BACKGROUND TACKLING MALNUTRITION IN EAST NUSA TENGGARA NTT:

THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 186 THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 187 4.2.2.3 Economic context Malnutrition breeds a poverty cycle by lowering productivity and income in adulthood, in turn feeding back into the likelihood of malnutrition for the next generation. It is not surprising, therefore, that NTT is one of the poorest regions in Indonesia. Based on data from the NTT Provincial Bureau of Statistics BPS 31 , the number of poor people in NTT in March 2009 was 1,010,000 people, or 23.31 per cent of the provincial population, far higher than the national average see the Figure 4.2.3. Poverty was at its most severe during the period 1993-1999 due to the economic crisis affecting Indonesia at that time, and since then the percentage of those living below the poverty line has been decreasing. The trend took a definite turn for the better after 2006 following a recovery from the removal of fuel subsidies and the ban on rice imports. While the percentage of the population living below the poverty line in NTT is considerably higher than the national average, the gap has been closing somewhat over time. 32 Figure 4.2.3: Percentage of population below the poverty line, NTT versus Indonesia 1999-2009 Source: BPS - Statistics Indonesia, Statistical Yearbook 2010, based on the National Socio-Economic Survey 2009 In general, there is a considerable disparity between the relative sizes of rural and urban populations living below the poverty line: 25.35 per cent in rural areas versus 14.01 per cent in urban areas. 33 According to the study by Barlow and Ria 2007 34 , the GDP per capita in NTT varied greatly among districtsmunicipalities, with that in the provincial capital, Kupang, and several other towns being over three times the average of other districts. In general, areas with the largest poor populations are those with high dependency on subsistence farming activities such as cultivation of corn and other basic foods for consumption rather than income. These include Sumba Barat, Kupang, Timor Tengah Selatan and Timor Tengah Utara, Lembata and Manggarai. Development initiatives to relieve poverty and malnutrition should focus on the poorest districts of NTT with the aim of closing this gap. 31 BPS - Statistics Indonesia 2009 Statistical Yearbook 2009 based on the National Socio-Economic Survey, SUSENAS, 2008, BPS: Jakarta 32 Ibid. 33 BPS - Statistics Indonesia 2009, Statistical Yearbook 2009, based on the National Socio-Economic Survey 2008 34 Barlow, C. and Gondowarsiot, R. 2007 Economic development and poverty alleviation in Nusa Tenggara Timur Percent 45.00 40.00 35.00 30.00 25.00 20.00 15.00 10.00 5.00 0.00 50.00 2000 1999 2001 2002 2003 2004 2005 2006 2007 2008 2009 Indonesia East Nusa Tenggara 46.73 23.43 18.95 18.40 18.20 17.42 16.66 15.97 17.75 16.58 15.42 14.15 36.52 33.01 30.74 28.63 27.86 28.19 29.34 27.51 25.65 23.31 Figure 4.2.4: Percentage of poor population by district, NTT 2008 Source: BPS - Statistics Indonesia, based on National Socio-Economic Survey 2008 35 4.2.2.4 Human development Figure 4.2.5: Trends in development indices, NTT 1999-2007 Source: HDI from BPSBAPPENASUNDP, Indonesia Human Development Reports 1999-2007; GEM and GDI from BPS - Statistics Indonesia and The Ministry of Women’s Empowerment, Gender Based Human Development 1999-2007 35 BPS - Statistics Indonesia 2009 Data dan Informasi Kemiskinan 2008 Buku 2: KabupatenKota based on National Socio-Economic Survey, SUSENAS, 2008 , BPS: Jakarta Index 70.0 65.0 60.0 55.0 50.0 45.0 40.0 1999 2002 2004 2005 2006 2007 60.4 56.8 56.3 58.6 59.6 61.3 63.1 56.3 46.2 46.4 57.3 59.0 61.0 60.3 62.7 63.6 64.8 65.4 Year HDI GDI GEM Kab. Flores Timur Kab. Nageko Kota Kupang Kab. Ngada Kab. Sikka Kab. Bellu Kab. Ende Kab. Manggarai Barat Kab. Alor East Nusa Tenggara NTT Kab. Kupang Kab. Timor Tengah Utara Kab. Manggarai Kab. Lembata Kab. Timor Tengah Selatan Kab. Sumba Barat Daya Kab. Rote Ndao Kab. Sumba Timur Kab. Sumba Barat Kab. Sumba Tengah 13.2 14.5 14.7 15.5 17.3 19.7 24.9 25.1 25.1 25.7 27.0 27.7 28.6 29.2 33.6 36.5 36.6 37.1 37.9 38.7 0.0 10.0 20.0 30.0 40.0 Percent THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 188 THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 189 In general, human development in NTT is far behind the national average, reflected by the human development index HDI. Between 2000-2007 the HDI of Indonesia has been constantly increasing to reach a level of 73.4 see Section 2. NTT, however, remains far below the national figure despite increasing from 60.4 in 1999 to 65.8 in 2007 see Figure 4.2.5. Significant improvements were made in the second half of the 2000s indicating there has been some improvement in life expectancy, education levels mainly at the