Contributing factors to malnutrition in context
THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 200
THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 201
Stuttard 2008
66
expands on and confirms some of the issues raised above in her report on nutrition in NTT. According to her findings in relation to low nutritional value of foods
consumed
67
, people’s diets in NTT are predominantly based on staple carbohydrate foods such as rice, cassava, corn and banana. Almost 50 per cent of people in her study had eaten no
vegetables or fruit in the last 24 hours, and more than 50 per cent had not consumed protein such as fish, meat or eggs, with many believing that protein rich food are not necessary for a healthy
diet. School children’s liquid intake was low, less than one litre per day, and 39 per cent reported drinking non-boiled water. Regarding breastfeeding, Stuttard finds that while the majority of
mothers do breastfeed their babies, most do not do so exclusively and very few are breastfeeding exclusively to six months of age. Babies are fed complementary foods from as early as one
month old. Around a third of women do not feed their babies colostrum.
Based on the results of FGDs with children themselves
68
, parents and children do not always acknowledge that malnutrition is a major problem for the general population, and participants
said that the problem occurred infrequently in their own neighbourhoods. This attitude potentially highlights the greatest barrier to overcoming malnutrition in the region, and most likely
underpins the lack of commitment to addressing the problem both at the community and political level. This inding is reinforced by ‘The Landscape Analysis’ report
69
which finds that the existing commitment to act for nutrition is misdirected at trying to resolve acute nutrition problems, rather
than putting into place systems and interventions to prevent children and women becoming malnourished, largely because the need for the latter is not generally recognised. According to
this study, the nutrition problem is still largely equated with severe undernutrition andor lack of food. Parents also highlighted that malnutrition is stigmatised, and that it carried a lot of shame
for parents if their children are classed as malnourished. In many cases where a child was classed as malnourished, the parent would dismiss the diagnosis of the health professional and refuse to
visit the health centre again for regular monitoring.
In terms of cultural practices relating to nutritional consumption and childbirth, health practitioners, civil society organisation CSO workers and midwives who participated in the
FGDs also highlighted in more detail a number of issues that may be preventing improvements in nutrition in NTT, which require concerted efforts to build knowledge and education for behaviour
change. Many highlighted the importance of including traditional and religious leaders in this process as they have influence over local communities. Some of the constraints highlighted
included:
• Despite wide availability, consumption of some nutritious foods is prohibited by local customs in some villages, e.g., chickens, eggs and fish
• It is a local tradition for women to eat only porridge after birth in some places • Women are considered unattractive if they put on weight, therefore they are discouraged from
eating much food • Decisions about medicines, treatment and birth are still dominated by men
• Women dispose of colostrum in some places as it is considered dirty • Busy working women are more likely to give sugared water or sweet tea to babies instead of
breastfeeding • It is frequent practice to give rice to children without vegetables, especially when parents have
limited cooking skills or understanding about food
66 Stuttard, J. 2008 Nutrition assessment report, NTT Province, TTS District 67 Based on the analysis of the 24-hour dietary intake of almost 150 primary school children and women of reproductive age
68 Focus group discussion with seven children, Kupang 9 September 2009 69 BAPPENASMinistry of Health 2010 The landscape analysis: Indonesian country assessment
• Older siblings tend to care for the young while their parents work, and they lack knowledge of how to prepare food and the importance of nutrition
Children themselves understood that it is the rural poor populations that suffer most, especially during a drought, which conirms the indings in this report. One participant, ‘Mawar’ talked
about her experience living in Rote during dry season when food was not only less available, but also lower in nutritional value - typically rice with sweet water.
70
Another key group affected by malnutrition that the children talked about were children living on the streets. A participant told
the story of ‘Kocar’ not his real name, a 14-year-old male child labourer who lives on the street and works as a transport driver’s assistant, having left primary school in Year 4. Children living on
the streets are considered to be the ‘scum of society’ and are afraid of authority igures, such as the police, who intimidate them rather than offer support.
