9. Basic Health Indicators including the U.N. Millennium Development Goals

Annex-2

Millennium Development Goals (MDGs)

A primary purpose of this first MDG Report of Indonesia is to establish consensus and reach agreement on Indonesia's progress with its MDG targets and to set benchmarks for future work. The report uses existing data sources and goes back to 1990, the baseline year for the MDGs. Wherever possible, this report examines the situation at both national and provincial levels.

Data sources: The Government of Indonesia’s five Working Groups for the MDG Report, supported by the Central Statistical Office of Indonesia (BPS-Statistics Indonesia) and the UN Task Force, reviewed several data sources for the MDG indicators, which can conveniently be grouped into surveys and censuses, and institutional reporting systems. 

Progress made by Indonesia towards achievement of health related MDGs is given here:

Goal 1: Eradicating Extreme Poverty and Hunger

Status and trends

Prevalence of underweight children

Trends: Child malnutrition, as measured by the proportion of children under five years of age, who are moderately or severely underweight, decreased from 37.5 percent in 1989 to 24.6 percent in 2000. However, a slight rise was seen between 2000 and 2002, reaching 27.3 percent in 2002. Over the same period, severe malnutrition has increased slightly, from 6.3 percent in 1989 to 8 percent in 2002. These statistics support the conclusion that Indonesia still has some way to go before reaching out to the poorest and most disadvantaged groups. It is also not on track in achieving the MDG target on malnutrition (Figures 1.6 and 1.7).

Disparities: There has been a greater reduction in numbers of moderately and severely underweight children in rural areas than in urban centres. In both areas, a consistently bigger proportion of male children are moderately or severely underweight than female children, across the years. The disparity in the proportions of underweight children between provinces is striking: from 17.1 percent in Yogyakarta and 17.9 percent in Bali to levels as high as 42.3 percent in Gorontalo and 38.6 percent in East Nusa Tenggara (NTT).

Prevalence of under-nourishment

Trends: The proportion of people with insufficient food is still high in Indonesia. Two-thirds of the population still consumes less than 2,100 kcal a day. The trend has not changed much over the years (Figure 1.8).

Challenges

The major challenges in reducing malnutrition and under-nourishment will be ensuring that the poor population, especially women and young children, have adequate nutritious food at an affordable price. Reaching this population with interventions for nutrition education will be another challenge.

Policies and programmes

Policy directions: Policies to address hunger are reflected by trends in community nutrition and the food sector, where the focus is on developing and strengthening food security systems based on a diversity of food sources, and on local institutions, cultures and coping mechanisms. The purpose is to ensure the availability of food with adequate nutritional quality at an affordable price.

Food and nutrition policies: The priorities are:

      Empowering families and communities – especially poor families and other vulnerable groups – to develop self-sufficiency in food through community-based activities.

      Strengthening early warning systems for food and nutrition, so there will be preparedness for critical periods.

      Improving the quality of nutrition and food services, and integrating them into poverty-reduction programmes.

      Enforcing sanctions on violations of laws and regulations on food and nutrition, among them laws on food fortification, advertising and labelling.

Programmes: These aim to address hunger and malnutrition and improve household food security, and include:

      Providing complementary feeding for infants and children under five years of age, and supplementary feeding for pregnant women from poor families or households lacking food security.

      Promoting and “socializing”eating patterns that are balanced and healthy.

      Producing and diversifying foods, including local and affordable alternatives.

      Educating families on nutrition and caring for children.

      Improving the efficiency of food distribution systems to ensure household food security.

      Developing community self-sufficiency in food.

      Improving early warning systems for food security to alleviate the impact of natural disasters and conflicts on vulnerable groups.

      Establishing supporting regulations for the Law on Food (No. 7/1996) and implementing pro-poor regulations on food security and nutrition.

