Indonesia: gender and health

GDP1 Current health expenditure2 Catastrophic health expenditure3 Proportion of out-of-pocket expenditure4
10933.74 11646.47 12301.75 333.5 362.6 367.9 3.45 3.61 2.70 42.5 41.1 37.6 34.6

Unit:
Unit: PPP per capita
2017 2018 2019 $ INT 2015 2016 2017 current $ INT 2010 2015 2018 Unit: % 2014 2015 2016 2017 Unit: %

Why does gender matter for health in Indonesia? Poverty level5 GINI6 Sex ratio at birth7
36.7 39.7 37.8 105 males per
Gender is a major determinant of health for women and 100 females
Unit:
men in Indonesia. Gender norms, roles and relations 3.6% Unit: scale of 0-100,
interact with biological factors, in turn influencing 2018 % 2009 2015 2018 with 0 being better
people’s exposure to disease and risks for ill health.
HDI-IHDI8 GDI9 GII10
Therefore, it is important for health policy-makers to
consider the different gender needs of all men and 0.67 0.72 0.58 0.68 0.72 0.57 0.68 0.72 0.58 HDI female 0.935 0.937 0.937 0.464 0.453 0.451
women. Tailoring health policies and programmes to HDI male
IHDI
Unit:
take account of these differences and trends can Unit: index
index from
improve their impact, reduce health inequities and Unit: index
from 0 to 1 0 to 1
from 0 to 1
advance the right to health for all. 2016 2017 2018 2016 2017 2018 2016 2017 2018

Do men and women in Indonesia have equal access to determinants of health?

Health is significantly determined by social, economic, and environmental factors that lie beyond the health sector, such as poverty, education, employment and physical
security. Gender inequality, an important determinant of health, remains a challenge in Indonesia, as elsewhere. Women lag behind men in many indicators of social well-being,
including literacy, share in agricultural holdings, labour force participation and the proportion of doctors.

Fewer than one in every 10 agricultural holders is a woman.11 Nearly seven in every 10 married women in Indonesia say that they, alone or jointly,make
major household decisions.12

Nearly nine in every 10 women in Indonesia have access to at least one form of mass media. Proportion of individuals who have used the Proportion of individuals who own a mobile phone
However, the slight gap between men and women in access to mass media persists.13 internet by sex14 by sex15
49.6 40.3 78.4 83.7

NEWS

Unit: % Unit: %
2017 2017

Literacy has improved but the Although girls have achieved parity with boys in school enrolment, only fewer than two While eight in every 10 men participate in the labour
slight gap in the rates between in every five science, technology, engineering and mathematics graduates are women.17,18 force, only about five in every 10 women do so and
men and women has persisted.16 0.97 0.97 0.97 this gap has persisted over time.19
Primary
96.79 97.11 97.17 97.33 50.7 82.9 51.0 81.8 53.2 82.2 Female
Male
1.03 1.02 1.03 Secondary
Male
Female Tertiary
93.45 93.34 93.59 93.99 1.13 1.15 1.16
Unit: %
2014 2015 2016 2018 2016 2017 2018 Unit: ratio 2013 2016 2018 Unit: %

Sex distribution of informal sector workforce20 Proportion of children engaged in child Slightly over half of all women in Indonesia Women in Indonesia earn only an estimated
labour by sex21 own a bank account.22 US$ 5 for every US$ 10 earned
54.2 55.0 51.0 52.4 Female
by men.23
Male
5.8% 7.9%
Men $ $ $ $ $ $ $ $ $ $

Women $ $ $ $ $

Unit: %
2018 2019 2009 2020

Women comprise two-thirds of general medical practitioners and nurses but only Fewer than one in three managers Only 0.5 % of households in Indonesia are now located
two-fifths of all medical specialists.24 in Indonesia is a woman.25 more than half an hour from a water source.26
Do men and women in Indonesia have similar life expectancies?

Women have slightly better life expectancy and healthy life expectancy at birth than men in Indonesia.

