BACKGROUND: POPULATION, ECONOMY AND HUMAN DEVELOPMENT

THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 230 THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 231 Figure 4.3.2: HDI, GDI, GEM over time, Papua 1999-2007 Source: HDI - BPSBAPPENASUNDP, Indonesia Human Development Report, 1999-2007; GEM and GDI – BPSThe Ministry of Women’s Empowerment, Gender Based Human Development, 1999-2007 Figure 4.3.3: HDI in selected districts, Papua 2004-2007 Source: HDI - BPSBAPPENASUNDP various years Indonesia Human Development Report 2004-2007

4.3.2 EDUCATION, HEALTH, NUTRITION, AND WATER AND SANITATION

The low level of education in the province of Papua captured as a part of the HDI is indicated by the youth literacy rate 15-24 years, which is much lower than at the national level in 2007 86 per cent versus 98 per cent, respectively. 218 Figures show that while literacy rates in Papua were decreasing in the first part of the decade, there has been considerable improvement from 2006-2008. 219 However, gender inequalities exist, with the number of illiterate women almost 10 218 BPS - Statistics Indonesia 2009 Statistical yearbook 2009, based on the National Socio-Economic Survey SUSENAS 2008 219 Ibid. per cent higher than the number of illiterate men 33 per cent versus 22 per cent, according to adult literacy rates aged 15+ years. 220 While the gender difference among youth is equally wide young male literacy is 10 per cent higher than for young females, yet literacy rates for each gender are higher overall 91 per cent for young males versus 81.5 per cent for young females than among adults, indicating that education efforts are starting to make inroads amongst the younger population. Nonetheless, the net attendance rate at primary schools in Papua was 82 per cent in 2008, and just 49 per cent for junior secondary school compared to national rates of 94 per cent and 67 per cent, respectively. Again gender differences exist, with girls’ attendance rates 2-4 per cent below that of boys. 221 Furthermore, any improvements in these attendance rates at both primary and junior secondary levels have stagnated in recent years. 222 It is important to note that quality of education is uneven across the province. Teachers’ levels of education, presence at schools and ability to teach vary widely, being particularly poor in geographically isolated areas. 223 It is difficult to attract qualified education and health personnel to work in areas without suficient infrastructure. For example, people in Jayapura enjoy comparatively better education and health facilities than do residents of more rural Wamena. In rural areas, non-government organisations NGOs tend to fill in the void of state-run schools. Faith-based organisations provide more than 50 per cent of basic education primary and junior secondary school in Papua. 224 Overall, the shortage of buildings, unequal distribution of teachers, low quality of teachers and other factors have slowed down the development of the education sector in Papua. 225 Special Autonomy has enabled Papua to allocate considerable portions of the budget for the development of various sectors. 226 For example, under the Special Autonomy Law, the provincial government must allocate 30 per cent of the Special Autonomy funds to enhance the development of the education sector. 227 With the enactment of the Provincial Regulation No. 52006 on Educational Development in Papua Province, the government has committed to allocating 30 per cent of its budget for education development in Papua. However, later discussion on policy interventions at the end of this subsection demonstrates that this does not seem to have been realised in practice. Despite considerable improvements in mortality rates over the past 10 years, levels are still higher in Papua than Indonesia as a whole, especially when it comes to under-five mortality rates U5MR. The infant mortality rate IMR was 41 per 1,000 live births in 2007 versus 34 at the national level while the U5MR was 64 per 1,000 live births versus 44 at the national level. 228 Rates were not as high as in NTT in the same year i.e., 57 and 80 per 1,000 live births, respectively. 220 Ibid. 221 Ibid. 222 ibid. 223 Universitas Cenderawasih 2005 Papua public expenditure analysis and capacity harmonization: Papua province report, Universitas Cenderawasih: Jayapura 224 Universitas Cendrawasih 2006 Studi evaluasi kebijakan dan implementasi Otonomi Khusus di Tanah Papua tahun 2002-2006, Universitas Cenderawasih: Jayapura 225 Halmin, M. Y. 2006 The implementation of Special Autonomy in West Papua, Indonesia: Problems and recommendations; Mollet, J. A. 2007 ‘Educational investment in conlict areas in Indonesia: The case of West Papua Province’, International Education Journal, Vol.82: 155-203 226 World Bank 2005 Papua public expenditure analysis 227 Mollet, J. A. 2007 ‘Educational investment in conlict areas in Indonesia: The case of West Papua Province’ 228 BPS - Statistics Indonesia and Macro International 2008 Indonesia Demographic and Health Survey IDHS 2007; BPS and Macro International: Calverton, Maryland, USA; See also data from IDHS 1994 and IDHS 1997. 