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Child Malnutrition inIndonesiaElfindri a & Gouranga Lal Dasvarma aa Andalas University , Padangb Flinders University of South AustraliaPublished online: 19 Aug 2006.

To cite this article: Elfindri & Gouranga Lal Dasvarma (1996) ChildMalnutrition in Indonesia, Bulletin of Indonesian Economic Studies, 32:1,97-111, DOI: 10.1080/00074919612331336908

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Bulletin ofZndonesirm EmMmic Sfudks Vol32 No 1, April 1996, pp. 97-111

CHILD MALNUTRITION IN INDONESIA

Elfindri

Andalas University, Padang

Gouranga La1 Dasvarma'

Flinders University of South Australia

This research is concerned with the patterns of child malnutnhon in Indonesia since the mid 1980s. Aggregate data show that malnourished children are found among lower income groups. In this study a 10% reduction in the proportion of the papulation under the poverty line was found to be accompanied by a fall of around 4 4 % in the number of children suffering hom protein energy malnutrition. It 1s suggested that poverty reduction as a development goal can make a large contribution to alleviating malnutntmn. However, malnutrition, particularly among preschool children, 1s still a major problem in Indonesia.

INTRODUCTION

There is ample evidence that malnutrition among the young populabon is a major problem in many parts of the world (WHO 1989). A consistent reduction has been achieved in the commonly identified states of malnutrition, e.g. stunting and wasting,' although this reducbon has not been uniform among countries (UNICEF 1990a). The global picture of malnutrition during the 1980s showed that the proportion of children classified as malnourished was high in Bangladesh (60%), Niger (49%) and Pakistan (39%) and lower in Bolivia (lj%), Peru (13%) and Venezuela (10%) (UNICEF 1990a). While the situation is also critical

*The authors are grateful to the anonymous referees for theb coments. 'Malnutrition is commonly defmed as any deviation of growth (weight, stature, etc.) or biochemical measurement from the 'optimal state'. This definition assumes the use of reference populahons to define what is optimal (WHO Working Group 1986).

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98 Elfindri and Gouranxa La1 Dasvarma

in Indonesia, the worlds third largest developing nation, the scale of malnutrition has been appreciably reduced there in the latter 1980s (BPS 1992a).

This paper analyses the levels and trends of malnutrition among children in Indonesia, giving particular attention to their relationship to reductions in poverty levels since the mid 1980s. Malnutrition in Indonesia is reviewed at an aggregate (provinclal) level. Identification of 'high risk ages, and differentials by children's gender, rural-urban residence, household expenditure, and province are also discussed. The study concludes with rough estimations of the number of malnourished pre-school children in Indonesia.

NUTRITION PROGRAMS IN INDONESIA

Malnutrition is prevalent during childhood in South and Southeast Asian countries, including Indonesia. Damage done by malnutrition in the early years of life (e.g. the first five years) is associated with social deprivation at older ages, particularly as it leads to poor performance in schools, low resistance to disease, and low productivity (Berg 1981; Jamison 1986; Bairagi 1981). Therefore, this vulnerable age group is a logical target for limited child nutrition resources.

Improvement in nutritional status is a primary objective of the Indonesian health care system (UNICEF 1990b), in which special attention is given to the needs of children and their mothers (Soekirman 1988; GOI-UNICEF 1988). Efforts to improve the nutritional status of the population have been directed through the family nutrition improvement program (UPGK) (GOI-UNICEF 1988; Swkirman et al. 1992). The combination of nutritional promotion and education is expected to reduce the prevalence of moderate and severe malnutrition? and of iron and vitamin A deficiency among children. Program implementation takes place mainly at the 'grass roots' level, through child weighing posts in villages, supervised by a volunteer village cadre (kader).

In the educational campaigns, the simple health monitoring card (Kartu Menuju Sehat), which covers about 70% of all children, is used

'Children falhng into the categories of moderate (i.e. 6049% of the median reference WHO-NCHS standardised weight for age) and severe (Le. less than 60% of the median reference WHO-NCHS standard) malnutrition are often referred to as having protein energy malnutrition (PEM) ( B E 1992a, p. 7).

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Chdd Malnutrition in Indonesia 99

to help mothers monitor the growth of their children. The card also contains simple pictorial messages about nutrition. However, the benefits of such educational campaigns have recently been questioned (Priyosusilo 1988): it has been suggested that the number of mothers involved in the campaigns varies widely among local communities. This is thought to be due mainly to variations in the contribution of the village kader in terms of time devoted, knowledge, and ability to encourage mothers to participate in monthly activities at the community- organised integrated health service posts (posyandu)?

