Progress for children Thirteenth Meeting of the Consultative Group on Indonesia Jakarta, 10-11 December 2003 UNICEF Statement Steven Allen, UNICEF Representative, Indonesia UNICEF is pleased to note the progress made over the past twelve months in a number of areas related to children in Indonesia. Legislation for children First, steps have been taken to operationalise the Child Protection Law adopted in October 2003. A Presidential Decree has been passed on establishing the Indonesian Commission for the Protection of Children (KPAI or Komisi Perlindungan Anak Indonesia) to report and monitor the implementation of the Law, and to advocate for child protection. Socialisation of the Law has begun. Second, a law on Civil Registration and Vital Statistics is being drafted and is expected to be adopted by the Parliament in 2004. The Bali Consensus The Program Nasional Bagi Anak The MDG Report Third, the Government of Indonesia hosted in May 2003 the Sixth East Asia and Pacific Ministerial Consultation on Children, which brought together 25 countries from the region to Bali, to commit themselves to the Bali Consensus on Partnerships with and for Children. This agreement calls for attention to four issues requiring priority action from governments in the region: malnutrition, maternal mortality, HIV/AIDS and the trafficking and commercial sexual exploitation of children. As the host, the Government of Indonesia took a leading role in the drafting and adoption of this Consensus, with the Ministry of Health taking the primary responsibility. Fourth, as follow-up to the United Nations Special Session on Children in May 2002 which many refer to as the Second Summit for Children the Government of Indonesia has developed and is now finalising the National Programme for Indonesian Children or Program Nasional Bagi Anak Indonesia (PNBAI). This Programme focuses on four key areas: maternal and child health; quality education; protection of children against abuse, exploitation and violence; and HIV/AIDS. Fifth, the Government of Indonesia is in the process of completing its first Millennium Development Goals Report, which reviews, analyses and records the status and trends of key indicators, including child-related indicators, the challenges, and the policy and programme framework for each goal and target. All of these are measures that aim to ultimately enhance the well-being and rights of children in Indonesia, and UNICEF wishes to congratulate the Government of Indonesia on these positive steps. UNICEF CGI Statement, December 2003 1
At the same time, UNICEF would like to encourage the Government of Indonesia to put in place the remaining regulations and structures that are required for implementing the Child Protection Law. Implementation of legal frameworks UNICEF would also like to urge the speedy adoption and effective implementation of the Law on Civil Registration and Vital Statistics. Civil registration, which includes birth registration, not only fulfils the fundamental right of every child to have a name and nationality at birth, but also has operational implications for social planning and programmes for children. UNICEF has often advocated that the absence of a functioning civil registration system makes it difficult to enforce age-specific legal frameworks relating to child labour, sexual exploitation and trafficking, and to implement sanctions against violators. Not having an adequate vital registration system also means that planning, resource allocation and facility-based reporting have to rely on population projections from periodic censuses and surveys. The Millennium Development Goals, poverty reduction and children In this and in other fora, UNICEF has often underscored the importance for children of the Millennium Development Goals (MDGs). Many MDG targets have indicators directly linked to children for instance, child malnutrition, basic education, gender equality, child mortality and immunisation, safe delivery, and HIV/AIDS orphans. Other MDG targets have a strong influence on the growth and development of children (maternal health, malaria, environment, water and sanitation). The MDG reporting process In this regard, UNICEF wishes to congratulate the Government of Indonesia on the progress made on preparing its First MDG Report. As the Task Force Manager for the UN Task Force supporting the Government of Indonesia in the preparation of this Report, UNICEF has appreciated the close cooperation with Government partners in this endeavour. In particular, UNICEF appreciates the MDG reporting process, led by Bappenas and the five Government Working Groups with representatives from all concerned Ministries and institutions, Bappenas and BPS. This is a process characterised by a frank exchange of views and discussions, and by an open and comprehensive review of each goal. The preliminary results from this work which is being circulated today by the Government indicate the achievements and progress towards the MDGs. Progress In the 1990s, Indonesia made rapid progress in reducing infant and child mortality, and in increasing access to primary education. Infant and child mortality rates were reduced by a third within a period of 6 years, and access to basic social services increased at impressive rates. Near universal primary education enrolment and literacy rates have also been achieved. UNICEF CGI Statement, December 2003 2
and challenges On the other hand, the results of the MDG Report also highlight the need for more attention to certain areas. The quality of basic education needs to be addressed, while children need to complete the required nine years of basic education. Indonesia has been successful in eradicating extreme poverty and is on track for achieving its MDG target for poverty, but the poorest and most vulnerable groups need more attention. This is shown not only by the poverty trends, but also by the trends in child malnutrition, an indicator that reflects the overall impact of poverty and the community and family environment on the growth and development of children. The impact of poverty on children Progress in reducing moderate child malnutrition 1 is taking place, but too slowly. More worrying is the fact that severe malnutrition has not been reduced, but has remained steady or increased slightly over the past decade. This is an indication that general socio-economic progress and/or public health and nutrition interventions have been effective in reducing mild to moderate malnutrition, but have not been intensive enough to reduce severe malnutrition, or to reach the most needy children and their communities. Stunting in children is not an explicit MDG indicator, yet it is an implicit part of the MDG target to reduce hunger. It is an important indicator for both child and maternal well-being, since stunting is often due to maternal under-nutrition, persists into adulthood and has an intergenerational effect. It is a risk factor for increased mortality, poor cognitive and motor development and other impairments in function. 