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 2004 Papua Jayawijaya Kab.Jayapura K ota Jayapura 2005 2006 2007 62.21 62. 8 63. 4 60. 9 47. 1 47. 6 53. 4 52. 67. 2 67. 5 68. 8 70.0 71. 9 72. 1 73. 1 73. 8 1999 45.0 47.0 49.0 51.0 53.0 55.0 57.0 59.0 61.0 63.0 65.0 58.8 55.7 57.4 49.0 61.9 62.8 63.4 54.3 57.1 58.6 59.3 61.1 60.1 60.9 62.1 63.5 63.8 2002 HDI GDI GEM 2004 2005 Year 2006 2007 Index THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 232 THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 233 Levels of malnutrition in Papua are comparable to the national levels and lower than in NTT, and this is certainly an area that needs further attention nationwide. Proportions of children who are underweight, stunted and suffering from wasting stood at 21.2 per cent, 37.6 per cent and 12.4 per cent, respectively, in 2007. 229 However, in some districts the problem of malnutrition is pervasive and rates are above those of NTT. Inter-district disparity is again key, especially for stunting, which varies from 16.7 per cent in Sarmi district up to 57.4 per cent in Waropen district. Part of the issue is that preventative measures are not extensive enough in Papua and programmes such as for immunisation have not been as successfully implemented as in other parts of the country. According to the 2007 Basic Health Research Riskesdas, Riset Kesehatan Dasar, only 32.8 per cent of Papuan children completed their childhood immunisations, while the national average stood at 58.8 per cent. Again, this can largely be attributed to the remote nature of the province, making it difficult to roll out such programmes universally. There is also a problem in Papua of access to clean water and adequate sanitation, which can both affect health and nutrition. Papua is far below the national average in these areas, and while access to adequate sanitation stood at a level similar to NTT in 2008 19.5 per cent in Papua versus 17.9 per cent in NTT, district disparities in Papua are far greater than in NTT, with only 0.6 per cent of the population having access to a private or public latrine in Tolikara district compared to 95.4 per cent in Merauke district, according to 2008 National Socio-Economic Survey data see annex 4.3. Similarly, according to the same data set, access to clean water in Papua is also poor compared to national averages, and below that of NTT 27.8 per cent in Papua versus 45 per cent in NTT, and inter-district disparities are similarly wide see annex 4.3. Papuan Special Autonomy status is intended to protect and empower the indigenous population, including women and children. The Papuan government has shown a political commitment to address health-related challenges through the enactment of the Governor’s Regulation No. 62009 on Health Care Provision for Indigenous Papuans. However, providing universal access to health care remains a challenge for the government, particularly when it comes to vulnerable groups such as poor people, women and children in such a large and geographically disparate province with poor basic infrastructure, such as roads, in many remote parts of the province. 230 Long distances from health services and transportation costs constitute the main causes of low rates of accessing quality health and education services 231 . This situation also creates substantial challenges for HIV and AIDS prevention initiatives in the province discussed later in this subsection. It is important to note that, compared to other provinces, Papua is lagging behind in terms of progress towards achieving the MDGs. 232 Children in Papua also face a number of other insecurities. The rate of early marriages under 18 years is growing in Papua Province from 33 per cent in 2000 to 38 per cent in 2008 and the rate of birth registration for children under five years old has fallen from 37.7 per cent in 2001 to 32.1 per cent in 2007 in both rural and urban areas, according to National Socio-Economic Survey data. Meanwhile, Ministry of Social Affairs puts the number of neglected children in Papua Province at 399,462 see annex 4.3. 229 Ministry of Health 2008 Report on the results of the National Basic Health Research Riskesdas 2007, National Institute of Health Research and Development: Jakarta 230 World Bank 2005 Papua public expenditure analysis 231 Hutagalung, S. A., Arif, S. and Suharyo, W. I. 2009 Problems and challenges for the Indonesian Conditional Cash Transfer Programme - Program Keluarga Harapan PKH . SMERU: Jakarta 232 UNDP 2008 Indonesia human development report As is evident in the discussion above, women and children suffer multiple insecurities in Papua in terms of access to education, health services, nutrition, clean water and sanitation and child special protection. These factors also interact with adolescent sex practices and the problem of growing HIV infection rates in the province, discussed under the next subheading. The economic development in the province and poor infrastructure, as discussed above, also make it difficult to reach rural and isolated communities with HIV and AIDS interventions and initiatives to improve health and education services, which are inadequate in many parts of the province.