In addition to educational campaigns related to nutrition, efforts are also directed at increasing household income in two ways. In areas with surplus food, a crash program is introduced to increase local production of nutritious foods, high in protein and vitamins. For the less arable lands, programs are developed to increase household income through fodder production, fisheries and forestry (Levinson 1982). These efforts are directed at helping households with inadequate food supply (both in quantity and quality), which account for a large proportion of malnourished children (UNICEF 1990a). The commitment of the Indonesian government and UNICEF to child survival has led to such explicit interventions being carried out particularly in the mid 1980s.

MALNUTRITION IN INDONESIA DURING THE MID 1980s

Quality of Data Child nutrition data have been collected regularly since 1986. Indonesia's National Socio-economic Surveys (Susenas) of 1986, 1987 and 1989 have used both the Harvard and the WHO-NCHS standards for assessing the nutritional status of children (BPS 1992a, p. 5). In this paper the WHO-NCHS standard is used.

However, there are limitations of methodology and quality of data in these surveys, which can be detected if one compares the trends in the reduction of malnutrition in Indonesia and its provinces. Malnutrition of young children is measured by using weight-for-age data. Since standardised weight for age is affected by temporary illness status at the time of measurement, standardised height for age may be a more useful measure of malnutrition (WHO Working Group 1986; Desai 1992). To allow researchers to choose the most appropriate index for use under

%e posyandu provide services in immunisation, child growth monitoring, control of diarrhoeal diseases, antenatal care and family planning.

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100 Elfindri and Gouranga L d Damma

any given circumstance, we recommend that future nutrition surveys in Indonesia collect data on height in addition to age and weight. We acknowledge that it may be necessary to use trained staff to collect detailed anthropometric data of good quality on height as well as weight. The likely cost may necessitate the collection of such data on a subsample of the main sumey, and the small sample sizes may reduce the usefulness of such data for identifying small target groups for policy and programs. However, it is the contention of the authors that rather than having no data at all on height, it would be preferable to collect it for a subsample sufficient to identify vulnerable large areas (such as provinces or districts); more detailed investigations can then be carried out within such areas.

Second, comparison of malnutrition in the 1986, 1987 and 1989 Susenas may be affected by differential sampling. All three sumeys used the sampling frame of the 1983 Agricultural Census, but the sampling design of the 1986 Susenas was different from that of the 1987 and 1989 Susenas, the latter two providing for a better coverage and better representation of households throughout Indonesia (details of the sampling design are available from the authors).

Third, the number of children in the sample for some provinces is smaller than that recommended by experts (WHO Workmg Group 1986); estimates of malnutrition based on such samples may not represent the provincial figures with the desired level of ac~uracy.~ The above factors must be taken into consideration in comparing the nutrition data over time.

Levels and Patterns of Malnutrition Age. As in many other developing countries, the problem of malnutrition in Indonesia is most acute during childhood. There is a transition from a relatively low percentage of malnutrition at six months of age to a relatively high percentage after the age of six months (table 1). This is the time when children need extra care from their parents, especially with respect to feeding and the treatment of frequent infections, mostly associated with contaminated food (Black et a f . 1982). Duration of breastfeeding per se may not be a good indicator of feeding intakes, since breastfeeding continues for quite a long period in Indonesia (Castle et al.

4For example, based on a malnutnhon level of 51% (in 1986), the sample size required for estimating malnutrition with a 9506 confidence interval in Bengkulu provlnce 111 1987 is 384, but the number of children m the actual ample for Bengkulu at the 1987 Susenas was only 369 (BPS 1992a, p. 32).

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Child Malnutrition in Indonesia 101

1988) and at later ages is accompanied by major intake of solid food. Instead, more attention should be given to supplemental feeding quality, particularly for the vulnerable group of children aged from six to 47 months.