“Kocar uses the little money he earns to purchase cigarettes and alcohol and rent a ‘PlayStation’, which he considers to be basic needs. He sometimes only eats twice a day and if he wants to eat
something special, he will not hesitate to steal it or beg for it. He has six brothers and sisters and they are classed as a poor family.” Interview, 18 September 2009
Children were aware of programmes that have been put into place to alleviate malnutrition, such as provision of food to families with malnourished children, provided either via midwives or the
community health service. They also talked about other poverty and hunger relief programmes such as Direct Cash Transfers BLT, Bantuan Langsung Tunai and Rice for the Poor Raskin, Beras
Miskin, which some considered to be very important. The children also talked about problem areas where relief programmes were lacking, such as efforts to change parents’ attitudes and
understanding of malnutrition, as well as negative attitudes towards children living on the streets.
4.2.3.3 Mortality Undernutrition is associated with 60 per cent of deaths among children under five years of age.
71
So it is not surprising that, as shown in Figure 4.2.9 below, child mortality is a serious problem in NTT and has received attention from various stakeholders. The latest infant mortality rate IMR
for NTT is 57 per 1,000 live births, compared to 34 in Indonesia overall. Not only has the IMR remained well above the national average between 1994-2007, but the figure has not reduced
significantly since 2003, indicating that the efforts to alleviate IMR in this province have not yielded satisfactory results, which has driven the creation of new policies on malnutrition, as
discussed further later in this subsection. Much stronger efforts will have to be made to reach the MDG for IMR, which is set at 19 per 1,000 live births by the year 2015. There are three main
factors that contribute to infant mortality, according to data from the Provincial Ofice of Health 2010. These are asphyxia 311, low birthweight 230 and infections 61, followed by a variety
of other factors.
72
In addition, the under-five mortality rate U5MR in this province is also significantly higher than the national figure and, more worryingly, has been increasing over time, from 73 per 1,000 live
births in 20022003 to 80 in 2007. Over the same period, the national figure has been decreasing. This indicator is still a long way from the MDG target of 32 per 1,000 live births by 2015.
70 Sweet water is derived from palmyra trees, especially the fruit 71 Pelletier, D. L., Frongillo, E. A. Jr., Habicht, J.-P. 1993 ‘Epidemiologic evidence for a potentiating effect of malnutrition on child
mortality’, American Journal of Public Health , Vol.83: 1130-1133
72 NTT Provincial Ofice of Health May 2010 Infant mortality data, 2009, NTT Provincial Ofice of Health: Kupang
THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 202
THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 203
Figure 4.2.9: Trends in IMR and U5MR, NTT versus Indonesia, 1994-2007
Source: IDHS 2007
According to Provincial Ofice of Health data from 2009, 1,377 babies were stillborn, neonatal deaths 0-6 days accounted for a further 794 deaths, and babies who died between 7-28 days
post-neonatal deaths constituted 184 cases that year.
73
The worst affected districts for stillbirths were Timor Tengah Selatan, Timor Tengah Utara, Manggarai Timur, Manggarai, Manggarai
Barat, Sumba Barat Daya and Flores Timur.
74
There may also be problems of underreporting for stillbirths given that many births take place at home see further discussion below.
The maternal mortality rate MMR is also an issue in NTT, however the trend has been moving in a positive direction between 2004-2007. Based on NTT Ofice of Health reported igures, the MMR
for 2007 was 306 per 100,000 live births, down from 554 in 2004.
75
Although there is still some way to go, if decreases continue along these lines, NTT could reach the maternal mortality MDG
of 110 per 100,000 live births by 2015. In the meantime, the government of NTT is aiming for its own target of a decrease in MMR to 150 by 2013.
76
According to data from the NTT Provincial Ofice of Health, the main direct causes of maternal mortality in 2009 were haemorrhage,
infections during pregnancy and infections during birth.
