THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 48
THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 49
INTRODUCTION
This section provides a general overview about key aspects of the situation of children and women in Indonesia. There are five broad clusters of analysis: health and nutrition focusing
on trends in outcomes relating to mortality rates and nutrition; water and sanitation; HIV and AIDS and adolescent health practices relating to sexually transmitted infections STIs; education
focusing on attendance, early leaving rates, access and quality; and finally, child protection including citizenship and birth registration, protection from violence, abuse, and exploitation,
alternative care systems, and child freedom and participation. The first subsection on health and nutrition, and the second on water and sanitation, relate to Millennium Development Goals
MDGs numbers 1, 4, 5, 6 and 7.
1
The third subsection, on HIV and AIDS, relates to Goal 6. The fourth part, on education, relates to Goals 2 and 3.
Due attention is given to MDGs in that the analysis presented here is centred on children and women, but we also consider inter-related analysis of the situation of child protection. In addition,
while presenting a large number of indicators that correspond to data aggregated at the national level, whenever possible the discussion also focuses on evidence of the profound and wide-
ranging disparities and inequalities which characterize Indonesia today. The fifth subsection, on child protection - or ‘special protection’ as it is known in Indonesia - is distinct in that it relies less
on indicators and aggregate quantitative data for the whole country due to data insufficiencies and more on in-depth case studies some of which include quantitative data, as well as
qualitative data. The approach in the analysis is intended to capture and illustrate the challenges and contradictions that accompany the incipient construction of child protection in Indonesia.
Whilst this section is divided into five distinct subsections, it is important to underline that these five areas of analysis are deeply interrelated, such that outcomes in one may affect changes in
others. Each section of analysis also identifies the major changes in policies and initiatives that have been undertaken in relation to the themes of the section, although the discussion is not
exhaustive given the rapidly changing policy and regulatory environment in Indonesia. Some mention is made of these changes in relation to decentralisation, although further discussion
takes place in the sub-national analysis in Section 4.
The following analysis highlights that, in terms of almost all the indicators and available data, considerable progress has been made towards improving the situation of women and children
over the past decade, both in terms of the regulatory framework and national aggregate figures in health, nutrition, water and sanitation, and education, although much work remains to be
undertaken in the area of HIV and AIDS prevention and child special protection. However, across these indicators, there are consistent inequalities and inequity between the provinces, such that in
many cases a few more successful provinces serve to raise the national average. Furthermore, the poorest quintiles and people in rural areas tend to be left behind in terms of the gains for women
and children in recent years. Moreover, on some indicators gender inequities remain. These results underline the importance of policy initiatives that aim to achieve the MDGs with equity
and to ensure that growth in Indonesia is pro-poor and seeks to remedy regional, socio-economic and gender inequities. The National Medium-Term Development Plan RPJMN 2010-2014 of the
Government of Indonesia GoI and the corresponding sectoral Strategic Plans Renstra, Rencana Strategis and government actions also place importance on reducing inequalities and inequities
and focussing on improving the situation of the poor. As such, the policy space exists to continue to strive for progress with equity in the coming decade.
1 These MDGs are as follows: Goal 1: Eradicate extreme poverty and hunger; Goal 2: Achieve universal primary education; Goal 3: Pro- mote gender equality and empower women; Goal 4: Reduce child mortality rate; Goal 5: Improve maternal health; Goal 6: Combat HIV
AIDS, malaria, and other diseases; Goal 7: Ensure environmental sustainability.
3.1 HEALTH AND NUTRITION
Appropriate health and nutrition, as well as access to clean water and adequate sanitation are vital for the welfare and wellbeing of children and women. Three of the eight MDGs Goal 1:
Eradicate extreme poverty and hunger; Goal 4: Reduce child mortality, and Goal 5: Improve maternal health have been specifically targeted at improving outcomes in the welfare of women
and children through reducing malnutrition rates, infant and child mortality rates, and maternal mortality rates. Other interrelated MDGs and sub-targets pertaining to assisted births, the use
of birth control, reductions in malaria and tuberculosis rates, HIV prevention, improved water and sanitation etc., contribute to improving health and nutrition outcomes overall, as well as
to child survival and development. The examination in this report of health and nutrition in relation to children and women in Indonesia comprises three subsections: mortality, nutrition,
and some related determinants including, access to water and sanitation. These various aspects of health are deeply interconnected, as shown by the conceptual framework on determinants of
malnutrition and mortality in Figure 3.1.1.
