Bulletin of Indonesian Economic Studies

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Towards a Healthy Indonesia?

Anne Booth, Raden Muhamad Purnagunawan & Elan Satriawan

To cite this article: Anne Booth, Raden Muhamad Purnagunawan & Elan Satriawan (2019)
Towards a Healthy Indonesia?, Bulletin of Indonesian Economic Studies, 55:2, 133-155, DOI:
10.1080/00074918.2019.1639509

To link to this article: https://doi.org/10.1080/00074918.2019.1639509

Published online: 17 Jul 2019.

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 Bulletin of Indonesian Economic Studies, Vol. 55, No. 2, 2019: 133–155

Survey of Recent Developments

TOWARDS A HEALTHY INDONESIA?

Anne Booth Raden Muhamad Purnagunawan

SOAS University of London Department of Economics, Padjadjaran University

Elan Satriawan
Department of Economics, Gadjah Mada University

During his first presidential term, Joko Widodo increased expenditure on, and the
coverage of, several social protection policies, including the conditional cash transfer
program. These policies began in the aftermath of the 1997–98 Asian financial crisis
and have proliferated in recent years. This Survey will examine these policies, paying
particular attention to implementation problems, including effective targeting through
the construction of a unified database. It will also examine both food policy and broader
health policy issues. It is widely agreed that health problems, such as those relating
to early childhood development, must be addressed in Indonesia in a wider context,
including through the provision of clean water and sanitation facilities, food security,
and social assistance. The Survey will also examine recent discussions of trends in
inequality and poverty, several of which claim that inequality has been increasing.
Using recent figures published by Statistics Indonesia, it is argued that expenditure
inequality has in fact been trending downward in recent years.

Keywords: growth, health policy, social protection, unified database, food policy, stunting
JEL classification: E20, E60, I12, I15, I38, Q18

INTRODUCTION
The parliamentary and presidential elections in April 2019 passed off peacefully,
and quick counts conducted after the polls closed suggested that Joko Widodo
(Jokowi) had won by a rather larger margin than in 2014. The official results released
on 21 May gave Jokowi 55.5% of the vote, and his opponent, Prabowo Subianto,
44.5%. Prabowo claimed that there had been massive cheating and irregularities in
the poll, and he will challenge the results in the courts, although it is not expected
that the challenge will be successful. Protests by his supporters led to eight deaths
and several hundred wounded in Jakarta. The results raised fears in some quarters
that Indonesia was becoming more polarised along religious lines; Jokowi polled
strongly in Central and East Java, in Bali, and in provinces in Sulawesi and Sumatra
with substantial Christian minorities, while Prabowo drew much of his support

ISSN 0007-4918 print/ISSN 1472-7234 online/18/000133-155 © 2019 ANU Indonesia Project

http://dx.doi.org/10.1080/00074918.2019.1639509
134 Anne Booth, Raden Muhamad Purnagunawan, and Elan Satriawan

TABLE 1  Undernourished Population, and Stunting and Wasting in Children (%)

Undernourished Stunting Wasting

(% of total population) in children in children

2004–06 2014–16 2005 2016 2016

Malayasia 3.9 < 2.5 17.2 17.7 8.0

Thailand 12.3 9.5 15.7 16.3 6.7
Indonesia 18.6 7.9 — 36.4 13.5
Vietnam 18.2 10.7 33.3 24.6 6.4
Philippines 16.3 13.8 33.8 30.3 7.9
Laos 26.8 17.1 47.6 43.8 6.4
Cambodia 20.0 15.3 43.7 32.4 9.6
Myanmar 32.1 16.9 40.6 29.2 6.4
Southeast Asia 18.1 10.2 34.1 25.8 8.9

Source: FAO et al. (2017), table A1.1.

Note: Countries are ranked according to their Human Development Index position in 2015. Stunting
refers to the percentage of children who have a low height for their age. Wasting refers to the percentage
of children who have a low weight for their height.

from West Java, South Sulawesi, and some parts of Sumatra. On the other hand,
the results showed that many Muslims in Indonesia continue to support Jokowi’s
brand of moderate Islam, and many gave their votes to secular political parties.
Jokowi made several statements in early 2019, promising that, if elected to a
second term, he would switch the focus of government spending from infrastructure,
on which he claimed that considerable progress had been made, to human resource
development (Kompas 2019). Other promises made during the campaign included
the ‘Sembako murah’ [Cheap food] pledge. This referred to the prices of the nine
staple commodities that have a high weight in the expenditures of low-income
households. They are rice, cooking oil, sugar, chicken, beef, eggs, corn, red onions,
and soybeans. Although the president appears to want domestic prices of these
staples to be ‘cheap’, in several cases, most notably those of rice and sugar, the prices
are well above those prevailing in global markets. This is also true of other foods,
including fruit and vegetables, the consumption of which is much lower in most
Indonesian households than World Health Organization standards recommend
(Arifin et al. 2018).
Poor diet, poor sanitation, and inadequate access to clean water are in turn
linked to other health problems in Indonesia, which have attracted considerable
international attention in recent years. These health problems include child stunting
(low height for age) and child wasting (low weight for height). According to a study
published by a group of United Nations agencies in 2017, Indonesia has a high
percentage of stunting and wasting among children under five, compared with
neighbouring countries (table 1).
During his first term, Jokowi increased expenditure on, and the coverage of,
several social protection policies, including the conditional cash transfer program.
Towards a Healthy Indonesia? 135

These policies began in the aftermath of the 1997–98 Asian financial crisis (AFC)
and have proliferated in recent years. This Survey will examine these policies from
a longer-term perspective than is usual in BIES Surveys, paying particular attention
to implementation problems, including the issue of effective targeting. It will also
examine both food policy and broader health policy issues. It is widely agreed that
health problems, including those relating to early childhood development, must be
addressed in Indonesia in a wider context, including through the provision of clean
water and sanitation facilities, food security, and social assistance (Rokx, Subandoro,
and Gallagher 2018, 5). Improved databases are also essential for compiling lists of
beneficiaries. This Survey will look at recent figures on poverty and distribution
published by Statistics Indonesia (BPS), and it will review the problems with data
from the National Socio-economic Survey (Susenas). It will then assess how useful
these surveys are for measuring trends in poverty and inequality, and for framing
future social protection policies in Indonesia.

MACROECONOMIC DEVELOPMENTS
Economic growth slowed slightly in the first quarter of 2019, to 5.07% (year on
year). In a press statement released on 16 May, Bank Indonesia (BI) cited a decline
in global economic growth, combined with uncertainty over the election result,
which affected investment expenditures, as a possible cause of this outcome. BI
also noted that the impact of the election on consumption expenditures was less
than expected. Some commentators thought that in the aftermath of the election,
BI might lower interest rates, but in fact it was announced on 16 May that the
benchmark rate (the seven-day reverse repo rate) would be kept at 6%. Other rates
were also kept on hold. The decision was influenced by a slight weakening of the
rupiah in early May, which BI attributed to the trade war between the United States
and China; they pointed out that the climate of global uncertainty was leading to a
general weakening of emerging market currencies. The policy appears to have been
successful at least in the short run; by the end of May, the rupiah had appreciated
slightly compared with earlier in the month.
Another cause for concern was the deteriorating export performance; in April
the current account deficit was $25 billion, an historic high. The account deficit for
2019 is projected to be between 2.5% and 3% of GDP. This should be manageable,
but if the deficit widens later in the year, there may be further pressure on the
rupiah. Some commentators have projected a decline in export receipts in 2019 of
between 8% and 9%, which would be higher than in any year since 2015. Inflation
accelerated slightly in April compared with the previous month, but at 2.8% (year
on year), it remained lower than in 2018 and well within government targets.
Recent World Bank forecasts of economic growth in 2019 suggest that it will be
about 5.2%, although if both domestic and foreign investor confidence returns after
the election, it could be slightly higher (World Bank 2018a, table ES 1).
Where are the clouds on the horizon? Clearly the uncertain global economic climate
remains a problem; a growth slowdown in China induced by the trade tensions
with the United States could further depress commodity prices and lead to a wider
balance-of-payments deficit. Perhaps more worrying are the budget projections
for 2019. The budget projections published by the World Bank (2018a, table A4)
show an increase of 43.6% in subsidies in the 2019 budget compared with 2018.
136 Anne Booth, Raden Muhamad Purnagunawan, and Elan Satriawan

TABLE 2  Household Consumption Expenditures:

Susenas Estimates as a Percentage of National Accounts Estimates

% of total expenditures % of food expenditures

2014 41.6 54.6

2015 42.7 52.5
2016 43.3 53.8
2017 44.3 57.2
2018 44.8 57.5

Source: BPS (Statistics Indonesia). Accessed 1 May 2019. www.bps.go.id.

