Reducing child mortality in Indonesia.

Despite considerable global progress on reducing child mortality, most recent estimates indicate that in 2008 about 8.8 million children died. 1 Debate continues on how best to meet millennium development goal 4: reduction of child mortality by two-thirds by 2015. Some believe that scaling up specific health interventions is the best way to achieve this, others point towards strengthening the health system in a comprehensive way, and a third group believes that overall economic development is more important than specific interventions. 2 The argument is that if people have more money, they will improve their living environment and spend more on items and services which are conducive to better health. Using the example of Indonesia, we claim that economic growth is not enough, but that scaling up beneficial health interventions and investing in the quality of health services are essential for improving child survival. Indonesia had a consistent economic growth of 3–5% per year over the past 20 years, except for a short period during the 1998 Asian economic crisis that lead to the replacement of an authoritarian regime by a democratic government and transferred central authority to 500 districts in 33 provinces. Since then, the financing and delivery of health interventions has been the responsibility of the district, but there are concerns about peripheral capacity to manage these interventions. 3 Indonesia has more than 8000 community health centres that supervise public health interventions and provide primary care. Indonesia's main strategy for ensuring better care for children has been the adoption of the Integrated Management of Childhood Illness (IMCI) in 1997. For health promotion and disease prevention, the community health centres rely on community health posts, which are staffed by health volunteers, supervised by a visiting nurse or village midwife. These posts provide growth monitoring, nutritional counselling, health education and immunization services. To reduce maternal and child mortality, village midwives ensure antenatal care, birth preparedness, skilled attendance at birth and postnatal care for mother and newborn. But hospital programmes for reducing maternal and infant deaths have lagged behind these primary health care interventions. Data on mortality, nutritional and health status and coverage of interventions are available from the annual socioeconomic survey and the demographic and health survey (DHS), which is done every 5 years, providing data on family planning, reproductive health and child health interventions. 4 Both surveys are used to produce child mortality estimates, and these estimates show that …