77
The ability to provide skilled assistance by health personnel during delivery plays a significant role in reducing infant and maternal mortality rates and the elevated MMR and IMR in NTT
is associated with low access to skilled delivery assistance see Figure 4.2.10. This is also discussed in Section 3 of this report in the subsection on assisted births, which outlines the GoI’s
Making Pregnancy Safer programme that is largely focused on increasing the number of assisted births. Following some good gains in the first half of the decade, the figures from 2004-2008
did not show any significant increase. The 2008 National Socio-Economic Survey data in line with 2007 IDHS data from the previous year showed that only 46 per cent of all deliveries were
attended by skilled health personnel, and NTT ranks thirtieth out of Indonesia’s 33 provinces in this regard. While rates of births assisted by skilled personnel are growing in NTT see annex
73 Ibid. 74 Ibid.
75 NTT Provincial Ofice of Health 2008 Health conditions in NTT 2008, NTT Provincial Ofice of Health: Kupang 76 NTT Provincial Government 2008 NTT Medium-Term Development Plan, NTT Provincial Government: Kupang
77 NTT Provincial Ofice of Health May 2010 Maternal mortality data, 2009, NTT Provincial Ofice of Health: Kupang
4.2, this is still far below the national average. National Socio-Economic Survey data revealed that in rural areas in 2008, the rate of assisted births by skilled personnel was 40.6 per cent,
compared with 76.6 per cent in urban areas of NTT, a wide disparity that indicates the need for a focus on this problem in the rural corners of the province.
Figure 4.2.10: Percentage of births attended by trained heath personnel, NTT 2000-2008
Source: BPS - Statistics Indonesia, Statistical Yearbook 2009, based on the National Socio-Economic Survey 2008
The ability to provide skilled assistance by health personnel during delivery plays a significant role in reducing infant and maternal mortality rates and the elevated MMR and IMR in NTT is
associated with low access to skilled delivery assistance see Figure 4.2.10 above. This is also discussed in Section 3 of this report in the subsection on assisted births, which outlines the GoI’s
Making Pregnancy Safer programme that is largely focused on increasing the number of assisted births. Following some good gains in the first half of the decade, the figures from 2004-2008
did not show any significant increase. The 2008 National Socio-Economic Survey data in line with 2007 IDHS data from the previous year showed that only 46 per cent of all deliveries were
attended by skilled health personnel, and NTT ranks thirtieth out of Indonesia’s 33 provinces in this regard. While rates of births assisted by skilled personnel are growing in NTT see annex 4.2,
this is still far below the national average. National Socio-Economic Survey data revealed that in rural areas in 2008, the rate of assisted births by skilled personnel was 40.6 per cent, compared
with 76.6 per cent in urban areas of NTT, a wide disparity that indicates the need for a focus on this problem in the rural corners of the province.
Section 3 discussed the importance of births taking place in institutions such as hospitals and clinics, especially to assist with complicated deliveries. In contrast to national figures, far more
people in NTT give birth at home 77.5 per cent compared with 52.7 per cent at the national level and only 16.1 per cent give birth in a public health facility according to 2007 IDHS data. There
have only been marginal improvements since the 2002-2003 IDHS was implemented. Many poor patients who live far from health facilities choose traditional healers instead of doctors to address
health issues according to data from the 2007 Basic Health Research Riskesdas, especially for deliveries. This together with the lower rates of skilled birth attendance may go some way to
explaining the stubbornly high IMR in the province. High rates of child marriage under age 18 years in the province, at 19.8 per cent of children, according to 2008 National Socio-Economic
Survey data, may also be related to mortality rates if girls are becoming mothers when they are very young, underdeveloped or suffering from poor nutrition, all of which can make delivery
more risky.
32.34 2000
30 32
34 36
38 40
42 44
46 48
2001 2002
2003 2004
2005 2006
2007 2000
34.39 37.25
38.40 46.11
45.26 43.38
42.46 46.05
120.0
IMR
Indonesia East Nusa Tenggara
USMR
66. 71.
52. 2
59. 7
43. 59.
4.0 57.
92. 8
107. 5
70. 6
90. 1
46. 73.
44. 80.
IDHS 1994 IDHS 1997 IDHS 2002- 2003
IDHS 2007 IDHS 1994 IDHS 1997 IDHS 2002- 2003
IDHS 2007 100.0
80.0 60.0
40.0 20.0
0.0
Per cent
THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 204
THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 205
While each district in NTT has a general hospital and there are also a few private and army hospitals, in 2003 there was a total of only 1,994 beds for over 4 million people, or around 1
bed per 2,000 population BPS – Statistics Indonesia, NTT, 2004, which is a long way from the ideal ratio of 1:500. In 2008, there were 33 general hospitals and 2 specialist hospitals, 284
puskesmas usually found at the sub-district level, 938 puskesmas pembantu pustu and 304 mobile units. Most puskesmas had an attending doctor, albeit not always full-time. During the
field research for this report it was evident that in rural areas pustu were often short of drugs and understaffed. Finally, there were 8,304 integrated health posts posyandu, catering especially
for nursing mothers and children, sometimes numbering several per village.
