Ind p INDONESIA HEALTH PROFILE 2008

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2 Ind p INDONESIA HEALTH PROFILE 2008 MINISTRY OF HEALTH R.I. JAKARTA 2010

3 EDITOR BOARD Advisor Dr. Ratna Rosita, MPHM Secretary General of MOH Chief dr. Jane Soepardi Head of Centre for Data and Epidemiological Surveillance of MOH Editors Dra. Rahmaniar Brahim, Apt, MKes Sugito, SKM, MKes Hary Purwanto, MKes, MMSi Hasnawati, SKM, Mkes Drg. Vensya Sitohang, M.Epid Members, Sunaryadi, SKM, MKes; Iskandar Zulkarnain, SKM, MKes.; Nuning Kurniasih, SSi, Apt.MSi; Drg. Rudy Kurniawan, MKes.; Marlina Indah Susanti, SKM; Farida Sibuea, SKM, MScPH; Evida Veronika Manullang, SSi; Supriyono Pangribowo, SKM; Istiqomah, SS; Dewi Roro Kumbini, S.Pd; Athi Susilowati, SKM; Margiyono, Skom; Sondang Tambunan; B.B Sigit Contributors BPS Statistics Indonesia; National Family Planning Coordinating Board; Ministry of Underdeveloped Areas; DG of Community Health MOHRI; DG of Medical Care MOHRI; DG of Diseases Control & Environmental Health MOHRI; DG of Pharmaceutical Services & Medical Devices MOHRI; National Board of Health Research & Development MOHRI; National Board of Health Human Resources Development & Empowerment MOHRI; Bureau of Budget & Planning; Bureau of Personnel MOHRI; Center for Managed Care MOHRI; Center for Crisis Response MOHRI

4 Ind p Catalog in Publishing. Ministry of Health RI Indonesia. Ministry of Health. Centre of Data and Information Indonesia Health Profile Jakarta : Ministry of Health RI 2010 I. Title 1. HEALTH STATISTICS This book is published by Ministry of Health, Republic of Indonesia Jalan HR. Rasuna Said Blok X 5 Kav 4 9, Jakarta Phone no: , Fax no: E mail: pusdatin@depkes.go.id Web site:

5 "Indonesia Health Profile 2008" is part of the profile series from previous years. Health profile is also a manifestation of accountability from the Centre for Data and Information. That the health profile is not considered confusing and left behind, the data and information is presented in accordance with the year listed. "Indonesia Health Profile 2008" is containing information such as previous health profile, in addition also includes significant events that occurred in Presentation of the "Health Profile of Indonesia in 2008" is still limited due to there are few data yet to be collected so that some indicators are still contains data for 2007, including contributions from the Riset Kesehatan Dasar, held in 2007 by Balitbangkes, MOH. Some of the data and information in 2008 that is not in the Indonesian Health Profile 2008 will be presented in other form other than Indonesian Health Profile. "Indonesia Health Profile" with all the limitations should still be published faster than the previous years. In addition to the version published in printed publication, Health Profile 2007 can be accessed through the Internet; Hopefully, "Indonesia Health Profile 2008" could be useful in filling the needs of data and the latest health information, with the hope of all of us. Jakarta, March 2010 Head of Centre for Data and Epidemiological Surveillance dr. Jane Soepardi NIP i

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7 I gladly receive "Indonesia Health Profile 2008" which has published faster than the previous years publication. Although tough and many challenges in the process of collecting data to fill out the health profile, finally Centre for Data and Epidemiological Surveillance has successfully collected data from 2008 and then arranged to be "Indonesia Health Profile 2008". Challenges in the provision of data and giving information on time has got so many obstacles data and information from each province and program institution is still not fully complete. With the publication of "Indonesia Health Profile 2008", which also contains the important events in 2008, I expect this profile could be used in making decisions based on the data and information (evidence based) and is used as a reference data and information. In this occasion I want to thank very much and give appreciation to the all contributors that has given contribution toward the finishing "Indonesia Health Profile 2008". Jakarta, March 2010 Secretary General Ministry of Health Dr. Ratna Rosita, MPHM NIP iii

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9 FOREWORD ACKNOWLEDGMENT OF GENERAL SECRETARY CONTENTS ANNEXES i iii v vii CHAPTER I INTRODUCTION 1 CHAPTER II SOCIO ECONOMIC, DEMOGRAPHY AND ENVIRONMENTAL SITUATION 3 A. Demographic 3 B. Economics 6 C. Education 9 D. Environment 12 E. People Behavior 16 CHAPTER III HEALTH STATUS 22 A. Mortality 22 B. Morbidity 29 C. Nutritional Status 62 CHAPTER IV HEALTH EFFORT 67 A. Primary Health Care 67 B. Referral and Support Health Care 83 C. Disease Control and Prevention 87 D. Improvement of Community Nutrition 105 E. Health Care in Disaster Situation 109 CHAPTER V HEALTH RESOURCE 110 A. Health Facility 110 B. Health Personnel 122 C. Health Financing 125 v

10 CHAPTER VI COMPARISON BETWEEN INDONESIA WITH ASEAN DAN SEARO COUNTRIES 127 A. Demographic 127 B. Health Status 135 C. Health Effort 144 BIBLIOGRAPHY 149 ANNEXES *** vi

11 Annex 2.1 Distribution of Administration Area by Province in Annex 2.2 Area Size, Total Population and Population Density by Province, 2008 Annex 2.3 Number of Population by Specific Age Group, Dependency Ratio and Province, 2008 Annex 2.4 Number and Percentage of Underdeveloped Area by Province, Annex 2.5 Percentage of Illiterate People by Age Group and Province, Annex 2.6 School Enrollment Ratio (SER) by Province, Annex 2.7 Net Enrollment Ratio (NER) by Province, Annex 2.8 Percentage of Household by Drinking Water Sources and Province in 2008 (Urban + Rural) Annex 2.8.a Percentage of Household by Drinking Water Sources and Province in 2008 (Urban) Annex 2.8.b Percentage of Household by Drinking Water Sources and Province in 2008 (Rural) Annex 2.9 Percentage of Household by the Average of Clean Water Usage per Person/Day and Province, Riskesdas 2007 Annex 2.10 Percentage of Household by Physical Quality of Drinking Water per Province, 2007 Annex 2.11 Percentage of Household with Drinking Water Sources from Pump/Well/Water Spring by Area Type, Distance to the Nearest Septic Tank/Other Waste Disposal and Province, 2008 Annex 2.12 Percentage of Households by Toilet (Water Closet) Facility, Area Type and Province, 2008 Annex 2.13 Percentage of Household by Closet Types and Province, 2008 (Urban + Rural) Annex 2.13.a Percentage of Household by Closet Types and Province, 2008 (Urban) Annex 2.13.b Percentage of Household by Closet Types and Province, 2008 (Rural) Annex 2.14 Percentage of Households by Final Disposal of Feces and Province, 2008 (Urban + Rural) Annex 2.14.a Percentage of Households by Final Disposal of Feces and Province, 2008 (Urban) vii

12 Annex 2.14.b Percentage of Households by Final Disposal of Feces and Province, 2008 (Rural) Annex 2.15 Percentage of Households by Area Type, Floor Area (M 2 ) and Province, 2008 Annex 2.16 Percentage of Households by Area Type, Floor Main Material and Province, 2008 Annex 2.17 Percentage of Households by Area Type, Outer Wall Main Material and Province, 2008 Annex 2.18 Percentage of Population Who Had Health Complaint during the Reference Month by Type of Health Complaints and Province, 2008 (Urban + Rural) Annex 2.18.a Percentage of Population Who Had Health Complaint during the Reference Month by Type of Health Complaints and Province, 2008 (Urban) Annex 2.18.b Percentage of Population Who Had Health Complaint during the Reference Month by Type of Health Complaints and Province, 2008 (Rural) Annex 2.19 Percentage of Population Who Got Ill during the Reference Month by Number of Ill Days and Province, 2008 (Urban + Rural) Annex 2.19a Percentage of Population Who Got Ill during the Reference Month by Number of Ill Days and Province, 2008 (Urban) Annex 2.19.b Percentage of Population Who Got Ill during the Reference Month by Number of Ill Days and Province, 2008 (Rural) Annex 2.20 Percentage of Population Who Were Treated Outpatient and Were Self Treated during the Reference Month by Area Type and Province, 2008 Annex 2.21 Percentage of Population Who Were Self Treated during the Reference Month by Area Type, Type of Medicine Used and Province, 2008 Annex 2.22 Percentage of Population Who Were Treated as Outpatient during the Reference Month by Place/Method of Medicine and Province, 2008 (Urban + Rural) Annex 2.22.a Percentage of Population Who Were Treated as Outpatient during the Reference Month by Place/Method of Medicine and Province, 2008 (Urban) Annex 2.22.b Percentage of Population Who Were Treated as Outpatient during the Reference Month by Place/Method of Medicine and Province, 2008 (Rural) Annex 2.23 Percentage of Household that Fulfill Good Clean and Healthy Behavior by Province, 2007 Annex 2.24 Percentage of Population Over 10 Years Old Who Had Good Behavior in Defecation and Handwashing by Province, 2007 Annex 2.25 Percentage of Population Over 10 Years Old by Smoking Behavior and Province, 2007 viii

13 Annex 2.26 Annex 2.27 Annex 2.28 Annex 2.29 Prevalence of Current Smoker and Average Number of Cigarettes that were Sucked by Population Over 10 Years Old by Province, 2007 Percentage of Population Over 10 Years Old Who Smoking by the Age Starting Smoking Every Day and Province, 2007 Prevalence of Alcoholic for Previous 12 Months and Previous 1 Month by Province, 2007 Prevalence of Over 10 Years Old Population for Deficient Consumption of Fruit and Vegetable, 2007 Annex 3.1 Estimation of Infant Mortality Rate (IMR), Life Expectancy Rate (e 0 ), Net Reproduction Rate (NRR), Crude Birth Rate (CBR) and Total Fertility Rate (TFR) by Province, 2007 Annex 3.2 Human Development Index and Its Component by Province, Annex 3.3 Distribution of Hospital Outpatient Based on ICD X Chapter in Hospital in Indonesia, 2007 Annex 3.3.a Distribution of Hospital Inpatient based on ICD X Chapter in Hospital in Indonesia, 2007 Annex 3.4 Distribution of Hospital Outpatient Based on ICD X Chapter in Hospital in Indonesia, 2008 Annex 3.4.a Distribution of Hospital Inpatient Based on ICD X Chapter in Hospital in Indonesia, 2007 Annex 3.5 Number of Case and Malaria Morbidity Rate by Province, 2008 Annex 3.6 Annual Parasite Incidence (API) Malaria in Java Bali, Annex 3.7 Coverage of TB Pulmonary Case Finding, 2008 Annex 3.8 Number of New Cases in TB Pulmonary AFB Positive by Sex and Province, 2008 Annex 3.9 Number of New Cases in TB Pulmonary AFB Positive by Age Group, Sex and Province, 2008 Annex 3.10 Number of AIDS Cumulative Cases, Deaths, and Case Rate per 100,000 Population by Province, 2008 Annex 3.11 Number and Percentage of AIDS Cases in IDU by Province until December 31, 2008 Annex 3.12 Number of Pneumonia Case to Under five by Province, 2008 Annex 3.13 Leprosy Situation by Province, 2007 Annex 3.14 Number of New Leprosy Cases and Physical Defect by Province, 2008 Annex 3.15 Yaws Prevalence by Province, 2008 Annex 3.16 Tetanus Neonatorum Case Total and Risk Factor by Province, 2008 Annex 3.16.a Tetanus Neonatorum Case Total and Risk Factor by Province, 2008 Annex 3.17 Number of Measles Cases and Measles Vaccination by Age Group and Province, 2008 ix

14 Annex 3.18 Frequency and Case Total to Measles Outbreak by Province, Annex 3.19 Number of AFP Cases by Province, 2008 Annex 3.20 Number of AFP Cases by Classification Criteria and Province, 2008 Annex 3.21 Diarrhea Outbreak, Annex 3.22 Number of Patients, Case Fatality Rate (CFR), and Incidence Rate (IR) of Dengue Hemorrhagic Fever (DHF) by Province, Annex 3.23 Number of Districts/Municipalities Infected by Dengue Hemorrhagic Fever (DHF) by Province, Annex 3.24 Number of Filariasis Patients by Province, Annex 3.25 Leptospirosis Situation on Human in Indonesia, Annex 3.26 Anthrax Situation on Human In Indonesia, Annex 3.27 Bubonic Plague Situation on Human in Indonesia, 2008 Annex 3.28 Number and Percentage of Infected Districts/Municipalities and Number of Animal Bites Infected by Rabies (GHTR) and Examination Result of Animal Specimen by Province, 2008 Annex 3.29 Number of Communicable Diseases that Can Be Prevented by Vaccination by Province, 2008 Annex 3.30 Number of Hepatitis C Cases, 2008 Annex 3.31 Percentage of Under five by Nutrition Status (Weight/Age) per Province, 2007 Annex 3.32 Percentage of Under five by Nutrition Status (Height/Age) per Province, 2007 Annex 3.33 Percentage of Under five by Nutrition Status (Weight/Height) per Province, 2007 Annex 3.34 Prevalence of Over Weight and Thin Children Aged 6 14 Years by Sex per Province, 2007 Annex 3.35 Percentage of Adult Nutrition Status (15 Years and Over) by Body Mass Index (BMI) per Province, 2007 Annex 3.36 Prevalence of CED Risk of Women Population Aged Years by Province, 2007 Annex 3.37 Percentage of Newborn Infant Weight in the Last 12 Months by Province, 2007 Annex 3.38 Number of Cases and Yaws Prevalence, 2008 Annex 3.39 Hajj Outpatient in Saudi Arabia Health Condition, Annex 3.40 Number of Indonesian Hajj Diseases Pattern Health Examination in Embarcation, Annex 3.41 Hajj Outpatient in Saudi Arabia by Disease Pattern, Annex 3.42 Caused of Hajj' Death in Saudi Arabia by Disease Pattern, Annex 3.43 Indonesian Hajj by Total Deaths per 1,000 Hajj (Death Rate), 2008 x

15 Annex 4.1 Coverage of 1 st and 4 th Visits (K1 & K4) of Pregnant Women, Delivery Assisted by Health Providers and Neonates Visits by Province, 2008 Annex 4.2 Percentage of Underfives by First Birth Attendance and Province, 2008 (Urban + Rural) Annex 4.2.a Percentage of Underfives by First Birth Attendance and Province, 2008 (Urban) Annex 4.2.b Percentage of Underfives by First Birth Attendance and Province, 2008 (Rural) Annex 4.3 Percentage of Underfives by Last Birth Attendance and Province, 2008 (Urban + Rural) Annex 4.3.a Percentage of Underfives by Last Birth Attendance and Province, 2008 (Urban) Annex 4.3.b Percentage of Underfives by Last Birth Attendance and Province, 2008 (Rural) Annex 4.4 Percentage of Ever Married Women 10 Years of Age and Over and Number of Children Ever Born Alive by Province, 2008 (Urban + Rural) Annex 4.5.a Percentage of Ever Married Women 10 Years of Age and Over and Number of Children Ever Born Alive by Province, 2008 (Urban) Annex 4.5.b Percentage of Ever Married Women 10 Years of Age and Over and Number of Children Ever Born Alive by Province, 2008 (Rural) Annex 4.6 Average Number of Children Ever Born per Woman Aged Years by Province and Area Type, 2008 Annex 4.7 Proportion of Married Women Aged Years and Using Contraception by Area Type and Province, 2008 Annex 4.8 Proportion of Married Women Aged Years and Used Contraception by Area Type and Province, 2008 Annex 4.9 Percentage of Married Women Aged Years by Contraception Methods and Province, 2008 (Urban + Rural) Annex 4.9.a Percentage of Married Women Aged Years by Contraception Methods and Province, 2008 (Urban) Annex 4.9.b Percentage of Married Women Aged Years by Contraception Methods and Province, 2008 (Rural) Annex 4.10 Result of Cumulative New Family Planning Acceptor Service by Contraception Method and Province, 2008 Annex 4.11 Number and Proportion of Cumulative New Family Planning Acceptor by Service Location and Province, 2008 Annex 4.12 Universal Child Immunization (UCI) Villages Achievement by Province, Annex 4.13 Basic Immunization Coverage to Infants by Province, 2008 xi

16 Annex 4.14 Hepatitis B Immunization Coverage to Infants by Province, 2008 Annex 4.15 Drop Out of DPT1 Measles Immunization Coverage to Infants by Province, Annex 4.16 Percentage of Underfives Who Have Ever Been Immunized by Province, Area Type and Immunization Type, 2008 Annex 4.17 TT Immunization Coverage to Pregnant Women by Province, 2008 Annex 4.18 Indicators of Government Public Hospital Services by Province, 2007 Annex 4.19 Number of Inpatient Visits in Hospital by Province, 2007 Annex 4.20 Examination of Dental and Oral Health in Local Government and Ministry of Health Public Hospital Services by Province, 2007 Annex 4.21 Number of Jamkesmas (Community Health Insurance) Participant Visits in Health Center, 2008 Annex 4.22 Number of Poor People and Not Affordable for Community Health Insurance by Province, 2008 Annex 4.23 Number of Jamkesmas (Community Health Insurance) Participants Visits in Hospital/BKMM/BKIM/BKM/BP4 by Province, 2008 Annex 4.24 Number of Advanced Level Health Care Provider of Jamkesmas by Province, 2008 Annex 4.25 Handling of Drug Abuser in Hospital by Ownership, 2007 Annex 4.26 Coverage of Pulmonary TB AFB+, Recovery, Complete Treatment and Succes Rate (SR) by Province, 2008 Annex 4.27 Finding Case Coverage of Underfives Pneumonia by Province, 2008 Annex 4.28 Distribution Coverage of Vitamin A Capsule, 2008 Annex 4.29 Coverage of Pregnant Women Got Iron Tablet by Province, 2008 Annex 4.30 Percentage of Children Aged 2 4 Years Who Ever Breastfed by Duration of Breastfeeding per Province, 2008 (Urban + Rural) Annex 4.30.a Percentage of Children Aged 2 4 Years Who Ever Breastfed by Duration of Breastfeeding per Province, 2008 (Urban) Annex 4.30.b Percentage of Children Aged 2 4 Years Who Ever Breastfed by Duration of Breastfeeding per Province, 2008 (Rural) Annex 4.31 Recapitulation of Disaster, 2008 Annex 5.1 Number of Health Centers and Ratio to Population by Province, Annex 5.2 Number of Health Centers and Health Centers with Beds by Province, Annex 5.3 Number of Health Facilities by Province, 2008 Annex 5.4 Number of Hospitals by Ownership and Province, 2008 Annex 5.5 Number of General Hospitals and Beds by Ownership, Annex 5.6 Number of Beds on General Hospitals by Class and Province, 2008 xii

17 Annex 5.7 Number of General Hospitals Owned by Ministry of Health and Local Government by Class and Province, 2008 Annex 5.8 Number of Specific Hospital and Beds by Type, Annex 5.9 Number of Pharmaceutical and Medical Device Production Facilities by Province, 2008 Annex 5.10 Number of Pharmaceutical and Medical Device Distribution Facilities by Province, 2008 Annex 5.11 Number of Health Polytechnics by Study Program and Province, 2008 Annex 5.12 Number of Study Program Accreditation Grades of Health Polytechnic in Indonesia, 2008 Annex 5.13 Number of Non Health Polytechnics by Study Program and Province, 2008 Annex 5.14 Number of Non Health Polytechnic Accreditation Grades Cumulative by December 2008 Annex 5.15 Number of Non Health Polytechnics by Ownership Cumulative by December, 2008 Annex 5.16 Number of Health Personnels and Ratio Based on Village Potency Survey by Province, 2008 Annex 5.17 Number of Health Personnels on Health Center by Type of Personnel and Province, 2008 Annex 5.18 Ratio of Doctor, Dentist, Nurse and Midwife to Health Center by Province, 2008 Annex 5.19 Number of Non Health Personnel on Health Center by Type of Personnel and Province, 2008 Annex 5.20 Number of Non Permanent Health Personnel by Province, 2008 Annex 5.21 Number of Budget Allocation and Realization Ministry of Health, 2008 Annex 5.22 Percentage of Population with Health Assurance by Province and Type of Area, 2007 Annex 5.23 Percentage of Population with Health Assurance by Type of Assurance and Province, 2007 Annex 6.1 Comparison of Population Data in Asean and Searo Countries, 2008 Annex 6.2 Birth Rate and Mortality Rate and Human Development Index in ASEAN and SEARO Countries Annex 6.3 Percentage of Access to Improved Drinking Water Sources and Access to Improved Sanitation in ASEAN and SEARO Countries, 2006 Annex 6.4 Comparison of Tuberculosis Data in ASEAN and SEARO Countries, 2006/2007 Annex 6.5 Estimation Rate of HIV and AIDS in ASEAN and SEARO Countries, 2007 Annex 6.6 Number of Communicable Diseases that Can Be Prevented by Vaccination in ASEAN and SEARO Countries, 2007 xiii

18 Annex 6.7 Comparison of Infant Immunization Coverage in ASEAN and SEARO Countries, 2007 Annex 6.8 Comparison of Health Efforts in ASEAN and SEARO Countries, Annex 6.9 Health Expenditure in ASEAN and SEARO Countries, 2006 *** xiv

19 Human development is a development process that aims to humans to have the ability in various fields, especially in the areas of income, health, and education. Human development as a measure of overall development performance established through the basic three dimensional approach, namely a long and healthy life, knowledge, and have a decent life. Each dimension is represented by the indicators. Long and healthy life is represented by the indicators of life expectancy; knowledge indicator is represented by literacy rates and average length of school; and a decent life indicator is represented by purchasing power. All the indicators that represent the three dimensions of human development is summarized in a single value, the Human Development Index (HDI). Meanwhile, the health development efforts undertaken by all the components of a nation that aims to increase awareness, willingness, and ability to live a healthy life for every person to a public health status manifested the highest possible. Community health status can be seen from various indicators, including indicators of life expectancy, mortality, morbidity, and nutritional status of the community. To improve community health status, the Ministry of Health in the period prioritize maternal health care and child as the first point in health development. The next priority is the health services for the poor, empowerment of health personnel, prevention of communicable diseases, prevention of malnutrition, and the management of catastrophic health crisis. Health Profile of Indonesia Year 2008 has attempted to describe in general about health conditions, health efforts, health resources, and related factors, and to compare Indonesia with ASEAN member countries and SEARO. Indonesia Health Profile 2008 consists of 6 (six) chapters as follows: Chapter I Introduction. The chapter about the reference to the Health Profile of Indonesia Chapter II Socio Economics, Demography and Environmental Situation. This chapter presents a general overview of Indonesia. In addition to the description of the geography, demographics, education, economic and other general information, this chapter also gives review the environmental factors and behavior. 1

20 Chapter III Health Status. This chapter contains a description of the results of the development of health until the year 2008 that includes about mortality, morbidity, age and life expectancy, and people nutrition status. Chapter IV Health Effort. This chapter contains a description of the efforts of health that has been implemented by the health sector until the year 2008, and to achieve successful development programs in the field of health. The description of the health effort has been made is achievement include the percentage of primary health service coverage, the percentage of the achievement of coverage of health services referrals, disease prevention and disease control program and people nutrition improvement. Chapter V Health Resource. This chapter describes the resources sector health development until the year Overview of state resources by the year 2008 includes the situation on health personnel availability, infrastructure and health financing. Chapter VI Comparison between Indonesia with ASEAN and SEARO countries. This chapter presents a comparison of several indicators covering certain demographic data, birth rates, death rates, Human Development Index, data, tuberculosis, a number of estimates of HIV/AIDS cases, the disease can be prevented by immunization, immunization coverage among infants and health efforts. *** 2

21 Indonesia lies between 6 o North Latitude to 11 o South Latitude, and from 97 o to 141 o East Longitude and located between two continents, Asia and Australia/ Oceania. This strategic position has a significant influence on the cultural, social, political, and economic. Indonesia is the largest archipelagic country in Southeast Asia, according to data Bakosurtanal, the number of islands in Indonesia, 17,508 (17,506 after deducting Sipadan island and Ligitan). The number of islands includes those in the estuary, river and delta. This fact makes Indonesia has a diversity of cultures and customs with different characteristics from each other. Diversity in various aspects is also associated with behavior related to health. Administratively, Indonesia in 2008 is divided into 33 provinces, 495 districts (399 districts and 96 cities). When compared with the number of districts/cities which have in 2007, then during the year 2008 has been the establishment of 30 of new districts/municipalities. The division of administrative regions in Indonesia in the year can be seen in Annex 2.1. In this chapter an overview will be described and the behavior of residents Indonesia in 2008 which include: state of the population, economic situation, state of education, environmental conditions, and behaviors related to population health. A. POPULATION Based on data from the Central Bureau of Statistics, Indonesia's population in 2008 was recorded at 228,523,342 consisting of 114,399,238 of men and 114,124,104 women. Through estimation results SUPAS 2005 BPS (Indonesian population estimation broken down by age group and sex in 2008), we can get a description of the population pyramid as follows. 3

22 GRAPH 2.1 POPULATION PYRAMID OF INDONESIA, 2008 Source: BPS Statistics Indonesia, Estimasi Penduduk Indonesia Dirinci Menurut Kelompok Umur dan Jenis Kelamin Tahun 2008 Nationally, the total area of 1,910, km 2 Indonesia the level of population density is 120 people per km 2. High density level is still dominated by the provinces in Java. Province has the highest population density is DKI Jakarta, in the amount of 13,774 people per km 2. West Java was a region that has the 2 nd highest population density with the density 1,157 people per km 2. Province with 3 rd the highest density was of Yogyakarta for 1,107 people per km 2. Lowest population density in Papua, which is only 6 people per km 2, West Papua is a province with the 2 nd lowest population density with 8 people per km 2, which was followed by Central Kalimantan, with a density 13 people per km 2. From the population projections can be seen there is discrepancy between the island population distribution. More than half the population of Indonesia stays in the Java Island, in the amount of 58.14%, with an area of only 6.77% of Indonesia. The rest was spread in Sumatera 21.36%, Sulawesi 7.23%, Kalimantan 5.62%, Nusa Tenggara Islands and Bali 5.43%, Papua and Maluku 2.22%. The population and population density figures per province are presented in Annex

23 GRAPH 2.2 PERCENTAGE OF POPULATION SPREAD BY BIG ISLANDS GROUP IN INDONESIA, 2008 Source: BPS Statistic Indonesia, Estimasi Penduduk Indonesia, 2008, Attachment of Home Affair Minister No. 6, Composition of the Indonesian population by age group, shows that young people (0 14 years old) of 27.23%, the productive age (15 64 years old) of 67.67%, and old age (> 65 years old) for 5.10%. Thus, the rate of Dependency Ratio of Indonesian population in 2007 was 47.77%. Province with highest percentage of Dependency Ratio was East Nusa Tenggara for 60.44%, followed by Maluku for 58.23%, and Southeast Sulawesi for 58.00%. Meanwhile, the province with the lowest number of Dependency Ratio was DKI Jakarta for 37.76%, followed by DI Yogyakarta for 38.12% and East Java for 40.36%. Details of the population according to age groups, provinces, and the rate of Dependency Ratio in 2008 can be seen in Annex 2.3. GRAPH 2.3 DEPENDENCY RATIO BY PROVINCE IN INDONESIA, 2008 Source: BPS Statistic Indonesia, Estimasi Penduduk Indonesia,