Note: GDP and Susenas data refer to the March quarter.

This was mainly due to the projected increase in fuel subsidies of more than 100%.
These projections were made on the assumption of world oil prices being $70 per
barrel; prices of both Brent Crude and West Texas in early June were lower than
this. On the other hand, tensions between the United States and Iran could worsen,
with consequences for world oil markets that are difficult to predict. But even if
the world oil price does fall below $70 per barrel in the second part of 2019, it is
likely that budget subsidies for fuel will increase, which would limit fiscal space
for other expenditures.

POVERTY AND INCOME DISTRIBUTION DATA

Over the past few years, a growing body of literature has discussed the apparent
rise in expenditure inequality, particularly during the first decade of the new
millennium (Yusuf, Sumner, and Rum 2014; World Bank 2016; Yusuf and Warr
2018). These estimates use the expenditure data from the Susenas household survey,
which has been carried out in Indonesia since the 1960s, although its coverage
has been national only since the late 1980s. Problems with the survey have in
fact received some attention in recent years, although not all researchers who
use Susenas to estimate inequality seem aware of them. The first problem is the
large gap between Susenas figures on household consumption and those from
the national accounts (Booth 2016, table 8.5). In 1996, the Susenas estimates of
household consumption expenditures were about 50% of personal consumption
expenditures as measured in the national accounts. After that, there was a steady
decline, to about 37% by 2009. There was some improvement after 2010, and from
2011 to 2018, the ratio appears to have fluctuated between 41% and 45%.
The disparity is greater for non-food than food expenditures, which suggests that
under-reporting is greater for expenditures such as housing, transport, and leisure
activities (table 2). This supports the argument that an important reason for the
disparity is that the better-off households in urban areas are difficult to enumerate,
either because they are too busy to fill in the form (which takes at least three hours
to complete) or because they do not give a full account of their expenditures. In
addition, there have been problems with the Susenas sample, which appears to
have been skewed towards the middle- and lower-income groups. In 2011, BPS
Towards a Healthy Indonesia? 137

undertook a major change in the sampling methodology, which led to a greater

diversity of neighbourhoods being included.1 As a result of this change, the
inequality estimates for 2011 and after are not strictly comparable with those from
previous years (World Bank 2016, 41).2 But even allowing for these changes, we see
that the problem of the disparity between the Susenas estimates and those from
the national accounts data persists. While there are valid reasons why estimates
in the national accounts data are likely to be higher than those in the household
survey data (the national accounts data include an estimate of the rental value of
owner-occupied housing and the contribution of the non-profit institutions serving
households), a disparity of more than 50% is usually considered to result from
understatement in the household survey data.3 In neighbouring countries such
as Thailand, Vietnam, and the Philippines, the disparity is less than in Indonesia
(Booth 2019, table 7). It appears that in spite of the changes in sampling procedures,
more affluent households in urban areas are still under-represented, or, if they are
included, that they understate their expenditures.
A further problem relates to the change in the estimation of the Gini ratio on
inequality, from using grouped data to using individual household data; this led
to an increase in the Gini and other measures of inequality after 2008 (Asra 2014;
Yusuf, Sumner, and Rum 2014). Using individual household data, Yusuf, Sumner,
and Rum (2014, figure 3), show that inequality increased from 2003 to 2013. But
these estimates ignore the change in sampling after 2010, to which the World Bank
(2016) drew attention. At least part of the increase was probably the result of the
post-2010 sample including more affluent neighbourhoods, especially in urban
areas. If we look at the estimates of the Gini coefficient from 2011 to 2018, which
are estimated using individual household data and the same sampling frame, it
would appear that there was little change in the Gini after 2011; indeed, between
March 2015 and March 2018, there appears to have been a fall, especially in urban
areas (figures 1 and 2).
To sum up, claims that there was an increase in inequality between 1999 and
2010 are probably correct, but they ignore the very sharp drop in the Gini and other
inequality indicators that took place after 1996.4 Using 1996 as the base year, we see
that there does seem to have been an increase in inequality, especially after 2003,

1. The sample of 300,000 households is now drawn from the 800,000 census blocks in
Indonesia, which are divided into three groups according to a wealth index compiled by
the BPS methodology division. But it is probable that the upper-income group contains
many households that are not in the top expenditure decile.
2. This change was probably the reason for the jump in inequality between 2010 and 2011
(World Bank 2016, 41).
3. A discussion of the disparity between national accounts data and those from household
surveys is given in Deaton (2010, 190–220). He examines the disparity in the context of India
and China but not Indonesia.
4. It is important to stress that this drop was in nominal terms; the data were not corrected
for inflation, which may have adversely impacted poorer groups more than the rest. One
study that attempted to correct the data for inflation between 1997 and 1999 using the 100
Village Survey found that various measures of inequality increased by up to 23% over these
two years, once the impact of inflation was considered (Skoufias, Suryahadi, and Sumarto
1999, table 4).
138 Anne Booth, Raden Muhamad Purnagunawan, and Elan Satriawan

FIGURE 1  Gini Ratio, All Indonesia, 1996–2017

.45
.41
.40
.39
.36
.35
.35
.33
.30

.25

.20
1996 1999 2002 2005 2008 2011 2014 2017

Source: BPS (Statistics Indonesia). Gini index by province, urban and rural areas, 1996–2018. Original
source: Susenas.
Note: Until 2005, Susenas was conducted on a three-yearly basis, and from 2007, on an annual basis.
Since 2011, the survey has been conducted twice annually, in March and September. From 2011, the
data in figure 1 are from the March round of the survey.

FIGURE 2  Gini Ratio, Urban, Rural, and All Indonesia, 2010–18

.50
Urban & rural U rban Rural

.40 .42 .42 .42

.38 .40

.30 .32 .33 .32 .33 .32

.20

.10

0
2010 2011 2012 2013 2014 2015 2016 2017 2018

Source: BPS (Statistics Indonesia). Gini index by province, urban and rural areas, 1996–2018. Original
source: Susenas.
* Data labels showing the values in alternate years are for urban and rural areas, starting in 2010.
Towards a Healthy Indonesia? 139

but that it is hardly as dramatic as some studies have suggested. Yusuf and Warr
(2018, 136) report that the Gini (using household data) was .365 in 1996 and .397 in
2016; the 2016 figure is probably overstated relative to the former because of the
changes in sampling methodology. So we are hardly looking at dramatic changes
in inequality over these two decades. Indeed, since 2015 there appears to have been
some decline in the Gini, especially in urban areas. The reasons are not entirely
clear, but it is possible that the social protection policies may have contributed to
the decline. These policies are examined in more detail below.
The headcount measure of poverty has continued to fall in recent years, although
the rate of decline has slowed. Between March 2012 and March 2018, the headcount
measure of poverty, using the BPS poverty line, fell from almost 12% to 9.8%. With
population growth of about 1.1%–1.2% per annum, the number of poor people has
fallen from 28.5 million to 26 million, a decline of only 1.5% per annum, which
is much slower than the per capita growth rate of GDP over these six years. It
seems that Indonesia is following ‘Gibson’s law’—that as the incidence of poverty
declines, the elasticity between poverty decline and GDP growth falls, while
the elasticity between poverty and inequality rises (Gibson 2016, 432). Gibson
made this observation based on data from Vietnam, but it also seems to apply to
Indonesia. To the extent that inequality has decreased only slowly between 2012
and 2018, it is to be expected that poverty decline will also be slow. This implies that
the Indonesian government, like other governments in Asia that have experienced
a fall in the headcount measure of poverty in recent years, will have to rely on more
than just economic growth to further reduce poverty.5