primary school level and income the contributors to the HDI. Even so, the HDI disparity among districts in NTT is considerable, with districts in rural areas generally on the lower end see annex 4.2. In 2007, the lowest HDI was attributed to Sumba Timur district with a score of 58.6, while the highest level achieved was in Kupang municipality, at 75.9 - higher than national HDI. Also shown in Figure 4.2.5, the gender development index GDI follows a similar pattern, increasing over time but continuing to sit at a level well below the national figure, and with ruralurban and inter-district disparities. The 2007 GEM gender empowerment measure of NTT is more of a highlight for NTT, currently at 61.0. A strong increase between 2002-2004 in the GEM and consistent increases since then mean that the level reached by NTT is higher than that of other larger provinces in Java, for instance Central Java where the 2007 GEM stood at 59.7. This accomplishment reflects the fact that in NTT, women’s participation in the workforce, women’s average wage in non-agriculture sectors, and woman participation in politics and decision-making women as professional workers, high rank officials, and managers are relatively good. Again the inter-district disparity can be observed with low figures in rural districts - the lowest being Manggarai Barat 46.8. 4.2.2.5 Basic education Annex 4.2 shows the trends in education in NTT. Early childhood education attendance rates according to the National Socio-Economic Survey have fallen from 10.21 per cent in 2004 to 6.6 per cent in 2007. From a low point in 2002, the primary school level net attendance rate 36 for NTT has experienced some considerable increases from 87.07 per cent in 2002 to 91.72 per cent in 2008, with attendance rates for girls and boys almost equal, again based on National Socio- Economic Survey data. However this remains below the national average, and since 2005, the trend has been flat. The relatively low attendance rates have been exacerbated by an increasing rate of early school leaving dropout for primary school - now standing at 3.53 per cent of students the second highest provincial rate in the entire country. Another concern is the low rate of transition to junior secondary level, 89.61 per cent in 200708, which has fallen in recent years from 99.4 per cent in 200506. Junior secondary school attendance now sits at 49.7 per cent. This correlates with the timing of the removal of fuel subsidies and the ban on rice imports, as well as policy changes in education, which are discussed in more detail below. This highlights the need for renewed initiatives to boost enrolment and retention levels to reach the target set in the MDGs for 2015 - 100 per cent net enrolment rates, in line with Education For All, which should not differentiate on the basis of gender. While levels of primary school attendance were not that dissimilar to the national average, there was greater disparity between the junior secondary school net attendance rate and the national average in 2008 49.7 per cent in NTT versus 67 per cent nationally. Again, following steady increases in attendance in the initial years of the 2000s, gains have tailed off in the latter years of the decade. Girls have slightly higher attendance rates than boys 64.44 per cent versus 61.84 per cent, but this minimal disparity is much smaller than at the beginning of the decade when girls’ 36 Since the figures are based on survey data and not actual reported figures from the Department of Education, net attendance rate is used in the place of net enrolment rate as the closest equivalent available. attendance was 64.16 per cent while boys’ attendance was only 45.55 per cent. Retention rates in NTT are poor, with early school leaving at a rate of 8.24 per cent in 200607, well above the national average of 3.94 per cent, for junior secondary school. 37 Early school leaving rates have been climbing sharply since 200304 when they were at a low point of 1.65 per cent, even below the national average of 2.83 at that time. 38 In 200708, repeat rates for NTT were the highest in the country at 1.55 per cent of secondary level students compared to the national figure of 0.42 per cent, and have been climbing steadily from their low point of 0.35 per cent at the beginning of the decade. Reasons for early school leaving shed some light on these indicators. In 2006, 84 per cent or 19,023 of early junior secondary school leavers cited economic reasons for leaving school. 39 This was followed by 7 per cent who considered the distance to school too far. 40 The third most common reason cited for leaving school was that the family does not prioritise education 5 per cent and it is not uncommon for parents to use scholarship money provided for students to satisfy their basic needs. 