24 B. ECONOMICS Economic condition is one aspect that is measured in determining the success of the development of a country. Indonesia's economic in 2008 grew 6.1% compared to the year Value of Gross Domestic Product (GDP) on the basis of constant prices in 2008 reached USD 2,082.1 billion, while in the year 2007 of USD 1,963.1 billion. When viewed under current prices, GDP in 2008 rose by USD 1,004.7 billion, from USD $ 3,949.3 billion in 2007 to Rp 4,954.0 billion in Assessing economic conditions, of course, not be separated from the inflation rate. BPS Statistics Indonesia recorded during the period January to December of 2008 inflation has been 11.06%. During the year 2008 the food group gave largest contribution to inflation of 16.35%. Another group in the year 2008, namely housing, water, electricity, gas and fuel contributed 10.92% of the national inflation; processed food, beverages, cigarettes and tobacco 12.53%, clothing group 7.33%, health groups 7.96%, education, recreation and sport 6.66% and the transportation, communications and financial services groups 7.49%. During the year 2008, all economic sectors experienced growth. The highest growth occurred in transportation and communication sector, which reached 16.7%, followed by electricity, gas and water 10.9%, the financial sector, real estate and housing services 8.2%, construction sector 7.3%, sector trade, hotels and restaurants 7.2%, services sector 6.4%, agriculture 4.8%, manufacturing industry 3.7%, and mining and quarrying sector 0.5%. Without oil, GDP growth in 2008 reached 6.5% which is higher than the overall GDP growth which was 6.1%. To know the level of unemployment, it is held Sakernas (Survei Angkatan Kerja Nasional = National workforce survey). Sakernas formulated unemployment concept before 2001 as a work force which do not work/ do not have a job and still looking for a job. Since 2001, the concept of unemployment become a work force who are looking for a job, preparing a business, not looking for a job because they felt it will impossible to get the job/feel desperate (before they were categorized as Not Work Force) and those who have a job but before start to work (categorized as Worked before). The percentage of open unemployment is the ratio between job seekers and a total workforce. Open unemployment is defined here as those who are seeking employment or who are preparing a business or is not looking for work because they feel no longer possible to get a job, including those who just got a job but not yet started work. Open unemployment does not include people who were in school or taking care of the household, thus including only those who work force is just that open unemployment. According to Sakernas, Work Force is a working age population who work or have a job but were temporarily absent from work, and umployment. While working according to Sakernas definition is an economy activity done by someone with aim to obtain an income or profit, at least one hour (without stopping) in a week ago. The activity is including unpaid employee activity that has helped in one business or economy activity. 6

25 Based on the data of the National Labor Force Survey (Sakernas) Central Statistics Agency (BPS) in 2007 to 2008, the year 2008 there was a decrease in unemployment, with the increase in employment in social service sectors such as carpentry services, domestic service, transportation, and agriculture. Workforce development, working population and unemployment in August 2007 August 2008 is as follows. TABLE 2.1 DEVELOPMENT OF THE NUMBER OF WORK FORCE, POPULATION WHO WERE WORKING, AND PERCENTAGE OF OPENED UNEMPLOYMENT IN INDONESIA, Y e a r August 2007 (million) August 2008 (million) Number of work force 109,94 111,95 Number of working people 99,93 102,55 Opened unemployment 10,01 9,39 Percentage of opened unemployment (%) 9,11 8,39 Source: BPS Statistic Indonesia, Survei Angkatan Kerja Nasional, Government intensively conducts economic development to promote improvement in any sector in all over the country especially to underdeveloped area. An area is categorized underdeveloped for several factors, i.e. geography, natural resources, human resources, facility, disaster and social conflict high risked area, and development policy. Facility limitation of any sector including health, affects to underdeveloped area people of running social economic activities. The smallest units in underdeveloped area used in National Strategy of Underdeveloped Area Development Acceleration (STRANAS PPDT) is a district administrative area. The determination of underdeveloped criteria was done by using an approach based on 6 basic criteria measurement, i.e.: community economic, human resource, facility (infrastructure), local financial ability (fiscal gap), accessibility and local characteristic, and based on district that under border area between countries and the small islands group, area most seriously affected by disaster and social conflict. Ministry of Development Acceleration of Underdeveloped Area states that number of underdeveloped districts was 199 districts in Indonesia. In 2008, the number of underdeveloped districts was 199 of 495 districts in Indonesia (40.2%). The number was higher than that of previous year when there were 197 underdeveloped districts. Addition of 2 districts was on West Sumatera, which rose from 7 in 2005 to 9 districts. Province with highest percentage of underdeveloped district/municipality was West Sulawesi with 100% ( ), followed by Central Sulawesi with 81.8% (2008) and Bengkulu 80% (2008). Number and percentage of underdeveloped district by province can be seen on Annex

26 GRAPH 2.4 PROVINCE WITH UNDERDEVELOPED DISTRICTS IN INDONESIA, 2008 Source: National Strategy of Acceleration of Underdeveloped Area, Poverty is an issue of public concern, including those who work in the health sector. Public affordability to health service relates to economic issue. Poverty is also a burden on filling needs of healthy food. As matter of fact that unsufficent healthy food feeding can affect to poor self immunity which may finally lead to vulnerability of several diseases. Severe and under nutrition burden frequently relates to economic condoition as well. Problem of adequate nutrition food consuming may lead to Kwashiorkor, Xeropthalmia, Scurvy, and Beri beri. In March 2007, the number of poor population decreased to million from 39.3 million poor people in March This shows that a decline in the 2.13 million poor people. The number of poor people in March 2008 of million people (15.42%). Compared with the poor population in March 2007 which amounted to million people (16.6%), means the number of poor fell by 2.21 million people. During the period March 2007 March 2008, the population of poor in rural areas decreased 1.42 million people, while in urban areas decreased 0.79 million people. The percentage of poor population between urban and rural areas has not changed much. In March 2008, most of poor people (63.47%) were in rural areas. Percentage of poor population from is presented in the next Graph

27 GRAPH 2.5 PERCENTAGE OF POOR POPULATION IN INDONESIA, Source: BPS Statistic Indonesia, Analisis dan Penghitungan Tingkat Kemiskinan, 2007, Press Release of BPS Statistic Indonesia 2008: Jumlah Kemiskinan.pdf C. EDUCATION Education has become one indicator assessed on evaluating human development level of a country. Through knowledge, education contributes to health behavior change. Knowledge affected by education issue is one of predispossing factor contributing to people s decision on health behavior. Through this section we may know about literacy, educational status, school enrollment and net enrollment ratio. Illiteracy rates correlated with poverty rates. Therefore, people who can not read indirectly bring them in ignorance, stupidity itself while they were close to poverty. The composition of illiterate people in Indonesia is various. The number of illiterate people in Indonesia is not only experienced by one generation, but consists of young and older generations. Based on BPS data , the percentage of illiterate population is declining because of the increased access to education in the last 5 years. The largest percentage of illiterate population in the age group of more than 45 years old, followed by age group less than 15 years. Thus, education as the main effort to eliminate the illiteracy is always good to touch the young generation and old generation. 9

28 GRAPH 2.6 PERCENTAGE OF ILLITERATE POPULATION BY AGE GROUP IN INDONESIA, Source: BPS Statistic Indonesia, In 2008, the highest percentage of population aged years and above who are illiterate was in Papua (26.23%), followed by East Nusa Tenggara (7.54%) and West Sulawesi (6.70%). The lowest percentage was DKI Jakarta (0.07%), followed by North Sulawesi (0.32%) and Riau (0.47%). The percentage of illiterate population by age group and province can be seen in Annex 2.5. Percentage of population aged years by province can be seen in Graph 2.7 below. GRAPH 2.7 PERCENTAGE OF ILLITERATE POPULATION AGED YEARS IN INDONESIA, 2008 Source: BPS Statistic Indonesia, 10

29 School Enrollment Ratio (SER) from the BPS are categorized into 3 age groups, which represent the age of 7 12 years at the primary, aged years represent the junior level, and years of age represent the high school level. In general, the SER at the primary level of %, junior and senior high school 81.08% 57.51%. The higher level of education, the lower of the SER. The percentage of School Enrollment Ratio (SER) by province is presented in Annex 2.6. GRAPH 2.8 SCHOOL ENROLLMENT RATIO (SER) IN INDONESIA, Source: BPS Statistic Indonesia, In contrast to the SER, Net Enrollment Ratio (NER) shows the number of school age population is still in school at the appropriate level of education with age. In general, NER at the primary level of 93.98%, junior school 66.75% and senior high school 44.22%. The higher level of education, the lower of the NER. The percentage of Net Enrollment Ratio by province is presented in Annex 2.7. GRAPH 2.9 NET ENROLLMENT RATIO (NER) IN INDONESIA, Source: BPS Statistic Indonesia, 11

30 D. ENVIRONMENT Environment is one of considerable sector on evaluating public health situation. Together with behavior, health care, and genetic factor, environment determines public health status. Describing environmental situation, the following describes percentage of healthy household, percentage of household by drinking water source, percentage of household with drinking water source from pump/well/water spring by distance to the nearest waste disposal, and percentage of household by toilet facility ownership. 1. Drinking Water Accessibility The Susenas 2008 divides drinking water source used by households into two main groups i.e. protected and unprotected drinking water source. Protected drinking water source consisted of packaged water, piped water, pump, protected water spring, protected well, and rain water. On the other hand, unprotected drinking water source consisted of unprotected well, unprotected water spring, river water, and others. Percentage of household with protected drinking water source was 94.20%, and percentage of household with unprotected drinking water source was 5.80%. DKI Jakarta became the province having highest percentage of household with protected drinking water source with 99.62%, followed then by Central Sulawesi with 98.17% and North Maluku with 97.78%. Meanwhile, Bengkulu was province having lowest percentage with 69.56%, followed by Lampung with 82.33% and Central Kalimantan with 83.62%. Most of households at protected drinking water source group had protected well, with 23.79%. It was followed by pump water with 21.45%, gage piped water with 18.57%, refill drinking water (12.36%), packaged water (7.80%), retail piped water (5.17%), protected spring water (3.39%), and rain water (1.66%). On the other hand, at unprotected drinking water source, most of households used unprotected well (4.32%), followed by unprotected spring water (0.78%), river water (0.43%) and others (0.26%). More details concerning to percentage of households by drinking water source, province and type of area are on Annex 2.8., 2.8.a. and Annex 2.8.b. GRAPH 2.10 PERCENTAGE OF HOUSEHOLD BY DRINKING WATER SOURCES IN INDONESIA, 2008 Source: BPS Statistic Indonesia, Susenas

31 2. Clean Water Consumption The amount of water usage per capita household is related to public health risks associated with hygiene. Public health risk in the group of people who access to clean water is categorized as having low risks. Operational definition based on the Riskesdas about average water consumption of individuals is the average amount of water usage in daily household divided by the number of household members. Average water consumption of individuals categorized into '<5 liters/person/day', ' liters/person/day', ' liters/person/day', ' liters/person/day' and ' 100 liters/person/day'. Results of Riskesdas 2007 stated that nationally there were 16.2% of households that are low in water consumption, consisting of 5.4% use water less than 5 liters/person/day and 10.8% used clean water liters/person/day, which has a high risk for experiencing health problems/diseases. The households that had access to the basic (minimum) were 26.9%, 25.3% for medium access and 31.6% for the optimum access. Provinces of households had access to clean water were still low (above 16.2%) among others, Gorontalo, West Sulawesi and West Sumatra. Meanwhile, the provinces had a high optimal access were DKI Jakarta, Yogyakarta and Jakarta. Percentage of households according to the average water consumption per person per day and the province in more detail is presented in Annex Physical Quality of Drinking Water Physical quality of good drinking water meanss the water is not cloudy, no odor, no taste, no color and no foam. Riskesdas 2007 showed the percentage of households with drinking water quality for good physical quality was 86.0%. There were 15 provinces that the percentage of the physical qualities of good drinking water was below the national percentage, which is the lowest in Central Kalimantan (58.60%). Percentage of households according to the physical quality of drinking water and the province in more detail is presented in Annex Distance of Drinking Water Source to Waste Disposal Drinking water source frequently become contaminant source of water borne disease. Therefore, it has to fill condition of localization and construction. Localization condition urges that drinking water source has to be retained from pollutant, so distance of drinking water source to latrine, waste hole, septic tank, and other contaminant sources. The distance depends on condition and declivity land. The distance between drinking water source and contaminant sources, including waste disposal generally is no less than 10 meters, and the position of drinking water source can not be under those contaminant sources. 13

32 The Susenas 2008 also provides data of percentage of household having drinking water source by distance to waste disposal and province. The national data indicates that 51.88% households had distance of drinking water source of pump/well/water spring to waste disposal more than 10 meters. Meanwhile, % households had distance 10 meters or less and 23.97% were unknown. In terms of households with distance more than 10 meters, three provinces with highest percentage were DI Yogyakarta with 71.73%, followed by South Kalimantan with 66.00% and Jambi with 63.66%. On the contrary, three provinces with lowest percentage were Gorontalo with 33.39% followed by Banten with 34.35% and Nanggroe Aceh Darussalam 35.82%. Details concerning to percentage of households having drinking water source of pump/well/water spring by type of area, distance to nearest waste disposal and province are on Annex GRAPH 2.11 PROVINCE WITH PERCENTAGE OF HOUSEHOLD WITH DISTANCE OF DRINKING WATER SOURCE TO SEPTIC TANK OR OTHER WASTE DISPOSAL OVER 10 M, 2008 Source: BPS, Susenas, Toilet Facility The Susenas 2008 divides households based on toilet facility i.e. private, shared, public, and none. At national level, percentage of households having private toilet facility was 61.68%, shared was 13.38%, public facility was 3.79% and none was 21.14%. Percentage of household having private toilet facility shows that on urban had the significant gap to those of rural. Urban percentage was 71.92%, while rural percentage was 52.00%. In terms of private toilet facility ownership, there were three provinces with highest percentage i.e. Riau Islands with 82.54%, followed by Riau with 81.88% and East Kalimantan with 77.03%. Meanwhile, three provinces with lowest percentage were Gorontalo with 31.82%, followed by West Nusa Tenggara 14

33 with 37.76% and North Maluku with 44.21%. To know more about percentage of households by toilet facility ownership, type of area, and provinces in 2008 can be seen on Annex GRAPH 2.12 PERCENTAGE OF HOUSEHOLD BY TOILET FACILITY OWNERSHIP IN INDONESIA, 2008 Source BPS Statistic Indonesia, Susenas 2008 Household using swan latrines was 74.67%, pit privy was 13.19%, and not using toilet was 3.70%. The using of types of closet of swan latrines in urban was higher than that of rural. While the using of types of closet of pit privy in rural was 5 times higher than that of urban. Percentage of types of closet and province in 2008 are on Annex 2.13, 2.13.a and Annex 2.13.b. Based on final disposal of feces, shown that septic tank 53.33% was the most often used in households, especially in urban was 72.29% while in rural was 35.39%. In East Nusa Tenggara and Lampung, most of people chose hole as a final disposal of feces (51.33% and 42.85%). Percentage of households of final disposal of feces and province in 2008 is on Annex 2.14, 2.14.a, and Annex 2.14.b. 6. Floor Width Population growth wheter at urban or rural have negative impact to comparation between floor width and number of occupant. It brings impact to degradation of open space at residences which finaly affects as well as to public health situation. Number of population relates to number of microbes. Number of existing microbes infecting respiratory tract will rise in line with number of occupant increase. Small and crowded house affects to mental growth of children. Children need free environment and wide playground which is able to support their creativity. In 15

34 other words, crowded house can enhance disease transmisión especially respiratory tract infection and affect child s growth. The Susenas 2008 provides data about percentage of households by floor width meter square was 43.08%, then percentage of floor width meter square was 34.60% and percentage of floor width meter square was 10.43%. More details about percentage of households by floor width, type of area, and province in 2008 are on Annex Types of Floor Main Material In terms of area type and floor area (meter square), most households lived in house which floor made from ceramics, not from land. Percentage of the using of floor made not from land in all over in Indonesia has reached over 80% with the highest was DKI Jakarta 98.20% and the lowest was East Nusa Tenggara 58.99%. Comparing by area of living, household whose house floor do not made from land at urban was higher than that of rural (94.10% to 81.32%). Percentage of households by area type, floor main material and province, 2008 is on Annex Types of Wall Main Material To measure the level of community welfare, it can be seen through the using of types of floor main material, i.e. brick, wood, bamboo or other. Nationally, there were 65.49% of households using brick as types of wall main material with highest percentage was in Bali (93.67%) and the lowest was in Central Kalimantan (14.23%). Percentage of households by area type, wall main material and province 2008 is on Annex E. PEOPLE BEHAVIOR Describing people behavior relating to public health condition, the following provides several indicators i.e. percentage of population taking outpatient care and having self treatment during during the reference month by type of area, percentage of population taking outpatient care during the reference month by place/method of treatment. Indicator presented refers to Susenas Population Taking Outpatient Care During the Reference Month One of indicators used to determine population health status is morbidity rate. The following is percentage table of population who showed population distribution by area type, sex, and health complaint during the last month, Nationally, percentage of population who had health complaints was 33.24%. The percentage of provincial population that has the largest percentage of health 16

35 complaints was Gorontalo (49.66%), East Nusa Tenggara (47.04%) and South Kalimantan (40.19%). There are 3 types of complaint in the last one month in 2008, i.e, cough (15.24%), influenza (14.83%) and fever (11.56%). According to area type, percentage of population who had complaint was higher in urban than that of rural. Percentage of population who had health complaints by area type and province, 2008 is on Annex 2.18, 2.18.a and Annex 2.18.b. Based on Susenas 2008, number of population who got sick or ill until cause of work, study or daily activity disturbed during the reference month (a month ago) in Indonesia was % for less than 4 days and get sick between 4 7 days was %. Percentage of population who got sick during the preference month and ill days by province, 2008 is on Annex 2.19, 2.19.a and Annex 2.19.b. 2. People Effort on Treatment Seeking Behavior The Susenas 2008 indicates that percentage of population having selftreatment during the reference month was bigger than those who are taking outpatient care. From 65.59% of population who had complaint during the reference month choose to have self treatment. While percentage of population taking outpatient care was 44.37% from all population who had health complaint during a month ago. Bali was the province had highest percentage of population taking outpatient care during the reference month with 55.04% followed by West Sumatera with 50.75% and DKI Jakarta with 50.71%. Meanwhile Southeast Sulawesi had lowest percentage with 28.03%, followed by Central Kalimantan with 28.10%, and Maluku with 31.97%. In terms of self treatment behavior concerning to health complaint during the reference month, North Maluku had highest percentage with 81.64%, followed by Gorontalo with 78.79% and South Kalimantan with 78.01%. Meanwhile, Papua had lowest percentage with 50.72%, followed by Bali with 51.85% and East Nusa Tenggara with 55.68%. Annex 2.20 provides details concerning to the issue. From population having self treatment, 90.49% of them were using modern drugs, 22.26% were using traditional drugs and 5.53% were using other types of drugs. Percentage of population who were having self treatment during reference month by province, types of drugs used and area type, 2008 are on Annex Place of Outpatient Care Percentage of population taking outpatient care concerning to health complaint during the reference month were categorized based on place of health care i.e. government hospital, private hospital, doctor s practice, health care/sub health center, paramedic, traditional healer and traditional birth attendance. The Susenas 2008 shows that health center/sub health center had highest percentage among other 17

36 places with 35.50%, followed by doctor s practice with 30.11%, and paramedic with 28.82%. GRAPH 2.13 PERCENTAGE OF POPULATION TAKING OUTPATIENT TREATMENT BY TREATMENT PLACE IN INDONESIA, 2008 Source: BPS Statistic Indonesia, Susenas 2008 GRAPH 2.14 PERCENTAGE OF POPULATION WHO TOOK OUTPATIENT TREATMENT TO HEALTH CENTER/SUB HEALTH CENTER IN INDONESIA, 2008 Source: BPS Statistic Indonesia, Susenas

37 In 2008, the province with highest percentage of the population that take outpatient treatment to the health center/sub health center was West Papua 73.83%, followed by East Nusa Tenggara 73.36% and Papua 72.36%. Meanwhile, the province with the lowest percentage of the population to health center/sub health center was North Sumatra for 20.28%, followed by East Java 26.18% and Riau 28.75%. Details of each province can be seen in Annex Clean and Healthy Living Behavior (PHBS) Based on Riskesdas 2007, the percentage of households that meet the criteria Behavior of Clean and Healthy Living (PHBS) with the national category of 38.7%. Provinces that had percentage above 38.7% were 5 provinces of DI Yogyakarta (58.2%), Bali (51.7%), East Kalimantan (49.8%), Central Java (47%) and North Sulawesi (46.9%). Provinces with low percentage of clean and healthy living behavior were Papua (24.4%), East Nusa Tenggara (26.8%), Gorontalo (27.8%), Riau (28.1%) and West Sumatra (28.2%). Percentage of households that meet the criteria of hygienic behavior and good health in detail by province are presented in Annex Hygiene Behavior Hygiene behavior surveyed in Riskesdas 2007 covered defecation and handwashing habits. Proper defecation habit is when people defecated in toilet and good hand washing is when people wash their hands with soap before eating, before preparing food and after defecation, after babies/children defecation and after handling poultry/animal. Data from Riskesdas 2007 nationally showed 71.1% of the population over 10 years had correct habit in defecation, but only 23.2% who had proper hand washing. Province which had the highest percentage in this hygienic behavior is DKI Jakarta is 98.6% in the habit of correct defecation and 44.7% in the habit of proper hand washing. Provinces with low percentage in defecation habit were the West Sulawesi (57.4%), Gorontalo (59.2%) and West Sumatra (59.3%). Then, provinces with the low percentage in handwashing habit were West Sumatra (8.4%), North Sumatra (14.5%) and Riau (14.6%). Percentage of population aged over 10 years who had correct defecation and good hand washing in detail by province are presented in Annex Smoking Behavior Based on Riskesdas 2007, the percentage of population aged over 10 years 23.7% were smoking every day, 5.5% were smoking occasionally, 3.0% were former smokers and 67.8% non smokers. 19

38 GRAPH 2.15 PERCENTAGE OF POPULATION AGED OVER 10 YEARS BY SMOKING BEHAVIOR IN INDONESIA, 2008 Source National Institute of Health Research and Development, Riskesdas 2007 According to the characteristics of respondents, the percentage of population who smoke every day that high value is in the productive age group (25 64 years old) with a range between 29% to 32%, in addition almost half the population were men who smoke every day (45.8%). According to education level, the highest percentage of residents who smoke every day is the population of high school graduated. GRAPH 2.16 PERCENTAGE OF POPULATION AGED OVER 10 YEARS BY SMOKING BEHAVIOR AND SEX IN INDONESIA, 2008 Source: National Institute of Health Research and Development, Riskesdas

39 Current smoking prevalence of daily smokers and occasional smokers was 29.2%. The highest prevalence of smokers is Province of Lampung (34.3%), Bengkulu (34.1%) and Gorontalo (32.6%). The average number of cigarettes smoked by current smokers is 12 cigarettes per day. The highest number of cigarettes smoked per day was in Nanggroe Aceh Darussalam (19 cigarettes), Riau Islands and Bangka Belitung Islands each was 16 cigarettes. Percentage of population over 10 years by smoking habits, number of cigarettes smoked, age started smoking and the province in detail is presented in Annex 2.25, 2.26 and Annex Drinking Alcohol Behavior The habit of drinking alcohol is a risk factor for the occurrence of health risks. Based on Riskesdas 2007, the national prevalence among the population aged over 10 years who drank alcohol during the last 12 months by 4.6%, and still drank alcohol in the last 1 month of 3.0%. Province that had high prevalence of drinking alcohol, including East Nusa Tenggara (17.7%), North Sulawesi (17.4%) and Gorontalo (12.3%). Based on age characteristics of alcoholic, the prevalence of alcohol drinking during the last 12 months and last month began a high at the age between years of 5.5% and 3.5%, then increased to 6.7% and 4.3% at age years, and then the prevalence declined with age increasing. According to sex status, the prevalence of alcoholic is greater in male than female. According to the education, the prevalence of high alcoholic is found at people from education level of Junior and Senior High School Graduated. Percentage of population aged 10 over years according to alcohol drinking habits and province are presented in more detail in Annex Less Consumption of Fruit and Vegetables Behavior Based on Riskesdas 2007, people are categorized enough vegetables and/or fruit consumption at least 5 portions per day for 7 days a week. Nationally, the percentage of population aged over 10 years who has the habit of eating less fruit and vegetables by 93.6%. Province who had the highest percentages in the habit of eating less fruit and vegetables were Riau (97.9%) and West Sumatra (97.8%). While the lowest were Gorontalo (83.5%), DI Yogyakarta (86.1%) and Lampung (87.7%). Percentage of population aged over 10 years according to the eating habits of fruit and vegetables and the province in more detail is presented in Annex *** 21

40 Health status situation in Indonesia is determined not only by health service and health facilities, but also by socioeconomic factors, education, genetic, and others factors. These factors influence morbidity, mortality and nutritional status of population. Morbidity rate, mortality rate and nutrition status describe health condition and health status of population. The rates also can be used for health program planning. The health status situation of population in 2008 was described by morbidity, mortality and nutritional status. A. MORTALITY Mortality is defined as number of mortality of a condition in one period and certain place. These are the infant mortality rate, under five mortality rate, maternal mortality rate, crude death rate and life expectancy number. 1. Infant Mortality Rate Infant Mortality Rate (IMR) is defined as a number of infant who died on the phase since birth to one year old per 1,000 live births. IMR is highly frequent used in measuring public health status, either on province or on national level. Various health programs focus on decreasing IMR. The following graph provides data figuring Estimation of IMR on GRAPH 3.1 ESTIMATION OF INFANT MORTALITY RATE (IMR) PER 1,000 LIVE BIRTHS Source: Result of Indonesia Demography and Health Survey, BPS Statistics Indonesia 22

41 In general, the number of IMR of Indonesia decreases year by year. Indonesia Demography and Health Survey (IDHS) 2007 estimates the IMR of Indonesia was 34 per 1,000 live births. Estimation of IMR in can be seen at Graph 3.1 above. The number of IMR estimates the IMR of 5 years period prior to the survey. For example, in IDHS 2007 IMR describe condition of years Decreasing trend of IMR occurred because of well distributed health care. Rising income of the community leading to better nutritional status and immunity against diseases can also contribute to the trend IMR of each province in the 2007 IDHS was estimation of 10 years periods prior to the survey ( ). Four provinces with lowest IMR to 1,000 live births were DIY (19), Nanggroe Aceh Darussalam (25), East Kalimantan and Central Java (26). Three provinces with highest IMR were West Sulawesi (74), West Nusa Tenggara (72) and Central Sulawesi (60). Data of IMR by province can be seen on the Graph 3.2. Data of IMR in Indonesia and 33 provinces are on Annex 3.1. GRAPH 3.2 ESTIMATION OF INFANT MORTALITY RATE (IMR) PER 1,000 LIVE BIRTHS BY PROVINCE IN INDONESIA 2007 Source: Indonesia Demography and Health Survey, BPS Statistics Indonesia In addition, number of still births and live births in hospitals is described on the Table 3.1. Year TABEL 3.1 NUMBER OF STILL BIRTHS AND LIVE BIRTHS AT INDONESIA IN Number of Hospital Number of Still Births 23 Number of Live Births ,234 3, , ,246 3, , ,268 3, , ,292 3, , ,319 3, ,282 Source: DG of Medical Care, MOH

42 2. Under five Mortality Rate (UMR) Under five mortality rate is defined as a number of child who died between birth and exact age five per 1,000 live births. Under five mortality rate >140 categorise as very high, as high, as moderate an <20 as low (MDGs manual). Under five Mortality Rate figures a chance of fatal case on phase from birth to 5 years old. Under fives Mortality Rate in the 2007 IDHS published by BPS, Statistics Indonesia was 44 per 1,000 live births for 5 years period prior to the survey ( ) Graph 3.3 below describes trend of Under five Mortality Rate (IDHS). Years in the graph indicate years when the survey was conducted and the rates indicate the rate of 5 years period prior to surveys. GRAPH 3.3 UNDER FIVE MORTALITY RATE PER 1,000 LIVE BIRTHS IN INDONESIA, Source: BPS Statistics Indonesia The 2007 IDHS estimates under five years mortality rate of each province for 10 years period prior to the surveys ( ). The three highest rates were West Sulawesi (96), Maluku (93) and West Nusa Tenggara (92). Meanwhile, DIY was province with the lowest rate of 22 per 1,000 live births followed by Central Java (32) and Central Kalimantan (34). Data of under five mortality rate by province can be seen on the following Graph

