Health and nutrition budgets

89 budget and it continued to decline, accounting for just 2.18 per cent in 2010 Figure 3.7. According to Figure 3.6, the budget for this programme represented only 5 per cent of the central government’s health budget in 2006 and decreased further to 2 per cent in 2010. The decreases in the budget for nutritional programmes in 2008 were caused by an Asian Development Bank ADB loan for the Nutrition Improvement Community Empowerment NICE project. The GoI has been receiving loans for NICE projects since 2008 and will continue to receive them through 2012. On average, the annual amount of the loan received is IDR120 billion, used as the companion budget of the NICE activities in the Ministry of Health, allowing the government to reduce the national budget allocated for nutrition. Thus, in 2008 some of the nutrition budget was transferred to other programmes, including an exclusive breastfeeding campaign within the programme for ‘Health Promotion and Community Empowerment’, coordinated by the Secretariat- General of the MoH. During 2006–2010, the Community Nutrition Improvement Programme was under the authority of the Directorate General of Public Health Development and it included funds for puskesmas. In 2011, there was a change in the organizational structure of the MoH, placing puskesmas under the coordination of the Directorate General of Community Health Figure 3.7: Budget for the Community Nutrition Improvement Programme, 2006–2010 Billion IDR 2006 2007 2008 2009 2010 700 650 600 550 500 450 400 350 300 586 668 490 449 393 Source:฀APBN,฀2006–2010 Development. Consequently, the budget for the Directorate General of Public Health Development decreased and it will also show a budget decrease for nutrition. The main component of the budget allocation within the Community Nutrition Improvement Programme was for community nutrition improvement activities, which received 60 per cent of the programme budget per year. In 2006– 2007 these activities were the main focus of the programme and were allocated IDR514 billion in 2006 and IDR537 billion in 2007. In 2008, a new activity was incorporated into the programme; the treatment of undernourished pregnant and lactating women, and children under the age of five. The budget allocated for this activity was IDR184 billion, or about 37.61 per cent of the total nutrition programme budget; in 2009 it amounted to IDR191 billion or 42.54 per cent of the total programme budget and in 2010 it had declined to IDR141 billion, or 35.87 per cent of the total programme budget Table 3.10. As for HIVAIDS expenditure, the main source of funding is still from external sources, although funding from the GoI has shown an increasing trend. In 2006, the total AIDS expenditure was US56,576,587, of which 73.42 per cent was financed by international sources and 26.58 per cent US15,038,484 was from central and local government funding NAC 2008, p. 26. In 2008, the total HIVAIDS expenditure was US49,563,284, of which 59.96 per cent was financed by international sources and 40.04 per cent US19,845,267 was covered by central and local government funds NAC 2009, p. 28. The largest spending allocation was for prevention efforts, which accounted for 49.84 per cent of the HIVAIDS budget in 2008 and 40.97 per cent in 2006. Care and treatment spending was 14.78 per cent in 2008 and 24.88 per cent in 2006 NAC, 2008, p. 28; NAC, 2009, p. 29. The main concern regarding HIVAIDS funding was sustainability, which put pressure on the GoI to increase allocation from domestic sources and reduce reliance on external funding sources NAC, 2009, p. 32. According to RISKESDAS 2007, health financing includes medical treatment for inpatient and patient service utilisation whereas the source of 90 Activities Community nutrition improvement Planning and design of health development and community nutrition programme Maintenance and recovery of health Community health improvement Improvement of health services for poor families Procurement of functional equipment Improvement of community nutrition education Treatment of undernourished pregnant and breastfeeding women, infants and under-fives Nutrition improvement community empowerment NICE Total 2006 88 5 3 3 1 100 2007 80 20 100 2008 57 6 38 100 2009 56 1 43 100 2010 24 2 36 38 100 Table 3.10: Allocation of the budget for the Community Nutrition Improvement Programme, 2006–2010 Source:฀APBN,฀2006–2010 financing is divided into selffamily financing, insurance, AskeskinSKTM 12 , Dana Sehat 13 , and others. The data shows that only 7 per cent of households have experienced inpatient hospitalisation and they utilize government hospitals 44 per cent more than private hospitals 28.5 per cent. The source of financing for inpatient services was dominated by self- financed 71 per cent or family out of pocket, followed by various types of ‘health insurance’ schemes, including AskesJamsostek 14 15.6 per cent, AskeskinSKTM 14.3 per cent, Dana Sehat 2.9 per cent and other sources 6.6 per cent. In terms of outpatient service utilisation, 34.4 per cent of households have experienced patient service and most of them have utilised maternity hospitals 43 per cent. In contrast with inpatient service financing, most patient service utilisation was self-financed 74.5 per cent, followed by AskeskinSKTM 10.8 per cent, AskesJamsostek 9.8 per cent, Dana Sehat 2.5 per cent and other sources 4.4 per cent. There were six provinces where the proportion choosing a puskesmas for inpatient services was higher than the national average: West Nusa Tenggara, East Nusa Tenggara, North Sulawesi, Central Sulawesi, West Papua and Papua. 12 Askeskin was described earlier, towards the end of section 3.1. SKTM is Surat฀Keterangan฀Tanda฀Miskin, a certificate or letter proving one’s status as poor. 13 Dana Sehat Health Funds is a community health insurance scheme under which households pay the insurance premium and the money is managed by the community themselves. 14 AskesJamsostek are non-subsidized health insurance schemes under which civil servants and formal workers pay their own premiums.