4.3.3 HIV AND AIDS PREVALENCE IN PAPUA

Section 3.3 discussed HIV and AIDS and trends in adolescent sex practices in Indonesia. However, given that the rate of HIV infection has reached a low-level generalized epidemic in Papua Province, much of the discussion in Section 3.3 focused on the problem of HIV and AIDS in Papua where the prevalence rate for the population aged 15-49 years is almost eleven times the national prevalence rate of 0.22 per cent. 233 In a province-wide population-based survey conducted in Papua in 2006, adult HIV prevalence was estimated at 2.4 per cent, and reached 3.2 per cent in the remote highlands and 2.9 per cent in less-accessible lowland areas. 234 These rates are somewhat higher among young Papuans. Among 15- to 24-year-olds, HIV prevalence was estimated to be 3 per cent. 235 HIV prevalence among the ethnic Papuans is higher 2.8 per cent compared to non- ethnic Papuans 1.5 per cent. 236 However, this difference does not relect vulnerability based on ethnicity, but rather reflects differences in knowledge levels, particularly related to prevention and safer practices. 237 By 2009, there had been a reported 426 deaths from HIV and AIDS in the province, although the actual number is likely to be higher Figure 4.3.4. Figure 4.3.4: Cumulative reported deaths from HIV and AIDS, Papua 2000-2009 Source: Directorate General Communicable Diseases Control Environmental Health, Ministry of Health 233 Indonesian National AIDS Commission KPA 2009 Country report on the follow up to the Declaration of Commitment on HIV and AIDS UNGASS , National AIDS Commission, Republic of Indonesia: Jakarta, p2. However, provincial level sources put this at 15.4 times that of the rest of Indonesia for Papua province - see Indonesian Ministry of Health 2009 Laporan triwulan situasi perkembangan HIV AIDS di Indonesia sampai dengan 31 Desember 2009 , Ministry of Health: Jakarta; Papua and West Papua AIDS Commission KPA 2008 Strategic communication plan for HIV and AIDS: Prevention and management in Tanah Papua, Indonesia, Papua and West Papua AIDs Commission: Jayapura 234 Papua and West Papua AIDs Commission KPA 2008 Strategic Communication Plan for HIV and AIDS: Prevention and Management in Tanah Papua, Indonesia , 235 Indonesian Ministry of Health 2009 Laporan triwulan situati perkembangan HIV AIDS di Indonesia sampai dengan 31 Desember 2009 236 BPS - Statistics Indonesia and Ministry of Health 2006 Situasi perilaku berisiko dan prevalensi HIV di Tanah Papua, BPS: Jakarta 237 Ibid. 50 100 150 200 250 300 350 400 450 95 112 140 149 107 192 221 238 426 351 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Number THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 234 THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 235 As discussed in Section 3.3, as of 2010, there were an estimated 14,228 cumulative cases of children living with HIV, and this is expected to increase to 34,287 cases by 2014, for Indonesia overall. 238 Although data on the incidence of mother-to-child transmission MTCT are still limited, the number of HIV-positive pregnant women is increasing. There were an estimated 5,170 who were HIV-positive pregnant women in Indonesia in 2009. 239 Of that number, only 196 received antiretroviral ARV drugs to reduce the risk of MTCT 3.8 per cent, indicating limited prevention of mother-to-child transmission PMTCT services. 240 It is projected that the number of HIV-positive women needing PMTCT services will increase from 5,730 people in 2010 to 8,170 people in 2014. 241 Furthermore, the number of children infected by their HIV-positive mothers at birth or through breastfeeding is expected to double from estimates of 2,470 in 2008 to 6,240 in 2014. 242 Finally, it is estimated that 1,070 babies were born with HIV in 2008 and this is expected to rise to 1,590 in 2014. 243 Given that the prevalence of HIV is highest in Papua and accounts for a large proportion of the infection rates mentioned above, it is important that initiatives focus on prevention for both women and children. Yet, in 2009 in Papua Province, 58 women accessing PMTCT HIV services tested positive for HIV but only 13 of these received ARV treatment. 244 Furthermore, there is likely a very high level of underreporting of HIV and AIDS cases given the low knowledge of HIV discussed below. All of this indicates that there is great scope for improvements in the coverage of the initiatives outlined in Section 3.3 for more effective HIV prevention.

