Investing in 51935 School Health and Nutrition in Indonesia Joy Miller Del Rosso Rina Arlianti OctOber 2009 Table of contents table of contents i list of tables, Figures, Boxes, and Maps ii acknowledgement iii acronyms iv list of Provinces v 1. Executive Summary 1 Poor health and nutrition among school-age children in Indonesia 2 Potential gains from Improving school-age health and nutrition 3 Building Blocks for school health and nutrition Investment in Indonesia 4 2. Summary of Recommendations and Next Steps 6 3. Introduction 8 shn and the Millennium development goals 10 4. Poor Health and Nutrition Impact on Education 11 Infectious disease at school-age 12 - diarrhea and typhoid 12 - acute respiratory Infection 13 - Malaria 14 - Intestinal Parasitic Infection 14 hunger and Malnutrition at school-age 16 - stunting at school-age 16 - Micronutrient deficiencies 20 > Iron deficiency 20 > Iodine deficiency 21 sensory Impairment 22 I Preparation of this document Water and sanitation 22 received partial funding from the 5. Potential Gains from Improving School-Age Health and Nutrition 23 InvestIng In school health & nutrItIon In IndonesIa netherlands and european com- education sector 24 mission Basic education capacity trust Fund under the supervision - Key education Indicators 24 of the World Bank. the findings, > enrollment 24 interpretations, and conclusions > attendance/Participation and Progress 25 expressed in this paper are that of the author and do not necessar- health sector 26 ily reflect the views of the World 6. Building Blocks for SHN Investment in Indonesia 27 Bank, the government of the Introduction 27 netherlands, the european com- mission, or the government of the uKs Program 28 Indonesia. the World Bank does - Institutional structure of uKs 29 not guarantee the accuracy of the - strengths and Weaknesses of uKs 29 data included in this work Water and sanitation in schools 30 all pictures: antara Public health center and schools 31 school Feeding 31 Private sector and ngo-supported school-Based services 31 7. Recommendations and Next Step 32 recommendations 34 reprInted In June 2010 next steps 35 8. References 36 List of Tables Acknowledgement Table 1: cost-effectiveness of school health and nutrition 9 Table 2: school health and nutrition overview 10 this document is the result of a situational analysis to assess the current school health Table 3: Pre and Post Program-level Intestinal helminth Infection rates 15 and nutrition situation, policies, institutional mechanisms and on-going school health and nutrition activities/programs in basic education in order to identify opportunities/ Table 4: consequences of Micronutrient deficiency on health, development 20 ways to strengthen and expand school health and nutrition in Indonesia. the situational and education analysis was conducted in 2009 by Joy del rosso (Manoff group, Washington dc) Table 5: access to clean Water and sanitation--cross country comparison 22 with the assistance of rina arlianti (consultant). over the period of the mission, the Table 6: Basic education statistics 24 two consultants worked as a cross-sectoral team to conduct field visits, meetings Table 7: adolescent risk Behaviors in Indonesia 26 and reviews and analyses of documentation related to school health and nutrition in Indonesia. Field visits were conducted in Malang and Batu. Table 8: Illustrative school Water and sanitation Initiatives 30 one of the major resource persons was dr. Widaninggar Widjajanti, the head of the national centre for Physical Quality development, Ministry of national education. From List of Figures Bappenas, the resource persons were suharti, head of sub directorate For Basic and early childhood education, and Yosi diani tresna, head of sub directorate for health Promotion and community nutrition. other resource persons came from the Ministry Figure 1: Prevalence of diarrhea in school age children 5-14 Years old 12 of health; Ministry of home affairs; Ministry of religious affairs; directorate for tK & by Province sd development and directorate for sMP development; key donor partners in shn including unIceF, World Food Program (WFP), World health organization (Who), Figure 2: typhoid Prevalence among children 5-14 Years by Province 13 Micronutrient Initiative (MI), usaId environmental services Project (esP); and a major Figure 3: Percentage of arI among children 5-14 Years by Province 13 non-governmental organizations working in shn: Yayasan Kusuma Buana. Figure 4: Percentage of Malaria among children 5-14 Years by Province 14 the city of Malang was recommended as one of the best districts managing the usaha Figure 5: stunting among children 6-15 Years by Province 17 Kesehatan sekolah (uKs). In Malang, the resource persons are from the education Figure 6: stunting by age and residence 17 district office, Puskesmas (health center), principals and teachers of selected sds Figure 7: (primary schools) and sMPs (junior secondary schools). similarly in Batu, resource trend in stunting 1993-2007 by age 18 persons are from the education district office, Puskesmas, principals and teachers of II Figure 8: trend in stunting 1993-2007 by residence 18 selected sds and sMPs. III Figure 9: Percentage of BMI > +1sd children 6-15 Years, by Province 19 the World Bank provided technical and financial support under the overall supervision Figure 10: trend in BMI >+1sd children 5-19 Years, by residence 1993-2007 19 InvestIng In school health & nutrItIon In IndonesIa InvestIng In school health & nutrItIon In IndonesIa of Mae chu chang, human development sector coordinator; sheila town, operations Figure 11: rates of Iron deficiency anemia by age, gender and over time 21 officer, and claudia rokx, lead health specialist. the financial support was provided Figure 12: three Pillars and Major activities of the uKs Program 28 through the Basic education capacity trust Fund (Bec-tF). eko setyo Pambudi assisted with generating graphs and figures from existing data. Figure 13: typical school health and nutrition Interventions 28 a seminar at the end of the study was conducted by Bappenas chaired by dr. taufik hanafi, director for religious affairs and education. List of Boxes Box 1: double Burden of Malnutrition in school-age children 19 Box 2: Preventing the spread of hIv/aIds 26 Box 3: Improving school canteens 29 List of Maps Map 1: Percentage of households using Iodized salt 21 Map 2: net enrollment in Junior secondary school 25 Acronyms List of Provinces ARI acute respiratory Infection Abbreviation name of Province BAPPENAS Badan Perencanaan Pembangunan Nasional (national Planning agency) Aceh nanggroe aceh darussalam BIAS Bulan Imunisasi Anak Sekolah (school Immunization Program) Sulut sulawesi utara EPI expanded Program on Immunization Sumbar sumatera Barat FRESH Focusing resources on expanded school health Riau riau GOI government of Indonesia Jambi Jambi IDD Iodine deficiency disorders Sulsel sulawesi selatan IQ Intelligence Quotient Bengk Bengkulu IRD International relief and development Lampung lampung MDG Millennium development goal Babel Kepulauan Bangka Belitung MoNE Ministry of national education Kepri Kepulauan riau MoH Ministry of health Jakarta dKI Jakarta MoHA Ministry of home affairs Jabar Jawa Barat MoRA Ministry of religious affairs Jateng Jawa tengah MOU Memorandum of understanding Yogya dI Yogyakarta NGO non-governmental organization Jatim Jawa timur NHHS national health and household surveys Banten Banten Puskesmas Public health center Bali Bali SD standard deviation NTB nusa tenggara Barat SHN school health and nutrition IV NTT nusa tenggara timur V SISWA system Improvement for sector-Wide approaches Kalbar Kalimantan Barat SPM Standar Pelayanan Minimal (Minimum standards of service) InvestIng In school health & nutrItIon In IndonesIa InvestIng In school health & nutrItIon In IndonesIa Kalteng Kalimantan tengah UKS Usaha Kesehatan Sekolah (school health Program) Kalsel Kalimantan selatan UNESCO united nations educational, scientific and cultural organization Kaltim Kalimantan timur UNICEF united nations children's Fund Sumut sumatera utara USDA united states department of agriculture Sulteng sulawesi tengah USAID united states agency for International development Sumsel sumatera selatan WFP World Food Program Sultra sulawesi tenggara WHO World health organization Goron gorontalo YKB Yayasan Kusuma Buana Sulbar sulawesi Barat Maluku Maluku Malut Maluku utara Pabar Papua Barat Papua Papua 1. Executive Summary School health and nutrition (SHn) interventions are important investments for education since poor health and nutrition among school-age children impede achieving education objectives. diseases and malnutrition affect children throughout child- hood and while school-age children are at lower risk for dying from these conditions, disease and malnutrition take their toll on participation and progress in school and learning. 1 hungry and poorly nourished school-age children have this framework specifies four core components to lower cognitive abilities--beyond any losses to cognition consider when designing school health and nutrition InvestIng In school health & nutrItIon In IndonesIa that may have resulted from nutrition deficits and poor programs: health-related school polices; provision of health suffered during their pre-school years or earlier-- safe water and sanitation; skills-based health education; and naturally perform less well and are more likely to and school-based health and nutrition services. shn repeat grades and drop out of school than children interventions also improve equity. diseases and some without impairments. the irregular school attendance of forms of malnutrition affect the poor more than the non- malnourished and unhealthy children is one of the key poor. children from poorer households are also less able factors in their poor performance. to have access to or afford treatment. shn interventions redress this inequity and unlike many educational Many of the diseases and malnutrition that impact interventions such as text-books, teacher training or school-age children are preventable and/or treatable. others that may tend to benefit the highest achieving schools offer a readily available infrastructure to reach students the most (possibly increasing inequality in the children and since some treatments are inexpensive, shn education system), shn benefits the poorest children interventions are among the most cost-effective health more and helps those who are most disadvantaged the interventions. Focusing resources on effective school chance to take better advantage of their educational health (Fresh) is a framework developed through opportunities. interagency efforts to promote and support effective school health and nutrition policy and programming that was launched in 2000 at the dakar education for all Forum. in childhood through the school-age years. data on can encourage or discourage attendance. girls, in micronutrients among school-age children in Indonesia particular, may choose not to go to school rather than are limited. anemia affected about half the population have to deal with inadequate facilities. When a school of school age children (5-9 years) and (10-14 years) in lacks access to a basic water supply and sanitation 1995. the use of iodized salt nationally in 2001 was 66 facilities and its students have poor hygiene habits, percent; district level results showed district-level use the incidence of major childhood illnesses increases Poor Health and of iodized salt varied significantly from 9 to 100 percent adversely affecting school children's participation and with 21 percent of districts reporting adequate household learning capacity. Much more progress is needed in Nutrition among consumption rates below 50 percent. Indonesia both in improving access to clean drinking water and improved sanitation. School-Age Children children spend a significant amount of time in and around their schools and appropriate facilities at school in Indonesia Many of the diseases afflicting children in young childhood (0-5 years) persist during the school-age years, especially in the early school years Potential Gains from (6-8 years). Malaria, acute respiratory infection and diarrhea continue to Improving School-Age cause significant morbidity and in some cases mortality among the school- Health and Nutrition age population. Other diseases may become more prevalent and intense among school-age children. data on reported prevalence of non-specific diarrhea are at risk for infection and that very few are reached with and typhoid among school-age children in Indonesia treatment. 