3.4 Children’s health and nutrition out comes

3.4.1 Child mortality in children under the age of five The Indonesia Demographic and Health Survey IDHS divided early childhood mortality into several groups namely: neonatal mortality, post-neonatal mortality, infant mortality, child mortality, under-five mortality and fetal death miscarriage. Infant mortality refers to deaths occurring between birth and the first birthday, while child mortality refers to deaths occurring between the exact age of one and five years, and under-five mortality includes all of those combined deaths, between birth and the age of five years. Overall, the improvements in malnutrition status have had a statistically significant effect in terms of declines in child mortality rates Pelletier and Frongillo, 2003. But the increasing prevalence of underweight in under-fives within poor households Q1 from 22.1 per cent to 22.7 per cent during 2007–2010 needs special attention because it might significantly contribute to under-five mortality. A child’s right to survival is usually appraised in terms of the under-five 91 mortality rate U5MR, which is as the basis for one of the MDGs. The mortality rates among infants and under- fives have declined considerably. The long- term picture of the progress in reducing the infant mortality rate IMR and the U5MR is presented in Figure 3.8. As shown, Indonesia has substantially reduced the national IMR from more than 100 per 1,000 live births in the 1970s and 1980s to 68 in 1991 and 34 in 2007. Meanwhile, the U5MR has declined from 97 per 1,000 live births in 1991 to 44 in 2007. This progress justifies optimism that the MDG target to reduce the U5MR by two thirds between 1990 and 2015 will be attained. However, it is important to be aware that the efforts to further reduce these mortality rates are likely to be much more challenging, and indeed the speed of the reduction has been slowing in recent years. During 1971–1991 the IMR declined by 2.7 per cent per year on average. The decline accelerated to 3.9 per cent per year during 1990–1999, but then significantly decelerated to an average of 0.5 per cent annually during 1999– 2007. The reduction of the U5MR has followed similar patter; it was declining by 2.9 per cent per year during 1971–1990, and accelerated to 4.4 per cent during 1990–1999, but slowed down to an average of 2.8 per cent per year during 1999–2007. In spite of the national progress, not all regions share the same level of accomplishment and provincial disparities are still clearly evident. The province of DI Yogyakarta recorded the lowest IMR and U5MR in 2007, 19 and 22 per 1,000 live births, respectively. At the other end of the scale, West Sulawesi recorded the highest IMR 74 and U5MR 96 among all 33 provinces. The majority of provinces lagged behind the national average. Only six provinces had IMR below 34 per 1,000 live births in 2007: Aceh, Jakarta, Central Java, Yogyakarta, Central Kalimantan and East Kalimantan IDHS 2007. Important efforts to reduce the IMR include the provision of antenatal care to pregnant women and improved access to trained health-care providers to assist at childbirth. 15 Meanwhile, seven provinces achieved U5MR lower than the national average, namely: North Sulawesi, Bali, East Kalimantan, Jakarta, Central Kalimantan, Central Java and Yogyakarta IDHS, 2007. Figure 3.8: Infant and under-five mortality rates, 1971–2007 250 200 150 100 50 Mortality per 1,000 live births 1971 1980 1990 1994 1997 1999 20022003 2007 218 158 99 93 71 60 34 46 145 109 71 66 52 46 35 44 IMR UMR Source:฀Badan฀Pusat฀Statistik฀BPS฀–฀Statistics฀Indonesia฀1971–1999;฀Indonesia฀Demographic฀and฀Health฀Survey฀IDHS฀20022003฀฀ and฀2007 15 IMR for children whose mother received antenatal care and childbirth assisted by a trained health-care provider was 17 deaths per 1,000 live births compared with 85 deaths per 1,000 live births among children whose mothers received neither antenatal care nor assistance at delivery from a trained provider IDHS 2007, p. 122. 