EVOLUTION OF SOCIAL PROTECTION POLICIES SINCE 1998

In spite of the fall in poverty as measured by expenditure over the past two
decades in Indonesia, both the government and many non-government groups
have been concerned about Indonesia’s performance on a range of non-monetary
indicators relating to both education and health. Recent studies have shown that,
for a middle-income country, Indonesia seems to be doing rather badly on several
human development indicators (table 3). These studies feature composite indexes
of human capital that have been used to rank countries across the globe. The
World Bank’s Human Capital Index, launched in 2018, ranked Indonesia at 87 out
of 157 countries; this was worse than the rankings of several other Asian countries
with similar or lower per capita GDP, including Sri Lanka, the Philippines, and
especially Vietnam. While all these indicators have their problems, the overall
message for Indonesia is not encouraging. On a range of health and education/
skills indicators, the country should be doing better.
The reasons for the rather disappointing performance are complex. Indonesia
was bequeathed a poor legacy by the Dutch in terms of both health and education
facilities. There was a rapid expansion of access to education after independence,

5. There are other issues with the poverty line in Indonesia that we cannot examine in detail
in this Survey. Priebe (2014) has documented the many changes in the BPS methodology
for estimating poverty since 1984; he argues that the methodology has been consistent only
since 2007. Booth (2019, table 4) shows that in 2011 the BPS poverty line was rather low in
comparison with other countries in Southeast Asia, including the Philippines and Vietnam.
140 Anne Booth, Raden Muhamad Purnagunawan, and Elan Satriawan

TABLE 3  Human Development Index Rankings

World Bank: Lim et al.: World Economic

2017 2016 (1990) Forum: 2017

Southeast Asia
Singapore 1 13 11
(43)
Brunei — 29 58
(35)
Malaysia 55 79 33
(106)
Thailand 65 72 40
(103)
Indonesia 87 131 65
(130)
Philippines 84 130 50
(124)
Laos 111 149 84
(157)
Vietnam 48 85 64
(116)
Myanmar 117 140 89
(152)
Cambodia 100 153 92
(158)
Other Asia
Republic of Korea 2 6 27
(18)
China 46 44 34
(69)
India 115 158 103
(162)

Source: World Bank (2018b); Lim et al. (2018); World Economic Forum (2017).
Note: Countries are ranked according to 2017 per capita GDP. The World Bank ranked 157 countries;
Lim et al. (2018) ranked 195; and the World Economic Forum ranked 130.

and in the Soeharto era many new schools were built under the Inpres programs.
But teachers were often poorly trained and could not teach subjects such as maths,
science, or foreign languages. By the 1980s, Indonesia had quite a high teacher-to-
student ratio compared with other developing countries, but a considerable number
of teachers were surplus to requirements. As many of them were permanent civil
servants (pegawai negeri), it was difficult to dismiss them.6 The problem has not

6. By the end of the Soeharto era, around 40% of civil servants were teachers or workers in
the education sector (Booth 2016, table 9.5).
Towards a Healthy Indonesia? 141

really improved in the post-Soeharto era. It is well known that Indonesian students
have performed badly in international tests such as the Trends in International
Mathematics and Science Study (TIMSS) and the Programme for International
Student Assessment (PISA).7 In spite of initiatives such as increased pay for teachers,
the problems of poor student achievement persist and are proving difficult to
ameliorate (Kurniawati et al. 2019, 285).
Health facilities were also expanded under Soeharto; the number of clinics
(puskesmas) and village health posts (posyandu) grew rapidly. But trained staff
were always in short supply, as were medicines and equipment. Newly graduated
doctors were obliged to spend up to five years working in puskesmas, but this policy
was changed in the 1990s and discontinued in 2007 (Rokx et al. 2010, 33–4). In recent
years, it has become clear that puskesmas are unevenly spread across the country,
and that there are wide variations in the quality of care they offer. According to
Ministry of Health figures, in 2018 only about 40% of all puskesmas had the five
categories of staff considered necessary for full preventive health services. Many of
the posyandu have become inactive in recent years. While some villages have used
their discretionary funds, including their village funds (dana desa), to build health
clinics, the problems of shortages of staff and equipment persist. The results of
these developments in terms of health outcomes will be discussed further below.
Growing worries among Indonesian policymakers in the post-Soeharto era about
the country’s poor performance in education and health, together with ongoing
concerns about poverty and vulnerability, have been an important factor in the
growth of social protection policies.8 Certainly funding has increased; one estimate
using Ministry of Finance figures shows an increase in budgetary funds for social
protection from Rp 19.42 billion in 2005 (.7% of GDP) to Rp 221.22 billion in 2017,
or 1.6% of GDP (McCarthy and Sumarto 2019, figure 13.1). What has the money
been spent on? An analysis of total expenditures on government programs aimed at
assisting those individuals and families considered deprived (tidak mampu) carried
out by the National Team for the Acceleration of Poverty Reduction (TNP2K) found
that in 2017 the total amount was Rp 203 trillion, or 1.5% of GDP.9 But 58% of this
amount went on subsidies for LPG, electricity, and fertiliser (table 4). These benefit
large numbers of households (54.9 million in the case of the LPG subsidy), but many
of these households are not poor in the sense of being below the official poverty line.

7. In both mathematics and reading, Indonesian students’ PISA results fall below the global
25th percentile average, although they improved between 2003 and 2015. But it should be
noted that as more low- and middle-income countries join the PISA tests, the average score
of the lowest 25% drops (Kurniawati et al. 2019, figures 10.2–3).
8. A useful summary of the social protection policies introduced between 1998 and 2014 is
given by Tohari, Rammohan, and Parsons (2017, 1–7).
9. This is slightly lower than the figure given by McCarthy and Sumarto (2019). The programs
in table 4 were selected from the following budget categories: social assistance, government
assistance, and subsidies. Programs such as Pamsimas, the community-based water
supply and sanitation program partly funded by the World Bank and implemented by the
Ministry of Public Works, were excluded on the grounds that they targeted areas rather than
people. Between 2008 and 2015, Pansimas provided around eight million people with access
to improved water facilities and 7.7 million with improved sanitation in 10,287 villages
(World Bank 2017, 25).
142 Anne Booth, Raden Muhamad Purnagunawan, and Elan Satriawan

TABLE 4  Funding of Social Protection Policies and Subsidies, 2017

Amount Implementing
Program (Rp trillion) ministry Beneficiaries

Subsidies
LPG 44.9 Energy & Mineral 54.9 million households
Resources
Electricity 42.1 Energy & Mineral 29.6 million households
900 VA (14.3) Resources
450 VA (27.8)
Fertiliser 31.0 Agriculture —
Other programs
Healthy Indonesia 21.1 Health 96 million people
Prosperous Rice Program 19.0 Social Affairs 14.2 million households
Housing Assistance 17.5 Public Works & 1.01 million people
Programa Housing
Cash Transfers 12.7 Social Affairs 6.2 million people
Smart Indonesia Program 11.3 Education & 18.1 million students
(school scholarships) Culture; Religious
Affairs
Non-cash Food Assistance 1.1 Social Affairs 1.2 million people
University Scholarships 1.1 Research, 80,000 students
(Bidikmisi program) Technology &
Higher Education
Otherb 1.1 Mixed —
Total 203
(1.5% of GDP)

Source: TNP2K (2018b).

a
This program comprises four different projects that are intended to help poor households buy a simple
house. The most important is the Housing Finance Liquidity Facility (FLPP), which is managed by the
Ministry of Public Works and Housing and channelled through the banking system.
b
There are about 12 other projects in the list compiled by TNP2K, implemented by several ministries.
The expenditures for these projects are all less than Rp 1 trillion.

