Addressing How Structural Barriers and Intersectionalities Influence Refugee Children and Adolescents Health in Indonesia

by Wilsen Widal Kho – Human Rights Education Facilitator

Background and Problem Statement

More often than not, refugees–particularly children and adolescents– have poor physical and mental health due to persecution, torture, abuse, and injuries they faced in every stage of migration. These conditions are aggravated by limited to no health care access and compounded by a high level of stressors that come with uncertain legal and economic status, family separation, and poor housing conditions (UNICEF, 2017; WHO,2018). Around 11,8 million refugee children are forcibly displaced mainly due to violence and conflict globally. At the regional level, surveys found that Asia and Africa are home to nine of the ten greatest refugee children populations (UNICEF, 2016). A substantial number of refugee children was also found in Indonesia, as children comprise 27% of the total refugee and asylum-seekers population (UNHCR, 2021). Their guardianship status differs from one another, some are accompanied by their parents or relatives, others are Unaccompanied Refugee Children (UAC). To put it into numbers, there are 3,796 children registered with UNHCR, around 2,5% are unaccompanied and 1,3% are separated by their parents as of July 2020. If we disaggregate the data based on sex, UNHCR found that 47% of these children were female (UNHCR, 2021). These data are daunting and believe it or not, the current data that depicts refugee children and adolescents’ conditions are often incomplete and only shows the tip of the iceberg (UNICEF, 2016).

Many policies, either health and/or health-related, tend to treat children as a generic group. However, children are a diverse group who need various approaches to respect, protect, and fulfill their basic rights, particularly their right to health. Thus, the policy enacted must consider the intersectionality they might have, for instance, the double vulnerability of being refugee and child. Therefore, based on the situational vulnerability and unique features–that make children most vulnerable refugees– as well as the indivisible and interdependent nature of their right to health, this paper intends to identify the gaps between international and Indonesian national laws on the right to health as well as using an intersectionality-based policy analysis framework to capture how intersectionality influences refugees children and adolescent health in Indonesia.

Gaps between International and National Laws on The Right to Health for Refugee Children

Indonesia has failed to deliver its obligation under the Convention on the Rights of the Child (CRC)– a legally bound document with legal consequences – particularly its duty to respect, protect, and fulfill refugee children and adolescent rights to health according to research done by Kristin and Dewi (2021) with the title ”The Rights of Children Refugee in Transit Country under the CRC, A Case of Indonesia: An Intended Negligence on the Implementation of Non-Discrimination Principle?”. Article 24 and 27 of the CRC stated that “states must ensure the children in its land can enjoy the highest standard of healthcare and the states shall provide a living standard that is adequate for a child’s physical, emotional, spiritual, moral, and social development within their territory”. These obligations are also reiterated under Law No.39 of 1999 on Human rights and Law No.35 of 2014 on Child Protection. The research also concluded the violation of the non-discrimination principles by the Indonesia Government, a peremptory principle stipulated under Law no.35 of 2014 and Article 2 of the CRC that highlight that the states have obligation to respect, protect, and fulfill children’s rights despite their nationality nor legal status, including refugee children.

Although Indonesia is not a party to the 1951 Convention and its protocol, The government of Indonesia needs to be commended for enacting Presidential Regulation No. 125 of 2016 that serves as the overarching legal framework for refugee issues in Indonesia. This decree was praised by many as it states special treatment is provided for refugees with special needs such as those who are ill, pregnant, disabled, and children. According to Yonesta (2019), many inconsistencies exist between international human rights instruments, the Constitution, and domestic statutes and regulations, causing confusion and misunderstanding among government officials, police, the judiciary, and civil society about where these rights fit into the Indonesian legal system.

In respect of implementation, evidence found by Ayuningtyas and Utami (2020) shows that the law has not been appropriately implemented at the local level and highlights the poor cross-sectoral coordination in Kupang. Two years after the enactment, research done by Legido-Quigley (2020) found that the sociopolitical inclusion of refugees remains difficult in Indonesia. Moving forward, we will discuss other findings that reveal many policy implementations that have not been adequately exercised in accordance with the international laws as well as other structural barriers that increase refugees children and adolescents’ vulnerability.

