An increase in life expectancy in the span of 30 years is actually a reasonable achievement. What seems to be beyond rationality is why stunting remains an insurmountable problem.

The November 2022 issue of TheLancet journal published Indonesia's national health report, which provides an overview of Indonesia's health over the past 30 years and its capacity to meet the United Nations' (UN) Sustainable Development Goals (SDGs).

The report, titled "The State of Health in Indonesia's Provinces, 1990-2019: A Systematic Analysis for the Global Burden of Disease Study 2019”, was compiled by the GBD 2019 Indonesia Subnational Collaborators. It was prepared by a team involving dozens of researchers, including former Health minister Nafsiah Mboi (2012-2014).

Based on the results of the 2019 “Global Burden of Diseases, Injuries and Risk Factors Study,” this research analyzed patterns of health in Indonesia at the provincial level between 1990 and 2019.

The long-term disease burden analysis gave an overview about Indonesia's health progress over a 30-year span and its capacity to meet the SDG target by 2030. The team used 1,915,207 rows of metadata as the source for compiling Indonesia's 2019 GBD estimates.

The research found the life expectancy of an Indonesian male, from 1990 to 2019, increased by 6.9 years from 62.5 to 69.4 years. For females, life expectancy increased by 7.8 years from 65.7 to 73.5 years. Female life expectancy appeared to be better than that of the male. The healthy life expectancy (HALE) for men increased from 55.5 to 61.2 years and for women from 56.5 to 62.9 years.

Life expectancy reflects the overall mortality level of a country's population. It weighs on various factors, such as genetics, nutrition, environment, lifestyle and quality of health services. With these various factors, there are disparities in life expectancy in several regions and countries. The more advanced and prosperous a country is, the longer the life expectancy of its citizens will usually be.

Based on the latest data released by Worldometers, the average life expectancy of world citizens is now 75.6 years for females and 70.8 years for male.

Indonesia is ranked 122nd with an average life expectancy (male and female) of 72.32 years. We are still trailing Vietnam, which is in the 84th position (75.77 years) and far behind Singapore in fifth place (84.07 years) and Hong Kong in first place (85.29 years).

According to the 2019 GBD report, Bali province has the highest life expectancy and HALE for males, followed by Riau and North Kalimantan. Meanwhile, Papua, South Kalimantan and North Sumatra are at the bottom. For female ranking, the top position is held by North Kalimantan, followed by Bali and East Java, while North Maluku, Gorontalo and West Papua are in the lowest positions.

There are marked disparities between provinces, with western Indonesia generally appearing to have better health development than eastern Indonesia.

Rather surprisingly, North Kalimantan has consistently been in the top ranks along with Bali, Jakarta and several other provinces in western Indonesia for almost all health indicators. Meanwhile, North Maluku and Papua are consistently at the bottom.

In summary, this research illustrates two things. First, for nearly 30 years, Indonesia has been continuously working to improve the health quality of its citizens, regardless of the political situation. Looking back, we went through major changes in the political situation during the 1990-2019 period, namely the change of government from the Soeharto era to the politically volatile Reformation era and to the more stable political order, up to the current Joko Widodo administration.

Despite turbulent periods, our national health has experienced progress, one of which is indicated by the increasing life expectancy and healthy life expectancy.

Second, apart from the progress in generally making people healthier, the national health policy has failed to address the perennial problem, which is the unequal access to development and prosperity between regions. This appears to be an insurmountable problem despite various development programs having been implemented by every government regime.

The relatively low life expectancy and healthy life expectancy in several eastern regions, such as North Maluku and Papua, show that healthcare services as part of the development program to provide the people with an even distribution of welfare has not been going well for the past 30 years.

Stunting in NTT

The healthcare-related gap between regions is not only reflected in the GBD report. We can see from other data that evokes a similar problem, for example, in the case of high prevalence of stunting.

It has been widely raised in recent media reports that based on the Indonesian Nutritional Status Study (SSGI), the prevalence of stunting in East Nusa Tenggara (NTT) reached 37.8 percent in 2021, which was the highest in Indonesia. This figure was far above the national prevalence at 24.4 percent. There were at least 15 regencies in NTT still categorized in the “red” status in the stunting case, meaning that an area had stunting prevalence above 30 percent.

The 2021 SSGI looked into the prevalence of stunting in 246 regencies/municipalities in 12 provinces on the priority list. There were 73 regencies/municipalities that fell into the red status category (the prevalence of stunting above 30 percent). There were 122 regencies/municipalities in the yellow category (20-30 percent), 51 regencies/municipalities in the green category (10-20 percent) and there are two regencies/municipalities in the blue category (under 10 percent).

In fact, the national prevalence of stunting has been improving or showing a decreasing trend, namely from 30.8 percent (2018) to 27.7 percent (2019) and 24.4 percent (2021). It means that there are still around 23 million toddlers who experience stunting or are unable to grow or develop properly. The figure is still above the WHO benchmark which sets a tolerance limit for the prevalence of stunting at 20 percent.