Rural-Urban Patterns. Malnutrition is higher in rural than in urban areas (table 1). The percentage of malnourished girls is lower than that of malnourished boys, and this is also observable for most provinces (table 4). Boys suffer 1.5 to 2.5 times more malnutrition than girls, except in Bengkulu province (but the number of children in the Bengkulu sample was small). This sex differential in malnutrition in favour of female children is generally found elsewhere, but is contrary to what has been observed in some other parts of Asia, e.g. India (Sen and Sengupta 1983) and Bangladesh (Bairagi 1981). The reverse pattern in Bangladesh is attributed to poor food allocation to female children because of their inferior status and the strong preference for male children. In Bangladesh the sex differentials in child nutrition status also vary

TABLE 1 Percentage of Re-school children k l o m Normal Nufrifional Status According to Standardised Werghifoor Age, by Sex,

for Rural and Urban Indonesia, 198ga

Age in Boys GUk Months Urban Rural Urban Rural

&2 19.5 27.9 18.5 23.5 >5 25.0 38.4 23.0 30.2 6-8 29.9 41.0 16.1 26.6 9-11 45.1 53.3 32.3 32.7 12-23 46.0 58.8 34.8 43.8 24-35 40.4 55.7 36.3 45.5 3 6 4 7 50.8 58.4 37.7 47.5 48-59 45.4 64.6 38.7 43.7

All ages 42.5 55.5 33.4 42.1

aThe WHO-NCHS standard (WHO Working Group 1986) has been used to compute the standardised weight for age. Source: BPS (lBZa), tables 15.b and 15.c.

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102 Elfindri and Gouranaa La1 Dasvarma

TABLE 2 Chzld Nutrition Status According to Weightfor Age and Household Expenditure, 1986'

Household Sever& Moderate and Severeb Expenditure per Malnutrition Malnutrition Month (Rp) (%) (%I

< 25,000 25.000-49.999 50.00Cb74.999 75,000-99,999 100,000+

Total

3.5 2.1 1.4 1.4 1.0

1.7

22.0 15.1 12.3 10.8 7.4

l3.1

Thildren aged less than 60 months. bFor a defimhon of 'severe' and 'moderate' malnuhihon, 5ee footnote 2 Source: B E (1990).

according to socio-economic position: any improvement in the latter benefits the male child more than the female (Bairagi 1981). It would be interesting to investigate in detail the patterns of sex differentials in child nutrition in Indonesia, if any, and their underlying causes, by collecting data on food allocation, medical treatment and other information which could identify possible gender bias. This has been investigated for rural West Sumatra in the first author's PhD thesis.

However, the present data (table 1) show that the problems of malnutrition are critical at ages 6 4 7 months, especially in rural areas, and are more prominent for boys.

Household Expenditure. Table 2 shows that moderate and severe malnutrition is highest among households with a monthly expenditure below Rp 25,000 (approximately $12 in 1986). But the reduction in the prevalence of moderate and severe malnutrition is not clearly discernible after household expenditures increase beyond Rp 50,000 per month This may indicate that household expenditure is not the only factor determining malnutrition. The importance of maternal education is documented elsewhere as a major contributor to reducing malnutrition, alongside household expenditure (BPS 1990). Further

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Child Malnutrition in Indonesia 103

studies are needed to examine how maternal education and household expenditure contribute towards improving nutritional status in Indonesia.

Regional Evidence on Malnutrition Regional Variation in Malnuhffion Levels and Trends. The prevalence of malnutrition and the rate of its reduction varies among provinces. If the provinces are classified into three categories according to prevalence of protein energy malnutrition-'low' (10% or less), 'medium' (10.1 to 15%) and 'high' (more than 15%)-then it is seen that South Sumatra, Central Kalimantan and Southeast Sulawesi experienced a large change, from the 'high category in 1986 to the 'low' in 1989 (table 3). In some other provinces, e.g. Aceh, hlaluku and Central Sulawesi, the change was moderate, from 'high' in 1986 to 'medium' in 1989. West Kalimantan, South Kalimantan and West and East Nusatenggara remained in the 'high' prevalence category during 198649, although all these provinces except South Kalimantan experienced large declines in the actual prevalence of protein energy malnutrition (BPS 1992a, table 8.a).

Although poverty reduction may not always imply lower levels of malnutrition, the picture for malnutrition is similar to that for the reduction of poverty between 1984-1987 and 1987-1990 in these province^.^ Over 20% of the population of West Nusatenggara, East Nusatenggara, West Kalimantan and South Kalimantan has been classed as poverty stricken; most of the population in these provinces is engaged in self-employed rural farming (Huppi and Ravallion 1991, p. 1,663).

A comparison between Yogyakarta and Aceh is interesting in this context. The percentage of the population below the poverty line in 1990 is similar in the two provinces--l5.5% in Yogyakarta and 15.9% in Aceh (BPS 1992b).6 However, the percentage of children suffering from moderate and severe malnutrition in Aceh is twice as high as in Yogyakarta. As Rusman (1991, p. 208) states, socio-cultural factors, 'khere the culture was compatible with the centralised government approach, and where the role and status of women was comparatively

These poverty reduction data are contained in an appendix avallable from the second author. 6Bidani and Ravallion (1993) show that Yogyakarta actually fares worse than Aceh in terms of food and total poverty indicators when new poverty mdices are calculated after taking into account local purchasing power.