Vulnerability Due to Lack of Access

Children and Adolescents Refugees have access to low-cost primary health care at Puskesmas through collaboration with the local government. However, any fees incurred from using these services must be paid by themselves. Taking into consideration that refugees aren’t able to work or engage in any income-generating activities in Indonesia due to their legal status, it is extremely difficult for them to feed themselves, not to mention paying for these healthcare bills. Because these refugee children are not Indonesian citizens, they will be discharged according to the foreigner’s price every time they do consultation and/or medication, which often gets doubled. Organizations like IOM and UNHCR give regular cash assistance for refugees. For instance, refugee children receive IDR 750,000 monthly in Kupang. However, some deemed that the amount is inadequate to fulfill daily living expenses (Ayuningtyas & Utami, 2020). “It is difficult for us to provide more money due to limited funding”, said Mr.Hendrik (UNHCR Indonesia) and reiterated by Ms.Marisa (CWS Indonesia)

During a virtual meeting with Ali Ghufron Mukti (Director of BPJS Kesehatan), Ann Mayman (UNHCR Representative for Indonesia) said that “Providing refugees with access to healthcare insurance in Indonesia (BPJS Kesehatan) will further support UNHCR in providing protection”. Despite the promising and sustainable solution to remove refugees’ financial barriers to health, Indonesian’s regulation poses yet another legal barrier as Presidential Regulation Number 82 of 2018 on Health Insurance stipulates that healthcare insurance is available for all, including foreigners, who have worked – a luxury refugee couldn’t afford– for a minimum of six months in Indonesia.

Indonesia has succeeded in protecting refugees children from vaccine-preventable diseases as no outbreaks have been reported. This is partly due to its effort in extending vaccination campaigns– OPV, Measles, and rubella– to refugees children through refugees school. At the community level, refugees have access to community maternity and childcare, which provides immunizations. For instance, Puskesmas Oepoi in Kupang provides essential vaccination services for babies, toddlers, and pregnant women through collaboration with Citra Husana Mandiri – a group of local midwives for integrated health services for babies and toddlers (IOM, n.d.). However, similar to access to education, access to healthcare for refugee children and adolescents might differ from one province to another. Therefore, this initiative in providing equal and non-discriminatory health services for migrants and local communities has provided the groundwork for harmonizing the health of refugee and migrant children, including preventive care, with that of all children living in Indonesia.

The right to health extends much further than just providing medical care. Due to its indivisible and interdependent nature, it extends to access to safe water and adequate sanitation, and other underlying determinants of health. By providing access to education, clean water and sanitation, nutritious food, and proper housing, we can further protect and fulfill refugees’ children and adolescents’ rights to health.

Schools are one of the platforms through which health can be delivered to children at a young age, including sexual and reproductive health for refugee adolescents. It is also a place where one can learn about Bahasa Indonesia to overcome barriers to language and health information. Taking into account, refugee children are allowed to be enrolled in national schools using the UNHCR identity card, delivering health programs to refugee children through health-promoting schools scheme could potentially be a cost-effective intervention.

Dietary cultures are expected to vary enormously across refugee populations and it changes even more in response to new conditions such as access to foods and availability of cooking facilities (Sellen, 2000). If it follows their dietary style, it can spend 4-5 times the allowance given (Kristin and Dewi, 2021). Lack of access to familiar food items and inability to create regular meals, food insecurity, and change in breastfeeding practice results in the inabilities of many refugees’ minors to have balanced nutritious food that will further cause malnutrition problems like stunting and micronutrient deficiency. In regards to this issue, our informants from CWS highlight some programs that UNHCR and CWS focus on to prevent malnutrition in refugee children, such as balanced nutrition for pregnant women and supplementary allowance for refugee-children-under-five-years-old. Unfortunately, program targeting refugee adolescent nutrition has been absent.

Vulnerability Due to Irresponsive Services

UNHCR Indonesia, through Church World Service (CWS), provides direct health support to emergency and life-threatening disorders which needed referral and hospitalization. Then again, CWS does not cover all medical care costs and the cost covered depends on eligibility criteria (UNHCR, 2021). According to an interview with a key informant working in CWS Indonesia– an NGO as the implementing partner of UNHCR regarding malnutrition amongst refugee children in Indonesia (CIMSA, 2021), CWS Indonesia found only one case of malnutrition in the Jakarta Metropolitan Area amongst refugee children, not because of the lack of access to nutritious food, but because of pre-existing microcephaly. Luckily, this case has been treated by a pediatrician after a referral from CWS. However this is not always the case, according to an interview done by Kristin and Dewi (2021), not everyone can attend a large hospital or receive access to free medication; each case must be handled individually. Hundreds of refugee children, however, are still unable to access these services. Even if these children did overcome the financial barriers to treat their illness, the process is time-consuming for some and time is often not on their side.

