Inequality in Reproductive, Maternal and Child Health in Indonesia

Transcription

1

2

3 SEA-NUR-467 Distribution: General Inequality in Reproductive, Maternal and Child Health in Indonesia Measuring and Monitoring Health Inequalities: A Post-Workshop Report

4 World Health Organization 2016 All rights reserved. Requests for publications, or for permission to reproduce or translate WHO publications whether for sale or for noncommercial distribution can be obtained from SEARO Library, World Health Organization, Regional Office for South-East Asia, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi , India (fax: ; The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. This publication does not necessarily represent the decisions or policies of the World Health Organization. Printed in India

5 Contents Acknowledgements... v 1. Introduction... 1 Page 1.1 Equity in health: the Indonesian context Indonesia s commitment to the Global Strategy for Women s and Children s Health Methodology Trends and latest status in maternal and child health indicators National coverage of health services, Inequality in health service by wealth, Inequality in health services by education, Inequality in health services by area, Inequality in health services by region, Inequality in health services by sex, Benchmarking of Indonesia against other countries National coverage Absolute and relative inequality Situation analysis Priority health service indicators Priority equity stratifiers in health services Data tables References iii

6 Annexes 1. Definitions of indicators and coding key List of participant Agenda iv

7 Acknowledgements The report was written by a subgroup of the workshop participants and was cleared for dissemination by the Government of Indonesia. Inputs from other workshop participants, namely, Ms Istiqomah Andjari Karnomo (Center for Data and Information, Ministry of Health, Indonesia), Mrs Mariet Tetty Nuryetty (Bureau of Central Statistics, Indonesia), Dr Ohn Mar Kyi (Department of Health Planning, Government of the Republic of the Union of Myanmar) and Mr Miguel Maria (Planning and Monitoring Department, Ministry of Health, Timor-Leste) are gratefully acknowledged. Technical facilitation and contributions to the draft were made by Dr Malee Sunpuwan (Faculty, Institute for Population and Social Research, Mahidol University, Thailand). Inputs from other workshop participants in the discussions and deliberations at the workshop are also gratefully acknowledged. The discussions and final report gained from technical support and guidance by Dr Ahmad Reza Hosseinpoor (WHO/HQ Technical Officer). Dr Devaki Nambiar (Research Scientist, PHFI, India) also carried out detailed review and technical editing of all reports derived from this workshop, with the assistance of Ms Anne Shlotheuber (WHO/HQ). The workshop was organized and coordinated with the efforts and key inputs of Dr Prakin Suchaxaya (Coordinator, Gender Equity and Human Rights, WHO-SEARO), Dr Suvajee Good (Health Education Specialist, WHO-SEARO) and Ms Benedicte Briot (Technical Officer, Gender, Equity and Human Rights, WHO-SEARO). Dr Ahmad Reza Hosseinpoor designed and facilitated the workshop. Ms Anne Schlotheuber contributed to the preparation of the workshop materials. Dr Oscar Jesus Alberto Mujica (Advisor, Social Epidemiology, AMRO/SDE), Dr Nandita Bhan (Research Scientist, PHFI, India), Dr Pojjana Hunchangsith (Faculty, Institute for Population and Social Research, Mahidol University, Thailand), Dr Manasigan Kanchanachitra (Faculty, Institute for Population and Social Research, Mahidol University, Thailand), Dr Indranil Mukhopadhyay (Senior Research Associate, PHFI, India), Dr Devaki Nambiar (Research Scientist, PHFI, India) and Dr Malee Sunpuwan (Faculty, Institute for Population and Social Research, Mahidol University, Thailand) contributed to the facilitation of the workshop. We also extend our gratitude to Ms Anita Saxena (Senior Administrative Secretary, Gender, Equity and Human Rights, WHO-SEARO) for her administrative support and Ms Nirmin Juber (Intern, WHO-SEARO) for her participation. v

8

9 1. Introduction 1.1 Equity in health: the Indonesian context Since Health Law Number 23 was enacted in 1992, Indonesia provided the legal basis for health sector activities. Its goal was to stipulate health programmes and development in order to increase awareness, willingness and ability of all citizens to live a healthy life. In 1998, the Indonesian Government introduced a new health paradigm that focused more on health promotion and prevention rather than on curative and rehabilitative services. Such a new paradigm brought about the motto Healthy Indonesia The Healthy Indonesia 2010 goal, set by the government, and the increasing importance paid to the United Nations Millennium Development Goals (MDGs) and their health-related targets are milestones in the process of national health development. These health policies and programmes have had a great impact on the national health system, which resulted in significant changes to the health sector in Indonesia. However, region-based inequality in the health system still existed due to large variations in geographical accessibility. People in remote interior locations or small islands have had particularly poor access to health services. As in many countries, health services are disproportionately concentrated in urban areas and particularly in the larger cities. Wealth-based inequality was another issue that showed inequality to access health-care services: people who could pay the fees could get access to health-care services whereas the poor could not. Another concern was the age of mothers evidence has shown that maternal, under-five, infant and neonatal mortalities were higher among mothers under the age of 20 compared with mothers above that age. These evidences indicated the importance of reproductive as well as adolescent health. However, reproductive, maternal and child health in Indonesia still have much room for improvement. 1