2
The diagram shows that malnutrition, for example, is not just attributed to a lack of available food or income to buy food, but also to caring practices
such as breastfeeding or hygiene practices and living in unhealthy environments for example, with poor access to clean water and sanitation. Good hygiene practices and nutrition can
also help to prevent the spread of common diseases and resilience to other illnesses such as diarrhoea, which can all in turn increase the risk of child and infant death. The provision and
access of services are essential for improving health and the likelihood of child and mother survival during childbirth. Information and education that promote healthy hygiene and sexual
practices are vital too, to prevent illness and the transmission of diseases. However, as Figure 3.1.1 demonstrates, improving nutrition and decreasing child and infant mortality rates also
relates to the policy and institutional environment, as discussed further in the case studies in later sections of this report.
2 UNICEF 1998 State of the world’s children 1998, Oxford University Press: Oxford
© UNICEF2004Rachel Donnan
THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 50
THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 51
Figure 3.1.1: UNICEF conceptual framework on understanding child malnutrition, death and disability
Source: Adapted from UNICEF, State of the world’s children 1998
As we will see, Indonesia has made significant progress with respect to a large number of indicators on child survival and development at the national level, but there are some remaining
and ongoing challenges, not only with regards to the provision of services and inter-provincial disparities, but with the promotion of healthy practices too. Since the last SITAN in 2000,
Indonesia has undergone a number of drastic political and institutional changes, not least a deep and complex process of decentralisation, which has had a profound impact on the delivery of
services, including health services in Indonesia. The impact of decentralisation is not always clear or evident. In some cases it has allowed for better responses to community needs, while in
others it has created gaps where service provision is uncertain. The context of decentralisation is important for the evenness of service provision across a country as large, diverse and complex
as Indonesia. One of the key aspects of this section is to provide in-depth information about the nature, extent and general trends of inequalities and disparities relating to key health issues in
Indonesia. In some cases, substantial improvements evident from aggregated data at the national level can be deceptive and can obscure the fact that women and children - especially those living
in rural areas, underdeveloped provinces and poor households - still live very precarious lives.
Child malnutrition, death and disability
Disease Immediate causes
Underlying causes at householdfamily level
Poor watersanitation and inadequate
health services Inadequate maternal and
childcare practices
Quatity and quality of actual resources - human, economic
and organizational - and the way they are controlled
Inadequate andor inappropriate knowledge
and discriminatory attitudes limit household access to
actual resources
Political, cultural, religious, economic and social
systems, including women’s status, limit the utilization of
potential resources Potential resources: environment, technology, people
Basic causes at sociental level
Outcomes
Inadequate dietary intake
3.1.1 MORTALITY RATES: MATERNAL MORTALITY RATIO MMR, INFANT MORTALITY RATE IMR AND UNDER-FIVE MORTALITY RATE U5MR
Since the 2000 UNICEF Indonesia SITAN, there have been significant improvements with respect to a number of health and nutrition indicators, notably the infant mortality rate IMR,
under-five mortality rate U5MR and maternal mortality ratio MMR, as well as the prevalence of malnourished children, as discussed later in the section data from 2002-2003 IDHS and
2007 IDHS. Figure 3.1.2, which summarises key mortality rate data captured in the Indonesia Demographic and Health Surveys IDHS since 1991, shows the general decline of mortality rates
in Indonesia. The general improvement of these key indicators over time has taken place prior, during and following the decentralisation of the provision of key health services.
Figure 3.1.2: Infant mortality rates, under-five mortality rates, and maternal mortality ratios, Indonesia 1991-2007
Source: Badan Pusat Statistik BPS - Statistics Indonesia and Macro International, Indonesia Demographic and Health Surveys IDHS 1991, 1994, 1997, 2002-2003 and 2007
After two decades of significant improvements in IMR and U5MR, progress is ongoing but at a much slower rate: a two-point reduction in the U5MR and a one-point reduction in the IMR
between 2003-2003 and 2007 see Figure 3.1.2. Furthermore, while the MMR has decreased to 228, the rate is still far above that of neighbouring countries in Southeast Asia in 2007, the
rate for Viet Nam was 160; Thailand was 12; Malaysia was 28; and 160 for the Philippines.