2 show that the proportion of children affected by province 3 ranges from 2 to 20 percent for diarrhea and from less chronic undernutrition measured by height-for-age, A country's education and economic status is closely linked to its health an indication of a lack of food experienced over an than 1 to more than 3 percent for typhoid. status: improve nutrition and health and education and the economy will be InvestIng In school health & nutrItIon In IndonesIa InvestIng In school health & nutrItIon In IndonesIa extended period of time is associated with lower school rates of acute respiratory infection (arI) at school-age performance. national level data show rates of stunting are almost uniformly high; 20 percent or higher across all range from about 20 to more than 50 percent by province strengthened. bettering nutrition and health among the school-age chil- provinces and 30 percent or higher in almost half of all and, in the overwhelming majority of provinces, more dren, like the critical effort to improve nutrition and health among infants, provinces. Malaria has been identified as a major cause of than a third of children 6 to 15 years old are stunted. shn school absenteeism and lower educational achievement. interventions are not typically designed with the intent of is a strategic element in the effort to develop the community. Healthier and In Indonesia, malaria is not a universal problem as most alleviating stunting particularly since most stunting has parts of the country are no longer seriously affected by occurred by the age of two. however, levels of stunting at better nourished children stay in school longer, learn more, and become the disease. the exception is at least three provinces the province, district and sub-district level can be useful healthier and more productive adults. (Papua, Papua Barat, and ntt) where rates among for targeting and monitoring shn interventions. also, school-age children range from as high as almost 70 it might be possible to expect some residual benefits of percent in Papua to about 15 percent in ntt. improvements in height-for-age, especially in the early addressing nutrition and health among school-age about 686,000 (142,000 boys; 544,000 girls) primary (kindergarten and primary) school years or during the It is well known and documented that worm infections children does more than improve the health and school children are out of school in Indonesia. regional adolescent growth spurt by addressing food insufficiency reach their peak in school-age children in countries where learning capacity of the treatment group; it also brings variations also exist; Papua lags significantly behind at school age. these infections are not under control because of poor or intergenerational nutrition and health benefits and even in primary school with net enrollment at about deficient water and sanitation systems. Worm infections among the most critical micronutrient deficiencies long-term economic gains as well. girls who stay in 80 percent and about 47% at junior secondary. other can play a significant role in the nutrition and health at school-age are iron deficiency anemia and iodine school longer tend to delay childbearing longer than provinces lag behind the national average at junior status of school-age children and where highly prevalent deficiency disorders (Idd). Iron deficiency anemia school-leavers, and merely delaying childbearing brings secondary level including Maluku, ntt (both at 47%) they contribute to absenteeism and reduced learning affects mental development and cognitive abilities and the intergenerational benefits of a lowered birth rate, and gorontalo (52%). despite progress in the transition capacity resulting in lower educational attainment. during pregnancy Idd puts girls/women at high risk for better birth outcomes, and better child health. the from primary to junior secondary school, only about 55 Indonesia is identified by Who as one of the countries complications. Idd are also directly related to cognitive gain from improving health and nutrition at school age percent of children from low-income families are enrolled where worm infections represent a public health problem; impairment both if experienced in-utero when cognitive is a combination of all of these benefits to health and in junior secondary schools. encouraging and supporting Who estimates suggest that more than 17 million people effects can be severe and when deficiency is suffered education, in the short-term and future. efforts to help children enroll in and complete the basic education cycle remain high priority for the education childbirth. schools can provide the infrastructure to easily the purpose of uKs is to improve the quality of education national education to improve the water and sanitation sector. Providing a healthy environment for children and reach girls with high priority education and health and and student learning achievement by: increasing environment at schools. a network for environmental overcoming any health and/or nutrition (hunger) barriers nutrition services. healthy life skills of students; creating a healthy school sanitation and clean water at schools is being established to school enrollment and participation are important for environment; and improving knowledge, changing to help coordinate implementation of various activities Young people must have access to information and reaching education goals. students' attitudes, and maintaining health by preventing and programs. skills to be able to protect themselves from high risk and curing diseases. this goal is reflected in the three at school-age, especially in adolescence, young people behaviors--smoking, alcohol, reproductive and sexual the school Immunization Program--Bulan Imunisasi program pillars--health education, health services at begin to make independent decisions about their health health, including hIv/aIds. schools may offer one of Anak Sekolah (BIas)--represents perhaps the most schools and healthy school environment. and to form attitudes and adopt behaviors that influence the best venues for reaching all young people with the consistent and effective health center - school linked their current and future health as well as the health of information and education that will help them lead at the school level the headmaster and one or more uKs health service provision. Introduced in 1998 initially as their future children. girls, particularly adolescent girls, healthier and safer lives. In addition, schools are also the teacher/"gurus" are appointed to oversee uKs activities a long-term control of tetanus by providing life-long are the key to the health of future generations. good best opportunity for promoting appropriate nutrition, in the school. the school is expected to collaborate immunity to all primary school graduates and diphtheria physiological development during adolescence prepares food choices and physical activity to help prevent with health center staff to implement some of the uKs boosters, the BIas program was integrated within the girls for pregnancy, childbirth, and motherhood. ensuring overweight in children. the proportion of school-age activities. the central level, primarily thought the Mone, existing uKs structure. In practice, uKs does not appear that girls are well nourished and healthy--especially children in Indonesia with a high Body Mass Index (BMI) plays a role in setting standards, providing guidelines to play a major role in implementation. the responsibility regarding their increased needs for iron and for growth is alarmingly high in some provinces and appears to have and establishing expectations for the uKs program. for the BIas program is through expanded Program on before the reproductive years begin--will decrease dramatically increased in the past seven years. effective despite the creation of the uKs program in Indonesia Immunization (ePI) and health workers work directly with the incidence of low birth weight and birth defects in promotion of key health, nutrition and physical activity many decades ago, remarkably little data and information schools without uKs support. their children and will reduce their risk of dying during practices is crucial to alleviating the significant burden of are available on the investment in the uKs program the Ministry of home affairs (Moha) maintains a overweight, obesity and non-communicable diseases. at any level--central, district, sub-district, school--or department responsible for school feeding although the impact of its programs and activities. as a national resources for programs now need to be allocated by the program implemented within a decentralized system, district so the central role is limited and uncertain. Prior what happens under the uKs program in one district may to decentralization, school feeding was a major program look very different than what is supported in another if under BaPPenas, the national development Planning a uKs program exists at all. at the province and district agency. currently, school feeding is the responsibility of Building Blocks for level the resources devoted to uKs are dependent on district/city government and not all districts implement the commitment of local legislative and decision-making programs. Moha ostensibly coordinates school feeding School Health and bodies. implementation and guidelines are now in the process the draft minimum level of services (Standar Pelayanan of review and revision. In 2009 school feeding continues Nutrition Investment Minimum/sPM) for schools includes standards for a under the auspices of the World Food Program (WFP). clean water supply and adequate sanitation facilities­ several non-profit organizations carry out relatively small- in Indonesia hand washing facilities and toilets. several efforts scale deworming and iron supplementation programs in 4 are underway under the auspices of different donor various regions of the country. 