It has been estimated that 40% of the electricity subsidies and 72% of the LPG
subsidies benefited non-poor households (TNP2K 2018a, 118–19).10 The fertiliser
subsidy has been criticised for poor targeting; it has also been claimed that
a substantial amount of subsidised fertiliser has leaked to larger farms and
plantations, especially in the palm oil sector (Wihardja 2019, 403).
The cheap rice program, which was introduced after the AFC, has gone through
several name changes, from OPK to Raskin and now Rastra, the Prosperous Rice
Program. Between 2001 and 2013, funding grew almost nine-fold, from Rp 2.4

10. Estimates indicate that the cost of the LPG subsidy will increase to Rp 69–73 trillion in
2019. Discussions are ongoing within government on how this can be reduced.
Towards a Healthy Indonesia? 143

trillion to Rp 21.5 trillion. This increase reflected both higher procurement costs
and increased storage and distribution costs (Timmer, Hastuti, and Sumarto 2018,
285–7). The number of households benefiting from the program increased from
20.9 million in 2002 to 32.8 million in 2013.
For two decades, the program has been criticised both for weak targeting and for
other failures, including the often poor quality of the rice, and the fact that many
beneficiaries received less than the 15 kilograms they were entitled to each month
and had to pay a higher price than the stipulated Rp 1,600 per kilogram. But in spite
of the targeting errors, it has been estimated that 72% of households in the bottom
decile did receive Raskin rice in 2014. Although the policy of distributing rice
remains popular, the government has announced plans to incorporate Rastra into
the non-cash food support program (BPNT), which in 2017 was being implemented
in 44 towns. The coverage will be expanded, and about 25% of the population will
receive a card that will allow them to buy both rice and eggs in shops equipped
with internet facilities (e-warung) up to a limit of Rp 110,000 per month.11
Other programs, such as those designed to help poor families purchase houses,
may be better targeted but benefit only a relatively small number of people. This
is also true of the scholarships that fund poor students’ university attendance,
such as Bidikmisi. The president indicated during the election campaign that this
scholarship program, which in 2017 reached only 80,000 students, may be expanded
into a much larger program. The Healthy Indonesia Program (PIS) reached 96
million people in 2017.12 It also paid for health insurance for people judged too poor
to pay the premiums for the National Health Insurance fund (JKN). But many of
the people receiving this assistance would not have been below the poverty line in
their province. The Social Security Management Agency (BPJS), which administers
the JKN, has been running a deficit in recent years; some critics argue that much of
this deficit is the result of non-poor households that do not have health insurance
using health facilities.
The most targeted program has probably been the Hopeful Families Program
(PKH), which provided conditional cash grants to 6.2 million poor families in
2017 and 10 million in 2019. The PKH program grew out of previous cash transfer
programs that were intended to compensate poor households for fuel price
increases. They began on a modest scale in 2007 in only seven provinces and
48 districts and cities (kabupaten and kota). In that year, there were only 387,947
beneficiaries. The expansion in the number of beneficiaries has been accompanied
by a rapid growth in the budget. In 2017, the estimated cost of the PKH was Rp 12.7
trillion, rising to Rp 32.6 trillion in 2019. There have also been changes in the amount
that each beneficiary, who must be a woman, is entitled to. Households qualify
for participation if they fall below a certain income threshold, have a pregnant
or nursing mother, at least one child below age six or attending school, or one
severely disabled member or a member over age 70. In 2019, the maximum amount

11. In fact, the termination of Rastra may be delayed, as the national logistics agency Bulog
still holds large stocks of rice that it argues can be more quickly run down through Rastra
than through the BPNT program.
12. The Healthy Indonesia Program targets not only people living below the official poverty
line but also those considered vulnerable. It covered about 35% of the population in 2017.
144 Anne Booth, Raden Muhamad Purnagunawan, and Elan Satriawan

a beneficiary can claim has been raised to Rp 10.15 million per year, although the
great majority of beneficiaries get less than that.
Given that about 25 million people were estimated to be below the official
poverty line in Indonesia in 2017, it is clear that many households who qualified
for participation on income grounds were still excluded from the PKH program in
that year (TNP2K 2018a, 74). This inevitably led to resentment and was probably
the reason for the substantial increase in both the number of beneficiaries and the
budget between 2017 and 2019 (an election year). But the government appears
committed to the continued expansion of the PKH to reach the bottom two quintiles
of the expenditure distribution, an estimated 28.8 million families. This will involve
a considerable increase in the cost of the program.
TNP2K (2018a, 98–9) has suggested that the Smart Indonesia Program (PIP) for
school scholarships and the PKH program be combined. They have a similar target
group, and it has been proposed that the government replace both programs with
a child benefit of Rp 200,000 per child per month paid to mothers for the first
three children. If targeted at families in the bottom three or four income deciles,
family benefits of this magnitude could have a significant impact on consumption
levels, as well as on school attendance. But the proposed program would involve
a substantially greater contribution from the budget than the existing PIP and
PKH allocations. Advocates of an expanded PKH program can point to research
suggesting that even the much smaller program implemented in earlier years led
to increased usage of health professionals for childbirth and halved the numbers
of children aged 7–15 who were not in school (Cahyadi et al. 2018). These authors
also claimed that children who had grown up in households receiving cash grants
showed considerable reductions in stunting.
Other suggested reforms include expanding the coverage of the PIS, although any
expansion is likely to run into supply-side constraints, especially in rural areas. The
problems facing the supply of health facilities in Indonesia will be examined in more
detail below. It is obvious that a reduction, or elimination, of the subsidies listed
in table 4 would free up considerable fiscal space for an expanded family benefit
scheme, or expanded health benefits. From a political viewpoint, eliminating the
LPG subsidy might be easiest, although this would have an adverse effect on many
small businesses. A reduction or elimination of both the electricity and the fertiliser
subsidy is likely to be more contentious.
In a review of programs intended to support early childhood development, the
World Bank (2017, 30) noted that ‘despite the multitude of interventions, programs
are neither integrated nor implemented at scale’, which reduces their impact. This
criticism would appear to apply to other programs listed in table 4 as well. In spite
of the increase, relative to GDP, in budgetary expenditures on social protection
policies since 1998, it is still the case that many programs are still too small to have
a significant impact on the population they are supposed to reach. Could more
accurate targeting improve their effectiveness? This question is addressed in the
next section.

TO TARGET OR NOT TO TARGET?

Most of the programs in table 4 involve some form of targeting. Many economists,
both Indonesian and foreign, tend to favour targeting on the grounds that universal
Towards a Healthy Indonesia? 145

programs would be very expensive. They also argue that the current policy of
targeting programs achieves greater social welfare than universal policies where the
available funds would be spread much more thinly, and many of the beneficiaries
would not be ‘poor’, however the term is defined. Hanna and Olken (2018) argue
that even rather badly targeted programs, which exclude people who should be
included, or include those who should be excluded, improve welfare, compared
with universal programs. But this argument seems open to dispute on several
grounds. The first concerns the cut-off point for receiving benefits. Those below the
cut-off point get cash grants or some other benefit, and those above it get nothing. If
the cut-off point is determined in a way that most people do not understand, it may
appear unfair. How many Indonesians understand how the official poverty lines,
or other cut-off points used for programs such as Rastra and PIS, are determined?
If they do understand, do they agree with the methodologies, which vary from
program to program? It has also been suggested that as families become more
familiar with the methods used to establish the threshold level of income, involving,
for example, proxy means testing,13 these families become aware of the strong
incentives for ensuring that they keep their declared income, or ownership of
assets, below the threshold level. This is especially the case when the cash and
other benefits are likely to be substantial relative to household income.
A second problem concerns what is often called income churning. Evidence
on this has been available for some years from panel data derived from rounds
of the Indonesian Family Life Surveys. Between 2007 and 2014, it is estimated
that one-third of all households climbed to a higher consumption quintile, while
another third fell back. Only one-third of households stayed in the same economic
class over this seven-year period (TNP2K 2018a, 43). There are obviously many
reasons for these movements; some households with low incomes may benefit
from remittances from members working in another province or abroad, while
others may be affected by the illness or death of the main earner. It is essential
if government assistance is to be seen as fair by non-beneficiaries that records of
household income be kept as up to date as possible.
In Indonesia, much effort over the past two decades has gone into producing
and maintaining a ‘unified database’ (UDB), which by 2019 contained detailed
socioeconomic information on almost 100 million people (see box). Although
there has been some progress in gaining the trust and cooperation of many local
governments across the country, it appears that a significant number of districts
do not regularly revise or update their data. Thus, the targeting of social protection
programs in these districts is likely to be flawed. Over time, there is a danger that
the entire targeting system may appear to many people to be arbitrary and unjust.
This is especially true where household income undergoes considerable change
from year to year. It is almost certain that public doubts about the targeting system
will increase if households that are considered poor when the UDB is compiled

