Location Matters: Trends in Inequalities in Child Mortality in Indonesia. Evidence from Repeated Cross-Sectional Surveys Andrew Hodge 1 *, Sonja Firth 1 , Tiara Marthias 2 , Eliana Jimenez-Soto 1 1 School of Population Health, The University of Queensland, Brisbane, Queensland, Australia, 2 Center for Health Policy and Management, Faculty of Medicine, Gadjah Mada University, Yogyakarta, Indonesia Abstract Background: Considerable improvements in life expectancy and other human development indicators in Indonesia are thought to mask considerable disparities between populations in the country. We examine the existence and extent of these disparities by measuring trends and inequalities in the under-five mortality rate and neonatal mortality rate across wealth, education and geography. Methodology: Using data from seven waves of the Indonesian Demographic and Health Surveys, direct estimates of under- five and neonatal mortality rates were generated for 1980–2011. Absolute and relative inequalities were measured by rate differences and ratios, and where possible, slope and relative indices of inequality. Disparities were assessed by levels of rural/urban location, island groups, maternal education and household wealth. Findings: Declines in national rates of under-five and neonatal mortality have accorded with reductions of absolute inequalities in clusters stratified by wealth, maternal education and rural/urban location. Across these groups, relative inequalities have generally stabilised, with possible increases with respect to mortality across wealth subpopulations. Both relative and absolute inequalities in rates of under-five and neonatal mortality stratified by island divisions have widened. Conclusion: Indonesia has made considerable gains in reducing under-five and neonatal mortality at a national level, with the largest reductions happening before the Asian financial crisis (1997–98) and decentralisation (2000). Hasty implementation of decentralisation reforms may have contributed to a slowdown in mortality rate reduction thereafter. Widening inequities between the most developed provinces of Java-Bali and those of other island groupings should be of particular concern for a country embarking on an ambitious plan for universal health coverage by 2019. A focus on addressing the key supply side barriers to accessing health care and on the social determinants of health in remote and disadvantaged regions will be essential for this plan to be realised. Citation: Hodge A, Firth S, Marthias T, Jimenez-Soto E (2014) Location Matters: Trends in Inequalities in Child Mortality in Indonesia. Evidence from Repeated Cross-Sectional Surveys. PLoS ONE 9(7): e103597. doi:10.1371/journal.pone.0103597 Editor: Chen-Wei Pan, Medical College of Soochow University, China Received May 5, 2014; Accepted July 4, 2014; Published July 25, 2014 Copyright: ß 2014 Hodge et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: The authors confirm that all data underlying the findings are fully available without restriction. All data files are available from the MEASURE DHS website, ,http://www.dhsprogram.com.. Funding: The research described in this paper is made possible through the Department of Foreign Affairs and Trade, Australia, grant ID 47734. The funders of the study had no role in the study design, data collection, the analysis or the interpretation of the results, or the writing of this paper. Competing Interests: EJS is on the Editorial Board of PLOS ONE. This does not alter the authors’ adherence to PLOS ONE policies on sharing data and materials. * Email: a.hodge@uq.edu.au Introduction In the Asia-Pacific region, large and populous countries like Indonesia are experiencing a profound transformation. At the beginning of the 1970s, Indonesia was one of the poorest countries in the world with low literacy and life expectancy rates. It is now classified as a middle-income country with 92 percent of the population being literate and life expectancy standing over 70 years [1]. However, concerns remain about stagnating progress and widening inequities. Previous studies have shown that access to health facilities and services is higher for those in urban, educated and wealthier households [2–4]. Health insurance coverage is low among the poor and near-poor [5]. Urban households on average enjoy better access to clean water and sanitation and facility-based delivery [3,6]. Higher level of maternal education is associated with higher utilisation of antenatal care services in Indonesia [7] as well as with lower early neonatal death [8]. Immunisation rates are higher for children in educated households [9]. Wealth related inequality is large, particularly for interventions that might attract out-of- pocket expenses, such as facility-based delivery or skilled birth attendance [10]. These disparities present serious challenges to the government’s goal of achieving universal health coverage by 2019. They are compounded by the difficulties of delivering services in a diverse and large archipelago with more than 17,000 islands. When compared to the most developed provinces of Java-Bali, other regions are particularly disadvantaged in terms of social PLOS ONE | www.plosone.org 1 July 2014 | Volume 9 | Issue 7 | e103597