5 institutions and the Ministry of health and the Ministry of InvestIng In school health & nutrItIon In IndonesIa InvestIng In school health & nutrItIon In IndonesIa national policies on school health have been in place since the 1950s. In the 1970s a task force for education and health was formed to implement health at the primary school level. In 1984 a school health policy and memorandum of understanding (MOu) was created that involved four ministries: Ministry of national education (Mone), Ministry of religious Affairs (MorA), Ministry of Health (MOH), and Ministry of Internal Affairs (now called Home Affairs) leading to the usaha Kesehatan Sekolah (uKS) School Health program. Recommendations Target SHN interventions where education outcomes are low and health insults and poor nutrition status or hunger are high -- the investment in shn programs must give highest priority to those districts and schools where health and nutrition are inhibiting 2. Summary of access, participation and progression in school, especially among girls. Strengthen collaboration within the education sector between MoNE and MoRA and between health and education -- shn is aimed first and foremost at helping to achieve Recommendations education goals, and the Ministry of national education and Ministry of religious affairs should continue to take the lead in shn. collaboration with the health sector is essential as the interventions require health sector guidance and support. and Next Steps Take advantage of the returns from certain low-cost SHN interventions by identifying and implementing district-level approaches to remediation -- Providing mass delivery of some shn services at the district level may make sense if health problems affect a large proportion of the school-age population in a certain area/district. Identify and develop a set of "packages/models" that take into account the three main contexts in Indonesia, urban, rural, island/coastal and also the type of school (e.g., boarding) -- the Fresh framework for shn provides overall guidance for shn interventions but specific models for the main Indonesia contexts need to be developed. Continue and expand on the current efforts to ensure clean water and adequate sanitation at all schools-- support for long-term solutions to water and sanitation at schools should be complemented by alternative technologies to ensure clean water (e.g., purification) and low-cost latrines at schools. Improve the quality of health education/behavior focused communications -- effective health, hygiene, nutrition and other education is required to promote practices linked to school-based services, (e.g., clean water, hand washing, etc.) and to develop other healthy behaviors. Develop separate model (or models) for stemming the tide of overweight and obesity 6 7 -- although not directly related to education, the seriousness of the increase in the issue the health and nutrition status of school-age children in of overweight in children in Indonesia suggests that strategies to promote appropriate nutrition and physical activity practices should be an element of shn in some contexts. InvestIng In school health & nutrItIon In IndonesIa InvestIng In school health & nutrItIon In IndonesIa Indonesia are likely to be important factors in the achieve- ment of "education for all" and MdG goals. If students are not healthy and well-nourished schools cannot achieve Next Steps their primary mission of providing effective, efficient and equitable education. the interventions to address some of ˇUtilizeon-going"goodpracticesinbasiceducation"mechanismstoidentifylocal private sector, NGO and/or government-supported school-based health and the major health and nutrition impediments to learning are nutrition interventions/programs that offer potential for creating context-specific "good practice models" for shn. document and package these "good practices" highly cost-effective and benefit the poor and disadvan- linked to specific contexts. taged children more than other education interventions ˇCreateaSHN"toolkit"andtrainingmodulesbuildingoffofthe"goodpractice" and international experience. the tool kit would be for use at the district and school while also reducing gender inequities. level to raise awareness and build capacity in identifying and addressing health and nutrition needs among school-age children in different contexts. ˇConductanin-depthinstitutionalcapacityassessmentatvariouslevels including national, district, sub-district and school to identify approaches to and needs for capacity building to support additional promotion and implementation of school health and nutrition interventions. that said, growth and development continue throughout the irregular school attendance of malnourished and the school-age years. In adolescence alone, children gain unhealthy children is one of the key factors in their poor as much as 15 percent of adult height and 50 percent of performance. adult weight, and prior to that period children continue to Yet, many of the diseases and malnutrition that affect gain height and weight. school-age children are preventable and/or treatable. hungry and poorly nourished school-age children have Furthermore, since schools offer a readily available lower cognitive abilities, beyond any losses to cognition infrastructure to reach children and some of the that may have resulted from nutrition deficits and poor treatments are inexpensive, school-based health and health suffered during their pre-school years or earlier. nutrition interventions are one of the most cost-effective children with diminished learning capacity and sensory health interventions (see table 1). this estimate of cost- 3. Introduction impairments naturally perform less well and are more effectiveness is without consideration of the effectiveness likely to repeat grades and to drop out of school than of shn in improving educational outcomes which, if children who are not impaired. they also enroll in included, would further increase the cost-effectiveness of school at a later age, and finish fewer years of schooling. shn. Table 1: cost-effectiveness of school health and nutrition Intervention Cost per DALY* gained Immunization Plus 12-30 school health and nutrition** 20-34 Family Planning services 20-150 Integrated Management of childhood Illness Program 30-100 Prenatal and delivery care 30-100 tobacco and alcohol Prevention Program 35-55 * disability adjusted life Year--a unit used to measure both global burden of disease and the effectiveness of health interventions, as indicated by reduction in the disease burden. (World development report, 1993) **Includes treatment of worm infection, micronutrient deficiencies and provision of health education source: Bobadilla, et al., 1994 8 9 1 School-age children (5-18 years) represent an important InvestIng In school health & nutrItIon In IndonesIa InvestIng In school health & nutrItIon In IndonesIa shn interventions are also attractive for their ability to highest achieving students the most, and as a result may and diverse target group for health and nutrition interven- improve equity. diseases and some forms of malnutrition increase inequality in the education system, shn benefits affect the poor more than the non-poor. and, not only the poorest children more and helps those children tions. children who have reached their fifth birthday are are children from poorer households more likely to who are most disadvantaged the chance to take better well past the period of high risk for child mortality, and suffer from diseases, but they are also less able to cope advantage of their educational opportunities.3 all told, with them--have access to or afford treatment. shn improving or maintaining good health and nutrition at any insults to health and nutrition suffered prior to age interventions/programs can redress this inequity in school-age can reap significant benefits for both health access to health and nutrition care. Furthermore, unlike and education through a combination of immediate and five, particularly during the first two years of life, may have many educational interventions such as text-books, long-term returns for individual children, families and caused irreversible damage affecting the child's capacity teacher training or others that may tend to benefit the nations. to achieve his/her full potential both in terms of physical and mental growth and development.2 1 classification of school-age varies by country and agency. the primary focus of this report is children ages 5-18 years including kindergarten (5-6 years); primary school (6/7-12-years); and junior secondary (13-15 years). 2 repositioning nutrition as central to development, World Bank, 2006 3 Jukes, drake and Bundy, 2008 SHN and the Millennium Development Goals (MDGs) 4. Poor Health and simply stated, school health and nutrition (shn) term hunger. on the health side (learn to be healthy), comprises interventions or programs that are aimed at schools are an important forum for health and nutrition ensuring that children are `healthy to learn and learn to education, including hIv/aIds prevention as well as for be healthy' (see table 2). on the education side (healthy other interventions to redress the impact of malaria and Nutrition Impact to learn) addressing poor health and nutrition at school- other infectious diseases related to Mdg #6. taking a age is important for the achievement of "education life cycle approach, shn can focus on adolescent girls for all" and related Mdg goals, particularly those that and potentially play a role in achieving Mdg #5 related on Education address access, gender equity and the quality of basic to maternal health. In short, the link between the shn education. education is an essential part of achieving and the Mdgs is through a combination of education and Mdg #1 (alleviation of poverty and hunger) and school health impacts the result of shn programming. feeding can specifically contribute to alleviating short- Table 2: school health and nutrition overview Healthy to Learn Learn to be Healthy Well-nourished appropriate behaviors related to health, not hungry nutrition, sanitation, etc. to maintain current and future health Free from disease safe school environment no unaddressed sensory Impairments appropriate behaviors to avoid risky behaviors (tobacco, hIv/aIds, other) support for special needs 10 11 Many of the diseases afflicting children in young child- InvestIng In school health & nutrItIon In IndonesIa InvestIng In school health & nutrItIon In IndonesIa hood (0-5 years) persist during the school-age years, especially in the early school years (6-8 years). Malaria, acute respiratory infection and diarrhea continue to cause significant morbidity, and in some cases, mortality among the school-age population. Other diseases, most notably, intestinal parasitic infections may become more prevalent and intense among school-age children. Health and nutri- tion status is a powerful determinant of learning capacity and how well a child performs in school. poor health can diminish a child's cognitive development either through physiological changes or by reducing the ability to partici- pate in learning activities--or both. Infectious Disease at School-Age Figure 2: typhoid Prevalence among children 5-14 Years by Province* 3,5 3 school-age children (5-14 years) in Indonesia have are less affected than younger children, infectious the lowest rates of mortality among all age groups diseases at school-age continue and are certain to 2,5 representing 1.9 percent of total mortality compared to negatively impact educational outcomes. Province-level 2 2.6 and 9 percent for children 1-4 years and less than one, prevalence information too masks variability in disease 1,5 respectively.4 these national level mortality data hide rates at the district and sub-district levels which are likely 1 what are likely to be significant regional and district-level to show certain areas within the province as a whole with 0,5 variations in mortality even at school-age. For morbidity, high rates of infectious disease at school-age. the same pattern holds true; while school-age children 0 Babel Jambi sumbar Jabar sulut sumsel lampung Pabar Jakarta Bali Kalsel Banten Kalteng Kepri Kaltim riau sumut Malut Kalbar sulbar sulsel Jatim Jateng Bengk sulteng aceh goron Papua Yogya sultra ntB ntt Maluku Diarrhea and Typhoid source: riskesdas Province reports, 2007 *Provinces are presented left (lowest) to right (highest) according to level of poverty data on reported prevalence of non-specific diarrhea (see Kalimantan selatan and Banten rates of typhoid are more Figure 1) and typhoid (see Figure 2) among school-age than 3 percent. typhoid is a serious infection, associated children show that the proportion of children affected with poor food hygiene and inadequate sanitation and ranges from 2 to 20 percent for diarrhea and from less in endemic areas incidence often peaks at school-age. Acute Respiratory Infection than 1 to more than 3 percent for typhoid. aceh stands More severe cases of diarrhea and typhoid among out as the province with the highest prevalence of school-age children would contribute to absenteeism and rates of acute respiratory infection (arI) at school-age diarrhea (20 percent) and also with a high rate of typhoid diminished learning opportunities. are almost uniformly high; 20 percent or higher across (almost 3 percent). even in some less poor provinces, all provinces and 30 percent or higher in almost half of provinces. no information is available on the severity Figure 1: of infection however these rates of infection suggest an Prevalence of diarrhea in school age children 5-14 Years old by Province* impact on school attendance and performance as illness diminishes child learning capacity and achievement. 