41 Interviews with staff at the provincial Office of Education also stated that with low incomes, many parents cannot afford to advance their children to higher levels of education beyond primary school. 42 Other interview respondents indicated that, coupled with these economic challenges, parents struggle to pay extra fees and charges from schools and the cost of uniforms and books. 43 Finally, many students are expected to help their parents by contributing to household income, by working as newspaper sellers, day labourers on building sites, farms or plantations, or as domestic staff. 44 With some of the worst performance in education indicators in the country in NTT, enrolment and retention at junior secondary level should be a priority for development workers to meet education targets in line with the MDGs. In Section 2 of this report, the social safety net programmes designed to support education for poor students were examined, in particular the Fuel Subsidy Reduction Compensation Programme PKPS-BBM for the Education Sector, which provided money directly to poor students, and the Schools Operational Assistance programme BOS, Bantuan Operasional Sekolah which replaced it in 200506, whereby money was provided to the schools to be managed in accordance with requirements determined by the central government. Although it is impossible to give a definitive reason as to why almost all the education indicators have reversed their generally positive trend into negative after the middle of the decade, it does call into question the effectiveness of providing money to schools to manage rather than directly to the families of poor students, since the timing of the change of policy correlates with the negative shifts in the education indicators. Office of education staff identified that in some cases BOS funds are used to pay honorariums to teachers due to limited school budgets, which is outside the BOS policy. 45 The low fiscal capacity of the district means that the Office relies heavily on the central government’s special budgetary allocation DAK, scholarship funds, and BOS funds. 46 37 Indonesia Ministry of National Education, Statistics of National Education, available at: www.depdiknas.go.idstatistik Last accessed 1 July 2009 38 Ibid. 39 East Nusa Tenggara NTT Provincial Ofice for Education, Youth and Sport 2009 Data collection report on children at secondary school, within the framework of compulsary of 9 years basic education , Center for Women’s Studies, Cendana University: Kupang, NTT 40 Ibid. 41 Ibid. 42 Interview with Kindergarten and Basic Education Section Staff, NTT Provincial Ofice of Education, Youth and Sport, Kupang 25 November 2005 43 Interview with coordinator of the women’s division, local NGO, Sikka district 19 September 2009 44 Interview with Kindergarten and Basic Education Section Staff, NTT Provincial Ofice of Education, Youth and Sport Ofice, Kupang 25 November 2009 45 Interview with Head of Basic Education Section, Ofice of Education, Youth and Sport, Sikka District, NTT 21 September 2009 46 Ibid. THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 190 THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 191 Education quality is also a problem in NTT. Staff from the Early Education and Primary School Section of the Office of Education in Sikka 21 September 2009 stated, for example, that aside from the problem of the scarcity of teachers, many teachers in villages do not have adequate education themselves - there are still primary school teachers who only completed junior secondary school, and junior secondary school teachers who only completed high school. Furthermore, many schools have limited facilities, lacking libraries, for instance. Many villages do not have electricity, so children rarely study at night. 47 Staff in the Office of Education argued that institutional capacity is also a problem. Given the high rotation levels of civil servants, many government officials in senior positions in the Office don’t have a background in education to manage the challenges of educational policy and services in NTT. 48 For example, in the Office of Education in Sikka, only three government officials have a background in education. 49 4.2.2.6 Child protection While data on child protection are scarce, annex 4.2 outlines some basic figures on child marriage, birth registration, neglected children and children living on the streets. The proportion of children aged under 18 years who were married was 19.8 per cent in 2008, and rates have actually increased since 2000 when the rate was 18.1 per cent, according to National Socio- Economic Survey data. The same data set revealed that only 14.4 per cent of children aged 0-59 months in 2007 had a birth certificate, with this being only marginally more likely for boys, and rates have been decreasing since 2000 when 18.2 per cent of children that age had birth certificates. Data from the Office of Social Affairs indicate that the number of neglected children has grown substantially to 492,519 in 2009 up from 58,776 in 2008, with 84,376 of these children aged under five years. The same office puts the number of children living on the streets at 12,397 in 2009 with little change since 2008. 