78
These are run by trained volunteers and, according to a study by Barlow and Ria
79
, have proved a most effective provider of services. It is admitted, however, that these health facilities have not reached some
areas of NTT and that some posyandu are not considered helpful in improving maternal and child health.
80
To address this, an initiative termed ‘Revolusi KIA’ maternal and child health revolution has been launched by the Health Ofice Dinas Kesehatan to reduce MMR and IMR by revitalizing
posyandu. The initiative is discussed later in this subsection.
In 2007, the number of health personnel working at various health facilities
81
was 9,133, comprising 772 doctors, 6,675 nurses and midwives, and 1,860 other health professionals.
82,83
This is equivalent to a ratio of 205 health professionals per 100,000 population, and represents a 65 per cent increase from 2005-2006 and a 33 per cent increase from 2006-2007. This figure is still
some way from the target of 158 per 100,000. The landscape of NTT and lack of funding are major factors in the province’s lacking of medical facilities, and access is particularly problematic for
island areas such as Pulau Pura, Ende, Raijaua, Palue and Ndao.
84
To deal with this issue, one of the goals highlighted in the 2009-2013 Regional Medium- Term Development Plan RPJMD, Rencana Pembangunan Jangka Menengah Daerah for the
health sector is to develop a health care system for the poor. This has been in place in Kupang municipality since 2008 based on the Mayoral Regulation on Free-of-Charge Health Services
in puskesmas and their networks for poor and underprivileged people
85
. To implement this regulation, the mayor of Kupang followed it with a Mayoral Decree.
86
In practice, however, the procedure to get health insurance for the poor is quite complicated and poor people are thus
reluctant to access public health services.
This is an even more pervasive problem in rural areas and in areas with large numbers of Internally Displaced People IDPs. In the case of Belu District and other areas such as Timor
Tengah Utara and Kupang, where there are large numbers of IDPs who fled the conflict in what was once East Timor now Timor-Leste, there is even greater pressure on health resources. As
many as 200,000 people fled to West Timor in the province of NTT, living in camps and army barracks.
87
Between 1999-2003, NTT was classed as being in an emergency phase by the GoI and UNHCR. When Timor-Leste became independent, many IDPs remained in Indonesia.
78 NTT Provincial Ofice of Health 2008, Health conditions in NTT 2008 79 Barlow, C. and Gondowarsiot, R. 2007 Economic development and poverty alleviation in Nusa Tenggara Timur
80 NTT Provincial Ofice of Health 2008, Health conditions in NTT 2008 81 Puskesmas, hospitals, and health personnel at district and provincial levels
82 Pharmacists, nutritionists, medical technicians, community health-care workers. 83 NTT Provincial Ofice of Health 2008, Health conditions in NTT 2008
84 Interview with staff of the NTT Child Protection Commission 21 November 2009 85 Mayoral Regulation No. 112008 on Free Health Services in Puskesmas and Corresponding Network for Poor People at Kupang
Municipality 86 No. 78KEPHK2008 on Determining Health Insurance Beneiciaries in Kupang Municipality 2008, and Mayor Decree No. 104.AKEP
HK2008 on Determining Free Health Service Beneiciaries for the Poor and Non Jamkesmas Health Insurance Beneiciaries in Kupang city
87 Djami, M., Filiana Tahu, M. and Sesilia 2007 Perempuan pengungsi masih terlupakan. Laporan bersama kondisi pemenuhan HAM perempuan pengungsi Aceh, Nias, Yogyakarta, Porong, NTT, Maluku dan Poso, Komnas Perempuan: Jakarta
However, this has caused tensions between host and IDP communities.
88
Homes have been burnt down or damaged, and there are violent clashes between IDPs and host communities which
have continued beyond the emergency phase.
89
These conflicts are underpinned by disputes over access to resources and employment, as well as the occupation of communal lands and
or indigenous land by the IDPs.