25 20 Figure 3: 12 15 Percentage of arI among children 5-14 Years by Province* 13 10 5 InvestIng In school health & nutrItIon In IndonesIa 70 InvestIng In school health & nutrItIon In IndonesIa 0 60 Kalbar Babel Bali Banten Kalsel Kalteng Jambi Kepri Kaltim sumbar sumsel riau sumut Malut Jabar sulut sulbar sulsel Jatim Bengk lampung Pabar Yogya Jateng sultra sulteng aceh goron ntt Papua ntB Maluku Jakarta 50 40 source: riskesdas Province reports, 2007 30 * Provinces are presented left (lowest) to right (highest) according to level of poverty; see annex 1 for complete names of provinces 20 10 0 Kalsel sumbar Babel Jambi sumut Kalbar Jabar sumsel lampung Bali Banten Kalteng Kepri Kaltim riau Malut sulut Yogya sulbar sulsel Jatim Jateng sultra Bengk sulteng aceh goron Pabar Papua Jakarta ntB ntt Maluku source: riskesdas Province reports, 2007 * Provinces are presented left (lowest) to right (highest) according to level of poverty 4 riskesdas, 2007 Malaria Indonesia is identified by Who as one of the countries Within 5-6 years of on-going, selective treatment,10 where worm infections represent a public health problem; prevalence levels drop to less than 50 percent in these Malaria has been identified as a major cause of school school-age children range from as high as almost 70 Who estimates suggest that more than 17 million people same schools, and ultimately after on-going, selective absenteeism and lower educational achievement. In percent in Papua (see Figure 4) to about 15 percent are at risk for infection and that very few are reached with treatment for 20 years infection rates are less than 10 Indonesia, malaria is not a universal problem as most in ntt. Malaria can be prevented through the use of treatment.9 the 2006 Indonesia health Profile shows percent. shorter-term, but also small-scale deworming parts of the country are no longer seriously affected by insecticide-treated bed nets and treated with anti- prevalence rates among school children of more than 30 programs implemented through Mercy corps within the the disease. the exception is at least three provinces malarial drugs, sometimes administered through schools to 40 percent based on examinations from 27 provinces context of school feeding show initial rates of intestinal (Papua, Papua Barat, and ntt) where rates among for school children. over the period 2002-2006. worm infections before programs began were from 20 to 50 percent (see table 3). While these data do a number of smaller scale program initiatives provide not present a comprehensive picture of the scope and some further insight into the prevalence of worm Figure 4: magnitude of the problem of worm infection among Percentage of Malaria among children 5-14 Years by Province* infections. a long-standing program of school-based school-age children in Indonesia, they are sufficient to parasite control supported by the Yayasan Kusuma conclude that where sanitation and water systems are Buana (YKB), donors and local government dKI Jakarta 70.0 inadequate it is likely that worm infections are prevalent as well as outside of Jakarta (Yogyakarta, semarang among school children. the precise levels and types of 60.0 and denpasar) have tracked levels of and treated worm worms are uncertain and additional surveys would be 50.0 infection in selected primary schools for the past 20 needed to identify the highest priority areas for intestinal years. Initial levels of infections before programs were 40.0 helminth control. initiated reached almost 100 percent in some schools. 30.0 20.0 10.0 Table 3: Pre and Post Program-level Intestinal helminth Infection rates 0.0 Kalteng Jateng sulteng Kalsel Babel sumut sumbar Kalbar Jabar sulut sulbar lampung aceh Jambi Bengk Jakarta Bali Banten Kepri riau Malut sumsel Pabar Papua Kaltim Yogya sulsel Jatim sultra ntB goron ntt Maluku Location/Sample Pre-treatment Infection Rates Post Infection Rates Jakarta (40-500 schools) 80% <5% source: riskesdas Province reports, 2007 seribu Island (18 schools) 96% 50% *Provinces are presented left (lowest) to right (highest) according to level of poverty sumatra (2000+students) 20-48% na Intestinal Parasitic Infection references: Yayasan Kusuma Buana (YKB), 1986-2007; Mercy corps, 2005 14 15 It is well known and documented that worm infections of disease), schools offer a readily available infrastructure reach their peak in school-age children in countries for deworming, and school-based treatment is safe InvestIng In school health & nutrItIon In IndonesIa InvestIng In school health & nutrItIon In IndonesIa where these infections are not under control because of and inexpensive, school-based deworming is highly poor or deficient water and sanitation systems.5 Worm recommended.6 deworming has been shown to improve infections can play a significant role in the nutrition cognition. effects are greatest among children with and health status of school-age children and where poor nutrition status and those with the heaviest worm highly prevalent they contribute to absenteeism and burdens.7 treatment of the school-age population also reduced learning capacity resulting in lower educational weakens a major source of community infection and the attainment. Because school children often harbor some of results can be dramatic.8 the heaviest worm burdens (which increases symptoms 5 www.dewormtheworld.org 8 In the caribbean Island of Montserrat, for example, more than 90 9 www.who.int/neglected_diseases/preventive_chemotherapy percent of schoolchildren age 4 through 12 were dewormed at four- 6 hall and horton, 2009 10 selective treatment involves stool examination prior to treatment; month intervals for two and one-half years. less than 4 percent of only infected children receive treatment. usually this approach is not 7 nokes et al., 1992; simeon et al., 1995; grigorenko et al., 2006. adults received treatment during the same period. as expected, the recommended as it is expensive and mass treatment protocols are incidence of parasitic infection in the school population declined to safe and effective. the YKB selective treatment approach is built on almost zero. and infections in the adult population declined an almost the premise that examinations provide a platform for education and equal amount because of reduced transmission from the school-age promotion of appropriate hygiene. unit costs for parasite diagnosis are population. (Bundy, et al., 1990) extremely low given a large number of diagnoses processed. Program longevity has created community demand and addressed compliance issues. Hunger and Malnutrition at School-Age Figure 5: stunting among children 6-15 Years (height-for-age < 2sd) by Province 60 Much of what is known about the impact of hunger and between chronic malnutrition and school performance-- 50 malnutrition at school-age has been learned within the lower achievement in stunted children--has been 40 context of school feeding programs. short-term hunger widely documented. since poverty is a factor in stunting 30 has been widely studied in developed and developing however, a causal relationship between stunting and countries alike by looking at the effects of missing educational outcomes cannot be concluded.15 20 breakfast on cognition and performance. alleviating 10 taken together, addressing undernutrition and hunger can short-term hunger at school helps children to be more enhance a child's capacity to learn although the size and 0 attentive and to raise their cognitive abilities. Improving Pabar Kalsel Banten Babel Jambi sumbar Jabar lampung Jakarta Bali Kalteng Kepri Kaltim sumut Malut Kalbar sulut sumsel sulbar sulsel riau Yogya Jatim Jateng sultra Bengk sulteng ntB aceh goron Papua ntt Maluku nature of the impact varies greatly depending on both the child cognition can advance other educational outcomes design of the program, the level and type of micronutrient including school achievement (performance on tests) and delivered, and the measure used to assess cognition.16 as school progress (regular, progression from grade to grade much as a 1/3rd higher standard deviation improvement * Provinces are presented left (lowest) to right (highest) according to level of poverty to completion of basic education).11 (5 points) in an IQ test among those participating in source: riskesdas, 2007, Who 2006 standard chronic undernutrition measured by height-for-age, the school feeding program has been documented; an indication of a lack of food experienced over an comparable to the increased difference in IQ between extended period of time, and deficiencies of certain breastfed and non-breast-fed children.17 small impacts on as is the typical pattern worldwide, stunting continues to level can be useful for targeting and monitoring of micronutrients are both associated with lower school child growth have been found. school feeding resulted in worsen as children get older and levels are significantly shn interventions. also, it might be possible to expect performance.12 addressing micronutrient deficiencies a significant, positive, consistent effect weight estimated higher in rural compared to urban areas (see Figure some residual benefits of improvements in height-for- almost uniformly shows an improvement in cognition to be between in the range of 1.3 to 4.5 kilograms over a 6). shn interventions are not typically designed with age, especially in the early (kindergarten and primary) or achievement although some programs only show an period of six years.18 the impact on height showed mixed the intent of alleviating stunting particularly since school years or during the adolescent growth spurt by impact on children who are malnourished.13 the impact results and so far has only been shown to be significant most stunting has occurred by the age of two. levels addressing food insufficiency at school age. of micronutrient interventions is more significant for for younger children.19 of stunting at the province, district and sub-district children with lower initial micronutrient status.14 a link Figure 6: stunting (< 2sd height-for-age) by age and residence Stunting at School-Age 16 since children do not change their environment continue throughout the school-age growth period.20 this 45 17 dramatically and their energy and protein needs are is borne out by data on chronic undernutrition among 40 35 maintained or increased (as children expend more energy school-age children in Indonesia. national level data 30 InvestIng In school health & nutrItIon In IndonesIa InvestIng In school health & nutrItIon In IndonesIa walking to school and doing other chores and continue to show rates of stunting range from about 20 to more than Percentage 25 grow) it is unlikely that their growth trajectory changes 50 percent by province and, in the overwhelming majority 20 substantially when they reach school-age. With no of provinces more than a third of children 6 to 15 years 15 10 major improvements in a child's environment, the trend old are stunted (see Figure 5). 