4.2.2.7 The voice of a child in context Mawar is an average adolescent in NTT. Her case is not particularly extreme given the high levels of poverty discussed above, but her case illustrates the multiple levels of insecurity that children from poor families face in terms of health, nutrition, education and child protection in NTT, and also underlines the importance of viewing the experience of children holistically. Her case illustrates the challenges of accessing health care despite health insurance programmes, and the challenges for children to stay in school in the face of poverty, and the ways that children avoid violence in school through absenteeism. Moreover, her story demonstrates how children make choices in challenging contexts as they strive for improved conditions and well-being. 47 Interview with Kindergarten and Basic Education Section Staff, NTT Provincial Ofice of Education, Youth and Sport, Kupang 25 November 2005 48 Interview with Head of Basic Education Section, Ofice of Education, Youth and Sport, Sikka District, NTT 21 September 2009 49 Ibid. Box 4.2.1: Mawar’s experience: Multiple insecurity for children in NTT Mawar is a confident and happy child of Alor ethnicity who is 16 years old. She was born in Kupang municipality. She has one older sister who completed primary school and now works in Osmo in another district as a domestic servant. Mawar’s parents did not complete primary school. When Mawar was eight years old, her father, who was a fisherman, drowned after falling from his boat while fishing. Since then, her mother has been a single parent, and she has a small kiosk at Osmo. When Mawar was four months old, her mother brought her to Rote a rural district where she lived with her extended family grandparents. She studied at a state primary school in Rote where some people, she says, including children, still often suffer from malnutrition because of drought and famines. “[There is] a scarcity of vegetables, vitamins and meats in the dry season in Rote,” she explained. “If there is a lack of food to eat, they will only eat rice or sometimes mix it with sap [sugar liquid that is obtained from palm trees]”. Mawar understands the importance of vegetables, protein and vitamins in people’s diets and thought that the government should help people in areas suffering from famine by giving them ‘charity’ so that they are able to eat. Recognizing these circumstances, she felt compassion for the life of poor people in Rote village. Mawar, was unable to sit her primary school exams when she was in Rote. Her grandfather who works as a ‘palm sap seeker’, selling the sap he gets by tapping palm trees, which is used to make palm sugar could not afford to send Mawar to school anymore. After moving to Kupang city area, Mawar and her mum have rented a small room of 4 by 4 meter space, with a wooden wall and sheet-metal roofing that costs IDR 90,000 US10 per month to rent. There are no appliances in the room, only a small lamp hanging from the ceiling that is turned on from 5 p.m. until 5 a.m. There is one bed, a wardrobe, a stove, and a draining-board which holds cups, plates and cutlery all plastic. She observes that people in their neighbourhood are often drinking, stealing, gambling, robbing people and playing billiards. Her neighbours earn money in diverse ways - some even by using force and violence. In Kupang, she enrolled at an informal school, through a non-profit organisation, called the Purnama Kasih Foundation. “Mum said the formal school is too costly, so [you] just have to study at Purnama Kasih.” Mawar finally was able to sit the national examination and completed primary school. She enjoyed it so she decided to undertake Kejar Paket B equivalent to junior secondary school. Each student has to pay IDR 16,000 US1.60 every month. However, poor households are entitled to free monthly education fees and this includes Mawar’s family. The school also provides several free study kits for the poor, including text books and note books, but not pencils or pens. Mawar’s mother now works as a trader at a traditional market Pasar Oeba, though she doesn’t have a permanent stall. Mawar often helps her mum at the market selling spices. They get the products from a wholesale distributor and then retail them directly to consumers at the roadside. If they are lucky, they will earn profits of around IDR 10,000 US1 per day. Studying at school two or three days a week, Mawar wakes up in