4.3.4 CONTRIBUTING FACTORS TO THE GROWING RATES OF HIV INFECTION IN PAPUA PROVINCE

4.3.4.1 General overview The discussion in Section 3.3 highlighted that in most parts of Indonesia the problem is concentrated in high-risk populations, including intravenous drug users IDUs, men who have sex with men MSM, sex workers and their clients, and the sexual partners of all of these groups. It also outlined the changes in the types of infected populations, highlighting that growing numbers of women - particularly the partners of IDUs and of male clients of sex workers - are being exposed to HIV infection, and thus there has been a feminization of the epidemic. 245 This could also lead to higher rates of children born with HIV. Section 3.3 highlighted that according to government reports, the two worst affected provinces in Indonesia are Papua and West Papua, and the generalized epidemic in these provinces is driven almost entirely by unsafe sexual intercourse, with HIV prevalence of 2.4 per cent among the general population aged 15-49 years. 246 Various other reports cited in Section 3.3 found that the patterns of HIV transmission are somewhat distinct in Papua, attributing this to the following factors: 238 BAPPENAS, National AIDS Commission KPA, UNICEF, and UNAIDS 2008 Mathematic model of HIV epidemic in Indonesia 2008- 2014 , Jakarta 239 Indonesian National AIDS Commission KPA 2009 UNGASS report, pix 240 Ibid. 241 BAPPENAS, et al. 2008 Mathematic model of HIV epidemic in Indonesia 2008-2014; see also the National AIDS Commission KPA 2010 National HIV and AIDS strategy and action plan 2010-2014 , KPA: Jakarta 242 BAPPENAS, et al. 2008 Mathematic model of HIV epidemic in Indonesia 2008-2014, p20 243 Ibid., p18 244 Ministry of Health, Directorate for Direct Transmitted Disease Control 2009 Internal report, Ministry of Health: Jakarta 245 BAPPENAS, et al. 2008 Mathematic model of HIV epidemic in Indonesia 2008-2014, Jakarta, p17 246 BPS - Statistics Indonesia and Ministry of Health 2007 Risk behavior and HIV prevalence in Tanah Papua, BPS: Jakarta. The data for this report were collected in 2006. • HIV transmission is largely taking place through unprotected sex and the frequent changing of partners. 247 • The early onset of sexual activity. 248 • Lack of knowledge about reproductive health, sexually transmitted infections STIs and means of protection. 249 • Low usage, availability and accessibility of condoms also play a part in the rapid spread of HIV infection. 250 • Women and girls tend to lack information as well as lack a voice in sexual decision-making, increasing their vulnerability to infection. 251 • Root causes and challenges, including poverty, low levels of education and knowledge of HIV, and isolation in rural highland communities. 252 Focus group discussions FGDs with government education officials at the provincial level and in Jayapura municipality, and with teachers, principals, civil society organisation CSO workers, health practitioners and health officials, also sought to identify what has led to the increase in the HIV epidemic in Papua. In addition to the factors identiied in the other reports discussed above, FGD participants also highlighted a range of contributing factors to HIV transmission and associated vulnerabilities which they related to poverty, the growing sex industry, sexual practices, unsafe sex, knowledge, stigma, attitudes towards illness, and structural problems with implementing policies, such as the regulatory environment and a lack of district level funding for initiatives see Box 4.3.1. Box 4.3.1: Contributing factors to HIV prevalence and emerging efforts to combat this in Papua - FGD results Views on contributing factors to HIV transmission: • The vast proportion of HIV transmission is through sexual intercourse. • It is common practice for men and women to have multiple sexual partners. • Drunkenness affects judgement and the likelihood that people will engage in unprotected sex. • The reality is that half of Jayapura’s population has never even heard of HIV or AIDS emphasised by health practitioners. • Women with low education don’t seek out prenatal care and relevant tests often until they are eight or nine months pregnant, when it is very late to initiate efforts to prevent transmission to their babies. Even if they know about HIV, if they can’t see how they might have been affected they are offended if they are offered Voluntary Counselling and Testing VCT services, as they associate it with being accused of having done something immoral. • HIV and AIDS is still highly stigmatized among those who know about it. When a woman or a child is found to be infected with HIV and AIDS they are often driven out of the house by their families, resulting in increasing numbers of street children exposed to other vulnerabilities. 247 UNDP 2005 Papua needs assessment: An overview of findings and implications for the programming of development assistance, UNDP: Jakarta Indonesia, cited in Indonesian National AIDS Commission KPA 2009 UNGASS report, p25 248 KPA 2009 UNGASS report, pp24 249 Ibid. 250 Ibid. 251 Ibid. 252 GoIUNICEF 2009 Averting new HIV infection in young people in Papua and Papua Barat: An education sector response, January 2010-December 2013 , GoIUNICEF: Jakarta