Stunting prevention in Indonesia: Raising awareness at the sub-national level
Akim Dharmawan (PhD) is the SUN Movement secretariat manager at the Ministry of National Development and Planning (Bappenas) in Indonesia. He has worked as a nutritionist and public health practitioner for more than 15 years, with experience in programme planning and management, behaviour change intervention, community development and monitoring and evaluation.
Pungkas Bahjuri Ali (PhD) is the Director for Public Health and Nutrition at the Ministry of National Development and Planning (Bappenas), and secretary of the technical team for the SUN Movement Indonesia. He works closely with both national and sub-national governments in aligning health and nutrition programmes.
Dr Entos Zainal is the Deputy Director for Community Empowerment and Public Nutrition at the Ministry of National Development and Planning (Bappenas). He is an expert in public health and nutrition programme planning and implementation.
Ardhianti has an MSc in public health and is part of the team responsible for the planning and technical coordination of Healthy Lifestyle Community Movement and integrated nutrition intervention for accelerating stunting reduction.
Evi Nurhidayati has worked as a programme assistant in the SUN Movement Secretariat of Indonesia at the National Development Planning Agency since 2016.
Nur Akbar Bahar has worked as a programme assistant in the SUN Movement Secretariat of Indonesia at the National Development Planning Agency since 2016.
Introduction
Indonesia is a lower-middle income country and the largest economy in Southeast Asia1. Rapid economic growth over the past ten years, coupled with government investments in social development, have led to the poverty rate being halved since 1999, to 10.9% in 20161. However, the benefits of economic growth do not align with an improvement of social and health indicators, and 36% of children under five (CU5) are stunted (low height for age), while 14% are affected by wasting (low weight for height)2.
The national prevalence of stunting (affecting nearly 9 million children under five) has been slowly decreasing for the last decade. However, the reduction of stunting was less than expected (it was 40% in 2007 and 37.2% in 2013)3. Although prevalence is similar across the 34 provinces of Indonesia, east Nusa Tenggara Timur province has a prevalence of 70%, whilst Jambi province has the lowest prevalence at 37.9%3. Children affected by stunting are found among both rural and urban populations (42.1% and 32.5%, respectively)3. Additionally, almost a third (29%) of CU5 among the wealthiest households are stunted, which suggests that stunting is not heavily influenced by location and economic status3.
Figure 1: Geographical distribution of stunting prevelance in Indonesia
Coordinating stunting efforts
Stunting prevention efforts have not been effectively implemented for many years, initially because nutrition was only associated with the health sector (Ministry of Health) and nutrition-specific interventions. Failure to address malnutrition may be costing the Indonesian economy an estimated 17.5-26 million USD (260-390 billion IDR) per year of Gross Domestic Product (GDP). Nutrition-specific and sensitive interventions do not appear to be fully coordinated at all levels in terms of planning, budgeting, implementation, and monitoring and evaluation, and this has been recognised as a key challenge for stunting prevention. Additionally, lack of local capacity at district, sub-district and village levels are constraints that still need to be addressed.
In recognition of the need to tackle stunting, the country launched a national strategy called Integrated Nutrition Interventions (INI) for Stunting Reduction and Prevention in August 2017. None of the activities in INI are ‘new’ activities, but the strategy (backed by the President, Joko Widodo) sets out guidelines for national and sub-national stakeholders to accelerate stunting prevention and reduction. The INI consists of five pillars: 1) commitment and vision of the state’s highest leaders; 2) National campaign focusing on behaviour change; 3) Convergence, coordination and consolidation; 4) Food security policy, and 5) Monitoring and evaluation.
To improve the quality of multi-sectoral interventions (such as those involving agriculture, education and social protection), a geographically-focused plan was designed to create awareness and commitment for INI in 100 districts (out of 514 districts in Indonesia) in 34 provinces in 2018. The choice of districts was based on a number of criteria, including number of CU5 and prevalence of stunting and wasting in CU5 and prevalence of poverty. There are plans to expand the coverage to a further 160 districts in 2019.
Strengthening sub-national action
The first pillar of INI aims to strengthen sub-national government’s commitment and capacity and a National Rembuk Stunting event (a type of ‘stunting bootcamp’ or summit) was held in November 2017 in Jakarta with the active participation of eight districts. Nineteen government ministries/institutions came together for the event, including development partners, civil society, academia and professional organisations, and the media. The event focused on sharing best practices at global and national level, as well as village experiences on how to strengthen coordination between national and local governments for programme effectiveness. A workshop with key leaders from the districts to develop an integrated action plan. The second and third National Rembuk Stunting events were held in March 2018 in Jakarta. In total, 26 districts participated in the second and third Rembuk (with 13 districts at each one).
Platform for district-level events
Rembuk Stunting has provided a new platform (to which SUN Movement networks have also been invited) for information sharing and learning between national and sub-national governments with a focus on planning and budgeting for INI. The national-level Rembuk Stunting events were followed by similar events at provincial and district level, with funding coming from the government budget and development partners/donors. So far, five districts out of 34 from the national event have conducted district and/or village level Rembuk Stunting. These were attended by local private sector, local academia, professional organisations, and local civil society organisations who have all contributed to discussions on stunting reduction and prevention at the district/village level.
Bappenas, with support from the World Bank, has developed a Rembuk Stunting curriculum along with facilitator guidelines, which includes stunting and other related health data for each district for discussion among district key leaders, a work plan with an activity and timeline template, and a health and nutrition dashboard. District government have learnt how to use and analyse health and nutrition data, developed recommendations with an evidence-based approach, chosen priority actions based on local problem analysis, and ensured adequate budget to fund selected priority actions. Villages have been urged to use Village Funds (from central government) to reduce stunting by investing in infrastructure, such as health clinics and water and sanitation facilities, and there are reports from the Ministry of Villages that health and nutrition activities have increased among focus districts.
Addressing challenges
It has been noted that capacity gaps between districts need to be properly assessed, with a follow up district planning session performed by either central or provincial government after a Rembuk Stunting event. Local universities/experts also need to be more widely included to provide technical advice for district governments. Coordinating working with sub-national governments is challenging due to lack of staff and heavy workloads at this level. Selecting a focal point for each Dinas (sub-national government organisations for health, education, village development, public work and housing, etc) and setting/agreeing regular meetings is crucial to ensure everyone is on board. Finally, advocacy tools and communication strategy should be developed to ensure the sustainability of the commitment. In addition, specific governor/mayor regulations are needed to justify and sustain the implementation of the INI.
Lessons learned and next steps
Rembuk Stunting is shaping up to be an effective advocacy tool for sub-national government leaders and has already provided opportunities for direct learning from field visits between focal districts to increase ownership of INI. Moreover, it has built capacity at sub-national level through improved knowledge and skills in planning, coordinating and monitoring INI, and the initial 34 targeted districts have now developed action plans. Further Rembuk Stunting events are planned to cover the remaining focal districts, and the monitoring and evaluation framework (including visits to each village) is being finalised so that progress can be reported.
Footnotes
1www.worldbank.org/en/country/indonesia/overview
2globalnutritionreport.org/wp-content/uploads/2017/12/gnr17-Indonesia.pdf
3Basic Health Survey (Riskedas) 2013, Ministry of Health, Republic of Indonesia