the morning before 6 a.m., helps her mother do domestic chores, and goes to the school at 7:30 THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 192 THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 193 a.m. by public transport. When she doesn’t go to school, she helps her mother in the stall. On those days, having finished the domestic chores like cooking and cleaning, at 6 a.m. they walk together to the market. They rest from 12-3 p.m. and return to the market where they work until 5 p.m. At noon they come back home to take a rest and then go back to the market from 3-5 p.m. Categorised as poor, Mawar and her mother receive the Direct Cash Transfer BLT, Bantuan Langsung Tunai although payments are haphazard for reasons she doesn’t understand. They also get Raskin a subsidised rice programme for poor families which provides 10 kilograms of rice per poor household at the price of IDR 1,000 per kilogram, as well as Jamkesmas free health care provision for the poor. Mawar says that the Jamkesmas is government assistance for the poor when they are sick, for which they use a health-care card. Mawar says her mother is very often sick. Her body is weak, and so she is susceptible to illness, so she often has the flu, nasal congestion, coughs and fevers. Only when she is really really sick, do they buy medicine at the little kiosk nearby. They don’t go to the puskesmas as it is too far away. Mawar often witnesses crime in the market, such as pickpocketing and robbery. She takes steps to prevent these things happening to her by giving all the money she earns to her mum once her goods are sold. “I don’t want to keep the money and prefer to give it to my mum. I am afraid of losing it,” she says. Mawar says she often experiences violence at home and at school. Her mum reprimands her and hits her if she makes a mistake. One thing that she still remembers is giving a consumer the wrong change by mistake that turned a day’s proit into a loss. Her mum hit her across the back, making Mawar cry with pain. “Mum often hits me when she is angry,” she says. At school, Mawar says that there are two bad-tempered teachers who often hit students as well as tweaking their arms or ears. Mawar’s ear was tweaked roughly when she was not able to answer the teacher’s questions. Mawar never reports these teachers, but she rarely attends school on Wednesdays because this is when those teachers are scheduled to teach. Because of her absence, she often receives school warnings: “If you dislike school, we’ll just expel you. Are you not afraid of that?” Mawar is very keen to continue her studies and move on to senior high school and to be a supermodel. Even though her mum and grandfather once said that Mawar doesn’t need to go to school, she doesn’t agree with them. “‘You don’t have to go to school, just learn to hold a cooking pot, in the morning, afternoon and at night,’ they said to me. But I think it will enlighten me, give me advantages and knowledge. School is an education so that we can read, calculate and achieve a better future. That’s the goal.” Mawar feels blessed by what she has achieved. She’s lucky, she says, because even though she lives a life of scarcity, she survives. Source: Child interview conducted by PSKK, UGM in NTT, 2009; Mawar is not his real name

4.2.3 THE CASE STUDY: HEALTH AND MALNUTRITION IN A GEOGRAPHICALLY LARGE BUT POOR PROVINCE

The discussion earlier in this subsection has already highlighted the improving but stubbornly high levels of poverty, lower than average education levels, lagging HDI, growing numbers of neglected children and difficult agricultural and economic conditions in NTT. Child marriages are also fairly common, and few children have birth certificates. This is in stark contrast to the indicators of child welfare in Central Java, discussed in a separate case study. The case of Mawar see Box 4.2.1 demonstrates the linkages between poverty and multiple levels of insecurity for children in NTT. Amidst these challenges, indicators of health and nutrition, while improving, are also concerning. The following discussion examines child welfare in a difficult context in terms of health and malnutrition and related factors, drawing on survey data and in-depth interviews from NTT. 4.2.3.1 Malnutrition Figure 4.2.6: Percentage of children aged under five suffering from wasting, stunting and underweight, NTT 2007 Source: Ministry of Health MoH, Report on the results of the National Basic Health Research Riskesdas 2007 Despite efforts to reduce the malnutrition levels in NTT discussed later in this section, the number of severely and moderately malnourished children still remains high, as seen in Figure 4.2.6. When it comes to the percentage of severely underweight 50 , stunted 51 or wasted 52 children under age five, NTT is one of the worst affected