According to our interview with Mr.Hendrik, A protection associate at UNHCR Indonesia, language barriers are one of the challenges refugees face when accessing healthcare services. Refugees also express the need for translation services to be held regularly due to the high burden of diseases they face. In Jakarta and the surrounding area, CWS conducts regular capacity buildings to train new translators to fulfill these demands (Kristin and Dewi, 2021). As refugees children are spread widely across Indonesia, it is recommended that this practice be replicated in other provinces.

Vulnerability Due to Social Identity

The Committee on the Rights of the Child (CRC) observations on the combined third and fourth periodic reports of Indonesia (2014) highlights the detention of children in Indonesia’s immigration detention facilities, as well as instances of severe brutality by immigration officials/guards, suffered and witnessed by children. Not to mention, lack of access to proper housing, water and sanitation, and nutritious food. These children also experience discrimination in regards to their access to health care and education. It is highly recommended for Indonesia to avoid detention as it has a detrimental effect on children and adolescents’ health. Instead, Indonesia should provide a child-friendly space, access to healthcare, and education if detention is used.

Indonesian Children with disabilities experience particular discrimination regarding access to health care (CRC, 2014). Imagine the triple vulnerability that refugee children with disabilities have while navigating health services in Indonesia. Unfortunately, the authors are not able to capture this population’s unique experiences during his environmental scan in the Indonesian context. However, findings from Arfa et al. (2020) show that parents of refugee children with disabilities experienced several challenges, including the need for information, support, and timely help.

The Committee on the Rights of the Child (CRC) is deeply concerned by the lack of protection provided to asylum-seeking and refugee children, particularly unaccompanied minors who are left without guardianship and are denied free legal representation. As a result, the committee requests that Indonesia take special precautions. Indonesia can learn more from the Unaccompanied Refugee Minors Program (URM) by the Office of Refugee Resettlement. By creating a legal authority to operate in place of the child’s unavailable parent, the URM program assures that eligible unaccompanied minor populations get the entire range of aid, care, and resources accessible to all foster children (Office of Refugee Resettlement, 2021).

Refugee girls are often faced with gender inequality issues, especially in countries where gender discrimination is deeply embedded in the social fabric. Gender-Based Violence (GBV) disproportionately affects women and girls, and their risk of exposure to GBV rises when they are displaced (UNHCR, 2021) Although Indonesia has been trying to mainstream gender into its program, it still has a long way to go to abolish discriminatory provisions still remaining in national legislation. Riadhussyah et al. (2021) argue that as a transit country, Indonesia has limitations in fulfilling the rights of women child refugees because Indonesia did not sign the Vienna Refugee Convention 1951. Due to the lack of legislation regulating refugees in ASEAN, they also call for collaboration among ASEAN member nations to synergize and assist each other in fulfilling refugees’ rights, particularly for those who are most vulnerable, such as women and children (Riadhussyah et al., 2021).

A Better Narrative For Refugees Children and Adolescent

I realize that I have painted a bleak picture, but it does not have to be like this. The government has many tools to change the narrative and regain lost ground. Starting from acceding to the 1951 Refugee Convention and its 1967 Protocol, harmonizing it with the national legal framework, eliminating inconsistencies, as well as delivering its obligation under the Convention and Constitution it abided to. Furthermore, ensure that there is a mechanism in place to ensure refugee children and adolescents are able to access responsive health care on the same basis as nationals (including through the provision of free and efficient services in addition to removal of restrictions on access to health insurance), address structural that may prevent children from accessing services (language, cultural, juridico-political, and sociocultural barriers), together with strengthening cross-sectoral collaboration as well as partnerships at many levels. Lastly, the government needs to promote the application of the intersectionality perspective in the study of refugee children and call for intersectionality as a guiding principle to provide more equity-based policies and programs.

About The Author

Wilsen is a fourth-year medical student at Universitas Gadjah Mada with experiences in public relations, advocacy, managing national-level health campaigns, and projects, as well as developing NGO communication & marketing strategy. He is currently in charge of creating/maintaining partnerships collaboration between CIMSA and United Nations Agencies. He is passionate about children and adolescents’ health, a supporter of meaningful youth participation, and a facilitator for human rights education.

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