Goal 4:  Reducing Child Mortality

Status and trends

Under-five mortality trends: Efforts to address the national under-five mortality rate (U5MR) were successful between 1960 and 1990, with the rate decreasing sharply.   In 1960, the U5MR was still very high, at 216 per 1,000 live births, but by 1986-91, this had declined to 97 per 1,000 live births. The series of Indonesia Demographic and Health Surveys (IDHS) have shown a further reduction over the past decade, down to 46 per 1,000 live births during 1998-2002 (Figure 4.1). On an average, the U5MR declined by seven percentage points annually during the 1990s, an improvement which was higher than the previous decade's, with four percent decline per year.  By 2000, Indonesia had reached the target set at the 1990 World Summit for Children.

Infant mortality trends: Indonesia has also made significant progress in reducing the IMR over the last few decades. In 1960, the IMR in Indonesia was 128 per 1,000 live births. This decreased to 68 between 1986 and 1991 and to 32 per 1,000 live births in 2005 (Figure 4.2).  During the 1990s, the rate of decline averaged five percent a year, slightly higher than the four percent annual decline during the 1980s. Despite these achievements, the IMR in Indonesia still exceeds that in other Southeast Asian countries. It is 4.6 times higher than in Malaysia, 1.3 times higher than in the Philippines and 1.8 times higher than in Thailand.

Disparities among provinces: The variation in the U5MR among provinces is wide.  According to IDHS 2002-03, West Nusa Tenggara (NTB) had the highest U5MR of 103 per 1,000 live births during 1998-2002. This was nearly five times higher than the U5MR in Yogyakarta at 23 per 1,000 live births. Over the same period, similar variations can be seen with the IMR, which was 74 per 1,000 live births for NTB and 20 per 1,000 live births for Yogyakarta.

Measles immunisation coverage: The proportion of children aged 12- 23 months  who received measles vaccination, either any time before the survey or before the age of 12 months,increased from 57.5 percent in 1991 to 71.6 percent in 2002 (Figure 4.3). The measles immunisation coverage in urban areas tends to be higher. For example, 77.6 percent of the children aged 12-23 months were covered with measles immunisation in 2002 in urban areas compared to 66.2 percent of them in rural areas.

Disparities in rates: There is wide variation in measles immunisation rates, ranging from 91 percent in Yogyakarta to 44 percent in Banten.

Challenges

Causes of Child mortality: The three main causes of infant mortality in 1995 were acute respiratory infections (ARIs), perinatal complications and diarrhoea. The combination of these three causes accounted for 75 percent of infant deaths.  By 2001, this pattern had not changed much. The main causes of death in children younger than one year of age were: perinatal deaths followed by ARIs, diarrhoea, neonatal tetanus, and digestive tract and neural diseases. The main causes of death among children under five are similar (ARI, diarrhoea, neural diseases – including meningitis and encephalitis -– and typhoid), Malaria and malnutrition are underlying causes of child mortality.

Maternal and neonatal health: One-third of infant deaths occur within the first month after birth, and approximately 80 percent of these deaths during the first week of life. Clearly, these are the result of poor maternal and neonatal health status; sub-standard access to and quality of maternal and child health services, especially during and immediately after delivery; and the care-seeking (both preventive and curative) behaviour of pregnant women, families and communities, which are not conducive to healthy pregnancy, safe delivery and early childhood survival and development.

Behavioural challenges: The direct and most important causes of infant and under-five mortality are comparatively easier to address, compared to the more difficult challenges of improving family and community health-seeking behaviour, and making these conducive to healthy pregnancy, safe delivery and appropriate care immediately after birth. Measures to address these challenges include improving access to healthcare; strengthening the quality of delivery care and the integrated management of childhood diseases; improving environmental health, including the provision of clean water and sanitation; controlling communicable diseases; and improving maternal nutrition.

Disparity challenges: Another challenge is to reduce urban-rural gaps and regional disparities between provinces and districts in health indicators. A key strategy is to target poor, vulnerable groups and population living in remote areas.   However, pockets of high mortality in urban areas cannot be neglected. These are high population-density areas, with large number of children.