10 Measuring and Monitoring Health Inequalities: A Post-Workshop Report 1.2 Indonesia s commitment to the Global Strategy for Women s and Children s Health Since Healthy Indonesia 2010, which paid considerable attention to the MDGS, Indonesia has set a number of targets for 2015 related to MDG 4 (measles immunization coverage, reduction of under-five and infant mortality) and MDG 5 (skilled attendance at birth and reduction in maternal mortality). Given the lackluster progress in achieving these MDGs, the United Nations Secretary-General launched the Global Strategy for Women s and Children s Health in Its goal was to save 16 million lives in the world s poorest 49 countries and pledged US$ 40 million in funding towards achieving MDGs 4 and 5. Subsequently, the World Health Organization (WHO) created the Commission on Information and Accountability for Women s and Children s Health ( Accountability Commission ) to develop a global strategy for monitoring progress towards child and maternal health goals in a way that would facilitate progress. In 2011, the Accountability Commission provided 10 recommendations in the final report on Keeping Promises, Measuring Results. The use of 11 specific indicators on reproductive, child and maternal health for monitoring progress towards the goals of the Global Strategy was among those recommendations. The report also emphasized the need to pay considerable attention to inequalities when monitoring these indicators. 2. Methodology This assessment of inequalities in reproductive, maternal and child health in Indonesia began with the selection of eight health service indicators related to maternal and child health. These indicators were, namely, coverage of antenatal care (at least one visit by a skilled provider), antenatal care (at least four visits), births attended by skilled health personnel, family planning needs satisfied, DTP3 vaccination, care-seeking for pneumonia, oral rehydration therapy, and early breastfeeding. The criteria for the selection of these eight indicators were based on recommendations of the Accountability Commission. The full definitions of the above-mentioned indicators are illustrated in Annex 1. 2

11 Inequality in Reproductive, Maternal and Child Health in Indonesia The selected health indicators were assessed by five stratifiers of inequality: wealth, education, area, region and sex. These stratifiers were taken into consideration because they have been widely used in previous studies. It is worth noting that an asset-based index, derived from information on specific household asset ownership collected by Demographic and Health Surveys (DHS), was used to stratify individuals into wealth quintiles. Asset-based indices were constructed by using the principal component analyses (PCA). Although PCA has certain limitations, it has a high correlation with other indicators of socioeconomic status, such as income and expenditure, which have been found from previous studies (Howe, Hargreaves and Huttly, 2008; Howe et al., 2012; Vyas and Kumaranayake, 2006). The estimates employed data that were extracted from the "Health Equity Monitor database" of the WHO Global Health Observatory (GHO) 1 to assess inequalities in health in Indonesia. These estimates are obtained from the analysis of the publicly available Indonesia Demographic and Health Survey (DHS) micro-data. The five rounds of DHS have been conducted in 1994, 1997, 2002, 2007 and These data series allowed us to assess the progress of these indicators across five different time points, during a period of 18 years. HD*Calc (Health Disparity Calculation) was used to calculate summary measures of inequality for each indicator. It is a publicly available software program that is specifically designed for the purpose of performing such calculations (see for more information). Microsoft Excel was used to visualize data in graphs. Rechecking of calculations of simple summary measures was also done using Excel. 1 Data are derived from re-analysis of Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) micro-data, which are publicly available. The definitions of each indicator are the standard definitions published in DHS and UNICEF documentation. The analysis was done by the International Center for Equity in Health based in the Federal University of Pelotas, Brazil. There may be slight differences between these results and those reported in DHS or MICS country reports in a few cases due to differences in calculation of indicators' numerators and/or denominators. Disaggregated data were extracted from the WHO Health Equity Monitor database in December 2013, and subsequent updates are likely to have occurred ( 3