5 in undernutrition from birth to five years can assume to 0 6 7 8 9 10 11 12 13 14 15 urban rural age type of residence source: riskesdas, 2007, Who standard, 2006 longitudinal data from Indonesia show some improvement in stunting over the past 15 years on the order of about a ten percent reduction overall, much of 11 del rosso, 2009 19 one study translated the impact of a school breakfast program into a that in the past seven years and a result of improvements 1/3rd standard deviation increase in height over the primary school 12 Jukes et al., 2008 in younger age-groups (see Figure 7). gains are almost years. In Bangladesh a snack program documented that the snack 13 grantham-Mcgregor et al., 1998, van stuijvenberg, 2005, chandler et provided was additive to the child's diet and that it increased BMI (Body equal in urban and rural areas (see Figure 8). these data al., 1995, Pollitt et al., 1998 Mass Index) by 4.3 percent. likely underestimate the overall prevalence of stunting 14 solon et al., 2003; Kruger et al., 1996 20 research on children who have been adopted and moved to significantly better living conditions can experience catch-up growth. as this survey does not include some of the poorest 15 Jukes, et al., 2008 While more effective when very young children are adopted it is still provinces in the eastern part of the country. 16 adelman et al., 2008 possible for older children to catch-up in growth (see references in 17 anderson, 1999 lancet series on Maternal and child undernutrition, January 2008) 18 Krisjanssen et al., 2007 Figure 7: trend in stunting 1993-2007 (< 2sd height-for-age) by age Box 1: double Burden of Malnutrition in school-age children; undernutrition and overweight 50 40 the co-existence of child undernutrition with the prob- disease. the proportion of school-age children with Percentage 30 lem of overweight children (and adults) has emerged as a high body Mass Index (bMI)21 is alarmingly large in 1993 an important issue in the nutrition landscape in some provinces (see Figure 1), and appears to have 20 2000 Indonesia. excess weight gain is now well understood increased relatively dramatically over the past seven 10 2007 to be an important factor contributing to the years (see Figure 2). While Indonesia continues to 0 development of non-communicable diseases (diabetes, struggle with addressing the primary nutrition prob- 5-<6 6-<13 13-<16 16-<19 total high blood pressure, heart disease, stroke, and several lem--stunting--the importance of monitoring child age group major cancers), currently among the major causes of growth and development for overweight and identifying death in Indonesia. Inappropriate nutrition practices strategies for addressing this problem must also be a source: Indonesia Family life survey, 1993-2007 and physical inactivity (and tobacco use) are the top priority for the national nutrition agenda. primary reasons for this increase in non-communicable Figure 8: trend in stunting (<2sd height-for-age) 1993-2007 by residence Figure 9: Percentage of BMI > +1sd children 6-15 Years, by Province 60 50 30 25 Percentage 40 20 30 15 1993 10 20 2000 5 10 2007 0 Kalteng Jateng sulteng Kalsel aceh Babel sumbar Kalbar sulbar lampung Bali Banten Jambi riau sumut Jabar sulut sumsel Bengk Pabar Papua Kepri Malut Yogya sulsel Kaltim Jatim sultra ntB goron ntt Maluku 0 urban rural total type of residence source: riskesdas, 2007 18 source: Indonesia Family life survey, 1993-2007 19 Figure 10: InvestIng In school health & nutrItIon In IndonesIa InvestIng In school health & nutrItIon In IndonesIa trend in BMI >+1sd children 5-19 Years, by residence 1993-2007 12 10 8 Percentage 6 1993 4 2000 2 2007 0 urban total source: Indonesia Family life survey, 1993-2007 21 BMI is an anthropometric index of weight and height that is defined as body weight in kilograms divided by height in meters squared. In children BMI is used to assess underweight, overweight and risk for overweight. BMI in children is gender and age specific. Micronutrient Deficiencies Figure 11: rates of Iron deficiency anemia by age, gender and over time Micronutrient deficiencies are another element of effects can be severe and when deficiency is suffered in 60 malnutrition affecting populations at all ages, including childhood through the school-age years. Zinc and vitamin 50 school-age. among the most critical deficiencies are a deficiency at school-age are also being recognized for 40 iron deficiency anemia and iodine deficiency disorders their negative impact on cognition by contributing to ill Male - 1995 30 (Idd). Iron deficiency anemia is important at school age health which can lead to absenteeism from school and Female - 1995 20 as it affects mental development and cognitive abilities missed learning opportunities. see table 4 for a summary M + F 2001 10 and during pregnancy it puts girls/women at risk for of the consequences of micronutrient deficiencies for 0 complications. Idd are also directly related to cognitive children. 0-4 years 5-9 years 10-14 years Pregnant Women impairment both if experienced in-utero when cognitive Table 4: source: nhhs, 1995, 2001; adapted from atmarita, 2005 consequences of Micronutrient deficiency on health, development and education Consequences Vit A Iron Iodine Zinc > Iodine Deficiency Impaired immune function/sick more often X X X the overall goiter prevalence rate, the marker for iodine percent with 21 percent of districts reporting adequate absent from school X X deficiency disorders, has declined from 30 percent household consumption rates below 50 percent.24 recent stunted growth X X X in 1980 to 11 percent in 2003 in large part due to the province-level data show that the coverage of iodized salt lower academic performance X X success of efforts to ensure the availability of iodized remains inadequate in many areas. less than 50 percent lower IQ/diminished mental development X X salt.23 the national iodized salt coverage rate in 2001 was of households in nine provinces and less than 80 percent about 82 percent and data showed about 58 percent of in more than half of the provinces have adequate iodized Key resources: Jukes, drake and Bundy, shn and education for all, 2008; del rosso and Marek, class action, 1996 the districts with coverage rates of 90 percent or higher. salt (see map 1 below). at a minimum, this reflects a lack however, in some districts coverage was only at 13 of progress in achieving universal consumption of iodized percent. the use of iodized salt nationally in 2001 was 66 salt if not reflecting a decline in consumption. school- percent but again district level results showed district- age children would be equally affected as other family > Iron Deficiency level use of iodized salt varied significantly from 9 to 100 members by a lack of iodized salt in the household. data on iron deficiency anemia among school-age 15-44 years age-group from about 50 percent in 1995 children in Indonesia are limited. the national health and to about 30 to 40 percent in 2001 is attributed to iron Map 1 20 household surveys (nhhs) in 1995 and 2001 provide supplementation programs for pregnant women. Percentage of household using Iodized salt 21 some evidence of the extent of deficiency and progress results from baseline surveys conducted to monitor made in addressing this deficiency. as shown in Figure InvestIng In school health & nutrItIon In IndonesIa InvestIng In school health & nutrItIon In IndonesIa the impact of deworming and iron supplementation NANGRO ACEH DARUSALAM 9, anemia affected about half the population of school programs also suggest that anemia is significant and has KALIMANTAN TIMUR GORONTALO N age children (5-9 years) and (10-14 years) in 1995, and SUMATERA UTARA MA RA ATER R SUMATER MALUKU UTARA MA not declined in the school-age population. a survey by RIAU KALIMANTAN BARAT a slightly lower proportion of children 0-4 years; the LA SULA AWESI TENGAH SI SULAWESI UTARA Mercy corps in 2005 found rates of 55 percent. another KEPULAUAN RIAU latter group ranged from 36 to 45 percent affected. In IRIAN JAYA BARAT small survey by YKB covering 210 primary schools in JAMBI JAM PAPUA 2001, data are only available on children 0-4 years; the KEPULAUA KEPU A A KEPULAUA TUN UNG U KEPULAUAN BANGKA BELITUN Jakarta and Bekasi showed initial anemia rates of 20 to proportion of deficient children increased to 48 percent. SUMATERA BARAT 35 percent.22 SULA ULAWESI TENGAH SULA A a decline in the proportion of anemic adults in the BENGKULU KALIMANTAN TENGAH I BARAT SULAWESI BARR DKI JAKARTA SUMATERA SELATAN AT KALIMANTAN SELATAN ULAWES LAW SULAWESI TENGGARA MALUKU A EN JAWA TENGAH LAMPUNG SI SULAWESI SELATAN BANTEN Percentage of Household JAWA TIMUR Using Iodized Salt JAWA BARAT BALI NUSA TENGGARA TIMUR < 30% NUSA TENGGARA BARAT 30 - 49% 50-69% 70-89% > 90% source: riskesdas, 2007 23 national Idd evaluation survey 2003, cited in atmarita, 2005 24 susenas 2001 data cited in semba et al., 2008 22 unpublished reports from Mercy corps and YKB Sensory impairment vision and hearing deficits can impact significantly on six years of age is the snellen chart. data indicate that a child's capacity to learn and thus are important issues low vision (20/60) ranges from approximately 2 to 5. Potential Gains to be identified and addressed in school children. no 10 percent and less than 20/60 from .3 to 2.6 percent information is readily available on the problem of hearing across the provinces. on average about 5 percent of deficits and limited data are available on vision and eye children show evidence of low vision and 1 percent have from Improving problems. the tool for assessing vision of children over more seriously impaired vision.25 Water and Sanitation School-Age Health and Nutrition children spend a significant amount of time in and Much more progress is needed in Indonesia both in around their schools and appropriate facilities at school improving access to clean drinking water and improved can encourage or discourage attendance. girls, in sanitation. Indonesia particularly lags behind in access particular, may choose not to go to school rather than to improved sanitation with only 52 percent of the have to deal with inadequate facilities. When a school population having access. although 80 percent have lacks access to a basic water supply and sanitation access to clean water, relative to other countries in the facilities and its students have poor hygiene habits, region, Indonesia still ranks low on this indicator (see the incidence of major childhood illnesses increases table 5). rates of access to clean water and adequate adversely affecting school children's participation and sanitation at schools are unknown; however, qualitative learning capacity. the unsanitary conditions typical surveys confirm that conditions in rural schools are worse of many school toilets also send children the wrong than urban schools. unlike rural schools, urban schools message about the importance of sanitation. ensuring tend to have sanitation facilities but often they are clean water and appropriate sanitary facilities in schools insufficient and unhygienic. can be especially effective in reducing the incidence of diarrhea and intestinal helminth infections. 