Life expectancy and healthy life expectancy at birth by sex27

Male 2015 61.5 68.8 Healthy life expectancy at birth

Life expectancy at birth
Female 2015 63.2 72.5

Male 2019 61.9 69.4

Female 2019 63.8 73.3 Unit: Years

Do gender, location of residence, education and income affect the health status of people in Indonesia?
The health status of all women and men in Indonesia, as elsewhere, is determined by the interaction between social (gender) and biological (sex) differences. The differences in health status
between men and women go beyond sexual and reproductive health. Besides gender, factors such as location of residence (urban/rural), education and income also affect health status.

Disease burdens are different between men and women.

Chronic obstructive pulmonary disease, road injuries and HIV/AIDS feature in the 10
leading causes of deaths among men, but not among women. Alzheimer’s disease,
hypertensive heart disease and breast cancer feature in the 10 leading causes of deaths
among women, but not among men.
10 leading causes of death among men and women28
Road injuries, cirrhosis of the liver, HIV/AIDS and chronic obstructive pulmonary
disease figure in the 10 leading causes of DALYs lost among men, but not among
women. Iron deficiency anaemia, diarrheal diseases, back and neck pain and asthma
feature in the 10 leading causes of DALYs lost among women, but not among men.
10 leading causes of DALYs lost among men and women29

Male 25.61 Ischaemic heart disease Male 20.59 Ischaemic heart disease
25.03 Stroke 19.85 Stroke
11.63 Tuberculosis 11.52 Tuberculosis
7.42 Diabetes mellitus 8.46 Diabetes mellitus
6.64 Chronic obstructive pulmonary disease 7.34 Road injury
6.26 Cirrhosis of the liver 7.19 HIV/AIDS
4.62 Road injury 6.46 Lower respiratory infections
4.41 Lower respiratory infections 6.28 Cirrhosis of the liver
Unit: Unit:
Cause-specific death 4.24 HIV/AIDS Disease-specific 6.25 Preterm birth complications
rates as % of 10 4.14 Diarrhoeal diseases DALYs lost as % of 6.01 Chronic obstructive pulmonary disease
leading causes 10 leading diseases

Female 31.72 Ischaemic heart disease Female 24.77 Ischaemic heart disease
19.38 Stroke 15.06 Stroke
11.24 Diabetes mellitus 13.59 Diabetes mellitus
7.66 Tuberculosis 8.87 Tuberculosis
6.56 Alzheimer disese & other dementias 7.89 Lower respiratory infections
6.18 Diarrhoeal disease 7.49 Preterm birth complications
4.50 Lower respiratory infections 6.94 Diarrhoeal diseases
Unit:
4.33 Hypertensive heart disease Unit:
5.14 Back and neck pain
Cause-specific death 4.25 Breast cancer Disease-specific 5.11 Iron-deficiency anaemia
rates as % of 10 4.19 Cirrhosis of the liver DALYs lost as % of 5.08 Asthma
leading causes 10 leading diseases

The survival of children under five years of age has improved steadily. However, children of mothers with lower education levels tend to fare worse. Children from the poorest
Under-five mortality rate by sex 30
Under-five mortality rate by location of residence 31
Under-five mortality rate by mother’s education 32 households have a 120% higher
risk of dying than those from the
45 35 37 26 Male 40 32 48 32 31 33 Total 82 58 36 31 28 27 No education richest households.33 Poorest
Female Urban Some primary Second
Rural 53 33 29 31 24
Completed primary Middle
Some secondary $ Fourth
Completed secondary $ Richest
$ $ $
Unit: per Unit: per $ $ Unit: per
More than secondary $ $ $
thousand thousand $ $ thousand
$ $ $
2012 2017 live births 2012 2017 live births 2017 Unit: per thousand live births 2017 live births

Nutritional status of children by sex34 Compared to their urban counterparts, children from In this age group, compared to children of highly educated
rural areas have a 6% higher risk of dying, a 28% higher mothers, children of uneducated mothers have a 203%
31.8 30.0 18.7 16.6 11.1 9.2 Male
higher risk of dying, a 43% higher risk of stunting, a 36%
risk of stunting, a 27% higher risk of being underweight
Female
and a 9% higher risk of wasting.35 higher risk of being underweight and a 14% higher risk
27.2 35.0 15.7 20.0 9.8 10.7
of wasting.36
Urban
34.7 24.1 18.9 13.8 10.9 9.6 Low education
Rural High education