12 Measuring and Monitoring Health Inequalities: A Post-Workshop Report Each indicator was assessed in terms of: i. the latest status (from DHS 2012); ii. iii. time trends (going as far back as DHS 1994); and benchmark against other countries in the Asia-Pacific Region. The benchmark in the assessment was done by selecting 14 neighbouring countries to be compared. Our assessment was restricted to only the low- and middle-income countries in the Asia-Pacific Region (26 countries). Only 14 countries among the assessed countries, other than Indonesia, had recent publicly available international household health data on the selected indicators DHS or Multiple Indicator Cluster Survey (MICS) from 2005 to These neighbouring countries were, namely, Bangladesh, Cambodia, India, Indonesia, Lao People's Democratic Republic, Maldives, Mongolia, Nepal, Thailand, Timor-Leste and Vanuatu. If recent data for a specific country were not available, that country would be dropped from the assessment. In general, the context of these countries and the Asia-Pacific Region is relatively diverse. Nevertheless, by comparing Indonesia with these neighbouring countries in the Region, we hoped to understand the broader context for the interpretation of information on health inequalities. Certain reproductive, maternal and child health indicators in countries of the Asia-Pacific Region have similar underlying causes of inequality that are in fact region-specific (AP-Health GAEN, 2011). Comparing with other countries in the Region through a benchmarking also helped workshop participants to develop a better understanding of the context as well as to assess priority areas where action is necessary to reduce health inequalities in Indonesia. During a three-day workshop on inequality monitoring from 8 to 11 April 2014 in Jaipur, India, group exercises were conducted in order to do all assessments (a list of participants is provided in Annex 2). Demonstrating values of indicators by each equity stratifier and summary measures of inequality through graphs and tables was done. Subsequently, participants discussed and identified the best and worst health indicators. The situation analysis was conducted in groups and focused on latest status, time trend and benchmarking (Table 1, 2 and 3). Participants examined the national coverage, absolute inequality and relative inequality 4

13 Inequality in Reproductive, Maternal and Child Health in Indonesia for each indicator, followed by scoring each indicator on a scale of 1 to 3, where the rating was based on the need for action. The scores were as follows: "1" (green) indicated that no action was required; "2" (yellow) indicated that action was required; and "3" (red) indicated that urgent action was required. It is noteworthy that there was some degree of subjectivity on the part of workshop participants in assigning these scores. For instance, there were many indicators that improved over time but were not scored as "1". This was due to participants' consensus that further action was nonetheless required. The situation analysis that was developed during the workshop was finalized by a small subset of workshop participants with assistance from WHO. The final presentation of the situation analysis and priorities in maternal and child health was given by representatives of participants. This report is intended as a preliminary document assessing maternal and child health inequalities in Indonesia. Certain terminology related to health inequality monitoring may not be familiar to all audiences. The WHO handbook on health inequality monitoring, which describes the terminology and additional considerations for health inequality monitoring, may be reviewed for more information. 3. Trends and latest status in maternal and child health indicators 3.1 National coverage of health services, During a period of 18 years from DHS 1994 to DHS 2012, Indonesia achieved increases in national coverage for all eight selected maternal and child health service indicators assessed (Table 4). These indicators were as follows: family planning needs satisfied; antenatal care (one visit); 5

14 Measuring and Monitoring Health Inequalities: A Post-Workshop Report antenatal care (four visits or more); births attended by skilled health personnel; early initiation of breastfeeding; DTP3 vaccination; care-seeking for pneumonia; and oral rehydration therapy. Early initiation of breastfeeding coverage was the largest increase, which increased from 7.9% coverage in DHS 1994 to 52.2% coverage in DHS 2012 (an increase of 44.3 percentage points in coverage of DHS data over 18 years). The second largest increase in coverage was births attended by skilled health personnel, which increased to 43.3 percentage points from DHS 1994 to DHS The remaining indicators also increased in their coverage at moderate levels during this time period: two of them increased more than 20 percentage points; others increased less than 15 percentage points over the 18 years. Latest status: In DHS 2012, it was found that four of the eight maternal and child health service indicators had coverage greater than 80%. These were, namely, family planning needs satisfied, antenatal care (both one visit and four or more visits) and births attended by skilled health personnel. The highest coverage among the selected health service indicators was one antenatal care visit, at 95.7%. Three of the eight indicators had high coverage between 80% and 90%. These indicators consisted of four or more visits of antenatal care, family planning needs satisfied and births attended by skilled health personnel. All other indicators (early initiation of breastfeeding, DTP3 vaccination, care-seeking for pneumonia and oral rehydration therapy) had moderate levels of coverage between 50% and 75%. Early initiation of breastfeeding had the lowest coverage rate of all indicators, at 52.2% of the population. 3.2 Inequality in health service by wealth, From DHS 1997 to DHS 2012, Indonesia achieved decreases in wealthbased inequality in six of the eight maternal and child health service 6

15 Inequality in Reproductive, Maternal and Child Health in Indonesia indicators assessed (Table 5). These indicators included the family planning needs satisfied, antenatal care (both one visit and four or more visits), births attended by skilled health personnel, care-seeking for pneumonia and oral rehydration therapy. Among six indicators with decreasing wealth-based inequality, births attended by skilled health personnel had the largest decrease in both absolute and relative inequality during the past 18 years in DHS: in terms of the absolute gap, it was found that the gap between the wealthiest and poorest quintiles decreased from 67.9 percentage points in DHS 1997 to 39.1 percentage points in DHS 2012, while the relative ratio was also decreased from 4.2 to 1.7 during the same time period (Figure 1). The second largest decrease in wealth-based inequality was four or more antenatal care visits. It was shown that the absolute difference between wealthiest and poorest quintiles decreased from 45.3 to 27.5 percentage points over 18 years, and the relative ratio of the quintiles decreased from 2.0 to 1.4 percentage points. Figure 1: Wealth-based inequality in births attended by skilled health personnel Source: Disaggregated data were extracted from the WHO Health Equity Monitor database in December 2013, and subsequent updates are likely to have occurred ( 7