3
An examination of the annual reduction rate ARR suggests a slowing down of the rate of decline
of IMR and U5MR following decentralisation in Indonesia, from 3 per cent to 1 per cent.
4
The
3 UNICEF 2008 State of the world’s children 2009: Maternal and newborn health, UNICEF: New York 4 According to IDHS data see BPS - Statistics Indonesia and Macro International 2008 Indonesia Demographic and Health Survey IDHS
2007 , BPS and Macro International: Calverton, Maryland, USA, p118, “The decline in childhood mortality indicated by the IDHS 2007…
may be exaggerated. Comparison of the last three IDHS surveys 1997, 2002-2003 and 2007 shows a different pattern of mortality decline. Infant mortality declined from 46 deaths per 1,000 live births in 1993-1997 to 34 per 1,000 in 2003-2007, with an annual reduction
rate ARR of 3 per cent. The ARR between 1998-2002 and 2003-2007 is less than 1 per cent from 35 deaths per 1,000 live births to 34 per 1,000. In the same period, under-five mortality declined from 58 deaths per 1,000 live births in 1993-1997 to 44 per 1,000 in 2003-2007,
with an annual reduction rate ARR of 3 per cent. The ARR in under-five mortality between 1998-2002 and 2003-2007 is also less than 1 per cent 46 deaths per 1,000 live births in 1998-2002 to 44 per 1,000 in 2003-2007…the three most recent IDHS surveys tend to give
lower 0-4 year period mortality estimates and higher 5-9 year period mortality estimates. The infant mortality estimate for the 0-4 year period preceding the survey for the 2007 IDHS therefore should be higher than 34 deaths per 1,000 live births, and for the 2002-2003
IDHS it should be higher than 35 deaths per 1,000 live births. Using estimates for infant mortality rates in the 5-9 year period preceding the survey, the ARR for the last two IDHS surveys is 3 per cent. Assuming this ARR is correct, the 0-4 year period estimate for the 2002-
2003 IDHS is 41 deaths per 1,000 live births, and for the 2007 IDHS it is 37 deaths per 1,000 live births. This means that in the 2002-2003 IDHS, the IMR estimate 35 per 1,000 for the period 0-4 years preceding the survey should be inflated by 17 per cent, giving an estimated
infant mortality rate of 41 deaths per 1,000 live births; for the 2007 IDHS, the IMR should be inflated by at least 10 per cent, giving an estimated infant mortality rate of 37 deaths per 1000 live births…”
Per 1,000 live births Per 100,000 live births
160 425
97
68 57
46 35
34 44
46 58
81 390
334 307
228 140
120 100
80 60
40 20
450 400
350 300
250 200
150 100
50
IDHS 1991 IDHS 1994
IDHS 1997 IDHS 2002-
2003 IDHS 2007
U5MR IMR
MMR
THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 52
THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 53
2007 IDHS data also highlight that IMR reductions may be overestimated.
5
However, whether the slowing down of the ARR can be attributed to the decentralisation process or whether other
factors are at play is unclear.
In addition, detailed data on infant and child mortality - in this case the contribution of neonatal deaths i.e., the death of a child born alive before 28 days and post-neonatal deaths i.e., the
death of a child born alive after 28 days but before one year old to the overall mortality rates - require further attention. The World Health Organisation WHO has estimated that globally,
almost 40 per cent of deaths of children under five occur in the first month of life, and three quarters of neonatal deaths take place in the first week early neonatal deaths.
6
According to WHO 2006 most of these are preventable.
7
Data from the 2007 IDHS indicate a similar pattern in Indonesia, with over two thirds of under-five deaths taking place within the first month after birth
77 per cent, and 80 per cent of these deaths taking place within the first week of life. The reduction of neonatal deaths is therefore essential to further reduce child mortality; one of
the main MDGs. The post-neonatal mortality rate has reduced by 40 per cent and the neonatal mortality rate has declined more slowly, by 32 per cent over the past 10 years.
8
However, the proportions of infants who died in the first day, in the first week and in the first 28 days after birth,
have all increased during the same period.
