MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING © 2021 International Bank for Reconstruction and Development/The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org This work is a product of the staff of The World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgement on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. The material in this work is subject to copyright. Because The World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING TABLE OF CONTENT CONTENT II FIGURES, BOXES AND TABLES IV WHAT IS THIS BOOK ABOUT? VI FOREWORD VIII ACKNOWLEDGEMENTS X ABBREVIATIONS AND ACRONYMS XII OVERVIEW XVI CHAPTER 1 A TRIBUTE TO LOCAL HEROES IN INDONESIA’S FIGHT AGAINST STUNTING XVIII CHAPTER 2 BEST PRACTICES: STORIES FROM THE FIELD 8 » SAMARINDA: A RIVER DOLPHIN SWIMS TO THE RESCUE 9 » SURABAYA: CHANGING HEARTS, MINDS AND DIETS THROUGH GAMES AND SONGS 17 » NGANJUK: EMPOWERING VILLAGE COMMUNITIES TO BOOST HEALTH AND WELL-BEING 23 » WEST LOMBOK: A POSTER CHILD FOR COORDINATING THE FIGHT AGAINST STUNTING 31 » EAST NUSA TENGGARA: NO TIME TO WASTE IN THE FIGHT AGAINST WASTING 41 » EAST NUSA TENGGARA AND EAST JAVA: ENHANCED PARTNERSHIPS AND INTEGRATED PROGRAMMING IMPROVES MATERNAL AND CHILD HEALTH 51 ii MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING » WEST SUMBAWA: BETTER SKILLS FOR HEALTH WORKERS PAY OFF FOR NUTRITION OF MOTHERS AND CHILDREN 61 » TIMOR TENGAH SELATAN: FOSTERING THE FARMING SKILLS OF HOUSEHOLDS FOR A BETTER DIET 69 » BANGGAI: ACADEMIA AND DISTRICT LEADERS COLLABORATING FOR IMPACT 77 » YOGYAKARTA: AWARD-WINNING SANITATION CLEANS UP CITY’S RIVERBANKS 81 CHAPTER 3 SNAPSHOTS: LESSONS LEARNED FROM IMPLEMENTATION 88 » PUBLIC-PRIVATE PARTNERSHIP: THE EARLY ADOPTER OF CONVERGENCE IN A REMOTE REGION WITH FOOD INSECURITY 89 » WHERE FISHPONDS AND RICE PADDIES MEET 97 » STRACOM: CHANGING BEHAVIORS THROUGH EFFECTIVE COMMUNICATION 107 » REDUCING STUNTING THROUGH PROGRAM KELUARGA HARAPAN (PKH) 110 » THE LENGTH MAT: “TIKAR PERTUMBUHAN” AN EASY EDUCATION TOOL TO RAISE AWARENESS ABOUT STUNTING 111 CHAPTER 4 INDONESIA IS MOVING FORWARD 114 REFERENCES 117 ANNEX 1: STUNTING PROJECTIONS FOR INDONESIA 123 ANNEX 2: SELECTION CRITERIA 137 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING iii FIGURES, BOXES AND TABLES FIGURES Figure 1:. Comparison of stunting rate for under fives, by district...........................................................2 Figure 2:. Baduta behavior change messages........................................................................................19 Figure 3:. Examples of emo-demo visuals...............................................................................................20 Figure 4:. Key steps in starting and implementing Gemadazi.................................................................37 Figure 5:. Flow of CMAM approach in the Kupang district.....................................................................44 Figure 6:. Key activities of the CMAM project ........................................................................................46 Figure 7:. MITRA Project phases..............................................................................................................53 Figure 8:. IFA compliance card from the MITRA program......................................................................55 Figure 9:. Pencerah Nusantara model.....................................................................................................63 Figure 10:. Puskesmas show improvement in standards of delivery after Pencerah Nusantara intervention...............................................................................................................................65 Figure 11:. Change in Human Resources of Health (HRH) readiness assessment indicators after 3 years intervention..................................................................................................................66 Figure 12:. Pencerah Nusantara program improves the potential sustainability of nutrition program at Puskesmas PotoTano...........................................................................................................68 Figure 13:. Conceptual framework of the relationship between household food production strategies and health and nutrition outcomes.........................................................................................71 Figure 14:. Horticulture planting calendar.................................................................................................74 Figure 15:. Recipe book cover and example of recipe..............................................................................75 Figure 16:. Prevalence of stunting and wasting in TTS district compared to national and province ENT data....................................................................................................................................90 Figure 17:. Project Laser Beam’s prototype to support the Government of Indonesia’s response to both immediate and underlying causes of undernutrition.....................................................91 Figure 18:. Examples of Project Laser Beam’s behavior change communication materials..................93 Figure 19:. Government assistance mechanism.....................................................................................101 Figure 20:. StraCom development timeline.............................................................................................108 Figure 21:. Stunting rate in Indonesia relative to comparator countries...............................................124 Figure 22:. National stunting projections for Indonesia.........................................................................135 Figure 23:. Stunting projections for Timor Tengah Selatan....................................................................136 iv MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING BOXES Box 1: The National Strategy to Accelerate Stunting Prevention..............................................................4 Box 2: How the success stories were chosen.............................................................................................6 Box 3: Cooking up new ideas......................................................................................................................11 Box 4: Health teams caring for groups of mothers and children.............................................................12 Box 5: Step-by-step guide to starting the Pesut Mahakam Program........................................................16 Box 6: Taman Posyandu criteria..................................................................................................................25 Box 7: When villages innovate....................................................................................................................27 Box 8: Governance and management of Taman Posyandu in Nganjuk district.......................................29 Box 9: Distinctions between nutrition-specific and nutrition-sensitive interventions ...........................32 Box 10: Key local regulations addressing stunting in West Lombok.......................................................39 Box 11: Relationship between wasting and stunting...............................................................................42 Box 12: MITRA program aims and beneficiaries.......................................................................................52 Box 13: MITRA Youth - Empowering adolescents with improved health & nutrition..............................59 Box 14: Yogyakarta - The host of sanitation initiatives............................................................................85 Box 15: What is Project Laser Beam..........................................................................................................90 Box 16: Design of the new Minapadi model..............................................................................................99 Box 17: Technical challenges are also common in the Minapadi program. ..........................................103 Box 18: Definition of nutrition-sensitive agriculture and food systems................................................105 TABLES Table 1:. Total households reached through RANTAI............................................................................72 Table 2:. Preconception posyandu program indicators, 2015 - 2018....................................................78 Table 3:. Minapadi program cycle..........................................................................................................102 Table 4.. Stunting decline calculations for Business as Usual Scenario...........................................125 Table 5.. Interventions identified for the model and current coverage ..............................................126 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING v WHAT IS THIS BOOK ABOUT? This book is written in several parts: an introduction In West Nusa Tenggara Province, West Lombok in Chapter 1; stories of best practices from the field in District has shown Indonesia and other parts of the Chapter 2, and lessons learned from implementation world how effective leadership and multisectoral of nutrition programs in Chapter 3. We conclude coordination and collaboration can turn the tide with a chapter highlighting key takeaways from against stunting. the best practices and lessons learned. A technical discussion on stunting projections at the national In Eastern Indonesia, more specifically the province and district levels is included in the annex. Chapters of East Nusa Tenggara, we learned how community two and three feature stand-alone stories of best engagement was key to sustainable treatment for practices or lessons learned from nutrition programs acute malnutrition or wasting, and how perseverance in Indonesia. The reader is welcomed to move from and continuous community involvement enabled a story to story in any order desired. donor-funded program – Community Management of Acute Malnutrition (CMAM) - to be developed and In Chapter 2, the stories feature projects in the integrated with the national program. As CMAM’s provinces of East Kalimantan, Central Java, East next iteration, the Integrated Management of Java, West Nusa Tenggara and East Nusa Tenggara. Acute Malnutrition (IMAM) is now being scaled-up nationwide. In East Kalimantan’s City of Samarinda, we learned about the innovative clustering method of the Whereas in parts of East Nusa Tenggara and East Program Pesut Mahakam – the brainchild of the head Java, integrated planning, implementation and of the local Puskesmas – which enabled kaders, monitoring of maternal nutrition programs – long midwives and nutritionists to deliver effective and managed independently of one another - were key to continuous maternal and child health care in an addressing micronutrient deficiencies and treating integrated manner. diarrhea among pregnant women and children, as evidenced by the Micronutrient Supplementation for In Surabaya City of East Java Province, one woman’s Reducing Mortality and Morbidity (MITRA) Program. drive and determination ensured no Posyandu was left behind when it came to accessing fun games and In West Sumbawa District of West Nusa Tenggara, songs delivered through emotional demonstrations through the award-winning Pencerah Nusantara – Emo-Demos - which served to change health and Program, we discovered that revitalizing the primary care-taking behavior of pregnant women and young health care centres (Puskesmas) with a team of well- families. trained, young healthcare professionals can make the difference in improving the health and well-being In Nganjuk District in the province of East Java, a of rural communities, including pregnant women and midwife’s community empowerment efforts triggered young children. a district-wide success in embracing the Taman Posyandu Program which integrates basic social In the Timor Tengah Selatan District of East Nusa services in the Posyandu. Tenggara, one of the most food insecure regions vi MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING of Indonesia, giving farming and animal husbandry In the Special Region of Yogyakarta, an innovative skills to households, especially those led by women, method to combine fish farming with rice farming proved pivotal to ensuring sustainable access (Minapadi), proved successful to increase not only the and consumption of micronutrient-rich foods. The household income, but also improved the diversity program, known as Rapid Action on Nutrition and in the diets of the villagers and this was done in an Agriculture Initiatives (RANTAI), was part of the environmentally friendly and sustainable manner. multisectoral Project Laser Beam, described in Chapter 3. Changing health behaviors and caring practices of the first 1,000 days households, as well as improving As the pilot site of a novel but crucial mentorship public awareness of stunting had been identified as program, the local government of Banggai District in crucial steps to addressing stunting in Indonesia. The the Province of Central Sulawesi received mentoring Ministry of Health developed the National Behavior and technical supervision for maternal and child Change Communication Strategy (StraCom) for health from Hasanuddin University (UNHAS), thanks stunting prevention and the story described the to the collaboration between the local government process of developing the StraCom. and experts from the Institut Gizi Indonesia (IGI). Program Keluarga Harapan, a conditional cash transfer As we move back to the Island of Java, specifically program initiated by the Government of Indonesia, the Special Region of Yogyakarta, we learned how was able to promote health and educational the local government worked hand-in-hand with investments in children. Large reductions in stunting the community to successfully implement the was also seen in children of beneficiaries. Community-Led Total Sanitation (CLTS) or Sanitasi Total Berbasis Masyarakat (STBM) strategy, winning The length mat is an important tool for raising awards from the Central Government along the way. community awareness of stunting. A summary from Read more on the role of the Sultan of Yogyakarta in an assessment on the usage of the length mat “Tikar the story. Pertumbuhan” provided recommendations on how the usage of the length mat can be optimized and In Chapter 3 of this book, we move from story-telling scaled-up. to provide lessons learned from nutrition initiatives implemented by the central government, non- Last but not least, in keeping with the structure of this governmental organizations, development partners series, an updated stunting projection for the national and private sector. level and a newly developed stunting projection for the district level are described in Annex 1 of this In East Nusa Tenggara Province, a multi-partner book. The models allow for estimations of stunting initiative introduced the multisectoral project, Project rates, based on nutrition-sensitive and -specific data. Laser Beam, to Timor Tengah Selatan District. The project focused on nutrition-specific and nutrition- sensitive initiatives to reduce child undernutrition. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING vii FOREWORD Human capital is key to Indonesia's future. By 2024, we aim to reach all 514 districts Investing in people is how Indonesia can in Indonesia. This will involve an all-of- achieve its goals of accelerating economic government and all-of-society approach to growth and reducing poverty and inequality. preventing stunting. All parties, from national to local level, are directly assigned to work Already, Indonesia is committed to investing together - from ministries to ministries, significant resources to improve its human sectors to sectors, and dinas to dinas, and capital, and has been implementing between all these - because it is evident programs to improve health, education and that addressing stunting requires a multi- social protection, including the National sectoral team working closely together. Strategy to Accelerate Stunting Prevention (StraNas Stunting). This book, which showcases some of the most promising and excellent local We know that the first 1,000 days of a initiatives from the districts, comes at a time person's life are very important and will affect when Indonesia is combatting the COVID-19 them for the rest of their lives. Children who pandemic. Not only does it threaten to delay eat adequate nutritious food, have access to the stunting progress Indonesia has made K.H. Ma'ruf Amin good healthcare, clean water and sanitation, since the StraNas Stunting was launched in and are given proper care face a much lower 2018, but the pandemic also inevitably puts risk of stunting and a higher chance of at risk our ambitious objective to lower the THE VICE reaching their potential. stunting rate to 14% in 2024. PRESIDENT OF Guided by the StraNas Stunting Framework However, despite the challenges and THE REPUBLIC - which consists of five pillars aimed at setbacks brought about by the COVID-19 raising public awareness of stunting, OF INDONESIA pandemic, the stunting prevention program securing nationwide commitments has shown remarkable resilience. Frontline to reduce stunting, and managing, workers who deliver the interventions have implementing, and converging the delivery demonstrated exceptional strength and of the priority nutrition interventions across commitment, ensuring key nutrition services all three levels of government - Indonesia continue to be delivered in the midst of a is on an accelerated path towards stunting pandemic. prevention. We believe that with a strong commitment and multi-sectoral approach, It is the passion of these frontline workers, we can reduce the rate of stunting (amongst along with the leadership and commitment children under 5 years old) to 14% in 2024 - of the local dinas and districts leaders, an ambitious, yet attainable goal. that makes this book such a compelling read. During these tough times, it reminds The Secretariat of The Vice President us of the gains we have achieved, and can of Republic of Indonesia is leading the continue to achieve as we adapt to the work of coordinating the many sectors conditions imposed by the pandemic. and stakeholders involved in Indonesia's fight against stunting. With the support of We hope this book will serve as an inspiration the implementing agencies at local level, to all stunting reduction actors and partners nutrition-specific and nutrition-sensitive at all levels, and enable us to learn from one interventions are delivered to the provinces, another as we continue our fight against districts and villages across Indonesia. stunting. Jakarta, September 2021 K.H. Ma'ruf Amin Vice President of the Republic of Indonesia viii MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING FOREWORD Human capital is key to achieving Indonesia’s access to nutrition-specific and -sensitive development goals of accelerated economic interventions ranging from health to growth and reduced poverty and inequality. education, social protection, water and Recognizing this, Indonesia has made sanitation, and more. This will give millions remarkable progress in its efforts to improve of Indonesian children the best possible its human capital. Since 2018 Indonesia has start in life, enabling them to live to their full sought to increase its investments in human potential. capital and in improving the utilization and The World Bank is committed to working outcomes of existing spending on health, with Indonesia to raise its human capital, education, and social assistance. Also, address stunting and continue to facilitate despite unprecedented challenges due to knowledge exchange between Indonesia the COVID-19 pandemic, Indonesia has and other countries. As Indonesia’s continued to invest in its people. steadfast partner and ally in this crucial Indonesia’s efforts have yielded results. undertaking, the World Bank supports the After a long period of stagnation, the national Government of Indonesia to achieve its stunting rate declined by an unprecedented ambitions by providing policy and technical Satu Kahkonen 3.1 percentage points between 2018 and advice, analytics and evaluation, innovative 2019. And Indonesia is aiming for further technology as well as results-based reductions by the year 2024. financing through the Investing in Nutrition COUNTRY and Early Years Program. DIRECTOR, The Government of Indonesia’s National Strategy to Accelerate Stunting Prevention This book showcases best practices WORLD BANK (StraNas Stunting) has enabled these from districts and sub-districts all over INDONESIA & remarkable gains in stunting reduction and Indonesia and serves as an inspiration for TIMOR LESTE prevention. This strategy employs a multi- Indonesia to continue the fight against sectoral convergent approach to address stunting. The passion and commitment stunting prevention, with as many as 23 shown by individuals, organizations, and ministries and almost US$4 billion per year local governments in the stories in this of government funds committed to the book remind us that while the challenges delivery of nutrition-specific and nutrition- of improving human capital outcomes and sensitive interventions. When the strategy reducing stunting are large, Indonesia has is fully implemented in all 514 districts and what it takes to address stunting and does cities in Indonesia, all households with a it with a plenty of heart. pregnant mother and/or a child under the age of two will be able to gain simultaneous MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING ix ACKNOWLEDGEMENTS This book is a compilation of stories from Marlina BR Ginting Manik, Mohammad all over Indonesia. It is told by many, and Abdullah, Nunuk Supraptinah, Payal written by Elvina Karyadi, Melissa Chew, Gupta, Pembayun Setyaning Astutie, Claudia Rokx, Yurdhina Meilissa, Elviyanti Prof. Abdul Razak Thaha, Prof. Em. Martini, Akim Dharmawan and Pratiwi Soekirman, Ratih Wijaya, Ravi Menon, Ayuningtyas. The projection model and Rika Ratna Puspita, Saskia de Pee, Siska Annex 1 are written by Lubina Qureshy. Verawati, Siti Nur Hayah Isfandiari, Sri Kusyuniati, Sri Sukotjo, Susmita Das, This book is edited by Paul Gallagher. Tutut Sri Purwanti, Widyana Perdhani, Yenuarizki, Yohana Sussie Emissa, This book would not have been Yudhie Suryanto, Zakiyah. possible without the help of many kaders, healthcare workers, district We are grateful to the following district and central governments, development and city governments for facilitating partners, civil society organizations, our visits: Samarinda City, Surabaya policy makers and academicians who City, Nganjuk District, West Lombok graciously shared their stories with us. District, West Sumbawa District, and Their earnest, and generous sharing of Special Region of Yogyakarta. The what they do, how they do it and the visits enabled us to observe how the important lessons they have learned programs are implemented and also while doing it, has contributed to a allowed us to gain valuable insights book that showcases some of the best on how effective multi-sectoral multisectoral stunting reduction efforts coordination for stunting reduction is in Indonesia. carried out. Specifically, we would like to thank We also want to give special thanks to the following individuals for their our partners in development, national contribution and international as well as civil society organizations and professional Achmad Noeroel Cholis, Agnes Mallipu, organizations. Among the most Airin Roshita, Andi Sari Bunga Untung, sustainable, scalable and important Anjali Bhardwaj, Blandina Rosalina nutrition-specific and nutrition- Bait, Christa Rader, Dhanie Nugroho, sensitive initiatives in Indonesia and Dian Nurcahyati Hadihardjono, Dian from whom we learned and have Sukmawan, Egi Abdul Wahid, Elan used their work in this book are: Satriawan, Endang Pamungkas Siwi, Global Alliance for Improved Nutrition Erna Yuniarsih, Frans Hero Making, (GAIN), United Nations Children’s Gatot Suarman, Gwyneth Cotes, Fund (UNICEF), Nutrition International H. Rachman Sahnan Putra, Hanna (NI), Center for Indonesia’s Strategic Herawati, Hj. Ni Made Ambaryati, Jee Development Initiatives (CISDI), World Hyun Rah, Jenna Juwono, Jigyasa Food Programme (WFP), Institut Nawani, Julia Suryantan, Lanny Gizi Indonesia (IGI) and Helen Keller Yusnita, Marcia Griffiths, Mardewi, International. x MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING We are thankful for the contribution We owe this book to the nutrition from the central government, including gurus of Indonesia, whose suggestion the Ministry of Health and Ministry of to feature stories from the districts, Marine Affairs and Fisheries. inspired us to embark on the journey of writing this book. In addition to our We thank our peer reviewers, Ali contributors Prof. Em. Soekirman and Subandoro, Noriko Toyoda, Hugo Prof. Abdul Razak Thaha, we would Brousset Chaman and Professor Fasli like to thank Nina Sardjunani, Dhian Jalal for their excellent comments and Proboyekti, Riskiyana Sukandhi Putra, suggestions which have enabled us to Atmarita, Prof. Endang L. Achadi, Prof. improve the stories and the flow of the Fasli Jalal, Minarto Noto Sudarjo, and book. Sugeng Eko Irianto for their valued inputs. We would also like to thank our colleagues for their helpful inputs and Picture credits: Atet Dwi Pramadia, feed-back: Samuel Clark, Gerda Gulo, CISDI, District Government of West Rini Mintarsih, Deviariandy Setiawan, Lombok, GAIN/Andrew Suryono, Indira Sari, Eko Pambudi, Pandu Helen Keller International, Melissa Harimurti, Inge Sutardi Tan, Sadwanto Chew, Nutrition International, Rika Purnomo and Rosfita Roesli. We are Ratna Puspita, UNICEF, World Food grateful to the “Investing in Nutrition Programme. and Early Years (INEY)” PforR team for allowing us to tap into their expertise. We thank Abdillah Kusumajati, Aditya P. Nugraha and their team for their We thank our management – Satu patience and the design of the book. Kahkonen, our Country Director, Bolormaa Amgaabazar, our Operations Financial support for this work was Manager, Aparnaa Somanathan, our provided by the Australian Department Practice Manager, Achim Schmillen, of Foreign Affairs and Trade (DFAT), our Practice Leader for Human the Global Financing Facility (GFF), and Development and Somil Nagpal, our the Bill and Melinda Gates Foundation Health Cluster Lead for their guidance and Tanoto Foundation through the and support. Indonesia Human Capital Acceleration (IHCA) Multi-donor Trust Fund (MDTF). We would also like to thank all the organizations who had submitted their This book is dedicated to Indonesian stories and information on their best nutrition and health front-liners, practices to us. Because of limitations whose relentless work in the midst of in length, the authors regret not being a pandemic, keeps Indonesia moving able to include all submissions, but forward in the fight against stunting. hope to do so in the future. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING xi ABBREVIATIONS AND ACRONYMS 1,000 HPK = 1,000 Hari Pertama Kehidupan - BPNT = Bantuan Pangan Non-Tunai - Non-cash First 1,000 days of Life Food Assistance ACF = Action Contre la Faim (Action Against BPS = Badan Pusat Statistik – Statistics Hunger) Indonesia AKKOPSI = Association of Cities and Districts C-MAM = Community-Based Management of Concerned about Sanitation in Indonesia Acute Malnutrition ANC = Antenatal care CCT = Conditional Cash Transfer APBD = Anggaran Pendapatan dan Belanja CED = Chronic Energy Deficiency Daerah - Local Government Budget and Expenditure CF = Complementary feeding APBN = Anggaran Pendapatan dan Belanja CISDI = Center for Indonesia’s Strategic Nasional - Central Government Budget and Development Initiatives Expenditure CNP = Cambodian Nutrition Project ATIKA = Hati ayam, telur, ikan - Chicken liver, eggs, fish D/S = Jumlah balita yang datang dan ditimbang/ Jumlah balita sasaran - Total under fives who BABS = Buang Air Besar Sembarangan - Open visited Posyandu and were weighed/Total defecation under fives in catchment area Balita = Bawah lima tahun - Under the age of five DAK = Dana Alokasi Khusus - Special Allocation Fund Bappeda = Badan Perencanaan Pembangunan Daerah - District Planning and Development DEWATS = Decentralized Wastewater Agency Treatment Systems Bappenas = Badan Perencanaan Pembangungan DF = Demonstration Farm Nasional /Kementerian Perencanaan Pembangunan Nasional - The National DHO = District Health Office Development Planning Agency/Ministry of National Development Planning of the Republic Dinas PUPR = Dinas Pekerjaan Umum dan of Indonesia Perumahan Rakyat - Office of Public Works and Housing BAU = Business as usual Disperdagin = Department of Industry and BCC = Behavior Change Communication Commerce BCD = Behavior-Centered Design DIY = Daerah Istimewa Yogyakarta - Special Region of Yogyakarta BCI = Behavior Change Intervention DKP = Dewan Ketahanan Pangan - Department of BF = Breastfeeding Food Security BKB = Bina Keluarga Balita DP = Dinas Pertanian - Department of Agriculture BOK = Bantuan Operasional Kesehatan - Health Operational Assistance EBF = Exclusive breastfeeding xii MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING ABBREVIATIONS AND ACRONYMS ECED = Early Childhood Education and I-MAM = Integrated Management of Acute Development Malnutrition EFA = Essential Fatty Acids IFA = Iron folic acid EHFP = Enhanced Homestead Food Production IGI = Institut Gizi Indonesia EJ = East Java IMCI = Integrated Management of Childhood Illnesses Emo-demo = Emotional-demonstration INEY = Investing in Nutrition and Early Years ENT = East Nusa Tenggara INI = Integrated Nutrition Interventions FAO = Food and Agriculture Organization IPC = Interpersonal Communication FBF = Fortified Blended Food ISP = Information System of Posyandu FCS = Food Consumption Score IYCF = Infant and Young Child Feeding FG = Family Guide J-PAL SEA = Abdul Latif Jameel Poverty Action Forsidas = Forum Komunikasi Daerah Aliran Lab Sungai - Watershed Communication Forum Jampersal = Program Jaminan Persalinan - GAIN = Global Alliance for Improved Nutrition National Health Insurance Scheme for Maternal Health GAMAK = Gerakan Anti Merarik Kodek JKN = Jaminan Kesehatan Nasional - National GDP = Gross Domestic Product Health Insurance Gemadazi = Gerakan Masyarakat Sadar Gizi KIA = Kesehatan Ibu dan Anak - Maternal and Child Health GMP = Growth Monitoring and Promotion KIP = Kampung Improvement Program GoI = Government of Indonesia KKN = Kuliah Kerja Nyata GSC Program = Generasi Sehat dan Cerdas Program KMS = Kartu Menuju Sehat - Growth Monitoring Card HDI = Human Development Index KRPL = Kawasan Rumah Pangan Lestari - HDW = Human Development Workers Sustainable Community-Based Farming HFIAS = Household Food Insecurity Access LBW = Low birth weight Scale LFBSM = Local Food Based School Meals HIV/AIDS = Human Immunodeficiency Virus/ Acquired Immunodeficiency Syndrome LNS = Lipid Nutrients Supplements HKI = Helen Keller International LO-ORS = Low-Osmolarity Oral Rehydration Salts HRH = Human Resource for Health Lombar = Lombok Barat - West Lombok MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING xiii ABBREVIATIONS AND ACRONYMS LROA = Layanan Rehidrasi Oral Aktif - Active Oral PAMMASKARTA = Paguyupan Air Minum Rehydration Service Masyarakat Yogyakarta - Yogyakarta Community Drinking Water Society LSHTM = London School of Hygiene and Tropical Medicine PAMSIMAS = Community-based Water Supply and Sanitation Project M&E = Monitoring and Evaluation PAUD = Pendidikan Anak Usia Dini - Early MAM = Moderate Acute Malnutrition Childhood Education and Development MCN = Mother and Child Nutrition PHO = Provincial Health Office MDG = Millennium Development Goal PIS-PK = Program Indonesia Sehat dengan Pendekatan Keluarga - Healthy Indonesia MITRA = Micronutrient Supplementation for Program with Family Approach Reducing Mortality and Morbidity in Indonesia PKH = Program Keluarga Harapan - Family Hope MMAF = Ministry of Marine Affairs and Program Fisheries PKK = Pemberdayaan dan Kesejahteraan MNP = Micronutrient Powder Keluarga - Family Welfare Movement MoH = Ministry of Health PLB = Project Laser Beam MoU = Memorandum of Understanding PLBI = Project Laser Beam Indonesia MP ASI = Makanan Pendamping Air Susu Ibu - PLW = Pregnant and Lactating Women Complementary Foods PMD = Dinas Pemberdayaan Masyarakat dan MUAC = Mid-Upper Arm Circumference Desa - Community and Village Empowerment Agency NAD = Nanggroe Aceh Darussalam PMT = Pemberian Makanan Tambahan - NGO = Non-Governmental Organizations Supplementary Feeding NI = Nutrition International PoA = Plan of Action NIHRD = National Institute of Health Research Poskesdes = Pos Kesehatan Desa - Village and Development Health Post NTT = Nusa Tenggara Timur - East Nusa Polindes = Pos Bersalin Desa - Village Maternity Tenggara Post ODF = Open Defecation Free Posyandu = Pos Pelayanan Terpadu - Community Health Post OKI = Ogan Komering Ilir POZISI = Pondok Gizi Terintegrasi ASI Ekslusif OPD = Organisasi Perangkat Daerah - Regional dan Perilaku Hidup Bersih Sehat - Integrated Apparatus Organizations Exclusive Breastfeeding and Clean and Healthy Lifestyle Nutrition Post ORS = Oral rehydration solutions/salts xiv MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING ABBREVIATIONS AND ACRONYMS Pustu = Puskesmas Pembantu - Auxiliary Setwapres = Sekretariat Wakil Presiden - Puskesmas Secretariat of Vice President Office PPSP = Percepatan Pembangunan Sanitasi SPAMDES = Sistem Penyediaan Air Minum Desa Permukimam - Urban Sanitation Development - Rural Drinking Water Supply System Program SPM = Standard Pelayanan Minimal - Minimum PSA = Potential Sustainability Assessment Service Standards PTT = Pegawai Tidak Tetap - Contract officers SSGBI-SUSENAS = Studi Status Gizi Balita Indonesia – Survei Sosial Ekonomi Nasional - RAD-PG = Rencana Aksi Daerah Pangan dan Gizi Indonesia Under-Five Nutritional Status Study - Local Food and Nutrition Action Plan – National Social Economy Survey Rakornis = Rapat Koordinasi Teknis - Technical SSK = Strategi Sanitasi Kabupaten - City Coordination Meeting Sanitation Strategies RANTAI = Rapid Action on Nutrition and STBM/CLTS = Sanitasi Total Berbasis Agriculture Initiatives Masyarakat - Community-Led Total Sanitation ROMS = Yogyakarta Regional Oversight StraCom = Strategi Komunikasi Perubahan Management Services Perilaku - National Behavior Change Communication Strategy RPJMD = Rencana Pembangunan Jangka Menengah Daerah - Regional Medium Term StraNas Stunting = National Strategy to Development Plan Accelerate Stunting Prevention RR = Risk Ratio SUN = Scaling Up Nutrition RT = Rukun Tetangga - Neighborhood TNP2K = Tim Nasional Percepatan Penanggulangan Kemiskinan - National Team for RUTF = Ready to Use Therapeutic Foods the Acceleration of Poverty Reduction SAM = Severe Acute Malnutrition ToT = Training of Trainers SBCC = Social Behavioral Change TTS = Timor Tengah Selatan Communication UNHAS = Universitas Hasanuddin SCN = United Nations Standing Committee on Nutrition UNICEF = United Nations Children’s Fund SD = Standard Deviation VAS = Vitamin A Supplementation SDG = Sustainable Development Goal WFP = World Food Programme SDIDTK = Stimulasi, Deteksi dan Interventsi Dini WHO = World Health Organization Tumbuh Kembang - Early Detection and Intervention for Growth and Development MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING xv OVERVIEW BEST PRACTICES: STORIES FROM THE FIELD Samarinda: East Nusa Tenggara A river dolphin swims to the rescue and East Java: Enhanced partnerships and Surabaya: integrated programming improves Changing hearts, minds and diets maternal and child health through games and songs West Sumbawa: Nganjuk: Better skills for health workers pay off Empowering village communities for nutrition of mothers and children to boost health and well-being Timor Tengah Selatan: West Lombok: Fostering the farming skills of A poster child for coordinating households for a better diet the fight against stunting Banggai: East Nusa Tenggara: Academia and district leaders No time to waste in the collaborating for impact fight against wasting Yogyakarta: Award-winning sanitation cleans up city’s riverbanks SNAPSHOTS: LESSONS LEARNED FROM IMPLEMENTATION Public-private partnership: Reducing stunting through Program The early adopter of convergence in Keluarga Harapan (PKH) a remote region with food insecurity Length Mat: “Tikar Pertumbuhan” Where fishponds and an easy education tool to raise rice paddies meet awareness about stunting StraCom: Changing behaviors through effective communication xvi MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING xvii SAMARINDA A river dolphin swims BANGGAI to the rescue Academia and district leaders collaborating for impact SURABAYA Changing hearts, minds and diets through