43 GRAPH 3.4 ESTIMATION OF UNDER FIVE MORTALITY RATE PER 1,000 LIVE BIRTHS BY PROVINCE IN INDONESIA 2007 Source: BPS Statistics Indonesia, SDKI 2007 More details of under fives mortality rate in Indonesia and provinces is described on Annex Maternal Mortality Rate Maternal Mortality Rate (MMR) is defined as a number of maternal mortality related to pregnancy, delivery and postpartum (in 42 days) per 100,000 live births. Maternal Mortality Rate is used to measure and evaluate mortality related to pregnancy. MMR is influenced by several factors including health status, education and pregnancy and delivery care. Both MMR and IMR are indicators of health development programs. Indonesia Demography and Health Survey 2007 indicates that IMR in 5 years preceding survey ( ) was 228 per 100,000 live births. It is lower comparing to 2002 MMR at 307 per 100,000 live births. Graph 3.5 below shows declining trend of MMR in Years in the graph indicate years when the survey was conducted. 25

44 GRAPH 3.5 MATERNAL MORTALITY RATE (PER 100,000 LIVE BIRTHS) IN INDONESIA Source: BPS Statistics Indonesia In addition, number of maternal mortality and live birth in hospital are on the following Table 3.2. TABLE 3.2 NUMBER OF MATERNAL MORTALITY IN HOSPITAL IN INDONESIA Year Maternal Deaths Live Births , , , , , ,086 Source: DG of Medical Care, MOH 4. Crude Death Rate (CDR) Crude Death Rate (CDR) is defined as a number of death in a certain period and place per 1,000 population of middle year. CDR 2007 was based on result of Inter Census Survey The number of CDR 2007 was 6.9 per 1,000 populations. This number was not change since Riskesdas 2007 (Basic Health Research) found that in a year, in 33 provinces, there were 4,552 cases from 258,488 households. So that it can be calculated that CDR was 4 per 1,000 population, i.e. 4,552 per 1,163,196 (=258,488 households x 4.5 average number of household members). Table 3.3 shows that the main cause of mortality of all age were stroke (15.4%), followed by TB (7.5%), Hypertension (6.8%) and injury (6.5%). Comparing to SKRT 1995 and SKRT 2001, by 4 groups of mortality cause, for 12 years ( ), epidemiology transition has been happened indicated by increasing proportion of non communicable disease followed by demographic transition. 26

45 TABLE 3.3 MORTALITY MAIN CAUSE OF ALL AGE RISKESDAS 2007 No Cause of Death Death Proportion (%) 1 Stroke Tuberculosis Hypertension Trauma/accident Perinatal Diabetes Mellitus Cancer Liver diseases Ischaemic heart diseases Lower respiratory tract diseases Heart Diseases Pneumonia Diarhoea Gastric ulcer and duodenal ulcer Typhoid Malaria Meningitis Encephalitis Congenital Malformation Dengue Tetanus Septicemia Malnutrition 0.2 Source: Riskesdas 2007 The following Graph 3.6 shows that proportion of communicable disease in Indonesia in 12 years decline from 44% to 28% proportion of non communicable disease increase from 42% to 60%. Proportion of maternal/perinatal disorders in 6 years did not decline, so that needs a special attention. GRAPH 3.6 DISTRIBUTION OF DEATH BY DISEASE GROUP SKRT AND RISKESDAS 2007 Source: Riskesdas

46 Gross Death Rate in hospital were on range % describes on the following Table 3.4. TABLE 3.4 GROSS DEATH RATE IN HOSPITAL IN INDONESIA Years Number of Number of Out Patient Death % ,270,657 81, ,140,954 99, ,561,106 85, ,233,204 84, ,687,996 94, ,775, , Source: DG Medical Care, MOH, 2009 The following Table 3.5 and 3.6 show 10 main diseases causing death in hospital in 2007 and TABLE MAIN DISEASES CAUSING DEATHS BY BASE TABULATION LIST IN HOSPITALS IN INDONESIA, 2007 No Cause of Illness Number of Death Patient CFR (%) 1 Diseases of circulatory system 21, Certain infectious and parasitic diseases 14, Certain condition originating in the perinatal period 9, Diseases of respiratory system 7, Diseases of digestive system 6, Injury, poisoning and certain other consequences of external causes 5, Endocrine, nutritional and metabolic diseases 5, Neoplasms 4, Diseases of genitourinary system 4, Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified 3, Source: DG Medical Care, MOH,

47 No TABLE MAIN DISEASES CAUSING DEATHS BY BASE TABULATION LIST IN HOSPITALS IN INDONESIA, 2008 Cause of Illness 1 Diseases of circulatory system 23, Certain infectious and parasitic diseases 16, Certain condition originating in the perinatal period 9, Diseases of respiratory system 8, Diseases of digestive system 6, Injury, poisoning and certain other consequences of external causes 5, Endocrine, nutritional and metabolic diseases 5, Diseases of genitourinary system 4, Neoplasms 4, Symptoms, signs and abnormal clinical and laboratory 10 findings, not elsewhere classified Source: DG Medical Care, MOH, (by August 2009) Number of Death Patient CFR (%) 4, Table 3.5 and Table 3.6 show that circulation diseases were the first number disease causing death in hospital either in 2007 and In 2007, circulation diseases causing death of 21,830 people or Case Fatality Rate (CFR) 11.02%, and 23,163 people in 2008 or Case Fatality Rate (CFR) 11.06%. 5. Life Expectancy at Birth (e 0 ) In addition to IMR, MMR and other indicators, Life Expectancy can be used to measure public health status and life quality of community, either in district/municipalities, province or country. Life expectancy can also be used to assess Human Development Index. Progression in health might be identified through rising Life Expectancy at Birth. BPS Statistics Indonesia estimates e 0 in 2007 at 68.7 slightly higher than in 2006 at 68.5 and 2005 at Province with highest e 0 in 2007 was DIY at 73.1 years old, followed by DKI Jakarta at 72.8 years old and North Sulawesi at 72.0 years old. Meanwhile, West Nusa Tenggara was province with lowest e 0 in 2007 at 61.2 years old, followed by South Kalimantan at 62.6 years old and Banten at 64.5 years old. Life Expectancy at Birth provided specifically of each province can be seen on Annex 3.1. B. MORBIDITY Morbidity is defined as incidence or prevalence of a disease in a certain population and period. Morbidity is influenced by incidence or spread of a disease in population, either fatal or nonfatal cases. Morbidity rate is more sensitive than mortality rate to assess health status of population, because many diseases that influence health status have low mortality rate. Next paragraph provides data of 10 main diseases in hospital, communicable and noncommunicable diseases. 29

48 1. Ten Main Diseases in Hospital Ten main diseases of hospital outpatient in 2007 by according to ICD 10 chapter indicate that the highest number of hospital outpatient came with factors influencing health status and contact with health services, followed by diseases of respiratory system, symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified, diseases of digestive system, and Certain infectious and parasitic diseases, as on the following Table 3.7. More details of number of hospital outpatient in 2007 are described on Annex 3.3.a.. TABLE MAIN DISEASES OF HOSPITAL OUTPATIENTS IN 2007 No 1 Factors influencing health status and contact with health services 2,142, Diseases of respiratory system 1,762, Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified 1,246, Diseases of digestive system 1,195, Certain infectious and parasitic diseases 1,143, Injury, poisoning and certain other consequences of external causes 955, Diseases of eye and adnexa 723, Diseases of circulatory system 545, Diseases of genitourinary system 529, Cause of Illness Diseases of the musculosceletas system and connective tissue 30 Number of Visit Admission Rate 500, Source: DG of Medical Care, MOH, 2009 Meanwhile, in 2008, the highest number of outpatient came with Diseases of respiratory system, followed by factors influencing health status and contact with health services, diseases of digestive system, certain infectious and parasitic diseases, and diseases of circulatory system as on the Table 3.8 below. More details of number of hospital outpatient in 2008 are described on Annex 3.3. TABLE 3.8 TEN MAIN DISEASES OF HOSPITAL OUTPATIENTS IN 2008 No Cause of Illness Number of Visit Admission Rate 1 Diseases of respiratory system 469, Factors influencing health status and contact with health services 463, Diseases of digestive system 360, Certain infectious and parasitic diseases 344, Diseases of circulatory system 324, Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified 211, Diseases of eye and andnexa 181, Endocrine, nutritional and metabolic diseases 180, Diseases of the musculosceletas system and connective tissue 175, Injury, poisoning and certain other consequences of external causes 168, Source: DG of Medical Care, MOH, 2009

49 The following Table 3.9 indicates 10 main diseases of hospital inpatients in 2007 according to ICD 10 chapter. The highest number of hospital inpatients was certain infectious and parasitic diseases, followed by pregnancy, childbirth and puerperium. However, the highest Case Fatality Rate (CFR) was patient with disease of circulatory system. More details of hospital inpatients by chapter of ICD 10 in 2007 are described in Annex 3.4.a. TABLE 3.9 DISTRIBUTION OF HOSPITAL INPATIENTS ACCORDING TO ICD 10 CHAPTER IN HOSPITAL IN INDONESIA 2007 No Cause of Illness Total Cases Death Patients CFR (%) 1 Certain infectious and parasitic diseases 568,981 14, Pregnancy, childbirth and the puerperium 335, Diseases of digestive system 225,212 6, Injury, poisoning and certain other consequences of external causes 202,100 5, Diseases of circulatory system 198,180 21, Diseases of respiratory system 197,780 7, Factors influencing health status and contact with health services 188, Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified 141,857 3, Diseases of genitourinary system 121,538 4, Neoplasm 95,070 4, Source: DG of Medical Care, MOH, 2009 In 2008, based on data collecting until August 2009, it describes that the highest number of hospital inpatients, as in 2007, were certain infectious and parasitic diseases, followed by pregnancy, childbirth and the puerperium. Meanwhile, the highest CFR was diseases of circulatory system followed by diseases of nervous system. More details of hospital inpatients data describe in following Table 3.10 and in Annex 3.4. No TABLE 3.10 DISTRIBUTION OF HOSPITAL INPATIENTS ACCORDING TO ICD 10 CHAPTER IN INDONESIA, Diseases of circulatory system 209,347 23, Diseases of nervous system 31,082 3, Certain condition originating in the perinatal period 93,466 9, Endocrine, nutritional and metabolic diseases 83,045 5, Congenital malformations, deformations and chromosomal abnormalities 12, Neoplasm 92,110 4, Diseases of respiratory system 205,076 8, Cause of Illness Diseases of the blood and blood forming organs and certain disorders involving the immune mechanism 31 Number of New Patients Death Patients CFR (%) 31,069 1, Diseases of genitourinary system 127,742 4, External causes of morbidity and mortality 63,707 2, Source: DG of Medical Care, MOH, 2009

50 2. Communicable Diseases a. Malaria Malaria is a vector borne infectious disease that caused by parasites (plasmodium) which transmit from infected mosquito s bites. In human body, the parasites multiply within liver and then infected the blood cells. Malaria is one of the communicable diseases that its controlling and its case decreasing effort is become an international commitment in Millennium Development Goals (MDGs). Malaria case in Indonesia generally tended to decrease however; it is still become the community health problem. GRAPH 3.7a MALARIA ANNUAL PARASITE INCIDENCE ( ) IN JAVA AND BALI IN Source: DG of DC & EH, MOH RI GRAPH 3.7b ANNUAL MALARIA INCIDENCE ( ) IN Source: DG of DC & EH, MOH RI In Graph 3.7a, and 3.7b, API and AMI have been tended to decrease since In 2000, API was on 0.81 per 1,000 population decreased to 0.15 per 1,000 population in The rate increasing became 0.19 per 1,000 population in 2006, then decreased up to 0.16 per 32

51 1,000 population in 2007 and The inclination also showed by AMI. In period of AMI was tended to decrease from to be 21.2 per 1,000 population. This rate rose in 2005 became however it have kept to decrease in 2008 to 16,82 per 1,000 population. In outside Java and Bali, the highest AMI was West Papua of per 1,000 population, and followed by East Nusa Tenggara (104.10) Papua (84.74) and North Maluku (51.42). Although West Papua was on the highest AMI in 2008, this point has decreased from 2007, which were per 1,000 population. For Java and Bali, the highest API was East Java that was 0.71 per 1,000 population and followed by West Java, which was 0.58 per 1,000 population, whereas the lowest were Banten and Yogyakarta that was 0.03 per 1,000 populations. The detail of API and AMI by province can be seen in Annex 3.5. b. Pulmonary TB Tuberculosis (TB) is an infection disease caused by Mycobacterium tuberculosis. More than half of the TB attacks lung and the other human organ. This disease spreads and transmits through the air, when TB people or people who are infected with TB bacteria coughing, sneezing, talking and spitting. Millennium Development Goals (MDGs) has a target to increase TB, malaria and HIV/AIDS cases. Coverage of TB new cases by province in 2008: the highest was North Sulawesi of 89.6%, followed by Jakarta of 85.5% and Banten, which was 78.6% from the estimation, infected cases. GRAPH 3.8 COVERAGE OF NEW CASES TB SPUTUM SMEAR POSITIVE BY PROVINCE IN 2008 Source: DG of DC & EH, MOH RI TB cases are categorized by Sputum Smear Positive Tuberculosis, Sputum Smear Negative, and relapse and extra pulmonary. Development of proportion TB cases by type is showed in table below. 33

52 Year TABLE 3.11 RESULT OF TB PATIENT DETECTION COVERAGE IN INDONESIA Case Finding Target Smear Positve Realization Smear Neg, Rontgent Positive Extra Pulmonary All Cases TB in Children Total Cases Estimation % CDR % CDR Relapse , ,822 31,377 1,727 89, ,731 72,21 9 3, , , ,1 02 3, , , ,429 76,981 4, , , ,446 85,373 6,1 42 5, , , ,227 91,029 7,01 3 1, , , , ,630 8,048 26, , , ,005 9, , ,329 Source: DG of DC & EH, MOH RI Proportion of new smear positive tuberculosis by sex in Indonesia from 2005 to 2008 has not much changed, male is about 57 59% and female is about 40 43% (Graph 3.9). GRAPH 3.9 PROPORTION OF NEW SMEAR POSITIVE TUBERCULOSIS BY SEX INI INDONESIA c. HIV & AIDS Source: DG of DC & EH, MOH RI HIV (Human Immunodeficiency Virus) is a retrovirus that primarily infected vital organs of the human immune system. HIV can be transmitted from one human to other by contact with body fluid of people infected by HIV, for example by a sexual intercourse, blood transfusion, by using contaminated injection, and mother to child transmitting when delivery and breast feeding. AIDS (Acquired Immune Deficiency Syndrome) is a health condition when HIV destroys human immune system to defend a disease. HIV and AIDS cases increase every year. Until December 2008, HIV positive infected people were detected of 6,015 cases. Meanwhile the cumulative cases were 16,110 cases or the additional of new cases were 4,969 for Number of deaths due to AIDS until 2008 was 3,362 cases of deaths Graph 3.10 shows that there is an increasing of new cases and cumulative people suffer by AIDS, which had occurred until

53 GRAPH 3.10 NUMBER OF NEW CASE AND CUMULATIVE OF DETECTED AIDS PATIENTS FROM VARIOUS HEALTH INSTITUTION IN INDONESIA Source: DG of DC & EH, MOH RI AIDS cases has been detected in 32 provinces, the only province with no AIDS is West Sulawesi. Cumulative number of AIDS cases divided by number of population (case rate) was 7.12 per 100,000 populations. The highest case rate was Papua per populations. Graph 3.11 showed that province with the highest number of AIDS cases orderly were West Java, DKI Jakarta, East Java, Papua and Bali GRAPH PROVINCES WITH THE HIGHEST AIDS CASES IN INDONESIA UNTIL DECEMBER 31, 2008 Source: DG of DC & EH, MOH RI Based on sex status, 74.9% of AIDS cases were males and 24.6% were females and 0.5% were not clear. By age, most of the AIDS people were productive age that 50.82% were in years age group followed by 29.36% were in years age group. One of the high risk groups infected with HIV is IDUs (Intravenous Drug User). AIDS cases in IDUs have risen significantly in period of There was increasing 13 times which was 120 cases in 2003 become 1,517 new cases in In

54 and 2008, new AIDS cases in IDUs were slightly decreased from 1,437 cases became 1,255 cases. This can be seen in Graph 3.12 below. GRAPH 3.12 NUMBER OF CASES IN IDUs IN INDONESIA UNTIL DECEMBER 31, 2008 Source: DG of DC & EH, MOH RI Based on categorize by sex, 92% with AIDS in IDUs were male, 7% were female and 1% were not clear. Then based on categorize by age, 65.2% were in age group of and 26.3% were in age group of It shows in Graph GRAPH 3.13 PERCENTAGE OF AIDS CASES CUMULATIVE ON IDU USER BY AGE GROUP IN INDONESIA UNTIL DECEMBER 31, 2008 Source: DG of DC & EH, MOH RI d. Acute Respiratory Infection (ARI) Acute Respiratory Infection (ARI) is an acute infection, which attack one part and or respiratory tract from nose, sinuses, pharynx and larynx (upper respiratory) to alveoli. ARI that become a health program is pneumonia because pneumonia is one of cause of death to child. Pneumonia is an acute infection process in alveoli. Infection can be caused by bacteria, virus, and fungi. Trauma or accident also can cause pneumonia, for instance: 36

55 inhale chemical part. Population at risk of pneumonia is children under 2 years old, >65 years old and people with health problem (malnutrition, immunological problem). ARI controlling program stated that all detection cases must treated with standard operational procedure. It means case detection of ARI also shows that it can describe the procedure has implemented properly. ARI cases in population are estimated 10% of population. National target coverage of ARI is 76% from estimated cases, nevertheless, in 2008 coverage of case finding only 18.81% (report from 26 provinces) Pneumonia case that happen to under five based on report from 26 provinces, 3 provinces with the highest coverage were West Nusa Tenggara (56.50%), West Java (42.50%) and Bangka Belitung Islands (42.50%). In addition, the lowest coverage is Yogyakarta (1.81%) Riau Island (2.08%) and NAD (4.56%). Coverage by province can be seen in Annex e. Leprosy Leprosy is chronic infection caused by Mycobacterium leprae. If it is not cured in standard operational, leprosy can be progressive, it cause permanent damage in skin, neurosurgeons, hand, arm, foot and eyes. WHO global strategy declared the indicator of leprosy elimination is Newly Case Detection Rate (NCDR) which substitute the last main indicator that was number of registered cases (prevalence rate < 1/10,000 per population) Prevalence of leprosy in Indonesia since 2000 to 2008 not change much, but in 2008 there was a slightly decrease from last year. While the spreading almost in all part of Indonesia but different number of cases. The highest number of leprosy cases is in East Java, West Java, Central Java and South Sulawesi (Annex 3.14). NCDR of leprosy in Indonesia since 2005 to 2008 shows inclination up to 0.76 per 10,000 populations in The highest NCDR was West Papua then Papua. Prevalence and NCDR by province can be seen in Graph GRAPH 3.14 PREVALENCE AND NEW CASE DETECTION RATE IN INDONESIA, Source: DG of DC & EH, MOH RI 37

56 New cases of leprosy in 2008 were 17,441 cases consist of PB type 3,113 cases and MB type 14,328 cases. The development of number leprosy in Indonesia from can be seen in this Table3.12 below. TABLE 3.12 NUMBER OF LEPROSY BY TYPE AND NCDR PER 100,000 POPULATIONS IN INDONESIA, Year Number of Cases PB Type MB Type NCDR (per 100,000 pop.) ,550 3,594 11, ,572 3,615 12, ,735 3,859 14, ,300 3,550 14, ,726 3,643 14, ,441 3,113 14, Source: DG of DC & EH, MOH RI In order to control leprosy in Indonesia, there are two indicators used to evaluate the effort i.e. proportion of 2 nd physical defect (visible defect) and proportion of children on new leprosy patients. Number of proportion of 2 nd physical defect is used to assess the performance of health personnel in detecting new cases. The high proportion of 2 nd physical defect indicates the delaying of detecting the case that caused by the low performance of health personnel and people s poor knowledge about the early sign of leprosy symptoms Meanwhile new cases proportion indicator of children is able to represent the contagious of leprosy in community. GRAPH 3.15 PROPORTION OF 2 nd PHYSICAL DEFECT AND NEW CASE PROPORTION OF CHILDREN IN INDONESIA, Source: DG of DC & EH, MOH RI In 2008, percentage of 2 nd physical defect reached 9.56%, increased from 2007, which was 8.8%. Besides the increasing of this percentage, that was still above the indicator target of the program, which was 5%. Province with the highest percentage of 2 nd physical defect was North Sumatera (22.87%) and Central Kalimantan (20.39%). Percentage of new cases and 2 nd physical defect by province can be seen in Annex

57 Proportion of patients of 0 12 year of age in 2008 was 11.3%, it increased comparing to 2007 that was 10.2%. The high proportion of patients of 0 12 year of age (was above program indicator target that is 5%) shows there is still contamination of leprosy in community in Indonesia. The highest percentage of leprosy was in Riau, which was 25.12%). f. Communicable Diseases Prevented by Immunization 1) Tetanus Neonatorum Tetanus is an acute disease caused by Clostridium tetani entering the body through the wound. Tetanus Neonatorum (Tetanus in newborn baby) is tetanus disease that still occurs in developing country, which caused by cutting the umbilical cord with nonsterilized equipment. Table 3.13 shows that in 2008 number of Tetanus Neonatorum were 165 cases and 91 deaths (Case Fatality Rate/CFR 55%). From all these Tetanus Neonatorum cases mostly was handled by traditional delivery assistants. TABLE 3.13 NUMBER OF TETANUS NEONATORUM CASES IN 10 PROVINCES, 2008 No Province Total cases Death CFR Traditional Health Officers Delivery Not Known Assistant 1 Banten West Java South Sumatera East Java Riau Lampung Central Java Central Sulawesi West Sumatera South Sulawesi TOTAL Source: DG of DC & EH, MOH RI 2) Measles % Delivery Helpers Measles or Morbilli is an acute infection and very contagious, often occur in children. Measles transmitted by direct and indirect contact through breathing that contaminated by secret of infected people at catarrhal phase (signed with rash in skin, fever, conjunctivitis, bronchitis). Table 3.14 below shows that the cases of measles in 2008 mostly were in West Java, there were 3,424 cases with no vaccination of the cases. Data in detail by province is presented in Annex

58 TABLE 3.14 NUMBER HIGHEST OF MEASLES CASES AND VACCINATION STATUS IN 10 PROVINCES, 2008 No. Province Number of Case with % of Cases Vaccination Vaccination Death 1 West Java Banten Central Java South Sumatera East Jawa South Sulawesi Lampung NAD North Sumatera DKI Jakarta Source: DG of DC & EH, MOH RI 3) Diphtheria Diphtheria is a disease that attacks upper respiratory tract illness characterized by throat ache, low fever, and an adherent membrane (a pseudomembrane) on the tonsils, pharynx, and/or nasal cavity. It is caused by Corynebacterium diphtheriae. Diphtheria is a contagious disease spread by direct physical contact or breathing the aerosolized secretions of infected individuals. Death due to Diphtheria is quite high in baby and old people, and usually death occurs in 3 to 4 days. TABLE 3.15 NUMBER OF DIPHTHERIA CASES AND VACCINATION STATUS IN PROVINCE, 2008 No Province Total Cases Vaccination No Vaccination Total 1 East Java South Sumatera West Java Central Java Papua West Sumatera South Sulawesi Banten Central Kalimantan Lampung DKI Jakarta North Sumatera South Kalimantan DI Yogyakarta Southeast Sulawesi Source: DG of DC & EH, MOH RI Table 3.15 shows province with the highest diphtheria cases there was East Java with 63 cases. From the 63 cases, 35 cases of them had received immunization. The next 40

59 highest cases number was South Sumatera with 61 cases, 19 cases of them had received immunization. 4) Polio and AFP (Acute Flaccid Paralysis) Polio is a communicable disease caused by virus, which attack nervous system and cause Paralysis. This disease attacks all ages especially children under 3 years old (>50% of the cases). The virus enters the body through oral then reproduces in digestive system. The symptoms are fever, tiredness, headache, nausea, cramping neck/stiffness, and pain in leg and arm. One of the 200 infected people can cause permanent paralysis and usually to the leg. Among the paralysis people, 5 10% died due to failure (not move) of respiratory muscle. AFP is an abnormal condition signed by the weaknesses, paralyse or loss of strength of muscle without clear cause. This is caused by disease or trauma that influences nerve that connect to the muscle. AFP usually explains as early sign of attack like Polio. No TABLE PROVINCES WITH THE HIGHEST AFP RATE, 2008 Province Number of AFP Cases AFP Rate / 100,000 pop Non Polio AFP Rate / 100,000 pop Percentage of Adequat Specimen 1 North Sulawesi DI Yogyakarta Gorontalo Bali Riau islands South Sumatera East Kalimantan Nanggroe Aceh Darussalam Lampung East Nusa Tenggara Source: DG of DC & EH, MOH RI Number of AFP cases in 2008 in Indonesia were 1,683 cases. Of the AFP cases, the highest rate was North Sulawesi that was 4.91 per 100,000 population, meanwhile the total cases of province with the highest rate the province was South Sulawesi, which was 84 cases followed by Lampung with 79 cases. Number AFP cases by province can be seen in Annex g. Outbreak Potential Disease Few diseases become outbreak potential in Indonesia for instance Dengue Hemorrhagic Fever (DHF), diarrhea and Chikungunya. DHF cause more death likewise Diarrhea, while chikungunya more affect economic loss. 1) Dengue Hemorrhagic Fever (DHF) Dengue Hemorrhagic Fever is caused by dengue virus and transmitted by Aedes aegypti mosquito. Generally, this disease attacks children under 15 years old, but also it attacks adult. 41

60 Graph 3.16 demonstrates the inclination DHF Incidence Rate since 2007 to 2008, but still shows the high number if compare with Case Fatality Rate (CFR) where CFR decrease from 1.01 in 2007 to 0.86% in The detailed by province can be seen in Annex 3.22 and GRAPH 3.16 DHF INCIDENCE RATE PER 100,000 POPULATION IN INDONESIA, GRAPH 3.17 DHF CASE FATALITY RATE IN INDONESIA, Source: DG of DC & EH, MOH RI Source: DG of DC & EH, MOH RI 2) Diarrhea Diarrhea defined as changing of faeces consistency and frequency of defecation. It is called diarrhea if the faeces more liquid from it is normally. Diarrhea also defined if defecation more than three times or the faeces is liquid but with no blood in 24 hours, while diarrhea with blood defined as dysentery. In 2008, it is reported there was outbreak in 15 provinces with 8,443 cases, 209 deaths and CFR 2.48%. Province, number of cases, CFR and Diarrhea outbreak from can be seen in Table 3.17, while number of death and CFR by province since can be seen in Annex TABLE 3.17 NUMBER OF CASES, CFR AND PROVINCE WITH DIARRHEA OUTBREAK IN INDONESIA, Year Total Provinces Total with Outbreak Cases Death CFR (%) , , , , , , , , , Source: DG of DC & EH, MOH RI The result of RISKESDAS 2007 stated the national prevalence of clinical diarrhea was 9.0% with range 4.2 % 18.9 %. Fourteen (14) provinces had diarrhea prevalence above the national prevalence, and the highest prevalence was Nanggroe Aceh Darussalam and the lowest was DI Yogyakarta. 42

