Child nutritional status: Underweight, wasting, stunting and overweight

108 by 17.8 per cent. No less important than the problem of undernourishment is the problem of obesity in children, which often escapes the attention of the government. The average prevalence of overweight children under the age of five in Indonesia in 2007 was 12.2 per cent, increasing to 14 per cent in 2010. There were 18 provinces that recorded a prevalence of obesity above the national average in 2007, and a decrease occurred in 12 provinces in the period between 25 20 15 10 5 50 45 40 35 30 25 20 15 10 5 Rural Rural Q2 Q2 Q5 Q5 Urban Urban 2007 2010 2007 2010 Q1 Q1 15.9 32.7 15.2 31.4 20.4 39.9 22.1 40.5 19.5 38.9 18.1 37.2 16.5 34.1 13.7 30.3 20.7 40.0 22.7 43.1 19.1 38.9 17.6 34.0 15.2 30.7 10.5 24.1 Q4 Q4 Q3 Q3 Source:฀RISKESDAS฀2007฀and฀2010 Source:฀RISKESDAS฀2007฀and฀2010 Figure 3.19: Prevalence of underweight children under age five by urbanrural location and household expenditure, 2007 and 2010 Figure 3.20: Prevalence of stunting among children under age five by urbanrural location and household expenditure, 2007 and 2010 2007 and 2010. The highest prevalence of obesity in 2007 occurred in South Sumatra Province 20.9 per cent and in 2010 it was in Jakarta 19.6 per cent. The lowest prevalence of overweight children in 2007 was in Gorontalo 6.8 per cent and in 2010 it was in North Maluku 5 per cent. Children who suffer from being overweight, a problem that has always been associated with rich households, are also found in poor households. In 2007, 12.2 per cent of under- fives were overweight. The data showed in the 109 poorest households quintile 1, 11.2 per cent of under-fives were overweight as were 5.7 per cent of children aged 6–14 years, and these numbers were not far below the rates in richer households Figure 3.22. Based on the region, the prevalence of overweight children was slightly more common in urban areas than in rural areas for both under-fives and children aged 6–14 years. In 2010, the proportion of under-fives suffering from being overweight had increased to 23.2 per cent RISKESDAS 2010. Children may become overweight due to their 18 16 14 12 10 8 6 4 2 Rural Q2 Q5 Urban 2007 2010 Q1 13.1 12.5 14.1 14.6 13.9 14.3 13 12.9 14 16.8 13.9 14.2 12.1 10.6 Q4 Q3 Source:฀RISKESDAS฀2007฀and฀2010 Figure 3.21: Prevalence of wasting among children under age five by urbanrural location and household expenditure, 2007 and 2010 of under 5 years old children 16.0 14.0 12.0 10.0 8.0 6.0 4.0 2.0 - Rural Q2 Q5 Urban Under 5 years old 6-14 years old Q1 12.4 7.1 12.0 11.2 11.8 11.9 12.8 14.0 6.0 5.7 5.8 6.1 7.1 8.3 Q4 Q3 Source:฀RISKESDAS฀2007 Figure 3.22: Prevalence of overweight children by urbanrural location and household expenditure, 2007 individual characteristics and behaviours, including genetic factors and behaviours such as poor or inadequate dietary intake, lack of physical activity and an increase in sedentary behaviour Davison and Birch, in Crowle and Erin, 2010. In 2007 among children aged 10–14 years as many as 63.1 per cent of children frequently ate sweet foods Figure 3.23. Over time, excess sugar can cause children to become overweight. In childhood, being overweight can result in respiratory disorders and diabetes, 110 among other health problems. According to UNICEF’s nutritional framework, malnutrition is influenced by multiple factors. Malnutrition is directly caused by unhealthy food consumption patterns and ill health, and indirectly influenced by child care, food availability, genetic factors, as well as social, economic, cultural and political factors.

