Investing in school and health and nutrition in Indonesia

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