16 Measuring and Monitoring Health Inequalities: A Post-Workshop Report The greatest decrease in wealth-based inequality in births attended by skilled health personnel and four or more antenatal care visits took place primarily in the 5-year interval from DHS 1997 to DHS 2002 and then in the 5-year interval from DHS 2007 to DHS The reduction of overall wealth-based inequality was due to the improvement of coverage of the lower quintiles rather than that of the wealthiest quintile. The decline in inequality in one antenatal care visit was also driven by improvements in coverage, primarily by an increase of the lowest quintile throughout a period of time. Furthermore the decrease in wealth-based inequality in DTP3 vaccination and care-seeking for pneumonia was driven by improvements in coverage, mainly by an increase in coverage in the three bottom quintiles during the period of DHS 2007 to DHS This similar pattern was also observed in the case of family planning needs satisfied. It was also found that the decrease in wealth-based inequality in early initiation of breastfeeding and oral rehydration therapy was driven by improvements in coverage, primarily by an increase in coverage in all wealth quintiles. Six of the eight indicators assessed by wealth showed little change in relative inequality from DHS 1997 to DHS They were as follows: family planning needs satisfied; one visit of antenatal care; early initiation of breastfeeding; DTP3 vaccination; care-seeking for pneumonia; and oral rehydration therapy. All these indicators showed low levels of wealth-based inequality in DHS It was revealed that absolute gaps between wealthiest and poorest quintiles were at less than 15 percentage points. Early breastfeeding and oral rehydration therapy were the two indicators where wealth-based inequality not only reduced, but also favoured the poorest quintile (i.e. the poorest quintile achieved the highest coverage). In contrast, for all other indicators, wealth-based inequality followed a gradient of greater coverage for more wealthy quintiles. 8

17 Inequality in Reproductive, Maternal and Child Health in Indonesia Latest status: In DHS 2012, three of the eight child and maternal health service indicators showed low levels of wealth-based inequality. It was found that the absolute gaps between wealthiest and poorest quintiles were at less than 5 percentage points. The indicators with absolute levels of inequality with less than a 5 percentage-point difference between the poorest and wealthiest were as follows: family planning needs satisfied; early initiation of breastfeeding; and oral rehydration therapy. These three indicators had relative ratios of inequality of less than 1.1. The lowest level of absolute and relative inequality was in the coverage of early initiation of breastfeeding with a difference between poorest and wealthiest of less than 1 percentage point and a relative ratio of 1.1. Two of the eight indicators showed moderate levels of wealth-based inequality in DHS An absolute gap between wealthiest and poorest quintiles of between 10 percentage points and 15 percentage points was found. These maternal and child health indicators included: antenatal care (one visit) and care-seeking for pneumonia. In contrast, three of eight indicators had high levels of wealth-based inequality in DHS Their absolute gaps were between 27 percentage points and 40 percentage points, and their relative ratios between quintiles ranged from 1.4 to 1.7. The births attended by skilled health personnel showed the greatest inequality by wealth of any indicator. Its absolute gap between wealthiest and poorest quintiles was at 39.1 percentage points and its relative ratio was at 1.7 (as shown in Figure 1). 3.3 Inequality in health services by education, Indonesia achieved decreases in education-based inequality (measured through the slope index of inequality) in all child and maternal indicators assessed during the period from DHS 1994 to DHS 2012 except for early breastfeeding (Table 6). Births attended by skilled health personnel saw the most dramatic decrease in inequality with the gradient in coverage by education showing a decrease of 41.9 percentage points over this period. 9

18 Measuring and Monitoring Health Inequalities: A Post-Workshop Report Most of this improvement occurred during the 5-year interval from DHS 2007 to DHS 2012, with the lower-educated groups showing large gains in coverage of births attended by skilled health personnel during that period, resulting in a drop in absolute inequality. Four of the eight health service indicators assessed showed higher levels of decreases in education-based inequality, which included antenatal care (four or more visits), DTP3 vaccination, care-seeking for pneumonia, and oral rehydration therapy. Indicators with greatly decreasing educationbased inequality showed a decrease between 20 percentage points and 35 percentage points during the assessment period. In addition, family planning needs satisfied and one visit of antenatal care saw more modest decreases in absolute inequality with decreases in the coverage gradient by education between 10 percentage points and 15 percentage points throughout the assessment period. In contrast to the other seven health service indicators assessed, where the drop in inequality was driven entirely by improvements in coverage in the lower-educated groups, there was an increase in absolute inequality for early initiation of breastfeeding coverage driven by drastic increases in coverage in the no education group (Figure 2). Figure 2: Education-based inequality in early initiation of breastfeeding Source: Disaggregated data were extracted from the WHO Health Equity Monitor database in December 2013, and subsequent updates are likely to have occurred ( 1540?lang=en). 10

