As one of developing
countries, nowdays, Indonesia is dealing with epidemiology
transition. The epidemiology transition is making a double burden for this
country. Infectious diseases such as malaria, dengue
haemorrhagic fever, cholera, typhoid, tuberculosis and other infectious
diseases have not disappeared.
Besides that, the non-communicable diseases are becoming dominant cause of
death until present day (see Figure 1). Moreover, Indonesia is a site of the emerging danger of
avian influenza, and re-emerging diseases such as poliomyelitis.
Figure 1.
Cause of death in Indonesia, 2002
Source:
World Bank
The health problem becomes more
complicated because Indonesia is also facing nutrition
transition which also has the double burden dimension. This paper will describe
more about Indonesia nutrition transition which is marked by malnutrition and
coupled with excess nutrition and note what has been done so far to tackle the
issues in Indonesian State.
Social,
Political and Economic Situation and Its Effect in Health Sector
Based on 2010 census data, the total Indonesian
population was 237.6 million people (206.2 million in 2000), which had
increased 41.39% from the 1971 census. In
2003, 42% or 90 millions people are live in the cities. Indonesia has 300
ethnics groups with literacy rate in 2003 was 89.8% (87.7% for women and 94.2%
for men).
Eventhough the latest rank of
Indonesian Human Development Index was remaining above 100 from assessment of
177 countries, the rank has indicated the improvements in literacy, life
expectancy, and income per capita as well as reduction in poverty on the last
decades. Life expectancy increased from about 52.5 years in 1980 to 59 years in
1990. Ini peningkatan tajam harus hati-hati
ditafsirkan, untuk alasan yang sama seperti yang untuk AKB.Between 2002
and 2010, the proportion of people living in income poverty fell from 18,2% to
13,3% (World Bank, 2012).
‘Indonesia had a consistent
economic growth of 3–5% per year over the past 20 years, except for a short
period during the 1998 Asian economic crisis that lead to the replacement of an
authoritarian regime by a democratic government and transferred central
authority to 500 districts in 33 provinces’ (Trisnantoro et al 2010). GNP per
capita (US$) was 1,110 in 1997 (before crisis) and decreased to 647.7 in 2000
(after crisis), and increased again to 817 in 2002.
Since decentralized era, the
financing and delivery of health interventions has been the responsibility of
the district. There are concerns about peripheral capacity to manage these
interventions. Indonesia has more than 8000 community health centres that
supervise public health interventions and provide primary care. These posts
conduct growth monitoring, nutritional counselling, health education and immunization
services.
Those health facilities and some
health care services have given some positive achievement for some health
indicators which is shown in Figure 2. For example, the percentage of
immunization coverage and percentage of birth with medical assistance were in good
progress in the last 10 years.
Figure 2. Indonesia Health
Indicators 1996-2010
Figure 3. Indonesia Health
Indicators 2006-2010
The impressive
attainment also occured to the mortality and fertility rate over the last two
decades. Periodic census survey data show that the infant mortality rate has
been roughly halved from around 145 per 1,000 live births in the 1971 to a
level of about 71 in the 1990 and 46 in 1999. The same trend also happened to
the Under Five Mortality Rate (see Table 1).
For the fertility rate, there were declining in the number of TFR from 6
in 1971 to 2,59 in 1999 (see Table 2).
Table 1. Infant Mortality Rate (IMR) and Under
Five Mortality Rate by Province 1971, 1980, 1990, 1994, 1997, 1998 and 1999
Infant Mortality Rate
|
Under Five Mortality Rate
|
|||||||||||
1971
|
1980
|
1990
|
1994
|
1997
|
1998
|
1999
|
1971
|
1980
|
1990
|
1994
|
1997
|
1999
|
145
|
109
|
71
|
66,4
|
52,2
|
49
|
46
|
218
|
158
|
99
|
92,8
|
70,6
|
59
|
Note
:
IDHS
= Indonesian Demographic and Health Survey
Source: 1971, 1980,
1990 Population Census, 1994 (IDHS and 1997 IDHS)
Table 2. Total Fertility Rate (TFR) in 1971, 1980, 1985, 1990, 1991, 1994, 1998,
and 1999
1971
|
1980
|
1985
|
1990
|
1991
|
1994
|
1998
|
1999
|
|
6
|
5
|
4
|
3
|
3
|
2,85
|
2,65
|
2,59
|
|
Source: 1971, 1980, 1990 Population Census, 1985
Intercensal Population Surveys, 1991 and 1994 Indonesia Demographic and
Health Survey
|
||||||||
Nutrition Status
Trends in nutritional status in Indonesia
below are data compiled in Statistics Indonesia which published by Central
Statistic Office of Indonesia. Table 3 shows percentage of well-nourished women
of child bearing age, 1995. The table shows that nationwide nutrition condition
of women child bearing age has only 76,04% who have well-nourished. It means
the proportion of those were under-nourished nearly 25%. From the table also
can be seen that there was slightly similarity on proportion of well-nourished
women of child bearing age between urban and rural.