22 23 Table 5: A country's education and economic status is closely linked to its health InvestIng In school health & nutrItIon In IndonesIa InvestIng In school health & nutrItIon In IndonesIa access to clean Water and sanitation--cross country comparison (Who, 2009) status: improve nutrition and health and education and the economy will be Country Access to Improved Drinking Water (%) Access to Improved Sanitation (%) strengthened. bettering nutrition and health among the school-aged, like Indonesia 80 52 the critical effort to improve nutrition and health among infants, is a strate- thailand 98 96 gic element in the effort to develop the community. In short, healthier and sri lanka 82 86 better nourished children stay in school longer, learn more, and become china 88 65 viet nam 92 65 healthier and more productive adults. Philippines 93 78 cambodia 65 28 addressing nutrition and health among school-age better birth outcomes, and better child health. and, as children does more than improve the health and noted, school-age children with lower levels of disease learning capacity of the treatment group; it also brings reduce the overall transmission of disease in the wider intergenerational nutrition and health benefits and community. the gain from improving health and nutrition long-term economic gains as well. girls who stay in at school age is a combination of all of these benefits, to school longer tend to delay childbearing longer than health, education, in the short-term and the long-term/ school-leavers, and merely delaying childbearing brings future. the intergenerational benefits of a lowered birth rate, 25 riskesdas, december 2008 Education Sector > Attendance/Participation and Progress these relatively favorable enrollment statistics mask in 2008 (on average 14.8%) compared to 2003 (on some of the realities of the education sector. While average 20.1%) extremely high levels persist in some the education sector in Indonesia is the fourth largest million school-age children. there is a high level of female data are not readily available at national or district areas reaching 33.5 percent in Kota Pekanbaru. thirty-six in the world with over 40 million students, 2.6 million participation in Islamic schools (more than 50%). Many levels, enrollment does not necessarily mean regular percent of teacher absences are without a clear reason. teachers and more than 200,000 schools. two ministries madrasah are supported by poorer communities and attendance. a recent survey aimed at examining the schools with a lack of basic infrastructure including are responsible for managing the education sector, the the great majority of parents who send their children to impact of special allowances for teachers in poor and water and sanitation have had higher rates of teacher Ministry of national education (Mone) and the Ministry madrasah live below the poverty line.26 conflict affected areas documented student absenteeism absenteeism.29 of religious affairs (Mora). Private schools are also rates ranging from 4.1 percent to 26.4 percent. the responsibility for delivery of public primary and public despite progress in the transition from primary to junior an important part of the education system in Indonesia level of absenteeism is influenced by socio-economic secondary education is shared between central, province, secondary school, only about 55 percent of children from especially at the junior secondary and senior secondary status of the area with lower status leading to higher district and sub-district, with a critical role held by district low-income families are enrolled in junior secondary levels where they account for 56 and 67 percent of the absenteeism.28 not only do children miss school because governments. Policy, strategy and standard setting are schools. Province-level data on enrollment levels in junior system, respectively. of illness and/or because parents need them to stay concentrated at the national level; the provinces are secondary school (see Map 2 below) indicate clearly that home to work or take care of younger children, teacher the Islamic sub-sector delivers basic education services responsible for planning and quality assurance; the encouraging and supporting efforts to help children enroll absences also cause declines in school participation. through madrasah and pesantren (madrasah with districts manage the resources and delivery of education. in and complete the basic education cycle remain high When teachers are absent classes are not held. teacher boarding facilities). there are about 40,000 madrasah as decentralization has evolved, provincial and district priority for the education sector. absences also assessed in this study found that while in Indonesia registered under Mora, of which 4,000 are governments have been given increasing responsibility for rates of absenteeism among teachers improved overall state-owned. together these accommodate about six delivering education that addresses local needs. Map 2: net enrollment in Junior secondary school Key Education Indicators NANGRO ACEH DARUSALAM > Enrollment ERA M TE SUMATER UTARA E KALIMANTAN TIMUR GORONTALO N MALUKU UTARA M RIAU KALIMANTAN BARAT S SULAWESI UTARA KEPULAUAN RIAU LAWESI TENGAH UL SUL net primary enrollment rates have increased significantly 686,000 (142,000 boys; 544,000 girls) primary school IRIAN JAYA BARAT from 72 percent in 1975 to 94.9 percent in 2007. net children are out of school. regional variations also exist; JAMBI JA PAPUA KEPUL UAN BANGKA BELITUN P LAU L U KEPULAU TUN TUNG TU enrollment for junior secondary rose even more quickly Papua lags significantly behind even in primary school SUMATERA BARAT SU U UL A SULAWESI TENGAH starting at a low level, 18 percent in the 1970s and rising with net enrollment at about 80 percent and about 47 BENGKULU U KALIMANTAN TENGAH SI ARAT A SULAWESI BARAT 24 to 71.6 percent in 2007. enrollment in senior secondary percent at junior secondary. other provinces lag behind LA SUMATERA SELATAN K DK JAKARTA KI KALIMANTAN SELATAN SULAWESI TENGGARA SULAWE LAW W MALUKU 25 J TENGAH JAWA TE has been rising much more slowly with net enrollment the national average at junior secondary level including LAMPUNG S SULAWESI SELATAN at 50.19 percent in 2007. It is estimated that about Maluku, ntt (both at 47%) and gorontalo (52%).27 Enrollment net SMP BANTEN InvestIng In school health & nutrItIon In IndonesIa InvestIng In school health & nutrItIon In IndonesIa < 50% JAWA TIMUR JAWA BARAT BALI 50 - 55% NUSA TENGGARA TIMUR 55-60% DAERAH ISTIMEWA YOGYAKARTA NUSA TENGGARA BARAT Table 6: 60-75% Basic education statistics >= 75% source: central Bureau of statistics/BPs, 2008 Total Number of Students 46.5 million Total Number of Teachers 2.78 million Total Number of Schools 258,047 (16% Mora) although no fees are charged for basic public education school environment as well as to the individual school in Indonesia, the opportunity costs and the non-fee child act as barriers to children entering and progressing Total Male Female expenses--e.g., uniforms, books, etc.--are a substantial in school. ensuring that schools are providing a healthy burden for the poor and are a barrier to entry as well as environment for children and overcoming any health and/ Primary net enrollment (2006) 95.4% 97.1% 93.7% continuation in school. In addition, some of the other or nutrition (hunger) barriers to school enrollment and Primary completion rate (2006) 98.8% 98.7% 98.9% health, hygiene and sanitation issues related to the participation are important for reaching education goals. Primary Age Children Out of School 686,000 142,000 544,000 source: World Bank edstats, based on most recent year available, 2005-2007 26 World Bank, 2008 28 toyamah, et al., the sMeru research Institute, april 2009 27 data from susenas 2006 and Mone 2006-07 cited in World Bank 29 Ibid project document Bos-KIta Health Sector school-age children do not comprise a high risk group low birth weight and birth defects in their children and for mortality risk and school-age girls, for the most will reduce their risk of dying during childbirth. schools 6. Building Blocks part, have not yet entered the vulnerable child bearing can provide the infrastructure to easily reach girls with years. From a health sector perspective this makes the high priority education and health and nutrition services. school-age population low priority for many health Many of the risks of adolescence (see table 7) are for SHN Investment sector interventions with certain important exceptions. universal--smoking, alcohol, reproductive and sexual at school-age, especially in adolescence, young people health, including hIv/aIds, etc.--and young people must begin to make independent decisions about their health have access to information and skills to be able to protect and to form attitudes and adopt behaviors that influence themselves from high risk behaviors. schools may offer in Indonesia their current and future health as well as the health of one of the best venues for reaching all young people with their future children. the information and education that will help them lead girls, particularly adolescent girls, are the key to healthier and safer lives. In addition, schools are also the the health of future generations. good physiological best opportunity for promoting appropriate nutrition, food development during adolescence prepares girls for choices and physical activity to help prevent overweight pregnancy, childbirth, and motherhood. ensuring that in children. effective promotion of key health, nutrition girls are well nourished and healthy--especially regarding and physical activity practices is crucial to alleviating their increased needs for iron and for growth before the the significant burden of overweight, obesity and non- reproductive years begin--will decrease the incidence of communicable diseases. Table 7: adolescent risk Behaviors in Indonesia--results from the Who global school-Based student health survey, 2007 Students who... Percent smoked cigarettes on one or more days in last 30 days 11.1 26 Went hungry most of the time or always in last 30 days 5.8 27 Introduction had at least one drink containing alcohol in last 30 days 2.6 Were physically attacked on one or more times in past 12 months 39.8 InvestIng In school health & nutrItIon In IndonesIa InvestIng In school health & nutrItIon In IndonesIa Were seriously injured one or more times in last 12 months 45.9 never or rarely washed their hands before eating in past 30 days 4.1 school health and nutrition interventions are not source: central Bureau of statistics/BPs, 2008 completely unknown in Indonesia. national policies on national uKs school health have been in place since the 1950s. In the Program 1970s a task force for education and health was formed to implement health at the primary school level. In 1984 a Box 2: school health policy and memorandum of understanding health law Water and Preventing the spread of hIv/aIds and services (Mou) was created that involved four ministries: though sanitation at Ministry of national education, Ministry of religious Puskesmas schools affairs, Ministry of health, and Ministry of Internal current prevalence of HIV/AIdS among adults in have now reported cases of HIV/AIdS. programmatic shn affairs (now called home affairs). In 2003 the Mou was Indonesia is low (.16%) with the exception of tanah efforts are primarily concentrating on high risk popula- revised and a coordinating team was created. In addition papua which has 2.4 prevalence among adults tions. nonetheless, prevention will be critical to staving to the uKs program, Indonesia has had different levels considered as a low generalized epidemic and primarily the continued spread of the epidemic. School would of experience historically and presently with a number national or Mgo or concentrated in `most at risk groups,' drug users and offer a mechanism