2018 2018 2018

Stunting Underweight Wasting Unit: % Stunting Underweight Wasting Unit: % Stunting Underweight Wasting Unit: %
Mothers’ chances of dying during and after childbirth in Total fertility rate by location of residence38
Indonesia have reduced to nearly two-thirds of the level
in 2000.37 2.6 2.3 2.8 2.6 2.4 2.8 2.4 2.3 2.6 Total

272 252 228 192 177 Urban

Rural

Unit: Unit: average

per 100,000 number of births
2000 2005 2010 2015 2017 live births 2007 2012 2017 per woman

Total fertility rate by level of education39 Total fertility rate by household income quintile40

2.4 2.8 2.6 2.7 2.8 2.9 2.7 2.4 2.7 2.9 2.5 2.3 No education 3.0 2.5 2.8 2.5 2.7 3.2 2.7 2.5 2.4 2.2 2.9 2.6 2.3 2.3 2.1 Poorest
Primary Second
Secondary $ Middle
$ $ $
$ $ $ $ $ $
Higher $ $ $ $ $ $ Fourth
$ $ $ $ $
$ $ $ $ $ $
$ $ $
$ $ $ Richhest
$ $ $ $ $ $ $
Unit: average number $ $ $ $ $ $ Unit: average number
$ $ $ $
of births per woman $ $ of births per woman
2007 2012 2017 2007 2012 2017

Fertility rates have declined more rapidly among adolescent women, compared to adult women, although inequities by location of residence, education and income persist. Adolescent
fertility is 112% higher among rural girls compared to their urban counterparts, 43.33 times higher among those with only primary education compared to those with the highest levels
of education and over seven times higher among those from the poorest households compared to their richest counterparts.41
Adolescent fertility rate by location of residence42 Adolescent fertility rate by level of education43
51 26 74 48 32 70 36 24 51 Total 86 98 35 32 91 125 42 5 130 35 3 No education
Urban Primary
Secondary
Rural
Higher

Unit: per thousand

2007 2012 2017 women aged 15-19 2007 2012 2017

Adolescent fertility rate by household income quintile44

49 50 71 63 52 93 72 45 35 13 73 50 38 17 10 Poorest

$ Second

$ $ $ $ Middle
$
$ $ $ $ $ $ $ $ Fourth
$ $
$ $ $ $ $ $ Richest
$ $ $ $ $
$ $
$ $ $ $ $ $ $ $ $ $ Unit: per thousand
$ $ $ $
2007 2012 $
2017 women aged 15-19

Do gender, location of residence, education and income affect exposure to health risks and vulnerabilities in Indonesia?

Biological and gender-related factors interact to result in differences between men and women in Indonesia in their exposure to health risks and vulnerabilities. Besides gender,
location of residence (urban/rural), education and income also affect exposure to health risks and vulnerabilities.

Overweight prevalence among adults by sex45 Obesity prevalence among adults by sex46
The higher prevalence of overweight and
28.6 27.0 31.0 27.2 20.3 36.1 Total 7.7 6.7 9.1 2.3 1.9 2.8
obesity among women and the lower Total
Male
prevalence of physical activity among Male
Female
women and girls than among men and boys Female
represent higher exposure to risk of
non-communicable diseases.
Unit: % population Unit: % population
2003 2006 2003 2006

Physical activity among adults by sex47 Alcohol consumption among adults by sex48 Prevalence rate of current tobacco use among adults by sex49

33.0 32.6 33.5 22.4 28.7 14.3 Total 3.7 6.0 0.3 1.7 2.9 0 Total 30.9 59.7 2.1 31.1 60.2 1.9 Total
Male Male Male
Female Female Female

Unit: % population Unit: % population Unit: % population

2003 2006 2003 2006 2016 2018
 Overweight among adolescents by sex50 Obesity among adolescents by sex51 Physical activity among adolescents by sex52 Prevalence rate of current tobacco
use among adolescents by sex53
14.8 15.1 14.5 Total 4.6 5.4 3.8 Total 12.9 13.4 12.3 Total
Male Male Male 12.7 23.0 2.4 Total
Female Female Female Male