19 Inequality in Reproductive, Maternal and Child Health in Indonesia Technical note on this section The education of the population was classified into three groups no education, primary school and secondary school. However, the population of women of reproductive age with no education assessed throughout the period of 18 years in Indonesia was quite a small proportion and has decreased over time. Its proportion was 10.7% in 1994 and 1.9% in Therefore, to examine education-based inequality, the group did not take the simple difference in coverage between the most and the least-educated groups into consideration because interpretation of overall level of inequality in relation to such small population sizes might be misleading. To describe the level of absolute inequality more accurately, the group chose to use slope index of inequality to measure inequality for each indicator throughout the whole educational spectrum, bearing in mind population sizes. The slope index of inequality is a means of measuring the gradient in coverage between those more educated and those less educated, including all three groups simultaneously. This measure also accounts for our no education group s low numbers by weighing each indicator s coverage by the proportion of the population in that group, so that the educational groups with more people are weighed more heavily than the groups with few people determining the slope index of inequality (WHO, 2013). Latest status: Two indicators of maternal and child health services showed high levels of absolute inequality in DHS It revealed that gradients in coverage by education exceeded 35%. The indicators with high levels of inequality were as follows: DTP3 vaccination, and births attended by skilled health personnel. 11

20 Measuring and Monitoring Health Inequalities: A Post-Workshop Report The indicator that showed the highest level of inequality was births attended by skilled health personnel. Its coverage gradient was 45.3% by education level (Figure 3). The antenatal care (four or more visits) showed a moderate level of absolute inequality with gradients in coverage by education at 29.1%. The remaining five maternal and child health service indicators illustrated lower-level inequality. Their gradients in coverage by education were below 16%. Early initiation of breastfeeding in DHS 2012 had a coverage gradient of 13.1%. It was the only indicator in DHS 2012 where the gradient of inequality showed better coverage for those who were not educated. All other indicators showed better coverage for those who were educated. Figure 3: Education-based inequality in births attended by skilled health personnel Source: Disaggregated data were extracted from the WHO Health Equity Monitor database in December 2013, and subsequent updates are likely to have occurred ( 1540?lang=en). 3.4 Inequality in health services by area, Indonesia achieved a decrease in area-based inequality from DHS 1994 to DHS 2012 in five of the eight health service indicators assessed (Table 7). Antenatal care indicators, births attended by skilled health personnel, DTP3 vaccination and care-seeking for pneumonia showed a decrease in both 12

21 Inequality in Reproductive, Maternal and Child Health in Indonesia absolute and relative area-based inequality. The births attended by skilled health personnel indicator was the indicator with the largest decrease in inequality between rural and urban areas. From DHS 1994 to DHS 2012, this indicator saw a decrease in the absolute gap in coverage by 33.2 percentage points, and the ratio of urban to rural coverage decreased from 2.9 to 1.2. Three of the eight assessed indicators showed minimal or no change in area-based inequality from DHS 1994 to DHS These indicators included: family planning needs satisfied; early initiation of breastfeeding; and oral rehydration therapy. Among these three indicators, the indicator on early initiation of breastfeeding showed low levels of inequality in DHS Its absolute gap between rural and urban was less than 1 percentage point and the relative ratio was less than 1.1. It is noteworthy that seven of the eight health service indicators assessed the decrease in inequality were driven by growth of coverage in rural areas compared with urban areas over this period. Only in early initiation of the breastfeeding indicator, the decrease in area-based inequality was driven by major growth of coverage in both rural and urban areas (Figure 4). 13

22 Measuring and Monitoring Health Inequalities: A Post-Workshop Report Figure 4: Area-based inequality in early initiation of breastfeeding Source: Disaggregated data were extracted from the WHO Health Equity Monitor database in December 2013, and subsequent updates are likely to have occurred ( 1540?lang=en). Latest status: Seven of the eight indicators had low levels of areabased inequality in DHS The absolute gaps in coverage between rural and urban areas were less than 11 percentage points and relative ratios were less than 1.2. One indicator, the births attended by skilled health personnel, stood out in DHS 2012 as having a higher level of areabased inequality, with an absolute gap in coverage between urban and rural at 17.2 percentage points and a relative ratio of Inequality in health services by region, From DHS 2007 to DHS 2012, Indonesia had not achieved any decrease in region-based absolute inequality in health service indicators assessed (Table 8). Four of the eight child and maternal health indicators showed an increase in region-based inequality, with the absolute gap between the highest and the lowest coverage between 38.0 percentage points and 61.3 percentage points. The indicators where absolute levels of inequality increased were as follows: antenatal care (one visit) and early initiation of breastfeeding. 14