provinces in the country. Of all 33 provinces in Indonesia, NTT has the third highest level of severely underweight children 9.4 per cent in NTT versus 5.4 per cent at the national level, third highest for severe wasting in children 9.5 per cent 50 Measured by comparing the weight-for-age of a child with a reference population of well nourished and healthy children, see: World Food Programme WFP, Hunger Glossary, available at: http:www.wfp.orghungerglossary Last accessed 30 September 2010 51 Reflects shortness-for-age; an indicator of chronic malnutrition and calculated by comparing the height-for-age of a child with a reference population of well-nourished and healthy children. According to the UN Standing Committee on Nutrition’s 5th Report on the World Nutrition Situation 2005, almost one third of all children are stunted. See: WFP, Hunger Glossary, available at: http:www.wfp. orghungerglossary Last accessed 30 September 2010 52 Reflects a recent and severe process that has led to substantial weight loss, usually associated with starvation andor disease. Wasting is calculated by comparing weight-for-height of a child with a reference population of well-nourished and healthy children. Often used to assess the severity of emergencies because it is strongly related to mortality. See: WFP, Hunger Glossary, available at: http:www. wfp.orghungerglossary Last accessed 30 September 2010 Wasting Stunting Underweight 0.0 10.5 9.5 22.5 24.2 24.2 9.4 10.0 20.0 30.0 40.0 50.0 moderate Percent severe THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 194 THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 195 NTT versus 6.2 Indonesia, and seventh highest for severely stunted children 24.2 per cent NTT versus 18.8 per cent nationally. Even when moderate and severe rates are combined, the rates in NTT are far worse than the national average: wasting 20 per cent in NTT versus 13.6 per cent nationally; stunting 46.7 per cent in NTT versus 36.8 per cent nationally; and underweight 33.6 per cent in NTT versus 18.4 per cent nationally. There are wide disparities among districts in NTT, most of which are explained by ruralurban comparisons see annex 4.2. Rural areas are much worse affected than the urban areas in terms of moderate and severe malnutrition, most likely due to their dependence on unreliable agricultural yields as well as local attitudes towards the consumption of different types of foods see discussion later in this section. From a gender perspective, the nutrition indicators are slightly higher for boys than for girls across the board. This pattern has also been observed at the national level and could be attributed to the phenomenon explained, for example, by Svedberg 1996 53 , who explains that because girls represent an asset for the future of household farming activities, they might be prioritised in terms of care practices and, in particular, feeding practices. Whatever the reason, malnutrition policy needs to take this gender disparity into account. Figure 4.2.7: Percentage of children aged under five suffering from being underweight, stunting or wasting, by rural versus urban area, NTT 2007 Source: Ministry of Health, Riskesdas 2007 As is evident from Figure 4.2.8 below, the prevalence of severely and moderately underweight children has been stagnant over time. The prevalence of underweight children in each district in NTT is also high across the board, with more than 30 per cent of children underweight in 13 of the 16 districts. This highlights the depth of the problem in this region. There is, however, a high disparity among districts with the highest proportion of underweight children in Rote Ndao 40.8 per cent, and the lowest in Kupang municipality 14.3 per cent. 54 Combined with poor agricultural conditions, NTT has the highest TFR in the country 4.2 55 , making tackling malnutrition increasingly difficult. 53 Svedberg, P. 1996 ‘Gender bias in Sub-Saharan Africa: Reply and further evidence’, Journal of Development Studies, Vol.32: 933 54 Ministry of Health 2008 Riskesdas 2007 55 BPS - Statistics Indonesia and Macro International 2008 Indonesia Demographic and Health Survey IDHS 2007, BPS - Statistics Indonesia and Macro International: Calverton, Maryland, USA Figure 4.2.8: Trends in prevalence of moderately underweight and severely underweight children, NTT 1989-2005 Source: Gizi.net 2009 in Working Paper12: A Brief Review on The Persistent of Food Insecurity and Malnutrition Problem in East Nusa Tenggara Province, Indonesia, Siti Muslimatun and Silvia Fanggidae, Institute of Indonesia Tenggara Timur Studies and Oxfam, February 2009 Based on Susenas Perhaps most alarming is that 20 per cent of children in NTT are suffering from wasting moderate and severe. 