to mainstream HIV/AIdS prevention donor- of other elements of shn including water and sanitation corporate female sex workers. but Indonesia is also experiencing education to protect and prevent school-age children assisted school health at schools, basic health center (puskesmas) and school school Feeding linkages, school feeding, and other school-based health the fastest growing epidemic in Asia. All 33 provinces from becoming infected. services services provided through ngos and/or corporate or other donors. The UKS Program Institutional Structure of UKS a uKs coordinating board with representatives from central level, primarily through the Mone, plays a role in Ministries of national education, health, religious affairs setting standards, providing guidelines and establishing the purpose of the school health Program, uKs, and home affairs who are included in the national Mou expectations for the uKs program. In addition, the is "improving the quality of education and student exists at national, provincial, district and sub-district national level utilizes resources to conduct annual uKs learning achievement by increasing healthy life skills of levels. the presumption is that the four ministries competitions and a national uKs meeting every other students and learners through creating a healthy school meet and make decisions as a team, but it is uncertain year that brings together national, provincial, and district- environment, improving knowledge, changing students' how consistently this occurs. at the school level the level personnel, teachers and students. these meetings attitudes, and maintaining health through preventing and headmaster and one or more uKs teacher/"guru" are are intended to identify priorities for the coming year of curing diseases"30 reflected in the three program pillars appointed to oversee uKs activities in the school. the uKs programming. In some instances uKs at the central (see Figure 10). school is expected to collaborate with health center level uKs provides support and technical assistance for staff to implement some of the uKs activities. the targeted activities at school. Figure 12: three Pillars and Major activities of the uKs Program Health Education Health Services at School Healthy School Environment Strengths and Weaknesses of UKS despite the creation of the uKs program in Indonesia ˇ The UKS "kader" and/or "little doctor" (the name and - Integrated into curriculum - health check - hand washing facilities many decades ago, remarkably little data and information tasks depend on the school level, primary or junior - training of uKs teachers - height and weight measurement - `greening' of schools are available on the investment in the uKs program at secondary program) is another key program element. - little doctors - uKs room - Improving school toilets - hand washing campaign - healthy canteen any level--central, district, sub-district, school--or the It ensures the involvement of students/children in the - referral to Puskesmas or hospital impact of its programs and activities. no evaluations school health activities. to become a "kader" or "little - Immunization are available and no consistent monitoring system is in doctor" appears to be a competitive process in most - deworming place. Based on discussions with key informants and schools. - Iron tablets for girls observations at a number or schools which might be ˇ Records of the provision of health services (deworming, considered "model" uKs programs, some preliminary iodine capsule distribution, iron supplementation for conclusions can be drawn. menstruating girls, or other) provided through schools Figure 13: ˇ UKS appears to be most known for its role as a school- are not readily available although some schools typical school health and nutrition Interventions based program that provides a place/room for children reported that these services were provided by the to go if they become sick at school or need first aid. health center at the school. 28 the uKs room or space in the school is considered an 29 Category (FRESH Framework) Intervention ˇ Many of the schools with a UKS program have hand essential first step to be considered a uKs school. washing facilities (most with soap) and clean, and at InvestIng In school health & nutrItIon In IndonesIa InvestIng In school health & nutrItIon In IndonesIa Policies codes of practice for teacher behavior ˇ UKS prioritizes providing periodic "health screening" at times, a sufficient number of toilets. hygiene promotion sale of foods at school school which includes some form of health check up in was a standard activity in the schools. numerous Inclusion of special needs children collaboration with the nearest health center, and height materials including posters and instructional materials Inclusion of pregnant girls and weight monitoring twice, quarterly or sometimes have been created to help raise awareness and increase avoidance of discrimination on a monthly basis. child health and growth cards knowledge about these topics (see more on water and School Environment access to safe water including point of use treatment are used for the growth monitoring and also to track sanitation below). hand washing facilities immunizations and the results of the health checks. access to adequate and gender-separate sanitation facilities "green" interventions--composting, recycling, etc. Skills-based and Behavior Change non-formal education linked to interventions, e.g., hygiene, malaria prevention Education curriculum-based education linked to specific interventions Box 3: Behavior-centered education focused on adolescent risk behaviors Improving school canteens Behavior-centered nutrition and physical activity education Health and Nutrition Services deworming Initiated in 2009, the uKS (central level) is supporting approximately $1,000 for one year. In addition to the treatment for malaria the improvement of school canteens through block grant, the central level of Mone is providing technical Micronutrient (iron) supplementation or point of use fortificationFirst-aid kits grants to schools and training activities. to be assistance and training to these same schools to raise school meals or snacks (fortified) considered for a block grant, schools must already have their capacity to create safer and healthier school referral to health center services functioning canteens since no infrastructure is provided canteens. Food safety test kits and healthy school counseling or psychosocial support under the program. 288 schools across 33 provinces canteen educational materials have been distributed to source: adapted from Bundy et al., 2006 and 36 districts--112 primary, 90 junior secondary, and these schools as part of this initiative. 86 senior secondary--are receiving the equivalent of 30 Widaninggar et al., May 2006 Public Health Center and Schools as a national program implemented within a "competition" that rewards the "best" uKs schools. decentralized system, what happens under the uKs the instrument used to select the winning schools is program in one district may look very different than what made up of indicators that are primarily related to the is supported in another if a uKs program exists at all. facility--latrines, health room, etc. other activities such at the province and district level the resources devoted as the national jamboree and national-level meetings to uKs are dependent on the commitment of local require a financial commitment from districts that may be the school Immunization Program--Bulan Imunisasi uKs structure. In practice, uKs does not appear to play legislative and decision-making bodies. In some areas more difficult to meet in lower-resourced areas or those Anak Sekolah (BIas)--represents perhaps the most a major role in implementation. the responsibility for these resources are not insignificant. where there is more competition for resources because of consistent and effective health center ­ school linked the BIas program is through expanded Program on greater overall health, nutrition and other school needs. service provision. Introduced in 1998 initially as a long- Immunization (ePI) and health workers work directly with given some of the primary activities promoted by the term control of tetanus by providing life-long immunity schools without uKs support. In some cases the uKs these factors suggests that rather than "leveling the uKs program--a traditional school health approach to all primary school graduates and diphtheria boosters, structure might have been helpful for the BIas program, playing field" through school health, the uKs program requiring a health room, school canteen, and other the BIas program was integrated within the existing but it does not appear crucial to the operation of BIas.32 may actually increase school inequity by directing what infrastructure in place--uKs appears to be more resources are invested in school health via uKs toward relevant to better-off schools and districts. the major better-off communities and schools. School Feeding incentive from the central level is the national level Water and Sanitation in Schools the Moha maintains a department responsible for ntB, ntt and east Java. until recently several nonprofit school feeding although resources for programs now organizations including Mercy corps and Ird among need to be allocated by the district so the central others provided school feeding through usda resources. the minimum level of services31 (Standar Pelayanan to improve the water and sanitation environment at role is limited and uncertain. In the past, prior to the approach to school feeding has included the Minimal/sPM) for schools includes standards for a clean schools (see table 8). a network for environmental decentralization, school feeding was a major program provision of in-school meals through local production water supply and adequate sanitation facilities­hand sanitation and clean water at schools is being established under BaPPenas. (resources were sent from central to district level to washing facilities and toilets. several efforts are underway to help coordinate implementation of various activities finance locally supplied programs), and the distribution In 2009 school feeding continues under the auspices under the auspices of different donor institutions and the and programs. of biscuits/snacks as well as some other commodity of WFP. through a combination of private sector and Ministry of health and the Ministry of national education programs including milk distribution and eggs. WFP resources, WFP is reaching more than 200,000 children in more than 1000 schools in the provinces of Table 8: Illustrative school Water and sanitation Initiatives 30 Institution Projects/Activities Private-sector and NGO-Supported 31 Ministry of National Education school sanitation program part of uKs School-Based Services InvestIng In school health & nutrItIon In IndonesIa InvestIng In school health & nutrItIon In IndonesIa Ministry of Health school hygiene and sanitation program; preparing guidelines for school sanitation UNICEF school sanitation and hygiene education (ssPh) several non-profit organizations have carried some additional areas and reach more than 700 schools. USAID environmental services Project--improved water resources management; out relatively small-scale deworming and iron deworming interventions were also conducted in expanded access to clean water and sanitation services supplementation programs in various regions of the conjunction with the school feeding programs supported IRD Yogya emergency response Program for Promotion of hygiene and country. the national level YKB ngo has supported a by Mercy corps, Ird and other non-profit organizations. sanitation at sd/MI school-based deworming and iron supplementation along overall, however deworming and micronutrient Plan Indonesia Promotion of child Friendly school and Fresh Framework with health promotion activities for the past 20 years supplementation has not been a major school-based in and around Jakarta. they have recently expanded to activity in Indonesia. 