61 GRAPH3.18 NUMBER OF DIARRHEA OUTBREAK AND CFR IN INDONESIA, Source: DG of DC & EH, MOH RI 3) Chikungunya Chikungunya is a disease caused by chik virus from Arbovirus group as Alphavirus which is Togaviridae family. Chikungunya come from Swahili language (in Africa) that means, walking bent". This may be because of the patient feel definitely pain in all joint so if in standing position the patient must bent down to relieve the pain. The patient can not go outside and can not do activities due to non permanent paralysis. Chikungunya fever is found especially in tropical area and frequently cause epidemic in interval time (10 20 years). Some factors that influence Chikungunya fever likewise lower immunity of population group, mosquito population density especially in rainy season. In last five years ( ), Chikungunya fever spread in 11 provinces (North Sumatra, South Sumatra, DKI Jakarta, West Java, Banten, Central Java, DI Yogyakarta, East Java, Central Kalimantan, North Sulawesi, and West Nusa Tenggara) with 13,634 cases, with no death and spread in 42 districts, 90 municipalities and 134 villages. In 2008, it was occurred in West Java, DKI Jakarta, Banten, West Sumatera and DI Yogyakarta with 2,608 cases. 43

62 No Province TABLE 3.19 NUMBER OF CHIKUNGUNYA FEVER CASES IN INDONESIA, 2008 District/ Total cases Total Municipality P M Sub district Village 1 West Java Bogor Bandung Cirebon 90 0 Tasikmalaya 10 0 Depok 10 0 Cimahi 12 0 Karawang Sukabumi Bandung 82 0 Sumedang 43 0 Cirebon 80 0 Bandung Barat DKI Jakarta 2 Kodya (Munic.) DI Yogya Yogyakarta Total Source: DG of DC & EH, MOH RI h. Rabies Rabies is a disease with high CFR. This disease caused by rabies virus infection and transmitted through biting of dog, cat, bat, monkey, fox, and wolf that is infected by rabies virus. Situation of rabies in Indonesia until 2008 can be seen in Graph From the graph, we can see rabies biting tended to decrease since 2005 to 2007, but increased twice in 2008 even jump up to 5 times during last five years. The increasing of rabies cases must followed by the increasing of Anti Rabies Vaccine (VAR). GRAPH 3.19 RABIES SITUATION IN INDONESIA, Source: DG of DC & EH, MOH RI In 2008, there were 1,024 specimens of rabies positive in animal reported. In last six years ( ), number of positive cases of animal was various, and it decreased from 1,396 cases in 2007 to 1,024 cases in Rabies situation by province in 2008 can be seen in Annex

63 GRAPH 3.20 NUMBER OF RABIES POSITIVE SPECIMEN ON ANIMAL IN INDONESIA, i. Filariasis Source: DG of DC & EH, MOH RI Lymphatic Filariasis is parasite disease where filaria worm (Wuchereria bancrofti, Brugia malayi and B. timori) infects lymph gland. This parasite transmits to human by infected mosquito bites. It changes its form to a worm and becomes adult worm in lymph gland. This disease frequently causes swelling in leg, arm and genital area as advanced sign of the disease. This disease is also called Elephantiasis, because the infected person frequently has swollen leg. The patient became unproductive due to their disability to do activities/jobs or people reluctant to involve with them. Graph 3.21 below shows the increasing of number of Filariasis from time to time. In 2008 it was reported 11,699 cases Filariasis in Indonesia. Three provinces with the highest cases were Nanggroe Aceh Darussalam, East Nusa Tenggara and Papua. The data of Filariasis by province in can be seen in Graph GRAPH 3.21 NUMBER OF FILARIASIS PATIENT IN INDONESIA, Source: DG of DC & EH, MOH RI j. Framboesia/Yaws Framboesia/Yaws is chronic infection usually occur in tropical area such as Africa, Asia, South America and Central America, and Pacific Island. This disease has many 45

64 names, for instance: pian, parangi, paru, frambesia tropica. Usually this case occurred in children under 15 years old and the highest incidence usually in 6 10 years old. The incidence rates of male and female are about the same. Framboesia is a rarely found disease. This disease is related to personal hygiene and water availability in an area. In Asia, this time Framboesia only found in Indonesia and Timor Leste. In therapy/treatment, Framboesia is a disease which simple/easy to be cured. With only one injection of Benzathine Penicillin, Framboesia can be cured. In 2008, there were found 5,926 Framboesia cases. The highest cases was found and reported in East Nusa Tenggara, Maluku and Papua. Framboesia should not be a health problem anymore, but although the prevalence is under 1% still need extra intervention. If this disease receives less attention can cause a phenomenon. called as neglected disease. GRAPH 3.22 FRAMBUSIA CASES IN INDONESIA, Source: DG of DC & EH, MOH RI Framboesia can be contagious or not contagious. Contaminated Framboesia were 3,466 and not contaminated framboesia were 2,460 cases. Number of Framboesia cases by province can be seen in Table 3.20 below. 46

65 TABLE 3.20 FRAMBOESIA CASES IN INDONESIA, 2008 Framboesia No Province Total Notes District Communicable Non Communicable 1 Nanggroe Aceh Darussalam 23 2 North Sumatera 28 3 West Sumatera 7 4 South Sumatera Lampung 10 6 East Java Central Sulawesi Southeast Sulawesi East Nusa Tenggara 2,245 1,950 4, Maluku , Papua Banten West Nusa Tenggara 9 14 Bali 9 TOTAL 3,466 2,460 Source: DG of DC & EH, MOH RI k. Anthrax Anthrax is an acute infection caused by spore of Bacillus anthracis. Bacillus anthracis spore can live in environment for years until enter the new host. Generally, this disease occurs in wild and domesticated mammals (herbivore) but also little kind of poultry. Human gets anthrax by direct and indirect contact or consumes contaminated animal meat. In 2008 there were reported 20 cases of Anthrax in human in Indonesia, 18 cases occurred in Bogor district and two cases in South Jakarta, with Case Fatality Rate 0%. Until 2007 there were still a few of endemic area Anthrax such as West Java, Central Java, West Nusa Tenggara, East Nusa Tenggara and South Sulawesi. Number of cases, deaths and CFR in is presented in the graphs below. GRAPH 3.23 NUMBER OF ANTHRAX CASE AND DEATH ON HUMAN IN INDONESIA GRAPH 3.24 ANTHRAX CASE FATALITY RATE ON HUMAN IN INDONESIA Source: DG of DC & EH, MOH RI Source: DG of DC & EH, MOH RI 47

66 l. Bubonic plague Bubonic plague caused by bacteria which called Pasteurella pestis. Bubonic plague is an infection of rodent animal which is produced from a rodent animal to other animal and sometimes from rodent animal to human caused by flea s bites. Active surveillance and passive surveillance to rodent animal and its flea are done routinely in four areas of bubonic plague; such as Central Java (Boyolali), West Java (Bandung), DI Yogyakarta (Sleman) and East Java (Pasuruan). In 2008, from examination in rodents, consist of 416 rodents in Sleman and rodents in Pasuruan, it were found 2 cases of positive result It also was examined to six people suspected of Bubonic plague in Pasuruan and found 3 cases of positive result. The full result of examination/test can be seen in Annex To review the situation of Bubonic plague in Indonesia, we can see in Graph 3.25 below. The focus area of Bubonic plague where in that place found Bubonic plague cases such as DI Yogyakarta and East Java. The result of rodent routine surveillance in focused area shows fluctuated number of examined rodent and number of rodent with bacteria. GRAPH 3.25 RESULT OF BUBONIC PLAGUE RODENT ROUTINE SURVEILLANCE IN FOCUSED AREA, Source: DG of DC & EH, MOH RI, 2009 According to data in 2008, we can see the drastic decreasing of symptoms/signs like bubonic plague in human comparing to previous years as can be seen in Graph

67 GRAPH 3.26 BUBONIC PLAGUE SITUATION ON HUMAN IN INDONESIA, Source: DG of DC & EH, MOH RI m. Helminthiases The graph below shows a decreasing of helminthiases prevalence during 2008 in primary school children in survey location, while in 2007 there is no survey. GRAPH 3.27 PREVALENCE DISTRIBUTION OF HELMINTHIASES IN ELEMENTARY STUDENTS IN SELECTED DISTRICT, Source: DG of DC & EH, MOH RI In 2008 feces observation was done in 8 provinces. The result of the observation shows helminthiases prevalence had a wide range that was 2.7 % in North Sulawesi and 60.7 % in Banten (Graph 3.28). 49

68 GRAPH 3.28 PREVALENCE OF HELMINTHIASES IN 8 PROVINCES, 2008 Source: DG of DC & EH, MOH RI, 2009 Prevalence distribution of helminthiases by type of worm in primary school students in 27 provinces during can be seen in the graph below. GRAPH 3.29 PREVALENCE DISTRIBUTION OF HELMINTHIASES BY TYPES OF WORM ON ELEMENTARY STUDENTS IN SELECTED DISTRICTS IN 27 PROVINCES n. Leptospirosis Source: DG of DC & EH, MOH RI, 2009 Leptospirosis is a disease caused by bacteria and usually occurs in tropic and sub tropic area with high occurrence of rain. Leptospirosis can cause disturbance of human body. The infected animal include domesticated animal can transmits the bacteria through its urine. Human can be infected by contact with water, ground, or plant that are contaminated from infected animal urine. Clinical manifestations of Leptospirosis are varies with symptoms such as influenza up to serious disorder even it causes a death. Leptospirosis can be prevented by avoid contact with water and mud that probably infected animal urine. Leptospirosis cases were reported in flood area. In , Leptospirosis cases most in Jakarta comparing to other endemic Leptospirosis provinces. However, in 2008 the highest number of Leptospirosis cases was in DI Yogyakarta with 125 cases. Other 50

69 provinces reporting Leptospirosis cases in 2008 were Central Java (72 cases), DKI Jakarta (37 cases) and East Java (29 cases). Comparing with the situation in 2007, there was a declining of total cases from 666 cases with 57 deaths become 263 cases to 16 deaths in GRAPH 3.30 LEPTOSPIROSIS SITUATION ON HUMAN IN INDONESIA Source: DG of DC & EH, MOH RI o. Avian Influenza (AI) Avian Influenza is a communicable disease on animal, which is caused of type A influenza virus A (H5N1) that generally infected poultry and pig. This disease infects human and cause influenza, which can effect to the death. New confirmed cases of Avian Influenza in 2008 were decreasing if comparing than those in 2007, that were from 42 cases in 2007 became 20 cases in It also decreased of Case Fatality Rate (CFR) from 88.1% in 2007 to 85% in AI confirmation cases development until 2008 can be seen in the following Graph GRAPH 3.31 SITUATION OF AI CONFIRMED CASES IN INDONESIA Source: DG of DC & EH, MOH RI 51

70 Graph 3.32 shows that in 2008 there were no additional AI confirmed case. The infected area of AI on human was decreased, comparing to those in 2007, and to the decrease of AI confirmed case in GRAPH 3.32 NUMBER OF PROVINCES AND DISTRICTS INFECTED BY AVIAN INFLUENZA ON HUMAN, Source: DG of DC & EH, MOH RI Table 3.21 shows that the highest number of AI confirmed cases was reported from West Java, DKI Jakarta and Banten. On the other hand, Central Java, North Sumatera, East Java, Riau, Lampung and South Sulawesi had no confirmation case report until December TABLE 3.21 CONFIRMATION CASES IN INDONESIA FROM Total NO Province Cases Death Cases Death Cases Death Cases Death Cases Death 1 DKI Banten West Java Central Java East Java Lampung West umatera North Sumatera South Sulawesi South Sumatera Riau Bali Total Source: DG of DC & EH, MOH RI The highest AI confirmed cases was in West Java, followed by DKI Jakarta, Banten, Central Java and North Sumatera, Lampung and South Sulawesi. In 2007, there is no reported case anymore. The distribution of AI infected area on human was decreased comparing to It was the same as the confirmed cases in

71 GRAPH 3.33 DISTRIBUTION OF AVIAN INFLUENZA CASE DETECTION IN INDONESIA BY 2008 Source: DG of DC & EH, MOH RI Since the first case was found in 2005 until 2007, number of confirm cases between male and female was relatively almost equal. GRAPH 3.34 AI CONFIRMATION CASES BY SEX IN INDONESIA, Source: DG of DC & EH, MOH RI The highest AI confirmed cases in 2005 to 2008 were found in West Java, DKI Jakarta and Banten. The distribution of cases and death due to AI in can be seen in Graph 3.35 below. 53

72 GRAPH 3.35 AI CONFIRMATION CUMULATIVE CASES AND DEATH BY PROVINCE, Source: DG of DC & EH, MOH RI According to contact history of AI patient 48.91% were exposed by direct contact to sick poultry, death poultry and other poultry products, 37.23% were exposed by environment, 2.19% were exposed by fertilizer and 11.68% were unknown. GRAPH 3.36 AI CONFIRMATION CASES BY CONTACT IN INDONESIA, Source: DG of DC & EH, MOH RI p. Hepatitis C Hepatitis C is a liver inflammation that caused by Hepatitis C virus infection. Hepatitis C is transmitted through blood and blood product such as through blood transfusion, re using non sterile syringe and medical device, sharing syringe among drugs user and tattoo and piercing with non sterile devices. Transmission can occur through sexual activity and perinatal but it seldom to occur. An infection is not always started by a symptom but also most infected people became chronic hepatitis, and keep straight to form scar in liver and become cirrhosis of the liver or liver cancer that occasionally comes up after a few years. This disease does not have a preventable vaccination yet. 54

73 Ministry of Health implemented an assessment of the first step of Hepatitis C in 11 provinces on October 2007, namely DKI Jakarta, North Sumatra (Medan), South Sumatra (Palembang), West Java (Bandung), Central Java (Semarang), East Java (Surabaya), South Sulawesi (Makassar), North Sulawesi (Manado), Bali (Denpasar), West Kalimantan (Pontianak) and Papua (Jayapura). The second assessment involved 10 provinces, which was occurred on October 1, 2008 March 31, 2009, namely Riau islands, Jambi, Riau, Lampung, South Kalimantan, East Kalimantan, West Sumatra, Banten, DI Yogyakarta and West Nusa Tenggara. This program was aimed to obtain a description of epidemiology and Hepatitis C problems through reports from related units. In 2008, there were reported 7,235 Hepatitis C positive cases from 21 provinces. The most three cases were DKI Jakarta, West Java and East Java. It is presented in the follow Table 3.22, while the detail data by age group can be seen in Annex TABLE 3.22 NUMBER OF HEPATITIS C CASES IN INDONESIA, 2008 No Province Total cases 1 DKI Jakarta 2,810 2 West Java East Java Bali South Sulawesi Central Java North Sumatera South Sumatera West Kalimantan North Sulawesi DI Yogyakarta Banten Riau Papua West Sumatera Lampung Riau islands East Kalimantan West Nusa Tenggara South Kalimantan Jambi 8 Indonesia Source: DG of DC & EH, MOH RI 7, Non Communicable Diseases SKRT 1995, SKRT 2001 and Riskesdas 2007 indicate increasing trend of mortality proportion caused by non communicable diseases, and on the contrary, decreasing trend of mortality proportion caused by communicable diseases. Proportion of mortality caused by communicable diseases in Indonesia during last 12 years decreased from 44% to 28% and proportion of non communicable diseases increased from 42% to 60%. According to 55

74 Riskesdas 2007, stroke, hypertension, ischemic heart disease and others heart diseases were main non communicable diseases that causing mortality. TABLE 3.22 PROPORTION OF MORTALITY CAUSE, COMMUNICABLE AND NON COMMUNICABLE DISEASES, Type of Disease Year Comunicable disease 69.49% 60.48% 50.72% 48.46% 44.57% Non communicable Disease 25.41% 33.83% 43.60% 45.42% 48.53% Source: Riskesdas Report 2007 (from SKRT 2003) a. Cardiovascular Diseases Scope of cardiovascular disease control program covered essential hypertension, renal hypertension, hypertension heart disease, stroke, heart failure, coronary heart disease, cardiomyopathy, rheumatic heart disease and acute myocardial infarction. Incidence of cardiovascular diseases tend to increase and might causing disability and mortality. Actually, most of cardiovascular cases might be prevented by health behavior changing and appropriate therapy. So, cardiovascular disease control program should have to get an appropriate attention in community health program. In developed country, cardiovascular diseases tend to decline because of better health behavior and better health awareness. Meanwhile, in under developed country, increasing trend has occurred because of life style, urbanization and increasing number of elderly population. 1) Hypertension Hypertension is defined as a condition of systolic blood pressure higher than 140 mmhg and/or diastolic blood pressure higher than 90 mmhg (Joint National Committee on Prevention Detection, Evaluation, and Treatment of High Pressure VII, 2003). Hypertension substantially contributes to increase risk of others diseases as coronary hearth disease, thrombo embolic, and stroke. Hypertension also may cause damages on hearth, brain, or kidney. Hypertension is part of vascular diseases. According to data of hospital information system, vascular diseases were one of 10 main diseases of hospital outpatients and inpatients in , Riskesdas 2007 indicated prevalence of hypertension among aged 18 years old or older in Indonesia was at 31.7%, the highest was in South Kalimantan (39.6%) and the lowest was in West Papua (20.1%). 2) Heart Diseases Heart diseases consist of various diseases that cause heart function disorder. Riskesdas 2007 collected data of heart diseases based on the answer of question if someone 56

75 ever has been diagnosed heart diseases by medical officer or has had symptoms of congenital heart diseases, angina, arrhythmias or cardiac decompensation. The result indicated that prevalence of heart disease in Indonesia was 7.2% according to interview and only 0.9% according to assessment of health personnel. 12.5% of respondent with symptoms of heart disease have been diagnosed by health personnel According to hospital recording and reporting system (hospital information system), number of new heart disease cases of hospital outpatients and inpatients in 2007, were as on following graph: GRAPH 3.37 NUMBER OF HEARTH DISEASES PATIENTS IN HOSPITAL IN INDONESIA, 2007 Source: DG of Medical Care, MOH Graph 3.37 above illustrates that the highest number of heart disease cases were others ischemic heart disease. If it added to number of myocardial infarct cases, it more distinctly that coronary heart disease was the highest number. According to Case Fatality Rate (CFR) the three highest rates were acute myocardial infarct (13.49%), heart failure (13.42%) and others heart disease (13.37%). GRAPH 3.38 CFR OF HEART DISEASE IN HOSPITAL IN INDONESIA, 2007 Source: DG of Medical Care, MOH 57

76 3) Cerebrovascular Diseases Cerebrovascular diseases have caused high morbidity, disability and mortality. The highest number of outpatients and inpatients with cerebrovascular disease were caused by stroke, as illustrated in following graph. GRAPH 3.39 NUMBER OF CEREBROVASCULAR DISEASE IN HOSPITAL IN INDONESIA 2007 Source: DG of Medical Care, MOH CFR of cerebrovascular diseases of hospital inpatients were between 11.2 % (cerebral infarction) and 34.46% (intracranial bleeding). In 2007, the main caused of mortality in hospital were stroke not specified as haemorrhage or infarction and intracranial haemorrhage respectively at 5.24% and 3.99% of all dead cases in hospital. Following graph describes CFR of cerebrovascular diseases in 2007 GRAPH 3.40 CFR OF CEREBROVASCULAR DISEASES IN HOSPITAL IN INDONESIA, 2007 Source: DG of Medical Care, MOH Riskesdas 2007 indicates prevalence of stroke in Indonesia were 8.3 per 1,000 population while prevalence stroke that had been diagnosed by health personnel were 6 per 1,000 population. It means that approximately 72.3% of stroke cases had been diagnosed by health personnel. The highest prevalence of stroke was in Nanggroe Aceh Darussalam 58

77 (16.6 or 16.6 per 1,000 population) and the lowest was in Papua (3.8 or 3.8 per 1,000 population). b. Diabetes Melitus (DM) Diabetes Mellitus (DM) is a chronic metabolic disorder with elevated blood glucose level as a result of insulin resistance or lack of insulin production by pancreas. Diabetes mellitus prevalence has increase simultaneously with life style changes. International Statistical Classification of Diseases and Related Health Problems (ICD 10) classify DM to 5 types: 1. Insulin dependent DM (DM type 1). 2. Non insulin dependent DM (DM type 2). 3. Malnutrition related DM. 4. Other specified DM. 5. Unspecified DM. In 2007, there were 28,095 new cases among hospital outpatients and 4,162 death cases or CFR at 7.02%. Among five types of DM, unspecified DM and non insulin dependent DM were two of 50 main causes of deaths, inpatient cases and outpatient visits in hospital in Unspecified DM has caused 2.34% of deaths, 1.21% inpatient cases and 0.89% outpatient visits while non insulin dependent DM caused 1.34% deaths, 0.56% inpatient cases and 0.48% outpatient visits. More details describes on the following table: TABLE 3.23 DIABETES MELITUS SITUATION IN HOSPITAL IN INDONESIA 2007 Type of DM Total % * Total % * Total % * Unspecified DM 2, , , Non insulindependent DM All Type of DM 1, , , ,162 (CFR=7.38 %* percentage to all dead or all inpatients or all outpatients Source: DG of Medical Care, MOH, 2009 Death Inpatient Outpatient 56,378 28,095 new cases In Riskesdas 2007, several respondents aged 15 years old or older who live in rural areas, had been interviewed and carried out blood glucose examination. Using diagnostic criteria from WHO and American Diabetic Association 2003, i.e. blood glucose level two hours after drinking a beverage containing 75 grams of glucose dissolved in water < 140 mg/dl as not DM, 140 < 200 mg/dl as impaired glucose tolerance (IGT) and > 200 mg/dl as Diabetes Mellitus (DM), prevalence of all DM (both respondents who have already diagnosed before and just after Riskesdas examination) were 5.7%. Only 1.5% (approximately 26% of all DM) has been diagnosed before Riskesdas. Meanwhile, prevalence of IGT was 10.2%. The highest prevalence of DM were in West Kalimantan and North Maluku (each at 11.1%), followed by Riau (10.4 %) and Nanggroe Aceh 59

78 Darussalam (8.5%). The lowest prevalence was in Papua (1.7%), followed by NTT (1.8%). The highest prevalence of IGT was in Papua Barat (21.8%), followed by West Sulawesi (17.6%), and North Sulawesi (17.3%). The lowest prevalence was in Jambi (4%), followed by NTT (4.9%). Comparing with result of Health Household Survey (SKRT), prevalence of DM in Riskesdas 2007 was lower. In SKRT 1995 and 2001, prevalence of DM respectively was at 1.2%, 7.5% and in SKRT 2003 was 14.7% in urban areas and 7.2% in rural areas. Number of hospital inpatient with DM in 2007 was 56,378 patients and CFR were 7.38%, while outpatients were 28,095 cases. c. Neoplasm/Tumor Neoplasm or tumor is defined as an abnormal growth of tissue. Neoplasm may be benign, pre malignant or malignant. The malignant type is synonymous with cancer. Data about neoplasm disease is only show number of patient data from hospital. Available data is just only from inpatient who leave from hospital with cancer diagnosis, so they did not show the number of inpatients cases. Although they do not provide exact neoplasm cases, they may illustrate neoplasm situation as a part of public health burden in Indonesia. Ten most frequent of inpatients cancer in was relatively constant. Three highest numbers of inpatients were breast cancer, cervix cancer and malignant neoplasm of liver and intra hepatic bile ducts. Graph 3.41 describes cancer situation in GRAPH MOST FREQUENT NEOPLASM OF HOSPITAL INPATIENTS IN INDONESIA, Source: DG of Medical Care, MOH Riskesdas 2007 collected data of people who had been diagnosed for tumor or cancer by health personnel. The result indicated prevalence of tumor/cancer at 0.43%, the highest prevalence was in DI Yogyakarta (0.96%) and the lowest in Maluku (0.15%). 60

79 3. Morbidity and Mortality of Hajj Pilgrims Indonesia Health Profile 2008 provides data of morbidity and mortality of Hajj Pilgrims in Hajj health care program, from preparation, departure, until come back to Indonesia. Data of Hajj pilgrims describes in Graph 3.42, 3.43, and then Annex 3.39 Annex GRAPH 3.42 NUMBER OF INDONESIAN HAJJ PILGRIMS WITH HIGH RISK Source: DG of DC & EH, MOH GRAPH 3.43 NUMBER OF INDONESIAN HAJJ PILGRIMS WITH HIGH RISK Source: DG of DC & EH, MOH Graph 3.43 and 3.44 describe number of Hajj pilgrims with illness among high risk people compare to among non high risk. 61

80 GRAPH 3.44 HAJJ PILGRIMS ILLNESS ACCORDING TO HEALTH EXAMINATION IN EMBARCATION IN INDONESIA Source: DG of DC & EH, MOH Disease situation of Hajj pilgrims in 2007 and 2008 relatively constant while cardiovascular disease was the highest frequent disease occurred in those years as described in Graph C. NUTRITIONAL STATUS Population nutritional status can be measured through some indicators as proportion of low birth weight, under fives nutritional status and nutritional status of woman aged years old. Recent data of nutritional status is result of Riskesdas Low Birth Weight (LBW) Low birth weight (LBW) is defined as birth weight less than 2,500 grams, is measured in 24 hours after delivery. LBW is one of the main factors that influences perinatal and neonatal mortality rates. LBW can be categorized as LBW due to premature (less than 37 weeks pregnancy) and LBW due to intra uterine growth retardation (IUGR) or at term birth with LBW. In developing countries, many cases of LBW due to IUGR because mother has severe under nutrition, anemia, malaria or sexually transmitted disease prior to conception of during pregnancy. Number of LBW in Indonesia has not available yet. Nevertheless, proportion of LBW can be estimated from IDHS result. Birth weight of several infants was not available. Among the available ones, 11.5% have birth weight less than 2,500 or LBW. Three provinces with higher proportion of LBW were Papua at 27%, West Papua at 23.8% and East Nusa Tenggara at 20.3%. Three provinces with lowest proportion of BBLR were Bali at 5.8%, West Sulawesi at 7.2% and Jambi at 7.5%. Proportion of LBW among females higher than males, respectively 13% and 10% (Riskesdas, 2007) Result of IDHS indicates that 7.6% newborn had LBW and as mention before, result of Riskesdas 2007 indicates proportion of LBW at 11.5%. Although the two surveys cannot compare directly because of different method have been used, the increasing trend of LWB should need more attention. 62

81 TABLE 3.24 PROPORTION OF LOW BIRTH WEIGHT AND S DKI Riskesdas 2007 National % Urban 6.6 Rural 8.4 Province Source: IDHS, Riskesdas Under fives Nutritional Status Under fives nutrition status is assessed according to age, weight and height and than presented as 3 anthropometry indicator i.e. weight by age (W/A), height by age (H/A) and weight by height (W/H). Weight and height convert into Z score according to WHO anthropometry standard, According to W/A, it is categorized as severe under nutrition if Z score < 3.0, under nutrition if Z score between >= 3.0 to < 2.0, normal if Z score between >= 2.0 to Z score <=2.0, and over nutrition if Z score >2.0. According to H/A, it is categorized as severe stunting if Z score < 3.0, stunting if Z score between >= 3.0 to Z score < 2.0, and normal if Z score >= 2.0. According to W/H, it is categorized as severe underweight if Z score < 3.0, underweight if between Z score >= 3.0 to Z score < 2.0, normal if Z score between >= 2.0 to Z score <=2.0 and overweight if Z score >2.0. W/A describes general nutritional status, not specified. Prevalence level of severe under nutrition and under nutrition indicates existence of nutrition problem but neither specified as chronic nor acute. Prevalence of severe under nutrition in Indonesia was at 5.4% while under nutrition was at 13.0%. It indicates that Indonesia had achieved target of nutrition improvement program in Mid Term Development Plan (RPJM) 2015 i.e. 20% and target of MDG for Indonesia i.e. 18.5%. National Socio economic Survey (Susenas), National Household Health Survey (SKRT) and Riskesdas 2007 describe trend of under fives nutrition status as illustrated in following Graph