2 While there is no nationally representative data on stunting across the years, even the limited data from regional surveys show that overall stunting levels in Indonesia remain high around 45 to 50 percent for moderate and severe stunting and around 20 to 25 percent for severe stunting. 3 Again, the data show that the neediest children are not being reached. Reversing malnutrition trends Reversing such trends in child malnutrition will not be easy. It will require concerted and coordinated efforts in all sectors, as child malnutrition is a complex phenomenon that is due to a number of interlinked factors. The most immediate causes are disease and inadequate nutrient intake. The underlying causes include inadequate care of the young child including inappropriate feeding practices and therefore insufficient knowledge and education of the mother; poor hygiene and sanitation habits; family poverty; lack of access to health services; unsafe water and an unsanitary environment. Additionally, since poor child nutrition often starts in utero and extends throughout the life cycle, young child nutrition is strongly affected by maternal health and nutrition. A pregnant woman normally receives antenatal care in her second trimester of pregnancy. By then, interventions may affect birthweight, but they will be too late to make an optimal difference and influence the course towards stunting. By and large, most nutrition programmes have focused on young children and have largely neglected this critical intrauterine period. As a result, efforts to address malnutrition in children have come too late in the life cycle to make a significant impact. 4 UNICEF CGI Statement, December 2003 3
and improving maternal health Water Child malnutrition therefore links up to the MDG for improving maternal health. Indonesia still has some way to go in this area. At issue are the quality of maternal health services and the disparities in access, especially for vulnerable groups and the poor. Under decentralisation, with declining numbers of village midwives for providing services to vulnerable groups and the poor, 5 special support will be needed to strengthen the reach and quality of maternal health services. Trends in water and sanitation are also worrying from the perspective of maternal and child health. The trends in progress towards the safe drinking water target and even towards increased access to improved water sources a more modest ambition than the first makes it likely that the MDG target will not be reached without substantial additional investments. Decentralisation and the impact on children Decentralisation forms a significant challenge, especially to efforts to improve child health and reduce child mortality. The impact on child health Experience in some of the districts where UNICEF works indicates that district governments are still struggling to cope with the new roles and responsibilities, and that health information systems are not working properly. The province where much of the technical capacity lies is no longer as involved as before. It is unclear to what extent effective budgeting, planning and targeting are taking place the capacity in many districts would appear inadequate for this. In the districts where UNICEF operates, the overall budget allocation for the health sector is less than 10 percent and often, only a tenth to a third of this limited health budget actually goes to health development activities. All this appears to be having an impact on immunisation programmes for children. As an example, measles immunisation coverage an MDG indicator increased quite significantly in the earlier part of the 1990s, but recent data indicate that this is stagnating at around 71 percent. DPT3 coverage has fallen, from 64 percent in 1997 to 58 percent in 2002. 6 Because of weaknesses in the facility based information system, such trends are not being caught or monitored properly. For example, survey data show that only half the children in South Sulawesi are being immunised with DPT3, 7 but the facility-based data show coverage levels of 86 per cent. Minimum Basic Standards In this regard, UNICEF commends the issuance in October 2003 of the Ministry of Health s Decree on Obligatory District Functions and Minimum Service Standards, 8 the application of which will contribute to assuring a minimum quality and coverage of health services in districts, including child immunisation. UNICEF CGI Statement, December 2003 4
District level monitoring and evaluation Implementation of the standards will require much support from all partners represented here today and will also require strong coordination by the Government. It will also require local authorities to monitor whether or not the standards are being met. To do this, strengthening of the facility based health information system will be needed, which is a long term effort that requires building institutional capacities. Meanwhile, the needs are urgent and cannot wait. Specific interim measures and targeted support for monitoring and evaluation at district level will be needed to help district authorities measure and track their efforts, and ensure that the poorest and most vulnerable groups are being reached. UNICEF 2004 financial commitments Toward supporting these endeavours, UNICEF commits to US$ 6.9 million from its core resources.* It also expects to mobilise from its donors an additional US$ 12 million as specific purpose contributions for Indonesia in 2004. * The US$6.9 million above includes only UNICEF's core resources, contributions from UNICEF National Committees in various countries, and contributions from the private sector. It does not include current, existing contributions to UNICEF from donor governments, which support the majority of UNICEF-assisted programmes in Indonesia. Notes 1 As measured by the proportion of children under five years of age suffering from moderate and severe underweight, or less than minus two standard deviations from the median weight for age of the standard NCHS/WHO reference population. 2 Allen, L, Gillespie, S. (2001). What Works? A review of the Efficacy and Effectiveness of Nutrition Interventions. ACC/SCN Nutrition Policy Paper no. 19, ADB Nutrition and Development Series No. 5, UNACC/SCN publication, September 2001. 3 Limited surveys reported in End Decade Statistical Report, BPS and UNICEF, 2000. 4 Sastroamidjojo, S (2003). Better Nutrition for Growth and Development. Presentation to the Sixth East Asia and Pacific Ministerial Consultation on Children, 5-7 May 2003, Bali. 5 Presented at the XIII IBI congress September 2003 (Midwives Professional Organisation National Conference) 6 Indonesia Demographic and Health Surveys (IDHS) 1997 and 2002-2003 7 IDHS, 2002-2003 8 Decree of the Minister of Health of the Republic of Indonesia. Number 1457 /Menkes/SK/X/2003, 10 October 2003 on Minimum Service Standards in the Health Sector in Districts/Municipalities. UNICEF CGI Statement, December 2003 5