3.5 Recommendations

Despite the various programmes initiated to improve the survival and health of Indonesian children, and the special attention and assistance being directed to the poor, the fact remains that children living in remote areas, in income- poor households and in households with low educational achievement are still more likely to be deprived. More resources and collaborative efforts are needed to increase the effectiveness of existing health programmes. Additionally, in terms of nutrition, the government has already implemented many programmes to address with nutritional problems. It has improved the situation at the national level, but these gains are not equally distributed between urban and rural areas, or across households with different consumption levels. Thus, special attention is needed to target the children of the households in the poorest quintile, and in rural areas. To improve the supply side, the government needs to: 1. Increase the budget allocation for health at the national, provincial and district levels to achieve the level required by the law. The budget allocation for child and maternal health should be increased and more equally allocated between curative and preventive efforts. The budget for nutrition improvement should also be increased, with a larger proportion being allocated to poor and vulnerable groups in society. 2. Develop more facilities in remote regions, distribute health personnel more equally, and increase the availability of medical equipment for respiratory aid in health centres and in every village. 3. Increase the effectiveness and reach of national and regional health insurance schemes so that all income poor households benefit. This includes increasing the role of health personnel to assist the poor in obtaining health assistance and better coordination across relevant institutions at the local level. 4. Increase the skills of village midwives to handle asphyxia in newborns. 5. Subsidize the cost of childbirth attended by a midwife, so that the cost is lower than that of a traditional birth attendant and can be paid in flexible instalments. 6. Improve the environmental conditions of housing for the poor. This will need strong cooperation between the Ministry of Public 80 70 60 50 40 30 20 10 Salty Innards Caffein Flavouring Sweet Fatty 63.1 24.4 13.5 2.1 5.6 8.6 16.3 75.7 Preserved Roasted Source:฀RISKESDAS฀2007 Figure 3.23: Prevalence of unhealthy food consumption in children aged 10–14 years, 2007 of 10-14 years old children 111 Works, the Ministry for Public Housing and the Ministry of Health, at the national and local government levels, in order to support the improvement of clean and healthy lifestyle behaviours. 7. Expand the focus of children’s health to include all children under the age of 18, not only under-fives, and focus attention on the prevention of pneumonia in addition to diarrhoea. 8. Improve monitoring and evaluation mechanisms to ensure full implementation of the minimum service standards SPM at the district level. 9. Adjust the current programme, which is quite general, to be more targeted towards the most deprived regions and households. 10. Increase the attention given to stunting. 11. Improve monitoring systems to allow for more frequent and inclusive monitoring of the nutritional status of children and pregnant women. Also, ensure the availability of valid and reliable data on child and maternal nutritional status. To support the demand side, there needs to be an increase in health-related knowledge and awareness, particularly among parents with low education levels, in order to reduce child mortality. This could be supported by a local government effort to increase the number of puskesmas implementing Integrated Management of Childhood Illness IMCI. In addition, there should be a mainstreaming of male roles in caring for under-fives during the period of antenatal and post-partum care. This could be achieved by expanding the coverage of Suami Siaga Alert Husbands. This requires the support and involvement of community leaders in places of worship, village offices and traditional adat institutions. In relation to nutrition, there is a lack of awareness among low income parents about the importance of nutrition, causing many children to have poor dietary habits. Parents are paying less attention to their children’s nutritional requirements, although this is essential during their growth period. To overcome this problem, the government should endeavour to raise awareness among parents about the importance of nutrition, especially the nutritional content of daily meals. This can be done through counselling in puskesmas and posyandu, and mass nutrition education campaigns. 113 CHAPTER 4 Education