82 GRAPH 3.45 THE PERCENTAGE OF UNDER FIVES WITH SEVERE UNDER NUTRITION, UNDER NUTRITION, NORMAL NUTRITION AND OVER NUTRITION (UNDER FIVES NUTRITION STATUS) IN INDONESIA Source: Susenas/Survei Garam Yodium Rumah Tangga, SKRT, Riset Kesehatan Dasar 2007 Although national target had been achieved, it has not spread throughout all 33 provinces evenly. The following graph describes severe under nutrition situation, and more details of nutrition status by province are described on annex. 3.31; 3.32; GRAPH 3.46 PERCENTAGE OF SEVERE UNDER NUTRITION SITUATION OF UNDER FIVES 2007 Source: Riset Kesehatan Dasar 2007 According to Riskesdas 2007, the highest proportion of severe under nutrition was occurred among aged group 0 5 months, while proportion among males slightly higher than females. 64

83 TABLE 3.25 SITUATION OF UNDER FIVES NUTRITION STATUS (WEIGHT/AGE) BY AGE GROUP AND SEX IN 2007 Caracterization Severe under Nutrition Under Nutrition Normal Nutrition Over Nutrition Age (Month) 0 5 6,5 8,2 76,7 8,7 06 Nop 4,8 8,1 82,2 4,9 Des ,3 78,8 4, ,9 14,5 75,7 3, ,3 14,8 75,4 3, ,9 14,2 77,2 3,7 Gender Male 5,8 13,3 76,3 4,6 Female 5 12,7 78,2 4 Source: Riset Kesehatan Dasar 2007 H/A describes nutrition status influenced by chronic condition. Stunting remains a serious problem in Indonesia with prevalence at 36.8%, and 18 provinces has higher prevalence than national stunting prevalence. More details about nutrition status according to H/A describe on annex W/H describes nutrition status influenced by acute condition. W/H also may be used as indicator of obesity. Children with W/H Z score < 3.0 SD or severe underweight must be got into malnutrition care program. National prevalence of severe underweight among under fives remains high at 6.2%. Under weight prevalence (consist of severe underweight and underweight) categorized as health problem if higher than 5% accumulatively, as serious health program if prevalence between 10.1% 15.0% and as critical heath problem if prevalence more than 15% (UNHCR). Underweight prevalence among under fives in Indonesia was at 13.6% indicates that underweight remains a serious health problem. Among 33 provinces, 18 provinces have critical problem (underweight prevalence >15%), 12 provinces have serious problem (underweight prevalence 10 15%) while only 3 provinces doesn t have serious or critical problem i.e. West Java, DI Yogyakarta and Bali. According to W/H, overweight prevalence among under fives in Indonesia was at 12.2%. More details describe on annex Nutrition Status of Women aged years with Chronic Energy Deficiency (CED) One method to identify nutrition status of women aged years is by measuring mid upper arm circumference (MUAC). Result of the measurement can be used to identify risk level of a women will have LBW new born. A women is categorized as suffering chronic energy deficiency if her mid upper arm circumference <23.5 cm. 65

84 Riskesdas 2007 used the average of mid upper arm circumference deducted 1 SD and controlled by age, as the standard to identify risk level of CED related to reproduction health. If mid upper arm circumference less than average of circumference upper arm circumference deducted 1SD controlled by age, a woman has risk suffering CED. Riskesdas 2007 indicates CED risk prevalence was 13.6%. Three provinces with highest prevalence were East Nusa Tenggara at 24.6%, Papua 23.1% and DI Yogyakarta 20.2%. Meanwhile three provinces with lowest prevalence were North Sulawesi at 5.8%, North Sumatra at 7.9% and Bengkulu at 8.2%. CED risk prevalence of 10 provinces with highest prevalence illustrated on Graph 3.47 and more details described on annex GRAPH 3.47 PREVALENCE OF WOMEN AGED YEARS WITH RISK OF CHRONIC ENERGY DEFICIENCY IN THE 10 HIGHEST PROVINCES, 2007 Source: Riskesdas 2007 *** 66

85 Achieving the highest position of public health status, many health efforts are required by participation of all potencies in our nation. When the health efforts cannot be implemented appropriately and health services are not equally accessible, it is hard to improve our public health status. Generally, health efforts consist of two main factors, community and individual health efforts. Community health effort is all activities conducted by government and/or community and private in order to maintain and improve health as well as prevent and control health problems in community. The community health effort cover health education, health sustainability, communicable disease control, noncommunicable disease control, basic sanitation supply and environmental health, community nutrition development, mental health, medical devices and pharmaceutical equipment control, usage control of addictive substance in food and beverage, narcotics, psychotropic and dangerous substances control, disaster response and humanity support. Meanwhile, individual health effort is all activities conducted by government and/or community and private in order to maintain and improve health condition as well as prevent and cure the disease and heal the individual health. It covers health education, diseases control, outpatient care, inpatient care, and paralysis cure and control, headed to the individual The following is description of health efforts for the last 5 years, especially in A. PRIMARY HEALTH CARE Primary health care is a crucial way in providing health service to public. By rapid and adequate primary health service, most public health problems could be managed. The primary health care is provided by health personnel as follows: 67

86 1. Child and Maternal Health Service A mother has a very important role in development and growth of the baby. Health problems of a pregnant woman could affect fetus condition in uterus, and until it is born and during baby s growth and development. Policy on newborn and maternal health specifically relates to newborn, delivery, postpartum and antenatal care provided in all type of health facility, from Posyandu to government hospital or private health facility. a. Antenatal Care (1st Visit K1 and 4th Visit K4 ) Antenatal care is a health service provided by health personnel to pregnant woman to maintain their pregnancy healthy in good condition based on the antenatal care instruction in midwifery standard services. This antenatal care purposes to provide health service that the pregnant woman can have healthy delivery and healthy baby, and to detect and anticipate problems of pregnancy fetus s growth early. Antenatal care involves 5 health services: body weighing, blood pressure, measuring height of uteri fundus, TT immunization status and Fe tablet supplementation. Technical guidance of SPM (Minimum Standar Services) on health in districts describes antenatal care as those 5 services and added with dialog (counseling and interpersonal communication) and basic laboratory test ((Hb, urine Protein) and/or based on the indication (HbsAg, Syphilis, HIV, Malaria, TB). Result of antenatal care is indicated by coverage of K1 and K4. First visit (K1) is the 1st visit of pregnant woman to health service facility in the first trimester of pregnancy to get antenatal care. Fourth visit (K4) is pregnant woman visit to get antenatal care for at least 4 times, 1 in the first trimester, 1 in the second trimester and 2 in the third trimester of pregnancy. Graph 4.1 shows increases of K1 and K4 coverages from 2004 to K4 sharply increases in 2008 with 6% (from in 2007), comparing to years before which ranges from %. 68

87 GRAPH 4.1 PERCENTAGE OF K1 AND K4 COVERAGE IN INDONESIA, Source: Dit. Maternal Health, DG of Community Health The graph presents difference betwen K1 and K4 coverages. During , the gap of K1 and K4 is reduced. In 2004, the difference was 11%, and in 2006 it decreased to 10% and reduced to 6.61% in This means the lower of national K1 K4 drop out rate, or in other words, the more pregnant women got antenatal care during the first visit and was continued until the fourth in the 3 trimester. Consequently, pregnancy was monitor appropriately by health personnel with midwifey competence Coverage of K4 service to pregnant woman by province is presented in Graph GRAPH 4.2 PERCENTAGE OF K4 SERVICE COVERAGE BY PROVINCE, 2008 Source: Dit. Maternal Health, DG of Community Health,

88 Graph 4.2. shows that DKI Jakarta, West Java and North Sumatera were three top provinces with K4 service coverage of 95.78%, 95.78% and 94.53%. On the other hand, Papua, West Sulawesi and Maluku were the three lowest provinces with coverage of 38.46%, 64.02% and 64.02%. There is a big gap between the highest (95.78) and the lowest (38.46%) K4 coverage, although the highest and the lowest had risen from 93% and 25% in In 2008, every province targeted K1 coverage 92.9% and K4 coverage 87%. There were 36% (12) provinces met the K1 target, and 20% (7) provinces met the K4 target as described in graph below. GRAPH 4.3a COVERAGE OF 1ST VISIT OF PREGNANT WOMEN BY PROVINCES, 2008 GRAPH 4.3b COVERAGE OF 4TH VISIT OF PREGNANT WOMEN BY PROVINCES, 2008 Source: DG of Community Health, 2009 Source: DG of Community Health, 2009 Graph 4.3a and 4.3b reveals provinces that have met K1 and K4 target. Provinces that had met K4 target were DKI Jakarta, West Java, North Sumatera, DI Yogyakarta, Bali, West Nusa Tenggara and East Nusa Tenggara. In addition to number of K4 coverage, quality of K4 should be improved based on the standard. One of quality standard during antenatal care is 90 iron (Fe) tablets supplement and TT (Tetanus Toxide) vaccination. Therefore, pregnant women included in K4 report were also included in TT2 and Fe3 supplement report. On graph 4.4, K4 coverage in 2008 was 86.04%, but 90 iron tablets supplement only covered 48.14%. There is a possibility of unintegrated report on those three variables. This situation similary occurs in TT2 vaccination, where the coverage of TT2 was lower than K4. 70

89 COVERAGE OF K4, Fe3 AND TT VACCINATION STATUS ON PREGNANT WOMEN IN INDONESIA, 2008 Source: Dit. Maternal Health, DG of Community Health, Detail data of K1 and K4 coverage by province in 2008 is presented in Annex b. Delivery Attendance by Health Personnel with Midwifery Competence Delivery attendance by health personnel with midwifery competence is safe delivery assistance provided by competent health personnels. These competent health personnels or professional are obstetric and gynecologic specialist, physician and midwife. Basically, delivery attendant must notice: 1) infection prevention; 2) standardized delivery assistance method; 3) referring cases that need service on higher level; and 4) early initiation of breastfeeding (IMD = Inisiasi Menyusu Dini). Graph 4.5 shows the increase of delivery attendance by health personnel with midwifery competence during The coverage in 2008 was even more than 80%. 71

90 GRAPH 4.5 COVERAGE OF DELIVERY ATTENDANCE BY HEALTH PERSONNEL IN INDONESIA, Source: Dit. Maternal Health, DG of Community Health Coverage of delivery attendance by health personnel by province is presented below. GRAPH 4.6 COVERAGE OF DELIVERY ATTENDANCE BY HEALTH PERSONNEL BY PROVINCE, 2008 Source: Dit. Maternal Health, DG of Community Health, 2009 Among 33 provinces, three provinces on the top coverage of delivery attendance by health personnel were Bali (97.72%), DI Yogyakarta (94.45%) and Riau Islands (92.67%), while three provinces on the bottom were Papua (45.47%), North Maluku (58.66%) and West Papua (60.10%). SUSENAS (National Socio Economic Survey) 2008 indicates under five s last birth attendants were midwife (53.96%), traditional birth attendant (30.27%) and physician (12.32%). In urban, most first birth attendants to delivery mother were 72

91 midwife (64.26%) and physician (20.71). The under five s last delivery attendance by traditional attendant in rural was 42.75%, while in urban was only 13.40%. People in rural were likely assisted by both midwife and traditional birth attendant. Comparison of delivery attendants in urban and rural is presented on the following Tabel 4.1. TABEL 4.1 PERCENTAGE OF UNDER FIVE BY LAST BIRTH ATTENDANT AND AREA 2008 Area General Practitioner Midwife Other health personnel Traditional Midwife Family Others Urban + Rural Urban Rural Source: BPS Statistic Indonesia, Susenas 2008 Detail percentage of under five by last birth attendant and province is in Annex 4.3. c. Postpartum Health Service Postpartum health service is standard maternal health treatment by health personnel starting from 6 hours to 42 days after delivery. For early complication detection to postpartum mothers, they have to do postpatum visit at least three times: 1) 1st postpartum visit (KF1) within 6 hours to 7 days after delivery; 2) 2nd postpartum visit (KF2) in 2nd week after delivery; and 3) 3rd postpartum visit (KF3) in 6th week after delivery. These visits should be during health service in posyandu and along with infant visit (KB1). The health personnels for postpartum visit include obstetric and gynecologic specialist, physician, nurse and midwife. Postpartum treatment covers: 1) taking blood pressure, pulse, respiration and body temperature; 2) measuring the high of fundus uteri (involusi uterus); 3) per vaginam bleeding; 4) examining breast condition and suggesting exclusive 6 months breastfeeding; 5) Vitamin A 200,000 IU supplement for twice (in 2 days); and 6) family planning service. Graph 4.7 presents percentage of postpartum woman getting Vitamin A by province. 73

92 GRAPH 4.7 PERCENTAGE OF POSTPARTUM WOMAN GETTING VITAMIN A BY PROVINCE, 2008 Source: Dit. Nutrition, DG of Community Health, 2009 During 2008, 58.57% postpartum woman got Vitamin A. Three provinces on the top position were Central Java (87.85%), Bangka Belitung Islands (86.37%) and South Sumatera (83.91%). Meanwhile, three provinces on the bottom position were West Papua (13.01%), West Nusa Tenggara (18.83%) and Maluku (23.97%). d. Neonates Visit During four weeks after born, baby is one age group with the most high risk. Health effort to reduce the risk includes delivery assisted by health personnel and health care to neonates (0 28 days) at least twice, which is once at age of 0 7 days (KN1) and once at age of 8 28 days (KN2). Neonates care provides not only medical check up to baby but also mother counseling of baby care. It includes basic neonatal health care (resuscitation, hypothermia prevention, early initiation and exclusive breastfeeding, infection prevention, e.g. eyes, skin and umbilical cord treatment, and immunization), the supplement of Vitamin K, integrated management of young under five (MTBM); and counseling of neonates treatment at home using Maternal and Child Health Book. Neonates visit (KN2) during tended to decrease, but since 2006 to 2008 KN2 exceeded coverage of 75%. In 2008, KN2 covered 78.04%. 74

93 KN2 coverage during is presented on Graph 4.8 below. GRAPH 4.8 COVERAGE OF NEONATES VISIT (KN2) IN INDONESIA, Source: Dit. Maternal Health and Dit. Child Health, DG of Community Health, MOHRI In 2008, three highest coverages of Neonates Visit (KN2) were in DI Yogyakarta, Bali and Central Java, while three lowest coverages were in Papua, West Papua and West Sulawesi. These are presented on Graph 4.9. GRAPH 4.9 COVERAGE OF NEONATES VISIT (KN2) BY PROVINCE, 2008 Source. Dit. Child Health, DG of Community Health, MOHRI,

94 Coverage detail of neonates visit by province is on Annex Family Planning Ovulation or woman fertile time of the month is very important for getting pregnancy. It increases changes for woman to get pregnant. Some studies reveal productive age of woman is between years old. Therefore, planning and spacing out their pregnancies, these women are more prioritized to use contraception. National Socio economic Survey 2008 finds out that in urban and rural area percentage of married/divorced/widowed women aged 10 years having 0 2 live births was 49.72% and 3 5 live births was 35.83%. Percentage of married/divorced/widowed women aged 10 years having live births > 3 in rural was higher than in urban. These can be seen on Tabel 4.2 below, and detail data by province is in Annex 4.4. TABEL 4.2 PERCENTAGE OF MARRIED/DIVORCED/WIDOWED WOMEN AGED 10 YEARS AND NUMBER OF THEIR LIVE BIRTHS, 2008 Area Live Birth Urban Rural Urban + Rural Source: BPS Statistic Indonesia, Susenas 2008 Average number of live births per woman aged years was 1.77, which was 1.57 in urban dan 1.98 in rural. Detail data of average live births per woman aged years by province is in Annex 4.6. Achievement of family planning service is indicated through FP acceptor coverage shown by program targets that are currently/once using contraception by living area, FP service place and type of contraception. Proportion of married women aged years who were currently/once using contraception during is presented on the following Graph

95 GRAPH 4.10 PROPORTION OF MARRIED WOMEN AGED WHO ARE CURRENTLY/ONCE USING CONTRACEPTION, Source: BPS Statistic Indonesia, Susenas 2008 Susenas 2008 mentions that proportion of married women aged years who were currently/once using contraception was 56.62%. It just slightly increased since Three provinces on the top position of coverage were Central Kalimantan (68.40%), Bengkulu (67.62%) and North Sulawesi (65.19%), meanwhile, three provinces on the bottom psition were West Papua (26.69%), Papua (27.71%) and Maluku (32.10%). Detail data is in Annex 4.7. This percentage is not too different with coverage in years before as shown in Graph In 2008, injection and pills were mostly used by FP acceptors with coverage of 58.7% and 23.9%. GRAPH 4.11 PERCENTAGE OF MARRIED WOMEN AGED YEARS BY TYPE OF CONTRACEPTION CURRENTLY USED, Source: BPS Statistic Indonesia, Susenas 77

96 Based on type of contraception by province, implant and IUD are mostly used in Bali and DI Yogyakarta. When national rate of implant was 7.1%, in Bali and DI Yogyakarta, the coverage was 35.35% and 21.56%. Detail data by province is in Annex 4.9. Percentage of new FP acceptor service during can be seen in Graph 4.12 below. GRAPH 4.12 PERCENTAGE OF NEW FP ACCEPTOR SERVICE IN INDONESIA, Source: National Family Planning Coordinating Board Data of National Family Planning Coordinating Board mentions that types of new FP acceptor service in 2008 are not to different to years before. Many new acceptors used government clinic as FP service (61.51%), while 31.01% used private midwife. Detail data is in Annex Immunization Service All baby, child and adult have the same risk of communicable diseases that can cause death, such as: Diphtheria, Tetanus, Hepatitis B, Influenza, Typhus, meningitis, lung inflammation, etc. Immunization is one of the best ways to protect those risk groups. When a substance enters the body and processes to cause disease (antigen), as the reaction, the body will produce antibody to fight it. Usually, first reaction of the body to produce antibody is not good, since it has not had experience yet. But on the next reactions, it has memorized to recognize the antigen that antibodies are produced more and faster. Therefore, in some hazardous diseases, immunization or vaccination is important in order to prevent body from the diseaseas, or else, to prevent from the fatal effect. 78

97 There are two types of immunization, active and passive immunization. Active immunization is entering live bacteria to body that it develops into disease in order to stimulate body producing antibodies. For example, Polio and Measles vaccinations. Passive immunization is injecting some antibodies to rise number of antibodies in body. For example, ATS (Anti Tetanus Serum) vaccination to victims of accident. An infant who usually gets antibodies from maternal bloodstream during pregnancy, is injected antibodies to fight measles. a. Basic Immunization Basic immunization of infant consists of 1 dosage of BCG, 3 dosages of DPT, 4 dosages of Polio, 4 dosages of Hepatitis B and 1 dosage od measles. Immunization of pregnant woman and eligible woman covers 2 dosages of TT, and immunization of school aged children covers 1 dosage of DT, 1 dosage of measles and 2 dosages of TT. Among kinds of disease that can be prevented by vaccine, measles is the main cause of death of baby. Therefore, measles prevention is an important factor to reduce under five mortality rate. One of some points in International Meeting on Child is sustaining measles vaccination coverage of 90%. In ASEAN and SEARO, measles vaccination is given to 9 11 months infant and the last immunization series to infant (BCG, DPT, Polio, Hepatitis and Measles). In 2008, Indonesia had covered Measles vaccination 90.5%, and it increased from 89.8% in It means Indonesia has met WHO target of Measles vaccination. Graph 4.13 shows percentage of Measles vaccination by province in GRAPH 4.13 COVERAGE OF MEASLES VACCINATION BY PROVINCE, 2008 Source: DG of Diseases Control & Environmental Health, MOHRI, 2009 From 33 provinces in Indonesia, 14 provinces covered Measles vaccination 90%, while 13 provincescovered 80% 90% and 6 provinces covered < 80%. Three provinces on the top position of coverage were DKI Jakarta (104.3%), DI Yogyakarta (99.5%) and Central Java (99.3%). Three provinces on the bottom were 79

98 Papua (58.6%), Maluku (68.7%) and Nanggroe Aceh Darussalam (70%). Data of basic immunization coverage by province is on Annex According to Riskesdas (primary health survey) 2007, education and expenditure per capita are closely related to percentage of baby aged months getting basic immunization, including Measles. The higher education of household head is the higher coverage of vaccination. It is also similar to expenditure per capita, that the higher expenditure per capita is the higher coverage of basic immunization. Tabel 4.3 below describes the relation. TABEL 4.3 PERCENTAGE OF INFANT MONTHS GETTING BASIC IMMUNIZATION BY RESPONDENT CHARACTERISTICS, 2007 Respondent Characteristics Type of Immunization BCG Polio DPT3 HB3 Measles Area Urban Rural Education of Household Head Uneducated Unfinished Elementary Elementary Graduation Junior High Graduation Senior High Graduation University Graduation Expenditure per capita Kuintil Kuintil Kuintil Kuintil Kuintil Source: National Institute of Health Research & Development MOHRI, Riskesdas 2007 Achievement of Universal Child Immunization (UCI) is basically a proxy to coverage of complete immunization to infants (0 11 months), pregnant woman, eligible woman and elementary school student. UCI village is a description of village (desa/kelurahan) with 80% infants had got complete basic immunization in a year. Minimum services standard sets target 100% UCI village in 2010 for each district/municipality. Graph 4.14 below presents percentage of UCI village that had not showed significant development during the last 5 years. The highest achievement was in 2005 with 76.23%. In 2008, 74.02% village in Indonesia had become UCI village. Province with the most UCI village was Central Java (86.59%) and province with the fewest was North Maluku (49.22%). However, national rate in 2008 came from reporting 20 provinces. UCI achievement by province is in Annex

99 GRAPH 4.14 PERCENTAGE OF UCI AHIEVEMENT IN VILLAGE LEVEL IN INDONESIA, Source: DG of Diseases Control & Environmental Health, MOHRI Ideally, infants get basic immunization based on their age so that the immunity of the body to fight diseases that can be prevented with vaccination could be optimal. In fact, many infants did not get complete basic immunization. They are called as immunization drop out. As rpoxy of droup out infants, DPT1 Hb and Measles vaccinations are used as basis for calculation. DPT1 Hb is the first type of vaccination injected to infant, while Measles vaccine is the last vaccination injected to infant. Therefore, infants who get Measles vaccination are assumed having got complete basic immunization. During past six years, the lowest national drop out rate was in 2005 with 1.4%. In 2008, the national drop out rate was 5.4%, and DI Yogyakarta had the lowest rate of 0%, while West Papua had the highest rate of 19.9%. These are presented on Graph 4.15 and detail drop out rate by province is in Annex

100 GRAPH 4.15 DROP OUT RATE OF DPT1Hb MEASLES VACCINATION TO INFANT IN INDONESIA, Source: DG of Diseases Control & Environmental Health, MOHRI b. Immunization to Pregnant Woman Tetanus is caused by toxin which is produced by Clostridium tetani bacteria. It can infect infant (Tetanus Neonatorum) through the infected mother or during delivery. Tetanus is one cause of infant mortality in Indonesia. Unfortunately, many pregnant women live in remote areas with not sterile condition for delivery. This condition rises risk of Tetanus to mother and infants. Maternal and Neonatal Tetanus Elimination (MNTE) is a Tetanus elimination program to neonates and eligible women, including pregnant women. Strategies to eliminate maternal and Neonatorum Tetanus are 1) safe and hygienic delivery assistance; 2) equally distributed and high coverage of regular immunization; and 3) surveillance. When a pregnant woman is exposed by the bacteria or spore, she has risk of infection. However, the infection can come from newborn umbilical cord because bacteria grows in wound and usually when the umbilical cord is cut with not sterile knife or scissor. After getting vaccine during their pregnancy, pregnant women have protected their infants and reduced the risk of Tetanus infection. It is enough for two months after delivery because a two month infant will get a series of vaccination as part of government program on regular immunization in order to prevent Diphteria, Pertussis and Tetanus. Some problems of TT vaccination to eligible women are: not optimum screening process, recording process started from cohort of eligible women (both 82

101 pregnet or not pregnet women) has not the same yet, and coverage of TT2 vaccination to pregnant woman is lower than coverage of 4th visit (K4). Graph 4.16 shows that condition of TT2 vaccination during the last 6 years does not indicate development, but decreasing. The lowest coverage occurred in Meanwhile, in 2008, 42.85% pregnant women got TT2 vaccination. The province with the highest coverage was West Nusa Tenggara with 80.89%, and the province with the lowest coverage was East Kalimantan with 4.08%. GRAPH 4.16 COVERAGE OF TT2 TO PREGNANT WOMEN IN INDONESIA Source: DG of Diseases Control & Environmental Health, MOHRI Steps that must be done immediately are informing officers on fields to refer to criterion of quality Ante Natal Care (ANC) with TT vaccination as a part of it and applying the same T1 T5 recording system in TT vaccination to eligible and pregnant women. B. REFERRAL HEALTH SERVICE Some main activities of individual health efforts are improvements of referral sevices, health service for poor people of 3rd class in hospital, coverage of emergency care, etc. 1. Health Service Indicator in Hospital Success of hospital services is indicated through facilities utilization, service quality and efficiency. Some standardized indicators related to health service in monitored hospital include Bed Occupancy Rate (BOR), Length of Stay (LOS), Bed Turn Over (BTO), Turn Over Interval (TOI), Gross Death Rate (GDR) and Net Death Rate (NDR). DG of Medical Care records that BOR in hospital during tended to increase, though it still ranged to 55% 57% and has not met the ideal rate (60% 85%) yet. In 2007, it increased to 65%, which means that BOR has met the ideal rate. 83

102 GRAPH 4.17 ACHIEVEMENT OF BOR AND BTO IN HOSPITALS IN INDONESIA Source: DG of Medical Care MOHRI Note: BOR = percentage of bed usage BTO = average beds used in hospital BTO is a frequence of bed usage in one period, which means how many times beds are used in one certain time. Ideally, in one year, one bed is averagely used times. The same data reports that in 2007 BTO in hospital has met the ideal rate, which is 44 times. Trend of BOR and BTO since 2003 is presented in Graph TOI is average number of days when beds are unoccuppied, starting from the bed is used until the next usage. This indicator describes efficiency of beds usage in hospital. Beds are ideally unoccupied for 1 3 days. Similar to BOR and BTO, in 2007 rate of TOI in hospitals in Indonesia has met the ideal target, which was 2.9 days. In other words, the beds usage in hospitals has fulfilled the standard. GDR is an inpatient death rate per 1000 discarges from hospital. The ideal GDR is < 45/1000 discharges. In 2007, GDR in Indonesia was 48.7 deaths per 1000 discharges in hospital. NDR is inpatient death rate after > 48 jam getting inpatient care per 1000 discharges. This indicator describes service qualty in hospital. The assumption is when patient dies after treatment for at least 48 hours, it means the hospital service might have relation to the death. On the other hand, when the patient dies less than 48 hours after getting treatment, it is assumed that the main factor is the lateness of patient entering the hospital. The ideal NDR is < 25/1000 patient. Since , NDR was always < 25. It was 23.6 in Therefore, NDR in Indonesia has met the ideal rate. LOS is average days a patient getting inpatient care. This indicator describes efficiency and service quality, and if it is applied in certain diagnosis, it needs more concern. In general, the ideal LOS is between 6 9 days. In 2007, LOS in Indonesia 84

103 was 5 days. Graph 4.18 presents that LOS during has not meet the ideal rate. GRAPH 4.18 HOAPITAL NDR, GDR AND LOS IN INDONESIA Source: DG of Medical Care MOHRI Notes: NDR = Net Death Rate (per 1000 discharges) GDR = Gross Death Rate (per 1000 discharges) LOS = Length of Stay (average days for inpatient care) 2. Jamkesmas Service (Managed Care) Jamkesmas purposes to increase access and quality of health service to poor people in order to achieve the optimal public health status effectively and efficiently. Jamkesmas is expected to reduce maternal mortality rate (MMR), infant mortality rate (IMR), under five mortality rate (U 5MR) and birth rate, in addition to improve health service to poor people. This Jamkesmas program has been developed for 4 years and provided many improvements on health service access for poor people in health center and its network, which is directly referred to health center. Health service in hospital is managed by Ministry of Health, while the cost payment to PPK (health personnel) is directly through State Treasury. Since 2005 to 2008, number of Jamkesmas target was tending to increase, except in 2008, it was the same with the previous year, which was 76.4 million people. Three provinces with three biggest targets were Central Java, West Java and East Java. Graph 4.19 presents realization of JPKM (managed care) program