games and songs WEST LOMBOK A poster child for coordinating the fight against stunting NGANJUK Empowering village communities WEST SUMBAWA to boost health and well-being Better skills for health workers pay off for nutrition of mothers and children TIMOR TENGAH SELATAN Fostering the farming skills of households for a better diet STRACOM, PKH, LENGTH MAT EAST NUSA TENGGARA No time to waste in the fight YOGYAKARTA against wasting Award-winning sanitation cleans up city’s EAST NUSA TENGGARA AND riverbanks EAST JAVA Public-private partnership: Enhanced partnerships and The early adopter of convergence in a integrated programming improves remote region with food insecurity Where fishponds and rice paddies meet maternal and child health 01 CHAPTER 1 A TRIBUTE TO LOCAL HEROES IN INDONESIA’S FIGHT AGAINST STUNTING This book is a tribute to local heroes in Indonesia’s were stunted. By 2018 this had fallen to just over 30% fight to reduce stunting in children. and in 2019 the Ministry of Health reports the rate at around 27% (Frankenberg & Thomas, 2000; NIHRD, It celebrates the passion, compassion and innovation 2013, 2018, 2019). of kaders, midwives, nutritionists, community health workers, government officials and local businesses. That, in no small part, was down to a national drive and determination to tackle the scourge of stunting It celebrates the success of a coalition dedicated to blighting the lives of millions of children. tackling chronic malnutrition in children. But it does more than merely celebrate success. This book follows Aiming High: Indonesia’s Ambition to Reduce Stunting, which told the national story It highlights how these small successes can be of nutrition in Indonesia and the way forward for a reproduced at scale to make a big difference in country dedicated to eliminating chronic malnutrition Indonesia’s drive to reduce chronic malnutrition in in children. Using a multi-sectoral approach and children. drawing from lessons learned in tackling stunting over the past several decades, Indonesia is now on It shows what can be accomplished when mothers, a renewed, ambitious path to accelerate stunting fathers, families, and communities not only reduction through the National Strategy to Accelerate appreciate the need for better health and nutrition Stunting Prevention (StraNas Stunting). but actively seek it out in the most far flung villages in a country seeking to educate and empower citizens The diversity of Indonesia has traditionally been to help eradicate stunting. reflected in the diversity of stories of success and failure in driving down rates of stunting in different Indonesia has come a long way in its fight against districts (Figure 1). stunting. In 2000 around 40% of children in Indonesia MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 1 2 Figure 1: Comparison of stunting rate for under fives, by district Stunting Rate, Stunting Rate, by district, by district, 2013 2013 Stunting rate, 2013 <25 25.1-35 Stunting rate, 2013 35.1-45 <25 25.1-35 45.1-55 35.1-45 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 45.1-55 >55 >55 Source: Source : Riskesdas 2013 Riskesdas 2013 Stunting Rate, by district, 2018 Stunting Rate, by district, 2018 Stunting rate, 2018 <25 25.1-35 35.1-45 45.1-55 Stunting rate, 2018 <25 >55 25.1-35 35.1-45 Source: Riskesdas 2018 45.1-55 >55 Source : Riskesdas 2018 Between 2007-2013 several districts recorded double Since it was first launched in 2017, StraNas Stunting digit reductions in stunting rates. Other districts saw has already been rolled out in 260 districts across 34 rates of stunting increase by double digits. provinces and aims to expand to an additional 100 districts in 2021 (See Box 1 for more information on Overall, this diversity resulted in rates of stunting StraNas Stunting). remaining stagnant between 2007 and 2013 at about 36 percent.1 Things have improved and improved In 2020, as many as 253 local leaders have committed markedly since then. to accelerate the prevention of stunting in their districts. By 2018 rates of stunting were falling nationwide with more and more districts reducing stunting rates. It has deployed more than 73,200 Human Development There were significantly fewer red spots on the map of Workers (HDW) in villages across the country to Indonesia marking districts where stunting affected harness the Village Fund (Dana Desa) for stunting more than half of all children under the age of five. prevention. HDWs are present in 98% of the targeted districts. As many as 32,000 HDWs are now actively For example, in Sumatera, in 2013, 15 districts had a using the eHDW app to conduct social mapping and level of over 55% for stunting among under-fives. By measure village convergence.2 2018, only one district had that high level. Nationally, 31 out of 496 districts in 2013 recorded stunting rate In addition, the strategy has tracked spending on above 55%. By 2018 only four out of 514 districts stunting at up to 20 government ministries. reported stunting rate above 55%. Successful local initiatives that reduce stunting and Indonesia is heading in the right direction but the improve maternal and child nutrition can serve to both journey towards negligible rates of stunting is far inspire and provide the impetus to trigger knowledge from over. sharing and ‘know-how’ exchange for national and local leaders. This publication is part of a series on stunting reduction which started with the Aiming High book. Many such local experiences, however, remain It showcases some of the best and most promising undocumented or are not documented in a manner local initiatives that have helped to turn the tide. conducive to effective learning. These initiatives are making a difference locally today This book aims to rectify that. but could make a difference nationally tomorrow if they are replicated at scale and adapted to local It features successful local initiatives, best practice conditions and circumstances. examples and provides a “how to” guide to cut stunting rates locally to reduce stunting nationally. Most of the stories shared in this book are about small-scale, local interventions that have unlocked The stories have been chosen to inspire, inform and success from one district to the next. influence others to join the march towards ending stunting in Indonesia (See Box 2 on how the stories We hope that these success stories have national featured were selected). resonance. They can inspire, inform and influence StraNas Stunting. They inspire us. We hope they inspire you too. 1 Indeed, Indonesia’s stunting rates are declining - in 2000 chronic malnutrition was at 40% (Frankenberg & Thomas, 2000), and according to Riskesdas, in 2007 at 36.8%, in 2013 at 37.2% and in 2018 at 30.8%. Recent SSGBI-SUSENAS data in 2019 reported national stunting prevalence at 27.7% (NIHRD, 2007, 2013, 2018, 2019) 2 The HDW measures village convergence through a scorecard that focuses on key nutrition interventions in the sectors of health and nutrition, Water, Sanitation and Hygiene (WASH), social protection and early childhood education and development (ECED). MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 3 Box 1: The National Strategy to Accelerate Stunting Prevention In Indonesia, the prevalence of stunting (affecting StraNas Stunting aims to drive the convergence of nearly 7 million children under the age of five) national, regional, and village stunting prevention has been slowly decreasing in the last decade. programs. It also aims to ensure better coordination However, stunting prevention efforts have not and better budget allocation of stunting prevention been effectively implemented for many years. In programs. In addition, StraNas Stunting supports addition, the planning, budgeting, implementation, priority nutrition intervention activities, in and monitoring and evaluation of nutrition- particular those related to improving the coverage specific and -sensitive interventions have not and quality of nutrition delivery services among been fully coordinated at all levels. These have the first 1,000 days households. StraNas Stunting been recognised as key challenges in the efforts brings together line ministries or agencies, to address and prevent stunting. In addition, the professional organizations, academicians, civil lack of local capacity at district, sub-district, and society organizations, and private sectors in its village levels are constraints that still need to be effort to address stunting. addressed (Sekretariat Wakil Presiden Republik Indonesia, 2019). A set of Convergence Actions has been established to increase the integration of nutrition interventions In recognition of the need to tackle stunting, (both nutrition-specific and -sensitive interventions the country launched the National Strategy and across administration levels) and to align all to Accelerate Stunting Prevention (StraNas available resources. The Convergence Actions Stunting) in August 2017. This is also mandated consist of eight activities: in the Presidential Decree No. 72/2021 on Acceleration of Stunting Reduction. The StraNas ACTION #1 Stunting consists of five pillars: 1) Commitment Identification and analysis of current situation and vision of the state’s highest leaders; 2) ACTION #2 National campaign focusing on behavior change; Planning activities to improve 3) Convergence, coordination and consolidation; integrated nutrition interventions 4) Food security policy, and 5) Monitoring and evaluation. ACTION #3 Stunting summit (rembuk stunting) To improve the convergence of multisectoral at district/city level interventions for stunting prevention, a geographically-focused plan was designed to ACTION #4 create awareness and commitment for StraNas Regent/Mayor regulation on the role of the Stunting implementation in 100 districts in 2018. village in integrated nutrition interventions Those districts were selected based on a number ACTION #5 of criteria which includes the number of children Human Development Workers (HDW) coaching under the age of five, prevalence of stunting and wasting in children under the age of five, ACTION #6 and poverty prevalence. The number of districts Stunting data management system will be added gradually each year to reach all 514 districts in 2022. In 2019 and 2020, the ACTION #7 strategy was rolled out in 160 and 260 districts Stunting measurement and publication respectively. In 2021, StraNas Stunting will be at the district/city level implemented in 360 districts. ACTION #8 Annual performance review 4 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING Through new fiscal instruments such as the The StraNas Stunting is also set to strengthen Bantuan Operasional Kesehatan (BOK) or Health citizen engagement and empower villages to Operational Assistance Fund, the StraNas hold sector line ministries and district offices Stunting enables the government to incentivize accountable for the delivery of nutrition districts to implement multisectoral programs. interventions. The StraNas Stunting provides Annually, Bappenas coordinates with the Ministry incentives to roll out innovative tools such as the of Finance to track spending on stunting at up Village Convergence Scorecard to track frontline to 20 ministries. In addition, the government delivery of priority nutrition interventions. conducts budget and development performance evaluation on stunting reduction. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 5 Box 2: How the success stories were chosen The success stories featured in this book most stories, the team conducted field visits were drawn from a shortlist. Selected central to observe the initiatives and activities, and to government ministries, as well as 73 local interview implementers and beneficiaries. The governments were invited to share best-practice team visited Kota Samarinda, Kota Surabaya, examples, including from districts where stunting Nganjuk District, West Lombok District, West prevalence has improved.3 But also more than Sumbawa District and DIY Yogyakarta between two dozen academics, non-governmental January and April 2019. organizations, civil society organizations, private sector and development partners, were consulted. A total of 15 stories showcasing successful initiatives from multiple sectors were selected to In addition, based on discussions with field and be featured in this book. While a few of the best sector experts inside and outside the World Bank, practices and lessons learned selected started selected stakeholders or districts were invited to with the implementation of the GoI’s StraNas submit best practices for consideration. Stunting, for the most part, the stories included in this book predates StraNas Stunting. After The determination of criteria4 for submission an initial full draft was completed, a writers’ and requests for stories took place between workshop was held in December 2019 to finalize September and November 2018. The team the draft. received more than 40 submissions of local initiatives from November 2018 to February 2019. Most of the stories featured were written before the COVID-19 pandemic happened and as such, do Shortlisted entries were reviewed further, followed not reflect operation conditions during COVID-19. by additional data request and interviews. For Author's Comments : Addressing stunting in a global pandemic Much like the rest of the world, the COVID-19 About 73% of Puskesmas maintained same service pandemic has affected Indonesia significantly and hours as before the pandemic, but patient visits disrupted the delivery of many services including have reduced. Nearly 84% of Puskesmas reported a health, water, sanitation and hygiene (WASH), and reduction in the number of patient visits. early childhood education and stimulation. The Posyandu, a smaller community health post Research from the National Institute of Health under the supervision of Puskesmas, forms the Research and Development (NIHRD) found that backbone of Indonesia’s primary health care system the continuity of essential health services was for pregnant women, mothers, and children. It is the disrupted during the COVID-19 pandemic, including first, and in many cases, the only point of access to public health efforts in community health centers healthcare for most villages in Indonesia. (Puskesmas).5 3 Determined by comparing 2007 and 2013 stunting prevalence from Riskesdas data. For detailed comparison methodology, see (World Bank, 2017b). 4 For a full list of submission criteria, please refer to Annex 2. 5 Using a cross-sectional, qualitative, rapid survey design, the researchers sampled over 4,798 puskesmas between April and May 2020 (Musadad, 2020) 6 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING COVID-19 has severely hampered the Posyandu’s The Government of Indonesia’s initial COVID-19 services. Nearly half (43.5%) of puskesmas have mitigation strategy include nutrition-sensitive stopped Posyandu services and about 37% have measures such as increasing beneficiaries for food reduced Posyandu activities in their catchment area. assistance and social assistance programs (World This has dire implications for key services such as Bank, 2020). However, increasing the number immunization, growth monitoring, micronutrient of beneficiaries alone might not result in much supplementation and antenatal care – the bulk of mitigation of COVID-19 impacts on stunting. which are delivered through the Posyandu. Stunting reduction calls for a convergent effort Already, Indonesia is seeing the adverse result of through both the service delivery interventions the disruption to essential health service delivery. as well as interventions such as conditional cash More than half (57%) of Puskesmas reported a transfers. decrease in immunization coverage. About one third of Puskesmas have suspended home visits to As the pandemic situation unfolds, the ability of key households with stunting or malnutrition. Another health services to resume as before the pandemic one third of Puskesmas reported not visiting faces great uncertainty. households with pregnant women. Despite the challenges, some Puskesmas are finding Research has shown that access to nutrition- new ways to ensure continued service delivery in the specific and nutrition-sensitive services, many of midst of the pandemic. which are facing service disruption, are vital to the continued fight against stunting (Lancet, 2013). Classes for pregnant women are held via Zoom platform. Applying the StraNas Stunting framework to the COVID-19 crisis’s impact on stunting, COVID-19 Puskesmas visiting hours are staggered to may affect stunting through four channels: loss of accommodate childhood immunizations affected income, rise in food prices, limited ability to deliver by Posyandu closure. health services, and a decline in non-COVID-19 spending on basic service delivery (Upcoming And in Samarinda City, the innovate clustering publication). format (see “Samarinda: A river dolphin swims to the rescue”) allows midwives to continue monitoring Specifically, the main impact of an income or price and communicating with pregnant women in their shock is a decline in food security, which would in clusters through platforms such as WhatsApp. turn affect the quantity and quality of food consumed Antenatal care visits are still conducted, but by and stunting. appointment to maintain physical distancing. Front-line service delivery, particularly via Posyandu The impact of COVID-19 has been severe on the and the early childhood education and development livelihoods of most Indonesians. For the first program Pendidikan Anak Usia Dini (PAUD), has been 1,000 days of life households, the impact of disrupted by the lockdown, and this directly affects COVID-19 extend beyond income loss and food the delivery of key health and education services. security. It affects the heights and minds of the next generation. There have also been cuts in spending on water, sanitation, and hygiene (WASH), a nutrition-sensitive intervention, due to the diversion of resources to tackle COVID-19. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 7 02 CHAPTER 2 BEST PRACTICES: STORIES FROM THE FIELD 8 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING SAMARINDA: A RIVER DOLPHIN SWIMS TO THE RESCUE SAMARINDA Dotted among the rice fields, the bustling roadside “We faced a significant budget cut for the stores, and homes of Samarinda City you will find the past three years. Thus, there was a city-wide vibrant community of Bukuan. Busy with laborers, mandate for innovations to ensure continued traders, and miners, it is a diverse community with service delivery,” said Endang Liansyah, the Assistant different cultures, diets, and habits. Despite their City Secretary for Samarinda. differences, they face a common problem: many of their children suffer from stunting. Not only Drg. Rika Ratna Puspita answered the call of the city that, money for combating the scourge of chronic authorities to innovate. malnutrition is tight. Facing budget cuts in 2016, the head of the local health authority, decided it was time for change. That is when the Mahakam River dolphin, locally named Pesut Mahakam and the symbol of East Kalimantan Province, swam into view, lending its name to an initiative to merge a maternal health program and a nutrition program to tackle stunting. The outcome was a single initiative with a common goal: improving the health and well-being of mothers and children with integrated services and staff. The initiative was the brainchild of dentist Drg. Rika Ratna Puspita, head of the local community health center, who saw a way to do more with less. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 9 MERGING THE NEEDS OF the home visits and ensure continuation of good caring MOTHER AND CHILD practices,” said Dr. Siti Wulandari, a doctor from Puskesmas Bukuan. First, she rolled two separate maternal health and nutrition programs into one (See Box 3). The closer bond between midwife, nutritionist and community health volunteer created by the new Then she created teams of midwives, nutritionists, merged program proved critical with the volunteer and community health volunteers (kaders) to work kaders gaining valuable insight and expertise from together to look after the health and nutrition needs working alongside healthcare professionals. In of a cluster of pregnant women, mothers, and their addition, they worked closely together to track and children in a particular area (See Box 4). support mothers and children at greatest risk. They worked together and planned together, “Before the Pesut Mahakam Program started, coordinating to ensure an efficient and effective we faced challenges in reaching out to the approach to track, counsel and support mothers and community and getting the community to their children in health and nutrition. The aim is to come to us, the healthcare providers,” according to Drg. track children intensively for the first and most crucial Rika Ratna Puspita. 1,000 days of their lives when they are at greatest risk of stunting. The program then continued to monitor “In addition, there was limited knowledge and awareness the children through the posyandu until the children of stunting among the kaders and community. The turn 5 years of age.6 kaders were not aware of the importance of the first thousand days of life, and simply did not know how to “Because of the clustering system, we improve the nutrition of the mothers and children in the can coordinate with the other midwives, community.” nutritionists and kaders more efficiently and pass on important information. For example, we had a The secret to the new program’s success was also case of a stunted child whose parents were frequently down to taking a “life cycle” approach, keeping in on the move due to work. But because of the clustering touch with mothers and children at different stages system, we were able to keep track of him and the of development. nutritionist from his new cluster was able to continue 6 See Box 5 at the end of this story for step-by-step guide to starting the Pesut Mahakam Program. 10 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING Box 3: Cooking up new ideas The Pesut Mahakam Program integrates two early initiation of breastfeeding, infant and young separate programs – a maternal health program child feeding and clean and healthy lifestyle. named Bidadari Ramah7 (Friendly Fairies) and a nutrition program named POZISI “Pondok Gizi The Pesut Mahakam Program convenes every three Terintegrasi ASI Ekslusif dan Perilaku Hidup Bersih months in a space that allows the young children Sehat” (Integrated Exclusive Breastfeeding and to play safely within reach of their mothers, Clean and Healthy Lifestyle Nutrition Post). with toys provided by the Pondok Gizi, while the mothers learn about exclusive breastfeeding, It aims to reduce high incidences of maternal and complementary feeding from the Puskesmas fatality and malnutrition problems, including nutritionist. In a nearby room, pregnant women stunting prevalence. are gathered to learn about pregnancy, healthy diets, additional nutrition requirements in their The Bidadari Ramah Program provides antenatal pregnancy and early initiation of breastfeeding care and postnatal care services, in addition to among other topics. As the space bustles with pregnancy education and counseling. the sound of laughing children and women, the highlight of the event for most mothers is the It provides scheduled home visits to the pregnant cooking lessons by kaders which allows the women, including pregnant women who are hard mothers to observe how healthy complementary to reach, or unregistered. food using locally available foods can be prepared. During the cooking demonstration, the The POZISI Program, on the other hand, provides kaders share their award-winning recipes, and the counseling services on exclusive breastfeeding, smiles of toddlers provide wordless testimonies of the delicious recipes. 7 Bidadari Ramah is an acronym for “Bidan dari desa mandiri rajin periksa mama hamil” or village midwife independently and diligently examining pregnant women. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 11 Box 4: Health teams caring for groups of mothers and children The success of the program lies in the innovative Specifically, the clustering is employed according “clustering” format. In fact, the Pesut Mahakam to program arm. For the maternal health arm Program is the first to use this approach, where (Bidadari Ramah Program), the peri-urban area is midwives and nutritionists are assigned to divided into eight clusters, of which one midwife clusters of pregnant women, mothers, and or nutritionist is assigned to each cluster; one children. Different from clustering based on cluster can consist of 150 to 300 households. administrative functions, the clustering format For the nutrition arm (POZISI) of the program, employed by the program accounts for the local the peri-urban area is divided into 3 clusters, characteristics of the area, the geographical reach with one midwife or nutritionist assigned to each and considers potential external supporters such cluster. With this clustering format, the midwife as private companies. As a result, the clusters are or the nutritionist provides oversight for their grouped according to Posyandu catchment areas, own cluster while before, a midwife coordinator and one cluster consists of four Posyandu for would provide oversight for the entire region. The children under-five. The clustering format enables clustering system also provided the advantage of the midwives and nutritionist to ensure program systematic data collection. During the Program coverage in a large area while also allowing them Indonesia Sehat dengan Pendekatan Keluarga (PIS- to gain access to hard-to-reach households with PK) data collection period, Puskesmas Bukuan pregnant women and young children and provide completed the data collection in an impressive tailored individual counseling through the first three months – others required one to two years. 1,000 days of life. It also builds camaraderie Puskesmas Bukuan became the pilot site for the between midwives and nutritionists from the Indeks Keluarga Sehat application8, an app that different Posyandus. visualized PIS-PK data for the city of Samarinda. 8 Indeks Keluarga Sehat is a mobile-based application that helps enumerators conduct data collection for the PIS-PK Program or Healthy Indonesia through the Family Approach or. The PIS-PK Program is MOH’s key intervention which was developed with three main objectives: (i) improving family access to a comprehensive healthcare package covering prevention services, health promotion, basic curative care and rehabilitation; (ii) supporting the local governments to achieve the Minimum Service Standards (MSS) by improving access to health care and health screening; and (iii) improving community awareness to become a JKN member. The first step to implementing PIS-PK is a visit by Puskesmas staff to each family to develop a database of 12 health indicators for all families in its catchment area. Analysis of the data will produce a Indeks Keluarga Sehat (Healthy Family Index) for village, sub-district, district, province, and national level. The Puskesmas will plan and conduct follow up home visits to address identified risks through behaviour change communication and by facilitating appropriate clinical care, as needed. 12 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING TRACK, SUPPORT AND COUNSEL PROMISING RESULTS Firstly, it tracks pregnant women, providing group A significant investment in time and effort have counseling, home visits and supplementary feeding yielded promising results. for those with chronic energy deficency. At the start of the program in 2016, there were 13 Secondly, each high-risk pregnancy is tracked more children who had acute malnutrition. After close to a intensively and a pregnant woman receives home year of follow-up, 12 children achieved normal weight. visits from both a midwife and kader. When the focus on acute malnutrition started shifting Thirdly, pregnant women are provided with the names to chronic malnutrition, in part due to the National and contact number of their appointed midwife to Strategy to Accelerate Stunting Prevention (StraNas contact during emergencies. Stunting), the program started focusing on height monitoring. Fourthly, babies born with low birth weight are more regularly and carefully monitored for their growth. Twenty-four children aged 1 to 5 were found to Growth promotion is provided in group counseling. be short for their age (height for age z-score ≤ - 2 Standard Deviation (SD)) in early 2018. By October Finally, mothers are invited to cooking courses 2018, 14 of these children had improvements in their and education on water, sanitation and hygiene. stature and had moved out of the high-risk zone. Supplementary feeding, using locally available food, is also provided for malnourished children. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 13 The program’s focus on improving nutritional status EMPOWERING KADERS of chronic energy deficient (CED) pregnant women has also shown impressive results. The commitment and motivation of the kaders was also reiterated by Dr. Siti Wulandari. According to Dr. In 2016, there were 34 women who had chronic Siti Wulandari, it was the kaders who first approached energy deficiency. Three of the resulting children the Puskesmas and midwives to ask for permission to born were reported as being low birth weight by the conduct home visits when they discovered children midwives who kept track of the women through the who had dropped out from the Posyandu program. program. The infants were followed up through the nutrition arm of the program, and all three infants had Now, with the kaders’ improved understanding on improvements in weight. maternal and child health and nutrition following the implementation of the program, the kaders are more In 2017, 38 pregnant women had CED, but due to the confident in carrying out their duties during Posyandu interventions delivered through the program, none of activities. the resulting births were reported to be of low birth weight. Empowering the kaders have also given the peri- urban area indispensable health advocates – some Many factors contribute to the success of the Pesut kaders have become the ambassador for their local Mahakam program: strong local governance at the community health development efforts, and others Kelurahan and Kecamatan level; supportive Health provided a catalyst in the community for exclusive Dinas, committed puskesmas head and staff including and continued breastfeeding. The kaders’ ability to nutritionists and midwives, and dedicated, proactive provide effective outreach has greatly benefited the kaders who provide much needed community Puskesmas, to the extent of assisting in the PIS-PK mobilization. surveys. “Sometimes I face the challenge of getting the The Pesut Mahakam Program also features a strong children to return for the following sessions public-private cooperation. Each cluster has the at the POZISI or Posyandu because the backing of local private companies. As part of their mothers felt discouraged to learn that their children are corporate social responsibility program, these malnourished. But I persevered and conducted home companies provide space or seed money for the visits instead, to ensure the children continue to receive establishment of the programs. Many continue to be the care they needed”, explained Sukinah, a kader at actively involved in the program, joining coordination Kelurahan Bukuan who was also recently appointed meetings that are held periodically. as a member of the inaugural Forum Peduli Kesehatan Anak at Kota Samarinda. While the active public-private sector partnership contributes to the sustainability of the program at Kelurahan Bukuan, the program continues to require funding and supervision from the local government to ensure long term sustainability. The Puskesmas, midwives, nutritionists and sanitarians also continue to need supervision from the Health Dinas – for example for data analysis to inform decision-making at the local level. Strong advocacy regarding the importance of nutrition interventions – both specific and sensitive – is 14 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING pivotal to ensure continuous local budget allocation CONCLUSION for innovative programs such as the Pesut Mahakam Program. The program plans to go from strength to strength, deepening its impact and widening its reach. It is now With promising results, and interventions that are hoping to track every child for the first 1,000 days of tailored to the local needs, the Pesut Mahakam its life. Program can be scaled-up to address maternal and child health and nutrition issues in Kota Samarinda For the time being the program, for budget reasons, is and surrounding districts. limited to tracking mothers with CED and babies with low birth weight. To do this, and to do it well, a multi-sectoral platform at the city-level which addresses stunting prevention But the ambition to do even more to drive down rates is needed. This is where support from the GoI’s of stunting is there. StraNas Stunting can make critical contributions (see Box 1 for more information on StraNas Stunting). More support from the city, provincial government and better coordination between local government While the program is very much driven by the health and health teams helping clusters of mothers and sector, cross-sectoral coordination happens with a children could turn that ambition from vision into few local Dinas or local government office such as reality. the Women’s Empowerment and Child Protection Dinas and Population and Family Planning Dinas. Much like the river dolphin after which the program is Wider cross-sectoral coordination involving the city named, Pesut Mahakam swims more easily with the administration and other sectors such as Public tide than against it. Works for example, is still much needed for further improvement. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 15 Box 5: Step-by-step guide to starting the Pesut Mahakam Program The following describes steps to starting the 4) Develop and strengthen kaders’ Pesut Mahakam Program: knowledge and skills 1) Building local or community political will a) Identify strengths and a) Identify a champion to advocate weaknesses of kaders nutrition and develop a vision b) Provide capacity building for b) Establish goal and purpose of program kaders, especially program- related knowledge and skills c) Channel resources and establish commitment for the program 5) Implement the program d) Hold village or community meeting to: a) Identify beneficiaries for maternal health and nutrition arms i) Advocate goal and purpose of program and confirm vision b) Identify clusters ii) Create awareness of health c) Assign midwives, nutritionists, problems and health risks and kaders to each cluster iii) Village or community meeting d) Track beneficiaries, provide home visits should involve Village/Lurah and tailored interpersonal counseling, Head, Village/Kelurahan monitor progress on a monthly basis Government official and other e) Conduct Posyandu Balita once sectors in the Kelurahan (e.g. a month and Pondok Gizi and Women’s Empowerment and midwife cluster meetings once Child Protection, Population every three months (including food and Family Planning) demonstration / cooking spectacle e) Upon establishing local sessions, and counseling sessions) commitment, clearly identify f) Conduct midwives’ meetings once roles for each stakeholder a month (provide counseling, f) Follow up initial meetings with information on early initiation of specific program planning (how, breastfeeding, and others) why, what, when, where, who) 6) Monitoring and evaluation of program 2) Contact the higher policy maker a) Monitor implementation of program in the region: Camat b) Check continuity of program a) Inform result of village or and activities community meeting c) Conduct kader meeting every six b) Request for support (e.g. months as feedback mechanism financial, legal, administrative) d) Improve the program 3) Contact local corporations or e) Prepare monthly reports private companies in the area 7) Sharing progress of program a) Explain goals and purpose of the a) Share the progress of the program program and areas of assistance to all contributing sectors, including b) Encourage local corporations’ or private Camat and Lurah Government, companies’ involvement in program corporate/private companies c) Acknowledge the public-private b) Share program results and partnership and the local outcomes. Encourage continued corporations/private companies’ support of all contributing sectors contribution to the program for program sustainability and community health development 16 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING SURABAYA: CHANGING HEARTS, MINDS AND DIETS THROUGH GAMES AND SONGS SURABAYA health posts (Posyandu) across the city to eat healthily, to breastfeed and to give their children a balanced diet. The idea was simple: to make mothers feel good about changing their behaviour to improve their health and that of their children. The idea was based on a concept first introduced by one of the world’s most renowned public health schools, The London School of Hygiene and Tropical Medicine (LSHTM). The approach, known as Behavior-Centered Design (BCD), combines evolutionary and environmental psychology and best marketing practice to design and test imaginative and provocative activities to encourage changes in behaviour. Great ideas need great champions. Promoted on Java as part of the Baduta In Java’s bustling port city of Surabaya, Chief of the program, implemented by The Global Alliance for local Family Welfare Movement, Siti Nuriyah Zam- Improved Nutrition (GAIN), a Swiss-based foundation, Zam Sigit Sugiharsono, 60, came across an idea so Siti Nuriyah Zam-Zam Sigit Sugiharsono saw the good she wanted to share it with everyone. potential of these activities almost immediately. The idea, rooted in evolutionary and environmental The secret of the approach’s success was to make psychology, was to inspire pregnant women and the activities relevant, easy to understand, fun and mothers through games and songs at community positive. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 17 Health workers and kaders play games, especially Soon she was championing the cause, eager to see all designed to encourage behavioural change, with mothers in the city having access to the emo-demos. mothers and pregnant women in the Posyandus. “I am like a mother of children from 31 sub- While each game educates, the main purpose of districts in Surabaya. Seventeen receive the games, known as “emotional-demonstrations or emo-demos, while the others do not. This is a emo-demos” is to create healthy habits. The goal is good program, so I felt sad for those not receiving emo- to trigger participants to remember or to associate demos”, she said. certain emotions or interests with desirable or undesirable behaviours. She was determined to do something about it. The potential of the emo-demos as part of an So, she proposed to the City Health Office to use the innovative infant and young child feeding (IYCF) city budget to train health volunteers (kaders) from program rolled out as part of the GAIN Baduta the non-intervention areas. As non-intervention areas, program is enormous. the 14 sub-districts had initially not been eligible for the emo-demo toolkits. It reached around 50,000 individuals monthly and transformed the health and well-being of families HELPING HAND FROM HAND- across the city. WRITTEN MATERIALS The Baduta program aims to improve child growth Siti Nuriyah Zam-Zam Sigit Sugiharsono did not let by enhancing the nutrition of pregnant women and this stop her. children under two years of age. It also aims to reduce the prevalence of infectious diseases. It has been She convinced the kaders to create emo-demo toolkits rolled out in five districts of East Java: Bondowoso, using their own resources. Siti Nuriyah Zam-Zam Jember, Probolinggo, Trenggalek and Surabaya Sigit Sugiharsono encouraged them to reproduce the (Keats et al., 2019). The “emo-demos” are very much tools by hand, without using any printing equipment. at the heart of the program. Her enthusiasm was infectious, motivating the kaders to roll out the program in their areas. Running in at least 1,600 Posyandus, the emo-demos have proved a runaway success since they were All 31 sub-districts now offer the emo-demo program launched in the city in 2018. but 14 are using their own handmade materials and are supported by the city health office budget. The only problem, at the start, was that the emo- demos only covered half the city. Thanks to her relentless efforts, Posyandu  ‘Kenanga II’ in Simokerto sub-district is one of the Posyandu This placed Siti Nuriyah Zam-Zam Sigit Sugiharsono, in the non-intervention areas that was finally able to in a predicament.9 deliver emo-demos successfully. According to the kaders, the activities in the Posyandu became livelier After first learning about emo-demos when GAIN with the introduction of emo-demos, as more mothers introduced the program to the city in June 2018, she were eager to attend the monthly event. received training and went on to train others. 9 Siti Nuriyah Zam-Zam Sigit Sugiharsono’s story first appeared in GAIN’s most significant change stories series. 18 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING CHANGING HEARTS AND MINDS Changing hearts and minds is not easy. It requires protein intake such as hati ayam, telur or ikan - ATIKA people to change habits while old habits die hard. (chicken liver, eggs or fish). Research in 2013 had shown that social status Secondly, encouraging exclusive breastfeeding until and reputation were found to be strong drivers 6 months and reducing infant formula feeding. of parenting amongst the target population. This knowledge influenced the program’s behavioural Thirdly, increasing dietary diversity of homemade change strategy and was reflected in messages complementary food for infants 6-23 months of age. targeting mothers on TV and on social media. This in turn was reinforced by games and songs during the Fourthly, reducing unhealthy snacks given to children emo-demos in Posyandus. through the promotion of healthy alternatives. The strategy’s brand identity Rumpi Sehat (Healthy Simple messages were developed (Figure 2) Gossip) focuses on four key target behaviours. and disseminated through social media, text messages, interpersonal communication and four Firstly, improving the eating habits of pregnant advertisements for national television. women so that they increased their daily animal Figure 2: Baduta behavior change messages Breastfeeding is Give balanced Give only healthy Pregnant women enough complementary snacks must eat animal foods protein foods Sources: Keats et al., 2019 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 19 The behaviour change messages were further REACHING OUT TO MORE reinforced in the community through emo-demo MOTHERS ACROSS THE CITY activities carried out at Posyandus. Despite an initial target of two years to deliver emo- Inserting the emo-demo into the waiting time of demos throughout Posyandus in half of Surabaya, the mothers at the Posyandu proved to be a highly GAIN successful achieved the targeted emo-demos effective strategy, maximizing exposure of key coverage within a year. messages to the target audience. The emo-demos also attracted a large crowd at the Posyandu because This meant delivering emo-demos to 1,616 Posyandus of the fun activities, catchy songs and phrases, covering 86 villages and 17 sub-districts, and further increasing the program’s reach. delivering key behaviour change messages to 50,000 mothers or caregivers at the Posyandus every month Figure 3 shows examples of emo-demo how-to- during the first year of program implementation. sheets. As many as 3,375 sets of emo-demo tools were “While traditional health education is distributed to Posyandus in 33 primary health informative, it is passive, and the participants centres and 558 emo-demo trainers, consisting of can quickly tune out. Emo-demos on the health officers, government representatives, and other hand are highly participatory. They involve ‘aha’ or academicians were trained to equip village kaders attention-grabbing moments and of course emotional with emo-demo delivery skills (Pamungkas, 2019). stimulation. These characteristics make emo-demos highly memorable and the messages are more tangible Recognizing the importance of the messages that so that participant are more likely to retain and try out emo-demos bring to the target audience, the Surabaya the new behaviours,” said Ravi Menon, the previous City Government, including Surabaya District Health Country Director of GAIN Indonesia. Office, allocated resources to scale-up emo-demos to non-intervention areas. Figure 3: Examples of emo-demo visuals Sources: Keats et al., 2019 20 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING The kaders complemented the city government’s In 2019, GAIN held a competition to develop new support with hand-made emo-demo tools and module content and as many as 12 modules were together, the local government and community selected from amongst participants from academic leaders work hand-in-hand to ensure no Posyandu – institutions and community health centers. and community - is left behind when it comes to emo- demos. Innovative, effective and scalable programs such as the emo-demo could greatly support Pillar 2 of the Since May 2018, emo-demo have been scaled up to be GoI’s StraNas Stunting, which focuses on Behavior implemented in almost 4,500 Posyandus throughout Change Communication (BCC). the five intervention districts of Bondowoso, Jember, Probolinggo, Trenggalek and Surabaya. Until the CHANGE IN MOTHER AND CHILD end of October 2018, GAIN has provided training HEALTH to 163 IYCF emo-demo trainers at the district level, facilitated training for 1,594 village-level trainers and An evaluation of Baduta shows that the program, of 9,065 Posyandu kaders. GAIN has also distributed which the emo-demos are an integral part, has borne emo-demo aids for three of the emo-demo IYCF fruit. modules to all Posyandu in the intervention area. There has been a significant increase in the rate of Scaling-up the program is challenging given the high exclusive breastfeeding and a reduction in the use of training costs. pre-lacteal foods. An estimated IDR 50 million (approximately USD There has been a substantial rise in the proportion 3,500) is needed to provide training for 50 persons of children aged 6 to 23 months consuming iron-rich per module and per Puskesmas. In addition, refresher foods. trainings are also required. There has been a pronounced increase in children Given the popularity of the program, GAIN frequently aged 6 to 23 months consuming an adequate number receives training requests from other non-intervention of food groups. districts. As the training costs could prove to be prohibitive to further scale-up, GAIN actively More mothers have better knowledge about the encourages local governments to adopt and scale-up benefits of exclusive breastfeeding (Keats et al., the program in their own districts. 2019). Meanwhile, GAIN uses online video tutorials - which The results speak for themselves. were initially prepared as an accessory for training - to conduct refresher training. According to GAIN, So does the enthusiasm, laughter, and camaraderie randomized controlled trials have shown that amongst the mothers clapping and singing during an screening the videos three times helps participants to emo-demo in the city. retain as much as they would in face-to-face training. The emo-demos have not just changed hearts and Currently, all 12 emo-demo IYCF modules have been minds. They have helped to change the health of its adapted to the East Java’s Posyandu guidelines and mothers and children for good. nutrition and health promotion teaching materials for 15 universities and higher education institutions in That, in no small part, is down to one of their leading Indonesia. In 2017, GAIN facilitated adoption through champions: Siti Nuriyah Zam-Zam Sigit Sugiharsono. a series of workshops and technical assistance. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 21 22 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING NGANJUK: EMPOWERING VILLAGE COMMUNITIES TO BOOST HEALTH AND WELL-BEING NGANJUK With its volcanoes, dense forests and rice paddies, Posyandu belonged to the kader (health volunteers) the villages of Eastern Java can feel remote. Many and midwives, not to the villagers themselves. are at least a day’s drive from the capital Jakarta. Among them is a village like many others. But it is The volunteers did everything they could to encourage a village with a difference. It is a village which has mothers and caregivers to bring their children to the become a model for community empowerment in Posyandu. They conducted home visits for children Indonesia’s drive to reduce stunting in children. who missed Posyandu sessions to be weighed and measured. Jati Kalen, in Nganjuk district, has become a byword for community empowerment in Indonesia’s push to Attendance rates10 improved but participation during improve maternal and child health. The community’s Posyandu sessions was still largely passive. empowerment was initially triggered by the Bidan (village midwife), Sri Murti. Mothers returned home after children had been weighed and did not remain on for counseling Back in 2006, attendance and participation by sessions. pregnant women and mothers in activities at the local Posyandu (community health post) was sporadic at Attendance also dropped drastically after the month best. of August when most events, such as Vitamin A administration and National Day celebrations are There was little active participation by the community. held. Most women visited the Posyandu merely to get their children weighed or immunized. In 2010, the midwife Sri Murti, along with the community health volunteers in the village, decided There was a sense among the community that the something had to be done. 10 The percentage of children weighed (out of all children in the catchment area) averaged at 88%, compared to 71% the year before. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 23 It was time to give the community a voice, a say and The idea was simple: to empower the local community a role in running activities to promote maternal and to shape events and activities in a way that met their child health. The village has not looked back since. needs. Ensuring events were fun and rewarding was key. Over the next three years, they worked with the women and mothers in the village to start planning The emphasis was on activities and interactivity. the Posyandu activities for the next year. First, they talked to the local women to find out which activities Children who completed their basic immunization and topics interested them. were given certificates and took part in a ‘graduation’ ceremony during Taman Posyandu events. Then they encouraged the local women to participate more fully in discussions, to make commitments and Mothers who were late to the events, on the other to solve problems as a community. The discussions hand were asked to perform a dance in front of the also provided an opportunity for health workers community. These light-hearted ‘punishments’ served and volunteers to reiterate how important regular as entertainment for the community, which increased attendance at health post events was to the health the attendance rate of the Taman Posyandu. of their children. The concept went from strength to strength as As a result, when the Taman Posyandu concept was local women took on roles assisting the kaders introduced in Nganjuk district in 2012, the Posyandu with documentation and local complementary food at Jati Kalen village was ready to embrace the preparation. challenge head-on. 24 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING CONVERGENCE OF BASIC SOCIAL SERVICES Nganjuk’s adoption of the Taman Posyandu model began in 2012 following a push by national and provincial governments to make basic social services available to everyone.11 The Taman Posyandu delivers three key basic social services: health and nutrition, early childhood development and parenting classes. Box 6 describes the criteria for establishing the Taman Posyandu. Health and nutrition services are delivered through Box 6: Taman Posyandu criteria the Posyandu functions. Early childhood development services are delivered through the Pendidikan Anak A Taman Posyandu must first fulfil the criteria Usia Dini (PAUD) program and parenting classes are of having a Purnama or Mandiri Posyandu administered through the Bina Keluarga Balita (BKB) classification. The Posyandu must also offer program. one or more extra services, in addition to the usual Five Tables system. Held once a month, all services are delivered over the course of three to four hours in the morning.12 A The Taman Posyandu must also offer early typical Taman Posyandu session at Nganjuk district childhood education and development starts with registration, group exercise, followed by services, also known as Pendidikan Anak Usia the emo-demo session (see “Surabaya: Changing Dini or PAUD. PAUD aims to provide early hearts, minds and diets through games and songs” stimulation for children between the ages of for more information). After that, the mothers zero to six to encourage cognitive, physical proceed to parenting class with the BKB kaders while and spiritual development. the toddlers join the PAUD kaders for early childhood education and development activities. Lastly, the A third requirement for a Taman Posyandu children and women receive the health services is the parenting class otherwise known according to the Posyandu Five Tables system.13 as Program Bina Keluarga Balita (BKB). The parenting class aims to increase the skills, All three services share the same location, typically knowledge, and awareness of parents and where the Posyandu is held. However, the Taman carers in developing their child’s cognitive, Posyandus can also be held in village halls, sub- social emotional, physical and motoric growth district halls and home of villagers. through parent-child interactions. Classes are typically conducted by BKB kaders and the By converging these services in one location, parents or caregivers are grouped according the program greatly improves accessibility and to their child’s age. attractiveness of these services to the mothers and children in the community. 11 Nationally, the integration of social services at the Posyandu started in 2011 when the Ministry of Home Affairs issued a regulation supporting the integration of basic social services in the Posyandu (Permendagri No. 19 Tahun 2011 Tentang Pedoman Pengintegrasian Layanan Sosial Dasar di Posyandu). These services included health and nutrition services, childhood education and development services, family economic improvement measures, food security and social services. In the same year, the East Java Provincial Government issued a regulation on holistic integrative development for early childhood in East Java (Peraturan Gubernur Jawa Timur No. 63 Tahun 2011 tentang Pengembangan Anak Usia Dini Holistik Integratif Provinsi Jawa Timur). Together with the support and partnership of the Family Welfare Movement or Pemberdayaan dan Kesejahteraan Keluarga (PKK) Leader in East Java, the Provincial Government developed and planned the Taman Posyandu Program for the East Java Province. 12 Only the PAUD events are held multiple times throughout the week. 13 Five-tables system refers to the typical arrangement in a Posyandu, where the tables represent the main activities carried out during a Posyandu event, e.g. Table 1 for registration; Table 2 for growth monitoring; Table 3 for recording; Table 4 for counseling and Table 5 for health services. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 25 RESULTS OF EMPOWERMENT was a sense of belonging, a sense that this Taman Posyandu belongs to my community and me,” said Nganjuk’s Taman Posyandu program has succeeded Yudhie Suryanto, the head of the Health Promotion in improving participation and more importantly, Section at the Nganjuk DHO. The officers at the DHO increasing the community’s understanding of the were quick to realize this was a winning formula. information being shared by the kaders. On average, 93% of children (out of all children in the catchment REPLICATING A WINNING area) were weighed every month in 2019, compared FORMULA to just 71% in 2006. Hoping to sow and spread the seed of community “The mothers now fill in the Buku KIA empowerment across the district using the Jati (maternity book), and KMS (growth monitoring Kalen model, the district officers organized internship card) along with the kaders. They discuss the sessions from other sub-districts and villages to Jati results on the spot. They are quick to point any errors in Kalen village. entry by the kaders,” Bidan Sri Murti explains. Initially, only kaders from the other villages were The innovation, commitment and good practices at assigned to the internship. But soon, the District Taman Posyandu Melati of Jati Kalen village soon Health Office (DHO) realized that a larger, cross- became known to the officers at the Nganjuk District sectoral team is needed for effective uptake and Health Office (DHO). On their visit to the Taman implementation of the model in other sub-districts Posyandu Melati, the officers were impressed with the and villages. So they sent a team which consisted response at the Taman Posyandu. of the village and camat Pemberdayaan dan Kesejahteraan Keluarga (PKK) members, Puskesmas “The children and women were sitting calmly health promotion staff, village midwife, midwives and patiently in a small, tight space. None coordinator, and kaders (all five) to Jati Kalen village of them were in a rush to head home, but for internship. instead, were very participative and fully engaged. There 26 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING There, the team learned about cross-sectoral coordination, shared decision making for the villagers, Box 7: When villages innovate and community empowerment. At Taman Posyandu Flamboyan, Gondang Most of all, they observed first-hand how a simple village, the CERIA SEHAT (Cerdaskan Ibu Anak act of involving the community in the planning and Sehat) innovation stood out with its focus decision-making, could make such a big difference on addressing appropriate complementary in participation and involvement of the women and feeding practices. Through the innovation, children in the Taman Posyandu. mothers and pregnant women are invited to bring a boxed lunch for their children and The DHO initially supported the internship sessions themselves to eat during a communal meal by providing transportation and food allowance after the Taman Posyandu event. This creates for the learning teams using local government an opportunity for the nutritionists, midwives funds (APBD). But now, the DHO finds that village and kaders to assess the appropriateness leaders have taken the initiative to start requesting of the meals. More importantly, it provides for internship sessions, and are also funding the a platform to learn and practice good infant internship sessions using village funds. It is now and young child feeding. As a reward, the best increasingly more common for village funds to be prepared lunch box is showcased14 and the used for stunting prevention programs, thanks to the winning mother or pregnant woman receives GoI’s StraNas Stunting. a small gift, further incentivizing them to try their best for the next CERIA SEHAT event. During the study visits, the visitors were also challenged by the kaders at Jati Kalen village, Another innovation highlight is the egg explained Bidan Sri Murti. donation drive at Taman Posyandu Bugenville, Kelurahan Kapas. At this location, mothers are “My kaders had asked the other kaders, if we encouraged to donate raw eggs to the event. can do it, why can’t you?” she said. The donated eggs are then distributed to the participants of the Taman Posyandu through a This created healthy competition among the kaders, random draw. In one event, as many as five each striving to do their best. It also resulted in local women could receive up to 20 eggs which innovations in each Taman Posyandu (see Box 7: can then be used to feed their families. The “When villages innovate”), which serve to encourage head of the sub-district, Tri Basuki Widodo, community participation even further. finds the egg donation drive to be a practical way for them to contribute to the fight In 2012, an initial 145 Taman Posyandus were against stunting. “Cheap, economical, easily established in Nganjuk. accessible and nutritious – this is our way to improve the nutrition of children under five in In 2018, the number almost doubled to 287 Taman the village,” added Dr. I. Made Dharmayukti, the Posyandus, of which 175 or roughly 61% of Taman head of Puskesmas Sukomoro. And this was Posyandus were performing optimally.15 even before international research confirmed the value of ‘an egg a day’ (Lutter et al., 2018). By 2019, at least one Taman Posyandu was established in each village. 14 The best lunchbox has adequate dietary diversity and included iron-rich meats and dairy products, carbohydrates, beans and grains, fruits and vegetables. 15 The Taman Posyandu is assessed according to four indicators: facility condition and diversity; kader performance, training and attendance; service frequency, and development (including cross-sector development) regularity. The indicators for all three components of the Taman Posyandu (Posyandu, PAUD and BKB) are assessed according to criteria of deficient (kurang or one tick (√)), good (baik or two ticks (√√)) or very good (sangat baik or three ticks (√√√)). A Taman Posyandu is defined as optimum when it obtains at least eight ticks (√) and does not receive a criterion of deficient (or one tick (√)). MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 27 COMMITMENT AND COORDINATION CRITICAL The Taman Posyandu program in Nganjuk district has found various innovative sources of funding for its Commitment, close coordination and good governance operations and activities. These include funding from structure are critical to the successful uptake of the the local government though local funds (APBD) and Taman Posyandu Program throughout Nganjuk district, funding from the provincial government. given the many stakeholders involved (Box 8). However, in recent years, due to the remarkable At the district level, the District Health Office, District community empowerment movement which Education Office and District Women’s Empowerment, triggered important buy-in from the local leaders and Child Protection and Population Office provide the community, the Taman Posyandu are increasingly supervision, training and oversight for the services receiving funds from Alokasi Dana Desa (allocated delivered. Other stakeholders including the Regional village funds), corporate social responsibility Population and Family Planning Board, District Rural programs, and most importantly, the villagers’ own Community Empowerment Office, District Social donations. Services Office, and Social Welfare Bureau were also involved in the development of the Taman Posyandu in Some Taman Posyandu activities, such as the ‘Recycle Nganjuk district. Bank’, where recyclable items are collected and sold, also provide funding for the Taman Posyandu. The The strong leadership of the provincial and district villagers’ contributions are used to buy small gifts leaders made the close coordination and convergence and trinkets for the children and women to incentivize across such wide-ranging stakeholders possible. and improve community participation. 28 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING Box 8: Governance and management of Taman Posyandu in Nganjuk district A permanent secretariat is set up in the district, Optimalizing the Taman Posyandu operations also sub-district and village to help with management meant that training must be conducted for all the and operations of the Taman Posyandu. Funded actors in the Taman Posyandu Program, including using village or kelurahan funds and backed by the management team at the district, sub-district local regulations, each secretariat is led by their and village levels. Those trained for management respective PKK leaders. in the district and sub-districts include the Health Promotion Staff from the Puskesmas, the midwife Routinely, the PKKs in the village, along with the coordinators, village midwives, and PKK leaders at village midwife, lead an evaluation to discuss the district and sub-district level. In the village, the issues and challenges, and share lessons learned PKK leaders at the village level and two Posyandu after each Taman Posyandu session. kaders are selected for the Village Level Taman Posyandu Management Training each year. In In addition, several key coordination meetings addition, content-based yearly training sessions take place throughout the year to optimize the are also held for selected kaders, and this operations of the Taman Posyandu. The first training includes topics on parenting class (BKB), is a Taman Posyandu Permanent Secretariat Stimulation, Early Detection and Intervention Coordination meeting, involving cross-sectoral for Growth and Development (SDIDTK), Taman stakeholders, which is held every three months to Posyandu Mentorship, and emo-demos. discuss results from the evaluation of the Taman Posyandu and decide on next steps. Another key The district also regularly conducts comparison meeting is an evaluation meeting which is held at field visits between Taman Posyandu to improve least once a year, and again involves all relevant stakeholders. In addition, the Posyandu Working the quality of Taman Posyandu operations. Team’s (Tim Pokjanal Posyandu) multisectoral yearly evaluation at the sub-district level also includes Taman Posyandu activities assessment. COMMITTED VOLUNTEERS OPENING THE DOOR TO COMMUNITY OWNERSHIP In the village, the members of the PKK (Family BOOSTS HEALTH AND WELL- Welfare Movement) manages the Taman Posyandu BEING Program whereas trained kaders (typically kader Posyandu, kader BKB or kader PAUD) run the day-to- The Taman Posyandu now include basic health, day operation of the Taman Posyandu Program. nutrition, early childhood education and development (ECED), food security and social assistance. The sense of ownership among PKKs and kaders is crucial to the successful implementation and What makes it a success is that it allows flexibility. continuity of the Taman Posyandu Program. Communities, such as the villagers of Jati Kalen, are encouraged to include their own innovations, a With a low turn-over rate of about 10% per change true community-based program with strong local in village leadership, kaders in the district of Nganjuk ownership. have been known to serve for over 20 years. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 29 What has succeeded in Jati Kalen has been replicated They now have monthly excellent participation at the throughout the district. Posyandus, which is key to stunting reduction. The amount of Taman Posyandus have doubled. The Jati Kalen model, with the support of local government, has been replicated far and wide. New ideas have emerged, including the creation of a community recycling bank to raise money for the It may be a village like many others. But it is a village meetings and a healthy lunch making competition for with a difference. It is a village that has made a mothers and children and pregnant women. difference in the fight against stunting. What sets Nganjuk apart is that they took the idea, saw it worked, and replicated it throughout the district. 30 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING WEST LOMBOK: A POSTER CHILD FOR COORDINATING THE FIGHT AGAINST STUNTING WEST LOMBOK Nestled under the fertile foothills of an active volcano a poster child for coordination and collaboration, for and flanked by the sparkling waters of the Bali Sea, multisectoral convergence to reduce stunting. the district of West Lombok attracts visitors from far and wide. Some are tourists. Some are not. That In 2007, alarmed at the exceedingly high number of is because West Lombok is remarkable for more stunted children in the district, the District Health than its beauty. It also has a proud track record of Office (DHO) of West Lombok realized that steps dramatically reducing rates of chronic malnutrition in have to be taken immediately to tackle stunting, in a children under five. Officials from across Asia-Pacific coherent and coordinated fashion. now travel here to learn from this success. Over the next decade West Lombok would strengthen In 2013 around half of children under five (47%) its multisectoral approach, seeking greater synergies, were stunted in West Lombok. It had one of the integration, and complementarity between and highest rates of stunting in Indonesia. By 2018 this across the sectors and programs. This went hand in had tumbled to around one in three children (34%). hand with a range of new initiatives to boost the use West Lombok became a byword for best practice of technology, education, counseling, and community in the coordinated fight against stunting, attracting engagement to drive down rates of stunting. government delegations from Timor-Leste, Cambodia, India, Sri Lanka, Nepal, and Bhutan. With a 13.3 percentage point drop in stunting prevalence over a period of five years, from 2013 The secret of West Lombok’s success? There was no to 2018 (NIHRD, 2013, 2018)16, West Lombok’s single solution. In fact, West Lombok is a powerful achievement lies largely in the effective simultaneous example of the importance of coordination in making implementation of nutrition-specific and nutrition- significant gains in reducing stunting. It has become sensitive interventions – from the district level, right down to grassroots level (Box 9). 16 According to Riskesdas, in 2013, West Lombok reported a stunting rate of 46.9% among children under the age of five. In 2018, this figure dropped to 33.6%. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 31 Box 9: Distinctions between This effective implementation is made possible by nutrition-specific and nutrition- the strong cross-sectoral coordination within the sensitive interventions district government. A two percentage points annual reduction in stunting is close to what the most successful programs have achieved. West Lombok’s Actions taken to improve the quality of nutrition success has proved a role model for StraNas Stunting for mothers and children can generally be and an inspiration for others (See Box 1 for more defined as nutrition-specific interventions, information on the GoI’s Stranas Stunting). such as an adequate, healthy and diverse diet (including breastfeeding), micronutrient In 2019, delegations from Timor-Leste, Cambodia, supplementation and appropriate young child India, Sri Lanka, Nepal, and Bhutan visited to learn how feeding practices. West Lombok achieved convergence in government efforts to target and reduce high rates of stunting. Actions taken to improve an enabling environment that can have an impact on Closer to home, officials from Indonesia’s Ministry of nutrition can be broadly categorised as Health, the Secretary of the Vice President’s Office, nutrition-sensitive interventions, such as the Ministry of Villages, and the Ministry of Education access to good health care for mothers and have also taken part in visits to villages in West infants, food security and safety, agriculture, Lombok to witness this success at first-hand. social safety nets, schooling, water, sanitation and hygiene (Lancet, 2013). 32 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING “This is a great opportunity for our team to International research shows that even the best learn in depth about policy and coordination, nutrition specific interventions have limited impact: right down to the grassroots. There is a there is only a 20% reduction in stunting prevalence lot to learn and plenty of experience we can take (Lancet, 2013). away for the future implementation of our program in Cambodia,” said H.E. Ny Kimsan, Deputy Director of More significant gains rely on multisectoral the National Committee for Sub-National Democratic interventions: strengthening links in the chain Development Secretariat (NCDDS) and the Project ranging from water and sanitation to immunization, Director of Cambodian Nutrition Project (CNP). breastfeeding and increasing access to affordable and nutritious food for mothers and infants. Success in the fight against stunting takes time. West Lombok sought to ensure that all interventions Initial interventions focused on health only showed were interlinked to ensure success. limited promise, with rates remaining stubbornly high in West Lombok. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 33 CLOUD SOLUTIONS TO TACKLE STUNTING West Lombok’s initial efforts to tackle chronic This cloud-based electronic health information malnutrition focused on routine and innovative health system records, reports and monitors the health and programs. Data would prove critical in combating the nutritional status of infants and children through scourge of stunting. the e-Puskesmas, e-Pustu/Poskesdes and e-Posyandu applications developed by the local DHO. The DHO prioritised data, conducting a district- wide census of children under the age of five during “Electronic recording and reporting started in Growth Monitoring and Promotion and Immunization 2008. But with the launching of the application Month.17 and cloud-based programs in 2017, we are now able to provide real-time monitoring and timely This allowed the DHO to obtain a more complete intervention delivery based on actual data,” said Drs. picture of nutrition for children in the district, as well H. Rachman Sahnan Putra, former head of the West as map the location of the children by name and Lombok DHO. by address. This created an opportunity for more targeted and effective intervention. To date, up to 900 Posyandus are using the e-Posyandu application. This up-to-date information Armed with this invaluable data, West Lombok was on the nutritional and health status of the children in able to create a cloud-based database for use in the West Lombok is proving crucial in efforts to reduce fight against stunting. stunting. 17 Growth Monitoring and Promotion (GMP) and Immunization Months are typically conducted once or twice a year. It is different from the monthly GMP and immunization activities as during the GMP and Immunization Months, there is increased attendance at Posyandu and Puskesmas due to intensive promotion and sweeping efforts to reach every household. In other districts, GMP Month can coincide with Vitamin A Month. 34 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING STRATEGIC CROSS-SECTORAL ADOLESCENT HEALTH IN COORDINATION SCHOOLS Data was not enough to make a difference on its own. One such intervention is the Aksi Bergizi Program Cross-sectoral coordination held the key. for adolescents in junior high school and high school. With technical support from UNICEF and West Lombok owes its successful cross-sectoral implemented through the collaboration of the health coordination, in no small part, to the leadership of its and education Dinas, Aksi Bergizi provides breakfast Head of district, Bupati H. Fauzan Khalid, S.Ag, M.Si. and iron supplements to students once a week. In addition, teachers provide health and nutrition His strong grasp of nutrition and understanding literacy classes. As of August 2019, as many as 48 of local conditions, even its most remote villages, schools in West Lombok were running the program. proved invaluable in steering for greater collaboration, coordination and convergence with the help of his MAKING A DIFFERENCE WITH team of Bappeda and Dinas heads. MARRIAGE COUNSELING “Stunting is not just the responsibility of the Another early intervention to prevent stunting Health Dinas. In fact, [to reduce stunting] most includes the Marriage Candidate counseling people concentrate on the first thousand days Program. A collaboration between the Religious of lives and nutrition interventions, but efforts need to Affairs Office and the Health Dinas, the program start earlier,” he said. provides information and counseling on health, household nurturing and prevention of violence "Everyone - from Health Dinas, non-health against women and children. In addition, participants Dinas, private sector and non-governmental are also provided health screening, including for HIV/ organizations (NGOs) – needs to work AIDS and sexually transmitted diseases. together to make a difference," he said. With historically high early marriage rates, West It is with this strategic thinking that West Lombok is Lombok has also implemented interventions to able to capitalize on a set of nutrition-specific and address early marriage among adolescents, one of nutrition-sensitive interventions, including those that the risk factors for stunting.18 address nutrition and stunting early. The key is to ensure everyone in every community is involved. One such intervention is the Gerakan Anti Merarik Kodek or GAMAK movement, which aims to prevent From early child marriage and adolescent health to early marriage among youths in West Lombok. nutrition for mothers and sanitation, every link in the With the support of community, religious, village chain is crucial in strengthening the region’s drive to and cultural leaders, the movement is changing the reduce stunting. community’s perceptions and behaviour on early marriage. 18 In 2016, a baseline study found early marriage prevalence to be 25% in West Lombok (Hidayana et al., 2016). MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 35 This drive has been underpinned by the publication of In addition, Therapeutic Feeding Centers have been a local regulation to prevent early marriage, Peraturan established in four Puskesmas to address severe acute Bupati Lombok Barat No. 30 Tahun 2018 tentang malnutrition (SAM) or wasting in the community (see Pencegahan Perkawinan Usia Anak. “East Nusa Tenggara – No time to waste in the fight against wasting” for more information on initiatives Principally implemented by the Office of Population to address SAM or wasting in Indonesia). Control, Family Planning, Women’s Empowerment and Child Protection, but supported by non-governmental In November 2016, the district of West Lombok organizations including Yes I Do, GAMAK is helping to launched an innovative movement, termed Gerakan create a community, cultural and religious consensus Masyarakat Sadar Gizi, (Gemadazi) to address in villages about the importance of preventing early malnutrition in the district. Although programs to marriage. address malnutrition have long been implemented in West Lombok, Gemadazi sets itself apart through its As a cultural practice, if the consensus is violated, ability to address malnutrition in an integrated, cross- cultural sanctions can be imposed. This informal sectoral manner. community consensus has proven to be more effective in preventing early marriages compared to The movement is integrated with all nutrition village regulations, according to Bupati H. Fauzan. prevention and treatment programs implemented in the district and involves the local community as well In addition to interventions that address stunting early, as stakeholders at every level (district, sub-district, the district of West Lombok has also implemented and village) to maximize available resources and a number of interventions aimed at addressing risk opportunities in each subdistrict. factors in the first thousand days of life. BUDDIES FOR BETTER NUTRITION AND HEALTH IN NUTRITION AND HEALTH VILLAGES Another innovative aspect of the Gemadazi movement These first thousand days of life interventions include is the appointment of ‘foster parents’ or ‘buddies’ for routine health services for pregnant women, such families with underweight child. These ‘foster parents’ as antenatal care, iron-folic acid supplementation, or ‘buddies’ play an important role in motivating the complementary feeding for chronic energy deficiency, parents and caregivers to get appropriate treatment congenital hypothyroidism screening and social and help for their underweight children, through health insurance for delivery at health facilities counseling, monitoring and home visits. Regulations (Jampersal). have been passed for the villages outlining the duties of the ‘foster parents’ or ‘buddies’ to ensure success. Interventions for infants and children under the age of two include growth monitoring and promotion at the Figure 4 below illustrates the key steps to starting Posyandu, complementary feeding for underweight and implementing the Gemadazi movement. children and counseling for infant and young child feeding (IYCF). Through the initiative of the DHO, West Lombok has also made significant progress in nutritionists are also now placed in villages (on a ratio its nutrition sensitive interventions, contributing to of 1 nutritionist to 2 villages) to strengthen nutrition the drop in stunting prevalence. services delivery, including counseling. 36 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING Figure 4: Key steps in starting and implementing Gemadazi Team Formation Distric level team of: Sub-Distric level team consist of: Village level team consist of: • Bappeda • Sub-dristric officials responsible for health, Puskesmas, • Village head • Health Dinas and district hospitals and other Dinas • Village midwife • Family Planning Board • hamlet head • Food Security Agency • Community leaders • Education Dinas • Religious leaders • Agriculture Dinas • Family Welfare Movement • Welfare Section of local goverment • Posyandu/health kader • Religious Affairs Agency • Community & Village Empowerment Agency Data Collection (on Posyandu day: Post-Posyandu: Pre-Posyandu: nutritional status) 1. Mobilize community and 1. Conduct GMP on day of Posyandu. if 1. Discuss results and coverage with health personnel, kaders, village leaders and other households to attend underweight children are found, stakeholders. Plan sweeping strategy. Posyandu GMP sessions. screen for acute and chronic 2. identify ‘foster parent’/buddies for families of newly discovered underweight children. ‘Foster Mobilization can be malnutrition and illnesses. Provide parent’/buddies can be kaders, head of hamlet, community leaders or religious leaders. ‘Foster conducted by kaders, treatment or refer to referral facilities parent’/companion must (a) live nearby the affected family; (b) committed; (c) trained in iYCF village leaders, if not able to manage condition in and (d) be literate. community leaders or Posyandu. Provide counseling to 3. identify complementary feeding needs and source of complementary foods. religious leaders. mothers or caregivers about disease 4. Health personnel provide information to ’foster parent’/companion on how to improve nutritional management and feeding practices. status of the child, and provide motivation to parent of underweight child on benefits of having Use iYCF approach in counselling on accompanying the family. feeding practices. 5. Health personnel map the nutritional status of children in the catchment area for monitoring purposes. 6. Conduct periodic monitoring to observe developments in nutritional status of underweight child. 7. Evaluate results of complementary feeding in subsequent GMP visits and also at the end of complementary feeding period. Accompaniment 1. Conduct home visit to observe condition, surroundings, menu and feeding practices of the child. Process 2. if child is found to be ill, immediately report to health personnel for treatment or referral. 3. Provide iYCF counseling to parent/caregiver. 4. Motivate family to provide adequate caregiving and feeding to child. 5. Help to routinely monitor nutritional status. 6. Record and report on development of child’s nutritional status using provided forms. Monitoring and 1. Conduct monitoring every two weeks for (a) effectiveness of complementary feeding; (b) development in child’s weight; (c) development in child’s health; (d) development in Evaluation cognitive and motoric skills, and (e) nutritional status category and record in underweight cohort form. 2. Evaluate results twice a year on (a) changes in nutritional status of child; (b) Posyandu service coverage; (c) development in underweight and acute malnutrition cases, (d) identification of implementation challenges and alternative solutions. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING Source: Buku Pedoman Gemadazi, West Lombok District Health Office 37 CLEAN WATER AND BETTER and the importance of consistent growth monitoring SANITATION (see “The Length Mat: “Tikar Pertumbuhan” an easy education tool to raise awareness about stunting). With close cross-sectoral coordination between the Office of Public Works (Dinas PUPR), Community West Lombok is also able to draw upon its and Village Empowerment Agency (PMD), DHO and network of religious leaders to increase awareness Bappeda, major gains have been achieved in the regarding health issues, including stunting, among district’s access to clean water and better sanitation. communities in the district. With a background in religious studies, Bupati H. Fauzan was able to In 2014, about 83% of households in the district had lead this innovative method of reaching out to the access to clean water and only 62.5% had access community. To date, close to 50 local religious to healthy latrines. About 12% of villages were Open leaders have been trained about health programs. Defecation Free (ODF). These religious leaders, termed Dai’ Kesehatan, are effective at communicating health messages and By 2020, 97.5% of households were able to access reminders to their congregations. both clean water and healthy latrines. In addition, 87.7% of villages are now ODF, a very impressive LEADERSHIP AND achievement (Dinas Kesehatan Kabupaten Lombok COORDINATION PIVOTAL Barat, 2020). Ultimately, the impressive drop in stunting prevalence Innovative local movements such as Gerakan in West Lombok is largely due to the committed and BERPIJAK (Beriuk Piak Jamban Keluarga) Sehat also strong leadership of the district head, and close encourage the community to contribute towards cross-sectoral collaboration of the local government building healthy latrines in the village to increase agencies. ODF coverage. The strong technical support from the DHO also As one of the pilot sites for the Human Development helped the local government agencies to understand Workers (HDW) concept, West Lombok has also seen the importance of addressing stunting. From the an increase in the involvement of the Community and first national Rembuk Stunting in November 2017, to Village Empowerment Agency (PMD), village leaders the first district Rembuk Stunting held in May 2019, and community in addressing stunting.19 no efforts have been spared to ensure programs and regulations are put in place. This is reflected in the local district work plan (RPJMD) for the year COMMUNITY INVOLVEMENT 2019, where stunting is included as one of the 19 GROWS performance indicators for the district. A mobile app - the e-HDW - which helps the HDW to conduct their social mapping more efficiently was In 2019, as much as IDR 256.3 million (approximately also piloted in the district with great success. USD 18,100) was allocated by the Bappeda for the cross-sectoral, district wide fight against stunting, a While training is underway for HDWs in the district, significant increase from the budget of IDR 20 million challenges still remain for the trained HDWs, (approximately USD 1,400) in 2018. In addition, including heavy workload, and smoother data sharing important local regulations have been updated, or coordination with the Health Dinas and Social Dinas. put in place in the recent years to ensure resources Nevertheless, as the district continues to smooth out and commitment to address stunting are secured the implementation of the HDW concept, tools such as and sustained. The key local regulations are listed in the Growth Length Mat help to improve the awareness Box 10. of communities in West Lombok regarding stunting 19 Started by the Ministry of Village’s Generasi Program together with Stranas Stunting, HDW support convergence of priority interventions at the village level. For more information on the HDW, please refer to Aiming High: Indonesia’s Ambition to Reduce Stunting, Box 5: Human Development Workers. 38 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING Box 10: Key local regulations addressing stunting in West Lombok 1. Peraturan Bupati Lombok Barat No. 25 Tahun 2018 Tentang 3 Program Utama: Pencegahan Stunting, Penanggulangan TB Paru dan Peningkatan Cakupan dan Mutu Imunisasi. (This regulation includes regulations on Behavior Change Communication (BCC), and training of BCC to puskesmas health workers, and the implementation of BCC in the district.) 2. Peraturan Bupati Lombok Barat No. 16 Tahun 2018 Tentang Alokasi Dana Desa dan DD Untuk Mendukung Upaya Kesehatan dan Keluarga Berencana. (This regulation is an update of a 2014 regulation to include stunting.) However, not all is smooth sailing for West Lombok, The district hopes to address this through better and the district leaders admit to making mistakes planning of strategies and programs and by and facing challenges in the fight against stunting. building better synergies across sectors early in the planning stage, for example through the Musrembang “Our biggest mistake was in forgetting the (community consultations on development) held at Posyandu,” said Bupati H. Fauzan. “Because all levels such as the district, subdistrict and village. of this, we lost our link to the community,” he The commitment of village leaders is also critical added. to ensure the success of the National Strategy to Accelerate Stunting Prevention (StraNas Stunting). The district is now in the process of revitalizing the Posyandu, with yearly jamborees to bolster the spirits Sometimes not all village leaders are committed to of the community and the kaders. Local regulations using village funds to prevent stunting. The district is have also been drawn up to allow for allocation taking steps to address this through local regulations of village funds for Posyandu activities (See Box and by increasing the awareness of village leaders 10). Plans are also in place to implement a Bunda about the importance of tackling stunting. Posyandu Program, akin to the PKK women’s group except that the Bunda Posyandu duties will be solely West Lombok has shown the world that the fight focused on the Posyandu. against stunting is never about a single solution. Despite good cross-sectoral coordination, challenges The whole is always greater than sum of its parts. in coordination between sectors, actors and programs still exist. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 39 40 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING EAST NUSA TENGGARA: NO TIME TO WASTE IN THE FIGHT AGAINST WASTING EAST NUSA TENGGARA When an 18-month old boy fell seriously ill with Marthen’s story20 highlights the crucial role severe acute malnutrition (SAM), also known as community has to play in detecting, treating and severe wasting, in the village of Poto in Indonesia’s reducing rates of wasting, and stunting, in Indonesia. southernmost province of East Nusa Tenggara, there was no time to waste to save his life. Severe wasting impedes children’s ability to grow to their full potential, increasing the risk of stunted Midwife Ibu Christine was quick to refer Marthen growth by more than three times. In addition, wasting, to the nearest hospital for treatment of medical and stunting share common risks, such as infections complications due to severe wasting. and inadequate diet (see Box 11 for relationship between wasting and stunting). Both also increase a After he was discharged from the hospital, he child’s risk of death. Evidence suggests addressing received outpatient treatment at his local community both must go hand in hand with an integrated health center (Puskesmas). With the right treatment, approach to health, nutrition, and care with significant and appropriate counseling for his parents, he fully community engagement and empowerment key to recovered from severe wasting and returned to his success. normal nutritional status. Access to community- based treatment not only helped to speed up the The GoI’s StraNas Stunting (see Box 1) provides boy’s recovery but allowed his parents to continue a platform for such measures and it is critical that working and support him as his condition improved. programs addressing childhood wasting taps into the infrastructure provided. 20 Marthen’s story was first featured in UNICEF Indonesia’s blog on Oct 31, 2016 (UNICEF, 2016). MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 41 Box 11: Relationship between wasting and stunting Although the exact mechanisms are unclear, (both maternal and child). Wasting and stunting wasting and stunting can, and often do, occur in also contribute to increased mortality – severe the same child. The extent to which the conditions wasting as high as 11.6 times compared to a occur together, however, is largely unreported. non-wasted child, severe stunting as high as 5.5 Gains in weight and height often occur at different times compared to a non-stunted child. However, times of year and seem to be related over time when stunting and wasting co-exist, the child is in a consistent way. Evidence points towards 12.3 times more likely to die compared to a non- height faltering peaking two to three months after stunted and non-wasted child. wasting levels have peaked. Early detection and treatment of child wasting is The measurement of association between wasting undoubtedly one crucial action to prevent stunting and stunting at population level is challenging. and its negative impacts. Most nutrition policies This is because most measurements of stunting and programs have separate approaches for and wasting use cross-sectional surveys, whilst wasting and stunting, and this division has been the nature and seasonal vulnerability of wasting increasing in recent years. Evidence however, means that wasting has a relatively shorter points towards a need to address both acute and duration. Depending on data collection periods and chronic malnutrition in an integrated manner due methods, an underestimation of the yearly burden to their overlapping pathways and links between of wasting compared to stunting can happen. ponderal and linear growth. There is a need for a bridging of policies and programs, in addition Wasting and stunting share many common risk to setting up a joint framework for wasting and factors, such as infections and inadequate diet stunting policy, programming and research. Source: Adapted from (Khara & Dolan, 2014) Marthen’s case is not uncommon. In many provinces, Nations Standing Committee on Nutrition (SCN) communities struggle to access nutritious food and introduced the Community-Based Management of healthcare. Many of these communities also practice Acute Malnutrition (CMAM) approach to treating their own cultural beliefs related to food, illnesses, children with severe wasting. and treatments. Marthen’s family had initially turned to spiritual healers to cure him when he first fell ill Using this approach, only severe wasted children with a cough and fever. Numerous delays in seeking with medical complications are treated in inpatient health services over the next six months after he first facilities, whereas uncomplicated severe wasted fell ill caused a rapid deterioration in his health. cases with good appetite may receive treatment in outpatient facilities with the support of a community- Then the midwife stepped in during a routine based program. vaccination visit. Prior to the introduction of the CMAM approach, There is no better example of the power of a life-saving management of severe wasted cases had only relied community-based approach to treating children with on treatment in inpatient facilities, and many of the severe wasting. treatment centres faced the challenges in finding and retaining severe wasted children until they were fully In 2007, UNICEF, the World Health Organization (WHO), cured. the World Food Programme (WFP) and the United 42 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING Relapses also occurred frequently due to early The first step was for community health volunteers discharge of patients, drop-outs or poor caring (kaders) to screen for severe wasted children at practices. Posyandu and at community events. The second step was to confirm cases. Once cases were confirmed Links with other health and nutrition services, such there was a two-pronged approach to treatment, as the Integrated Management of Childhood Illnesses including inpatient and outpatient treatments. (IMCI) and Infant and Young Child Feeding (IYCF) counseling, were almost non-existent. The third step was to treat severe wasted children without medical complications and with a good The treatment of wasting has been a standard appetite with ready to use-therapeutic food (RUTF) in component of health services in Indonesia for many outpatient services. years. Inpatient care for children with severe wasting has been provided in district and provincial hospitals, This ability to treat the children locally was crucial in some health centres and therapeutic feeding centres. remote and disadvantaged communities with poor However, the coverage and quality of care for access to health services far away. children with severe wasting in Indonesia is low. The Children with medical complications would be Ministry of Health (MoH) reports that it treats around hospitalized until they stabilized and then continued 20,000 children with severe wasting a year, which is to receive outpatient treatment. estimated to be less than one percent of the total burden of severe wasting. Fourthly, home visits supported a child’s recovery and nutrition, such as through counseling to ensure that FIVE STEPS TO TACKLE SEVERE parents provide good care and practice appropriate WASTING infant and young child feeding (IYCF) and also continue to access ready-to-use therapeutic food Change was needed and the community had a crucial (RUTF) through weekly visit to Puskesmas. role to play in that. Last but not least, CMAM was integrated into wider The CMAM approach identified five steps, rooted in health and nutrition services in local communities in local communities, to dealing more effectively with East Nusa Tenggara. severe wasting (Figure 5). MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 43 Figure 5: Flow of CMAM approach in the Kupang district • Children with MUAC indicators showing yellow (moderately acute malnourished) or red (severely acute malnourished) color or green MUAC but visibly thin or bilateral pitting oedema that were • Conducted in Posyandu by kaders detected in the community every month referred to health facilities SCREENING • Could also be carried out during (Pustu/Polindes) community events (such as PAUD • Trained health workers confirm activities, weekend school, or nutrition status of referred children celebratory events) • Children with severe wasting without medical complications and have good appetite to receive outpatient treatment CONFIRMATION • Children with severe wasting and medical complications referred to hospitals. Once condition • Children enrolled in CMAM treament stabilizes, children will return to post to receive RUTF for one week community for outpatient consumption and essential treatment medicines TREATMENT • All parents/carers of children with • Weekly visit to Pustu/Puskesmas for acute malnutrition will receive examination and collection of RUTF iYCF counseling • RUTF given based on body weight ratio of child • When necessary, home visits conducted by health workers HOME VISITS during treatment duration. Home visits especially for children without weight gain in two consecutive weeks to assess feeding practices, hygiene and sanitation • CMAM approach is integrated with INTEGRATION WITH OTHER other existing health services in the • Home visits also conducted by HEALTH Puskesmas and Pustu/Polindes, such kaders, PKK and village heads to SERVICES as iMCi, iYCF, immunization motivate parents to give RUTF accordingly, motivate parents to bring child to Pustu/Puskesmas for examination and RUTF collection and to bring child to Posyandu for growth monitoring Source: Kupang District Health Office The CMAM approach is designed to overcome This approach also helps to reduce burdens on the challenges, such as low coverage and high relapses, health system. It also helps the families by reducing by focusing strongly on community mobilization21 the time and cost of treatment as most children can and active case finding22 to ensure all children with stay at home during treatment. severe wasting in the community are identified at an early stage and referred for treatment. 21 Community mobilization covers a range of activities that help frontline health workers and kaders build a relationship with the community and foster people in the community to use, in this case, CMAM services. 22 Active case finding is a unique approach where frontline health workers and kaders at the households and the health facility actively seek out sick and malnourished children. 44 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING POST-TSUNAMI RESPONSE In Indonesia, the drive to introduce CMAM started set out to engage the community, improve the quality in 2005 during the Aceh Tsunami Response, where of health services and to record vital lessons learned RUTF was distributed as therapeutic foods for to share with others. wasted children in emergency situation. The key activities of the CMAM Project included In 2007–2015, CMAM was also rolled out in districts training frontline health workers on severe wasting such as Lombok in West Nusa Tenggara Province, treatment, maternal nutrition, integrated management and Sikka and Belu in East Nusa Tenggara Province. of childhood illness (IMCI), infant and young child However, these earlier attempts ended as pilots, feeding (IYCF) and handwashing. It also provided without successful scale up. capacity building for the community, including kaders, on community mobilization and active case In 2015, together with the Ministry of Health and finding including how to measure children mid-upper Action Against Hunger, UNICEF piloted CMAM in arm circumference (MUAC)24 using simple coloured six sub-districts of Kupang District in the province MUAC tapes for early detection of severe wasting of East Nusa Tenggara, where severe wasting was (see Figure 6 for detailed activities). critically high.23 The supply chain management for equipment and The project aimed to reduce mortality and improve the medication, such as mid-upper arm circumference recovery of children with severe wasting. Specifically, (MUAC) tapes, anthropometric tools, ready-to-use it sought to ensure children received appropriate therapeutic food (RUTF) and other routine medication treatment through CMAM. The ultimate ambition was was strengthened. In addition, the government of for these projects to allow the model to be scaled up Kupang District also carried out monitoring and in other parts of Indonesia. evaluation of the project. This would be used to share lessons learned for other parts of the country During three years of the pilot, the local government to follow suit. of Kupang District and East Nusa Tenggara province 23 According to Riskesdas survey data, Kupang District acute malnutrition prevalence for children under five was 33.4% in 2013 (NIHRD, 2013). 24 Mid-Upper Arm Circumference (MUAC) is a simple way to screen for malnutrition or thinness among children aged between six months to five years old in the community - an alternative to weight-for-height (Kementerian Kesehatan RI, 2019). MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 45 46 Figure 6: Key activities of the CMAM project Active community engagement Health service provision Documentation ⃣ Train village stakeholders on ⃣ Train nutritionists and health workers ⃣ Monitor and evaluate the project to community mobilization and active on the management of severe wasting, determine the impact of the new approach case finding (screening for wasting) including community mobilization, on treatment of severe wasting screening, diagnosis, treatment, ⃣ Train kaders on Maternal Nutrition ⃣ Document and disseminate the lessons supply management, supportive and IYCF counseling and the learned to provide the evidence for supervision, monitoring and reporting promotion of handwashing scaling up to other districts/provinces ⃣ Train nutritionists, health workers, and ⃣ Conduct community mobilization sanitarians on Maternal Nutrition and to increase demand by community IYCF Counseling, including handwashing MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING members for CMAM services with soap and safe drinking water ⃣ Conduct regular screening of under ⃣ Procure supplies and equipment five children for wasting, involving for CMAM services kaders/PKK, religious leaders, and other community leaders ⃣ Strengthen WASH facilities and practices in health facilities ⃣ Provide information and counseling to women and caregivers on maternal nutrition and IYCF Source: UNICEF MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 47 CHALLENGES CONFRONTED AND OVERCOME In its first year, the pilot faced the challenges of low Community engagement was improved by speaking coverage of the CMAM project, high drop-out rates, with parents, government authorities, religious and slow recovery periods for the severe wasted leaders and community leaders about severe wasting, children in the six sub-districts. the importance of screening and growth monitoring. Therefore, in 2016, UNICEF conducted a Kaders visited household and encourage Posyandu semiquantitative evaluation in selected sub-districts attendance. to understand the reasons for the low coverage and disappointing performance of the CMAM Project. Community was intensively involved in tackling the problem, including through screening, gained support They found a low level of community awareness of from local religious leaders and Pemberdayaan acute malnutrition. dan Kesejahteraan Keluarga, PKK (Family Welfare Movement) members. There were also issues with the need to travel from home to seek treatment. To improve finding children in need of support, kaders visited households with children who had missed Health workers and kaders’ technical knowledge of Posyandu sessions. Screening for severe wasting was severe wasting and CMAM also left something to be provided to these children, followed up by support for desired. children suspected of possible severe wasting and referral services for confirmation of severe wasting Screening of children at the Posyandu failed to diagnosis. In addition, in their efforts to improve significantly identify a large proportion of severe treatment adherence, the kaders conducted multiple wasted children as only 14% of eligible children home visits to the same households to encourage under the age of five were registered in the Posyandu. parents and carers to bring the children to treatment In addition, follow-up of identified severe wasted centres; on occasion, these efforts also included children was low (approximately 25%) and only 44% helping with transport to treatment centres to deter of children under treatment recovered. Close to 50% drop-outs. At the same time, the MoH and Kupang of children dropped out of treatment (Bait et al., District Health Office provided support by increasing 2019). efforts to integrate CMAM into existing health services (Bait et al., 2019). The results from this evaluation was used to improve the program. These efforts paid off. Within a year, the district had boosted community engagement in reducing the All this led to low parental attendance at Posyandu and prevalence of severe wasting, increasing its rate of low interest in the CMAM program in the community detection, screening, and treatment. (Bait et al., 2019). The severe wasting screening rate increased from In an effort to overcome the challenges, UNICEF, 17% to 66% between October 2015 and March 2018. Action Contre la Faim (ACF or Action Against Hunger) and the local government of Kupang District Posyandu attendance improved from around 50% to intensified efforts to improve the coverage and 79%. quality of the program by strengthening community engagement, increasing active case findings and The percentage of children with suspected severe improving the capacity of health workers and kaders wasting attending treatment centres proportion rose between January 2017 and February 2018. from zero to (in October 2015) to 70% (in March 2018). 48 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING In 2017, the program met three out of four Sphere Malnutrition (IMAM) program. Project performance indicators25: 79% (256/326) of children recovered and only 10% (34/326) dropped In 2019, the national protocol for treatment of severe out. Less than one percent (2/326) died (Bait et al., wasting was updated to include CMAM for the first 2019). time, in addition to facility-based treatment under the IMAM program. Success breeds success. And in 2020, all 22 districts in East Nusa Tenggara The local district and provincial government successfully introduced and implemented the IMAM committed their own funds and resources to scale up approach, mobilizing local government budget and CMAM to 18 non-pilot sub-districts in Kupang District resouces. Plans to roll out IMAM across 260 districts and 21 districts in the East Nusa Tenggara province, in Indonesia are underway. respectively. With the community at its heart, the program to CMAM has gone from strength to strength. The conquer the scourge of severe wasting now points Ministry of Health is ramping up the role played by to a brighter future for boys and girls like Marthen CMAM with its Integrated Management of Acute across Indonesia. 25 Sphere Project provides standards and key indicators for planning, implementation, monitoring and evaluation of humanitarian response to both slow- and rapid onset situations following natural disaster or conflicts. The Sphere minimum standard is the percentage for which the outcomes of the program is deemed successful. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 49 50 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING EAST NUSA TENGGARA AND EAST JAVA: ENHANCED PARTNERSHIPS AND INTEGRATED PROGRAMMING IMPROVES MATERNAL AND CHILD HEALTH EAST NUSA TENGGARA EAST JAVA Getting people around a table can make all the Nutrition International, in partnership with the difference. governments of Indonesia, Australia and Canada extended support to the Ministry of Health (MoH), This was no easy task when it came to gathering and provincial and district governments to address stakeholders in the provinces of East Nusa Tenggara micronutrient deficiencies in pregnant women (ENT) and East Java (EJ) to join forces to reduce and children, as well as diarrhea treatment, in an anemia in pregnant women and improve child health. integrated manner. For years, the various departments in the province and This led to the inception of the Micronutrient district health offices—nutrition, health promotion, Supplementation for Reducing Mortality and maternal and child health, and pharmacy—had Morbidity (MITRA) program in Indonesia in 2015. worked in silos, with minimal cross-departmental MITRA program is an integrated micronutrient coordination. supplementation (vitamin A, iron-folic acid [IFA], zinc, and low-osmolarity oral rehydration salts [LO-ORS]) That changed when a leading international program implemented in 20 districts of both East NGO, Nutrition International, helped to gather all Java (EJ) and East Nusa Tenggara (ENT) provinces stakeholders around a table for integrated planning, (Box 12). implementation, and monitoring for maternal nutrition programs aimed at delivering proven Micronutrient supplementation is a nutrition-specific nutrition interventions to high-need communities, intervention and can contribute to stunting reduction. through technical assistance. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 51 Both provinces reported very high childhood stunting rates: in 2013, ENT and EJ provinces reported 51.7% Box 12: MITRA program and 35.8% prevalence of stunting in children under aims and beneficiaries five respectively (NIHRD, 2013). In 2018, these prevalence reduced slightly to 42.6% and 32.7% The MITRA program was introduced in these respectively (NIHRD, 2018). Evidence shows that provinces with an objective to improve stunting can be prevented with concerted action access to health services for both pregnant targeting its drivers in the first thousand days of women and caregivers of children under five, a child’s life (from conception to a child’s second leading to better health. The program aimed birthday) (Black et al., 2013). Thus, it was crucial to to improve the management and prevention introduce local initiatives, such as MITRA, in these of diarrhea among children through use of regions to contribute not only to reduced mortality zinc and low-osmolarity oral rehydration salts and morbidity, but also to alleviate stunting. (LO-ORS), reduce vitamin A deficiency among children through vitamin A supplementation What set the MITRA program apart was its focus on (VAS), and prevent and reduce anemia integration, health systems strengthening, and behavior among pregnant women through iron & folic change to improve maternal and child nutrition (Figure acid (IFA) supplementation. 7). Since its inception in 2015, in East Java and “Most provincial and district health offices, due East Nusa Tenggara, the MITRA program has to their mandate, typically work independently. reached: For example, Communicable Diseases Department handles childhood diarrhea prevention, while the Community Health Department manages 211,000 pregnant women with IFA supplements family health and health promotion. However, at the village-level both of these programs are implemented by the village midwives. Nutrition is intricately linked with 720,000 children all of these programs,” said Mardewi, former Program (6-59 months) with vitamin A Coordinator of the Maternal and Child Health Program supplementation at Nutrition International, Indonesia. 64,000 children The lack of integration and coordination caused suffering from diarrhea with zinc uncertainty, especially considering that target and LO-ORS treatment beneficiaries across departments were the same: pregnant women and children under the age of five. Though the interventions were different, they required similar tasks. For example, all interventions to address anemia among pregnant women and child morbidity involved micronutrient supply-chain management processes. All interventions required advocacy to increase awareness among health workers and counseling by health workers to improve compliance among the targeted population. 52 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING Figure 7: MITRA Project phases PREPARATORY IMPLEMENTATION EVALUATION ⃣ Aug 2015 - March 2016: ⃣ March-May 2018: ⃣ Nov 2016 - Sept 2018: Inception phase - project staffs Endline survey recruitment, program introduction, Technical assistance ⃣ May-Sept 2018: districts selection, project launch, ⃣ March - Augt 2018: BCC review, and baseline Sustainable strategy development Advocacy meetings at national and subnational levels ⃣ Sept 2018: ⃣ April - Oct 2016: Advocacy meetings at province (province and districts) Project evaluation dissemination and districts, cascade training ⃣ April - May 2018: ⃣ Oct 2019 - Sept 2019: for PHO, Puskesmas staff Advocacy meetings at national Advocacy to non-NI districts, selection, and dissemination and provincial levels best practices and lessons of module and BCI materials learned documentation Integration and health system strengthening emphasized throughout all phases MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 53 SHARING RESPONSIBILITY AND INTEGRATED CARE During the preparatory phase, cross-department participants from Nutrition, Pharmacy, Maternal and advocacy meetings and training sessions were held Child Health, Communicable Disease, and Health with provincial and district health offices. The aim of Promotion departments were involved. While, for these meetings was to consolidate efforts and raise Puskesmas training, Nutrition Officers, Coordinating awareness of collective and shared responsibilities. Midwives, Diarrhea Officers, Pharmacy Officers, Doctors and/or Heads of Puskesmas were included. Moreover, the goal was to ensure that the target A comprehensive training module was developed as population received integrated care, and to promote learning tools for all participants about the benefits robust data recording and reporting. of micronutrient supplementation. In addition, each Puskesmas was provided 4-6 sets of Behavior These integrated sessions brought together different Change Intervention (BCI) materials which could be departments (e.g. Pharmacy, Nutrition, and Family implemented in the community. Health) and proved to be essential in breaking down barriers and increasing service efficiency. “We wanted to strengthen the micronutrient For example, integrated planning with a focus supplementation program and it was very on health system strengthening helped improve helpful to get Nutrition International’s support micronutrient supplement logistical forecasting to from the ground up, to help us build more commitment, ensure continued service delivery. Integrated training train our staff and also bring the different aspects of the sessions provided health workers with knowledge program together,” said Ngurah Suarnawa, Head of and awareness to effectively manage, prescribe and the Family Health Division, Kupang City Health Office, counsel on IFA, LO-ORS, zinc and vitamin A. East Nusa Tenggara province. Nutrition International also supported the MoH to “It enabled us to make the programs more efficient, conduct integrated annual meetings and carry out especially in terms of supply chain management to a comprehensive cascade training to provincial and ensure regular availability of IFA tablets and vitamin A. district health offices. This proved to be an effective This support enabled us to integrate learning from the approach, low in intensity and cost, yet high in impact. MITRA program very well within the Puskesmas,” he said. Cascade trainings began with training of trainers (ToT) for the Provincial Health Office (PHO), By October 2016, training for integrated micronutrient followed by District Health Office (DHO) staff, and management was completed, DHOs and Puskesmas subsequently, selected Puskesmas. The trainings began implementing the integrated approach in the emphasized an integrated multi-disciplinary and field. However, the roll-out came with its share of multi-level approach. For PHO and DHO training, setbacks. 54 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING OVERCOMING CHALLENGES The program experienced a period of shortages for for awareness raising about zinc as an adjunct iron folic acid (IFA) supplements in EJ and ENT in treatment for diarrhea through district meetings and the year 2016, and in 2017 for ENT. Those shortages field visits to Puskesmas. occurred due to changes in the formulation and packaging of IFA supplements, resulting in Adherence (daily consumption) to IFA supplements procurement delays and stock shortages. However, during pregnancy was yet another hurdle to Nutrition International encouraged several districts overcome. The IFA program had traditionally to overcome this short-term challenge by procuring prioritized expanding and ensuring coverage, their own IFA supplies using their local budget. while a focus on increasing IFA consumption was getting missed. To this end, Nutrition International The low prioritization of zinc in diarrhea management introduced the IFA supplement compliance card to posed another challenge, as the national zinc record receipt and consumption of IFA tablets by program was relatively new in 2015. Many doctors pregnant women (Figure 8). Not only did the card help were not aware of the program and often resorted pregnant women in keeping a record of the tablets, it to prescribing antibiotics for diarrhea treatment also acted as a reminder for them and their family instead of the WHO recommended ORS-Zinc therapy. members to ensure there were no missed doses. In In addition, there was limited budget allocation by addition, the card became a useful monitoring tool the DHO and PHO for essential program activities for the health workers at the facility and community like training and technical meetings as this was levels. IFA compliance cards, initiated during the considered a lower priority. To overcome this implementation of the MITRA program, have emerged challenge, Nutrition International encouraged the as a significant tool in improving the monitoring of MoH to provide technical assistance to the districts the IFA supplementation program in EJ and ENT. which resulted in budget allocation and personnel Figure 8: IFA compliance card from the MITRA program MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 55 BEHAVIOR CHANGE INTERVENTIONS MAKE A DIFFERENCE The MITRA program focused heavily on behavior Puskesmas in Alor and Manggarai Barat in ENT, change initiatives to improve health-seeking and Sampang, Ponorogo, and Bondowoso in EJ behaviors and adherence to micronutrients. Nutrition were encouraged to develop their own locally- International supported the development of Behavior contextualized BCI materials like the flipbook, Change Intervention (BCI) materials to enable health compliance card, poster and calendar. workers to effectively deliver relevant, contextualized messages for their target beneficiaries. Both health In addition, Southwest Sumba district in ENT province workers and beneficiaries found that BCI materials and Bangkalan, Pacitan district in East Java provinces were effective. established Layanan Rehidrasi Oral Aktif (LROA), or Active Oral Rehydration Service, to administer zinc Jeni, Coordinating Midwife, Puskesmas Kota on-site, provide counseling on zinc adherence, and Kupang said: “The BCI materials provided by teach mothers to prepare and administer zinc plus LO- Nutrition International have been very helpful, ORS. This initiative strengthened the use of zinc and especially the IFA flipbook. Whenever we give IFA tablets ORS for diarrhea management by facilitating more to a pregnant woman, we use the flipbook so she can frequent meetings, training and budget allocation by clearly understand that taking IFA tablets is important DHOs. for her and also her fetus, while also learning about the adverse effects of anemia. Their monitoring card has Through close collaboration between Nutrition and also helped us monitor the consumption of IFA tablets.” Pharmacy departments, several districts (EJ province: Jember, Banyuwangi, Sampang, Bondowoso, “These days, the midwife explains the benefits Lumajang and ENT province: Kupang City, Alor, Ende, of IFA to us using a flipbook with pictures. I am Sumba Tengah, Manggarai Barat) procured IFA using able to understand better as the book has big Anggaran Pendapatan dan Belanja Daerah (APBD), or pictures which I find interesting and easy to remember,” Province/District Government Budget Allocation, to said Kholifah, a 27-year-old pregnant woman in ENT ensure the sustainability of IFA supply for pregnant Province. women. Improved awareness and knowledge regarding Health workers in Bangkalan, Pacitan, Bondowoso micronutrient management has empowered health - EJ province, and Sumba Barat Daya, Nagekeo - workers from the project sites to devise innovative ENT province conducted home visits to ensure zinc ways to deliver micronutrients and provide health consumption compliance and provided counseling to services. Taking Nutrition International’s lead, caregivers of children suffering from diarrhea. provincial and district health offices also extended their full support to develop and replicate BCI materials to be used as learning tools for targeted beneficiaries and the whole community. 56 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING IMPROVED NUTRITION FOR ENSURING UNINTERRUPTED MOTHERS AND CHILDREN SERVICES The evaluation of the MITRA Project26 with 10 Starting from the district level, the MITRA program comparison districts in South Sulawesi province supported the integrated cross-department sharing showed improvements on key nutrition indicators. of responsibilities and budgets for micronutrient supplementation programs. Through continued Consumption of 90 or more IFA tablets during advocacy among government stakeholders, the pregnancy increased in both intervention and program led to an increase in investment in nutrition comparison districts. Anemia prevalence among and health programs in ENT and EJ. An increase pregnant women decreased and correspondingly, of 30-60% in budget allocations was observed for serum hemoglobin levels showed an increase both in different components of the government maternal EJ and ENT. and child health programs. Favorable outcomes were recorded for child health The MITRA program shows how collaboration and and nutrition indicators – vitamin A supplementation integration can make a real difference to maternal among children (6-59 months) increased from 70% and child health. in 2016 to 76% in 2018; diarrhea prevalence among children aged 6-59 months decreased by half in East A focus on strengthening the health system and Java (from 11.1% in 2016 to 4.7% in 2018) and East promoting behavior change led to significant Nusa Tenggara (from 7.1% in 2016 to 2.6% in 2018) improvements in the health and nutrition of pregnant with increased zinc plus LO-ORS usage for diarrhea women and children under five. treatment. 26 The MITRA project was evaluated using a pre- and post-intervention study design, 2016 to 2018. Two rounds of cross-sectional surveys were conducted in 20 intervention districts of EJ and ENT and 10 comparison districts of South Sulawesi (SS). Multi-stage cluster sampling was adopted, with clusters selected using Probability Proportional to Size (PPS). MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 57 Drawing mainly on local resources, this integrated prevention. This is critical, as diarrhea among children micronutrient model could potentially be replicated affects absorption of nutrition and hence increases the and scaled up in other provinces to achieve success. risk of undernutrition.” The feedback from local government and testimonies Yosafat Laka, Head of the Health Promotion Section, from the field show that the MITRA program has the Alor DHO, ENT Province, said the project has made a potential to boost maternal and child health more real difference. widely across the country. “The MITRA project improved our “Prior to this, diarrhea was considered understanding of the IFA supplementation a very low priority in terms of program intervention. Earlier we used to administer one implementation and budgeting at all levels. IFA tablet per day to every pregnant woman. However, MITRA was instrumental in increasing awareness through MITRA we learned that if the pregnant woman about the program among DHOs and Puskesmas, hence is anemic, she should be given two tablets per day. Even improving their priority for addressing diarrhea,” said after the phase-out of MITRA, this education and the Agus Handito of the Hepatitis and Gastrointestinal principle of integrating various programs will continue. Infection Sub-Directorate at the MoH. “Now, diarrhea Take the example of Behavior Change Intervention (BCI) treatment using zinc and LO-ORS is acknowledged as materials required for health promotion,” said Yosafat one of the nutrition specific interventions for stunting Laka. 58 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING “Previously, at the planning stage, those BCI materials were ignored. Nutrition International supported us with the package of BCI Box 13: MITRA Youth - materials. Seeing the importance of these materials Empowering adolescents with in supporting the maternal and child health program, improved health & nutrition in 2017, the Health Promotion Department was able to allocate budgets to re-print and distribute anemia Building on MITRA’s successful strategy prevention dialogue cards, diarrhea treatment posters, of multi-sectoral collaboration, Nutrition and anemia among pregnant women posters tor all International has initiated MITRA Youth for sub-district Puskesmas, Puskesmas Pembantu (Pustu), adolescent girls in Indonesia. Pos Bersalin Desa (Polindes) and Pos Kesehatan Desa (Poskesdes) in Alor. Radio spots on IFA using the The MITRA Youth (Weekly Iron Folic Acid native language of Alor were also developed, and has Supplementation for Prevention and successfully disseminated messages in the community.” Reduction of Anemia among School-Going Adolescent Girls) project is an integrated set MITRA has now expanded the program to include of nutrition activities (including micronutrient adolescents via the MITRA Youth Project (Box 13). supplementation) that is being implemented in 20 selected districts of East Java and THE WAY FORWARD East Nusa Tenggara provinces. In addition to intensifying efforts for improving nutrition Reduction in stunting prevalence is a priority for education and ensuring diet diversity, MITRA Indonesia’s government. Youth is part of Nutrition International’s larger objective to address nutrition issues in StraNas Stunting, the National Strategy to Accelerate adolescent girls to accelerate improved health Stunting Prevention, is a significant step towards and well-being among the girls and break the ensuring that all households with pregnant women inter-generational cycle of malnutrition. or children under two years of age get access to a complete package of basic health services essential The overall objective of the MITRA Youth to prevent stunting. is to improve the nutrition for school-going adolescent girls (15-18 years) through Nutrition International’s MITRA program has increased access to nutrition information contributed to the government’s priority area and coupled with the consumption of weekly has successfully introduced innovative approaches, iron folic acid (IFA) supplements. Activities activities, and tools to improve health and nutrition are being implemented to reinstate the among women and children. government’s focus on the needs of adolescent girls for improved health and The program has demonstrated the benefits of education outcomes through evidence-based building bridges between central, provincial, and advocacy to the district, provincial and central district governments. It has shown how integrated and governments. coordinated care for pregnant women and children under five is vital to tackle stunting successfully. (see "West Lombok: A poster child for coordinating the fight against stunting" for It has shown that getting everyone around the same another example of nutrition intervention to table makes a real difference in the fight against improve anemia among adolescents) stunting. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 59 60 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING WEST SUMBAWA: BETTER SKILLS FOR HEALTH WORKERS PAY OFF FOR NUTRITION OF MOTHERS AND CHILDREN WEST SUMBAWA Sometimes an old idea needs a new approach. Strengthening skills is at the heart of the program’s success. The approach is also in line with the Indonesia’s ageing system of community health National Strategy to Accelerate Stunting Prevention centres (Puskesmas) has for decades provided (StraNas Stunting) by focusing on both a “top-down” primary health care across an archipelago spanning and “bottom-up” approach. a distance equivalent to one-eighth of Earth’s circumference. Ensuring community health centres are adequately staffed and that their staff are fully equipped is crucial The Puskesmas are in the front line in Indonesia’s to tackle stunting in a strategic and sustainable way. fight against stunting. After it was first rolled out in in seven areas in a three- Volunteers play a significant role in ensuring year pilot, its success paved the way for adoption communities far and wide get the healthcare they across the country in 2015. need. “October 28, 2012, was the first day when Pencerah Nusantara, an award-winning program I was standing in front of a group of young which deploys a team, including a young doctor, a people. Everyone was below 30 years of midwife, a nurse, a specialist in public health and a age, graduates with a health background. They said nutritionist, to community health centres has played they wanted to serve the country. They didn’t know at a pivotal role in improving maternal and child health that stage where they were going. But they knew they since it started in 2012. would live in a remote place for a year. They declared their readiness to serve. We are now in our 7th year It does so by boosting the skills and knowledge of into our adventure, everybody has come back safely, volunteer health workers (kaders) and the knowledge thank God. And I see the philosophy of developing the and involvement of local communities in improving healthcare system from the bottom-up stays within nutrition and health for pregnant women, mothers, them and could be a playbook for their future,” said Diah and children. Saminarsih from the Center for Indonesia’s Strategic Development Initiatives (CISDI) Board of Trustees who founded Pencerah Nusantara. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 61 LOCAL ACTION TO TACKLE A NATIONAL PROBLEM Pencerah Nusantara, which means “the Guiding Light philanthropies and civil society. Team members are of the Archipelago”, has set out to revitalise rural chosen based on priorities in each community. Often health care by sending teams of professional health there is a strong focus on improving maternal and care workers into communities to boost health, child health and community nutrition. improve the skills of local volunteers and workers and empower communities. It is different to the Pencerah Nusantara encourages interprofessional Pegawai Tidak Tetap (PTT) program27, which contracts collaboration, a proven approach to increase the individual doctors and nurses to work in remote effectiveness of health services delivery (D’Amour et locations after graduation to deliver curative care for al., 2005). It aims to improve the quality of the health patients. workforce, task-sharing, skill-mixing, and cross-sector collaboration (Saminarsih et al., 2014). The mixed- Pencerah Nusantara makes the most of young skill workforce from both clinical and non-clinical professionals with backgrounds in health and other professions, provides a comprehensive approach relevant areas. Carefully selected teams made up of of preventive, promotive, curative, and rehabilitative a young doctor, a midwife, a nurse, a nutritionist, and care. a specialist in public health carry out voluntary work in communities for one year. Pencerah Nusantara strongly believes that quality human resource is the first and main investment in The volunteers are carefully chosen by CISDI, with strengthening basic health services, as evident in the support from their partners from sub-national Pencerah Nusantara model (See Figure 9). government, academic institutions, the private sector, 27 The Pegawai Tidak Tetap (PTT) or contract employee program was introduced in 1992. Under this program, newly graduated doctors/nurses were contracted for 1-2 year appointment as “non-permanent employees” in a remote Puskesmas (Rokx et al., 2010). 62 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING Figure 9: Pencerah Nusantara model Young Inter-Professional Teams MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 63 EQUIPPING TEAMS WITH SKILLS THAT MAKE A DIFFERENCE Ahead of their deployment, each Pencerah Nusantara Pencerah Nusantara employs a range of tools for team member undertakes seven weeks of training. identifying and solving community health problems. They receive tailored training to suit the specific The Community Health Survey gathers health- needs of their target population. related data (e.g. state of sanitation and nutrition, knowledge about current services and their quality, The teams are equipped with medical, leadership and etc.) at the sub-district level with the involvement of managerial knowledge and skills. This allows them local residents. This participatory approach builds to build local health providers’ capacity, help run ownership and enables the community to better Puskesmas operations more effectively, and become accept the survey’s findings. information hubs for the community. Once the data is analyzed, another survey - the They are provided with training in communication Survey Mawas Diri (SMD) or Self-Awareness Survey - skills, advocacy, and cross-sector collaboration. It assesses opinions of shared responsibility towards helps to enhance skills, efficiency and collaboration, health status and service conditions. A village including with education Dinas, Bappeda, and others. meeting (Musyawarah Masyarakat Desa) is then held Cross-sector involvement strengthens the position to determine priority issues, solution design strategy and strategic role of Puskesmas as the main driver of and feasible action plans that identify and mobilize regional health development. available local resources. The teams also have skills in cultural adaptation and Each Puskesmas nurtures Badan Penyantun advocacy, as well as burnout prevention and stress Puskesmas, a community-based forum that functions management. Those skills increase the likelihood as a watchdog, and act as an ambassador of that health workers are accepted by the community health and an extension of healthcare workers in (WHO, 2018). disseminating health promotion messages to the public. One Puskesmas receives three Pencerah Nusantara teams over three years with teams rotating annually. It The program has led to improvements in Minimum also focuses on planning, accountability, monitoring Standards of Service28 for the Puskesmas which and evaluation. received Pencerah Nusantara teams (Figure 10). 28 Minimum standards of services are benchmarks of the quality of healthcare delivered by primary health care to be applied by district government. They cover the compulsory service community health centres deliver: primary health care centre management, health promotion activities, environmental health interventions, maternal and child health interventions, nutrition improvement efforts, infectious diseases prevention and eradication efforts, and basic medical treatment (see Minister of Health Regulation No. 741 of 2008 for details). 64 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING Figure 10: Puskesmas show improvement in standards of delivery after Pencerah Nusantara intervention CISDI PROGRAM ACHIEVEMENT PENCERAH NUSANTARA PRIORITY PROGRAM 3 YEARS IMPLEMENTATION PUSKESMAS 9 PENCERAH NUSANTARA LOCATIONS BEFORE AND AFTER PN INTERVENTION (2016-2019) BEFORE INTERVENTION PN 2016 ADMINISTRATION & MANAGEMENT INDIVIDUAL HEALTH MANAGEMENT PUBLIC HEALTH (NUTRITION & MATERNAL AND CHILD HEALTH) PUSKESMAS PERFORMANCE SCORE BEFORE INTERVENTION PN 2018 ADMINISTRATION & MANAGEMENT INDIVIDUAL HEALTH MANAGEMENT PUBLIC HEALTH (NUTRITION & MATERNAL AND CHILD HEALTH) PUSKESMAS PERFORMANCE SCORE MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 65 The pre-service training and on-the-job experience The transparency, accountability and responsiveness provided by the Pencerah Nusantara Program has in their design and delivery led Pencerah Nusantara also succeeded in increasing the readiness of to receive an Open Government Awards in 2015. health workers as measured through the Community Till this day, Pencerah Nusantara remains a platform Readiness Assessment (CRA) tool (Figure 11). for testing new ideas for strengthening primary healthcare locally without extensive funding. Since its inception, Pencerah Nusantara has been designed as a pilot which would be rolled Up until 2019 the Pencerah Nusantara program has out nationally. Locations of deployment were deployed 222 young health professionals to 16 target representative of the country’s diversity. The Pencerah locations with more than 262,000 beneficiaries. Nusantara replication manual29 outlines the steps and Various community-based health programs are now provides tools and resources so other organizations available in each village of the participating locations, can develop adapted versions of the program. with full support of local inhabitants. In 2015, the Ministry of Health scaled-up Pencerah Today, building from their experience, CISDI has Nusantara nationally as the Nusantara Sehat program modified Pencerah Nusantara program with a special (“Healthy Archipelago”). It was launched by the mission to limit human-to-human transmission of President and directly monitored by the Executive COVID-19, care for those affected, and maintain Office of the President. When the program launched essential health services during the outbreak. The in 2015, as many as 120 community health centres Pencerah Nusantara teams are now working with eight (Puskesmas) in 44 districts in the remote, border, and Puskesmas in COVID-19 red zones in North Jakarta underserved areas were selected as the deployment and Bandung. sites.30 Figure 11: Change in Human Resources of Health (HRH) readiness assessment indicators after 3 years intervention HRH climate 3.6 2.4 Resources related to the nutrition issue 3.7 3.0 Leadership of HRH 4.0 3.3 Nutrition program 4.0 2.6 Knowledge of the nutrition program 3.8 2.8 Knowledge about the nutrition issue 3.7 3.1 1 2 3 4 5 6 2019 2016 29 The Pencerah Nusantara replication manual is available upon request from CISDI. 30 In 2017, the Nusantara Sehat program was expanded to include an individual-based contract scheme, to accommodate several Puskesmas that might need less than five of those health workers. The participants would serve at the deployed place for two years and return after finishing the placement contract. Between 2015-2018 as many as 3,380 Nusantara Sehat team participants were sent to 162 districts/cities. In 2017-2018 as many as 3,997 individual Nusantara Sehat participants were sent to 225 districts across 29 provinces. 66 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING Another innovative aspect of Pencerah Nusantara was to increase the participation of local communities in health activities with the Puskesmas. One such initiative which proved popular and successful was to encourage local communities to improve nutrition by using moringa, a highly- nutritious plant, rich in calcium, iron, and vitamins, to boost nutrition. The program had invited health center nutritionists and kader to make snacks from moringa leaves, including moringa pudding and nuggets. Successful BOOSTING THE NUTRITION OF cooking lessons were held in every village in the Poto MOTHERS IN POTO TANO Tano sub-district. One of the success stories of the program was a As a result, regulations were issued for the drive to boost nutrition among mothers and pregnant conservation of moringa trees: Perbup No. 80 tahun women by providing health workers with the technical 2017 tentang Gerakan Menanam dan Melestarikan Kelor skills and support they needed to make a difference (Gemari Kelor). In addition, the West Sumbawa District in Poto Tano. Health Office is working with the food industry to produce moringa-based foodstuffs. This was achieved through training to provide a mix of hard and soft skills. The Pencerah Nusantara program has made a lasting impact on nutrition program of Puskesmas in Poto This included helping nutritionists to learn how to use Tano sub-district. This was assessed through the software and helping staff to plan, budget, monitor Potential Sustainability Assessment (PSA), where the and evaluate health programs. Accurate record team assessed changes to the Puskesmas and the keeping and use of equipment to monitor the health local community in regards to nutrition improvement and growth of children was also a priority. programs.31 After 3 years of intervention, there was an increase in the overall scores of nutrition program “Nutrition class materials are adjusted to the sustainability - from 2.7 in 2016 to 4.2 (maximum problems in Poto Tano sub-district, such as of 5) in 2019. This indicates an overall change in all the existence of food taboos and local food aspects of sustainability for the nutrition program potential, such as moringa which can be developed (Figure 12). into complementary feeding (PMT Penyuluhan) and healthy food for children,” said Laily, the Nutritionists Skills, scale and sustainability by involving local of Puskesmas Poto Tano. communities and leaders have been at the heart of the program’s success. “Pencerah Nusantara taught me to analyze coverage trends. I also learned to collaborate Sometimes an old idea needs a fresh approach. with cross-programs at the Puskesmas and advocate across sectors. I feel that I have more Sometimes it also needs new skills to tackle the age- knowledge about nutrition programs,” she said. old problem of stunting. 31 Program Sustainability Assessment (PSA): a tool for driving the completion of an organizational self-assessment of eight sustainability domains: environmental support, funding stability, partnerships, organizational capacity, program evaluation, program adaptation, program communication, and strategic planning. It provides tools to assess domains and develop action plans to increase the likelihood of sustainability. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 67 Figure 12: Pencerah Nusantara program improves the potential sustainability Potential Sustainability of nutrition Assessments program at Puskesmas (PSA) of Nutrition Poto Tano* Program at Puskesmas Pototano 2019 2016 Overall Score 4,2 4.2 2,7 2.7 Program Communications 4,4 4.4 2,8 2.8 Program Adaptation 3,6 3.6 2,6 2.6 Program Evaluation 3,8 3.8 2,8 2.8 Strategic Planning 4,4 4.4 2 Organizational Capacity 3,8 3.8 2,2 2.2 Funding Stability 4,8 4.8 2,8 2.8 Partnerships 4,2 4.2 2,4 2.4 Environmental Support 4,8 4.8 3,6 3.6 * Potential Sustainability Assessment (PSA) of nutrition programs at Puskesmas Poto Tano in 2016, 2019. 68 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING TIMOR TENGAH SELATAN: FOSTERING THE FARMING SKILLS OF HOUSEHOLDS FOR A BETTER DIET TIMOR TENGAH SELATAN Food and farming matter. Nowhere does it matter Acute and chronic malnutrition is traditionally a problem more than in the southernmost province of Indonesia: in this region. The province of East Nusa Tenggara is East Nusa Tenggara. The right food at the right time one of the highly vulnerable areas of the country, both in is often scarce here. terms of food security and undernutrition. The province experiences the highest levels of stunting and wasting As a result, stunting and other nutrition issues are among children under the age of five in Indonesia, a major public health problem. But a program to reaching nearly 52% and 15%, respectively in 2013 promote the farming skills of men and women in (NIHRD, 2013). 