90
The situation is further complicated by individual land conflicts such as cases where IDPs have been unable to make all payments for land purchases, and
disputes over land rights, particularly in Belu district.
91
Resettlement and livelihood assistance for IDPs has also generated tensions in host communities who are less likely to receive such
assistance, even though poverty levels are high in Belu
92
, as one respondent stated: “So, local residents can just watch; wherever there are IDPs, assistance comes. Clean water
is provided, toilets, plates, all kinds of things for the kitchen. It continues to be provided by all variety of NGOs. So local residents watch this unfold and it stimulates jealousy, as we don’t
have toilets, for example. Why is it not given to us?” Local resident, Belu district, 17 August 2010
However, one of the great dificulties that IDPs face is organising appropriate letters and documentation of ‘poor status’ in order to access free or cheap health care. If IDPs are assisted by
CSOs and non-government organisations NGOs they may succeed in organising the appropriate documentation, but are less likely to be able to do this alone.
93
Staff from the Center for Internally Displaced People argue that the main problem is the ‘extra fees’ charged by neighbourhood
heads and village staff for this documentation, which should be provided for free. This is further complicated by complex and long administrative processes.
94
Maternal and child mortality rates tend to be higher in IDP camps due to these difficulties and other problems, such as domestic
violence.
95
Following advocacy by residents and CSOs to the government, settlements outside the camps have begun to be built by the GoI, funded by CIS, Oxfam and the GoI. However, the contract was
given to the Indonesian military armed forces to build the settlements at a cost of IDR 14 million approximately US1,500 per home, and problems have emerged relating to the quality of the
houses provided.
96
Local CSOs have endeavoured together with Oxfam and the European Union to build further shelters, involving the community directly in this process, using local materials
and involving women in the design of these homes, with the cost allocated at around IDR 6 million approximately US650.
97
CSOs such as CIS have also begun programmes 2008-2011 to assist with improving relations between IDP and host communities, particularly in villages where
conflicts have broken out.
98
They work with women as an entry point to begin the peace-building process through livelihoods programmes and creating farmers’ groups, and joint projects to
build pipe systems for access to clean water, amongst others.
99
Yet the challenge for providing adequate access to health facilities and free or cheap services remains given the administrative
problems outlined above.
88 Interview with staff from the Center for Internally Displaced Persons, Kupang Municipality 17 August 2010 89 Djami, M., Filiana Tahu, M. and Sesilia 2007 Perempuan pengungsi masih terlupakan
90 Sunarto et al. 2005 Overcoming violent conflict: Volume 2, Peace and Development Analysis in Nusa Tenggara Timur, CPRU-UNDP, LabSosio and BAPPENAS. See also: CIS Staff, Kupang Municipality 17 August 2010
91 Interview with staff from the Center for Internally Displaced People, Kupang Municipality 17 August 2010 92 Ibid.
93 Ibid. 94 Ibid.
95 Ibid. 96 Ibid.
97 Ibid. 98 Ibid.
99 Ibid.
THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 206
THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 207
4.2.3.4 Diseases and ill health Good levels of nutrition can help to prevent the spread of common diseases and improve
resilience to other illnesses such as diarrhoea, thus reducing the risk of child and infant death. Undernutrition during pregnancy and childhood contributes to the disease burden and reduced
resilience against disease and to more than one third of child mortality globally.
100
This section explores prevalence of certain common diseases and illnesses in NTT, as well as the quality and
reach of some of the preventative measures that exist to combat them. See annex 4.2 for further data and the trends discussed below.
Malaria is endemic in eastern Indonesia and common in NTT. Despite mosquito net distribution drives
101
, for families with children and pregnant women, cases have fluctuated between 2004- 2008, spiking in 2004 624,278 cases and hitting their lowest point in 2005 70,390 cases. Since
then, the incidence of the disease has remained fairly constant
102
, indicating that mosquito nets distribution needs to be widened, or community education programmes on effective use of the
nets may be necessary, if the initiative is to have a positive effect on reducing rates of malaria. Data from the 2007 IDHS
103
revealed that only 6.7 per cent of children in NTT were protected by insecticide treated mosquito nets.