104 GRAPH 4.19 REALIZATION OF JPKM PROGRAM Source: Center for Health Insurance MOHRI From target of 76.4 million poor and almost poor people, million used health facilities, health center or hospital, as health personnel. It was higher than during years before, that were not more than 7 million people. Easy access to Jamkesmas service might increase the service utilization for poor and almost poor people. PPK (health provider) of Jamkesmas consists of primary health care and advanced health care. Primary health care provider includes health center and its network (sub health center, village maternal hut/village health post, mobile health center) with total number of 8,234 units. Advanced health care provider in 2008 numbered 920 units: 56% government hospital, 7% armed/police hospital, 33% private hospital and 4% polyclinic, as described in Graph GRAPH 4.20 ADVANCED HEALTH CARE PROVIDER OF JAMKESMAS 2008 Source: Center for Managed Care, MOH RI,

105 West Java, Central Java and East Java were three provinces with highest number of advanced health care providers, that were 140, 115 and 80 PPK. It is caused by the high number of Jamkesmas target in those provinces. When in other provinces, total poor and almost poor people are less than 5 millions, and in some provinces even are less than one million, each of those 3 provinces have more than 10 millions population. C. DISEASES CONTROL AND PREVENTION 1. Polio The 41 st WHA (World Health Assembly), 1988 attended by health ministers of WHO member states, declared global polio eradication initiative to eradicate polio in This initiative is then supported by World Summit for Children in 1989, where Indonesia was also the signatory. The eradication is not only to prevent Polio but also means wider, which is to cut transmission of wild polio virus in the world. Polio Eradication is a condition where indigenous wild polio virus not found for 3 years in a row on certain region, proved by AFP surveillance based on sertification standard. Backgrounds of Polio Eradication are: 1. Human is the only reservoir and no longterm carrier on human. 2. Polio virus can not survive in environment. 3. Availability of vaccine which is > 90% effective and easily given. 4. Operationally applicability. During the past 10 years, there is no AFP case of wild polio virus found in Indonesia. AFP surveillance has been conducted in Indonesia since the middle of By 2002, the achievement kept fluctuating, but it started to indicate significant improvement since surveillance officer is available in province. Polio control and prevention have been implemented through polio immunization. It is then followed by epidemiologic surveillance actively to Acute Flaccid Paralysis (AFP) cases on age group <15 years in certain period to detect possibility of wild polio virus in community through fecal specimen of AFP cases found. Nationally, AFP surveillance to population aged <15 during results description as in Graph

106 GRAPH 4.21 PERCENTAGE OF ADEQUATE SPECIMEN DESPATCH AND NON POLIO AFP RATE, Source: DG of Diseases Control & Environmental Health MOHRI Every AFP case found in surveillance intensification will be referred to fecal specimen examination to detect wild polio virus in community. The Graph 4.21 shows that percentage of adequate specimen dispatched for polio virus detection was increased. Therefore, result of detection can more represent the real condition. Since 2003, AFP surveillance performance keeps increasing. WHO targets non Polio AFP rate 2.5 per 100,000 children aged < 15 years, while for adequate specimen standard, WHO targets >80%, which means that minimum 80% fecal specimen of infected cases must meet the requirements of being sampled 14 days after paralysis and with specimen temperature of 0 8ºC arriving at the laboratory. Therefore, since 2003 to 2008, adequate specimen has met WHO target, except in 2006 with 79.10%. There were 18 provinces having met WHO target of non polio AFP rate 2.5 per 100,000 children aged < 15 years and adequate specimen. Those provinces are presented in Graph 4.22 below. 88

107 GRAPH 4.22 AFP CASE DETECTION BY ADEQUATE SPECIMEN BY PROVINCE, 2008 Source: DG of Diseases Control & Environmental Health MOHRI, 2009 In 2005, AFP surveillance system in Indonesia has successfully detected imported cases of wild polio virus from Middle East country. However, in 2008, AFP surveillance has not detected any wild polio cases in Indonesia. 2. Pulmonary TB Four main purposes of Pulmonary TB are: 1) to reduce incidence rate of Pulmonary TB by 2015; 2) to halve prevalence and death rate by 2015, comparing to 1990; 3) to detect and cure at least 70% cases of Pulmonary TB AFB+ with DOTS (Directly Observed Treatment Shortcourse Chemotherapy); and 4) at least 85% of succes rate. Pulmonary TB Control Program with DOTS strategy has been developed and by 2008 has been implemented in all provinces in Indonesia, involving 462 districts/municipalities. Quantitavely, DOTS has been implemented in 8,088 health centers (94.7%) from total 8,548 health centers. About 65% or 41 of 63 BP4 (provincial pulmonary clinics) and RSTP (pulmonary TB hospital) and 38.1% or 563 of 1,478 hospitals have implemented DOTS. By 2008, Pulmonary TB Control Program has successfully reduced incidence of communicable diseases from 130/100,000 population (WHO 1995) to 101/100,000 population. DOTS is a short course Pulmonary TB therapy with direct observation. This therapy should accelerate the healing process. It emphasizes on the important of observing directly the patient to take medicines in the right combinantion for the the correct duration until successfully healed. DOTS strategy contributes high success rate, rising to 95%. This strategy is recommended globally by WHO to control Pulmonary TB. DOTS strategy consists of 5 components, those are: 1) Political commitment of government to seriously fight TB. 2) TB diagnosis by sputum smear examination microscopically. 89

108 3) TB treatment with shortcourse anti TB manual, directly observed by PMO (person to ensure the patient to take medicines). 4) consistent manual of shortcourse anti TB therapy. 5) standard recording and reporting of TB cases. Every year, government effort to control TB significantly shows progress, and it is indicated by the rising of cases detected and cured in every year. Graph 4.23 presents percentage of suspect cases to Pulmonary TB case estimation and percentage of Pulmonary TB AFB+ to Pulmonary TB suspect cases During , the highest percentage of suspect cases to Pulmonary TB case estimation was in 2003 and the lowest was in GRAPH 4.23 PROPORTION OF SUSPECT CASES TO PULMONARY TB CASE ESTIMATION AND PULMONARY TB AFB+ TO SUSPECT CASES Source: DG of Diseases Control & Environmental Health MOHRI Subject to the target, percentage of Pulmonary TB AFB+ is estimated 10% of suspect cases in community with tolerating rate 5 15%. Therefore, since percentage of AFB+ to suspect cases was still tolerated. It means the health personnels had diagnosed based on the standard. Graph 4.24 presents trends of Case Detection Rate (CDR) and Success Rate (SR). During , CDR rose from 20% in 2000 to 72.82% in The highest CDR was in 2006 with 75.7%. Due to CDR world target of 70%, Indonesia has met the target since 2006 although in 2007 it slightly decreased under the target. 90

109 GRAPH 4.24 PERCENTAGE OF CASE DETECTION RATE (CDR) AND SUCCESS RATE (SR) IN INDONESIA, Source: DG of Diseases Control & Environmental Health MOHRI The success of TB therapy is indicated by the obedience and regularity on treatment, physical and laboratory check up. Success rate during fluctuated between 86% (2001 and 2002) and 91% (2005 and 2006). In other words, since 2000 Indonesia has met SR target (85%). WHO standard of TB Success rate is 85%. In 2008, it reached 91.02%, ranging from 60% (Papua) to 99% (Gorontalo). Graph 4.26 shows that 27 provinces in Indonesia have met the target. GRAPH 4.26 SUCCESS RATE OF PULMONARY TB AFB+ BY PROVINCES, 2007 Source: DG of Diseases Control & Environmental Health MOHRI,

110 3. Acute Repiratory Infection (ARI) Acute Respiratory Infection (ARI) still becomes a crucial public health problem since it causes high under five and infant mortality rates, averagely 1 of 4 deaths. Every child is estimated having 3 6 ARI episodes annually. About 40% 60% visits in health centers is related to ARI. Most deaths are caused by pneumonia an happened to infants aged less than 2 months. ARI control program (P2 ISPA) determines ARI into pneumonia and not pneumonia. Pneumonia is cathegorized by serious level into severe pneumonia and non severe pneumonia. Cough cold diseases such as rynitis, pharyngitis, tonsillitis and other upper respiratory infections are cathegorized as not pneumonia. Etiology of those upper respiratory infections mostly are virus and do not need antibiotic therapy. Pharyngitis by Streptococcus is rarely found in under fives, but when it is found, it must be treated with penicillin. All acute ear related inflammations must get antibiotic. ARI control program (P2 ISPA) determines all cases found should be managed due to the standard. Therefore, ARI case detection also represents ARI case management. Nationally, pneumonia detection rate on under fives has not met the target as in Graph 4.27 below. GRAPH 4.27 COVERAGE OF PNEUMONIA DETECTION IN INDONESIA Source: DG of Diseases Control & Environmental Health MOHRI Since 2005 to 2008, coverage of pneumonia case detection was low and tended to decrease. Some problems appear during efforts of rising under five pneumonia detection in Health Center, as follow: 92

111 a. Skilled personnel on MTBS do not implement standard operation procedure in Health Center. b. Limited financing (logistic & operational). c. Lack of gradual supervision (technical, monitoring and evaluation. d. ARI is a forgotten/non priority pandemic, but ARI problem is a multisectoral problem. e. Symptoms of ARI are undetectable by common people and unskilled health personnel. Graph 4.28 presents coverage of under five pneumonia detection by province has not met national target of 76%. However, there were two provinces with straightly higher coverage than other provinces, West Nusa Tenggara (56.60%) and West Java (41.63%). Average national coverage in 2008 was 19.19%. GRAPH 4.28 COVERAGE OF UNDER FIVE PNEUMONIA DETECTION BY PROVINCE, 2008 Source: DG of Diseases Control & Environmental Health MOHRI, HIV/AIDS and STI (Sexually Transmitted Infection) Control Health services of HIV/AIDS control are for treating cases found and also focused on the prevention efforts through early case detection and counseling. Case detection is managed by HIV/AIDS sceening to blood donor and monitoring high risk of STI, such as sex workers, IDUs, prisoners, and even the lowrisk group as housewives, etc. The HIV/AIDS surveillances during past five years indicate increasing result, as presented in Table

112 Year TABLE 4.4 HIV/AIDS CASE DETECTION IN INDONESIA HIV Positive AIDS Positive Death (AIDS Positive) per year cummulative per year cummulative per year cummulative Source: DG of Diseases Control & Environmental Health MOHRI AIDS national cummulative rate by Desember 31, 2008 was 7.12 per 100,000 population. Three provinces on the top position were Papua with , Bali with and DKI Jakarta with A phase from HIV positive to AIDS is known as window periods which is still unknown exactly its periodic that this infected group becomes very potential to spread the virus. Inspite of the treatment, this infected group must be supported by counseling to develop their responsibility to actively prevent the transmission, especially from themselves. 5. Dengue Hemorrhagic Fever (DHF) Control Dengue Hemorrhagic Fever (DHF) is one disease which spreads fast and can cause death in short time. It is a communicable disease often occurring as outbreak in Indonesia. Methods to prevent DHF consist of: 1) improvement of disease and vector surveillance; 2) early diagnosis and treatment; and 3) improvement of DHF vector elimination. These methods emphasize activation of public potency to involve in mosquito nest elimination (PSN) and regular larva monitoring. The success of PSN program is indicated with Free Larva Rate (ABJ) as a measurement of vector elimination. When ABJ 95%, DHF should be able to be prevented and eliminated. The PSN program is implemented through 3M movement: 1) draining water reservoir; 2) closing water reservoir; and 3) burying unused things that can keep water. Meanwhile, regular larva monitoring is empowered by Jumantik (skilled larva monitoring worker) and cadre of PKK (training for women on family affairs). Table 4.5 shows achievement of DHF control(p2dbd) indicator program during the past two years, , which has not met the target >95%, as percentage of standardized DHF incidence which also has not met target of 80%. P2DBD achievement is presented in table below. 94

113 TABLE 4.5 ACHIEVEMENT AND INDICATOR OF P2DBD PROGRAM INDICATOR Target Realization Target Realization Free Larva House in endemic area (%) > > DHF responded by standard procedure (%) DHF Incidence Rate (per 100,000 population) Source: DG of Diseases Control & Environmental Health MOHRI < < DHF Mortality Rate (%) < < Since 2004, Communication for Behavioral Impact (COMBI) has been recognized as a message/information delivery/communication method which affects behaviour changes in implementing PSN with local socio culture approachment. In 2007 some cities e.g. South Jakarta, East Jakarta, Padang and DI Yogyakarta, implemented PSN with COMBI. Meanwhile, other 5 cities, South Jakarta, Bandung, Tangerang, Semarang and Surabaya, implemented it in This PSN with COMBI method starts becoming one priority of P2DBD program. 6. Malaria Control Malaria has been a public health problem in Indonesia. About 73.6% is Malaria endemic area with almost a half (45%) population has risk of being infected. The rising of malaria cases and outbreak has close relationship with these factors: 1) environemental change which extends malaria vector nest; 2) high population mobility; 3) climate change which makes rainy season is longer than dry season; 4) prolonged economic crisis increasing number of undernutrition community that they are more risky of malaria infection; 5) ineffective therapy because of resistance of Plasmodium falciparum to klorokuin and extended resistance area; and 6) less concern and awareness of people to integrated malaria elimination program. Malaria elimination program has pusposes: General Objectives to free DKI Jakarta, Bali, Barelang Binkar: 2010 to free Java, NAD, Riau Islands: 2015 to free Sumatera, West Nusa Tenggara, Kalimantan, Sulawesi: 2020 to free Papua, West Papua, East Nusa Tenggara, Maluku, North Maluku:2030 Specific Objectives2 1. By 2010, villages with malaria positive 5 per 1000 population decreased by 50%. 2. By 2010, all districts/municipalities are capable of examining patient s blood sample and providing appropriate and accessible malaria treatment. 95

114 3. By 2020, all regions in Indonesia has controlled malaria with intensification and integration. People using ways to prevent malaria can be found in survey of population using effective prevention ways of bed net to fight malaria. In 2005, it was 1% population, and in 2006 based on surveys in Alor, West Sumba, East Florest Districts and some districts in Sumatera Islands, it involved 24% population. Comparing the target, those percentages are still lower. Target in 2006 was 60%, while in 2007 survey was not available. According to surveys in NAD, North Sumatera (Nias and South Nias Municipality) and 5 provinces in eastern Indonesia, in 2008 the usage of bed net to under fives was 86.7% and to pregnant women was 87.75%. Target and realization of people using effective prevention ways to fight malaria during are presented in Graph 4.29 below. GRAPH 4.29 PEOPLE USING EFFECTIVE PREVENTION TO FIGHT MALARIA IN INDONESIA, Source: DG of Diseases Control & Environmental Health MOHRI Treated malaria case is percentage of suspected and/or positive malaria cases that come to health facilities and get standard treatment for 1 year. Percentage of treated malaria case since 2003 to 2008 was 100%. It means all suspected and/or positive malaria cases that come to health facilities get standard treatment. The realization has met the target as shown in Graph

115 GRAPH 4.30 TARGET AND PERCENTAGE OF MALARIA TREATMENT Source: DG of Diseases Control & Environmental Health MOHRI Coverage of laboratory confirmation indicates that not all blood samples of malaria clinical cases are examined. Laboratory confirmation of 100% has been reported in Java and Bali. In general, during percentage of blood sample examination to clinical malaria cases has significantly risen from 48% in 2004 to 71% in 2008, as presented in Graph 4.31 below. GRAPH 4.31 MALARIA MICROSCOPIC/LABORATORY CONFIRMATION IN INDONESIA, Source: DG of Diseases Control & Environmental Health, MOHRI 7. Leprosy To evaluate personnel performance in leprosy case detection, it uses propotion rate of physical defect case at second level (due to neurogical damage and 97

116 visible handicapped). The high rate of second level physical defect proportion indicates the delay in detecting cases, in other words, the low performance of personnel in detecting cases and lack of people s knowledge. Second level physical defect case during was relatively stable 8.6% 8.7%), but in 2008 it slightly increased to 9.6% as shown in Table 4.6. Until 2008, the proportion has not met the target <5%. It means the transmission still occurred in community, and cases were lately detected since when they were found they had already had second level physical defect. TABLE 4.6 POPULATION EXAMINATION, CASE DETECTION RATE (CDR) AND SECOND LEVEL PHYSICAL DEFECT CASES IN INDONESIA, Year Positive Suspect PB MB CDR 2nd level physical defect (%) 8. Filariasis ,615 12, ,056 15, ,550 14, ,643 14, ,113 14, Source: DG of Diseases Control & Environmental Health, MOHRI Notes : MB = Multi Basiller, PB = Pausi Basiller, CDR = Case Detection Rate Filariasis (usually called as elephantiasis) spreads almost thoughout provinces in Indonesia. Filariasis elimination program is established based on WHO Global 2000 The Global Goal of Elimination of Lymphatic Filariasis as a Public Health Problem the year 2020 as realization of WHA (World Health Assembly) resolution in This elimination program is implemented through 2 pillars: a. Mass Drug Administration (MDA) to all people in filariasis endemic districts using DEC 6 mg/kg BB combined with Albendazole 400 mg once a year for 5 years in order to cut the transmission. b. Case management of filariasis clinical cases to prevent and reduce physical defect. Since 2005, Implementation Unit (IU) used in Filariasis Elimination Program is district/municipality. It means the smallest area in this program is district/municipality, both for endemicity determination and mass drug administration. When a district/municipality has been a filariasis endemic, target of mass drug administration covers all residents of the district/municipality. They have to take medicine, but it is temporarily delayed for children under two (2) years, pregnant woman, people with serious illness, filariasis chronic patient in acute attack and marasmus/kwashiorkor under five. 98

117 GRAPH 4.32 REALIZATION OF FILARIASIS CLINICAL CASE MANAGEMENT IN INDONESIA, Source: DG of Diseases Control & Environmental Health, MOHRI During , filariasis chronic case management indicated increasing. In 2005, 1,461 (21%) chronic cases were treated, while in 2008 it increased to 4,695 (40.13%) cases. In years ahead, it should increase and meet target of 90%. Since 2005, percentage of districts/municipalities providing mass drug administration (MDA) kept increasing, from 13.25% (of 234 endemic districts/municipalities) in 2005 to 30.70% in Meanwhile, percentage of districts/municipalities providing MDA as width as the district/munipality kept also increasing for the past 4 years, from 9.68% in 2005 to 53.61% in GRAPH 4.33 FILARIASIS MDA (MASS DRUG ADMINISTRATION) IN DISTRICT/MUNICIPALITIES, Source: DG of Diseases Control & Environmental Health, MOHRI Not all districts/municipalities had implemented MDA with all population as the target because of many factors, such as the high operational cost and not all local 99

118 governments commit to Filariasis MDA. Both district/municipal and provincial governments are responsible to the operational cost, while central government is responsible to medicine supply. Therefore, coordination and commitment of local and central governments are very important as well as seeking foreign aid to support operational cost of MDA in regions. Mass drug administration of Filariasis during is presented in Graph 4.34 below. GRAPH 4.34 NUMBER OF FILARIASIS MDA IN INDONESIA, Source: DG of Diseases Control & Environmental Health, MOHRI MDA target in 2008 was 29.7 million people, while the realization reached 12.3 million people (41.34%). The MDA coverage recently kept increasing as the MDA target. On the other hand, percentage of population taking Filariasis medicine tended to decrease from 86.85% in 2004 to 41.34% in Avian Influenza Avian influenza (AI) transmission is prevented by avoiding poultry feces and secretions contaminated materials with some preventions such as: Washing hands with liquid soap in running water before and after doing anything; Environmental hygiene; Self cleanliness; Wearing safety mask or special glasses when having contact with material from poultry s gastrointestinal tract; Materials from poultry s gastrointestinal tract, e.g. feces, must be buried or burned that it could not be sources of transmission to surrounding people; Washing with disinfectant all tools used in housbandry; Do not bring out cage and feces from farming area; 100

119 Consuming only birds meat cooked in 80 o Celcius for one minute, birds egg boiled in 64 o Celcius for five minutes. Graph 4.35 presents that during about 28% Avian Influenza cases went to private clinic and 18% to midwife (bidan/mantri) before to health facility with more complete facilities. Therefore, socialization of case management involving AI case detection and reference to referral hospital becomes a priority of AI case management program. GRAPH 4.35 HEALTH FACILITY FIRSTLY VISITED BY AI CONFIRMED CASES IN INDONESIA, Source: DG of Diseases Control & Environmental Health, MOHRI Avian Influenza Surveillance Strengthening that have been implemented are: 1. Training on Outbreak Response and Investigation, especially related to AI, for TGC (fast responding team) in province and disttric/municipality levels. a. TGC in province: 28 provinces had been trained (involving 5 regions) and other 5 provinces would be trained on early b. TGC in district/municipality: 345 districts/municipalities had been trained, while the remains were still in process of financing proposal to WHO. 2. TGC Review in province had been held once to discuss development of trained TGC. 3. District Surveillance Officer (DSO) Training involved 90 districts/municipalities in 9 provinces: Banten, DI Yogyakarta, Bali, Lampung, East Java, Central Java, West Java, North Sumatera and DKI Jakarta. Each district/municipality has 2 DSO coordinating to PDSR (Participatory District Surveillance and Response) of animal farming sector. This DSO PDSR is a focal point of integrated AI surveillance officer in each area, in order to early detect AI cases and improve sharing information. 4. DSO Review (August 2008) was attended by DSO and heads of subdivision to discuss problems of DSO in field and improvement of DSO performance in the next. 101

120 5. Assessment to DSO and TGC is conducted by external team, which is WHO. The Assessment was conducted in 6 provinces and 2 districts/municipalities in either those 6 provinces. Generally, it concludes that TGC and DSO had responded to AI cases but it still needed improvement for other potential outbreaks and DSO data management system and refreshing training for DSO and TGC. 6. Each pilot province periodically held DSO review, which was involving also technical officers from center (surveillance subdirectorate). It purposed to review DSO activities, coordinating to animal farming sector, and share experiences and information among DSO in performing tasks and solving problems in the field. Some feedbacks from center and province about reports sent by DSO were reviewed also. 7. epidemiological investigation to cases considered need to be supported by center, and on the job training. 8. Socialization about integrated AI surveillance to technical meetings in district, province and national levels. 9. Some analyses from DSO report and DSO working performance. 10. Vector Surveillance One thing that must be always concernid in vector control is monitoring vector resistance to insecticida Salah satu hal yang senantiasa harus diperhatikan dalam pengendalian vektor adalah monitoring resistensi vektor terhadap insekticide used by many units, including government institution, such as district health office and their staff as officers performing vectror control. In addition, central Technical Units in region, e.g. Port Health Office (KKP), also performs regularly vector and other nuisance animal control. Many pest control companies, both registered and unregistered legally, control vector and insect usually using pesticide as the popular method to reduce vector population. Insecticide in household is one problem that cannot be ignored. Household insecticide which is freely sold and unmonitored utilized would accelerate the resistance process. Today, vector control is identical to insecticide though other methods might be considered also. Therefore, this insecticide usage and its effects must be monitored that it is still effective and does not cause environmental pollution. a. Indicator of Vector Control Program Achievement of vector control target by 2008 is presented in Table 4.7. There are still many indicators having not met the target yet, and this condition is caused by some factors; First, the financing that is usually not realized by end of the year; second, those indicators are not only tasks of vector Control Subdirectorate but also responsibility of other institution (cross program and sector in centre and region). 102

121 TABLE 4.7 ACHIEVEMENT OF VECTOR CONTROL SUBDIRECTORATE BY TYPE OF INDICATORS, UP TO 2008 No Indicators Unit Target Realization 1 Percentage of animal borne endemic (infected) % districts with technical skilled officers 2 Percentage of districts implementing Malaria vector elimination based on vector data and Malaria transmission dynamics % Percentage of districts carrying vector % susceptibility test 4 Percentage of provinces mapping Malaria vector % Percentage of districts carrying eficacy test to % insecticide 6 Percentage of Malaria endemic districts evaluated % with vector control quality 7 Percentage of DHF endemic districts evaluated % with vector control quality 8 Percentage of districts with positive of Aedes aegypty larvae (House Index/H I < 5%) % 1.36 Source: DG of Diseases Control & Environmental Health MOHRI b. Insecticide Vector control is carried out by some methods, such as physical, biological, and chemical. The recommended method is known as Integrated Vector Control. In certain condition, number of vector population has straightly increased and cases are significantly increased. Some efforts to reduce vector population appropriately are important, and insecticide is an avoidable choice. The following is data of insecticide usage permitted by WHO to control some types of adult mosquitoes within 15 years as presented on Table 4.8 below. TABLE 4.8 TYPE OF INSECTICIDE PERMITTED BY WHO FOR VECTOR CONTROL Year DDT Lindane Malathion Type of Insecticide Fenitrothion Propoxur Chlorpyrifos methyl Pirimiphos methyl Bendiocarb Permethrin Cypermetrin Alpha cypermethrin Cyfluthrin Lambda cyhalothrin Deltamethrin Bifenthrin Etofenprox Source: DG of Diseases Control & Environmental Health MOHRI Notes: 103

122 Organochlorines Organophosphates Carbamates Pyrethroids c. Monitoring Resistance Continuous usage of insecticide in certain area would lead to resistance of targetted species. To prevent the vector resistance to insecticide, the policy of insecticide usage should be made based on the existing standard. Vector monitoring in some areas is very crucial to ensure vector susceptibility status. It is implemented under MOHRI and universities control. Description of Aedes aegypti resistance to malathion 0.8 % in areas is on Graph GRAPH 4.36 RESISTANCE OF AEDES AEGYPTI TO MALATHION 0.8% IN INDONESIA, BY 2008 Source: DG of Diseases Control & Environmental Health MOHRI Monitoring resistance also includes Malaria vector to some used insecticide. Result of this Malaria vector species resistance to Lamda cihalothrin, Bendiocarb 0.1 % and Deltametrin is shown on Graph 4.37 below. GRAPH 4.37 MONITORING RESISTENSI OF MALARIA VECTOR IN INDONESIA,

123 Source: DG of Diseases Control & Environmental Health MOHRI D. IMPROVEMENT OF COMMUNITY NUTRITION Improvement of community nutrition is basically intended to solve nutrition problem in community. Observations find some nutrition problems commonly in community, such as vitamin A deficiency and iron nutrition anemia. 1. Vitamin A Supplementation Vitamin A is an essential nutrition for human. This vitamin cannot be produced by human body; therefore, it must be supplemented from outside the body. Some vegetables contain vitamin A, such as spinach, cassava leaves, ripe papaya, breast milk, foods fortified with vitamin A and high dose vitamin A capsule. Vitamin A is important for eyes health and to prevent blindness. The most important is that vitamin A increases body immunity. When children with enough vitamin A intake having diarrhea, measles or other infections, they will not get the diseases worsening and endangering their lives. Some facts have shown the important roles of vitamin A in decreasing mortality rate. In addition to prevent blindness, vitamin A currently is associated with child survival, health and growth. The most secure and sustainable way to increase consumption of vitamin A foods is through KIE (education information comunication) process, although health information process does not give real effects. On the other side, vitamin A fortification is still initiated. Therefore, response to vitamin A defiency is through supplementation of high dose vitamin A. Targets of high dose vitamin A capsule are infant, under five and postpartum mother. 1. Infant 105