Table 3. Percentage of well-nourished women of child bearing age, 1995
Selected Indicator
|
1995
|
||
Urban
|
Rural
|
U+R
|
|
% of
well-nourished women of child bearing age
|
78,98
|
74,21
|
76,04
|
Source:
Statistics Indonesia
Table 4. Percentage of Children Under-Five by Nutritional Status, 1998-2005 (%)
Nutritional Status
|
1998
|
1999
|
2000
|
2001
|
2002
|
2003
|
2005
|
Severely
Malnourished
|
10,51
|
8,11
|
7,53
|
6,30
|
7,47
|
8,55
|
8,80
|
Lack of
Nourishment
|
19,00
|
18,25
|
17,13
|
19,80
|
18,35
|
19,62
|
19,24
|
Moderately
Nourished
|
67,33
|
69,06
|
72,09
|
71,10
|
71,88
|
69,59
|
68,48
|
Well
Nourished
|
3,15
|
4,58
|
3,25
|
2,70
|
2,30
|
2,24
|
3,48
|
Source:
Statistics Indonesia
Table 4 shows the nutritional status in Indonesia in the period 1998 to
2005 remaining stagnant in all categories. In the six years, the percentage of
severely malnourished decreased only 1,71%, and the percentage of lack of nourishment
increased 0,24%. The proportion of the children under five who have poor
nutrition status were still high; It was nearly 30%. It means, in 2005, one of
four children under five in Indonesia
was under nourished.
There was a study conducted to examine
nutritional status against economic class. The study was conducted by Jus’at
(1991) using data from the National Socio Economic Survey in 1987, and breaking
down the prevalence of underweight children into quartiles of expenditure
(presented as an adult equivalent unit, a unit of energy requirement. The
result identified that the following independent risk factors of children
nutrition status: male sex, rural residence, high number of siblings, low level
of income, low calorie consumption, and poor maternal education (Soekirman et
al, 1992).
Food Consumption Pattern
Indonesia has
struggled to combat the iodine deficiency disease (IDD). According to the table
5, eventhough the percentage of household consumed iodine salt were not high
enough, but there was a good trend from year to year. The percentage of
household consumed iodine salt had increased roughly 7% from 58% in 1996 to 65%
in 1998.
Table 5. Percentage of
household consumed iodine salt, 1996-1998
Selected Indicator
|
1996
|
1997
|
1998
|
% of
household consumed iodine salt
|
58,01
|
62,1
|
65,18
|
Source:
Statistics Indonesia
Table 6. Average of Daily
Per-Capita Food Consumption, 1990-1996
Selected Indicators
|
Unit
|
1990
|
1993
|
1996
|
Average of
daily per-capita protein consumption (including rough estimation of protein
consumption from prepared food)
|
Gram
|
47,39
|
48,89
|
54,49
|
Average of
daily per-capita calorie consumption (including rough estimation of calorie
consumption from prepared food)
|
Kcal
|
1983,23
|
2018,97
|
2019,79
|
Source:
Statistics Indonesia
Table 6 shows that the trend of average of daily per-capita protein
consumption increased in the period between 1990 to 1996. This tendency also
happened for average of daily per-capita calorie consumption (including
estimation of calorie consumption from prepared food). This average already
excessed the standar of fullfillment of calorie and protein consumption which
is proposed by an Indonesian nutrition expert, Prof. Sajogyo: 1800 Kcal calorie
and 45 Gram protein (BPS 2008).
The growth in the per capita consumption of preferred foods, such as
meat, fruit vegetables, and processed foods is expected to increase over the
next two decades. This projection will lead the prevalence of overweight and
obesity which already emerging as a massive global pattern including Indonesia
(Atmarita 2005). From the first national survey was in 1996/1997 collected data
on BMI of adult male and female in urban areas (27 cities), the rate of
overweight (BMI >251) among adult male was 14.9% while adult female was
24.0% (Atmarita ibid.).
The Role of The State
As previously discussed, although
the malnutrition is still a serious problem, Indonesia has made both impressive
in nutrition and economic. Nutritional gains along with a decline in
fertility, high coverage of immunization, and a better economic environment are
all believed to account for the decline in infant mortality.
Indonesia's
health policy goals related to epidemiology transition, national strategies are
focusing on multiple public health approaches related
to not only communicable diseases but also non communicable
diseases. Cost-effective
intersectoral strategies and interventions exist to support
basic and priority health in the frame of Millenium Development Goals (MDGs).
Figure 4. Scheme of additional
resource devotion and attention to all major public goods that determine
health outcomes
Source: BAPPENAS
Figure 5 evaluates how public expenditures in the health sector significantly increased from
about Rp 4,6 trillion in 1995 to about Rp 20,3 trillion in 2008. This trend indicated that in line with
policy, Indonesia has made substantial investments in developing the basic
infrastructure and human resources for a comprehensive primary health care
delivery system, which also serves as the support base for outreach services.
Figure 5. Trend in public health expenditures,
1995-2008
Source: World Bank staff calculations, based on data from MoF.
Note: At constant 2000 Rupiah prices.
References
Atmarita (2005). ‘Nutrition
Problems in Indonesia’. Accessed 9 January 2012
BPS (2008). ‘The Consumption Pattern of Buton Regency
in 2008’. Buton: BPS Kabupaten Buton.
Indicators
of Indonesia. Accessed 1 January 2012 < http://data.worldbank.org/indicator
>.
Soekirman, I. Tarwotjo, I.
Jus'at, G. Sumodiningrat and F. Jalal (1992). ‘Economic Growth, Equity and Nutritional
Improvement in Indonesia’. United Nations.
Trisnantoro, L., S.
Soemantri, B. Singgih, K. Pritasari, E. Mulati, F.A. Agung, and M.W. Weber
(2010) ‘Reducing Child Mortality in Indonesia’. Bulletin of the World Health Organization 2010;88:642-642.
Yavuz, E. and Claudia Rokx
(2008) ‘Investing in Indonesia’s Health: Challenges and opportunities for
Future Public Spending’. BAPPENAS and World Bank of Indonesia.
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