31 the minimum level of services is still in draft 32 school Immunization in Indonesia, unpublished report, JsI/ Immunization BasIcs not only does shn play a role in achieving education participation, improve fiduciary arrangements for greater objectives, but school-based health and nutrition transparency and accountability of the Bos program to interventions are important for health sector goals. For consequently better utilize current Bos funds. the loan some diseases and deficiencies, school-age children project total is $600 million for 2008-2010, and this contribute significantly to the overall burden of disease project is supplemented by additional support under the (e.g., intestinal helminth infection, iron deficiency). dutch education trust Fund.33 7. Recommendations effective school-based programs are also crucial the goI has also provided a framework for national to helping children develop healthful practices and standards for education to support the decentralization avoid risky behaviors related to both the continued process. sIsWa (system Improvement through sector burden of communicable and the rising burden of Wide approaches) a new basic education development and Next Steps non-communicable diseases in Indonesia. education framework being created in conjunction with the attainment is closely linked to future health, especially medium term sector plan (2010-14) covers key strategies among girls as their health and nutrition status and their and programs to improve access and quality of basic skills and practices have a direct and indirect impact on education under the Ministry of national education, the health and nutrition of future generations. Ministry of religious affairs, and the Ministry of home the government of Indonesia (goI) with support from a affairs. It is intended to provide a coherent policy wide range of donors and partners has made education framework for donor support. one of the key areas of a top priority. a centerpiece of that support is the Bos focus under sIsWa is to help districts in part through (Bantuan Operasional Sekolah or school operational providing access to better and more information on how assistance) program that has been disbursing block to improve education. grants to school across the country on a per student Within these efforts to improve the quality and equity basis since 2005. Bos is part of the government's effort of education, school child health and nutrition has not to improve access to quality education to students at all figured significantly. so far, the focus appears to be more income levels. Bos operational funds are eligible to be school and classroom- rather than child-focused. the used for extracurricular activities that could contribute to standards for minimum services in basic education the physical health of students. include expectations for a clean water supply and hand the World Bank is supporting the Bos program through washing and appropriate and adequate toilet facilities Bos KIta (school operational assistance--Knowledge at all schools. the potential for national, district and Improvement for transparency and accountability), community-level policies and actions in school health a project which aims to improve access to quality and nutrition to significantly contribute to improving education for all children ages 7 to 15 by working to educational and health outcomes in Indonesia however 32 strengthen school committees, increase community remains to be fully exploited. 33 the evidence in this report suggests that the health and InvestIng In school health & nutrItIon In IndonesIa InvestIng In school health & nutrItIon In IndonesIa nutrition status of school-age children in Indonesia are likely to be important factors in the achievement of "education for All" and MdG goals. the messages are clear: health and success in school are inextricably connected. If students are not healthy and well-nourished schools cannot achieve their primary mission of providing effective, efficient and equitable education. the interventions to address some of the major health and nutrition impediments to learning are highly cost-effective and benefit the poor and disad- vantaged children more than other education interventions while also reducing gender inequities. 33 Bos Kita (school operational assistance--Knowledge Improvement for transparency and accountability); dutch trust Fund documentation Recommendations clean water and sanitation standards at schools may place. as with any intervention, education for health be most difficult to achieve but shn investment should promotion and/or behavior change needs to monitored be focused on those "neediest" schools. support for and evaluated to ensure that the desired outcomes are long-term solutions to water and sanitation at schools achieved. should be complemented by alternative technologies 7. Develop separate model (or models) for stemming for ensuring clean water (e.g., purification) and low- the tide of the overweight and obesity--although the considerable commitment of the GOI and its partners to improving the cost latrines. not directly related to education, the seriousness of 6. Improve the quality of health education/behavior the increase in the issue of overweight in children quality and effectiveness of basic education in Indonesia provides an excel- focused communications--health, hygiene, nutrition in Indonesia suggests that strategies to promote lent platform on which to redirect and increase the investment in school and other education is required to promote practices appropriate nutrition and physical activity practices linked to school-based services, including the use of should be an element of shn in some contexts. as health and nutrition. the situational analysis of school health and nutrition clean water, hand washing facilities and latrines, as mentioned above, any approaches that entail promotion well as for the development of other behaviors among or education must be developed with appropriate documented in this report points to the following major conclusions that school children. strategies for developing effective technical and other expertise and be monitored and should guide the next steps toward an enhanced SHn program. messages and materials are available but require an evaluated for effectiveness. investment in technical and other expertise to put in 1. Target SHN interventions where education outcomes 3. Take advantage of the returns from certain low-cost Next Steps are low and health insults and poor nutrition status SHN interventions by identifying and implementing or hunger are high--For the biggest "bang for the district-level approaches to remediation--Providing buck" the investment made in shn programs must mass delivery of some shn services (deworming, iron give high priority to those districts and schools where supplementation, treatment and prevention of malaria) health and nutrition are inhibiting access, participation at the district level may make sense if these problems A number of opportunities may exist for beginning to act on these recom- and progression in school, especially among girls. affect a large proportion of the school-age population in If effectively targeted, shn interventions have the a certain area/district. this approach could offer some mendations. Some preliminary thoughts on where to start are presented potential to help reach some of five percent who are benefits in terms of economies of scale for training, below. currently un-enrolled in school and those who are technical support, etc. as well as quick and significant not participating fully. shn must be understood and returns for a limited investment. monitored and evaluated as an educational intervention 4. Identify and develop a set of "packages/models" first. that take into account the three main contexts in 34 Indonesia, urban, rural, island/coastal and also the ˇ Utilize on-going "good practices in basic education" ˇ Conduct an in-depth institutional capacity assessment 35 2. Strengthen collaboration within the education mechanisms to identify local private sector, ngo and/ at various levels including national, district, sub-district sector between MoNE and MoRA and between type of school (e.g., boarding)--the Fresh framework or government-supported school-based health and and school to identify approaches to and needs for education and health ministries--shn is aimed first for shn provides overall guidance for the type of InvestIng In school health & nutrItIon In IndonesIa InvestIng In school health & nutrItIon In IndonesIa nutrition interventions/programs that offer potential capacity building to support additional promotion and foremost at helping to achieve education goals, intervention that is most effective in achieving specific for creating context-specific "good practice models" for and implementation of school health and nutrition and the Ministry of national education and Ministry outcomes related to health, nutrition and education. shn. document and package these "good practices" interventions. of religious affairs appropriately should continue to While context matters, to simplify and maximize the linked to specific contexts. these "good practices" take the lead in shn. these two ministries need to opportunity to achieve scale in implementing shn could be at the district, sub-district or school level and work together in shn as well as in collaboration with interventions, a set of "model" shn programs can be should be directly linked (with concrete evidence where the health sector since the interventions require health developed that will account for the main contextual possible) with improving the quality of education in the sector guidance and support. the education and health variations in communities and schools in Indonesia. most disadvantaged schools. sector collaboration is most essential at the local and 5. Continue and expand on the current efforts to school level but also important at higher levels. given ˇ Create a SHN "tool kit" and training modules building ensure clean water and adequate sanitation at all the important role of the Ministry of home affairs in off of the "good practice" and international experience. schools--Water and sanitation at school is one of the implementation of education, collaboration with this the tool kit would be for use at the district and school key elements of the Fresh framework. the fact that ministry will help to improve the effectiveness of shn level to raise awareness and build capacity in identifying this is already a priority for the education sector given programming. as has been indicated, madrasah and and addressing health and nutrition needs among the minimum education standards bodes well for pesantren are potential targets for shn as students school-age children in different contexts. the tool kit generating support for these shn interventions. that in these schools are often from the lowest income and modules would be introduced through a district- said, where school infrastructure is weakest, meeting families. level training strategy. one module in the tool kit should address the need for a simple set of indicators to use at the school, district and province level to guide progress in shn programming. 8. 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Jenderal sudirman Kav. 52 ­ 53 Jakarta 12190 Phone : (021) 5299 3000 Fax : (021) 5299 3111