23 Inequality in Reproductive, Maternal and Child Health in Indonesia Of these indicators, early initiation of breastfeeding showed the most drastic increase in region-based inequality. The difference between the highest and the lowest performing provinces was 37.4 percentage points in DHS 2007 and rose up to 56.3 percentage points in DHS 2012; the ratio of highest to lowest coverage increased in the same period from 2.6 to 4.2. Although four of the eight indicators showed trends in decreasing region-based inequality, there still remains high region-based inequality in Indonesia. The absolute gap between the highest and the lowest coverage was between 30.5 percentage points and 64.5 percentage points, and the ratio of highest to lowest coverage ranged from 1.4 to 4.2. These health service indicators with declines in region-based inequality were as follows: births attended by skilled health personnel; DTP3 vaccination; care-seeking for pneumonia; and oral rehydration therapy. Of these indicators, the DTP3 vaccination indicator showed the least decline in region-based inequality over the period (Figure 5). It is noteworthy that region-based inequality in health in Indonesia was driven by the low coverage in the eastern region of Indonesia, which included East Timor and Papua. Current status: In DHS 2012, five of the eight indicators showed a high level of regional inequality with absolute gaps between regions in coverage (greater than 40 percentage points). The relative ratio between regions in 10 of these indicators exceeded 1.7. Only oral rehydration therapy and one antenatal care visit had lower relative ratios of less than 1.7. The highest level of absolute region-based inequality was of early breastfeeding, which had a gap of 56.3 percentage points. The between group variance was of 141.9; and the range ratio was 4.2 with a Theil index of The coverage of oral rehydration therapy was among the lowest levels of absolute inequality by region in DHS 2012, with an absolute gap between most and least-covered regions of 31.7 percentage points. However, adjusting for population sizes, the lowest between group variance (absolute inequality measure) was seen for satisfaction with family planning services at 20.1 in DHS 2012 and a nominal Theil index (relative inequality measure) of

24 Measuring and Monitoring Health Inequalities: A Post-Workshop Report Figure 5: Region-based inequality in DTP3 vaccination coverage Source: Data were derived from the re-analysis of publicly available Demographic and Health Surveys (DHS) micro-data, using the standard indicator definitions as published in DHS documentation. The analysis was carried out by the International Center for Equity in Health based in the Federal University of Pelotas, Brazil. 16

25 Inequality in Reproductive, Maternal and Child Health in Indonesia 3.6 Inequality in health services by sex, From DHS 1994 to DHS 2012, there was virtually no change in sex-based inequality in any of the four health service indicators assessed (Table 9). For all four indicators, coverage in DHS 1994 showed no absolute or relative inequality by sex, except oral rehydration therapy indicator, which slightly favoured girls over boys in 1994 but the opposite occurred in 2012 (Figure 6). Latest status: In DHS 2012, there was fairly low and often negligible absolute and relative inequality by sex in all four indicators of child and maternal health services assessed. Figure 6: Sex-based inequality in oral rehydration therapy coverage Source: Disaggregated data were extracted from the WHO Health Equity Monitor database in December 2013, and subsequent updates are likely to have occurred ( 4. Benchmarking of Indonesia against other countries 4.1 National coverage Indonesia ranked among the five leading countries in the Region in terms of overall national coverage in six of the eight indicators (Table 10): family planning needs satisfied; 17

26 Measuring and Monitoring Health Inequalities: A Post-Workshop Report antenatal care (both one visit and four or more visits in a 3- year survey period); births attended by skilled health personnel (in a 3-year survey period); care-seeking for pneumonia; and oral rehydration therapy. The national coverage for satisfaction with family planning and four or more visits of antenatal care indicators (in a 3-year survey period) was found to be among the best in the Region (Figure 7). National coverage for the remaining indicator early initiation of breastfeeding in the 3 years previous to the survey was in the midrange of countries assessed. Figure 7: Benchmarking of satisfaction with family planning needs Source: Data were derived from the re-analysis of publicly available Demographic and Health Surveys (DHS) micro-data, using the standard indicator definitions as published in DHS documentation. The analysis was carried out by the International Center for Equity in Health based in the Federal University of Pelotas, Brazil. 4.2 Absolute and relative inequality When benchmarked against other similar countries in the Asia-Pacific Region, Indonesia ranked among the four leading countries in lower-level wealth-based absolute inequality for three of eight assessed child and maternal health service indicators based on DHS These indicators included: 18