13. Proxy means testing involves allocating transfers, or other government grants, on the
basis of household scores based on easily observed household characteristics such as quality
of housing or possession of consumer durables. These are assumed to be adequate proxies
for the actual income or expenditure of households. Community-based targeting is based
on local knowledge, but this is often provided by local officials who may have their own
agendas when it comes to the distribution of government grants (Ravallion 2016, 560–65).
146 Anne Booth, Raden Muhamad Purnagunawan, and Elan Satriawan

BOX  Indonesian Unified Database (UDB)

When Indonesia began to implement targeted social assistance programs after the AFC,
it used locally validated data from the National Family Planning Coordinating Board
(BKKBN). As the economy recovered, several of these programs were continued and
new ones were introduced. The need for better information on individual households
emerged when the government cut the fuel subsidy in 2005 and 2008, and needed to
launch compensation programs. This led to special surveys being implemented; in 2005,
a socioeconomic population survey (PSE 2005) took place—and later was updated in
2008 through the Data Collection for Social Protection Program (PPLS)—to establish
a database that could be used to compile a beneficiary list for some compensation
programs, including the unconditional cash transfer (BLT) program, Rice for the Poor
(Raskin) program, and Health Insurance for the Poor (Askeskin) program. For both
the PSE 2005 and the PPLS 2008, the main source of the household pre-lists was input
from village administrations.
In the next PPLS round in 2011, the government mandated TNP2K and BPS to improve
the data enumeration and the method by which the household pre-list was compiled.
The 2011 PPLS used a combination of poverty mapping and community suggestions to
compose lists of poor households. Field surveys were carried out by BPS using proxy
means testing, but there were problems. Implementation guidelines were not always
followed, and in many districts, households deemed non-poor by enumerators or by
community leaders were removed from the lists. Despite the problems, the 2011 PPLS
covered 45%–50% of the population. Results from Susenas were used to determine the
number and percentage of households in each decile and district. Households included
in the UDB were divided into the four poorest deciles (Bah, Nazara, and Satriawan
2015). The PPLS 2011 laid the foundation for the UDB, which was intended to be a
national registry of households identified as poor and needing government assistance.
After the 2011 PPLS was carried out, a permanent national targeting unit in TNP2K
was established to manage the UDB and to facilitate its use by line ministries and local
governments. Since 2012, the main social assistance programs—PKH, Raskin, PIP, and
the national community health insurance program, Jamkesmas—have used the UDB
to identify beneficiaries. Local governments have also used the UDB to plan their own
social assistance programs and to target the beneficiaries of the program. The most
recent nation-wide updating of the UDB was carried out in 2015. In composing the
household pre-list for updating, TNP2K and BPS conducted Development Research
Forums (FKP) at the local level to scrutinise the lists, using input from both local
governments and representatives from the community.
The cost of establishing the UDB has been estimated at Rp 600 billion for data collection
(PPLS 2011), with an annual average operating cost of Rp 16.3 billion between 2012 and
2014 (Bah, Nazara, and Satriawan 2015). This worked out at Rp 8,700 per registered
household per year. This was less than the cost per registered household for similar
programs in parts of Latin America. Also, new social assistance programs can share the
database rather than having to fund and design their own targeting systems. Between
2012 and 2014, the costs of the UDB were about .5% of the four main programs, PKH,
Raskin, PIP, and Jamkesmas.
Since 2017, more regular updating of the UDB has been introduced, managed by
the Ministry of Social Affairs. By 2018, the UDB contained detailed socioeconomic
information on 28.8 million families. Responsibility for managing the UDB has gradually
been transferred to the Ministry of Social Affairs and its regional offices (dinas sosial).
Updating the database is now done twice yearly with support from local governments,
although not all districts comply. In September 2018, it was estimated that 388 districts
had updated their data, and 126 had not. Officials in the Ministry of Social Affairs have
pointed to several reasons why districts are reluctant to update. These include the
difficulties involved in visiting all households (especially in remote areas), high budget
costs, and the lack of skilled enumerators in some districts. In addition, it appears that
not all local governments understand the UDB and its potential benefits.
Towards a Healthy Indonesia? 147

stay in the system and continue to get grants, even if their income improves, while
others who drop down the income scale receive nothing.
Some studies have claimed that targeting is likely to be more successful in rural
areas than in towns and cities, because village government is quite strong and
local leaders usually know who and where the poor are, and they will ensure that
the available cash and other assistance get to the people who need it. But that may
not be the case everywhere in the country. One study in Aceh found that the zakat
was better targeted than government programs such as the PKH, because local
religious leaders really did understand where the needs were greatest (McCarthy
and Sumarto 2019, 376). The authors argued that half the people benefiting from
the PKH cash grants were not poor based on the community’s own criteria. When
poor villagers saw that they were excluded from receiving government grants
while their better-off neighbours were not, they became resentful and blamed the
village leaders.
It also needs to be recognised that Indonesia is now urbanising rapidly and over
time fewer people will be living in traditional village communities. Increasingly the
demand for health and education services will come from urban and peri-urban
households. Quite a high proportion of the urban and peri-urban populations will
be recent migrants. Even if the local officials are reasonably honest and competent,
it will not always be easy for them to assess household income in order to target
programs effectively. It may be easier, especially in urban areas, to screen out
the better-off households, using proxy means tests, than to determine which
households are in the bottom three or four deciles of the income distribution at
any point in time. But even this may prove to be unpopular, and local officials may
be reluctant to screen out potential beneficiaries.

FOOD POLICY ISSUES

Food security is a crucial component of social protection policy, especially in
Indonesia, where there is still widespread evidence of poor nutrition, particularly
among children. Stunting and wasting in children appear widespread; stunting
affected at least 30% of the under-five age group in 2018 (table 5). There is
much medical evidence that poor nutrition in early childhood affects cognitive
development (Rokx, Subandoro, and Gallagher 2018, 6–7). The food security
problems in Indonesia centre around rice policy and broader food availability
issues, which in turn lead to the vexed question of greater reliance on food imports.
Rice availability and the rice price are important in Indonesia because the poor
still spend about 26% of their expenditure on rice and 65% on all foods, tobacco,
and beverages. Researchers have shown that increases in rice prices, other things
being equal, lead to an increase in the headcount measure of poverty. But over
time, economic conditions do change; from 2010 to 2018, the headcount measure
of poverty fell in spite of an increase of over 70% in the wholesale price of rice
(table 6). Of course, it is likely that poverty would have fallen faster if the price of
rice had been stable, or had risen less rapidly.
The reasons for the rapid increase in the rice price after 2010 are complex and
cannot be attributed simply to rising protection, as the domestic price of rice
was already close to twice that of the ex-Vietnam export price in 2010, and the
differential has not changed much since then. The explanation seems to lie, at
148 Anne Booth, Raden Muhamad Purnagunawan, and Elan Satriawan

TABLE 5  Health Indicators for Children under Five: 2007, 2013, and 2018 (%)

Nutritional status Physical size

Poor Inadequate Stunted Wasted

2007 5.4 13.0 36.8 13.6

2013 5.7 13.9 37.2 12.1
2018 3.9 13.8 30.8 10.2

Source: Ministry of Health (2019).