Synchronization and coordination of programmes: Given the complexity of factors influencing infant and under-five mortality, support from different sectors is necessary for achieving the targets. Institutions, the government, the private sector, communities, and non-governmental organizations (NGOs) are very much needed to synchronize and coordinate programmes. These contributions should fit within an overall child health policy, with specific strategies depending on the beneficiaries and service providers at different levels.

Poor families: Health protection and services for poor families are crucial, given their already-poor health and nutrition status. In 1995, the IMR of the poorest families in 1995 was almost twice that of the IMR in the richest families. While this disparity has decreased, in 2001, the IMR in 2001 in the poor population was still 1.5 times that of the rich. Considering the fact that a significant proportion of Indonesians are poor (37.34 million, or 17.4 percent, in 2003), ensuring health protection and services for this group remains a daunting challenge. Cost-effectiveinterventions, sustainable health protection including health insurance, inter-sectoral cooperation, and efforts to eradicate poverty, all play important roles in improving maternal and child health.

Decentralization: Since 2001, the decentralization of health has created a significant challenge to efforts to reduce the IMR and U5MR. The management and flow of information, especially facility-based data collection, is not functioning properly. The delineation of roles and authorities among the central, provincial and district governments is still unclear. District health planning still needs to be improved.

Policies and programmes

The National Development Programme 2001-04: Reducing the IMR and U5MR is one of the priorities in national health development. In the National Development Programme 2001-04 (Propenas), the aim is reflected in the national health programmes, namely, the Healthy Environment Programme; Healthy Behaviour and Community Empowerment Programme; the Health Promotion Programme; and the Nutrition Improvement Programme.

Supporting activities and strategies: Plans for reducing the IMR and U5MR include:  improving hygiene and sanitation at individual, family and community levels - through the provision of clean water; improving health awareness and behaviour, and awareness relating to early childhood illness and child development; controlling communicable diseases; increasing immunisation coverage; improving reproductive health services, including contraceptive and maternal services; controlling malnutrition, chronic energy deficiency and anaemia;  and promoting exclusive breastfeeding and growth monitoring.

The National Social Safety Net Programme: The economic crisis and population growth since 1998 has limited the access of the poor to health services. In response, the government launched a National Social Safety Net Programme, which supports routine maternal and child health services. There are other programmes that provide free basic and referral health services for poor families, pregnant mothers, deliveries, post-partum mothers and infants, as well as assist in the development of health facilities.

Legislation. Law No. 23 on Child Protection (in 2002) aims to ensure better and more opportunities for children to live healthy lives and grow and develop to their optimal level. It states that every child has the right to obtain health services and social security, according to his or her physical, mental, spiritual and social needs.

The National Programme for Indonesian Children. Reducing infant and child mortality is an important part of the National Programme for Indonesian Children (PNBAI). The programme is part of the 2015 Vision for Indonesian Children and emphasizes promoting healthy lives for children. National strategies to reduce the IMR and U5MR include empowering families and communities, improving inter-sectoral cooperation and coordination, and improving the coverage of comprehensive, and quality health services for children.

GOAL 5:  Improving Maternal Health

Status and trends

Maternal mortality ratio: Indonesia does not have the vital statistical systems to directly collect information on this indicator. Direct age-specific estimates of maternal mortality from the reported survivorship of sisters were obtained from the series of Indonesia Demographic and Health Surveys (IDHS). While the data indicates some reduction in maternal mortality – down to 307 per 100,000 live births for the period 1998-2002, the IDHS cautions that, given the technique, it may be premature to judge a substantial decline in the maternal mortality ratio (MMR). Among the five million deliveries occurring in Indonesia annually, an estimated 20,000 women die due to complications related to pregnancy and delivery. With the current trends, the MDG target is unlikely to be achieved unless extra efforts are made to reduce the MMR.

Disparities: Like other health indicators, there are variations in the MMR between regions. Using estimates of the proportion of maternal deaths in females of reproductive age (PMDF) in 1995 for five provinces, calculations showed that the MMR of Central Java (248) was much lower than that of Maluku (796), Papua (1,025), West Java (686) and East Nusa Tenggara (NTT, 554).

