Gender and Development

Indonesia

Health and Nutrition Sector Development Program, 1999

Sustaining Human Development:

In terms of women and children's physical and human development, the economic crisis experienced by Indonesia in the late 1990s has had terrible adverse affects. Rising unemployment and underemployment, hyper inflation, and the government's severely constrained budget have resulted in more and more people falling below the poverty line, making it increasingly difficult for Indonesian families meet their health, nutritional and social needs. The real earnings of the poor have fallen and the incidence of poverty has risen. The severity of the impact in cash-dependent urban areas is magnified as people cannot revert to subsistence agriculture or cannot depend upon the informal support networks that exist in many rural areas.

Women and children under five are most vulnerable to the social and economic shocks associated with this economic crisis. Even relatively short-term down turns in the provision of health, nutrition and family planning services have significant long-term human and economic costs. Poor health results in people becoming ill more frequently, reducing productivity for adults and children's learning capacity. Poor health and nutrition are also directly correlated with maternal, infant and child morbidity and mortality rates. With increasing poverty and malnutrition, the incidence of tuberculosis, malaria and other communicable diseases also rise, particularly in crowded urban slums. The decline in the health and nutrition status of women and children is further exacerbated by the budgetary constraints faced by the Indonesian Government, which makes it difficult for the government to maintain basic services and supplies, including salaries, drugs and vaccines.

Nutrition is a critical element here. Since the onset of the crisis, food availability and purchasing power for staple foods have declined. Changing food consumption patterns most affect pregnant women, infants and children. Girls are particularly at risk due to traditional patterns of food allocation with the household. As a rule, school age and adolescent girls are more malnourished than boys of the same age. The situation worsens as girls enter childbearing years and become mothers. Malnourished mothers are likely to give birth to low weight babies, who in turn have three to four times the risk of dying from diarrheal diseases and acute respiratory infections than normal birth weight infants.

Since the crisis, there has been a growth in micronutrient deficiencies, notably iron, iodine and vitamin A. One fourth of maternal deaths are associated with iron deficiency anemia. Iodine deficiency is endemic among mothers and children in the eastern provinces. And night blindness among women - an indicator of vitamin A deficiency - has increased dramatically in Jakarta's slums.

The health and nutritional status of Indonesia's street children is of particular concern. All street children are at extremely high risk of increased health and nutrition problems given their precarious living and working conditions. Females in particular are at high risk of sexual violence, sexually transmitted diseases and unwanted pregnancies. It is estimated that following the economic crisis, the number of street children has risen from around 12,000 in 1996 to more than 40,000 in the 12 largest cities. Domestic violence - an indicator of increasing stress and tension within families - is another contributing factor pushing women and children out of their homes and onto the streets for survival and income. This has led to increasing numbers of female-headed households, which in the Indonesian context tend to be the most economically marginal. At the same time, there has been an increase in the number of neglected children abandoned to orphanages, and this at a time when orphanages are least able to afford increasing numbers of children.

In response to Indonesia's severe health and nutritional problems, the government and ADB formulated the Health and Nutrition Sector Development Program.¹ The project aims to mitigate the effects of the economic crisis on the poor in relation to their health and nutrition status, while at the same time implement policy reforms necessary to develop sustainable health and nutritional service delivery. Although the project impacts on the lives of poor Indonesians in general, particular emphasis has been placed on targeting women and children in recognition of women and children's heightened vulnerability during economic crisis. More generally, this project acknowledges the extent to which women's and children's health is integral to poverty eradication. For example, children's health and nutritional status effects their educational attainment and thus their range of employment opportunities. Similarly, women's health and nutrition directly impacts on the health of infants and children as well as on their income earning potential.

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Project Design:

The overall objective of the project is to safeguard access of the poor to basic health services and to strengthen management of health services delivery through decentralization. The project's outputs are grouped in the following six areas:

1. Maintain effective health services by ensuring continued operation of health centers and the availability of essential drugs and vaccines
2. Improve nutrition by providing complementary and supplementary feeding (including micronutrients) for nursing mothers, infants and children under three years of age
3. Strengthen communicable disease control programs
4. Reinforce family planning and reproductive health programs
5. Expand programs to protect the health and well being of street and neglected children in urban areas
6. Implement health management information systems for the Ministry of Health at the national, provincial and district level; and develop information systems to support the current project

The project will distribute a health card to poor families to enable them to access free primary health care. Existing public health services will be expanded through the development of NGOs, private voluntary organizations and community-based organizations. This will improve coverage of densely populated urban slum areas, as well as encourage the development of health services and facilities that are more responsive to the needs of the local community. The expanded outreach program developed through this network of government, non-government, private and community organizations will also assist public health surveillance, particularly in the areas of immunization, mother and child nutrition, and communicable diseases.

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Gender Inclusive Design:

The project includes a number of features directed at improving the health and nutritional status of women and children:

Health Care

Women and children will benefit most from the distribution of health cards to poor families, as they are in general the greatest users of primary health care services. Other project features include:

• The maintenance of immunization programs for children
• Continuation of out reach activities by midwives and other community health volunteers, to provide pre and postnatal visits to pregnant and nursing women and their infants. Such visits facilitate the early detection of pregnancy complications and child and maternal health problems
• As well as monitoring infants' growth, the midwife is also instrumental in arranging immunization schedule for infants

Nutrition

As part of the project's nutrition focus:

• A public health surveillance systems will be developed to track changes in the nutrition status of the population, in particularly weight/height changes in young and school-age children
• Community volunteers, with the help of health workers, will be supported to develop outreach programs to provide supplementary feeding for eligible pregnant women and nursing mothers, and children under two years of age
• Additional health and supplementary feeding programs will be developed to meet the needs of neglected and street children

Neglected and Street Children

A network of safe houses and orphanages, managed by qualified NGOs, will be established to meet the needs of neglected and street children, including:

• Having their physical needs met
• Counseling services to encourage their continuation at or return to school
• Counseling by qualified social workers will also help children deal with issues of family breakdown, violence and sexual exploitation/abuse that many have experienced
• Scholarships and supplementary tutorials will be provided to children returning to school full time
• For those unable to continue, practical skills training will be provided. Such skills training will be particularly important for street and neglected girls, who because of sexual exploitation and abuse are unable to integrate back into normal schooling

The concern with the safety and welfare of girls neglected and living on the street has been pursued in a complementary JFPR project.² The project Assisting Girl Street Children at Risk of Sexual Abuse aims to develop a model approach in Yogyakarta to reduce the number of girl street children and the incidence of child prostitution and sexual abuse, at the same time as rehabilitating the girls who have already been affected. The project will fund experienced NGOs to pilot culturally acceptable, cost effective and sustainable interventions to prevent and rehabilitate girls, including counseling, safe housing, scholarships, technical and vocational training, food supplements and a range of outreach health programs including maternal and child, reproductive and sexual health. Monitoring, evaluation and documentation of such interventions will be conducted by the University of Gadja Mada in order to provide recommendations on future projects in other urban centers of Indonesia.