56 In general, inter-district disparity is not as great as for some other indicators. However one district - Manggarai - stands out as particularly bad with levels of wasting at 33 per cent of children under five years old, with 19.6 per cent of them suffering severe wasting compared to the national rate of 9.5 per cent. Wasting is an acute condition suffered by undernourished children, and children with severe wasting require additional nutrition and immediate rehabilitation of their nutrition status because this condition can be fatal, highlighting a situation of chronic and acute malnutrition in NTT. Furthermore, 20 per cent of all babies are born with low birthweight 2,500 grams, which is an indicator of maternal undernutrition gizi buruk. Again this rate is the third highest among Indonesia’s provinces, and much higher than the national level of 11.5 per cent. 57 Low birthweight is associated with a higher risk of mortality, childhood undernutrition and, in particular, stunting. 58 A low birthweight is strongly associated with increased risks of death for children, which goes some way to explaining why child mortality is high in NTT. Research at the global level indicates that infants born at term weighing 1,500-1,999 grams are eight times more likely to die during the neonatal period. Children weighing between 2,000-2,499 grams are three times more likely to die from all causes during the neonatal period than are those weighing more than 2,499 grams at birth 59 . Furthermore, neonatal deaths among low birthweight babies are often related to conditions such as sepsis, pneumonia and diarrhoea. 56 Ministry of Health 2008 Riskesdas 2007 57 Ministry of Health 2008 Riskesdas 2007 58 BAPPENASMinistry of Health 2010 The landscape analysis: Indonesian country assessment, National Development Planning Board BAPPENAS, Indonesia: Jakarta 59 Black, R. E. et al. 2008 ‘Maternal and child undernutrition: Global and regional exposures and health consequences’, The Lancet, Vol.371: 243-260 Percent 45.00 37.21 8.20 1989 1992 1995 1998 1999 2000 2002 2003 2005 10.19 11.88 15.65 10.13 10.88 11.80 12.52 13.00 36.22 28.26 28.18 23.09 22.72 26.80 25.93 28.00 40.00 35.00 30.00 25.00 20.00 15.00 10.00 5.00 0.00 Underweight Severe Underweight W astin g Stuntin g Unde r- weight Rural Urban Rural Urban Rural 10 20 30 40 50 60 Urban Severe Moderate 4.1 9.8 7.9 25.5 17.5 19.5 25.5 10.3 17.2 23.1 10.5 10.7 THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 196 THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 197

4.2.3.2 Contributing factors to malnutrition in context

The micronutrient status 60 of the population in NTT shows a high prevalence of anaemia among preschool children - over 40 per cent. The anaemia prevalence among children aged 6-23 months was 77.2 per cent, while the provincial figure was 68.4 per cent. 61 A study by UNICEF in three districts Kupang municipality, Sumba Tengah and Sumba Barat Daya, found that at least 24 children had died of malnutrition related causes - including gastroenteritis 2, TB 1, diarrhoea 2, upper respiratory tract infection 1, cancer 1, acute respiratory infection ARI and pneumonia 1, pneumonia 4, ARI 1, malaria and pneumonia 1 and marasmus 1. 62 It is evident from Table 4.2.1 that problems of poor nutrition are more prevalent in NTT compared to Indonesia as a whole, with one third of the province having poor nutritional intake. It is particularly problematic in some of the more isolated and rural districts of the province. Table 4.2.1: Nutritional status, NTT versus Indonesia 2007 Source: NTT Office of Health, based on the Riskesdas 2007 Findings from The Landscape Analysis: Indonesia Country Assessment 63 highlight a shortfall when it comes to coverage of preventative nutritional interventions, which would help to relieve malnutrition. Instead there is a tendency to focus on ‘curative’ approaches when serious situations arise. According to this report, effective preventative interventions would include promotion of and counselling on breastfeeding and complementary feeding, iron folate, protein and energy supplementation for women, worming treatment for women and children, treatment of diarrhoea with zinc, and improved coverage of food fortification and home food fortification programmes. 