124 Vitamin A 100,000 SI capsule is supplemented to all infants (aged 6 11 months) in either health or sick condition. It is once in six months every February and August. 2. Under five Vitamin A 200,000 SI capsule is supplemented to all under fives (aged 1 4 years) in either health or sick condition. It is once in six months, every February and August. 3. Postpartum mother Vitamin A 200,000 SI capsule is supplemented to postpartum mother that their newborn will get enough A through breastmilk. It is given at least 30 days after delivery. Vitamin A supplementation by target in 2008 is presented in Graph 4.38 below. GRAPH 4.38 PERCENTAGE OF VITAMIN A CAPSULE SUPPLEMENTATION BY TARGET IN INDONESIA, 2008 Source: Directorate of Community Nutrition MOHRI, 2009 There are some certain conditions that need vitamin A capsule immediately: a. Xerophthalmia; with symptoms of night blindness, white spot, dry or cloudy eyes. The supplementation should meet these requirements: After found: immediately given one capsule of Vitamin A 200,000 SI; Next day: one capsule of Vitamin A 200,000 SI; Next 4 weeks: one capsule of Vitamin A 200,000 SI. b. Measles Child suffering of measles needs one capsule of Vitamin A 200,000 SI immediately. For baby, it should be one capsule of Vitamin A 100,000 SI. 2. Iron Tablet Supplemetation 106

125 Nutritional anemia is a health problem contributing to the high maternal and infant mortality rates, working productivity, exercise and study capabilities. Therefore, nutritional anemia control becomes one potential program to develop quality of human resources, which has been implemented by government since 1 st long term development program. Pregnant woman is one group susceptible to nutrition problem, especially anemia caused by lack of iron (Fe). SKRT (household health survey)/riskesdas (basic health survey) during years in Indonesia is described in Graph There is significant decrease in percentage of anemia in pregnant women, from 73.3% in 1986 (SKRT) to 24.5% in 2007 (Riskesdas, 2007). GRAPH 4.39 PERCENTAGE OF PREGNANT WOMEN SUFFERING OF ANEMIA IN INDONESIA Source: Directorate of Community Nutrition, and National Board of Health Research & Development To determine whether someone gets anemia or not, some limit values are usually used, subject to Health Ministerial Decree No. 736a/Menkes/XI/1989, those are: Hb of adult male: >13 g/dl Hb of adult female: >12 g/dl Hb of child: >11 g/dl Hb of pregnant woman: >11 g/dl Someone gets anemia when the Hb level is less than those normal standard. Less intake of adequate iron (Fe) leads to nutrition anemia. When Hb level is under 11 g/dl, some symptoms occur, such as pale, listless, tired, weak and bleeding. Indonesia government still faces the problem of relatively high prevalence of anemia on pregnant women, and it is mostly caused by lack of iron, which is important for hemoglobin formation. It is known as less iron anemia. Condition of less iron on pregnant women can cause growth problems or obstacle on fetus body or brain cells. It can also cause miscarriage, premature, low birth weigh and bleeding 107

126 before and during delivery. In serious anemia case, it can cause death to baby and mother. In child case, it cause growth problems (can not achieve the optimal high) and less intelligent. Graph 4.40 shows tendency of Fe1 and Fe3 coverage since 2003 which tended to decrease in GRAPH 4.40 COVERAGE OF Fe1 AND Fe3 TO PREGNANT WOMEN IN INDONESIA, Source: Directorate of Maternal health, DG of Community Health MOHRI In 2008, coverage of Fe3 (90 tablets) was 48%, ranging from 20% in Maluku to 86% in Bangka Belitung Islands. Coverage of Fe3 to pregnant women by province is presented in Graph 4.41 below. GRAPH 4.41 COVERAGE OF Fe3 TO PREGNANT WOMEN BY PROVINCE, 2008 Source: Directorate of Maternal health, DG of Community Health MOHRI,

127 Some efforts must be done to control iron deficiency in pregnant women immediately due to those effects caused by anemia that can reduce quality of human resources in Indonesia. Therefore, Indonesia government has been starting to run a program of iron supplementation since twenty years ago. This program is implemented in purposes that every pregnant woman regularly checking their pregnancy to health center or posyandu. Iron is provided by health personnel to pregnant women for free. E. HEALTH SERVICE IN POSTDISASTER SITUATION Disaster in Indonesia is classified into 2 categories. They are environmental and natural disasters. Environmental disaster occurs as results of environment damage. It includes flood, landslide, drought, land and forest burning, industrial accident, and oil spilling on sea. On the other hand, natural disaster occurs as earth crust activities or natural phenomenon, such as earthquake, tsunami, volcanic eruption and storm that are unpredictable. Center for Crisis Response observed that during 2008 there were 456 disasters in Indonesia, and it caused health crisis. They were flood, landslide, transportation accident, hurricane, industrial accident and social conflict. Some were huge disasters that killing hundreds people and injuring thousands as well as causing internally displaced people (IDP). Flood was the most frequent disasater with 42% of all disasters. Other frequent disasters were landslide (17%) and hurricane (14%). The high frequent of flood occurred during January March and November December. The highest mortality was caused by landslide with 103 victims and by flood with 58 victims. Internally displaced people (IDP) in 2008 were mostly caused by flood with 303,277, flashflood with 23,075 and earthquake with 10,747. Detail data is described in Annex 4.30 That is description of health efforts in Indonesia until *** 109

128 Health resources have contribution in providing qualified health services in order to increase public health status. This chapter explains health resources through description of health facility, health personnel, and health budgeting. A. HEALTH FACILITIES Health facilities described on this chapter consist of: health center, hospital (general and specific), community based health facility, pharmaceutical production and distribution facilities, medical devices, and educational institution of health human resources. 1. Health Center Health center is a technical unit of district/municipal health office on carrying out integrated health programs. It has functions as center of health development, community based health effort mobilization and primary health care. Number of health centers by the end of 2008 was 8,548 units. There were 2,438 units of health center with beds and 6,110 units of health center without beds. On assessing population accessibility to health center, it is used ratio of health center per 100,000 population. Ratio in shows increasing trend which was 3.48 in 2004 and 3.74 in The following graph describes the rising trend. 110

129 GRAPH 5.1 RATIO OF HEALTH CENTER PER 100,000 POPULATION, Source: DG of Community Health and Center for Data and Information, MOH RI Ratio of health center per 100,000 population by province in 2008 indicates that West Papua had highest ratio at while Banten had lowest ratio at Ratio of health center on provincial level in 2008 illustrates on the graph below. More details of the data are on Annex 5.1. GRAPH 5.2 RATIO OF HEALTH CENTER PER 100,000 POPULATION, 2008 Source: DG of Community Health and Center for Data and Information, MOH RI In order to improve health care quality of health center, local government has upgraded several health centers to health centers with beds. On recent five years ( ) number of health centers with beds rose from 2,010 units to 2,438 units. Number of health centers and health centers without beds in are illustrated on following Graph 5.3. Annex 5.2 provides more data about number of health centers and health centers with beds. 111

130 GRAPH 5.3 NUMBER OF HEALTH CENTERS AND HEALTH CENTERS WITH BEDS Source: DG of Community Health and Center for Data and Information, MOH RI In improving accessibility of health center to population, it is supported with facilities such as sub health center, mobile health center and polindes/poskesdes. According to Podes (village potency survey) of BPS Statistics Indonesia in 2008, there were 23,163 units of sub health centers. It indicates that ratio of sub health center to health center was 2.7. More details about number of sub health centers in 2008 can be seen on Annex Hospital Health development in Indonesia is not merely of promotive and preventive activities. It has also curative and rehabilitative efforts. Hospital is one of health care facility with curative and rehabilitative approach. Hospital can also be referral health care of health center or clinic. There were 1,371 units of hospital with 1,079 units of general hospital and 292 units of specific hospital. They are managed by government (Ministry of Health, local government, armed forces/police and other ministries) and private sector. In recent five years there were rising trend on number of hospitals. Number of hospitals in 2004 was 1,246 units which increased to 1,371 units in Table 5.1 provides number of hospitals (general and specific) in Data about number of hospitals in 2008 by ownership and province are on Annex

131 TABLE 5.1 NUMBER OF HOSPITAL (GENERAL AND SPECIFIC) No. Ownership Ministry of Health/ Local Government Armed Forces/Police State Owned Corporation/Other Ministries Private Total 1,246 1,268 1,292 1,319 1,371 Source: DG of Medical Care, MOH RI Number of general hospitals either was managed by government or private increased in There were 976 units of general hospitals in 2004 and it rose to 1,079 units in Data about general hospital can be seen on Annex 5.5. The following Graph 5.4 describes rising trend on number of general hospitals in GRAPH 5.4 NUMBER OF GENERAL HOSPITAL Source: DG of Medical Care, MOH RI General hospitals are classified into 4 classes e.g. A, B, C and D. Most of general hospitals managed by Ministry of Health/local government in Indonesia are class C. Among 431 units of general hospital managed by government, there were 256 units (59.4%) of Class C, 88 units (20.42%) of class D, 79 units (18.33%) of class B and 8 units (1.86%) of class A. Graph 5.5 illustrates percentage of general hospital by class. 113

132 GRAPH 5.5 PERCENTAGE OF GENERAL HOSPITAL OWNED BY MINISTRY OF HEALTH/LOCAL GOVERNMENT BY CLASS, 2008 Source: DG of Medical Care, MOH RI Number of general hospitals managed by Ministry of Health and local government classified as class A are 8 units. The hospitals are located on Medan, Jakarta, Bandung, Semarang, Yogyakarta, Surabaya, Denpasar and Makassar. More details about the general hospital managed by Ministry of Health and local government described by class and province can be seen on Annex 5.7. In recent five years, number of specific hospitals remained rising trend. There were 270 units in 2004 which increased to 292 units in The Graph 5.6 describes increase of specific hospital during GRAPH 5.6 NUMBER OF SPECIFIC HOSPITAL,

133 Source: DG of Medical Care, MOH RI Among specific hospitals in Indonesia, most of them are maternal and child hospitals with 79 units. The following graph explains number of specific hospital. Meanwhile, data about number of units and beds of specific hospital are on Annex 5.8. GRAPH 5.7 TYPE OF SPECIFIC HOSPITAL IN INDONESIA, 2008 Source: DG of Medical Care, MoH RI Number of beds on hospital may indicate its capacity on providing health care. Number of beds on general hospital and specific hospital in shows increasing trend described on Graph 5.8 as follows. GRAPH 5.8 NUMBER OF GENERAL HOSPITAL BEDS AND SPECIFIC HOSPITALS BEDS, Source: DG of Medical Care, MoH RI 115

134 Availability of referral health care can be measured by ratio of hospital beds to population. Ratio of beds per 100,000 population in showed rising trend from in 2004 to in Number of beds and ratio per 100,000 population are on Graph 5.9. More information about number of beds on general hospital and specific hospital can be seen on Annex 5.5, Annex 5.6 and Annex 5.8. GRAPH 5.9 NUMBER OF HOSPITAL BEDS AND RATIO PER 100,000 POPULATION IN Source: DG of Medical Care, MOH RI Proportion of beds in general hospital by class indicates that most of beds are 3 rd class at 44.4%, followed by 2 nd class at 23.6% and 1 st class at 11.9%. Besides those three classes, there are VIP and no class group. Percentage of VIP class was 8.4% and no class was 11.7%. More information about number of general hospital beds and the percentage by class and province are on Annex 5.6. In improving poor and vulnerable people accessibility to health care, Ministry of Health and several local governments provide health insurance on health center and 3 rd class patient of hospital to member of Jamkesmas. Jamkesmas covers 76,400,000 population in Meanwhile, there were only 57,147 beds for 3 rd class patient on general hospital. Hence, ratio of beds to 3 rd class patient on general hospital was 75 beds per 100,000 member of Jamkesmas. 3. Production and Distribution Facility of Pharmaceutical and Medical Device Supply Number of production and distribution facilities of pharmaceutical and medical device supply remained rising trend in recent five years ( ). The following Graph 5.12 illustrates the trend. More details about number of the facility can be seen on Annex

135 GRAPH 5.10 NUMBER OF PHARMACEUTICAL PRODUCTION FACILITIES AND MEDICAL DEVICES, Source: DG of Medical Devices and Pharmaceutical Services, MOH RI In line with production facilites, number of pharmaceutical and medical devices distribution facilities also showed rising trend. The rising trend is described on following Graph Annex 5.10 provides the details about number of pharmaceutical and medical devices distribution facilities. GRAPH 5.11 NUMBER OF PHARMACEUTICAL AND MEDICAL DEVICES DISTRIBUTION FACILITY, Source: DG of Medical Devices and Pharmaceutical Services, MOH RI 117

136 4. Community Based Health Effort (UKBM) Health effort can be conducted through several approaches. Community may contribute to implementation of health programs. Implementation of health programs on community level established by mobilization their capacity known as UKBM (community based health effort). Types of UKBM in Indonesia are posyandu (pos pelayanan terpadu), polindes (pondok bersalin desa = village maternal post), poskesdes (pos kesehatan desa = village health post), toga (tanaman obat keluarga = family herbal medicine) and POD (pos obat desa = village drugs post). Posyandu is one of UKBM that has long been implemented on community level. It has 5 prior programs. They are maternal and child health, family planning, nutrition improvement, immunization and diarrhea control. In evaluating its activities, posyandu is classified into 4 classes, Posyandu Pratama, Posyandu Madya, Posyandu Purnama and Posyandu Mandiri. Based on podes held by BPS Statistics Indonesia in 2008, there were 70,046 units of active posyandu. It indicates that ratio of active posyandu to village was 0.9 per village. On improving accessibility to health care especially gynecology, polindes are developed on village. Polindes provides maternal health care and delivery attendance. Podes indicates that number of Polindes in 2008 were 25,271 units. Ratio of Polindes to number of villages in 2008 was Province with highest ratio was East Java of 0.66 followed by West Kalimantan of 0.59 and Bangka Belitung Islands of More information about ratio of polindes by province in 2008 are on Graph 5.12 as follows. GRAPH 5.12 RATIO OF POLINDES TO VILLAGE, 2008 Source: Podes, BPS Statistics Indonesia,

137 Number of poskesdes in 2008 was 11,287 units. Ratio of poskesdes to village in 2008 was Province with the highest ratio was South Sumatera and East Java at 0.32, followed by Central Java at The following Graph 5.13 describes ratio of poskesdes by province in Annex 5.3 provides data about number health facilities based on Podes, BPS Statistics Indonesia in GRAPH 5.13 RATIO OF POSKESDES TO VILLAGE, 2008 Source: Podes, BPS Statistics Indonesia, Educational Institution for Health Manpower Sustainable health development requires health manpower. In order to have qualified health personnel, it needs qualified education. Ministry of Health has responsibility on providing qualified health personnel through health polytechnic and non health polytechnic. There were 1,068 educational institutions in 2008 with 214 health polytechnics and 854 non health polytechnics. It increased from 954 institutions in 2007, with 208 health polytechnics and 746 non polytechnics. According to type of study program, it mostly was nursing with 137 (64.02%) study programs, followed by nutrition with 26 (12.15%) study programs and public health with 20 (9.35%) study programs. Number of study programs of health polytechnic is described on Graph 5.14 as follows. 119

138 GRAPH 5.14 NUMBER OF STUDY PROGRAMS IN HEALTH POLYTECHNIC, 2008 Source: Center of Education & Training, National Board of Health Human Resources Development and Empowerment, MOH RI 2008 Meanwhile, among 854 institutions of non health polytechnic, most of them were nursing with 640 (74.94%) study programs, followed by pharmaceutical with 97 (11.36%) study programs and medical technician with 77 (9.02%) study programs. The following Graph 5.15 provides number of study programs of non health polytechnic in GRAPH 5.15 NUMBER OF STUDY PROGRAMS ON NON HEALTH POLYTECHNIC, 2008 Source: Center of Education & Training, National Board of Health Human Resources Development and Empowerment, MOH RI, 2008 In evaluating development of health polytechnic institution, Ministry of Health has established accreditation. By the end of 2008, there were 183 study programs having been accredited and 31 study programs having not been accredited. Among those accredited study programs, most of them were grade B with 99 study programs (54.1%). Remaining accredited study programs were Grade A with 77 study programs (42.08%) and Grade C with 7 study programs (3.83%). Percentage of accreditation on health 120

139 polytechnic study program can be seen on the Graph 5.16 as follows. More information about accredited study program can be seen on Annex GRAPH 5.16 PERCENTAGE OF STUDY PROGRAM ACCREDITATION OF HEALTH POLYTECHNIC, 2008 Source: Education Center, National Board of Health Human Resources Development and Empowerment, MOH RI, 2008 Accreditation is also implemented on educational institution of non health polytechnic. Number of accredited institutions was 538 institutions and 316 institutions were not accredited. Among those accredited, there were 67 institutions (12.45%) of grade A, 424 institutions (78.81%) of grade B and 47 institutions (8.74%) of grade C. The following Graph 5.17 provides percentage of educational institution accreditation of non health polytechnic. More details about the percentage by province are on Annex GRAPH 5.17 PERCENTAGE OF EDUCATIONAL INSTITUTION ACCREDITATION OF NON HEALTH POLYTECHNIC, 2008 Source: Education Center, National Board of Health Human Resorces Development and Empowerment, MOH RI

140 In terms of ownership, it indicated that most of non health polytechnic were managed by private sector (85.25%). Meanwhile, 11.24% was managed by local government and 3.51% was managed by Armed Forces/Police. Details about number of non health polytechnic educational institutions ownership are on Annex B. HEALTH PERSONNEL 1. Number of Health Personnel and Ratio of Health Personnel Health personnel have significant role to sustainable health development in Indonesia. Podes in 2008 indicates number of physicians in Indonesia were 44,759 with ratio per 100,000 population of was Range of physicians ratio was physicians per 100,000 population. Province with highest ratio was North Sulawesi at physicians per 100,000 population and the lowest one was Lampung at physicians per 100,000 population. The following Graph 5.18 illustrates ratio of physicians to population by province in GRAPH 5.18 RATIO OF PHYSICIAN TO 100,000 POPULATION IN INDONESIA, 2008 Source: Podes, BPS Statistics Indonesia, 2008 Number of dentists in 2008 were 7,649 with ratio at 3.35 dentists per 100,000 population. Range of ratio were dentists per 100,000 population. Province with the highest ratio was West Papua at dentists per 100,000 population, meanwhile, the lowest one was South Sumatera at 1.56 dentists per 100,000 population. Podes 2008 indicates that number of midwives were 98,074 with ratio at per 100,000 population. The indicators of Indonesia Sehat 2010 urges that ratio of midwife achieved up to 100 midwives per 100,000 population. There were 2 provinces 122

141 met target 100 midwives per 100,000 population, West Papua and NAD. Based on the same survey, number of other health personnel were 80,605 and traditional birth attendants were 155,470. Description about number of health personnel and the ratio to population based on Podes 2008 can be seen on Annex Distribution of Health Human Resource a. Health Human Resource on Health Center Availability of health human resource significantly influences health center performance on providing primary health care. There were 185,401 personnel worked on health center. They consisted of 157,030 health personnel and 28,371 non health personnel. Number of physicians increased from 2007 to 2008, they were 11,701 physicians in 2007 to 11,865 physicians in Ratio of physician to health center in 2008 was 1.39 physician per health center. Province with the highest ratio of physician to health center was Riau Islands at 3.05 physicians per health center, followed by DI Yogyakarta at 2.43 physicians per health center and Bali at 2.23 physicians per health center. Various ratio of physicians among 33 provinces in Indonesia described on Graph 5.19 as follows. GRAPH 5.19 RATIO OF PHYSICIAN ON HEALTH CENTER TO NUMBER OF HEALTH CENTERS IN INDONESIA, 2008 Source: Center for Data and Information, MOH RI, 2008 Number of dentists in 2008 was 5,278, compared to total health center in 2008, it may conclude not all health centers have dentist. Other health personnel giving contribution to health center are specialist and nurse. There were 109 specialists on health center, mostly distributed on DKI Jakarta with

142 specialists (58%). Number of nurses in 2008 was 55,194. Hence, there were 6 7 nurses on every health center. Number of health personnel on health centers is provided on the following Graph More details of the data can be seen on Annex 5.17 and ratio of health personnel to health center can be seen on Annex GRAPH 5.20 NUMBER OF HEALTH PERSONNEL ON HEALTH CENTER IN INDONESIA, 2008 Source: Center for Data and Information, MOH, 2008 Beside health personnel, there were also non health personnel giving contribution to primary health care of health center. Most of non health personnel were 9,617 administration staffs and 8,006 Pekarya. More details of the data describing by type of personnel and province are on Annex Non Permanent Health Personnel Health personnel with non permanent status in Indonesia consist of physician, dentist and midwife. There were 17,553 non permanent health personnel on very remote, remote and common area. Among those non permanent health personnel, there were 4,619 physicians, 1,502 dentists and 11,432 midwives. Non permanent health personnel mostly worked on common area, 9,109 personnel, remote area 6,123 personnel and very remote area 2,321 personnel. Province with highest number of non permanent health personnel was North Sumatera (459 personnel), followed by Central Java (371 personnel) and Nanggroe Aceh Darussalam (304 personnel). Meanwhile, non permanent dentist mostly worked on East Java with 133 personnel, East Nusa Tenggara with 121 personnel and Central Java with 107 personnel. Non permanent midwives mostly worked on North Sumatera (2,104), followed by Central Java (1,783) and East Java (1,483 personnel). 124

143 The following Graph 5.21 provides number of non permanent health personnel in Details about the data can be seen on Annex GRAPH 5.21 NUMBER OF NON PERMANENT HEALTH PERSONNEL, 2008 Source: Bureau of Personnel, MoH RI, 2008 C. HEALTH FINANCING One of significant factors on health development is health financing which is funded by government and community. The following describes Ministry of Health budgeting and public health insurance. 1. Ministry of Health Budgeting Ministry of health in 2008 allocated Rp18,475,260,479,000 with realization of Rp 15,885,074,513,113 (85.98%). Distribution of Ministry of Health budgeting by echelon I indicates that highest allocation in 2008 was DG of Medical Care at Rp 10,250,275,495,000 (55.48%), while the lowest one was Inspectorate General at Rp 103,743,900,000 (0.56%). The highest budgeting realization of Ministry of Health was on DG of Pharmaceutical and Medical Devices Services at 94.91%. Meanwhile the lowest one was Inspectorate General at 63.84%. In recent five years allocation and realization of budgeting increased. In 2004, the budgeting allocation were 6.16 billion rupiahs with realization of 5.2 billion rupiahs (84.42%), those increased to billion rupiahs with realization of billion rupiahs (85.98%). The following Graph 5.22 illustrates the increase of budgeting allocation and realization in and the details information are on Annex

144 GRAPH 5.22 MINISTRY OF HEALTH ALLOCATION AND REALIZATION IN Source: Bureau of Planning and Budgeting, MoH, RI 2. Public Health Insurance According to Center for Managed Care, there were 26.05% of population covered by health insurance. Percentage of population with health insurance (JPK MM), Kartu Sehat and JPK Gakin Kartu Miskin was 4.35%. Following Graph 5.23 provides data about percentage of population covered by health insurance in More information about the percentage by province in 2007 are on Annex 5.22 and Annex GRAPH 5.23 PERCENTAGE OF POPULATION COVERED BY HEALTH ASSURANCE IN 2007 Source : Center for Managed Care, MoH RI *** 126

145 ASEAN (Association of Southeast Asia Nations) is an organization geopolitics and economics from countries in Southeast Asia, which is aims to increase economic growth, social progress and cultural development of member countries, and promote peace on the regional level. Number of ASEAN member countries until now are 10 countries. Ten countries are Brunei Darussalam, Philippines, Indonesia, Cambodia, Lao People's Democratic Republic, Malaysia, Myanmar, Singapore, Thailand, and Vietnam. Meanwhile, based on the grouping of countries by the WHO, Indonesia, including in the countries of SEARO (South East Asia Region/SEARO) together with other 10 countries, namely Bangladesh, Bhutan, DPR Korea (Democratic People's Republic of Korea), India, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, and Timor Leste. Comparisons between Indonesia and other countries, both with ASEAN and SEARO countries, is important to see Indonesia position against other countries especially in the neighboring countries. This chapter studies comparison between Indonesia with ASEAN and SEARO countries in aspects of demographic, health degree, and health efforts. A. DEMOGRAPHIC Information about population is very important to be known so that development can be directed in accordance with the needs of population as actors of development. The large number of people can be seen as a burden but also capital in country development. Some of the indicators used to know the condition of the population, namely the number of population, population density, population growth rate, dependency ratio, and birth rate. 1. Population Number and Density According to the World Populations Data Sheet 2008, in mid 2008, Indonesia was a country with the largest population among other ASEAN member countries with a population of million. With the country which has largest area in ASEAN region, Indonesia also occupied as a country with the highest population in ASEAN. Meanwhile, Brunei Darussalam had total population of the lowest 0.4 million. 127

146 If in the ASEAN region, Indonesia was the country with the largest population, in the area of SEARO Indonesia was the second largest country after India (with number of population 1,149.3 million. Meanwhile, 9 other countries had less than 150 million people, there were even 2 countries with a population of 1 million or less, namely Bhutan (0.7 million), and Maldives (0.3 million). Number of population in ASEAN and SEARO country can be seen in graph 6.1. GRAPH 6.1 POPULATION NUMBER IN ASEAN & SEARO COUNTRIES 2008 Source: World Population Data Sheet, USAID, 2008 Meanwhile, when viewed based on population density, Singapore recorded as the most populous countries in the ASEAN region, namely 7,013 people per km square. This value was far above the other ASEAN member countries. The lowest population density in Laos PDR was 25 people per km square. While in the area of SEARO, even though Maldives has smallest population, with the area which is also relatively small, it was a country with the second highest population density in the area SEARO with the 1,040 people per km square. Bhutan had the lowest population density; that was 14 people per km square. Meanwhile, Indonesia had population density 126 people per km square. Compared to dilihat dari tahun , population density keep increased (118 inhabitants per km square in 2006 and 122 inhabitants per km square in 2007). Indonesia is in the fifth highest population density in the area of ASEAN. While Indonesia is in the eight highest population density (and the fourth lowest population density) among 11 countries. ASEAN and SEARO countries population density in 2008 can be seen in below graph

147 GRAPH 6.2 POPULATION DENSITY IN ASEAN & SEARO COUNTRIES (people per km square) 2008 Source: World Population Data Sheet, USAID, Population Growth Rate Indicator of population growth is very useful to predict the number of residents in a region or country in the future. By knowing the number of people in the future, we also known basic needs of the population in all areas of life. The indicator is known as population growth rate. The population growth rate is influenced by three factors, namely; birth, death and migration. GRAPH 6.3 POPULATION GROWTH RATE IN ASEAN & SEARO COUNTRIES, Source: World Population Data Sheet 2008, USAID During the period , as the highest population growth among the ASEAN member countries were Brunei Darussalam with the rate of population growth 2.5%. Meanwhile, Thailand was a country with a lowest population growth rate, 1%. 129

148 Based on the same source during the period the population growth in the SEARO countries ranged between 0.7% and 2.7% with the highest rate occurred in Timor Leste. Meanwhile, the lowest rate of population growth occurs in Sri Lanka and DPR Korea. Indonesia population growth rate is 1.4. Among the 18 countries in the ASEAN region, Indonesia is at the lowest 3th rank for population growth rate. While among 11 SEARO countries, Indonesia is at the 6th in population growth rate. 3. Population by Age Group One indicator that indicate a rough economic situation of a country whether classification as developed countries or developing countries is the dependency ratio. The higher the percentage of dependency ratio shows the higher the burden that must be responded by the productive population to pay the expences for the non productive population (age group 0 14 yearsand age group 65 years and above). Seeing from the percentage of the population of age group 0 14 years and age group 65 years in2008, Laos PDR was the highest countries that for those age group compared to other countries in the ASEAN region that is 48%. Singapore wasthe lowest countries for composition of the population age group 0 14 years and 65 years age group that is 28%. Among the countries in the region SEARO, Timor Leste was a country whose the highest population of non productive age, namely 48%. On the contrary, a country whose the lowest population of non productive age in the region was DPR Korea, which was 26%, which can be seen on the graph 6.4. GRAPH 6.4 POPULATION COMPOSITION IN ASEAN & SEARO COUNTRIES 2008 Source: World Population Data Sheet 2008, USAID Percentage of non productive population that is age group 0 14 years and 65 years age group has the influence to the dependency ratio. The dependency ratio is a value to measures how the load of social economic responsibility that must be responded by age group of productive population, namely the population aged group years. Based on the distribution of the population, as has been described above, Laos PDR was a country with the highest dependency ratio (92%) in the ASEAN region. Meanwhile, Singapore was a country with the lowest dependency ratio (39%). 130