Other countries: Indonesia has a relatively high maternal mortality ratio when compared to some other Southeast Asian countries. The risk of a mother dying in childbirth in Indonesia is estimated to be 1 in 65, compared to 1 in 1,100, in Thailand.

The major medical causes: Haemorrhage, Eclampsia or convulsions resulting from hypertensive disorders of pregnancy, abortion complications, obstructed labour, and infections are the main medical causes of maternal death. Haemorrhage, responsible for 28 percent of all maternal deaths, is usually unpredictable and its onset is sudden. Most haemorrhages happen in the post-partum period, due to retained placenta and atonia uteri.  This indicates inadequate management of the third stage of labour and the failure to provide timely emergency obstetric and neonatal care in the health system. Eclampsia is the second major cause of maternal mortality in Indonesia (13 percent of all deaths, compared to 12% globally). Deaths from Eclampsia can be prevented by careful monitoring during pregnancy and ensuring access to simple and low-cost treatment.

Unsafe abortions: Eleven percent of maternal deaths in Indonesia are due to unsafe abortions, compared to 13 percent globally. These deaths can be prevented if women have access to contraception information and services, and care for abortion complication. The 2002-03 IDHS results show that 7.2 percent of births were unwanted.

Sepsis: Sepsis, another important factor of maternal mortality, often occurs due to poor hygiene during delivery or untreated sexually transmitted infections. It accounts for 10 percent of maternal deaths, compared to 15 percent globally. The early detection of infection during pregnancy, clean delivery and proper post-partum care are crucial to address the problem of sepsis. Prolonged labour accounts for nine percent of maternal deaths in Indonesia, compared to eight percent globally. 

Contraceptive prevalence rate: Modern contraceptives play an important role in reducing unwanted pregnancies and, therefore, deaths from unsafe abortions. The IDHS 2002-03 showed that the estimated unmet need for contraceptives was nine percent and has not changed much since 1997. There has been a slight increase in the contraceptive prevalence rate in Indonesia – from 50.5 percent in 1992 to 54.2 percent in 2002 (Figure 5.2); the Selected Indicators of Social- Economic of Indonesia shows  the rates to be 74 percent in 2005 .

Proportion of births attended by skilled health personnel: The patterns of maternal mortality show the importance of obstetric and neonatal emergency care, and attendance at the birth by skilled health personnel. Although most women deliver at home, the presence of skilled staff during delivery can help recognize a medical emergency and support the family’s decision to seek emergency care. The proportion of births attended by skilled health personnel has increased steadily – from 40.7 percent in 1992 to 68.4 percent in 2002 (figure 5.3). This figure, however, varies between provinces. In 2002, Southeast Sulawesi had the lowest rate at 35 percent and Jakarta the highest at 96 percent.  But in 2004, deliveries attended by skilled health personnel had reached 72.     

Underlying causes of death: The risk of maternal mortality can be aggravated by the existence of anaemia and infectious diseases such as malaria, tuberculosis, hepatitis and HIV/AIDS. In 1995, the prevalence of anaemia was alarmingly high – at 51 percent among pregnant mothers and 45 percent among post-partum mothers.

Challenges

Increasing needs: Meeting the MDG for maternal mortality poses a major challenge in terms of demographic transition, health decentralization, service delivery and public funding. The Indonesian population of 206 million, according to 2000 Census, is estimated to increase to 242 million by 2015.  The need for health services will increase. The structure of the population will have a higher proportion of women of reproductive age, and the need for health services will increase.

Health decentralization: This will also remain a key challenge in coming years. The roles and responsibilities between central and local governments are not clearly defined and understood. All institutions will need to adjust to their new roles, and networks will need to be built and strengthened at all levels. With decentralized budgets, low-income regions will have difficulties in allocating sufficient budgets for health, with other competing development priorities. The central level will play an important role in supporting districts in managing their resources. Advocacy efforts will also be essential to ensure that commitments to improve maternal health are implemented at all levels.