Female

Unit: %
Unit: % population
2015 2015 Unit: % population 2015 Unit: % population 2015 population

Ever use of marijuana among adolescents by sex54 Alcohol consumption among adolescents by sex55 Only about one in eight adolescent girls in Indonesia has comprehensive
knowledge about HIV/AIDS.56
1.4 2.2 0.6 Total 4.4 7.2 1.6 Total
Male Male

Female Female

More than one in five women in Indonesia experience intimate partner violence in
their lifetime.57

2015 Unit: % population 2015 Unit: % population

Women and girls are exposed to household smoke from fuels while performing their assigned gender role of cooking. In Indonesia, about three in every 10 households use unclean fuels
for cooking.58

Do gender, location of residence, education and income affect access to health services in Indonesia?

Geographical, financial, socio-cultural or other barriers may compound gender-related barriers to access to services. Women in Indonesia report facing gender-related barriers
such as problems in going alone to seek care, getting money for treatment and distance to the health care facility.

DTP3 vaccination rate by sex59 Children from urban areas have an 8% higher Children of mothers with the highest levels of education have a 44% higher
DTP vaccination rate than their rural counterparts.60 rate of DTP vaccination than children of uneducated mothers.61
72.0 73.1 70.9 76.7 75.8 77.6 Total
Male 77.3 67.0 79.9 73.7 Urban 25.9 61.9 75.6 85.8 56.6 65.7 80.0 82.0 No education
Female Primary
Rural
Secondary
Higher

Unit: % population Unit: % population

2012 2017 Unit: % population 2012 2017 2012 2017

Children from the richest households have a 22% higher DTP vaccination Urban women have a 2% higher probability of Women with the highest education levels have a 41%
rate than those from the poorest households.62 receiving antenatal care.63 higher probability of receiving antenatal care than
52.2 69.1 74.9 80.4 85.1 66.8 73.4 79.9 81.9 81.6 Poorest 95.7 98.2 93.3 97.5 98.6 96.5 Total those with no education.64
Second Urban 64.0 92.6 97.9 99.1 70.1 95.4 98.5 99.3 No education

Middle Primary
$ Rural
$ $ $ $ Fourth Secondary
$ $
$ $ $ $ $ $ $ Higher
$ $ $ Richest
$ $ $ $ $ $ $
$ $ $
$ $ $ $ $ $ $
$ $ $
$ $ $ $ $ $ $
$ $ $ Unit: % population Unit: % of women Unit: % of women
$ $ $ $ $ $ $
$ $ 2012
$
$ $
$ 2017 2012 2017 2012 2017
$ $ $ $ $
$

Urban women have an 11% higher probability of Unmet need for family planning by location of residence66 Uneducated women have a 75% higher probability of having an
receiving skilled birth attendance than rural women.65 unmet need for family planning than women with the highest
8.4 8.3 8.6 7.7 7.7 7.7 Total levels of education.67
83.1 91.8 74.6 90.9 95.8 86.2 Total
Urban 10.8 10.9 6.9 7.4 9.8 9.6 7.3 5.6 No education
Urban Primary
Rural
Secondary
Rural
Higher

Unit: % Unit: % Unit: %

2012 2017 2012 2017 2012 2017
Women from the poorest households have a 6% higher probability of having an unmet need for family About one in two women in Indonesia has health insurance coverage.69
planning than women from the richest households.68
Poorest
10.4 7.8 7.7 8.1 8.3 8.3 7.7 7.4 7.3 7.8
Second
$ Middle
$ $ $ $ $ $ $ $ $
$ Fourth
$ $ $ $ $ $ $ $ $
$ Richest
$ $ $ $ $ $ $ $ $
2012 2017 Unit: %

Are gender, equity and human rights perspectives reflected in the legal and institutional arrangements and capacity in Indonesia?