149 In the area of SEARO, Timor Leste was a country with the highest dependency ratio, that is 92%, while DPR Korea was a country with the lowest dependency ratio, that is 35%. Meanwhile, Indonesia has the dependency ratio 54%, it means that every 100 people in the productive age had responded 54 people who has not been productive and was not considered to be more productive. The composition of the population according to age groups and the dependency ratio among countries in the ASEAN and SEARO region can be seen in Annex Human Development Index The HDI provides a composite measurement of three dimensions about development of long age and healthy life human (measured by life expectancy), educated (measured from the level of literacy and adult high school enrollment in primary school, secondary and higher) and have a standard of feasible living (measured by purchasing power parity, income). However, the index is not yet a comprehensive measurement about human development. Based on international standards, the human development index is categorized as very high when HDI>0.900; high when HDI> 0.799, medium when HDI , and low when HDI < According to these categories, in 2007, there were two ASEAN countries with very high category: Singapore and Brunei Darussalam; the remains were medium, included Indonesia. As the highest among ASEAN member countries, Singapore was on the 24 th position and Myanmar as the lowest was on the 138 th, while Indonesia was on the 111 th position of 182 countries. HDI of Indonesia in 2007 was 0.734, and it increased comparing to 2006 with Human Development Report (HDR) 2007/2008 states that HDI of Indonesia in 2006 was on the 109th position of total 179 countries. GRAPH 6.5 HUMAN DEVELOPMENT INDEX IN ASEAN & SEARO COUNTRIES, 2007 Source: Human Development Report

150 In 2007, of 11 countries in the SEARO (without DPR Korea), there was no country with high and very high categories. Nine (9) countries were in medium and one country was in low category, which was Timor Leste. HDI in ASEAN and SEARO during is presented in Annex Total Fertility Rate TFR is a decription about the average number of children born from a woman from age 15 to 49 years old. Comparison TFR value between countries can show success in implementing the country's socio economic development. The high number of TFR reflects the low level of marrying age average, the low level of education, especially female, the low level of socioeconomic and the high level of poverty. In addition, of course, shows the level of success of family planning programs implemented in the region. Knowledge of TFR description in a region will help development program officer to increase the average of marrying age, and improve services related to health services and maternal child care. Total Fertility Rate (TFR) can be classified into 3 levels, namely; low, medium, and high (ADB, Key Indicators 2002). Low fertility occurs when the number of women fertility 2.1 or less; medium fertility is between ; and high fertility if the number of women 4 or more. By using these classifications, in the year 2007 the countries included in the category of low fertility was Singapore (1.4) and Thailand (1.6). While Laos PDR was the only member country of ASEAN, which included in the high category of fertility, that was 4.3. Meanwhile, Indonesia was included in the medium category with fertility rate 2.6 that means for every woman in Indonesia had children averagely 2 until 3 during his life. In 2007, among 11 countries in SEARO, Thailand, Sri Lanka, and DPR Korea were included as countries with low category. Indonesia, Myanmar, Maldives, Bhutan, India, Bangladesh, and Nepal were included in the medium category. While, Timor Leste was the only country in SEARO which had high category, that was 6.7. Description of total fertility rate per country can be seen in Graph 6.6 as follows. 132

151 GRAPH 6.6 TOTAL FERTILITY RATE IN ASEAN & SEARO COUNTRIES, 2007 Source: World Population Data Sheet 2007, USAID The higher of the fertility rate represent the higher number of crude birth rate, on the contrary the lower fertility rate the lower crude birth. The high of crude birth rate also give contribution to the percentage of the population age group 0 14 years and eventually give impact on the dependency ratio. So that the country which have high fertility rate was likely to have high dependency ratio, this happened in Laos PDR and Timor Leste. Meanwhile, countries that have low fertility rate have possibility of low dependency ratio that occurred in Singapore and Thailand. In Annex 6.2, it can be seen that the high fertility rate affect the number of crude birth per 1,000 populations. 6. Crude Birth Rate Crude Birth Rate (CBR) is a number that indicates the number of births in a year per 1,000 populations in the mid year. The births level in the past affect the high level of fertility nowadays. Number of births in the past accompanied by a decrease in infant mortality will be evoke amount of babies are still living in a larger number compared with the previous years while infant mortality is still high. Crude birth rate in 2007 in the ASEAN countries with a range of 11 to 34 per 1,000 populations. The highest CBR, as in previous years, occurred in Laos PDR with CBR 26 births per 1,000 populations, followed by Cambodia that was 26 per 1,000 populations. Meanwhile, Singapore has the lowest crude birth rate was 11 births per 1,000 populations. Indonesia itself had CBR 21 births for every 1,000 births of the populations. In the year 2007, CBR values in SEARO countries were in range per 1,000 populations. CBR of Thailand was the lowest (13) and DPR Korea (16) while the highest CBR were Timor Leste (42) and Bhutan (30). 133

152 Meanwhile in Indonesia, there were 21 births per 1,000 populations in In ASEAN area, Indonesia is at the 4 th highest rank while in SEARO area it is at the 6 th highest for crude birth rate. GRAPH 6.7 CRUDE BIRTH RATE IN ASEAN & SEARO COUNTRIES 2007 Source: World Population Data Sheet 2008, USAID Graph 6.7 shows comparison of CBR in the ASEAN and SEARO region. 7. Sosio Economic National income is one indicator to measure a country's economic growth. Gross National Income per capita consists of the value of goods and services produced by a country, with income received from other countries. The highest gross national income per capita among the ASEAN countries (not including Myanmar) was Brunai Darrusalam (US$ 49,900 per capita), followed by Singapura (US$ 48,520 per capita). While other countries in ASEAN had gross national income per capita less than US$ 10,000. Laos PDR and Cambodia had lowest gross national income per capita, each US$ US$ 1,940 and US$ 1,690. Meanwhile, Indonesia had a gross national income per capita US$ Gross national income in ASEAN and SEARO in 2007 can be seen in the following graph

153 GRAPH 6.8 GROSS NATIONAL INCOME ASEAN & SEARO COUNTRIES, 2007 Source: World Population Data Sheet 2008, USAID From nine countries in SEARO (data not available in 2 countries), the highest gross national income per capita was in Thailand, that was US$ 7,800. Meanwhile, six other countries, namely Bhutan, Sri Lanka, Indonesia, India, Bangladesh, and Nepal had gross national income per capita less than US$ 6,000. Comparing with 9 countries in the SEARO, Indonesia was at the highest ranked 5 th of gross national income per capita. B. HEALTH STATUS 1. MORTALITY a. Infant Mortality Rate The infant mortality rate (IMR) is classified into four groups, namely low if IMR less than 20; medium if IMR 20 49; high if IMR and very high if IMR more than 100. GRAPH 6.9 INFANT MORTALITY RATE IN ASEAN & SEARO COUNTRIES 2007 Source: World Population Data Sheet 2007, USAID 135

154 Based on Graph 6.9, according to these classifications, 5 ASEAN countries, namely Singapore, Brunei Darussalam, Malaysia, Vietnam, and Thailand were countries with low infant mortality. While 2 ASEAN countries, namely Philippines, and Indonesia were in the medium IMR classification. Then other 3 countries were included in high infant mortality. No country in the group was included in very high infant mortality (> 100 per 1000 live births). Based on the same classification, 2 SEARO countries, namely Sri Lanka and Maldives were included in low infant mortality, 5 countries were in the medium category, and the rest which was 4 SEARO countries were included in high categories. Infant mortality rate in ASEAN and SEARO countries ranged from Indonesia had the infant mortality rate 34 per 1,000 live births and was ranked 10 th of 18 countries. b. Under five (Under Age 5) Mortality Rate (UMR) The decrease of death cases in children is one aspect that is considered important in the Millennium Development Goals. In the high case of death, the high number of death is often occurred at the age of five, at that age is vulnerable to the disease. Statistics show that more than 70% of deaths caused by diarrhea, pneumonia, measles, malaria and malnutrition. GRAPH 6.10 UNDERFIVE MORTALITY RATE IN ASEAN & SEARO COUNTRIES 2007 Source: World Health Statistics 2009 Data obtained from "The World Health Statistics 2009" shows the significant differences of under five mortality rate among ASEAN countries in The lowest underfive mortality rate was achieved by Singapore, which was 3 deaths per 1,000 live births, while the highest mortality was Myanmar, namely 113 deaths per 1,000 live births. Most ASEAN countries had under five mortality less than 50 per 1,000 live births, only in Myanmar, Cambodia and Laos PDR that had more than 50 per 1,000 live births. According to the same data source, the under five mortality rate in SEARO ranged from 7 to 113 per 1,000 life birth. Myanmar was a country with the highest mortality rate, while the lowest was Thailand. In ASEAN there were 3 countries (of 10 countries) with 136

155 UMR more than 50 per 1,000 live births. On the other hand, in SEARO, there were only 3 countries (of 11 countries) had UMR less than 50. According to Graph 6.10, it shows that ASEAN had UMR relatively low when compared with SEARO countries. It has been presented previously that most of under five deaths caused by diarrhea, pneumonia, and malnutrition. This means that countries in the ASEAN may have sanitation and economic situation better than countries in the SEARO. Meanwhile, in ASEAN region, Indonesia was in the highest rank 4 th of UMR and in SEARO region Indonesia was in the lowest rank 4 th of UMR, with the UMR 31 deaths per 1,000 live births. c. Maternal Mortality Rate (MMR) Based on the maternal mortality rate classification from the WHO, it is classified as follows; <15 per 100,000 live births; per 100,000; per 100,000; per 100,000; and 1,000 per 100,000. GRAPH 6.11 MATERNAL MORTALITY RATE IN ASEAN & SEARO 2005 Source: World Health Statistics 2008 In 2005, only 2 ASEAN countries reached MMR <15, namely Brunei Darussalam and Singapore, each 13 and 14 per 100,000 live births. Countries with MMR > 500 in ASEAN also reached 2 countries, namely Laos PDR (660 per 100,000 live births) and Cambodia (540 per 100,000 live birth). In the same year, countries in the SEARO did not reach MMR <15, about 55%, had MMR per 100,000 live births. And 18% of SEARO countries had MMR > 500, which was Nepal (830) and Bangladesh (570). Among the two regions, Indonesia was in rank 12 th of the lowest MMR (from 18 countries in ASEAN and SEARO) with MMR 420 per 100,000 live births 137

156 d. Crude Death Rate Crude Death Rate (CDR) is a value that shows the number of deaths that occur in a particular year for every 1,000 populations. The value is called crude because it does not yet count the age of the population. Elderly population has a higher risk of death compared with younger population. If there are no other indicators of the death, this value is useful to provide a description about the situation on the welfare population in that year. GRAPH 6.12 CRUDE DEATH RATE IN ASEAN & SEARO COUNTRIES 2007 Source: World Population Data Sheet 2008, USAID Among the members of ASEAN countries, in 2007, Laos PDR and Myanmar were a country with the highest Crude Death Rate (CDR); it was 10 per 1,000 populations The number of CDR conditions in the countries of the SEARO region, not much different with the countries in the ASEAN region. Timor Leste was a country with the highest CDR (11 deaths per 1,000 populations) and the lowest was Maldives (4 deaths per 1,000 populations). Meanwhile, in Indonesia occurred 6 deaths per 1,000 populations. In ASEAN region, Indonesia was at the highest fifth rank of Crude Death Rate while in SEARO region, Indonesia was the lowest second rank. e. Life Expectancy The success of the health program and social economic development programs in general can be seen from the increase in life expectancy of the population of a country. Increasing health care through primary health care, and increasing people's purchasing power will increase access to health services, able to meet the needs of nutrition and calories, able to have a better education, so that get a job with sufficient income, which in turn will improve health and extend the life expectancy. Graph 6.13 shows that in 2007 among ten members of ASEAN countries, Singapore was a country with the highest life expectancy (Expectation of Life at Birth), that was 81 years old. Countries that had lowest life expectancy namely Laos PDR, that was 61 years old. 138

157 GRAPH 6.13 LIFE EXPECTANCY IN ASEAN & SEARO COUNTRIES 2007 Source: World Population Data Sheet 2008, USAID For SEARO region, Maldives had the highest Expectation of Life at Birth that is 73 years old. While Timor Leste has the lowest Expectation of Life at Birth that is 60 years old. In ASEAN region, Indonesia was at the higehst sixth rank which had life expectancy 70 years old, while in SEARO region, it was at the fifth rank. Data of Life Expectancy in ASEAN and SEARO can be seen in Annex MORBIDITY a. Prevalence of Tuberculosis (TBC) Data was taken from World Health Statistics 2009 showed the differences of tuberculosis prevalence per 100,000 population and deaths associated with tuberculosis per 100,000 population in ASEAN and SEARO countries. The prevalence of tuberculosis in 2007 in ASEAN countries ranged from 27 to 664 per 100,000 populations. Cambodia was a country with the highest prevalence of Tuberculosis in the ASEAN, namely 664 per 100,000 populations. Meanwhile, Singapore and Brunei Darussalam had prevalence of tuberculosis below 100 cases per 100,000 populations, each were 27 and 65 cases per 100,000 populations. Based on the same source, the death caused by tuberculosis in 2007 occurred in Cambodia, which was 77 deaths per 100,000 populations. Meanwhile, the lowest cases of death caused by tuberculosis occurred in Singapore and Brunei, each were 3 and 7 deaths per 100,000 populations. 139

158 GRAPH 6.14 PREVALENCE AND DEATH CAUSED BY TUBERCULOSIS IN ASEAN & SEARO COUNTRY, 2007 Source: World Health Statistics 2009 Like other countries in ASEAN, prevalence of tuberculosis in 2007 in SEARO countries had significant gaps, ranged 48 to 750 per 100,000 populations. Country with the highest prevalence of tuberculosis in 2007 was Timor Leste (750 per 100,000 populations) and the lowest was Maldives (48 per 100,000 populations). Meanwhile, deaths caused by tuberculosis in SEARO countries ranged 4 to 47 per 100,000 populations. As tuberculosis prevalence, the highest death rate caused by tuberculosis also occurred in Timor Leste was 47 deaths per 100,000 populations. Similarly, the lowest death case of tuberculosis occurred in Maldives (4 per 100,000 populations). Among 18 countries in ASEAN and SEARO, Indonesia with prevalence of 326 per 100,000 population was at the 6 th highest rank as can be seen on annex 6.4. b. Avian Influenza Appearance of new influenza virus strain in humans (H5N1 strain) was detected first time in Hong Kong. As a result, 18 people must be treated in the hospital, and 6 of them died. The fact was found in the first time that the Avian influenza virus can spread directly from poultry to humans. Before 1997, scientists believe influenza virus transmission from poultry to humans does not occur directly. Avian influenza in first time went into the ASEAN region in 2003 through Vietnam, 3 people was stated suffering from the disease, and they all died. Until the end of the year 2008, 6 countries of ASEAN region in had been infected with avian influenza, namely Vietnam, Thailand, Indonesia, Laos PDR, Myanmar and Cambodia. 140

159 GRAPH 6.15 NUMBER OF CASES AN AVIAN ID DEATHS CAUSED BY AVIAN INFLUENZA IN ASEAN & SEARO COUNTRIES, Source: WHO, 2008 Graph 6.15 shows the number of cases and deaths due to avian influenza in the region of ASEAN since 2003 until First case occurred in Vietnam attacked 3 victims that all of them was dead finally. In 2004, the number of cases increased to 46 with 32 deaths. In addition, in the same year, Vietnam, Thailand, was infected with the H5N1 virus. At the end of 2005, the number of people and countries that infected avian influenza continues to increase, 90 people became victims. However, this time the number of deaths can be pressed, if in the previous time was almost 100% ended in death, in % from 90 people died. Then, the number of cases of avian influenza continued to decline, but not with its CFR. In 2008, there were 31 cases of avian influenza from 3 countries in ASEAN with 80.65%. TABEL 6.1 NUMBER OF CASES AND DEATHS CAUSED BY AVIAN INFLUENZA BY COUNTRY, Country Total C D C D C D C D C D C D C D Cambodia Laos Viet nam Indonesia Myanmar Thailand ASEAN SEARO Source: WHO, 2008 Notes: C = Cases D = Deaths Table 6.1 shows that Laos PDR and Myanmar were able to control the spread of avian influenza so the occurrence was decline in the number of cases of avian influenza, even in the year 2008 found no cases. The disease of bird flu began to attack people in SEARO region in 2004, first time in Thailand. Countries in the SEARO were infected by bird flu since 2004, these countries also joined in ASEAN. These countries were Thailand and Indonesia. In the year 2007, at the first time since the last four years, 1 person of Myanmar population was infected by the virus, 141

160 although the virus did not cause death, then in 2008 there were no more avian influenza cases found. c. Polio Some diseases can spread quickly, so they can be potential for outbreaks. However, among those diseases, some diseases can be prevented by immunization. The diseases are usually called the disease that can be prevented by immunization (in Indonesia it is called PD3I). The diseases are diphtheria, pertussis, tetanus, tetanus neonatorum, measles and poliomyelitis. TABLE 6.2 CASES NUMBER OF POLIO PER COUNTRY COUNTRY Cambodia Lao PDR Indonesia Myanmar Bangladesh India Nepal ASEAN SEARO Source: Incidence Series Immunization, WHO, 2007 Since 2001, no case was found in the countries in ASEAN. However, in 2004, wild polio virus had returned to attack the population in ASEAN region. In report, one case was founded in Laos PDR. In 2005 the number of polio cases reached its peak, 350 people from 2 countries in ASEAN was infected by polio virus, namely Cambodia and Indonesia, 349 of them occurred in Indonesia. In 2006, polio transmission of the disease started to be handled, that were only 4 people in this area, 2 people came from Indonesia and each 1 person from Cambodia and Myanmar. In 2007, among the countries of ASEAN, only in Myanmar, was still found cases of polio even that increased in number compared to the case founding in the previous year (only 1 case). Indonesia in 2005, the polio outbreak occurred with finding of 349 polio cases, but then it was able to control the disease so that in 2007, it was found no more cases of polio. 142

161 GRAPH 6.16 CASES NUMBER OF POLIO IN ASEAN & SEARO COUNTRIES Source: WHO, 2007 If we compared between countries in ASEAN region, the total number of incidences of polio in SEARO region was higher enough since 2002 and previous years. Since 2004 until 2006 the number of case was slowly increasing again. The high incidence of this was caused by contribution of India in the large number of cases. India was one of the 4 polio endemic countries. In 2007, number of polio incidence in SEARO region were 893 cases, 98% of them occurred in India. d. Tetanus Neonatorum Many tetanus cases are found in tropical countries and the countries that still have low health condition. Data from World Health Organization (WHO) shows the death caused by tetanus in developing countries is 135 times higher than developed countries. Tetanus is an infected disease and has risk of death. Tetanus in infants, known by the term tetanus neonatorum, generally happens in new born baby or under the age of one month baby. The cause of disease is Clostridium tetani spores that enter through the umbilical cord injuries, because the action or treatment that does not meet hygiene requirements. In 2007, the highest number of cases of tetanus neonatorum among 8 ASEAN countries occurred in Philippines and Indonesia. Numbers of patients from both countries were more than 100 people. However, if compared with the total population, the highest number of cases of tetanus neonatorum occurred in Cambodia, Indonesia precisely in order was in 5 th position. Meanwhile, Singapore and Thailand were the countries with the lowest cases, both from the number of cases and compared with the total population. In Singapore there were no reported cases of tetanus neonatorum. Based on Incidence Series Immunization, in the year 2007, number of cases of tetanus neonatorum which occurred in India were higher than cases number in other countries in ASEAN region, namely 937 cases when compared with the number of cases from the second and third largest in this area, namely Bangladesh and Indonesia respectively 206 and

162 cases. While in Bhutan, DPR Korea, Maldives, and Sri Lanka there are no reported cases of tetanus neonatorum. However, if compared with the total population, the highest number of cases occurred in Timor Leste and Bangladesh. India occupied ranks 5 th of highest number of tetanus neonatorum cases. The number of cases that can be prevented by immunization in the ASEAN countries and SEARO in 2006 can be found in detail in Annex 6.6. C. HEALTH EFFORT 1. Immunization Coverage Immunization is one effort made to prevent the death of infant with vaccine giving. Some of the immunization must be given to infant is polio, BCG and measles. BCG is often used as a reflection of children who are protected from a severe form of tuberculosis for their first year living, and also can be used as one indicator to health services access. Besides BCG, the other vaccine must be given to the baby is polio. Polio immunization is to prevent disease of polio. Unlike the BCG or measles immunization, which requires 1 dose, polio immunization requires 3 doses. So that to measure the success of effort is used polio 3 when the baby has to get polio immunization as much as 3 doses (3 times). Among the diseases in children that can be prevented with vaccines, measles is a major cause of children mortality. Therefore, prevention of measles is an important factor in reducing the under five mortality (UMR). From 22 goals agreed in the world meeting about children, one goal is to maintain measles immunization coverage of 90%. In all the countries of ASEAN and SEARO, measles immunization is given to the average age of 9 12 months and it is the last immunization given to infants between the other compulsory immunization (BCG, DPT, Polio, Hepatitis). Thus, it is assumed that infants receive measles immunization have complete immunization. It means the amount of coverage of measles immunization coverage also describes the coverage of infants who have received complete immunization. If compared with other immunization, Graph 6.17 shows that BCG immunization coverage in infants is higher than others. This occurs because the schedule of immunization of BCG, which is relatively given early compared with other immunization even in some other countries BCG immunization is given after the baby was born so that the baby is still in the control of health personnel. In 2006, Thailand and Malaysia achieved the highest BCG immunization coverage among countries in ASEAN region, each was 99% and Laos had the lowest BCG immunization coverage that was 56%. In SEARO region, 7 of 11 countries of BCG immunization coverage reached 90%. These countries were Thailand, Bangladesh, Bhutan, Korea DPR, Maldives, Nepal, and Sri Lanka. Meanwhile, Timor Leste was a country with the lowest immunization coverage of BCG that was 74%. 144

163 GRAPH 6.17 IMMUNIZATION COVERAGE IN ASEAN & SEARO COUNTRIES, 2007 Source: WHO vaccine preventable diseases: monitoring system 2007 In 2007, 50% of ASEAN countries had reached polio immunization coverage that was 90%. The highest coverage was achieved by Brunei Darussalam, namely 99% and the lowest was Lao PDR, it was 46%. According to the same source, 55% countries in SEARO region had reached 90% of 3 rd polio immunization coverage. The highest 3 rd polio immunization coverage was in Korea DPR with their respective 99% and the lowest was India that was 62%. In the same year, 50% of ASEAN countries had also reached the target for measles immunization that was 90%. These countries were Brunei Darussalam, Philippines, Malaysia, Singapore, Vietnam, and Thailand. Brunei Darussalam was a country with the highest measles immunization coverage that was 97%. While the lowest coverage was Lao PDR, it was 40%. In ASEAN region, 5 from 11 countries have reached measles immunization coverage, 90 %. Those countries were Thailand, Bhutan, DPR Korea, Maldives, and Sri Lanka. While Timor Leste was a country with lowest measles immunization coverage, 63%. Almost all the countries in ASEAN and SEARO region, hepatitis immunization is given as the basic immunization of infants, but that does not happen with India. In India hepatitis immunization is not basic immunization, then in Annex 7 can be seen only India with the percentage of infants who were given 3 rd hepatitis immunization 6%, while other countries had reached the immunization above 50%, even some of them had exceeded 90%. Meanwhile in Indonesia, as much as 91% of infants had received 3 rd immunization BCG, 83% got 3 rd polio immunization, and 80% got the measles immunization. The coverage of five basic immunizations in ASEAN and SEARO can be found more detail in Annex Pulmonary TB Control WHO has set a target for the findings of Pulmonary TB cases through DOTS strategy 70% and success rate 85%. While the global achievement in the world in case findings of Pulmonary TB 60% and success rate had reached 84%. This means that the achievement of 145

164 both indicators still did not yet reached the target; although for success rate it was almost reached the target. In 2007, 80% of ASEAN countries had reached the target of finding cases that had set by WHO; 70%. Even some countries had reached 100%, namely Myanmar. Only Cambodia and Indonesia had not reached the case detection target of Pulmonary TB patients (61%) and (68%). From 11 countries in SEARO region only 36% of the countries that had reached the finding case target of Pulmonary Tuberculosis patients. These countries were Maldives, Myanmar, Sri Lanka, and Thailand. The lowest number finding of tuberculosis patients was in Bhutan. While the highest case finding of Tuberculosis were in Myanmar, which has reached 100%. RAPH 6.18 FINDING CASES OF TB IN ASEAN & SEARO TCOUNTRIES, 2006 GRAPH 6.19 SUCCESS RATE OF TB LUNG IN ASEAN & SEARO COUNTRIES, 2005 Source: World Health Statistic 2008 Source: World Health Statistic 2008 According to the same source, in 2006 there were 50% in ASEAN countries with success rate reached the target (85%). Indonesia was including one of the countries that reached the target for success rate, which was 91%. Brunei, Malaysia, Singapore, Malaysia and Thailand were the countries that had not yet reached the target of success rate. With the highest number was achieved by Cambodia with 93% and the lowest was Malaysia with 48%. In Graph 6.19 it was seen that 63% SEARO countries in the region had reached success rate target. The highest of success rate were in Bangladesh with the respective 92% and the lowest was Thailand with 77% of success rate. In Graph 6.18 and 6.19, it shown that Indonesia had reached the target set of indicators of case detection rate (number of cases finding) and the success rate (number of healings/treatments recovery). Even for success rate, Indonesia was on the second highest number of success in SEARO region. 146

165 3. Clean Water Source and Sanitation In 2006, among the 10 countries of ASEAN (Brunei Darussalam has no data), 7 countries had 80% or more population using clean water resources. Only Cambodia and Lao PDR with the percentage of the population had access to clean water less than 80%. Singapore achieved the highest percentage that was 100% and the lowest with 60% was Lao PDR. In the same year, among the countries in the SEARO region, almost all countries had population which used source of clean water, 80% or more. Only Timor Leste with the percentage of the population using clean water resources was 62%. Country with the highest percentage was DPR Korea that was 100%. GRAPH PERCENTAGE OF POPULATION USING CLEAN WATER SOURCE AND SANITATION ON FACILITIES IN ASEAN & COUNTRIES, 2006 Source: World Health Statistics 2009 Based on above graph, it shows the population who using healthy sanitation facilities had large differentiates in percentage among ASEAN countries. The country with coverage by 27% was Nepal and the country with coverage of 100% was Singapore. Comparing to the percentage of the population using clean water sources, the percentage of population that use healthy sanitation facilities was relatively low. There were still 11 countries with population using healthy sanitation facilities less than 80%. Percentage of population using clean water and healthy sanitation facilities in ASEAN and SEARO 2006 can be seen in Annex Maternal Health Care Of 10 ASEAN member countries (data of Brunei Darussalam, Lao PDR, Malaysia and Singapore are not available), Indonesia was the country with the highest percentage of antenatal care (4th visit) with 81%, while Cambodia was reported as the lowest with 27%. In SEARO, the highest coverage was DPR Korea with 95%, followed by Maldives with 91%. The lowest coverage was achieved by Bangladesh with 21%. 147