Child illness is one of the immediate determinants of nutritional status in Indonesia, and diarrhoea and acute respiratory infection ARI are the main causes of death for infants and children under
five.
104
Prevalence of these illnesses is also high in NTT. It is estimated that 15 per cent and 17 per cent of children in NTT had diarrhoea and ARI, respectively, in the two weeks preceding the
2007 IDHS survey compared to 11 per cent and 14 per cent at the national level. Yet, only 62 per cent received treatment or advice from a health facility or provider for ARI, and 51 per cent
for diarrhoea.
105
However, on a positive note, parents are knowledgeable on basic treatment of diarrhoea when it does arise, with 83 per cent of sufferers having been given some form of oral
rehydration, which is substantially higher than the national level of just 61 per cent.
106
According to district level health information for NTT see annex 4.2, 84 per cent of villages had achieved universal child immunisation by 2007, having increasing steadily from 77 per
cent in 2004. On this basis, NTT would be considered to have reached the WHOUNICEF Global Immunization Vision and Strategy GIVS, which set a target for countries to reach at least 90 per
cent national vaccination coverage and at least 80 per cent vaccination coverage in every district or equivalent administrative unit.
107
However, the 2007 IDHS data tell a different and more complex story, with only two immunisations reaching above or near to this level of coverage for children
aged under two in NTT: HB3
108
87 per cent and measles 77 per cent. Progress in immunisation coverage at the end of the 1990s has reversed in the last decade and is down between 9-26
percentage points in 2008 compared to 1997 polio down 26 per cent, DPT3
109
down 20 per cent, measles down 9 per cent, BCG down 8 per cent.
100 Countdown to 2015 Core Group. 2008 ‘Countdown to 2015 for maternal, newborn, and child survival: The 2008 report on tracking coverage of interventions’, The Lancet
, Vol.371: 1247-1257 101 UNDG 2010 MDG good practices: MDG-4, MDG-5, MDG-6, child mortality, maternal health and combating diseases, available at: http:
www.undg-policynet.orgextMDG-Good-PracticesGP_chapter3_mortality.pdf Last accessed 20 November 2010 102 Ministry of Health 2008 Indonesia health proile 2004-2008, Ministry of Health: Jakarta; Centre for Health Data, Ministry of Health
2009 Indonesia health profile 2006-2009 , Ministry of Health: Jakarta
103 BPS - Statistics Indonesia and Macro International 2008 IDHS 2007 104 Ibid.
105 Ibid. 106 Ibid.
107 WHOUNICEF n.d. Global Immunization vision and strategy, available at: http:www.who.intimmunizationgivsenindex.html Last accessed 11 October 2010
108 Hepatitis B 109 Diphtheria
Figure 4.2.11: Percentage of children under age two who were immunised, NTT 1994-2007
Source: IDHS 2007
4.2.3.5 Water and sanitation The discussion above outlined the problem of malnutrition and access to health services in NTT.
Those problems are further complicated by poor access to clean water and adequate sanitation, which contributes to illness and undernutrition as discussed in Section 3 of this report, and has
also influenced the participation of children in schools.
110
Education officials have highlighted that in almost all rural districts, such as Sikka district, students are more frequently sick due to
the inter-related problems of malnutrition, ill health, and poor access to clean water and adequate sanitation, and thus school attendance is lower.
111
Figure 4.2.12: Trends in access to clean water, NTT versus Total Indonesia 2000-2008
Source: BPS - Statistics Indonesia, Statistical Yearbook 2009 based on the National Socio-Economic Survey 2008
20 40
60
Percent
80 100
120
IDHS 1994 IDHS 1997
IDHS 2002-2003 IDHS 2007
BCG 78.1
95.4 92.7
86.5
67.8 84.4
54.7 34.3
36.9 58.1
72.5 66.9
85.5 68.0
7.01 88.6
52.6 77.2
Polio 3 DPT 3
HB 3 Measles
110 Interview with the Head of the Kindergarten and Basic Education Section, Ofice of Education, Sikka District, NTT 21 September 2009 111 Ibid.