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Child Malnutrition in Indonesia 105

TABLE 4 PIevalmce ofProtf+n Energy Malnut i t i d m g children byPmnitlceandSex,1986,1987,and 1989

(%)

Province Bays Girk 1986 1987 1989 1986 1987 1989

Aceh N Sumatra W Sumatra Riau Jambi s Sumatra Bengkulu La rn p u n g

DKI Jakarta W Java C Java Kogyaakarta E lava

Bali W Nusatenggara E Nusatenggara Timor Timur

W Kalimantan C Kalimantan S Kalimantan E Kalimantan

N Sulawesi C Sulawesi S Sulawesi SE Sulawesi

Maluku Irian Jaya

Indonesia

20.9 14.4 20.3 15.3 17.7 20.7 15.4 14.1

11.0 17.4 15.2 7.9

15.4

3.4 23.4 29.7 26.5

29.9 21.2 22.6 15.2

12.3 20.3 15.5 15.1

16.9

1 7 1 15.5 13.6 18.0 20.4 19 4 9.4 9.1

14.7 15.3 14.7 4.0

13.2

8.3 22.7 18.0 38.3

24.8 20.5 21.6 15.8

10.7 12.9 18.0 20.5

21.5 17.6

16.4

19.6 16.0 10.0 14.9 8.8 9.6 5.1 9.9

12.4 12.8 11.5 6.5

12.3

6.4 18.2 24.8 29.7

18.0 13.3 20.9 8.1

7.4 13.6 16.1 8.7

16.4 17.1

13.8

10.5 6.9

12.6 9.9

11.7 11.1 12.4 9.5

7.8 10.1 9.8 5.9

10.0

5.3 19.0 16.3 17.7

18.1 11.6 10.4 10.2

11.3 14.6 12.5 15.1

10.8

9.0 8.6 7.9 11.4 6.5 10.1

12.0 6.8 8.7 8.8 7.1 8.3

10.1 9.2 8.1 8.5

5.8 6.6 10.7 8.8 7.9 8.6 5.6 4.1 7.9 9.0

4.0 3.2 12.7 12.5 12.0 8.3 8.0 17.2

11.5 13.4 6.4 6.7

11.1 10.3 5.8 2.7

8.1 7.3 15.5 8.9 9.9 9.8 6.9 5.7

7.7 8.4 10.7 11.8

9.3 9.0

aFor a definition of Protein Energy Malnutrition ( E M ) see footnote 2 Source: BPS (1992a). tables 8.b and 8 r .

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106 Elfindri and Gouranga Lal Daw-

TABLE 5 Relatiaships between Selected Dependotf Varinbles and h e 1 of Poverty by Promnce, 198P

Dependent Variables beta t R2

%of PEM children (both sexes) .58 2.82.. .33

% of PEM boys .59 2.93'. .A5 %of PEM girls .23 .93 .05

%of PEM rural chiidren (both sexes) .a 1.86' .18

aJambi, Bengkulu, Timor Timur, Central Kalirnantm, East Kalimantan, Central Sulawesi, Southeast Sulawesi, Maluku, Irian Jaya are not included in the regression analysis. 'Significant at .05 level. 'Significant at .01 level. Source: Authors' calculations.

malnutrition has either increased or remained unchanged. Malnutrition has been relatively high among boys in most of the provinces of Sumatra, and in West and East Nusatenggara, Timor Timur, West Kalimantan and South Kalimantan.

Socio-economic Factors-Regional Evidence. A study in East Kusatenggara carried out by Wilopo (1990, pp. 31&23) concluded that socio-economic factors did not affect the nutritional status of children, because of the utilisation of posyandu. However, given the BPS (1990) finding that maternal education has a strong effect in reducing malnutrition among children, and given that the educational level of most mothers in the Susenas East Nusatenggara sample is primary school or under, it is highly probable that the low educational levels of mothers are indeed an obstacle in efforts to reduce malnutrition.

Estimating the Impact of Poverty The question can also be asked whether a reduction in poverty during the 1980s in Indonesia has been associated with a corresponding reduction in the proportion of malnourished children. An attempt has been made to answer this question using a simple Ordinary Least

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Child Malnutrition in Indonsia 107

Square (OLS) regression analysis on the basis of cross-provincial data. In this analysis the dependent variable is the proportion of children classified as malnourished, and the independent variable is the proportion of the population below the poverty line. The OLS regression is carried out separately for male and female children and for both sexes combined.