Service delivery and utilization: These are the other key challenges. The issues are the quality of private and public services, and disparities in accessing health services, especially for the poor and vulnerable groups. Recent data shows that the number of village midwives providing services to the poor and vulnerable groups has decreased. Tackling this new and largely unexpected situation is one of the challenges faced by the central and regional governments. As limited household resources prevent access to essential services, innovative mechanisms to address financial constraints at the household level are urgently needed.

Coordination and donors:  Coordination between related institutions and with donorsis crucial to avoid overlapping and piecemeal projects, so that improvements in maternal health can be more effectively and efficiently achieved. The sustainability of programmes will also be a challenge in coming years.

Policies and programmes

A national priority: Reducing maternal morbidity and mortality has become a central priority in health sector development, as stated in the National Development Programme (Propenas). Its components include improving reproductive health services; improving communicable disease control; improving basic and referral health services; reducing chronic energy deficiency; and reducing anaemia among women of reproductive age, during pregnancy, delivery and the post-partum period.

Making Pregnancy Safer: Within the framework of the Healthy Indonesia 2010 vision, a national strategy called Making Pregnancy Safer (MPS) has been set up as a continuation of the Government’s Safe Motherhood Programme to accelerate the reduction of maternal and neonatal morbidity and mortality. MPS promotes a systematic and integrated planning approach to clinical interventions and health systems, relying on partnerships among government institutions, donors, lenders, the private sector, communities and families. It emphasizes providing appropriate and continuous skilled care, with a focus on the availability of skilled birth attendants, and pays special attention to community-based actions to ensure women and newborns have appropriate access to care.

Strategies: There are four main strategies for reducing maternal morbidity and mortality. The first is to improve access to and coverage of cost-effective and quality maternal and neonatal healthcare. The second is to build more effective partnerships through cooperation of programmes, institutions and partners. The third is to empower women and families by improving their knowledge of and attitudes towards health behaviour. The fourth is to involve communities in the provision and utilization of available maternal and neonatal health services.

Messages: The three key messages of MPS are that every delivery should be assisted by a trained health provider; every obstetric and neonatal complication should be managed adequately; and every woman of reproductive age should have access to services for preventing unwanted pregnancy and managing the complications of unsafe abortions.

Special groups: Special attention is needed for low-income and vulnerable groups in peri-urban and rural areas, as well as people in remote areas, particularly young women who do not have adequate access to health services. The Social Safety Net Programme, launched in 1998, ensured funding for basic service provision and will need to be maintained.

Factors in maternal deaths: The wider context in which maternal death occurs also needs to be addressed. Maternal death is often the result of complex and multiple factors in more than one sector. The correlation of safe deliveries with a woman’s educational level and her use of contraceptives is well known. Adequate reproductive health services for adolescents are also needed. Gender issues and reproductive rights for both men and women still need to be emphasized and promoted at all levels.

Goal 6:  Combating HIV/AIDS, Malaria, and Other Diseases

Status and trends

Status: The first AIDS case reported in Indonesia was a foreign citizen in Bali in 1987. In the following years, reports came from more provinces. The number of reported AIDS cases has continued to rise since 1987, affecting all age groups, particularly adolescents and adults of productive age. By the end of September 2003, 1,239 AIDS and 2,685 HIV cases had been officially reported. Experts estimate that there are 90,000 to 130,000 Indonesians living with HIV. With 2.5 percent birth rate, it is thought that 2,250 to 3,250 infants at risk of HIV infection will be born each year. The most common mode of transmission is through sexual intercourse, followed by needle abuse in injecting drugs.

Injecting drug user: Surveillance data in hospitals for drug addiction in Jakarta showed an increase in HIV infection among injecting drug users from 15 percent in 1999 to 48.8 percent in 2000 and 47.9 percent in 2002.  Data from these hospitals also recorded that 15 percent of young people seeking medical services are HIV-infected.