2000 2001
2002 2003
2004 2005
2006 2007
2008 57.51
56.25 47.05
42.34 46.96
39.19 46.90
37.82 46.60
41.11 48.98
41.46 49.69
43.30 52.92
43.33 55.07
45.13
10 20
30 40
50 60
70
Per cent
Year
Indonesia East Nusa Tenggara
THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 208
THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 209
In general, the climate in NTT is semi-arid with dry periods of up to eight or nine months per year. Such long dry periods mean a lack of accessible water springs. Not surprisingly, in a province
characterised by rugged terrains, dry temperatures and poor infrastructure, access to clean water and basic sanitation is low compared to national averages see Figure 4.2.12, based on National
Socio-Economic Survey data. At the provincial level in 2008, NTT was 10 percentage points below the national average 45.13 per cent NTT versus 55.07 per cent Indonesia. Moreover, the
gap worsened at the beginning of the decade and has only marginally improved since. There is also a huge difference between rural and urban figures, such that in urban areas access to clean
water is more than double that in rural areas 80 per cent of the population have access compared to 38 per cent in rural areas; see annex 4.2. Disaggregated district level data see annex 4.2 show
stark disparities between the best and worst affected areas - in Kupang municipality 78 per cent of residents have access to clean water, but in Sumba Tengah and Sumba Barat Daya the rates are
only 9 per cent and 5 per cent, respectively.
Figure 4.2.13: Trends in the proportion of households with sustainable access to adequate sanitation ventilated pit latrine and septic tank, NTT, 2000-2008
Source: BPS - Statistics Indonesia, Statistical Yearbook 2009, based on the National Socio-Economic Survey 2008
Despite considerable improvement in the latter part of the decade, access to sanitation in NTT is substantially below the national average 18 per cent NTT versus 50 per cent Indonesia; see
Figure 4.2.13 above. The ruralurban disparity in access to sanitation is even greater than for access to clean water, with the urban population almost four times as likely to have adequate
sanitation compared to the rural population 47.58 per cent urban compared with 11.47 per cent in rural areas see annex 4.2. Integral to this problem is the issue of lifestyle practices common in
rural areas, including the practice of building houses without bathing-washing-toilet facilities and combining living areas with cattle stalls. Furthermore, the 2007 Indonesia MDGs progress report
highlights the problem of poor awareness and knowledge about the relationship between unclean water and poor sanitation, and illness.
112
Barbiche and Geraets 2007
113
have listed some of the major issues in relation to water and sanitation in NTT based on their study, which focuses on the districts of Timor Tengah Selatan
112 BAPPENAS and UNDP 2008 Laporan pencapaian Millennium Development Goals, Indonesia 2007, UNDPBAPPENAS: Jakarta 113 Barbiche, J. C. and Geraets, C. 2007 Water and sanitation and food security assessment NTT- Dec-2006Jan 2007. A report for Action
Contre le Faim, available at: http:www.ntt-academia.orgAcF-NTT-Report-v32.34581808.pdf Last accessed 10 November 2010
and Alor. Along with the climate and geography, they found that most of the water access indicators are below standard. Wells often unlined and water points attached to springs are the
most common water sources. Water points are very sensitive to the change of seasons, easily becoming dry in summer, and dirty in the rainy season. In Timor Tengah Selatan, water sources
are located on average 710 metres from houses, taking an average of one hour for a round trip to collect water. The average quantity of water consumed per person per day for hygiene
and drinking is 14 litres. As discussed in Section 3 of this report, such a low quantity of water consumption can be directly linked to the incidence of water-related diseases, and can represent
an underlying cause of infant malnutrition.
Clean water and sanitation are a fundamental problem in NTT and a major contributing factor to the malnutrition and ill health of children and women in particular, as well as the poor more
generally in the province. Climate and lifestyles practices in NTT have contributed to this issue. Meanwhile, the local government has not been able to cope with these problems.
114
According to the 2007 MDGs report, this is now one of the top priorities for the GoI
115
. Related to this, the government has incorporated ‘Clean and Healthy Living Patterns’ into its National Medium-Term
Development Plan Rencana Pembangunan Jangka Menengah Nasional, RPJMN 2009-2014 strategic goals on improving public health. The attainment of this goal will be measured by the
‘healthy house’ indicators, with a target of 47.26 per cent by the year 2013.
116