9
The increasing proportion of neonatal deaths as a part of infant deaths has been attributed to several factors. In particular, the ongoing difficulties
in reaching the many babies who are born at home without effective and timely neonatal interventions, as also discussed later in this section.
10
This is a particular challenge, as close to 60 per cent of births still take place at home in Indonesia.
11
3.1.1.1 An overview of disparities: Patterns in mortality rates Whilst the general progress and improvements in infant and child mortality rates have to be
acknowledged, a more detailed examination of disaggregated data provides a more nuanced picture, within which gaps, disparities and uneven achievements can be observed. Disparities in
Indonesia are multifaceted; they occur between and within provinces within-province disparities are detailed in the case studies chapters, between urban and rural areas, between age and
gender groups, and among groups of different socio-economic status. These disparities need to be noted both by national and international actors, to inform policymaking and facilitate the
delivery of appropriate services where they are most needed.
The breakdown of IMR and U5MR by provinces is consistent with general patterns of regional disparities in Indonesia. At a national level, the IMR stands at 34 per 1,000 live births and the
U5MR at 44 per 1,000 live births, but at a provincial level these rates are as low as 19 IMR and 22 U5MR for Yogyakarta and as high as 74 IMR and 96 U5MR for the newly formed province
of West Sulawesi. It is notable too that the majority of provinces underperform compared to the national average 26 out of 33 provinces, both for the IMR and the U5MR while only a handful of
better developed East and Central Kalimantan, Jakarta, Bali and populous provinces typically Yogyakarta consistently perform very well. It is interesting to note that by 2007, Aceh had a low
5 Ibid. 6 WHO 2006 Making a difference in countries: Strategic approach to improving maternal and newborn survival and health, WHO:
Geneva 7 Ibid.
8 Badan Pusat Statistik BPS - Statistics Indonesia and Macro International 2008 Indonesia Demographic and Health Survey IDHS 2007 9 Ibid.
10 Ibid. 11 Ibid.
IMR, indicating that following the tsunami, the province has managed to ensure that many of the direct causes of the IMR outlined earlier in this section have been addressed. There is an absence
of comparable provincial level data on the MMR and hence disparities cannot be ascertained. While there have been notable improvements in MMR, IMR and U5MR, there is a danger that a
handful of high-achieving provinces are driving up aggregate indicators, leaving under-achieving provinces far behind.
Figure 3.1.3: Infant mortality rate IMR by province, Indonesia 2007
Source: IDHS 2007. Note: The figures presented here are for the ten-year period preceding the survey
Figure 3.1.4: Under-five mortality rate U5MR by province, Indonesia 2007
Source: IDHS 2007
As has been illustrated in the section above and will be discussed again below, there are multiple and multidimensional aspects to some key areas of mother and child health in Indonesia,
and disparity indices allow us to observe the general trends of disparities in IMR and U5MR in Indonesia over the past decade. An index of disparity ID is a summary measure of disparity
Papua W
est Papua W
est Sumatra W
est Kalimantan Jambi
Riau Riau Islands
East kalimantan Banten
Bangka Belitung Central Kalimantan
Bali W
est Java Maluku
Gorontal o
East Nusa T enggar
a
W est Nusa T
enggar a
D.I. Aceh Lampung
Central Sulawesi Southeast Sulawesi
Bengkul u
Central Java D.I. Y
ogyakarta East Java
South Sumatra South Kalimantan
D.K.I Jakarta North Sumatra
North Maluku North Sulawesi
South Sulawesi W
est Sulawesi Indonesi
a 10
20 30
40 50
60 70
80 74 57
41 36
34 26
25 19
Per 1,000 live births
Papua W
est Papua W
est Sumatra W
est Kalimantan Jambi
Riau Riau Islands
East kalimantan Banten
Bangka Belitung Central Kalimantan
Bali W
est Java Maluku
Gorontal o
East Nusa T enggar
a
W est Nusa T
enggar a
D.I. Aceh Lampung
Central Sulawesi Southeast Sulawesi
Bengkul u
Central Java D.I. Y
ogyakarta East Java
South Sumatra South Kalimantan
D.K.I Jakarta North Sumatra
North Maluku North Sulawesi
South Sulawesi W
est Sulawesi Indonesi
a 20
40 60
80 100
120 96
80 64
45 44
32 22
Per 1,000 live bi rths