4,000 poor households has proved a success in improving nutrition, hygiene, and income. The prevalence of stunting here has remained unchanged in the past 11 years, while the national rate Seeds and support are at the heart of a program to has decreased from 48% in 1995 to 37% in 2013 (Central help poor households, especially those where the Bureau of Statistics et al., 1996; NIHRD, 2013). Timor mother is raising her family without a partner, grow Tengah Selatan (TTS) district was one of the worst up to six different types of vegetables and fruits districts in the province in-terms of food security and in their gardens throughout the year to diversify undernutrition: 70% of children suffered from stunting family diets. From collard greens, spinach, lettuce, and 14% suffered from wasting (NIHRD, 2013). long beans, green beans and tomatoes to eggplant, cassava, sweet potato, pumpkin, and papaya, the Helen Keller International, as part of the Project Laser program promotes better nutrition with a hands- Beam (see “East Nusa Tenggara: Project Laser Beam on approach. Local women were also supported in helps mother and children in a remote region with rearing chickens, constructing chicken coops and food insecurity”) with support from the private sector, healthy cooking skills to increase consumption of the Mondelêz International Foundation, launched nutrient-rich foods. In return, the farmers used their an Enhanced Homestead Food Production (EHFP) farming tools such as shovel, and watering buckets program, a nutrition-sensitive agricultural approach to as their in-kind contributions. boost nutrition and sustainable access to food in the TTS district between 2012 to 2015. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 69 The EHFP program was a food-based approach to to purchase micronutrient-rich food and to pay combating malnutrition, designed to bring sustained, for household expenses, such as healthcare and lasting improvements to the health and nutrition of children’s education (Haselow et al., 2016). vulnerable household members, especially mothers and children (Girard et al., 2012). “Helen Keller, through its Homestead Food Production program in our village, has Boosting the agricultural skills of women farmers and improved my family’s life because we now harnessing their knowledge of nutrition is a powerful plant organic vegetables and raise poultry, as well as weapon in the fight against stunting. That has proven catfish in our yard,” said Margarita (Rita) Manes a to be the case across the Asia-Pacific region since villager. “Production of those vegetables, chicken and the Helen Keller first rolled out the EHFP concept in catfish is so good that I can sell some to the market and Bangladesh in 1991. it has improved our economic condition while fulfilling the basic needs of my family.... I am sure the result of The benefits of the EHFP program included: this activity will help me to provide enough money to pay for my children’s school fees. I really hope that the ⃣ Improving access to and consumption of year- government will continue supporting this activity,” she round micronutrient-rich foods added. ⃣ Promoting essential nutrition and hygiene In Cambodia, Vietnam, and Bangladesh, other EHFP actions project sites, the program has enjoyed similar ⃣ Boosting family incomes and livelihoods success. Many households there enjoy improved food security and income-generation (Khetran, 2012; Through nutrition training and counseling, targeted Olney et al., 2013). households were encouraged to increase the production and consumption of nutrient-rich food Figure 13 illustrates the conceptual framework of such as vegetables, fruits, eggs, and meat. Income the relationship between household food production from the sale of excess produce was typically used strategies and health and nutrition. 70 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING Figure 13: Conceptual framework of the relationship between household food production strategies and health and nutrition outcomes Capacity building of farmers to apply effective agricultural methods and technologies Increased agricultural production from improved and developed gardens Provision of high quality Increased income for agricultural inputs - households seeds, saplings, poultry, livestock Increased market sales of EHFP produce Greater empowerment for Nurturing Connections© - women, more equitable transformational gender household dynamics actions Increased nutrition and Improved Maternal and WASH knowledge Child Health and Nutrition Essential Nutrition Actions and Essential Improved maternal and Hygiene Actions capacity child diets building and SBCC Transformation of household dynamics and decision-making between men and women Marketing and livelihood Improved health care, training hygiene, and feeding of Improved nutrition newborns, infants and counseling and outreach; young children linkages to health and agriculture services established Strengthening community support structures MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING Source: EHFP minimum program standard (Helen Keller International, 2018) 71 The EHFP program in TTS district was known RANTAI aimed to improve food security and nutrition locally as Rapid Action on Nutrition and Agriculture for approximately 4,000 remote vulnerable households Initiatives (RANTAI). and their family members. To achieve this goal, Helen Keller divided program implementation into two The project targets poor households and households phases as listed in Table 1. The first phase served as with children under 5 years of age, with a focus on a pilot to test delivery content and modalities before improving nutrition within the “First 1,000 days scaling up. This model utilizes existing community of life.” This is also known as 1,000 Hari Pertama structures and systems to establish Demonstration Kehidupan (1,000 HPK), the developmental period of Farms (DFs) to support the beneficiary households. children from conception to two years of age. The Two hundred demonstration farms were established GoI’s Stranas Stunting aims to ensure that resources in TTS district to serve as a sustainable knowledge are directed and allocated to support and finance and information resource for participants. quality priority nutrition activities, particularly among 1,000 HPK households. Table 1: Total households reached through RANTAI The main objectives of the EHFP/RANTAI program were to: Target Phase 1 Phase 2 Total 1. Increase diversity and year-round production of fruit and vegetables Households 1,601 2,400 4,001 2. Increase year-round production of animal-source foods Demonstration 3. Improve consumption of micronutrient-rich 80 120 200 Farms (DF) foods, especially among women and young children, through increased production and Villages 40 34 74 nutrition-related education 4. Improve health and nutrition of women and children in participating households Sub-Districts 13 4 17 72 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING RANTAI selected household participants based on village level through the mapping exercise. the following criteria: The village mapping involved all stakeholders ⃣ Primary criteria: poor households with young in the village, such as heads of village and sub- children and/or pregnant or lactating women, as villages, village midwives, kaders (community health locally determined by key village stakeholders volunteers) and community and religious leaders. Criteria for poor households were discussed and ⃣ Secondary criteria: poor households where the agreed upon by all stakeholders; households that male parent is not in the village or not with the fulfilled the criteria were selected and project staff family anymore (regardless of children) then performed a monitoring visit to verify the selected RANTAI mapped the villages to gain an in-depth households. During the visit, Helen Keller staff understanding of the target communities and explained the purpose of the project, the expected resources available. roles and responsibilities of each household, and confirmed the household’s commitment to participate During the village mapping, community members in RANTAI. The selected households signed a letter provided information on the total population, of commitment and participation. Then, participating agricultural resources (e.g., water, agricultural inputs households formed a group and selected a leader to and family and community assets), animal husbandry be the head of the demonstration farm. inputs, assets, and current practices. The number of participating households and the Helen Keller staff also learned about the availability number of demonstration farms has more than and access to health services at the village and sub- doubled over both phases of the program. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 73 DEMONSTRATION FARMS SHARE Figure 14: Horticulture planting calendar SEEDS AND FERTILIZER The role of the head of the demonstration farm was extremely important as this person was the lead resource person in the community showcasing different aspects of RANTAI, linking households Bedeng with health and agriculture service providers, and 1 maintaining communication with Helen Keller staff 2 and participant households when necessary. 3 4 The heads of demonstration farms served as a source 5 of technical assistance to the other households (both 6 participants and non-participants) and distributed 7 agricultural inputs—such as fruit and vegetable seeds 8 and fertilizer. The project provided seeds for a variety 9 of micronutrient-rich foods, prioritizing commodities 10 that were both nutritious and could be sold in local 11 markets. 12 These seeds produced vegetables native to the district. The goal was for each garden to grow four to six different types of vegetables throughout the year REARING CHICKENS FOR EGGS AND to contribute to a diverse diet. The project also taught MEAT the households how to use rainwater harvesting for irrigation. RANTAI also promoted raising chickens as the eggs and the meat could provide an animal source of To assist in planning what to grow in the garden, each protein for households and generate income from the participant received a planting calendar to identify sale of surplus eggs and meat. the best time to grow each vegetable by months as shown in Figure 14. This planting calendar--usually RANTAI provided chicks (aged 10-12 weeks) to the hung on the participant’s wall—was also used as a participants to raise. Heads of demonstration farms teaching tool during refresher meetings. received 20 chickens (15 females and five males) and members of demonstration farm groups received six Helen Keller held routine refresher meetings chickens (five females and one male). Helen Keller throughout the program to get updates on activities in purchased these chickens locally in the villages, the demonstration farms, learn how to administer and and provided training on raising chickens including fill out the monitoring forms, share success stories producing feed for poultry using locally available and challenges, and revise each demonstration materials such as corn, rice, green beans, fish, and farm’s work plan based on discussion and sharing. coconut. The project also taught families how to construct a chicken coop, and the nutritional value RANTAI promoted the use of local seeds based on of chickens, eggs, catfish and other animal sources the results of germination tests conducted by project of protein. With the help of the District Animal staff, and trained the participants on using low-cost Husbandry Office, the heads of demonstration farms materials resources that were available within their vaccinated chickens against common illnesses to community to increase sustainability. prevent disease and reduce mortality. 74 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING INCORPORATING NUTRITION EDUCATION INTO WAY OF LIFE At the start of the project, Helen Keller conducted farms, who facilitated nutrition education sessions research to adapt the RANTAI program locally. The to members including mothers and mothers-in law to results showed that local people obtain information encourage families to use fruit, vegetables and animal about nutrition from a number of sources including sources of protein that are rich in micronutrients for from family members, community and religious their own consumption. They also encouraged the leaders. The church has strong links to the community use of iodized salt, consumption of diverse diets, down to the village level. Helen Keller staff routinely food safety, handwashing, and participation in health met with key religious leaders in the community and nutrition services. to discuss how they can help to provide nutrition education to their congregation in RANTAI-supported To help a family to prepare healthy and delicious areas. The other important findings were the role of meals for children, Helen Keller conducted popular mother in-laws: they have great influence over infant cooking demonstrations and created a family recipe and young child feeding practices and family feeding. book to guide mothers on how to prepare nutritious As a result, they were encouraged to play an active meals at low cost (Figure 15). The book contains role in nutrition education training and meetings special recipes for different age groups, nutrient (Mardewi, 2013). content of the meals with their cost, and tips and tricks to cook healthy meals using ingredients that Incorporating nutrition education into agricultural were available locally, focusing on foods that were projects is likely to improve consumption and related familiar to the participating families. Materials nutrition (FAO, 2016). RANTAI provided nutrition included pictorial descriptions to aid those with low education training to the heads of the demonstration levels of education. Figure 15: Recipe book cover and example of recipe KUMPULAN MENU KELUARGA Bergizi & Murah MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 75 IMPROVING DIETS USING LOCAL INGREDIENTS Helen Keller collected data at the beginning and the However, the EHFP model places greater emphasis end of the project as part of baseline and endline on health and nutrition improvement for children and studies and found important and significant changes pregnant and lactating women. in project households, associated with improved nutrition and health-seeking practices. The data The Ministry of Agriculture intends to scale up the from the endline studies showed that the number KRPL model across Indonesia. Helen Keller has of households with an acceptable diet, as shown by already shared the project’s materials and lessons Food Consumption Score (FCS – an estimate amount learned from EHFP with the Ministry of Agriculture for of quality food eaten by households) improved potential collaborations and replications, and intends considerably from 34% to 67% (p<.0001) in phase 1. to continue sharing this data with key stakeholders to inform national policy and programming for food and Households in phase 2 also experienced an nutrition security. Local government representatives improvement in FCS from 47% to 59% at the end of were also involved and informed about the project project. However, this difference was not statistically results and recognized the benefit of the RANTAI significant. project to communities. The households participating in phase 1 were less “The farmers groups formed in Tune Village likely to have an acceptable diet at baseline as are very helpful because they raise chickens compared with phase 2 households at baseline. The for eggs and meat consumption. It is also very change was higher in phase 1 households as they helpful for planting vegetables, so people that used to had an additional year to implement the program shop in a market in the city can pick it up from their own compared to households in phase 2. Additionally, yard now. The village government is willing to help the the sample for the endline for phase 2 may not have management and distribution of the produce to increase been sufficient to detect a statistically significant income in the households,” said Arid Oematan, Chief difference. Financial Officer of Tune village. Household food insecurity, as assessed using Community based nutrition sensitive agriculture the Household Food Insecurity Access Scale programs can help to ameliorate food insecurity (HFIAS), also improved significantly. Nearly 30% of and improve dietary intake, even in the poorest and households in phase 1 were severely food insecure most remote communities. The use of a pilot period at baseline. This dropped to less than 10% at the end allowed the project to test modalities and adjust of the project (p<0.05). Similarly, more than 30% of implementation delivery before scaling to a larger households in phase 2 were severely food insecure community. The sustainable model has produced at baseline. Again, this fell significantly to 18% by the statistically significant results. end of the project. The data also showed that children from households in both phases were consuming more vegetables, meat and eggs at end of the project, although for meat and eggs, this change was only statistically significant in phase 2 households (p<0.05) (Helen Keller International, 2016). Helen Keller’s EHFP model complements the Ministry of Agriculture’s model for food security: Kawasan Rumah Pangan Lestari (KRPL). Both work to improve household food security and income generation. 76 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING BANGGAI: ACADEMIA AND DISTRICT LEADERS COLLABORATING FOR IMPACT BANGGAI Universities are more than places of knowledge, local government in the driving seat, carrying out all skills, and learning. They are beacons of hope in activities directly. communities suffering from high levels of maternal mortality and child stunting. One initiative, which provides health checks and health and nutrition counseling to all women of Increasingly universities in Indonesia are playing the reproductive age in the district, and has proved vital role of mentors to local government officials particularly successful in boosting the health of seeking to step up Indonesia’s drive to improve mothers and children during the first 1,000 days of maternal and child health. In Central Sulawesi, life (1,000 Hari Pertama Kehidupan or 1,000 HPK). experts from two institutions - Hasanuddin University (UNHAS) and Institut Gizi Indonesia (IGI) – have The Posyandu Pra-Konsepsi or Preconception lent their knowledge, skills and learning to local Posyandu emerged in 2015 after discussions between government officials since 2014 in a successful local officials and their academic partners. program based on mentoring and supervision of workshops, taskforces and working groups seeking With a maternal mortality rate of 267 deaths per to improve health for mothers and children in Banggai 100,000 live births in 2014, the root cause of maternal District. deaths in the District of Banggai was thought to be linked to malnutrition among pregnant women Supported by the Ministry of Health and the District (Dinas Kesehatan Kabupaten Banggai, 2019). It Government of Banggai, the program is a departure soon became clear that intervening early (before from more tried and tested health collaboration conception) was crucial to maternal health and child between local government and universities. The health. focus is on support, facilitation and mentoring with MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 77 Despite existing programs to address malnutrition Women of reproductive age were offered health among pregnant women, such as iron folic acid checks and nutrition counseling, either when they supplementation and family nutrition programs, enrolled in pre-marriage courses through the Office of the prevalence of anemia and malnutrition among Religious Affairs or when they were visited by officials pregnant women remained high. This could be for Program Indonesia Sehat dengan Pendekatan attributed to late contact for the first antenatal care Keluarga (PIS-PK) data collection or identification. (ANC) visit, which typically occurred in the second trimester. There was also a high prevalence of anemia All participants received anthropometric among adolescent females. Relationships between measurement services, including upper mid- pregnant women, the midwife or healthcare workers arm circumference and hip circumference were not strong. measurements, blood pressure measurement and monitoring, proteinuria testing, hemoglobin In March 2015, the Preconception Posyandu was testing and iron-folic acid or micronutrient vitamin launched in sub-districts and villages. supplementation. Participants were also required to attend preconception counseling classes. The program drew on a coalition of support, including the members of the Pemberdayaan dan Kesejahteraan POSITIVE EARLY RESULTS FROM Keluarga (PKK) or Family Welfare Movement, officers THE PRECONCEPTION POSYANDU from the Religious Affairs Office and sub-district and PROGRAM village government. Local regulations32 help to ensure the sustainability By the end of 2015, all Puskesmas in the district of the program. Early results are positive, with of Banggai had successfully launched the rates of anemia and maternal mortality dropping Preconception Posyandu. considerably in just one year (Table 2). Table 2: Preconception posyandu program indicators, 2015 - 2018 Indicator 2015 2016 2017 2018 First ANC (Average 16 4.2 2.6 1.8 week of pregnancy) Anemia Prevalence 46% 18% 12% 10.4% MMR (per 100,000 206 180 154 143 live births) IMR (per 100,000 13 11 8 7 live births) 35.6% 31.2% Stunting prevalence Unavailable Unavailable (Riskesdas, 2013) (Riskesdas, 2018) Source: Dinas Kesehatan Kabupaten Banggai, n.d. 32 Banggai Regent Regulation No. 33 of 2015 concerning Integrated Women’s Services for Banggai Regency Preconception; Decree of the Regent of Banggai No. 440/230/Health Office About the Formation of the First 1000 HPK Movement Task Force Team in Banggai Regency. 78 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING Deep commitment to multisectoral convergence provide policy and planning insights, including for to address nutrition and stunting translated into budgeting, in sub-districts and in villages. concrete steps taken at the district, sub-district and village levels. At the village level, a model of family coaching in PIS- PK was used. In the program, each Family Guide (FG) This was achieved by creating the First 1,000 Days provides coaching and monitoring for 100 families. of Life Task Force, meeting every three months to provide more in-depth understanding of stunting These FG workers were recruited from amongst a prevention measures. Stunting forums were also held pool of health workers. Every FG was assisted by 10 at the sub-district level every three months. Stunting Dasawisma33 kaders in which he or she supervised 10 working groups were also formed in villages. IGI and families. Evaluation of the results was done through UNHAS provided advisors for these activities. the Jamboree of kader. This data collection has been carried out since June 2019.34 “The key to successful nutrition leadership in Banggai District lies in the leadership and The “mentoring model” in Banggai District has technical competency of its leaders – from proved an inspiration to others. It has been replicated the Head of the District to the Head of the Bappeda, in other districts. In November 2019, an agreement allowing them to approach the challenge from both to implement the mentoring model was signed by programmatic and budgetary aspect,” added Prof. (Em) the Chancellor of Universitas Hasanuddin and four Soekirman. districts and one city: Majene, Mamasa, Polewali Mandar from West Sulawesi Province, Pidie from Although the initiative was established before NAD Province and Pare-pare City in South Sulawesi StraNas Stunting, the steps taken strongly supported Province. In 2020 other parts of Sulawesi committed the convergence actions of the GoI’s StraNas to replicate the model too. Stunting. The Ministry of Health is now backing plans to roll Grass roots involvement is key. Village heads, out the model in 16 universities across Indonesia. midwives and subdistrict heads are invited to task This is coordinated by IGI. The Ministry of Health force meetings. Plans are adapted to the needs of is providing IDR 500 million (approximately USD each village, supported by academic staff. 35,000) to each University to mentor each district. Universitas Hasanuddin received the same amount The sub-district government functions as a supervisor to continue mentoring in sub-districts, villages and and verifier, while the village government functions households in Banggai. as a planner, implementer and monitor for stunting countermeasures in the area. Research by students Mentoring, for the local officials, is making a real from UNHAS under supervision of IGI has helped to difference to health and wellbeing. 33 Dasawisma, means a block of 10 houses. It was an old PKK concept that is refunctioned to reach all families in the area. 34 Jamboree of Kader is a meeting at the Puskesmas level, where monitoring and evaluation of data updating is conducted, as well as surveillance to resolve the problems encountered. Jamboree participants include Posyandu kaders, PK and Dasawisma kaders. The Jamboree moderator is the Regent/Vice Regent. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 79 80 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING YOGYAKARTA: AWARD-WINNING SANITATION CLEANS UP CITY’S RIVERBANKS YOGYAKARTA Yogyakarta is not known as a riverine city. The waters Although the campaign was community-led, the coursing through it do not characterize the place in community living along the Gajahwong river worked the way London is defined by the Thames, Paris by hand-in-hand with the local authorities and other the Seine, or Bangkok by the Chao Phraya. stakeholders on the health and sanitation campaign. Three main rivers run through the urban areas of The impetus for this change were public events Yogykarta: the Winongo, the Code and the Gajahwong. at which the community was shown how fecal These strips of brackish water scarcely get seen contamination spreads from exposed excreta to their by most guests more interested in shopping on living environments and food and drinking water. Malioboro Street or looking at the Hindu sanctuaries that encompass the city. During these events, a map of the urban ward was drawn on the ground and communities were asked The Gajahwong is the easternmost of the city’s to indicate where they live, where they defecate, and three rivers. It is in informal settlements, along the the routes they take there and back. This illustrated river’s banks, that a community-led campaign has that everyone was ingesting small amounts of each successfully helped to combat diarrhea and other other’s feces. Shock and disgust led locals to declare diseases linked to poor child health and stunting. the area an open defecation free (ODF) community and hence, efforts to clean up the city’s riverbanks started in ernest. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 81 CHANGING COMMUNITY PRACTICES THROUGH BEHAVIORAL CHANGE The District Health Office led the change through the announcement when homes need to flush waste on implementation of a Sanitasi Total Berbasis Masyarakat a weekly basis – not into the river – but into septic (STBM) or Community-Led Total Sanitation (CLTS) tanks. strategy, which encouraged the community to discuss the negative health consequences of existing “We observed a decrease in the community’s sanitation practices. It did so rather than adopting tolerance of open defecation. The award- the more traditional approach of providing sanitation winning CLTS program is associated with facilities or subsidies to build them. The aim was a decrease in roundworm infestation. In recent years to achieve universal access to a clean water, better we started to see this having a significant impact on sanitation and zero slums (the 100-0-100 program). nutritional intake and as reflection in declining numbers of anemia and weight or height gains,” said the local Rather than rely on authorities alone to provide better Puskesmas’ Bidan (midwife). sanitation facilities, the local community agreed on five steps to improve sanitation in the community. The  Kampungs  — small, almost self-sufficient The first step was to make it socially unacceptable communities — that hug the river have been on the to engage in open defecation. The second step was frontline of the fight for better sanitation for decades. to encourage hand washing with soap and the third It is here that the threat of poor sanitation is most was promoting safe water treatment and safe food pronounced. Dense housing, poor sanitation and open handling practices in homes. The fourth was the defecation were problems which blighted the health safe disposal and management of solid waste. The of local communities for generations (Kumorotomo fifth was the safe management of wastewater by et al., 1995). The residents of the riverbank tend households. to be migrants who work in the informal sector in Yogyakarta. They come from areas around Yogyakarta The community’s behavior has changed, reducing the such as Klaten, Wonogiri, Magelang, Purworejo, and risk of contamination from Escherichia coli (E. coli), even some cities in West Java. a bacterium causing diarrheal disease. Town hall meetings and public events encouraged people not “Back in the 1970s, despite being so close to throw waste and refuse into the river. Signs warned to the river, people had no fresh running about the danger of not keeping the river clean. The water. Instead they had to draw it from wells program focused on community mobilization to stop manually every time they wanted to bathe or do their open defecation. The government’s focus also shifted laundry. For all the activities along the riverbank, the from constructing treatment facilities. Instead it actual water itself was a mess. The river had also been encouraged the community to manage its own waste used as a public toilet as well as the place for garbage by emptying septic tanks, recycling treated sludge disposal. People continued to throw their trash into the and upgrading leaking pits to standard septic tanks. stream, which in turn provides opportunities for the less fortunate who wade the waters looking for rubbish The community-based approach builds on existing that may have a resale value,” said Sukamto who lives patterns of social organization, values, and local around the Gajahwong Valley. traditions. For example, the local mosque makes an 82 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING SEPTIC TANKS SPILLS LINKED TO STUNTING RISKS Most families here rely on septic tanks located under Diarrheal diseases and intestinal worms are also a or close to their houses, but many are not watertight. significant cause of malnutrition – by reducing normal There is even a popular misconception in Indonesia food consumption and nutrient absorption. This can that a good septic tank is one that leaks, as it will not lead to impaired physical growth, reduced resistance need to be emptied. As a consequence, only a few to infection, and long-term gastrointestinal disorders. households ask for their tanks to be emptied regularly by calling either public or private service providers. Yogyakarta is not alone. Today, about half of Indonesia’s population live in urban areas. Estimates “Most of my neighbours have a septic tank show this will rise to around 68% by 2025. Progressive at home. The public well was located near approaches to urban sanitation have led to millions some of them, so I know the water was of Indonesians gaining access to improved services contaminated,” said Teti, a housewife. She was also over the past decade – but inequality persists. aware of the consequences. “Bacteria from the septic Currently, of the 29.6% of urban households with tank is a health hazard to my family, especially my access to piped water supply, the bottom 40% make children. They can get diarrhea or not grow as well as up just 7.5%, whereas the top 60%  make up 22.1%. other children their age,” she said. Although the vast majority of households in urban areas use a toilet connected to a septic or sewerage Open defecation and untreated wastewater and system (78%), less than two percent of those are contaminated water facilitate the spread of fecal connected to sewerage (World Bank, 2017a). borne illnesses. In addition, it is the persistent gaps in service quality— Two of the four main causes of death for children rather than barriers to access—that is the main under five in Indonesia (diarrhea and typhoid) are challenge facing Indonesia in its drive to achieve the fecal-borne illnesses linked directly to inadequate Sustainable Development Goals (SDGs). Although water supply, sanitation, and hygiene issues. About most households are gaining access to drinking 11% of Indonesian children have diarrhea in any two- water and sanitation due to rapid urbanization week period and it has been estimated that more than and increasing living standards, not everyone is 33,000 die each year from diarrhea (NIHRD, 2018). benefitting from the same quality of service. StraNas Stunting aims to address water, sanitation and hygiene challenges through its multisectoral approach. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 83 POOR SANITATION DAMAGES HEALTH AND THE ECONOMY Despite these gains, an estimated 95% of fecal waste The economic impacts of poor sanitation in Indonesia still makes its way into the nearby environment due are significant. to poor quality on-site septic tanks, lack of adequate emptying and disposal, or poorly functioning A study carried out by the World Bank’s Water and wastewater treatment. Sanitation Program estimates that Indonesia lost IDR 56 trillion (approximately USD 6.3 billion) in 2007 due These conditions raise the cost of water treatment, to poor sanitation and hygiene, equivalent to about and lead to environmental degradation, greater risk 2.3% of the country’s gross domestic product (World of disease, and poor child health and stunting. Bank, 2013). The poor in urban Indonesia are not only less likely Underinvestment in urban infrastructure and lack to have adequate sanitation but are more likely to of adequate planning limits the potential economic live in areas where their neighbors also lack these growth and development benefits of growing cities services. Failure to address the sanitation conditions and contributes to widening inequalities. Over the of urban dwellers, especially those living in informal past decade, for every one percent increase in settlements, could exacerbate inequalities, and is urbanization, Indonesia achieved only two percent among the greatest threats to the inclusive growth gross domestic product (GDP) growth, below the and sustainability of Indonesian cities (World Bank, return on urbanization in other Asian countries 2017a). such as China, Vietnam, and Thailand, which have significantly benefited from economies of From the government’s perspective, riverbank areas agglomeration. are also not ideal for settlement because of their vulnerability to climate change and natural disasters, Yogyakarta has played host to many initiatives such as flooding. aimed at improving water, sanitation and hygiene infrastructure and practices (Box 14). 