Ratification of treaties that include the right to health70

Ratified International Covenant on Economic, Social, and Cultural Rights

Ratified International Covenant on Civil and Political Rights
Ratified International Convention on the Elimination of all forms of Racial Discrimination
Ratified Convention on the Elimination of All Forms of Discrimination against Women
Ratified Convention on the Rights of the Child
Ratified International Convention on the Protection of the Rights of all Migrant Workers and Members of their Families
Ratified Convention on the Rights of Persons with Disabilities

Constitutional provisions on equality and non-discrimination71

• “All citizens shall be equal before the law and the government and shall be required to respect the law and the government, with no exceptions” (Article 27).
• “Every person shall have the right of recognition, guarantees, protection and certainty before a just law, and of equal treatment before the law” (Article 28D).
• “Every person shall have the right to receive facilitation and special treatment to have the same opportunity and benefit in order to achieve equality and fairness”
(Article 28H).
• “Every person shall have the right to be free from discriminative treatment based upon any grounds whatsoever and shall have the right to protection from such
discriminative treatment” (Article 28I).

Legal arrangements related to inheritance, land ownership, divorce, marriage, sexual orientation, gender identity and intimate partner violence72

Inheritance Land ownership Divorce Intimate partner violence 73

Widows and daughters enjoy
0 the same rights as widowers
and sons to inherit land and
non-land assets. This applies
to all groups of women.
Customary, religious and
traditional laws or practices
do not discriminate against
women's inheritance rights.
Women and men have the same legal rights
0 and secure access to land assets, without
legal exceptions regarding some groups of
women. Customary, religious and traditional
laws or practices do not discriminate
against women’s legal rights.
Women have both the same rights to initiate
0 divorce and the same requirements to finalise
divorce or annulment as men, without
negative repercussions on their parental
authority. This applies to all groups of
women. Customary, religious and traditional
laws or practices do not discriminate against
women's rights regarding divorce or parental
authority after divorce.
The legal framework protects women
0 from violence including intimate
partner violence, rape and sexual
harassment, without any legal
exceptions and in a
comprehensive approach.

Widows and daughters enjoy
0.25 the same rights as widowers
and sons to inherit land and
non-land assets. This applies
to all groups of women.
However, there are some
customary, religious or
traditional laws that
discriminate against women's
inheritance rights.
Women and men have the same legal rights
0.25 and secure access to land assets, without
legal exceptions regarding some groups of
women. However, some customary,
religious or traditional practices or laws
discriminate against women’s legal rights.
Women have both the same rights to initiate
0.25 divorce and the same requirements to finalise
divorce or annulment as men, without
negative repercussions on their parental
authority. This applies to all groups of
women. However, there are some customary,
religious or traditional laws or practices that
discriminate against women's rights
regarding divorce and/or parental authority
after divorce.
The legal framework protects women
0.25 from violence including intimate
partner violence, rape and sexual
harassment, without any legal
exceptions. However, the approach is
not comprehensive.

Widows and daughters enjoy
0.5 the same rights as widowers
and sons to inherit land and
non-land assets. However,
this does not apply to all
groups of women.
Women and men have the same legal rights
0.5 and secure access to land assets. However,
this does not apply to all groups of women.
Women have both the same rights to initiate
0.5 divorce and the same requirements to finalise
divorce or annulment as men, without
negative repercussions on their parental
authority. However, this does not apply to all
groups of women.
The legal framework protects women
0.5 from violence including intimate
partner violence, rape and sexual
harassment. However, some legal
exceptions occur.

Widows or daughters do not
0.75 enjoy the same rights as
widowers and sons to inherit
land and/or non-land assets.
Women and men have the same legal rights
0.75 to own land assets; but not to use, make
decisions and/or use land assets
as collateral.
Women do not have the same rights over
0.75 divorce as men: either their rights to initiate
divorce and/or the requirements to finalise
divorce or annulment are unequal, or their
parental authority after divorce is restricted.
The legal framework protects women
0.75 from some forms of violence including
intimate partner violence, rape or
sexual harassment but not all.