64 However, there is a lack of data on exclusive breastfeeding practices at the provincial level. While data show that there is a high percentage of under-five children who have been breastfed in NTT at one point during their infancy 97.3 per cent, 2007 IDHS data, it is dificult to ascertain whether they were exclusively breastfed for the first six months of their lives, and whether this was followed by appropriate complementary feeding practices. The results of the focus group discussions discussed in Box 4.2.2 below indicate, however, that exclusive breastfeeding for infants up to six months of age is uncommon in both the districts where the study was conducted, and responses were similar at the provincial level. Severe and moderate malnutrition Indonesia NTT Districts in NTT Rote Ndao Timor Tengah Selatan Kupang district not municipality Timor Tengah Utara Manggarai Percentage 18.4 33.6 40.8 40.2 37.9 37.5 37.3 Adequate nutrition Indonesia NTT Districts in NTT Kupang municipality Ngada Sumba Timur Lembata Manggarai Barat Percentage 77.2 64.4 80.4 71.7 70.9 68.7 67.9 60 Adequacy of vitamins and minerals in the diet 61 Sample taken by SEAMO and CRS in their studies in Belu and TTU in 2006: see WFP December 2006 Food security assessment and phase classification pilot, Indonesia , WFP in cooperation with FAO, National Food Security Council Ministry of Agriculture, Badan Koordinasi Nasional Bakornas, Ministry of Health, SEAMEO, ACF, SMERU and ECHO: Jakarta 62 UNICEF 2008 Rapid assessment of malnutrition in NTT, Kupang Municipality, Sumba Tengah and Sumba Barat Daya, Mimeo: Kupang 63 BAPPENASMinistry of Health 2010 The landscape analysis: Indonesian country assessment 64 Ibid. In addition, the 2007 Basic Health Research Riskesdas data see annex 4.2 demonstrate that poor families in NTT in the lowest three wealth quintiles are less likely to consume adequately iodised salt around one quarter do so compared to those in the wealthiest quintile nearly half. Overall, only around one third of people in the province consume adequately iodised salt. This is also less likely in rural and isolated districts. Furthermore, 2007 IDHS data reveal that only 37.9 per cent of pregnant women receive at least 90 iron tablets albeit an improved rate since 2002- 2003 when it was just 25.4 per cent. As described, the prevalence of anaemia in children is high, exclusive breastfeeding rates are likely low, many poor families don’t consume adequately iodised salt, and many pregnant women do not take adequate levels of iron supplementation. All of these factors are likely contributing to poor nutrition and health in the province. An interview with a staff member of the Ofice of Health in Kupang municipality revealed that they had identified at least 105 children with severely poor nutritional status nine of whom subsequently died, and 3,808 children had moderately poor nutritional status in the municipality in 2009 20 October 2009. The main causes, according to the office staff, were poor understanding of the importance of nutrition in the community and low household incomes. This also highlights that knowledge about nutrition andor cultural consumption patterns are adding to the problem see further discussion below. In order to further explore the context and causes of malnutrition in NTT, FGDs with health practitioners, government staff and community members were conducted at the provincial and district levels 65 , and the results are summarised in Box 4.2.2 below. The findings confirm the opinion of the staffmember mentioned above and also add further information on the complexities of malnutrition in NTT. The summary indicates that the opinions among participants are that malnutrition problems must be solved with a multi-sectoral approach and that the problem is underpinned by food availability, poverty, and consumption patterns based on both cultural practices and access to food. Further discussion later in this subsection also demonstrates poor knowledge of the importance of nutrition, the importance of access to clean water and sanitation, and institutional policies that are inadequate to overcome – and potentially contributing to - the pervasive malnutrition problem in NTT. 65 Focus group discussions were held at the provincial level in NTT, and in Kupang municipality and Sikka districts. Participants included representatives from BAPPEDA District Development Planning Agencies, several civil society organisations CSOs, midwives, nurses, health clinic staff, and staff from the hospital including doctors. CSO staff and BAPPEDA dominated the discussion on putting forward the issues about the causes of malnutrition in NTT. The midwives, nurses, and hospital staff put forward opinons on problems in service provision and the problems they face in providing services to tackle malnutrition. The CSOs tended to be more critical in terms of proposals put forward and offered their opionons, whereas other practitioners only answered questions when asked. CSOs were more likely to be of the opinion that malnutrition was caused by inadequate services and lack of awareness among parents. Midwives and health clinic staff complained of the lack of awareness and knowledge among mothers regarding the nutrition they provide for their children, in addition to factors relating to disease and culture. Planners, such as staff from BAPPEDA and the Ofice of Health, focused on the problems of geographic access, poverty and lack of funds.