27 Inequality in Reproductive, Maternal and Child Health in Indonesia family planning needs satisfied; early initiation of breastfeeding; and oral rehydration therapy. For two of the eight indicators DTP3 vaccination and care-seeking for pneumonia Indonesia was among the five leading countries with the highest wealth-based absolute inequality. Among the 14 countries assessed, Indonesia had no indicator assessed with the highest level of wealth-based absolute inequality in this Region. For two of the indicators early initiation of breastfeeding and oral rehydration therapy the wealth-based absolute and relative inequality in Indonesia was such that the poorer population groups achieved better coverage than the wealthier groups. Six of the 14 neighbouring countries showed similar trends in early breastfeeding and oral rehydration therapy coverage favouring poorer population groups. With regards to relative inequality, family planning satisfaction was one indicator that stood out for Indonesia. For one, it had among the highest levels of national coverage among countries assessed. Moreover, Indonesia also had extremely low within-country wealth-related relative inequality for this indicator. In addition, Indonesia managed to reach comparably low levels of relative inequality for another six indicators. These indicators were as follows: antenatal care (both one visit and four or more visits); births attended by skilled health personnel; early initiation of breastfeeding; care-seeking for pneumonia; and oral rehydration therapy. For the DTP3 vaccination indicator, Indonesia has the third highest levels of wealth-related relative (and absolute) inequality (after India and Lao People's Democratic Republic) and coverage levels that approximate the median of the group. 19

28 Measuring and Monitoring Health Inequalities: A Post-Workshop Report 5. Situation analysis Priority health service indicators The single most inequitable health service indicator across all equity stratifiers assessed was births attended by skilled health personnel. This indicator had the highest level of absolute inequality of any indicator when assessed by wealth, education, area and region (Table 1). The wealth-based absolute inequality was the greatest, with an absolute gap in coverage between poorest and wealthiest quintiles at 39.1 percentage points in DHS Compared with other countries in the Asia-Pacific Region, Indonesia was in the midrange of absolute wealth-based inequality of skilled birth attendant coverage of any country in our assessment (Table 3). Although inequality in coverage of skilled birth attendants showed some improvement by all selected equity stratifiers, from DHS 1994 to DHS 2012, inequality still existed (Table 2). Other high priority health service indicators that showed high levels of inequality across several equity stratifiers were antenatal care visit indicators and DTP3 vaccination. These indicators showed high levels of absolute and relative inequality across wealth, education and region. With regards to wealth, each of these indicators had an absolute gap between wealthiest and poorest groups of greater than 12 percentage points in coverage and relative ratios exceeding 1.1 in DHS The region-based inequality in DHS 2012 for each of these indicators was greater than a 40 percentage-point absolute gap between most and least-covered regions with ratios exceeding 1.6 for all indicators. The education-based inequality for each of these indicators was modest, with a gradient in coverage by educational level between 15 percentage points and 36 percentage points in DHS Over time, the trend for inequality in one and four or more antenatal care visits and DTP3 vaccination was slightly less promising than the situation for the births attended by skilled health personnel. Inequality in antenatal care visits decreased across three stratifiers (wealth, education and area) from DHS 1994 to DHS 2012, although inequality by region increased during this period. DTP3 vaccination also saw reduction in inequality by all selected stratifiers. 20

29 Inequality in Reproductive, Maternal and Child Health in Indonesia While the situation for these indicators one and four or more antenatal care visits and DTP3 vaccination proved to have some moderate levels of inequality across a variety of stratifiers, the situation of Indonesia was similar to comparable countries in the types of inequality seen for these indicators. Indonesia was among the five countries with the lowest wealth-based relative and absolute inequality for indicators of antenatal coverage (both one and four or more visits). This was, however, not the case for DTP3 vaccination coverage, where Indonesia ranked the third highest in its levels of absolute inequality among comparable countries. Workshop participants identified care-seeking for pneumonia and oral rehydration therapy as additional areas of concern for Indonesia in terms of achieving the national target of these two indicators. By region, these indicators had absolute differences between most and least-covered regions of over 30 percentage points with relative ratios of 1.6 and greater. Wealthbased inequality also had moderately high levels with an absolute gradient in coverage by wealth of 12.5% for care-seeking for pneumonia. The situation by education-based inequality was slightly better, with the absolute difference in care-seeking for pneumonia between poorest and wealthiest at only 12.2 percentage points. For neither indicator did the relative ratio of wealth quintiles exceed 1.3 in DHS 2012, nor was there any significant inequality by either sex, especially in relation to other indicators. In terms of time trends, care-seeking for pneumonia and oral rehydration therapy indicators proved to have reductions in absolute and relative inequality from DHS 1994 to DHS 2012 by all selected stratifiers. When the wealth-based relative and absolute inequality was benchmarked against comparable countries, Indonesia ranked among the five leading countries in lower-level inequality for both indicators. Indonesia was also among the five leading countries in the Region in the overall national coverage for care-seeking for pneumonia and oral rehydration therapy. The only indicator that stood out as having an especially favourable position in terms of inequality across multiple stratifiers, was family planning needs satisfied. By DHS 2012, this indicator showed low levels of absolute and relative inequality across wealth, education and area. By wealth, 21