Commercial sex workers and other high risk groups: The sex industry comprises approximately 150,000 female sex workers. Among these women, HIV rates are high: in Merauke, Papua, 26.5 percent of female sex workers are already infected by HIV. Infection rates are also high in prisons and correctional institutions; for example, at one institution in Jakarta, 22 percent of the inmates are HIV-infected.

Condom use at last high-risk sex: Among commercial sex workers, the rate of condom use when they last had high-risk sexual intercourse was reported to be 41 percent, but this is by no means consistent. There are approximately seven to 10 million male clients of sex workers in Indonesia, but fewer than 10 percent of commercial sex workers consistently use condoms to protect themselves from infection. A survey on commercial sex workers in 13 provinces showed that condom use during last sexual intercourse varied between regions, ranging from 18.9 percent in Karawang, West Java, to 88.4 percent in Merauke, Papua.

Condom use rate of the contraceptive prevalence rate: Among the general population, National Socio-Economic Surveys (Susenas) data show that the proportion of contraceptive-using married women of reproductive age (from 15 to 49 years) who use condoms is very low, at 0.4 percent in 2002, and has remained under 1 percent since 1994.

Knowledge of HIV/AIDS: The percentage of young people (aged 15 to 24) with comprehensive correct knowledge of HIV/AIDS can be estimated through proxy indicators from surveys. In 2002-03, 65.8 percent of women and 79.4 percent of men in the 15 to 24 age group had heard of HIV/AIDS. Among women of reproductive age, the majority had heard of HIV/AIDS (62.4%), but only 20.7 percent knew that using a condom every time would prevent them from HIV/AIDS and 28.5 percent knew that a healthy person could be infected with HIV/AIDS. One study showed that only 38.4 percent of Jakarta high school students, aged from 15 to 19, in 2002 correctly identified ways of preventing sexual transmission of HIV/AIDS and rejected major misconceptions. Another study in West Java, South Kalimantan and East Nusa Tenggara (NTT) found that 93.3 percent of young people knew that HIV could be transmitted by sexual intercourse, but only 35 percent knew that sharing needles could also transmit the disease, and 15.2 percent still believed that normal social contact could transmit HIV.

Pregnant women and infants: The prevalence of HIV among pregnant women was 0.35 percent in Riau and 0.25 percent in Papua. Voluntary counselling and testing (VCT) programmes in North Jakarta showed that 1.5 percent of pregnant women in 2000, and 2.7 percent in 2001, were HIV-positive. Those using VCT services probably knew that they were at risk, and the data are not representative of HIV infection among pregnant women in general. Nonetheless, these high rates indicate that transmission into communities is taking place through the bridging population. Passive reports from 1996 to 2000 showed 26 pregnant women and 13 infants were infected by HIV from East Java, Jakarta, Papua, Riau and West Java.

Young people and children: To date, the prevalence of HIV/AIDS among people aged 15 to 29 is estimated to be still below 0.1 percent. The number of HIV-infected children is still low compared to that of some other countries. Twelve HIV/AIDS cases were reported among children under four years of age, four in the 5-14 age group, and 67 in the 15-19 age group. Reported cases are probably much less than the real numbers, and therefore, strengthening surveillance systems at every level of administration is crucial.

Challenges

Large-scale epidemic: The biggest challenge will be preventing a large-scale generalized HIV epidemic. The HIV epidemic in Indonesia is concentrated, with still-low HIV infection rates in the general population, but with high incidence among certain populations. Trends indicate that Indonesia is at risk of an epidemic on a much larger scale in the near future. The alarming rise of HIV infection in high-risk groups in several parts of the country is one indication of the sharp increases to come. It is estimated that, by 2010, there will be approximately 110,000 people suffering from AIDS or who have died because of AIDS, and one million more who are HIV-infected.