least partly, with the depreciation of the rupiah, which also affects the price of
other important food staples in Indonesia, including corn, wheat, soybean, and
meat. Supply factors would also affect the trends shown in table 6. How much
rice is in fact being produced in Indonesia? Until 2015, BPS used figures from
the Ministry of Agriculture, although over the years many observers have raised
doubts about the reliability of these figures, especially those relating to harvested
area. In 2018, BPS published the results of a major survey of rice production in 15
provinces. It demonstrated what the critics have long suspected—that the planted
and harvested area of rice is much less than the official statistics, supplied by the
Ministry of Agriculture, have claimed.14 This in turn means that rice production
figures are overstated. The 2018 estimates put production of paddy (gabah kering
giling) at 56.54 million tonnes, which converts to 32.42 million tonnes of milled rice.
Consumption availability of rice is estimated at 29.57 million tonnes or about 112
kilograms per capita (BPS 2018, 12).
The difference between production and consumption of about 2.85 million
tonnes in 2018 was presumably added to stocks, together with imports, which have
fluctuated in recent years but reached 2.25 million tonnes in 2018. These stocks were
used for the Rastra subsidised rice program and also to stabilise domestic prices
in the run-up to the election in April 2019. In fact, domestic price rises between
2016 and 2018 were modest, at under 5% over two years. This compares with rises
of more than 8% per annum from 2010 to 2016. Although this reversal in policy
seems to have received little publicity, the government now appears to be using
rice imports to stabilise domestic prices, albeit with domestic prices pegged at a
much higher level than the international price.
If the second Jokowi administration is to honour its pledge of keeping the prices
of staples stable over the next five years, it seems inevitable that imports not only of
rice but also of other foods will rise. In fact, imports of both wheat and corn have

14. A joint study by BPS and the Japan International Cooperation Agency in 1998 found
that the harvested area was over-reported by 17.1%. The problem seems to have worsened
since then. BPS estimated that the harvested area of rice in 2018 was 10.9 million hectares. In
2017, the Ministry of Agriculture figures gave the total harvested area of rice as 15.7 million
hectares, or 44% higher. It has been suggested that one reason for the over-statement of
harvested area is that farmers think they will receive more subsidised fertiliser if they claim
they are planting more rice than is actually the case.
Towards a Healthy Indonesia? 149

TABLE 6  Rice Prices: Ex-Vietnam and Indonesia Wholesale

Vietnam Indonesia Poverty

export price wholesale price Exchange incidence
(Rp) (Rp) rate (%)

2010 3,782 7,084 9,090 13.3

2011 4,429 7,890 8,770 12.5
2012 4,055 8,643 9,387 12.0
2013 4,090 8,941 10,461 11.4
2014 4,865 9,638 11,865 11.3
2015 4,726 10,915 13,389 11.2
2016 4,618 11,511 13,308 10.9
2017 4,978 11,535 13,381 10.6
2018 6,065 12,054 14,237 9.8

Source: Vietnam export prices in dollars: International Rice Research Institute. https://.ricestat.irri.org.
Indonesia wholesale price of rice and poverty incidence: BPS (Statistics Indonesia). www.bps.go.id.
Exchange rate: Bank Indonesia. www.bi.go.id/en/statistik.

been increasing over the past two decades; according to figures from the United
States Department of Agriculture, Indonesia is now among the largest importers of
wheat in the world. Especially in urban areas, consumption of wheat-based foods
(bread and noodles) is growing rapidly. But rates of effective protection on all food
crops, as well as on milled rice and wheat flour, remain high in Indonesia, and
indeed they appear to have increased between 2007 and 2015. Estimates of effective
rates of protection on both food crops and food-processing industries show that
they more than doubled over these eight years (Marks 2017, table 4), and in 2015
effective protection on food crops was five times the overall average on all traded
goods. The increases appear to be mainly due to increased quantitative restrictions.
Effective rates of protection were highest on field rice and sugar cane, followed by
fruit, vegetables, and corn.
As will be seen below, health experts have expressed concern about the low levels
of consumption of fruit and vegetables in Indonesia, especially among children. A
more liberal import policy would reduce domestic prices and increase consumption.
Indeed, economists have pointed out that import barriers on food affect the poor
more than the non-poor, as food comprises a greater share of their expenditure, and
most poor households are net consumers rather than producers of food. Should the
Indonesian government focus more on removing barriers to trade in food rather
than allocating budgetary resources to conditional cash transfers and other social
protection policies? This question merits further research.15 Producer welfare would
be adversely affected if food crop protection were reduced or eliminated, but poor
consumers would benefit, and scarce budgetary resources could be re-allocated to

15. Using a CGE model, Yusuf and Warr (2018, 149) find that increasing protection in the
food crop sector does increase poverty, but the effect is small. The effect is greater in urban
than in rural areas.
150 Anne Booth, Raden Muhamad Purnagunawan, and Elan Satriawan

other sectors to achieve improvements such as greater access to clean water and
better sanitation, especially in poor areas.

THE HEALTH SECTOR

Since the AFC and the departure of Soeharto from office, the health sector has been
through a number of changes; probably the most important have been a decline
in the role of the government in providing and staffing public clinics, and a rise
in the number of health professionals in private practice (Rokx et al. 2010, 50–54).
For much of the Soeharto era, most doctors were civil servants, although many
had private practices as well as public employment. Immediately after the AFC,
the number of physicians relative to population declined, although it is unclear
whether this was due to retirement or emigration. Between 1996 and 2006, there
was an increase in the total number of physicians relative to population, although
because of rapid urbanisation over these years, there was a decline in the number
of doctors per 100,000 people in urban areas. The number of midwives increased
relative to population in both urban and rural areas. The number of physicians per
puskesmas also increased in the decade up to 2007, but this growth was accompanied
by an increase in the number of puskesmas without a doctor, because doctors tended
to cluster in urban areas where the opportunities for private practice were greater
(Rokx et al. 2010, 42–8).
Decentralisation reforms created further problems for the health sector. It was one
of the sectors where responsibility was devolved to the districts, so almost 250,000
health workers were transferred to local governments. But in reality, the centre
retained considerable financial control (Rokx et al. 2010, 32–3). Overall expenditure
on health care remained low in Indonesia; the United Nations Development
Programme (UNDP 2010, 198–9) estimated that in 2007, per capita spending on
health care in dollars adjusted for purchasing power parity was lower than in any
other country in the medium development category except Pakistan. Since 2011,
government spending on health has risen as a proportion of the national budget,
from 3% to about 5%, but it is still less than 1% of GDP. Of the Rp 111 trillion
budget allocation to health in 2018, Rp 21 trillion went to the Healthy Indonesia
Card (KIS) program, whose direct benefit to the poor has been questioned. Other
government expenditures on health provision are also not well targeted to poor
people. Johar et al. (2018) find that only access to outpatient care in puskesmas was
pro-poor in the years from 2011 to 2016. Access to most other facilities, both public
and private, tends to benefit the non-poor, although in urban areas in-patient care
at public hospitals is pro-poor. The serious supply-side problems in the health
sector, which were already obvious before 1998, persist and in some areas have
worsened. They affect access both to facilities (clinics and hospitals) and to skilled
health workers in these facilities.
In 2018, Ministry of Health figures showed that of the 283,370 posyandu in the
country, only 61% were active in the sense that they offered services to the public.
But there was enormous variation across provinces, from 99% of posyandu being
active in North Sulawesi to only 8% in Maluku. The posyandu were set up in the
1980s to be the village-level units offering midwifery services, baby measuring and
weighing programs, and advice on nutrition to expectant and nursing mothers. The
staff were unpaid, although they did receive some travel money. They were trained
Towards a Healthy Indonesia? 151

TABLE 7  Number of Puskesmas and Posyandu per Million People by Region, 2018

No. of No. of No. of posyandu

posyandu puskesmas per puskesmas

Sumatra 479 45 10.6

Java–Bali 746 24 30.7
Nusa Tenggara 864 52 16.6
Kalimantan 335 57 5.9
Sulawesi 635 68 9.3
Maluku 302 114 2.7
Papua 874 560 6.6
Indonesia 656 38 17.3

Source: Kurniawan et al. (2018).