84 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING Box 14: Yogyakarta - The host of sanitation initiatives In 1984/1985 the government of Yogyakarta homes, provide communal toilets for people who launched its first Kampung Improvement Program do not have healthy toilets at home. The houses (KIP). This program aimed to overcome further must be built away from the riverbanks (“Mindur”) Kampung deterioration by improving their physical and in higher areas (“Munggah”), living rooms environment and sanitation (BAPPENAS & UNICEF, must be re-located to face the rivers (“Madhep”), 2015). Pavements, water drainages, squatting and provide legality for communal water sources toilets (Jamban Keluarga), clean water facilities and which is managed by the community called the sewerage systems were built with the KIP funding. Sistem Penyediaan Air Minum Desa (SPAMDES) Kampung conditions improved in some parts of the or Rural Drinking Water Supply System which slum. But the influx of people residing in the slum subsequently developed into the Paguyupan Air meant the settlement continued to grow. Minum Masyarakat Yogyakarta (PAMMASKARTA) or Yogyakarta Community Drinking Water Society. Beginning in 2000, the central government, Wathershed Communication Forum (Forum coordinated by Bappenas, embarked on a series of Komunikasi Daerah Aliran Sungai, Forsidas) was initiatives to reform water supply and sanitation created and fostered by the government. policies. These reforms were aligned with decentralization which devolved responsibility for The Asian Development Bank also helped sanitation to local government. Acceleration of Yogyakarta, Sleman and Bantul districts the Percepatan Pembangunan Sanitasi Permukimam (agglomeration known as Kartamantul) to (PPSP) or Urban Sanitation Development Program rehabilitate and expand sanitation facilities was established to assist local government in through the Metropolitan Sanitation Management comprehensive citywide sanitation planning and Health Project. Executed by Department through the preparation of Strategi Sanitasi of Public Works, Housing and Mineral Energy Kabupaten (SSK) or City Sanitation Strategies. Sources of the Special Region of Yogyakarta, the project built communal sanitation facilities Yogyakarta realizes that to be designated as an area in poor areas and provided support to mobilize with a high human development index (HDI), DIY community involvement in the planning, operation must be able to continue its healthy environment and maintenance of these facilities. It also built policy and implement an innovative program that wastewater treatment and rehabilitated and is simple for the community to replicate. expanded sewerage systems for settlements along rivers and in flood areas (Ministry of Public Yogyakarta city released its first strategic plan Works and Housing, n.d.). in 2007 (Pemerintah Kota Yogyakarta, 2007) and joined the Aliansi Kabupaten dan Kota Peduli Sanitasi Other funding for sanitation infrastructure in (AKKOPSI) or Alliance of Cities and Districts Yogyakarta is the Community-based Water Supply Concerned about Sanitation in Indonesia in 2010, and Sanitation Project (PAMSIMAS). Yogyakarta committing at least two percent of its budget to has received PAMSIMAS funding from 2014- sanitation. In addition to that, Yogyakarta Governor 2019. The PAMSIMAS project supported more Sri Sultan Hamengku Buwono X launched Yogya than 190 villages: 55 villages in Bantul Regency, Sadar Sehat in 2010. 52 villages in Kulonprogo Regency, 50 villages in Gunungkidul Regency and 40 villages in Sleman The Governor said that healthy awareness must Regency. The facilities that were built included begin with healthy behavior and environments. communal latrines and communal drinking water His policy at that time was realized with the facilities. The project also included upgrades to settlement of a sanitation structuring program by other sanitation facilities. inviting residents to separate livestock pens from MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 85 In Yogyakarta, concrete actions were taken to address The community has led the clean-up. the situation. Thanks to the directions and guidance of the Governor, who is also the Sultan of Yogyakarta, The riverbanks are starting to bloom as attitudes the local government implemented policies and change. programs to improve the health and sanitation of the The border line (Sempadan) along the rivers have communities living along the riverbanks. Residential turned into alleyways filled with flowers and fruit areas along the river were tidied up and public spaces trees. were built, providing the community with clean and comfortable space for social interactions. This has provided an incentive for locals to move their doors to face the riverbank. “Before, we would transport the sludge from one place to another. Basically, just moving When they open the door, they do so safe in the the problem to a new location,” said the head knowledge that sanitation in their community has of Domestic Wastewater Processing in Kampung changed and changed for good. Gambiran. “With the new treatment plants, it is easily solved.” Treatment plants with a more compact design are working well. 86 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 87 03 CHAPTER 3 SNAPSHOTS: LESSONS LEARNED FROM IMPLEMENTATION 88 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING PUBLIC-PRIVATE PARTNERSHIP: THE EARLY ADOPTER OF CONVERGENCE IN A REMOTE REGION WITH FOOD INSECURITY EAST NUSA TENGGARA In 2011, seven years before the start of the StraNas The idea for a multisectoral partnership was first Stunting, Timor Tengah Selatan (TTS) district in East conceived at the World Economic Forum in Davos Nusa Tenggara (ENT) Province was the project site in January 2009. Upon its launch in September of for one of the earliest initiators of a multisectoral 2009, five major organizations - the United Nations approach to addressing child undernutrition, Project World Food Programme (WFP), the Global Alliance Laser Beam (PLB). for Improved Nutrition (GAIN) and private sector partners Unilever, Mondelêz International Foundation Ahead of its time, Project Laser Beam focused on (formerly Kraft Foods Foundation), and Dutch life addressing child undernutrition in a holistic manner. sciences group Royal DSM committed to a five-year It addressed both the direct and the underlying public private partnership. The partnership aimed to causes of undernutrition throughout the life cycle of create a scalable, replicable, and sustainable program a child (Box 15). model to significantly reduce child undernutrition, contributing to the achievement of the first Millennium In 2009, this was a novel concept. Development Goal (MDG) of eradicating poverty and hunger (WFP et al., 2015). It followed evidence from the Lancet Series on Nutrition, which in 2008, had set out new information In Indonesia, this collaboration was expanded to in a number of areas such as greater priority include Indofood and Garudafood Indonesia – for national nutrition programs, multi-sectoral both major players in the local food industry. Other approaches, better coordination in nutrition systems, partners include the Government of Indonesia, Helen and highlighted the importance of focusing programs Keller and Yayasan Kegizian untuk Pengembangan on the first 1,000 days of a child’s life as well as using Fortikasi Pangan Indonesia. integrated approaches to improve child development (Lancet, 2008). MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 89 FOCUSING ON TIMOR TENGAH Box 15: What is Project Laser Beam SELATAN (TTS) Project Laser Beam’s aim was to create As its name suggests, the partnership had a “laser sustainable, scalable and replicable solutions beam” focus on selected countries and regions, to significantly reduce child undernutrition. namely Bangladesh and Indonesia, to maximize the collective impact of interventions in areas of great Project Laser Beam addressed child need. Both countries have high levels of stunting and undernutrition through nutrition-specific and wasting amongst children under five (UNICEF, 2013). nutrition-sensitive interventions. Specifically, it did this through four programmatic pillars. In 2010, PLB brought the multisectoral approach to address child undernutrition to TTS. It aimed to First, it directly provided food and improve the nutrition and food security situation in micronutrients through the Food and TTS district. Micronutrients Pillar. Second, it provided clean drinking water and TTS was one out of 22 districts in ENT that ranked sanitation facilities through the Water and as most food-insecure in the province and continued Sanitation Pillar. to face a combination of acute and chronic food insecurity due to issues of food access and utilization Third, through the pillar of Health and Hygiene, (WFP, 2009). This contributed to severe under- it addressed the direct and underlying causes nutrition among its population. Rates of wasting of undernutrition related to lack of basic stood at 14% and stunting rates were as high as 70% healthcare/hygiene and nutrition deficiencies. for children under five in 2013 (see Figure 16). And Lastly, it provided sustainable opportunities not only children, one in four women of reproductive for communities to address the underlying age were too thin and micronutrient deficiencies cause of undernutrition through the Food were of concern, both for women and children. The Security and Income Generation Pillar. situation in TTS was critical.35 Figure 16: Prevalence of stunting and wasting in TTS district compared to national and province ENT data Prevalence of stunting Prevalence of wasting 90 25 80.55 80 70.43 20 Percentage of population of U5 Percentage of population of U5 20 70 57 58.44 15.3 15.44 60 51.73 46.8 15 13.3 50 14 13.7 40 36.8 35.6 37.2 12.1 10 11.37 30 20 5 10 0 0 2007 2010 2013 2007 2010 2013 iNDONESiA NTT TTS Source: Riskesdas from respective years (NIHRD, 2007, 2010, 2013) 35 The population of TTS was 440,470 with 110,070 households in 32 sub-districts in 2010 (Statistics Indonesia, 2010). 90 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING ADDRESSING LOCAL NEEDS Preparations for PLB started in 2010, and the to address the issue of food security, in addition multisectoral partners comprising of WFP, Ministry to addressing the other major causes of child of People Welfare, Ministry of Development and undernutrition. Planning, Ministry of Health, Ministry of Education, the Office of Special Envoy of MDGs, Unilever, DSM, Thus, local-food-based interventions and GAIN, Mondelêz International Foundation, Indofood, micronutrients supplementation became a major and Garudafood, assessed the project location in focus for the PLB. Conscient of the multisectoral 2011. determinants, the partnership also continued to address the direct and underlying causes of It became clear to them that TTS, and other districts undernutrition through comprehensive behavior in ENT, faced a serious food security issue. Food change communication (BCC), dietary diversity and accessibility was poor, and the local purchasing income generation activities, as well as water and power was low. sanitation improvements for a clean environment. PLB also embarked on cross-cutting efforts such as The partners knew that in order to improve child policy and advocacy, and monitoring and evaluation at undernutrition in TTS, the interventions would have its project sites (see Figure 17 for more information). Figure 17: Project Laser Beam’s prototype to support the Government of Indonesia’s response to both immediate and underlying causes of undernutrition “1,000 Days” 24-59 School Children PLW 6-24 months months (6-12 years) Fortified Food *Prevent Stunting: High-energy Local Food Based Biscuit Sandwich Fortified Blended Food biscuit (HEB) School Meal (Development (Development and Provision) (Provision) (Provision) and Provision) *Prevent MAM: Interventions addressing LNS (Lipid based nutrient (Local) Food Based supplement) Interventions (Development and Provision) IMMEDIATE CAUSES OF CHILD UNDERNUTRITION Micronutrients • Fortified Food (through food based interventions) • Rice and oil fortification advocacy • Micronutrient powder (MNPs) for school children Pilot through school Design and implementation of a multi-entry, comprehensive BBC strategy on: Comprehensive Behavior • IYCF (Infant and Young Child Feeding) Change Communication • Health and Hygiene • Dietary Diversity Interventions addressing • Maternal Nutrition UNDERLYING Food Security and Income • Enhanced Homestead Food Production/Village Model Farms (HKI) CAUSES OF CHILD Generation • Food for Assets UNDERNUTRITION • Improved Local Food Processing • Safe Water and Sanitation (with other partners) Water and Sanitation • Deworming (Dinas Kesehatan) • Link to BCC (health and hygiene, handwashing) Capacity Development Policy Advocacy PLB NUTRITION KEY PRIORITIES CROSS-CUTTING M&E Knowledge Managemet INTERVENTIONS MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 91 BRINGING A DIVERSE RANGE OF EXPERTISE TO IMPROVE LOCAL CONDITIONS The partnership brought to the TTS, a diverse range Mondelêz and Helen Keller improved food security of expertise; the whole is greater than the sum of and income generation locally by improving the its parts: while each partner utilized its strength farming and animal husbandry skills of women and to address local needs, the project benefited from households through RANTAI’s Enhanced Homestead collaboration and synergies. Food Production Project (see "Timor Tengah Selatan: Fostering the farming skills of households for a better For example, working closely with the Government of diet"). Indonesia, World Food Programme (WFP) carried out local food-based interventions by distributing high- WFP, Unilever and DSM collaborated to provide energy fortified biscuits for pregnant and lactating local-food-based school meals and behavior change women (PLW). WFP also worked with Indofood and communication on health and nutrition to school- DSM to distribute fortified blended complementary going children in the district. food for children aged 6-24 months through the Posyandu.36 WFP reached 11,500 children aged 6-23 GAIN worked with Yayasan Kegizian untuk months and 6,000 PLW in 442 Posyandu in TTS. The Pengembangan Fortifikasi Pangan Indonesia to fortify program covered all the target beneficiaries in half of oil with vitamin A, an essential micronutrient. the district of TTS (17 out of 32 sub-districts). The local government of TTS worked to improve Prolonged lean seasons are common in TTS, requiring access and utilization of safe water and family a longer-term approach. latrines. WFP further brought expertise locally by working with Unilever and local non-government organizations Garuda Food and DSM to develop and test a medium (NGOs) complemented the local government’s WASH quantity lipid-based nutrients supplements (LNS) facility upgrades by educating the target beneficiaries named Kaziduta (Makanan Bergizi untuk Anak berusia on proper hand-washing techniques and clean and Dua Tahun – nutritious food for children under two) healthy lifestyle.37 for the prevention of wasting during lean seasons. LNS are ready-to-use foods which provide a range WFP, DSM and Unilever collaborated closely of vitamins and minerals, as well as energy, protein, with the Ministry of Health Indonesia to design and essential fatty acids (EFA) for prevention of a comprehensive BCC strategy, including BCC undernutrition. strategies to improve maternal nutrition, infant and young child feeding (IYCF), balanced diet and In addition to the LNS, the partners also collaborated dietary diversity, and clean and healthy lifestyle. BCC with the local governments, PKK and Puskemas materials were provided to health facilities, Posyandu, to support Posyandu activities such as growth and public places. Posyandu kaders provided health monitoring and promotion, vitamin A supplementation, and nutrition education during Posyandu sessions deworming for children 1-5 years old, immunization and home visits using the educational materials and the provision of IFA tablets for pregnant women. (Figure 18). 36 Pregnant and lactating women received 100 gr per day (or 3 kg per month) of fortified high energy biscuits during pregnancy and lactation in the first 6 months after birth, providing 400 Kcal, 8 gr protein, 10 gr fat, and 14 vitamins and minerals per day. All children (6-23 months old) in the intervention areas received three sachets of 20 gr complementary food per day (60 gr/day) per month. This complementary food provided 240 Kcal, 9.1 gr protein, 3.7 gr fat, and 14 vitamins and minerals per day. 37 Promoting hand washing is part of Unilever´s global commitment, the Unilever Sustainability Living Plan, which aims to help more than a billion people take action to improve their health and wellbeing. 92 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING And they all coordinated so that all the interventions Using modules developed by the MoH and UNICEF, came together in the same communities, to ensure the IYCF training greatly helped the health staff convergence of interventions. Having simultaneous and kaders to build their skills in inter-personal access to the right information, essential health and communication. nutrition services, access to a diverse diet and a clean environment all at the same time in the same Strengthening the capacity of health staff and kaders place, drives stunting levels down. was crucial to PLB’s success. Training on IYCF counseling and anthropometric measurement were The PLB also focused on developing the capacity conducted so the health staff and kaders were able of local health staff and kaders, especially on Infant to provide better services and advice on nutrition, to and Young Child Feeding (IYCF) practices to improve monitor progress and report accurate data. Length/ maternal nutrition, breastfeeding and complementary height boards were also provided to the Posyandu. feeding practices of mothers of children under two. Figure 18: Examples of Project Laser Beam’s behavior change communication materials MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 93 RESULTS Several months after the program activities ended, a She herself also realized the importance of gaining final evaluation was conducted by SEAMEO RECFON new knowledge and learning on what and how to in December 2015 (SEAMEO-RECFON, 2016). The prepare a healthy diet for her children, herself and her evaluation compared beneficiaries in the intervention entire family. areas to children in non-PLB intervention areas. “MP-ASI SUN is good for Johana…thanks to This evaluation found a lower (67.9%) prevalence PLB for supporting us with this nutritious of stunting among beneficiary children aged 18 – food,” she said. 35 months compared to those not in the program area (74.8%). On infant and young child nutrition A higher proportion of MCN program beneficiaries knowledge attitudes and practices, the evaluation possessed a growth monitoring card (KMS) or found that food and nutrition outcomes were better Maternal and Child Health books (Buku KIA Pink) than overall among beneficiaries of the MCN program of those not in the program (p<0.001). More than 90% PLB. It is likely that these behaviors have changed of MCN program caregivers visited a Posyandu in the for the long term, making sure the efforts are not lost previous 3 months. after the program itself stops. Delivery of the food rations using the local Infant and young child nutrition knowledge, attitudes Posyandu system contributed to high coverage and and practices, were overall better among beneficiaries acceptability. However, 66.3% of caregivers, who of the MCN program. The timely introduction of received food rations, reported sharing them, due complementary foods was higher (p<0.001) among largely to food sharing practices, as well as high levels beneficiaries (79.8% vs. 68.7%). of household food insecurity. The fortified blended food for children was shared with siblings (52.7%) Food availability and food access were frequently- and the fortified biscuits for PLW were sometimes reported to be challenging in this setting, but the shared with other family members (13.6%). Program beneficiary children in the MCN program area had team members also felt pressure to give food rations significantly higher proportions of meals that met to all children, who came to the Posyandu, not just the minimal meal frequency, minimal diet diversity and intended beneficiaries. minimal acceptable diet (p<0.001). Despite the success, stunting levels continue to be Food rations fortified with micronutrients were “highly very high, in both intervention and non-intervention appreciated”, “well-liked”, and “easy to consume.” areas. This reflects the scale of the challenges faced Coverage was high but frequency was low; 86.4% of by families in this poor region and the many more PLW received fortified high energy biscuits and 98.3% efforts that are needed to overcome this issue. of children aged 6–23 months received fortified blend foods (MP-ASI) at least once. One of the critical factors for success was to ensure good coverage of all of the program package over the Paulina, a mother of three children from Oelbubuk entire first 1,000 days of life. village, about 12 km from Soe, in Timur Tengah Selatan (TTS) district said her two children always The project was also challenged by the weak capacity looked forward to eating the MP-ASI fortified blended of the local health system. Adequate access to health food, especially her 22 months old daughter Johana. care is an important driver of stunting reduction. 94 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING The extensive use of volunteers, limited budgets Indofood now sells the new and improved fortified and lack of trained staff, especially nutritionists complementary food MP-ASI at affordable prices all to provide guidance and support required were over Indonesia. further challenges. Budget and capacity issues also disrupted the local manufacturing of LNS which led The project also highlighted the importance of to the project drawing on more support from the affordable nutrition. private sector. This was not a sustainable solution. In some areas, transport was so challenging that local The Cost of Diet study had shown that more than production was the only efficient manner to produce 70% of the population could not afford the minimum the LNS. cost of nutritious diets. The availability of affordable food was a problem in TTS (Baldi et al., 2013). Social While the local government was very keen to take protection for the poor was critical. Local companies over the project, there were budget constraints which have a critical role to play in ensuring the availability added another challenge. But every challenge has of affordable fortified nutritious food in the local lessons that can be learned. The project drew on the market. resources of the Ministry of Health and other central government ministries and encouraged local firms Coordination and engagement with local NGOs, PKK, to produce affordable fortified food to help prevent academia, other UN agencies is also important. undernutrition in remote and the poor districts of Scaling Up Nutrition (SUN) Networks have also been TTS, a good example of a public-private partnership strengthened to provide support to the government and corporate responsibility. and other stakeholders in TTS. The SUN Network actively supports the SUN movement and the The Ministry of Health started distributing government’s efforts to reduce stunting through the supplementary food (fortified high energy biscuits) National Strategy to Accelerate Stunting Prevention for malnourished children under five and pregnant (StraNas Stunting). women in early 2017, following the end of the PLB (Kementerian Kesehatan RI, 2018). “The collaboration between local government and WFP started before PLB. The PLB has PUBLIC-PRIVATE improved weight, especially among the COLLABORATION CAN YIELD malnourished children and pregnant and lactating LASTING IMPROVEMENTS women. Attendance rates at Posyandus has improved. There is a positive change in the health and nutrition WFP’s strategy never intended to design large status of children and pregnant women. All the programs, but rather to work with the government to achievements are due to the involvement of various create prototypes which can generate lessons to be elements, including local NGOs, community and local integrated into a broader government program. government. We thank WFP for involving us directly in the implementation of the program,” said Mayor of TTS Scaling up homestead food production to the whole Ir. Paul V. R. Mella. district was identified as crucial. Local-food-based school meals (LFBSM) was replicated to other Project Laser Beam has shown that public-private districts by the Ministry of Education with the name partnership can play a major role in reducing PROGAS (Program Gizi Anak Sekolah). GAIN supported malnutrition and improving the well-being of the a vitamin A fortified oil pilot in other provinces. most vulnerable. Moreover, it provides crucial lessons learned for the GoI’s StraNas Stunting. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 95 96 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING WHERE FISHPONDS AND RICE PADDIES MEET YOGYAKARTA As light rain starts to fall, fish swim about a rice field in a natural fertilizer for the rice. The rice grows better, the fertile volcanic soil of Yogyakarta province, seemingly increasing the production and can be sold at higher prices oblivious to the water ripples created by the rain and because of its better quality and higher protein content. breeze. Farming both rice and fish is good for the household, good Small fish, locally known as the Nila fish, measuring about for the environment and good for the planet. 10 centimetres each, dart between the clumps of rice plants, made accessible by the spacing method used by The link between improved nutrition through improved the farmers to improve yield. At one end of the rice field, diets and rice-fish farming is promising. Indonesia is fish move freely between a deep pond and the plants, exploring opportunities to tap into this innovative method feeding on weeds and naturally occurring food organisms. of improving diets through the rice-fish farming program. For the district of Sleman, farming both rice and fish has For now, there is limited information regarding the impact proven to be a winning formula in a drive to boost nutrition, of rice-fish farming on improved nutrition. health, and income. However, qualitative information points towards improved Fish farming in rice paddies started as a way to boost local availability and accessibility of fish in families and the rice production. It revived an age-old method of boosting community. rice yields. The fish not only eat weeds and fertilize the rice crop. They provide an invaluable source of protein to local “Oh yes, one of our farmers’ group members families or can be sold for cash at market. is responsible for selling the fish in the local market. Our families now can consume the Brilliant in its simplicity, rice-fish farming starts with fish easily too,” explained one of the farmers in Sleman existing rice paddies, where the lay out of the paddies is district, when asked about the impact of rice-fish changed to allow more space and depth around the paddy farming on their diets. for the fish. They grow bigger and their ‘waste’ provides MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 97 REVIVING AN OLD TRADITION Rice-fish farming has a long history in Asia. The Now rice-fish farming is making a comeback thanks to exact origins of rice-fish farming is unclear, but the Ministry of Marine Affairs and Fisheries (MMAF), archaeological and written evidence points to China supportive local governments and assistance from more than 1,700 years ago (Halwart & Gupta (eds), development partners. 2014). In 2015, the Food and Agriculture Organization of the In Indonesia, rice-fish farming was believed to have United Nations (FAO) in Indonesia provided catalytic started in the Ciamis Regency in West Java, in the mid- support for increasing the number of Minapadi in 1800s (Ardiwinata, 1957). Over the years, changes in Indonesia. With an initial supporting fund of IDR 2 the land ownership system and governance led to billion (estimated USD 149,254) in 2015 from the FAO, a few methods of rice-fish farming being employed, the MMAF piloted a new model of Minapadi farming typically the fallow-season crop (Palawija) and ‘rice- in Yogyakarta Province (Sleman district), and West fish system’ (Minapadi). In the early days, Palawija Sumatera Province. was the preferred method of rice-fish farming, and was first practiced as a means to increase income The pilot proved to be a success. In the Sleman during the field resting (fallow) period (Halwart district, one of the pilot sites, the new model & Gupta (eds), 2014). With the advent of modern developed by the FAO and MMAF in partnership with technology, techniques and information-sharing, the the local marine and fisheries office of Yogyakarta preferred method of rice-fish farming in Indonesia of Province and Sleman district, and military support late is Minapadi, where the fish and rice are farmed stationed in Sleman district, demonstrated the strong simultaneously in the same field. In addition to fish, feasibility of implementation and scale-up. The pilot crustaceans such as prawns can also be farmed with sites provided a solid business case and a healthy the rice (known as Ugadi). However, by far the most profit margin. popular livestock to be farmed with rice is fish. More importantly, the model - and its proven Interest in rice-fish farming in Indonesia has waxed profitability - garnered interest among groups of and waned over the years. farmers and the Yogyakarta Provincial Government. 98 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING Box 16: Design of the new Minapadi model As a result, the Yogyakarta Governor committed to Termed Minapadi Jajar Legowo, the new the development of at least 50 hectars of land in Minapadi model utilizes a 2 to 1 or a 4 to 1 the sub-districts of Pakem and Minggir for rice-fish row spacing of the rice plant. In other words, farming and rice-prawn farming. the rice plants are placed in rows of 2 (or 4), spaced by one unplanted row, before being The program was scaled up to 30 districts in 2018 and placed in rows of 2 (or 4) again (IAARD, the Ministry of Marine Affairs and Fisheries (MMAF) 2016). The regulation of space between rice is allocating budget to scale up in an additional 27 plants has been shown to result in higher districts. rice yield: the plant volumes increase by 33% per hectare and rice productivity increase by The resounding success of the Minapadi pilot 12-22% (IAARD, 2016). In addition, a study convinced the Government of Indonesia of the conducted in Indonesia indicated a higher feasibility of scaling-up the Minapadi model in protein content for rice produced using the selected districts in Indonesia. Between 2016 and Minapadi model compared to monoculture 2018, the government allocated at least IDR 18 billion system – about 10% to 11% higher (Sudiarta (approximately USD 1.3 million) of state budget et al., 2016). (APBN) to scale-up Minapadi in at least 580 hectars throughout 30 districts in Indonesia. In 2019, the The design of fish trenches and a deep MMAF allocated IDR 12 million (approximately USD pond also play a key part in increasing 849,337) to develop Minapadi in a total of 400 hectars soil accessibility for the fish, which in turn in 27 districts (MMAF, 2019). facilitates nutrient uptake by rice when the fish releases nutrients from the soil. This The new Minapadi model is distinguishable from occurs either by disturbing the soil-water traditional rice-fish farming by the row spacing of interface or by making the soil more porous. the rice plants, the design of the field, including fish Increased soil accessibility also allows the trenches and a deep pond, and the formation of fish better access to weeds, which is recycled farmers’ groups (Box 16). into nutrients when the fish graze on the weeds. Overall, fish contribute to mineral availability in the field, such as nitrogen and phosphorus, which are essential for rice plant growth and production (Halwart & Gupta (eds), 2014). One other key feature of this Minapadi model is the construction of a deep pond, measuring 80cm in depth and taking up a maximum of 20% of field space. Although the deep pond utilizes space which could be used for rice planting, the deep pond plays an important role in rice-fish farming, including providing protection for the fish, increasing access to the rice field, facilitating the fish harvest, and containing fish during rice harvest. The loss of space due to the deep pond is off-set by the increased rice productivity. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 99 FARMERS TROUBLESHOOT COMMON PROBLEMS Another distinguishable feature of the new Minapadi capacity building, networking, monitoring and model is the formation of rice-fish farmers’ groups. evaluation, and supervision through the help of on- site extension officers. This is in fact, a key success factor of the renewed Minapadi program. By forming a rice-fish farmers’ Recognizing that the initial start-up cost and group, the farmers in the community were able to technical knowledge requirement are major hurdles maximize available manpower to modify existing rice for most farmers, the MMAF developed a government fields or build new ones to the required specifications, assistance scheme that makes it easier for groups of work together to troubleshoot common problems, farmers to request assistance from the government capitalize on economies of scale for fish seed (Figure 19). (the term for young fish), fish feed, equipment and other purchases, and help each other out during In addition, the MMAF and FAO have joined forces critical periods throughout the farming cycle. In with the local marine and fisheries district office to Sleman district, in addition to the main secretariat build demonstration farms for rice-fish farming at of the farmers’ group (which includes the head, pilot sites. These demonstration farms assist the secretary and treasurer), there are working clusters groups of farmers through the entire program cycle that are responsible for tasks such as irrigation, (Table 3) to give hands-on experience to the rice-fish field and harvest security, marketing and program farmers. To date, 685 hectares of demonstration sustainability. The formation of rice-fish farmers’ farms, used by 96 farmers, have been developed. group also allows the MMAF and local marine These include locations such as Sleman district and fisheries offices to channel assistance more in Yogyakarta Province, Tabanan district in Bali effectively. Province, and Sukoharjo district in Central Java. The MMAF Minapadi program is aimed at increasing The Ministry of Marine Affairs and Fisheries the income of farmers through rice-fish farming, and assistance program aims to increase the uptake increasing fish consumption among farmers and of the Minapadi Program. The assistance includes community. Since its inception, the MMAF and the proposal submission; identification, selection and local marine and fisheries offices have given strong verification of candidates; selection of beneficiary; backing to ensure the success of the new Minapadi pooled procurement process, and distribution of program. The support includes technical assistance, services, assistance and goods to the beneficiary. 100 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING Figure 19: Government assistance mechanism Proposals fulfilling criteria is Community groups submit Identification, selection and submitted to Commitment Officer Selected candidates are proposals to the MMAF or the local verification of proposals by and DG of Aquaculture to be announced in a decree published government authorities selected via website: www.kkp.go.id The provider carries out the Procurement of government Items and goods channeled to procurement of goods according to assistance is carried out via recipient of assistance through the contract and channels auction local authorities assistance directly to recipients, assisted by technical unit or third parties MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 101 Table 3: Minapadi program cycle Phases Preparatory phase Rice-fish farming phase Post-harvest phase Key activities 1. Location selection 1. Rice planting according 1. Monitoring and to jajar legowo method evaluation of rice- fish farming 2. Selection of partner fish 2. Rice field fertilizing, 2. Product marketing farmers (consisting of typically conducted one farmers without prior to two times per harvest fish farming experience) cycle (non-rice-fish and formation of working farming field fertilization groups and clusters is two to three times per harvest cycle) 3. Orientation, 3. Wire installation, on 3. Financial management preparatory meetings periphery of field and for sustainable program and discussions on top of field for implementation predator prevention 4. Procurement of 4. Fish seed stocking necessary equipment (typically 3-4 fish/ and materials including m2, on 7th - 10th day fish seed, fish stock and after rice planting) suitable pesticides 5. Land preparation 5. Harvesting (either fish including deep pond and followed by rice, or trenches construction, rice followed by fish) land fertilization and irrigation arrangements according to FAO technical guidelines A BOOST TO FARMERS’ INCOME Even with higher overall cost from fish seed and feed procurement, rice-fish farmers still reported higher The new Minapadi program has increased farmers’ revenue compared to rice farmers due to the income incomes. generated from the sale of the fish. For example, in Widodomartani, Wedomartani and Bimomartani Results from many sites have demonstrated that Ngemplak villages in Yogyakarta Province, the profit rice-fish farming leads to improved rice productivity from rice-fish farming was estimated at IDR 43 million and better fertilizer efficiency. (approximately USD 3,200) in one cycle per hectare. In neighbouring villages, the profit was estimated at The profit margin from rice sales is also higher due IDR 53 million (approximately USD 4,000) in one cycle to a higher selling price - rice from rice-fish farming per hectare or over 3 to 4 months (Bidang Perikanan, is marketed as healthier due to low pesticide use. 2016). 