Widows and daughters do not Women do not have the same legal rights as Women do not have the same rights over The legal framework does not protect
1 enjoy the same rights as
1 men to own land assets. 1 divorce as men: their rights to initiate divorce 1 women from violence nor intimate
widowers and sons to inherit and/or the requirements to finalise divorce or partner violence nor rape and
land and/or non-land assets. annulment are unequal, and their parental sexual harassment.
authority after divorce is restricted

Name of law: Law on the Elimination

Indonesia score of Violence in the Household
(Law no. 23/2004)
Marriage74
Article 51 of Law No. 39 of 1999 on Human Rights provides for equal rights and obligations for men and women in marital relationships regarding all matters related to their married life. The Marriage Law 1974
prescribes 21 years as the legal age of marriage for women and men, but also allows girls to marry with parental permission at 16 and boys at 19. Parents can also request religious courts or local officials to
authorise marriages of daughters even earlier, with no minimum age in such cases. In 2019, the Parliament voted to amend this law, raising the minimum age of marriage for girls to 19; the change is expected
to be implemented within three years. The marriage law of 1974 also allows courts to permit a man to have more than one wife.

Legal protection for all sexual orientations and gender identities.75

Indonesia does not have specific gender identity recognition laws. Same sex-marriage is not legal. Same-sex acts are legal in certain provinces, but illegal and criminalized in others.

Legal arrangements related to sexual and reproductive health and rights76

Abortion Direct support for family planning

Permitted when there is fetal impairment, rape, or the life of the mother is at risk. Yes, direct support is provided by the legal framework.

Institutional arrangements and capacity77

National gender machinery Ministry of Women Empowerment and Child Protection

Whether national development policy mentions gender Yes. Presidential Instruction No. 9 (2000) provides the legal basis for gender mainstreaming. Gender is mentioned in the 2015-2019
mainstreaming and the most recent one? National Development Plan (Presidential Regulation No.2 (2015) on the Medium-Term Development Plan, 2015-2019).
Gender policy from national women's machinery No
and year introduced?
Gender-responsive budgeting78

Yes. A Joint Circular Letter on the national strategy to accelerate gender mainstreaming through gender
Mention of gender-responsive budgeting in plans, year introduced
responsive planning and budgeting was issued in 2012.

Legislation for gender-responsive budgeting No

National plan/strategy for gender-responsive budgeting Yes; 2012

Gender focal points in government79 Yes, since 2016, twenty sector ministries have established working groups and gender focal points to mainstream gender in their policies and
programmes. Annual meetings are held between the gender focal points and the Ministry of Women Empowerment and Child Protection.

Gender policy/strategy in the Ministry of Health80 Yes. A 2012 joint agreement between the Ministry of Women Empowerment and Child Protection and the Ministry of Health provides for the
implementation of gender mainstreaming in health. A 2016 Minister of Health Decree directed the establishment of a gender mainstreaming
team in health.

Gender training for Ministry of Health staff81 Yes. A 2011 Minister of Health Decree provides for establishment of a training centre for gender in health.

Gender analysis by the Ministry of Healthf82 Yes. Gender analysis in health development was earlier undertaken in 2002. In 2017, the Ministry undertook analysis of health inequities in Indonesia,
including of health staff and facilities.

Conclusion

Forward-looking policies, if effectively implemented through suitable institutional mechanisms and adequate capacity support the mainstreaming of gender, equity and
human rights perspectives in health and enable change towards greater equity.
Recommendations
• Given the influence of gender on health in Indonesia, putting a gender perspective into health interventions is important. When applying a gender lens to health interventions, it is
important to remember that gender interacts with other forms of social exclusion, such as ethnicity, age, sexual orientation and socioeconomic position.

• Several tools are available for gender analysis, assessment and planning or programming, which can help to identify gender issues and inequalities in health and tailor the design,
implementation and monitoring of health policies and programmes to take account of these differences, for improved outcomes. These tools include the WHO gender analysis matrix
(GAM) and gender analysis questions (GAQ), the WHO gender responsive assessment scale (GRAS) and gender analysis tool (GAT), the WHO gender and health planning and
programming checklist and the WHO gender responsive log-frame.83

• The Innov8 approach84 and Human Rights and Gender Equality in Health Sector Strategies: how to assess policy coherence85 are tools that support the development of equity-
enhancing, gender-responsive and human rights-based national health policies, programmes and strategies. Additionally, using a human rights framework in health planning and
policy making can help in identifying and adequately addressing the biological and sociocultural factors that differentially influence the health of men and women.

Endnotes

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14. Ibid.
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