The analysis shows that provincial reduction in poverty has a statistically significant influence on reductions in malnutrition among male children and children of both sexes combined, but the influence is not significant for female children (table 5 ) . A similar conclusion can be drawn for rural areas, where the highest concentration of poverty is found, The beta coefficients imply that where the regressions are significant, a 10% reduction in the proportion of the population under the poverty line would be accompanied by a fall of between 4.3% and 5.9% in the number of children suffering from protein energy malnutrition. Table 5 shows some important results, but it would also be interesting if the analysis could be done separately for age (in months), for income and for urban areas. However, because of small sample sizes, it was not possible to analyse the age and urban aspects. Since income data are not published, information about the percentage of the population below the poverty line has been used here as an indicator of income.

Estimated Number of Malnourished Children in the 1990s Malnutrition can be measured not only in t e r n of prevalence, but also in terms of numbers. Table 6 estimates the number of children who will suffer from moderate and severe malnutrition in the 1990s. The prevalence figures are taken from the 1989 Susenas results. It is estimated that around 2.5 million children will suffer from moderate and severe malnutrition and three to four hundred thousand children from severe malnutrition.

With declining poverty and improving female education the actual number of malnourished children will probably be less than that shown in table 6, though the prevalence figures for 1989 are not expected to decline by much in 1990. The estimated number of malnourished children in 1990, based on the 1989 prevalence figures, provides an upper bound.

Muhilal and Soekirman (1986) show that as a consequence of malnutrition roughly 50 to 70 thousand children will suffer from blindness because of vitamin A deficiency. Since moderate and severe malnutrition is strongly associated with mortality (Kielman and McCord 1978), the current nutritional problem should be taken into account in planning the nation's health and population programs.

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108 Elfindri and Gouranga La1 Dasvanna

TABLE 6 Rough Estimation offhe Number OjMalnounshed Children in the 1990s In Indrmesia

Prevalence Estimates of (94 Mahourished

Childrena ('000)

Moderate and Severe Girls

High Medium Low

Bsw High Medium Low

High Medium Low

Total

Severe Only Girls

High Medium Low

Bsvs High Medium LOW

Total High Medium Low

11.0 9.0 7.0

15.0 13.0 11.0

2.0 1.5 1.0

2.0 1.5 1 .o

1,193.7 968.5 753.3

1,Y3.6 1,329.2 1,124.7

2,717.3 2,297.7 1,878.0

215.2 161.4 107.6

204.5 153.4 102.2

419.7 314.8 209.8

aThe estimated number of malnourished children is obtained by multiplying the prevalence rates from the 1989 Susenas with the number of males and females 0-4 years of age from the 1990 Census results-10,224.3 and 10,760.9 respectively. Sourcrs: 1989 Susenas; 1990 Census.

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Child Malnuhition in Indonesia 109

C 0 N C L U S IO N

The analysis in this paper is based on published data from the National Socic-economic Surveys (Susenas) of 1986,1987 and 1989 conducted by the Indonesian Central Bureau of Statistics.

The analysis supports findings in other countries (WHO 1989) that the prevalence of malnutrition increases with age among children from six months to four years. Male malnutrition is higher than female malnutrition, and the incidence of malnutrition is higher in rural than in urban areas. In general the prevalence of malnutrition in Indonesia declined between 1986 and 1989. However, for some provinces the decline was not as large as for others, and for some there was an apparent increase. This study has shown that the reduction of malnutrition is strongly associated with a decline in the incidence of poverty, although socio-economic factors including maternal education may also have an important bearing on child nutrition.

Poverty alleviation is an integral part of development. Along with efforts to reduce the proportion of the population below the poverty line and to improve the fulfilment of basic social needs in the population, an appropriate nutrition policy could be directed toward 'high risk groups. Improvement in economic status is not a necessary precondition for combating malnutrition. The nutrition policy should also be concerned with increasing the knowledge of mothers about feeding practices.

This analysis describes malnutrition in Indonesia with particular reference to the nutritional stabs of preschool children. Available data permit the assessment of nutritional status only on the basis of standardised weight for age, which does not reflect the total picture of malnutrition. It is suggested that in future surveys data be collected about standardised height for age (stunting) and weight for height (wastmg), to give a more accurate picture of malnutrition at the national and provincial levels. In addition, data should be collected on all feeding practices, to shed light on the impact of breastfeeding and supplementary feeding on nutritional status.

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