92 More detailed data reveal greater challenges in reducing neonatal mortality, particularly among baby boys. The neonatal mortality rate, which is the number of babies under the age of 28 days who have died per 1,000 live births, among boys during 20022003–2007 was higher than girls and remained steady at 24, while the rate among baby girls declined from 21 to 19 in the same period. The mortality rate among boys aged 28 days to 11 months the post-neonatal mortality rate was also relatively higher than among girls of the same age. The under-four and under-five mortality rates U4MR and U5MR among boys are also slightly higher than girls Table 3.11. These figures indicate the need to devote more attention to babies under 28 days of age and children aged 1–4 years. According to data from the 2007 RISKESDAS, the causes of post-neonatal and under-five deaths were dominated by communicable diseases, especially diarrhoea and pneumonia. These diseases were responsible for 55.2 per cent of deaths among infants aged 29 days to 11 months, and 40.5 per cent of deaths among children aged 1–4 years. The analysis using data from the IDHS 20022003 and IDHS 2007 on the treatment of diarrhoea Table 3.12 shows Table 3.11: Neonatal, post-neonatal, under-four and under-five mortality rates by sex, 1994–2007 Neonatal mortality rate Post-neonatal mortality rate Under-four mortality rate Under-five mortality rate Total Male Female Total Male Female Total Male Female Total Male Female 1994 33 34 28 93 1997 25 27 19 71 20022003 23 24 21 20 21 19 12 13 11 54 58 51 2007 19 24 19 15 19 16 10 13 12 44 56 46 Source:฀IDHS฀1994฀and฀1997,฀IDHS฀20022003฀and฀2007 that under-fives were generally brought to a health facility or provider if they had diarrhoea. People living in urban areas were more likely to bring their sick children to a health facility. IDHS 2007 data showed that the utilisation of health facilities for cases of children’s diarrhoea was higher among the richest families quintile 5 compared to the poorest quintile 1 families. There was a strong correlation between both parental lack of any formal education and very low household income and higher U5MR. Access to professional medical facilitiesproviders was controlled for in the analysis. Table 3.13 shows that neonatal and infant mortality were higher among children whose mothers lacked any education, and received no medical care during pregnancy or delivery. Rates were also higher amongst the lower income groups and among rural children. Thus, additional support and awareness-raising, and research on child mortality issues, are required to decrease the U5MR, especially in rural areas where there is a stark difference in comparison to urban areas. With a view to reducing child mortality, in 2007 the GoI implemented a programme called Desa Siaga Alert Village aimed at assuring that every childbirth is attended by a skilled midwife at an adequate health-care facility. Raya and Lada 2009 evaluated 34 ‘Alert Villages’ in East Nusa Tenggara and concluded that the programme had succeeded in boosting the demand for improved maternal and neonatal health, as well as family health. However, it had failed to significantly improve the supply side, due to high staff turnover among midwives in remote villages and the absence, or inadequacy, of health facilities. One of the main barriers was the lack of effort among local governments to support the increasing awareness and demands for improved health in remote villages by providing additional funding and health extension workers. 93 Table 3.12: Treatment of diarrhoea, 2002 and 2007 Characteristic Age in months 6 6–11 12–23 24–35 36–47 48–59 Sex Male Female Residence Urban Rural Wealth Quintile Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5 2002 24 60 59.7 55.2 39.1 43.7 49 52.7 54.6 47.3 - - - - - 2007 31.3 59.1 57.1 52 39.7 52.3 52.1 49.7 54.4 49.7 37.7 46.2 61.3 58.3 64.3 2002 15.3 35.5 35.4 34.7 40.4 46.6 33 38 35 35.9 - - - - - 2007 6.6 28 40.2 37.7 35.1 42.7 35.4 33.7 33.4 35.4 31.6 36.1 38.4 39.6 27.4 2002 25.3 26.3 29.1 30.3 24.7 33.4 24.9 32 29 27.9 - - - - - 2007 22.8 23 33.8 33.9 26 34.3 31.1 29.4 29 31.1 27.2 28.8 34.6 31.4 32.4 2002 - - - - - - - - - - - - - - - 2007 10.1 14 17.3 10.8 16.6 11.7 13.3 14.9 14.4 13.8 12.3 17 16.5 11.3 13.2 2002 41.1 16.6 12.2 8.2 12.4 4.3 15.3 12 12.6 14.7 - - - - - 2007 50.1 23 9.2 14 16.3 11.3 14.2 20.4 16.1 17.4 20.2 14.3 13.5 18.8 16.1 Taken to a health facility or provider Oral rehydration therapy ORT Increased fluids Traditional medicineother No treatment Treatment Source:฀Indonesia฀Demographic฀and฀Health฀Survey฀20022003฀and฀2007 Table 3.13: Child mortality rates by demographic characteristics and type of obstetric services, 2007 Mother’s education No education Complete primary Secondary or higher Antenatal caredelivery assistance Both antenatal care and delivery assistance Antenatal care only Delivery assistance only No antenatal care and no delivery assistance Household expenditure Quintile 1 poorest Quintile 2 Quintile 3 Quintile 4 Quintile 5 richest UrbanRural Urban Rural Neonatal 39 23 14 10 9 35 54 27 25 19 17 17 18 24 Infant 73 44 24 17 18 58 85 56 47 33 29 26 31 45 Under-five 94 56 32 na na na na 77 59 44 36 32 38 60 Source:฀IDHS฀2007