
available resources. The small scale of such collaboration ensures good communication
and the
flexibility to alter methods or aims as required. The
drawback of using personal networks to carry out
collaborative work is that this format maximizes
specificity of problem solving at the expense of
general applicability. Large donor agencies in the
field of community health services generally have a
programmatic approach to development aid. They
are less willing to consider supporting small projects,
especially those instigated outside established networks of consultancy. A major concern of large
funding bodies (e.g. WHO, USAID and UNICEF) is
replicability. It is dubious whether the Udayana
project, for instance, fulfils their conditions of replicability because it was generated through a unique set
of personal ties and because the sociocultural educational model stresses that in-country personnel at

LISDA H. CONS-ORand NICK HIGGISBOTHAM
680 zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA

each site be given control over adapting the generic
model to their needs.

ation than their primary job. At various times
teaching staff are also participating in development
projects which may be time-consuming and difficult
Minimum recolution
to coordinate with other commitments.
UnderThe consultants’ observations about innovation
standably, all curriculum development initiatives are
within Indonesian bureaucracies is that change is first assessed by teaching staff in terms of the amount
adopted more readily when one proposes to put new
of extra time they will occupy in already overloaded
wine into old bottles. Early on, staff at Udayana
schedules with large numbers of students.
alerted us to the necessity to plan the curriculum
Staff are required to participate in UCHP on a
project so that it would enhance but not greatly
compulsory, rotating basis. Yet, because of comrestructure the existing community health program.
peting activities which are assigned higher priority
They were in favor of stage-by-stage changes rather
(e.g. special seminars, university ceremonial activities,
than a sweeping reform of the program. A minimum
requirements of second teaching jobs, national and
provincial holidays), it is often difficult for them to
revolution strategy is also an antidote for ‘project
disease,’ in which infusions of development aid set up
function as supervisors. There is a long history of
faculty not turning up for classes or fieldwork superadministrative structures that disintegrate once funds
vision, and this was one of the things students
are depleted and consultants have departed. In the
mentioned when they complained about inadequate
Udayana case, the faculty’s apprehensions about
supervision. Solutions to this problem were proposed
project disease was such that they requested a new
curriculum that could be implemented given present
in the supervisor’s workshops. Two-person teams are
institutional constraints and minimum resources. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFE
now responsible for each student group, increasing
the probability that at least one person will be present
Cash -less exchange
on any given occasion. The new field exercises have
Related to the principle of minimum revolution is
been structured to allow the students greater indepenthe recognition that extramural injections of cash into
dence in their foster family visits. Thus the superan institution’s administrative structure can do more
visors’ burden of participation in all field trips is
harm than good unless sensitively managed. On the
removed, encouraging greater student initiative in
positive side, supplementary
income, allowances,
field visits [14].
equipment and so on is welcomed in a situation where
Continuing faculty education
such resources are perceived to be in short supply.
The negative consequence is that staff often resent a
If medical faculty are to appreciate social science
system that forces them to work for incentives, that
approaches in their teaching, then provision must be
may destroy preexisting initiatives that did not demade for their continuing education in this field. The
pend on outside funds and that may undermine
Udayana project found that the doctors assigned as
routine commitments. There is in consequence confield supervisors had little or no training in commusiderable ambivalence in the attitudes of personnel
nity health practice or research when they were
involved in projects.
students. As teachers, they have undergone no special
The Udayana project sought to resolve these probeducation, apart from occasional lectures in commulems by operating within the routine budget for
nity medicine approaches to their subject. Without
in-country curriculum development activities, while
training in theory or field methods, it was difficult for
soliciting outside funding for additional activities
them to fulfill the goals of UCHP.
such as the overseas workshops, research and equipThe supervisors’ handbooks aim to help these
ment [13]. There is no doubt that staff morale impeople gain more confidence teaching community
proved when news of outside funding was received.
concepts about health. The written materials however
However, at the end of the second East-West Center
only partly solved these problems. The handbook
content required much more discussion and review
workshop (February 1986) many of the major decisions about the research project budget allocation
than was originally envisaged, and supervisors, despite their initial enthusiam for written curriculum
had not yet been made, and project coordinators
have expressed some concern that this could be a
materials, were not prepared to read through the
rather lengthy handbooks. UCHP coordinators acdivisive process if not sensitively handled.
cordingly have made plans for an ongoing process of
Acknowledge competing demands
curriculum materials discussion and revision. The
planned participation
of as many supervisors as
Also related to the principle of minimum revolupossible in the UCHP research project in partnership
tion is the fact that it is unrealistic to make too many
with the anthropologists provides yet another opporadditional time demands upon the medical faculty in
tunity for faculty improvement in fieldwork skills and
implementing the new curriculum. Supervision of
knowledge of community aspects of health.
UCHP activities is only one of many tasks that
medical faculty undertake. Supervisors for the first
Awareness of time and space logistics
three semesters are draw