Laksono TrisnantoroI; Soeharsono SoemantriII; Budihardja SinggihII; Kirana PritasariII; Erna MulatiII; Francisca Handy AgungIII; Martin W WeberIII,*
IGajah Mada University, Yogyakarta, Indonesia
IIMinistry of Health, Jakarta, Indonesia
IIIWorld Health Organization, Indonesia country office, Bina Mulia 1 Building, Jalan HR Rasuna Said Kav. 10, Jakarta 12950, Indonesia
Despite considerable global progress on reducing child mortality, most recent estimates indicate that in 2008 about 8.8 million children died.1 Debate continues on how best to meet millennium development goal 4: reduction of child mortality by two-thirds by 2015.
Some believe that scaling up specific health interventions is the best way to achieve this, others point towards strengthening the health system in a comprehensive way, and a third group believes that overall economic development is more important than specific interventions.2 The argument is that if people have more money, they will improve their living environment and spend more on items and services which are conducive to better health.
Using the example of Indonesia, we claim that economic growth is not enough, but that scaling up beneficial health interventions and investing in the quality of health services are essential for improving child survival.
Indonesia had a consistent economic growth of 3-5% per year over the past 20 years, except for a short period during the 1998 Asian economic crisis that lead to the replacement of an authoritarian regime by a democratic government and transferred central authority to 500 districts in 33 provinces. Since then, the financing and delivery of health interventions has been the responsibility of the district, but there are concerns about peripheral capacity to manage these interventions.3
Indonesia has more than 8000 community health centres that supervise public health interventions and provide primary care. Indonesia's main strategy for ensuring better care for children has been the adoption of the Integrated Management of Childhood Illness (IMCI) in 1997. For health promotion and disease prevention, the community health centres rely on community health posts, which are staffed by health volunteers, supervised by a visiting nurse or village midwife. These posts provide growth monitoring, nutritional counselling, health education and immunization services. To reduce maternal and child mortality, village midwives ensure antenatal care, birth preparedness, skilled attendance at birth and postnatal care for mother and newborn. But hospital programmes for reducing maternal and infant deaths have lagged behind these primary health care interventions.
Data on mortality, nutritional and health status and coverage of interventions are available from the annual socioeconomic survey and the demographic and health survey (DHS), which is done every 5 years, providing data on family planning, reproductive health and child health interventions.4 Both surveys are used to produce child mortality estimates, and these estimates show that rates of improvement have been slowing over the past decade.
During this time, skilled attendance at birth and immunization rates have improved. However, giving oral rehydration salts to children with diarrhoea has declined, and exclusive breastfeeding of children less than 6 months of age has fallen from 40% in 2002 to 32% in 2007. 4 The baby-friendly hospital initiative, which should promote early and exclusive breastfeeding in all maternity services, was just revitalized after years of neglect, and the International Code of Marketing for Breast Milk Substitutes has only been partially implemented. Moreover, complementary feeding is the most deficient area of infant feeding, leading to a high proportion of stunted children.
It is difficult to ensure equitable access to care on all the islands in Indonesia. The distribution of the health workforce to peripheral areas has been insufficient. Urban areas of Java are oversupplied with doctors, but community health centres in remote areas are often lacking a doctor and district hospitals lack essential specialists such as obstetricians and paediatricians.5 Nurses and midwives have limited authority to prescribe and dispense drugs, despite the adoption of IMCI and the village midwife models, which include treatment of pneumonia with antibiotics by trained nurses and medical management of delivery complications by midwives. Regulations for task shifting are being developed.
In many areas, newborn babies are not taken out of the house for 40 days following delivery. If neonates get sick, or have risk factors such as low birth weight, they may die at home without being seen by a health worker. National policy has been to provide two postpartum health visits for mother and baby one in the first week and the second within the first month. Indonesia is now introducing an additional visit during the first 48 hours after birth.
Deficiencies in care provided for children in hospitals and primary health centres are being addressed through a quality improvement pilot and the publication of the Indonesian version of WHO Pocket book of hospital care for children.6
Indonesia faces challenges in providing quality care to its population. While the right foundations are in place, every child needs to have access to a health worker able to reliably deliver quality health care. Quality improvement initiatives are slower and more cumbersome than a magic bullet approach, but essential for child survival at all levels of the health service. Economic growth is important, but not sufficient by itself for better health outcomes.
1. Black RE, Cousens S, Johnson HL, Lawn JE, Rudan I, Bassani DG et al.; Child Health Epidemiology Reference Group of WHO and UNICEF. Global, regional, and national causes of child mortality in 2008: a systematic analysis. Lancet 2010;375:196987. PMID:20466419
2. The World Bank. World development report 1993: investing in health. Oxford, New York, Toronto: Oxford University Press; 1993.
3. Trisnantoro L, Kosen S, Jimenez E, Firth S, Hollingworth S. Developing an investment case for financing equitable progress towards MDGs 4 and 5 in the Asia Pacific region: Indonesia country mapping report. Jakarta: Kebijakan Kesehatan Indonesia; 2009.
4. Statistics Indonesia (Badan Pusat Statistik-BPS) and Macro International. Indonesia Demographic and Health Survey 2007. Calverton: BPS and Macro International; 2008.
5. The World Bank. Indonesia's doctors, midwives and nurses: current stock, increasing needs, future challenges and options. Jakarta: The World Bank; 2009.
6. Pocket book of hospital care for children: guidelines for the management of common illnesses with limited resources. Geneva, World Health Organization, 2005.