Risk factors: In Indonesia, risk factors fuelling the spread of HIV/AIDS transmission include high HIV prevalence rates among high-risk groups; the increasing use of injecting drugs; risky practices such as needle sharing; high rates of sexually transmitted diseases among children working and living on the street; a general unwillingness among male clients of sex workers to use condoms; high migration rates, population displacement and movement; and the lack of adequate knowledge of and information on how to prevent HIV/AIDS, especially among young people. Effective programmes to address these risk factors include harm reduction among injecting drug users. Other challenges include the limited supplies and high prices of anti-retroviral drugs.

Policies and programmes

National and international commitments: The rapid spread of HIV/AIDS, especially among high-risk groups, is a major concern for the Government of Indonesia. National responses in HIV/AIDS control are a reflection of the Government’s international commitments to the United Nations (UN) Declaration of Commitment of the UN General Assembly Special Session (UNGASS) on HIV/AIDS (2001), the Association of Southeast Asian Nations (ASEAN) Declaration on HIV/AIDS (2001) and the UN Declaration, “A World Fit for Children (2002). HIV/AIDS control in Indonesia comprises prevention; care, support and treatment for people living with HIV/AIDS; and surveillance.

Prevention: Particularly relevant to the situation and of high priority, is the strategy of HIV/AIDS prevention implemented through information, education and communication (IEC) campaigns conducted in ways appropriate to cultural and religious values. Pregnant women are encouraged to visit antenatal care clinics to obtain HIV information, counselling and services, including information on preventing mother-to-child transmission. Other interventions for disease control are aimed at high-risk groups, such as commercial sex workers and their clients, infected people and their partners, injecting drug users, and health workers exposed to HIV/AIDS.

Care, support and treatment for people living with HIV/AIDS: VCT clinics at existing health facilities provide care, support and treatment for people with HIV/AIDS. VCT is conducted not only by the government but also by private health facilities and non-governmental organizations (NGOs). Such efforts emphasize the importance of caring for people living with HIV/AIDS while protecting their human rights by reducing or eliminating stigma and discrimination. To improve the quality of services, more training and education are needed, especially for service personnel, enhanced supplies of the required drugs and more guidance on care, support, treatment and counselling.

Surveillance: The surveillance of HIV/AIDS and other sexually transmitted diseases includes systematically collecting, processing and analyzing data, and providing information on the numbers, prevalence and trends among population groups with different risk levels.

i. Malaria

Status and trends

Malaria prevalence and death rates: Nearly half the Indonesian population – more than 90 million people – lives in malaria endemic areas. About 30 million cases of malaria are expected to occur annually, only 10 percent of which will be treated in health facilities. The highest disease burden is in the eastern provinces where malaria is endemic. Most rural areas outside Java-Bali also have a risk of malaria, which has re-emerged in Central Java and West Java. Data from public facilities in 2001 estimate malaria prevalence as 850.2 per 100,000 people, with rates as high as 20 percent in Gorontalo province, 13 percent in NTT and 10 percent in Papua. The National Household Health Survey (2001)  estimated the malaria-specific death rate at 11 per 100,000 for men and 8 per 100,000 for women.

Percentage of population using effective prevention against malaria: Prevention efforts focus on minimizing the contact between humans and mosquitoes via bed nets and residual house spraying. Environmental management and larviciding can be used in selective ecological settings dependent on the vector species. Insecticide-treated mosquito bed nets are an effective way to prevent malaria, particularly for the most vulnerable groups, i.e., pregnant women and children under five years. Nationally, about one in three children under the age of five years sleeps under a bed net (32%), although this proportion is higher (40.1%) among children younger than one year-old. In 2000, about 0.2 percent of children slept under an insecticide-treated bed net. One obstacle to the widespread use is the cost of bed nets, which can be relatively high for poor families.

Percentage of people with malaria effectively treated: Among children under five years who experienced clinical symptoms of malaria, an estimated 4.4 percent received anti-malarial drugs, while the vast majority was given other drugs to reduce fever (67.6%). Self-medication is an important but neglected area of care-seeking behaviour that needs strengthening in Indonesia through better health education.