30 Measuring and Monitoring Health Inequalities: A Post-Workshop Report education and area, the indicator saw absolute coverage gaps of less than 6 percentage points and relative ratios at 1.1 or less. By region, the indicator saw a difference in coverage between highest and lowest coverage provinces of 40% and relative ratio of 1.8 by DHS It is noteworthy that region-based inequality in family planning needs satisfied still existed in The coverage of family planning needs satisfied is a story of success for Indonesia, evidenced by the declines in inequality by wealth, education and area over the last 18 years of DHS data. Compared with other countries, Indonesia is doing well with regard to this indicator. It ranked among the leading countries in terms of national coverage and is one of the three countries with the lowest relative inequality. Early breastfeeding was notable not just for its low levels of inequality, but also for being the only health service indicator for which coverage consistently favoured the less educated, poorer and more underserved groups. Compared with other countries, this was common in the Region, as 5 of the 12 countries assessed had wealth-based inequality that favoured the poorer population groups with regards to early breastfeeding. The overall coverage for Indonesia in early breastfeeding fell into the midrange of comparable countries. 5.2 Priority equity stratifiers in health services Inequality by region and education proved to have the most wide-reaching inequalities of any equity stratifier assessed (Table 1). In DHS 2012, all eight health service indicators had an absolute difference in coverage between most and least-covered regions, exceeding 30 percentage points with relative ratios of 1.4 or greater. The high levels of region-based inequality were primarily due to low coverage levels in the eastern part of Indonesia, which includes East Timor and Papua. In all health service indicators, other than early breastfeeding, the eastern region had the lowest level of coverage in DHS

31 Inequality in Reproductive, Maternal and Child Health in Indonesia Between DHS 2007 and DHS 2012, there was little improvement in inequality for the eastern part of Indonesia. Only the coverage of early initiation of breastfeeding improved in terms of region-based inequality during this time, with coverage of early initiation of breastfeeding seeing improvements in both relative and absolute inequality. All other inequalities in health services by region remained essentially unchanged. The DHS 2012 data showed gradients in coverage by education exceeded 15% in six of the eight health service indicators. The indicator with the greatest level of education-based absolute inequality was the births attended by skilled health personnel with a slope index of inequality of 45.3% in coverage by education. Similar to region-based inequality, there was hardly any chronological trend towards improvements in educationbased inequality in most indicators. The only indicator with substantial improvements in education-based inequality from DHS 1994 to DHS 2012 was the coverage of early initiation of breastfeeding and family planning needs satisfied. While six of the eight indicators saw drops in absolute inequality, these were driven by decreases in coverage in the lower-educated group. In contrast to inequality by region and education, Indonesia proved to have little inequality by sex or area. None of the assessed health service indicators had more than a 7% range difference in sex-based inequality during the DHS 1994 to DHS 2012 period. By DHS 2012, six of the eight assessed indicators had very low levels of area-based inequality, with absolute gaps between urban and rural at 10 percentage points or less with the sole exception of skilled attendance at birth and relative ratios at less than

32 National average Absolute Relative Absolute Relative Absolute Relative Absolute Relative Absolute Relative Absolute Relative Measuring and Monitoring Health Inequalities: A Post-Workshop Report 6. Data tables Table 1: Situation analysis of latest status Inequality Wealth Education Sex Area Region Average inequality score Indicator Family planning needs satisfied Antenatal care (at least one visit) Antenatal care (at least four visits) Births attended by skilled health personnel Early initiation of breastfeeding DTP3 immunization Care-seeking for pneumonia Oral rehydration therapy for children with diarrhoea RMCH interventions Source: Participants of WHO Workshop on Measuring and Monitoring Health Inequalities, held in April 2014 in Jaipur, India. 24

33 National average Absolute Relative Absolute Relative Absolute Relative Absolute Relative Absolute Relative Absolute Relative Inequality in Reproductive, Maternal and Child Health in Indonesia Table 2: Situation analysis of time trends Inequality Average inequality score Wealth Education Sex Area Region Indicator Family planning needs satisfied Antenatal care (at least one visit) Antenatal care (at least four visits) Births attended by skilled health personnel Early initiation of breastfeeding DTP3 immunization Care-seeking for pneumonia Oral rehydration therapy for children with diarrhoea RMCH interventions Source: Participants of WHO Workshop on Measuring and Monitoring Health Inequalities, held in April 2014 in Jaipur, India. 25

34 Measuring and Monitoring Health Inequalities: A Post-Workshop Report Indicator Table 3: Situation analysis of benchmarking latest status National average Absolute Inequality Wealth Family planning needs satisfied Antenatal care (at least one visit) Antenatal care (at least four visits) Births attended by skilled health personnel Early initiation of breastfeeding DTP3 immunization Care-seeking for pneumonia Oral rehydration therapy for children with diarrhoea Relative RMCH interventions Source: Participants of WHO Workshop on Measuring and Monitoring Health Inequalities, held in April 2014 in Jaipur, India. Table 4: Indonesia national coverage Indicator Year Percent Coverage Fps anc anc sba ebreast DTPv carepold Ort Source: Data were derived from the re-analysis of publicly available Demographic and Health Surveys (DHS) micro-data, using the standard indicator definitions as published in DHS documentation. The analysis was carried out by the International Center for Equity in Health based in the Federal University of Pelotas, Brazil. 26