only in delivering basic disease prevention and primary care (Rokx, Subandoro,
and Gallagher 2018, 53–9). They were linked to the PKK, a Soeharto-era family
welfare institution designed to improve health and welfare in villages. The PKK
groups were often headed by the wives of village officials, who did not always
have much knowledge of primary health care. Nonetheless, the posyandu have been
credited with some success in the reduction of some health problems, including
stunting. After the AFC, there was a steep drop in the number of children attending
the posyandu.
In 2018, there were on average 656 active posyandu per million people in
Indonesia, but there was considerable variation across regions (table 7). There
were slightly more than 17 posyandu per puskesmas in Indonesia, but again there
was considerable variation across regions. Puskesmas staff are supposed to support
and supervise posyandu in their activities, but in many cases they lack both the staff
and the equipment to carry out their tasks. In Java–Bali, each puskesmas on average
supervises over 30 active posyandu, which imposes a considerable burden on staff.
In more remote rural areas, the ratio appears better, but distances are considerable
and puskesmas staff often have neither the time nor the budget to visit posyandu in
more remote villages on a regular basis. Between 2014 and 2017, an estimated 6,504
villages built new health clinics (polindes), which offer the services of midwives to
local women in fixed premises, although it is unclear whether the advent of a new
building improves the quality of service, or improves supervision by the puskesmas.
But in spite of the ongoing supply-side problems in health provision, there
have been some signs of progress, especially from 2013 to 2018. A key source
of information has been the three rounds of the Basic Health Research survey
(Riskesdas), conducted by the Ministry of Health in 2007, 2013, and 2018. These
data show a modest improvement in the nutritional status of children under five,
and a decline in stunting and wasting, although the proportion of stunted children
was still 30% in 2018 (table 5). But other indicators were less encouraging. The
figures on rates of immunisation for infants aged 12–23 months showed a slight fall
in the percentage receiving all the recommended vaccinations between 2013 and
2018 (from 59% to 58%). The numbers of those not being vaccinated have stayed
152 Anne Booth, Raden Muhamad Purnagunawan, and Elan Satriawan

quite stable at a little over 9% between 2007 and 2018. A worrying trend concerns
the prevalence of anaemia among pregnant women, which increased from 37%
in 2013 to almost 49% in 2018. Although the government has tried to increase the
supply of iron tablets available in puskesmas, the medication does not appear to be
getting to the pregnant women who need it. Many aspects of the Indonesian diet
are inadequate; for example, in 2018, 95.5% of the population were not getting the
recommended five portions of fruit and vegetables per day. The high cost of fruit
and vegetables relative to income is no doubt one reason for this.
A striking feature of the Riskesdas data was the very considerable regional
variations in many health indicators. The proportion of children under five who
were stunted varied from 17.7% in Jakarta to 42.6% in East Nusa Tenggara. The
percentage of those considered wasted varied from 4.6% in North Kalimantan to
14.4% in West Nusa Tenggara. The proportion of babies who had received all the
recommended vaccinations varied from only 20% in Aceh to 90% in Bali. While
there is a general tendency for health indicators to be worse in Eastern Indonesia
than in Java–Bali and Sumatra, this is not always the case. A possible explanation
for the low, and in some provinces falling, percentage of vaccinated children is
an active campaign on social media promoting the view that vaccinations contain
fluids derived from pigs. It is often very difficult for the government to counter
such views, without offending Islamic opinion.
There are sound economic reasons why Indonesia should devote more resources
to improving nutrition among the general population, especially among pregnant
and nursing mothers and children under five. Hoddinott et al. (2013) construct
what they term credible estimates of benefit–cost ratios for a plausible set of
nutritional interventions aimed especially at the reduction of stunting in children.
They obtained very high estimates for several countries in South and Southeast
Asia; in Indonesia the ratio was 48, and in the Philippines it was 44. Although
these estimates can be criticised, they do suggest that there has been significant
underinvestment in improving nutrition in many developing countries, with
Indonesia being a striking example.16 The key problem for Indonesian policymakers
will be to design a package of nutritional and other interventions that will achieve
improvements in the health of young children, at a reasonable cost.
The Jokowi government has initiated a national strategy to combat child stunting
(StraNas Stunting), which has prioritised 100 districts across the country where
the problem appears most severe.17 A major government concern is that multiple
government programs to expand access to basic services on maternal and child
health, parenting and nutrition counselling, water, and sanitation, as well as to
provide social protection, are still not reaching many households across the
country (Rokx, Subandoro, and Gallagher 2018, 59). Simply increasing the health
budget, or the social protection budget, may not in itself be sufficient to solve the
problem of coordination across several central government departments and many
district- and village-level administrations. Indeed, it could make the problem worse.

16. A detailed assessment of the problems in estimating the benefits of nutritional

interventions can be found in Alderman, Behrman, and Puett (2017).
17. The number of districts covered by the program rose to 160 in 2019 and is projected to
increase to 260 in 2020. By 2023, there will be full national coverage of the program.
Towards a Healthy Indonesia? 153

Starting in 2018, more than 3,000 human development workers will operate in five
pilot districts to coordinate programs at the village level, and to support posyandu in
implementing StraNas Stunting programs. These initiatives are likely to be scaled
up in the next five years.

CONCLUSIONS
Over the past two decades, a number of social protection policies have been
implemented in Indonesia, including the distribution of subsidised rice, cash
transfers (unconditional and conditional), health cards, and grants to assist children
to stay in school. In addition, subsidies have been used to lower the prices of LPG,
electricity, and fertiliser. The total cost of these policies has risen rapidly both in
absolute terms and relative to GDP. But there are concerns about targeting. The
government has devoted considerable resources to the construction of the UDB,
which provides comprehensive data on the income and assets of close to 100 million
Indonesians, in order to target social assistance programs more accurately. But
it appears that a minority of local governments have been slow in updating the
information (see box).
Some research has shown that the beneficiaries of the various social protection
programs have been able to access health care and keep their children in school,
although it could be argued that other policies, including the reduction or
elimination of quantitative controls on food imports, could have a greater impact
on the incomes of the poor. The high cost of many basic foods in Indonesia, relative
to import prices, is one reason for poor nutrition among children under five and
many adults, including pregnant and nursing mothers. But there are other reasons
for Indonesia’s rather weak performance on a number of health indicators. The
supply of health workers (doctors, nurses, and midwives) has grown over the past
two decades, but many have opted for private practice, and government facilities
are often understaffed and unable to offer a full range of treatments. Government
spending on health has increased as a share of the government budget over the past
decade but is still low relative to GDP. The decentralisation of health services to the
districts does not appear to have improved the range of services available to many
Indonesians, especially in Eastern Indonesia. There are often marked disparities
between provinces in both maternal and child health, which government policies
at both central and local levels have yet to address.

REFERENCES
Alderman, Harold, Jere R. Behrman, and Chloe Puett. 2017. ‘Big Numbers about Small
Children: Estimating the Economic Benefits of Addressing Undernutrition’. World Bank
Research Observer 32 (1): 107–26.
Arifin, Bustanul, Noer Azam Achsani, Drajat Martianto, Linda Karlina Sari, and Ahmad Heri
Firdaus. 2018. ‘Modelling the Future of Indonesian Food Consumption’. Report submitted
to the National Development Planning Agency (Bappenas), World Food Programme
(WFP), and Food and Agricultural Organization of the United Nations (FAO). Jakarta.
https://docs.wfp.org/api/documents/WFP-0000073760/download/
Asra, Abuzar. 2014. Cerdas Menggunakan Statistik [Accurate use of statistics]. Bogor: In Media.
154 Anne Booth, Raden Muhamad Purnagunawan, and Elan Satriawan