We deserve to be appreciated for the decrease in the national prevalence, though some provinces, such as NTT are still showing high prevalence of stunting. While the province has 15 regencies/municipalities in the red category, Aceh and North Sumatra each has 13 red regencies/municipalities.

Ironically, the high prevalence of stunting is still rife despite the government having formed the Team for the Acceleration of Stunting Prevention (TP2AK) under the coordination of the Secretariat of the Vice President in support of a human development policy. If so, where is the problem?

Catastrophic diseases

As a national health problem, stunting is very different from cancer, heart attack or stroke, acute kidney injury, diabetes, hypertension or leukemia, which are classified as catastrophic (major acute or chronic) diseases.

Catastrophic diseases cause damage and malfunction of organs. Patients who have recovered from a stroke, for example, often find that some of their limbs are not functioning normally. They will usually struggle in communication due to aphasia. While being noncontagious, catastrophic diseases are the most common causes of death.

In addition, catastrophic diseases require high-cost treatment, from emergency response, hospitalization, medicine to the process of recovery. A family that is quite well-off might fall into an unbearable, financially straining situation because of the cash-draining treatment and care of a family member who has cancer.

Based on data from the Catastrophic Health Expenditure Study conducted in 133 countries, it was found that between 2005 and 2010, incidences of catastrophic diseases increased from 9.7 percent to 11.7 percent. There is another survey involving 89 countries, which shows around 150 million people have a risk of an incurring catastrophic disease each year.

In Indonesia, based on data at the Healthcare and Social Security Agency (BPJS Kesehatan), catastrophic diseases account for most of the disbursement claims in the National Health Insurance (JKN) program. According to BPJS, of the Rp 374.86 trillion in health insurance claims during the 2016-2020 period, around 83.31 percent were disbursed for referral service claims over catastrophic disease treatment. In other words, these catastrophic diseases have drained the BPJS financial reserve nationally.

A catastrophic disease is distinctly different from stunting, which is a condition of malnutrition or lack of nutrients resulting in slow physical growth at infancy and making them susceptible to disease. It is generally related to poverty, in which children do not receive enough intake of nutritious food.

If there are many stunting children in an area for a long time, this could indicate that there are many poor people in that area. The cost in tackling a stunting case is basically very low, far below than that for cancer or acute kidney injury.

A child with stunting only needs to be given adequate nutritional intake and supported with a healthier environment and a more hygienic lifestyle. It does not need substantial spending. Several types of food, such as mung bean porridge, milk, vegetables and tubers, can be routinely given to children at schools or integrated healthcare facilities (Posyandu) that are available in rural areas.

This kind of initiative is far less costly than spending on treatment of a patient with a catastrophic disease. The Posyandu-centered health campaign has been carried out for a long time and proved quite effective. Of course, there are many other ways. That is at least what can be done as part of the short-term program.

For other types of diseases, such as malaria, it can be said that their incidences are increasingly rare. Likewise, dengue hemorrhagic fever is getting under control day by day, especially after the development of spreading male Aedes aegypti mosquitoes infected with Wolbachia bacteria. Eggs of female Aedes aegypti mosquitoes that mate with males infected with Wolbachia bacteria cannot hatch, so their breeding chain is cut off.

Even for the recent outbreak of COVID-19, our scientists were able to develop and produce vaccines. Among them is Inavac Unair-Biotis, which received its emergency distribution permit from the Food and Drug Supervisory Agency (BPOM) on 4 Nov.

This is an example of how scientific and technological research can respond to long-circulating diseases. But why have there not been sufficiently systematic prevention and treatment measures over stunting and instead leaving it largely to ad hoc and emergency responses?

Back to the GBD report, we are grateful that in the past three decades life expectancy and healthy life expectancy have improved significantly nationally. Of course, this is due to multifactors and contributions from many parties.

Our state budget has continued to increase manyfold over the past three decades. In fact, based on purchasing power parity data reported by the International Monetary Fund (IMF), Indonesia is currently ranked seventh among the countries with the largest gross domestic product (GDP), edging Britain in eighth place.

The budget for developing national health, whether handled directly by the Health Ministry or other institutions, has also continued to increase manyfold.

Therefore, an increase in life expectancy in the span of 30 years is actually a reasonable achievement. What seems to be beyond rationality is why stunting remains an insurmountable problem.

The front campaigners in handling stunting are local governments. Their leading initiatives are needed to capitalize on the available resources in handling stunting.

Areas with many stunting children can be associated with poverty and meager regional income, needing financial assistance from the central government either through special allocation funds (DAK), profit-sharing funds (DBH) or other forms of center-to-region transfer mechanisms, for example, for extra food provision programs for poor children.

Of course, funding is not the only instrument to solve the problem. Initiative, leadership and collaborations with various parties are integral in the stunting-managing measures.

Djoko Santoso
Professor of Medicine, Airlangga University (UNAIR)
Chairman of the East Java Indonesian Ulema Council (MUI) Health Agency

This article was translated by Musthofid.