4.1 Laws and policies on education

The right to receive basic education in Indonesia is guaranteed in the nation’s constitution. Chapter XIII, Article 31 in the Indonesian Constitution UUD 1945 clearly states that every citizen has the right to receive an education, and that the government has to provide the necessary resources to operate a national education system. In addition, an amendment to the constitution mandates that the government is obliged to allocate a minimum of 20 per cent of the state and regional budgets to education. The specific foundation for the framework of the education system in Indonesia is provided by Law No. 202003 on Education. It unambiguously states that education must be delivered to all citizens without any form of discrimination and that this education, at least for basic level education, shall be free from tuition fees. As education expenses do not consist solely of tuition fees, but include other related costs such as those for books, uniforms, and fares, the law also mandates that students have the right to receive an educational grant if hisher parents are not able to bear the cost of education expenses. Moreover, it emphasizes that every citizen should complete nine years of compulsory education. This goal was later reinforced by Presidential Instruction No. 52006, on the National Movement to Hasten Compulsory Nine-Year Basic Education Attainment and the Fight against Illiteracy. The educational policy directions and objectives are set out in the National Medium-Term Development Plan RPJMN and in the Strategic Plan of the Ministry of National Education Kementerian฀Pendidikan฀Nasional, MoNE. General objectives for the next five years are set out in the RPJMN 2010–2014, which states that the education development aims are to improve equal access, quality, relevance and efficiency in education management. The specific targets are: 1 to increase the net enrolment rate in primary schools from 95.14 per cent in 2008 to 96 per cent in 2014; 2 to increase the net enrolment rate in junior secondary school from 72.28 per cent in 2008 to 76 per cent in 2014; 3 to increase the gross enrolment ratio in senior secondary schools from 64.28 per cent in 2008 to 85 per cent in 2014, 1 and;4 to reduce disparities in participation 1 The net enrolment rate NER at any particular level of education e.g., primary is the proportion of children of official school age at that level who are enrolled in education at that level as a percentage of the total number of children of that age group. The gross enrolment ratio GER is the proportion of pupils enrolled in a given level of education, regardless of age, expressed as a percentage of the population in the theoretical age group for that same level of education. 114 coverage of basic education, reducing the school participation gap between children in urban and rural areas, and improving the quality of basic education services. To this end, several important and large scale programmes have been crafted and implemented over the past several decades. One particular programme that laid the foundation for increased equality in access to primary education was the ‘Sekolah Dasar Inpres’ programme. This programme was implemented between 1973 and 1978, during which time the government constructed one primary school building for every 1,000 children in each district and recruited the additional teachers needed for the new schools. With US500 million in funding, more than 61,000 primary schools were established across districts, while the number of teachers increased by 43 per cent over the period Duflo, 2001. This programme significantly raised enrolment rates among children aged 7–12 years, from 69 per cent in 1973 to 83 per cent in 1978. The impact of this programme on these children’s futures and the quality of education services across regions, genders, social economic groups, and among education services that are implemented by the government and by private institutions. In order to attain these goals, the Ministry of National Education has outlined more strategic and specific plans in their Strategic Plan 2010– 2014 Rencana Strategis, Renstra. In comparison to the previous Strategic Plan 2004–2009, the current Strategic Plan places more emphasis on increasing equitability and ensuring access to educational services Table 4.1, whereas the 2004–2009 plan paid more attention to improving the quality of education and education management.

4.2 Key national education programmes

As a developing nation, Indonesia still faces challenges in achieving universal or near- universal coverage at every level of education. Hence, inarguably, the emphasis of government intervention in the education sector should primarily be focused on achieving universal Source:฀Ministry฀of฀National฀Education฀Kementerian฀Pendidikan฀Nasional,฀Strategic฀Plan฀2010–2014 Notes:฀NER=net฀enrolment฀rate;฀GER=gross฀enrolment฀rate Table 4.1: Strategic objectives of national education policy, 2010–2014 Level Early childhood education ECE Primary education SDMIPaket A Junior secondary SMPMTsPaket B Senior secondary SMAMASMK Strategic objectives - National GER ≥ 72.9 - At least 75 of provinces have GER ≥ 60 - At least 75 of cities have GER ≥ 75; at least 75 of districts have GER ≥ 50 - Teacher qualifications: o Formal ECE: 85 have a universitydiploma degree, and 85 have a certificate o Informal ECE: 55 have been trained - National NER ≥ 96 - At least 85 of provinces have NER ≥ 95 - At least 90 of cities have NER ≥ 96; at least 90 of districts have NER ≥ 94 - Enrolment rate of children aged 7-12 is 99.9 - Teacher-student ratio from 1:20 to 1:28 - National NER 76.8 - National GER ≥ 110 - At least 90 of provinces have GER ≥ 95 - At least 80 of cities have GER ≥ 115; at least 85 of districts have GER ≥ 90 - Enrolment rate of children aged 13-15 is 96 - Teacher-student ratio from 1:20 to 1:32 - National GER ≥ 85 - At least 60 of provinces have GER ≥ 80 - At least 65 of cities have GER ≥ 85; at least 70 of districts have GER ≥ 65.