Bah, Adama, Suahasil Nazara and Elan Satriawan. 2015. ‘Indonesia’s Single Registry for
Social Protection Programmes’. Research brief no. 49, International Policy Centre for
Inclusive Growth, Brasilia, July.
Booth, Anne. 2016. Economic Change in Modern Indonesia: Colonial and Post-colonial Comparisons.
Cambridge: Cambridge University Press.
Booth, Anne. 2019. ‘Measuring Poverty and Income Distribution in Southeast Asia’. Asian-
Pacific Economic Literature 33 (1): 3–20. https://doi.org/10.1111/apel.12250.
BPS (Statistics Indonesia). 2018. Luas Panen dan Produksi Beras di Indonesia 2018 [Rice harvest
area and production in Indonesia 2018] Jakarta: BPS.
Cahyadi, Nur, Rema Hanna, Benjamin A. Olken, Rizal Adi Prima, Elan Satriawan, and
Ekki Syamsulhakim. 2018. ‘Cumulative Impacts of Conditional Cash Transfer Programs:
Experimental Evidence from Indonesia’. NBER Working Paper 24670, National Bureau of
Economic Research, Cambridge, MA, May. http://www.nber.org/papers/w24670
Deaton, Angus. 2010. ‘Measuring Poverty in a Growing World (or Measuring Growth in
a Poor World)’. In Debates on the Measurement of Global Poverty, edited by Sudhir Anand,
Paul Segal, and Joseph Stiglitz, 187–224. Oxford: Oxford University Press.
FAO (Food and Agriculture Organization of the United Nations), IFAD (International Fund
for Agricultural Development), UNICEF (United Nations Children’s Fund), WFP (World
Food Programme), and WHO (World Health Organization). 2017. The State of Food Security
and Nutrition in the World: Building Resilience for Peace and Food Security. Rome: FAO.
Gibson, John. 2016. ‘Poverty Measurement: We Know Less than Policy Makers Realise’. Asia
and the Pacific Policy Studies 3 (3): 430–42.
Hanna, Rema, and Benjamin A. Olken. 2018. ‘Universal Basic Incomes versus Targeted
Transfers: Anti-Poverty Programs in Developing Countries’. Journal of Economic Perspectives
32 (4): 201–26.
Hoddinott, John, Harold Alderman, Jere R. Behrman, Lawrence Haddad, and Susan Horton.
2013. ‘The Economic Rationale for Investing in Stunting Reduction’. Maternal and Child
Nutrition 9 (S2): 69–82.
Johar, Meliyanni, Prastuti Soewondo, Retno Pujisubekti, Harsa Kunthara Satrio, and Ardi
Adji. 2018. ‘Access Inequity, Health Insurance and the Role of Supply Factors’. Social
Sciences & Medicine 213 (September): 134–45.
Kompas. 2019. ‘Jokowi: Infrastruktur Bisa Ditinggal, Kita Fokus ke SDM’ [Jokowi: infrastructure
can be left behind, we will focus on SDM]. 12 February. https://nasional.kompas.com/
read/2019/02/12/19541131/jokowi-infrastruktur-bisa-ditinggal-kita-fokus-ke-sdm
Kurniawan, Rudy, Boga Hardhana, Yudianto, and Tanti Siswanti, eds. 2018. Data dan
Informasi Profil Kesehatan Indonesia 2018 [Data and information on the health profile
in Indonesia 2018]. Jakarta: Ministry of Health. http://www.depkes.go.id/resources/
download/pusdatin/profil-kesehatan-indonesia/Data-dan-Informasi_Profil-Kesehatan-
Indonesia-2018.pdf
Kurniawati, Sandra, Daniel Suryadarma, Luhur Bima, and Asri Yusrina. 2019. ‘Education
in Indonesia: A White Elephant’. In The Indonesian Economy in Transition: Policy Challenges
in the Jokowi Era and Beyond, edited by Hal Hill and Siwage Dharma Negara, 266–88.
Singapore: ISEAS–Yusof Ishak Institute.
Lim, Stephen S., Rachel L. Updike, Alexander S. Kaldjian, Ryan M. Barber, Krycia Cowling,
Hunter York, Joseph Friedman et al. 2018. ‘Measuring Human Capital: A Systematic
Analysis of 105 Countries and Territories 1990–2016’, Lancet 392 (10154): 1217–34.
Marks, Stephen V. 2017. ‘Non-tariff Trade Regulations in Indonesia: Nominal and Effective
Rates of Protection’. Bulletin of Indonesian Economic Studies 53 (3): 333–57.
McCarthy, John, and Mulyadi Sumarto. 2019. ‘Distributional Politics and Social Protection
in Indonesia: Dilemma of Layering, Nesting and Social Fit in Jokowi’s Poverty Policy’. In
The Indonesian Economy in Transition: Policy Challenges in the Jokowi Era and Beyond, edited
by Hal Hill and Siwage Dharma Negara, 362–84. Singapore: ISEAS–Yusof Ishak Institute.
Towards a Healthy Indonesia? 155

Ministry of Health. 2019. ‘Hasil Utama Riskesdas 2018’ [Main results of Riskesdas 2018].
PowerPoint presentation, Jakarta.
Priebe, Jan. 2014. ‘Official Poverty Measurement in Indonesia since 1984: A Methodological
Review’. Bulletin of Indonesian Economic Studies 50 (2): 185–205.
Ravallion, Martin. 2016. The Economics of Poverty: History, Measurement, and Policy. New York:
Oxford University Press.
Rokx, Claudia, John Giles, Elan Satriawan, Puti Marzoeki, Pandu Harimurti, and Elif Yavuz.
2010. New Insights into the Provision of Health Services in Indonesia: A Health Workforce Study.
Washington, DC: World Bank.
Rokx, Claudia, Ali Subandoro, and Paul Gallagher. 2018. Aiming High: Indonesia’s Ambition
to Reduce Stunting. Washington, DC: World Bank.
Skoufias, Emmanuel, Asep Suryahadi, and Sudarno Sumarto. 1999. ‘The Indonesian Crisis
and Its Impacts on Household Welfare, Poverty Transitions, and Inequality: Evidence
from Matched Households in the 100 Village Survey’. SMERU Working Paper, Social
Monitoring and Early Response Unit, Jakarta, September.
Timmer, Peter, Hastuti and Sudarno Sumarto. 2018. ‘Evolution and Implementation of
the Rastra Program in Indonesia’. In The 1.5 Billion People Question: Food, Vouchers or
Cash Transfers, edited by Harold Alderman, Ugo Gentile, and Ruslan Yemtsov, 265–310.
Washington, DC: World Bank.
TNP2K (National Team for the Acceleration of Poverty Reduction). 2018a. The Future of the
Social Protection System in Indonesia: Social Protection for All. Jakarta: TNP2K.
TNP2K (National Team for the Acceleration of Poverty Reduction). 2018b. Program Bantuan
Pemerintah Untuk Individu, Keluarga dan Kelompok Tidak Mampu: Menuju Bantuan Sosial
Terintegrasi: Rinkasan Eksekutif [Government program for poor individuals, families, and
groups: towards integrated social assistance: executive summary]. Jakarta: TNPK.
Tohari, Achmad, Anu Rammohan, and Christopher Parsons. 2017. ‘Targeting under
Complementarities: Evidence from Indonesia’s Unified Targeting System’. IZA Discussion
Paper 10968, IZA Institute of Labor Economics, Bonn, August.
UNDP (United Nations Development Programme). 2010. Human Development Report
2010: The Real Wealth of Nations, Pathways to Human Development. Basingstoke: Palgrave
Macmillan.
Wihardja, Maria Monica. 2019. ‘Has Indonesian Food Policy Failed?’ In The Indonesian
Economy in Transition: Policy Challenges in the Jokowi Era and Beyond, edited by Hal Hill
and Siwage Dharma Negara, 385–413. Singapore: ISEAS–Yusof Ishak Institute.
World Bank. 2016. Indonesia’s Rising Divide. Jakarta: World Bank.
World Bank. 2017. Indonesia Economic Quarterly: June. Jakarta: World Bank
World Bank. 2018a. Indonesia Economic Quarterly: December. Jakarta: World Bank.
World Bank. 2018b. The Human Capital Project. Washington, DC: World Bank.
World Economic Forum. 2017. The Global Human Capital Report 2017. Geneva: World
Economic Forum.
Yusuf, Arief Anshory, Andy Sumner, and Irlan A. Rum. 2014. ‘Twenty Years of Expenditure
Inequality in Indonesia, 1993–2013’. Bulletin of Indonesian Economic Studies 50 (2): 243–54.
Yusuf, Arief Anshory, and Peter Warr. 2018. ‘Anti-globalisation, Poverty and Inequality
in Indonesia’. In Indonesia in the New World: Globalisation, Nationalism and Sovereignty,
edited by Arianto A. Patunru, Mari Pangestu, and M. Chatib Basri, 133–56. Singapore:
ISEAS–Yusof Ishak Institute.