Challenges

Links with poverty: Malaria is a preventable condition. Its high prevalence, therefore, reflects financial and cultural obstacles to prompt and effective treatment and prevention. Malaria is linked to poverty, both as cause and effect. The disease disproportionately afflicts the poor living in remote areas, out of the reach of health services. The natural environment provides ample breeding sites for malaria-spreading Anopheles mosquitoes, such as stagnant rivers and streams during the dry season, or rain puddles in the forest during rainy season. But unhealthy environments are also created, such as burrow pits left by sand-excavation or mining, unattended shrimp and fish hatcheries, and denuded mangrove swamps, leading to increased vector-borne illnesses.

Political unrest, natural disaster or population movements: These factors may contribute to outbreaks and also to re-emerging endemic areas. Man-made disasters often exacerbate malaria incidence within internally displaced communities. High population mobility has resulted in outbreaks within areas that were previously declared free of malaria. Increased population density has encouraged people to move into forest and forest-fringe areas, where malaria is endemic. The likelihood of continuing economic pressures and social turmoil will continue to challenge malaria-control efforts.

Limited human resources: Since the economic crisis, health workers were retired without replacement. In Java-Bali, the number of village malaria workers (Juru Malaria Desa, or JMD) is decreasing. This is particularly alarming given that malaria workers are key to early detection and treatment. In areas that are central to Indonesia’s economic development, but have a high incidence of malaria, extra village malaria workers need to be recruited to intensify detection and treatment of malaria, while refresher training remains a continuing need.

Funding: The funds for malaria-control activities are inadequate. The changes in roles and responsibilities associated with decentralization may threaten funding for malaria control activities. This may be especially true for public-health activities such as disease surveillance and vector control – given that bed nets and insecticides for house spraying are relatively expensive.

Resistance: In all provinces, resistance has been reported – both for existing drug regimes and also for insecticides. Chloroquine-resistant strains of malaria were first identified in Indonesia in 1974 and are now prevalent across the archipelago. Inadequate treatment, inappropriate medication, high population mobility along with intense transmission dynamics led to this situation. Drug resistance implies that the existing treatment will become less and less effective and that more expensive drugs will be required in the future.

Policies and programmes

International commitment: Malaria control and prevention will be intensified through the Roll Back Malaria (RBM) approach, an international commitment, with the following strategies: detecting early patients who need to be treated with appropriate medication; actively involving community components in malaria prevention; and improving the quality of malaria control through strengthening health staff capacity. Also important is the approach of integrating malaria eradication activities into other health initiatives, such as Integrated Management of Childhood Illnesses (IMCI), and health promotion.

Strategies: These include early warning systems and containment of epidemics, control through surveillance intensification, early diagnosis and prompt treatment, and selective vector control. Policies focus on emphasizing decentralization, community involvement and building partnership among sectors, NGOs and donor agencies. The Gebrak Malaria movement, which started in 2000, is the operational form of RBM and prioritizes partnerships among government institutions, the private sector and communities in preventing the spread of malaria.

Activities: The Malaria Control Programme in Indonesia includes eight main groups of activities: early diagnosis and prompt treatment; insecticide-treated net programmes; indoor spraying; surveillance of active and passive case detection; mass fever survey and migrant surveillance; epidemic detection and control; other control measures such as larviciding and source reduction; and capacity building. To overcome the problem of Chloroquine-resistant strains of malaria, central and local governments will begin to use new combination drugs to improve treatment success. Because these drugs are more expensive, their distribution is targeted at areas with a high prevalence of proven drug resistance.  

Disease surveillance: Ensuring the timely flow of data from health facilities, including hospitals, closer monitoring of incidences of malaria to detect and contain outbreaks, and organizing prevalence surveys as needed, are essential disease surveillance activities. To accurately target interventions, including rational insecticide spraying, research to determine the types of mosquito populations and their habits is needed. Ideally, each province will regularly survey drug efficacy to monitor areas of parasite resistance to anti-malaria drugs.