102 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING CHANGING ATTITUDES The technical challenges of the Minapadi program are described in Box 17. Despite continuous efforts to promote rice- fish farming in Indonesia, there are significant programmatic, behavioral and technical hurdles to Box 17: Technical challenges are also overcome. common in the Minapadi program One major challenge that affects the success of the Challenges include ensuring appropriate fish program is the difficulty in garnering adequate interest trenches specifications; proper selection from potential rice-fish farmers. Although most of rice type and quality and use of suitable farmers who tried rice-fish farming are convinced fertilizers; appropriate and quality use of once they experienced the increase in income, it is fish seed, including uniformity of spreading still difficult for non-initiated farmers to depart from seeds and protecting rice and fish from the traditional way of rice farming. natural predators and pests. With the help of field extension officers, the MMAF provides “It is a big challenge to overcome. Most rice farmers guidance and capacity building for farmers to are not convinced that culturing fish along with rice will overcome these technical issues. The MMAF increase rice production, especially since a significant also play a key part in providing quality amount of land has to be allocated for fish farming. fish feed and helping set up a network of It is challenging to change this perception, as most qualified suppliers of fish seed such as local (farmers) need to observe this before they can believe technical implementing units for freshwater it”, said Dian Sukmawan, from the Directorate General culture. In addition, the MMAF has been also for Aquaculture, MMAF. working with the Ministry of Public Works and Housing to create a technical irrigation policy The MMAF hopes to overcome this by setting up to provide guidance on irrigation and water demonstration farms in selected spots, but has found management issues, and with the Ministry of the demonstration farms are not always successful in Agriculture to provide potential farmland and raising the interest of the farming community in rice- to produce a better inputs for the Minapadi. fish farming. One potential solution is to introduce Minapadi as a national program in the hopes that it will garner more sustainable support and interest. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 103 RICE-FISH FARMING’S NUTRITION POTENTIAL Improving nutrition through increased consumption 2. Assess the context at the local level, to design of fish among farmers, families and communities appropriate activities to address the types and remain a significant challenge to overcome in the causes of malnutrition. For example, taking into Minapadi program. consideration the local nutrition status when considering Minapadi demonstration sites or The common perception is that improved availability scale-up sites. and accessibility of fish results in an increase in fish consumption in the household and community. 3. Target the vulnerable and improve equity However, this does not take into account that the through participation, access to resources and main driver of rice-fish farming adoption is the decent employment. For example, ensuring opportunity to earn extra income. Market prices could the government assistance mechanism for dictate that all the marketable fish are sold, with Minapadi is accessible to families in vulnerable none consumed by the farmer’s household. Likewise, populations, or 1,000 days households. marketable fish could also be sold to cities where the demand - and thus, prices - of the fish is higher. 4. Collaborate with other sectors and programs. This challenge is not unique to the Minapadi program For example, collaborating with the health sector and Indonesia (Halwart & Gupta (eds), 2014). Aware for nutrition promotion and education, and the of this significant challenge, the MMAF is planning education sector to introduce fish into school to assess the link between Minapadi and improved feeding programs. nutrition in the near future. 5. Empower women. For example, by including Recognizing the intricacies of improving fish women within the Minapadi program either in a consumption - and thus nutrition - is the first step farming role or other roles. Research has shown in addressing this program challenge. The next is that empowering women has a positive impact on understanding that addressing nutrition through nutrition because women are most likely to direct rice-fish farming will involve making the agriculture- resources and income towards food, education, aquaculture system more nutrition-sensitive (see health, and care. Box 18 for definition of nutrition-sensitive agriculture and food systems).38 This will enable the Minapadi 6. Improve processing, storage and preservation to program to contribute to improving nutrition and retain nutritional value and food safety, to reduce health more efficiently. Some ways to improve seasonality and post-harvest loses, and to make the nutrition-sensitivity of the Minapadi program healthy foods convenient to prepare. For example, include39: by ensuring the Minapadi program contributes to a nutrition-sensitive food value chain. 1. Incorporating explicit nutrition objectives and indicators into the program design. For 7. Expand market access for vulnerable groups, example, incorporating indicators that assess particularly for marketing nutritious foods. For fish consumption among households and example, by making sure 1,000 days households, communities. school-going children and adolescent girls in the community have access to marketable fish. 38 Nutrition-sensitive interventions are those that address the underlying determinants of fetal and child nutrition and development - food security; adequate care-giving resources at the maternal, household, and community levels; and access to health services and a safe and hygienic environment and incorporate specific nutrition goals and actions (Ruel & Alderman, 2013). 39 Adapted from (FAO, 2017). 104 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 8. Incorporate nutrition promotion and education. For example, through interventions that ensure Box 18: Definition of nutrition-sensitive increased fish and rice production and/or income agriculture and food systems translates into improved diets and improved nutrition status. One such intervention include Nutrition-sensitive agriculture is an approach interpersonal communication and cookery classes that seeks to ensure the production of a that empower the caregiver to prepare nutritious variety of affordable, nutritious, culturally meals for the whole family with a special focus appropriate and safe foods in adequate on small children, while addressing food-related quantity and quality to meet the dietary taboos and beliefs that affect food choices and requirements of populations in a sustainable distribution in the household. manner. The recognition that addressing nutrition requires taking action at all stages of Currently, the MMAF Minapadi program is the food chain - from production, processing, collaborating with the Ministry of Agriculture, retail to consumption - has led to a broader Ministry of Public Works and Housing, donor focus which encompasses the entire food partners and also local marine and fisheries system. departments. Source: (FAO, 2017) It is important that the Minapadi program from MMAF collaborates with the Ministry of Agriculture, especially the Ministry of Agriculture’s own rice-fish such as providing food sources originated from rice and farming program. fish, where it can also produce organic rice that is free of pesticides. Meanwhile, from an economic perspective, The aim is to find more synergies including with this system can increase fish production that leads to other stakeholders such as the Ministry of Health the increase of farmers’ income.” and Ministry of Education, as well as their local counterparts. This would lead to boosting availability, “The Directorate General of Aquaculture will continue access, and consumption of nutrient-dense and high- to support rice-fish farming activity by allocating quality diets for 1,000 days households, school-going additional budget from the national budget (APBN) and children, adolescents and vulnerable populations. work together with the FAO, Ministry of Agriculture, Ministry of Public Works and Public Housing, banks, StraNas Stunting provides the perfect platform to etc to develop the program. It is expected that there accelerate coordinations such as these. will be more rice-fish farming activity in many areas in Indonesia in the future, therefore national nutritional While the scaling-up of the MMAF’s Minapadi needs as well as national food security can be ensured,” program can be challenging, there is much potential he said. in addressing the underlying determinants of child nutrition, as well as food security in Indonesia One thing is for sure. For farmers and their families, through the Minapadi program. the fish swimming in their rice paddies are welcome guests. “Indonesia needs to continue to develop rice-fish farming to support national food Not only do they help the rice crop to grow strong security. Indonesia is one of the countries but their children too. And in the fight against chronic that has sucessfully developed rice-fish farming system malnutrition, that means the Minapadi program is nationally,” said Dr. Ir. Slamet Soebjakto, the Director swimming in the right direction. General of Aquaculture, MMAF. “Through this system, there are many benefits and positive values obtained, MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 105 106 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING STRACOM: CHANGING BEHAVIORS THROUGH EFFECTIVE COMMUNICATION President Joko Widodo, has elevated the issue of campaign for stunting prevention. StraCom provides stunting reduction to a national priority that is central guidance to related stakeholders in developing to Indonesia’s human capital development.40 The local strategies to implement behavioral change country developed an official package of “Integrated communication to accelerate stunting prevention at Nutrition Interventions (INI) for Stunting Prevention the provincial, district, city and village levels. StraCom and Reduction” in late 2017. Then, President Widodo describes the target recipients and messages related launched the National Strategy to Accelerate to behavioral changes, and other technical elements, Stunting Prevention (StraNas Stunting) in 2018, such as platforms for interpersonal communication, with an initial focus on 100 priority districts with the choice of communication channels, and policy highest stunting prevalence rates in the country. advocacy activities. STRACOM CONTRIBUTION TO STRACOM STRATEGIC THE NATIONAL STRATEGY FOR PLANNING PROCESS STUNTING PREVENTION The strategic planning process starts with A general lack of awareness about stunting and its collaborative joint planning across sectors at the consequences, combined with scattered policies national level, followed by the provincial and district for stunting prevention, especially those focusing levels. The Ministry of Health, specifically the Health on Behavior Change Communication (BCC) and Promotion Directorate, is responsible for leading the inter-personal communication (IPC), have been coordination and planning of the Behavior Change acknowledged as some of the main causes for Communication (BCC) strategy at both the national stunting. Therefore, the National Behavior Change and subnational levels. Meanwhile, the Ministry Communication Strategy (StraCom) for stunting of Communication and Information Technology, in prevention was introduced in October 2018 to collaboration with the MoH, is responsible for national address these factors. Led by the Ministry of Health mass campaign to improve awareness of stunting. and the Ministry of Communication and Information The key steps for developing a behavior change Technology at national level, StraCom builds upon communication strategy includes: a) analyzing Pillar 2 of StraNas’s 5 Pillars for stunting prevention. the situation b) determining the target group c) defining key messages d) developing communication The objective of StraCom is to increase public approach e) managing communication channels and awareness and change people’s behavior related to f) designing communication materials. stunting prevention. StraCom includes strategies for: a) campaigns and outreach at national and subnational MILESTONES level b) improving interpersonal communication skills for health care provider and kaders c) advocating The development timeline of the StraCom is described decision makers to give stunting reduction a high in Figure 20. StraCom was introduced in October priority and to adequately develop regulation to 2018, led by the Ministry of Health as the follow up implement stunting prevention programs and from StraNas Stunting. In November 2018, StraCom behavior change communication strategy. StraCom was introduced to 100 priority districts during the is jointly coordinated by the Ministry of Health for National Technical Coordination Meeting (Rakornis) behavior change communication, and the Ministry for Health. Those priority districts were expected of Communication and Information for the national to establish their localized regulation for StraCom implementation. 40 Plenary Meeting with House of Representative on August 16, 2016 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 107 108 Figure 20: StraCom development timeline Kick off Meeting Alignment BCC key Capacity building workshop messages led by MoH for BBC facilitators introduction of StraCom led by Promkes MoH Alignment of DLi 6 targets Capacity building workshop between Vice President for Health agency (Dinkes) Coordination Meeting for Development of iPC Module Office Secretariat staffs East Java and NTT StraCom led by Bappenas (Setwapres) and World Bank OCTOBER NOVEMBER FEBRUARY MARCH APRIL MAY JUNE OCT/NOV/DES 1 2018 2 2018 3 2019 4 2019 5 2019 6 2019 7 2019 8 2019 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING Coordination meeting within Regional capacity building Socialization of six priority internal with MoH Health Alignment BCC key workshops behaviors during Rakornis Directorates messages led by MoH 2019 implementation guideline DLi 6 introduction during and branding guidline National Technical review by MoH Coordination Meeting (Rakornis) 2018 iPC orientation to district governments StraCom socialization to 100 districs At the national level, an Inter-Personal Communication understanding that effective BCC implementation can module was developed and six priority behaviors were only occur if it is carried out in a convergent manner selected as the main focus for stunting prevention. across multi-stakeholders. To date, implementation The behaviors include: 1) iron folic acid consumption guidelines for district StraCom implementation and for pregnant women 2) antenatal care visits 3) campaign branding guideline have been drafted and appropriate infant and young children feeding – early are under review. This is being led by the Ministry of breastfeeding initiation, exclusive breastfeeding Health. for 6 months, and appropriate complementary feeding starting at the age of 6 months 4) Posyandu OPPORTUNITIES AND attendance 5) proper hand washing and 6) use of CHALLENGES healthy latrines. Opportunities include regional technical assistance A capacity building workshop for BCC facilitators at through WhatsApps (WA) groups. WA groups have the national level was held in April 2019. The main been established after the regional workshops (West, objective of the workshop was to: 1) strengthen Center, and East). The purpose of the WA groups is the capacity of Ministry of Health staff in the to coordinate with districts on the development of development of district StraCom and to enhance regulations, district StraCom, and inter- personal quality supportive supervision to the priority districts, communication activities. In addition, the WA and 2) collaboratively design BCC Implementation groups were also used to share information, ideas, Guidelines for the district level BCC strategy. This best practices, and lesson learnt. This WA group is national level workshop was followed by capacity managed by the Health Promotion Unit within the building workshops for the District Health Office Ministry of Health. in East Java and East Nusa Tenggara led by the national BCC facilitators who were trained in April Districts can work together in a multi-sectoral 2019. Important lessons were learnt from both manner to develop their local BCC strategy and the national and district workshops, such as: 1) its implementation. However, key challenges in building knowledge and capacity of the Ministry of coordination among multiple stakeholders, as well Health team to understand BCC and its development as development and implementation of local BCC, process 2) building the knowledge and capacity of remain. the district team to develop their local BCC strategy, 3) creating opportunities for potential collaboration There is a need for greater coherence across related with multi-stakeholder to work together on the local stakeholders, both at national and subnational level. BCC strategy in greater detail, and 4) identifying Currently, multi-sectoral coordination, both at national key gaps in the national StraCom to be further and sub-national levels, is still not being fully aligned. strengthened and revised (i.e. key priority behaviors, Continuous communication from the leading sector behavior indicators, key messages, program/behavior (MoH) still needs to be strengthened. While there indicators). have been efforts in facilitating coordination among key related stakeholders, some continue to operate In May and June 2019, the Ministry of Health in siloes. started the alignment process of BCC key messages along with the Vice President’s Office, Ministry of Operationalizing the local district StraCom is the next Communication, Bappenas, and Ministry of Home big challenge. There is a need to improve national Affairs. The final six key messages are undergoing and subnational resources and capacity to develop pretesting. Three regional technical assistance sound and effective BCC intervention for stunting workshops (West, Center and East) for developing prevention, as well as communication skills (e.g., district behavior change regulations were conducted interpersonal communication, counseling), to ensure in the last quarter of 2019. In general, the workshops adequate BCC implementation at both national and increased awareness and knowledge about the subnational levels. importance of BCC and the need for strengthening BCC regulation and strategies, and increased MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 109 REDUCING STUNTING THROUGH PROGRAM KELUARGA HARAPAN (PKH) In 2007, the Indonesian government-initiated Program The baseline survey in 2007 was designed as a Keluarga Harapan (PKH) or Family Hope Program, a randomized evaluation at the sub-district level - assigning conditional cash transfer (CCT) program, rolled out in 360 sub-districts into 180 treated and 180 control areas seven provinces, before becoming a national program - in which selection of eligible sub-districts was based in 2013. on characteristics including prevalence of malnutrition, poverty rates, school drop-outs and availability of health PKH initially targeted the poorest households, and education facilities. especially those with pregnant and lactating mothers, children below the age of 6 and school-aged children Researchers found that six years after PKH was up to middle school. However, in 2014, the Indonesian introduced, it continued to promote health and educational government expanded the program to also include investments in children. the non-poor including people with disability and the elderly, reaching as many as 10 million families in Children of PKH beneficiaries experienced large reductions 2018. in stunting, by 9-11 percentage points (23-27% percent reduction in the probability of being stunted) relative to the To access benefits, beneficiaries are required to meet comparison group, where 39% of the group reported cases a range of health and education conditions, including of stunting. PKH also reduced severe stunting by roughly attending pre- and postnatal check-ups, undergoing 10 percentage points (45%) relative to the comparison assisted delivery, bringing children to monitor their group, where 18% of households reported children with growths at the Posyandu, fully immunizing children, severe stunting. The effect was slightly larger among boys and complying with school enrollment and attendance than girls. Notably, these impacts on stunting were not requirements. Trained facilitators visit households to observed two years following the program, but only six verify that they meet these conditions. years after implementation. Researchers suggested the effects on stunting were driven by prolonged attention to In 2009 the World Bank conducted an impact weight and nutrition during the early lifecycle of children evaluation which may have captured some of PKH’s whose parents received cash transfers. Households incentivized behavior indicators in the short-term. who received the PKH cash transfer also increased their utilization of a number of health services, more likely to However, certain health outcomes, including stunting, have childbirths assisted by trained professionals and might reflect effects over the long-term, which to fully immunize their children six years following the warrants further evaluation. introduction of the program. This motivated the National Team for the Acceleration Mothers who received PKH were 13 to 17 percentage of Poverty Reduction -- Tim Nasional Percepatan points (18 to 24%) more likely to undergo childbirth at a Penanggulangan Kemiskinan (TNP2K) to conduct health clinic compared to the comparison group, who endline survey in 2013 to identify longer-term impact delivered in health facilities 73% of the time. of the program where enumerators revisited all sub- districts and re-interviewed households in baseline As of 2018, the PKH has reached more than 10 million sample, including split households and new household households. But there is still room for improvement, members. To examine those potential long- term and such as ensuring adequate implementing organizations, cumulative impacts of PKH on health, education, and adequate number and quality of PKH assistants and human capital, a team of researchers from TNP2K and sufficient education and health facilities in PKH areas. Abdul Latif Jameel Poverty Action Lab (J-PAL SEA) analyzed the 2013 data from nearly 14,000 households With such improvements PKH can go from strength to across 360 sub-districts in Indonesia. They compared strength not only in tackling poverty, but also in accelerating the results with baseline data collected in 2007. stunting reduction efforts under StraNas Stunting. 110 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING THE LENGTH MAT: “TIKAR PERTUMBUHAN” AN EASY EDUCATION TOOL TO RAISE AWARENESS ABOUT STUNTING41 Ending malnutrition in all its forms is critical. convergence of critical multi-sectoral, evidence- Childhood stunting, a sign of undernutrition and based interventions known to reduce chronic growth poor early childhood development, has life-long and development problems in young children across consequences for individual health, productivity, Indonesia. and well-being. A nation with a high burden of child stunting sees repercussions in human capital and In January 2018, under a pilot project implemented by economic growth (Victora et al., 2008). the Generasi Sehat dan Cerdas (GSC)/Human Capital Program, the Tikar Pertumbuhan or Child Length Mat Measuring the weight and height of infants and was shared with and accepted by stakeholders at children, especially before their second birthday, the Vice-President’s office (Sekretariat Wakil Presiden, is particularly important to early detection of poor Setwapres), the National Development and Planning nutrition. Agency (Bappenas), the Ministry of Health and the Ministry of Village as an inexpensive and easy Regular assessment of a child’s growth and to use tool in the community to help parents and development combined with behavior change community agents visualize linear growth. It aides in counseling, known as growth monitoring and the identification of stunting for children under two so promotion (GMP), can help identify early growth there could be better efforts on stunting prevention. faltering or cases of excess weight gain. The Child Length Mat was developed by The Manoff With adequately trained and supported health Group to help parents and community workers workers, GMP can help caregivers understand and visualize poor linear growth and stunting and trigger address the underlying causes of unhealthy growth. actions to prevent or correct it in children under two There are, however, many challenges in conducting years of age. GMP, including: The mat is poly-vinyl with a head board and has 1. Reliable and accurate measurement and separate sides for boys and girls. Countries determine recording of the measurements is often poor. the periodicity of measurement, but commonly 2. Measurements are not always used to children are measured every three months, starting counsel caregivers about growth and actions from three months of age. The mat clearly shows they can take to protect healthy growth or whether a child’s length, while lying on the mat, is <-2 correct poor growth. Standard Deviation (SD) of the current WHO standard 3. GMP data use for decision-making at all for the child’s age. Validation in Cambodia and levels (from caregiver to national level) to Guatemala showed high sensitivity and specificity prompt action is not always implemented in identifying stunting compared to results when a (World Bank Group, 2019). height board was used. Workers found it easier to use (NOURISH PROJECT, 2016; Nutri-Salud Project, In 2017 Indonesia launched its National Strategy to 2018). The Child Length Mat is being used in Bolivia, Accelerate Stunting Prevention (StraNas Stunting). Cambodia, Guatemala, Indonesia, and Rwanda. In each country, the mat design, the training package, The World Bank under its Human Capital Project is and the guidelines for family and community actions supporting the government in its efforts to enhance are tailored to the local context. Health services, service delivery and accountability at every level of communities, and families find positive benefits. strategy implementation, striving to achieve the 41 Summarized from a final report “Implementation of the Child Length Mat: Assessment and Recommendations” (Griffiths, 2019) MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 111 From January – April 2018, the Child Length Mat FINDINGS AND IMPLICATIONS was developed, tested and reproduced along with a guide book and counseling cue cards for counseling The assessment of the Length Mat pilot was eye- for the Human Development Worker (HDW) under the opening. It demonstrates the importance of taking a Generasi (GSC) Pilot Program. periodic, in-depth look at operations to catch policies or procedures that need realigning and to refine A community score card managed by the HDW implementation. Listening to those implementing added an area to summarize Length Mat outcomes the program, plus direct observation and a detailed for the community’s children under 2 years of age review and discussion of records is crucial to capturing to prompt collective action and accountability. Over an accurate assessment of operations. Of upmost 3,000 HDWs were trained to use the Length Mat and importance for an assessment of this type is an 725 mats were distributed to HDWs to trial in their understanding among all involved that problems villages during Posyandu (community integrated or mistakes are viewed as inputs for learning and health service delivery posts) sessions. improving how the program functions. This can ensure learning and bring us closer to providing what In December 2018, the Generasi (GSC) Pilot Program is needed in different contexts for children to grow to ended. However, in most areas the HDWs continued their potential. working and using the Length Mat with financial support from the local government. This made The evaluation found that the HDWs were able to use early 2019 a good time to assess Length Mat the Length Mat correctly to identify growth faltering in implementation under the pilot. children under two. From April to May 2019 the World Bank supported a However, coverage and use remain limited. review of Length Mat implementation to determine: 1) if use of the Length Mat should continue, and 2) While most HDW used the Length Mat with consistency if so, under what conditions. Given that the Length in a few Posyandu, there was no village in the Mat is a community tool meant to be used as part assessment where the HDWs used the Length Mat in of Posyandu activities, the general operations of the all Posyandu in a village. This could be attributed to the Posyandu also became a subject of this assessment. high number of Posyandu, limited number of available length mats (typically one length mat per village) and The assessment was conducted in three districts time constraints in taking the Length Mat to every (West Bandung, Central Lombok and Ogan Komering Posyandu every month. Therefore, no HDW had used Ilir (OKI))and, among these, in seven sub-districts and the mat with all village children (3-24 months) during 14 villages. Of the 14 villages, 11 had been introduced the pilot. As a result, the assessment could not observe to the Length Mat; three had not seen the mat. the ease and impact of having and presenting growth Thirteen villages had a HDW, nine from the Generasi information quarterly to village leadership and the program and four added by the local government village generally. The full potential of the Length Mat to since the end of Generasi. All 11 villages with a Length create heightened awareness of stunting and action to Mat had a HDW. promote healthy child growth by parents, village leaders and kader has therefore yet to be demonstrated. 112 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING In addition, the length mat was not properly introduced RECOMMENDATIONS AND NEXT to the health sector in each province or sub-district, STEPS leading to misunderstandings about its use. The assessment recommended the following: As a result, some health officers/nutritionists advised 1. Continue to use the Length Mat as a community kader and HDWs to stop using it. And, in most areas education tool to prompt family and community the Length Mat was not properly incorporated into action to improve young child growth. However, Posyandu operations. Rather it was a side activity the Length Mat should be introduced in a different carried out by the HDWs with little involvement of operational context, through the Ministry of the kader or the sub-district nutritionists. The HDWs Health as a part of Posyandu operations with the who received formal training on the use of the Length support of the Ministry of Village. The Ministry of Mat were supposed to train the kader so they could Health will support the revision of the guidelines help the HDWs or use the Length Mat themselves for the Length Mat. during Posyandu, but this did not happen due to some opposition or poor support from the sub-district. 2. Agree on and define the operational integration of the Length Mat into Posyandu operations. Posyandu operations overall, were below minimum Convene a meeting between the key actors who quality standards, further hindering efforts to find and support Posyandu and those with experience correct early growth faltering. with the Length Mat. At a minimum the following should be considered: one length mat per Posyandu, easy procurement of standard Counseling offered by the kader either was not done (quality) Length Mats using Village Funds (Dana on a regular basis or was done superficially. Even if the Desa), integrating Length Mat and weight gain sub-district nutritionist was present at Posyandu, they outcomes when counseling families, providing did not fill the counseling gap. training and job-aids for HDWs, Kader, and health staff, etc. The new KMS (child growth card) is the bright spot in Posyandu operations as it reinforces and makes 3. Strengthen the link between convergence it easier for the kader to detect early growth faltering programming and growth outcomes: using adequate weight gain, although detection is not ⃣ Make stunting information visible for yet prompting actions. Child growth information, even village decision-making and heightened adequate weight gain, is not yet being used at the accountability of village leaders and Posyandu or community level for local problem solving local health personnel. Build the HDW’s or investment decisions. confidence to lead a discussion about trends in stunting rates and needed action to ensure that every child is experiencing healthy growth. ⃣ Review the home visit protocol and ensure a strong link between the HDW programming and that of the kader, Posyandu and Bidan (village midwife) to bring needed support to families struggling with child feeding and general child care issues. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 113 04 CHAPTER 4 INDONESIA IS MOVING FORWARD 114 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING Indonesia is moving forward! The world’s largest of stunting and a higher chance of reaching their archipelago, in all its diversity, has shown a unity full potential. That in turn unlocks the potential of purpose in tackling the scourge of stunting. With of every community and the whole of the country. each step it moves closer to successfully halving stunting rates in less than a decade. ⃣ Collaboration: The key to success in reducing rates of stunting is coordination and The length and breadth of the country, a blend of local collaboration. Indonesia owes much of its determination, regional multisectoral coordination success to a multisectoral approach. It is using and national leadership has paid off. From East an all-of-government and all-of-society approach Kalimantan, Central Java and East Java to Sulawesi, to prevent stunting. With the help of 23 ministries, West Nusa Tenggara and East Nusa Tenggara, local provincial governments, district and sub-district heroes have played their part in this story of success. governments, academia, NGOs, development partners, and private sectors Indonesia is moving From midwives and fish farmers to nutritionists the whole nation forward, calling on everyone and community leaders, local champions in the to work together everywhere to reduce rates of fight against stunting have translated a nation’s stunting. aspirations into reality. These champions, from all walks of life and every corner of the country, took ⃣ Diversity: There are many and diverse ways different approaches to tackle the same problem. to tackle stunting. This openness to diverse approaches holds the promise of moving a This book, however, is more than a story of standalone diverse country like Indonesia forward more successes. quickly. It shows that small initiatives can make a big impact. From better nutrition, sanitation, health and education, their endeavors have culminated in a picture of ⃣ Environment: This book shows what a country collective achievement. They present a bigger can achieve when it has the confidence to picture of best practices and lessons learned from empower local people to find local solutions nutrition programs in Indonesia. This book celebrates to national problems. That means creating their achievements but also identifies some of the an enabling environment for new ideas and common characteristics which have contributed to approaches to be tried, tested, and thrive. When results locally, regionally, and nationally: cities and regions are given sufficient freedom, trust, and resources they can make an enormous ⃣ Commitment: Indonesia has committed contribution to achieving national strategic significant time, energy, and resources to boost goals. Showing confidence in the ability of local health, education, and social protection, including people to find locally appropriate and effective the National Strategy to Accelerate Stunting solutions to tackle stunting is one of the key Prevention (StraNas Stunting). As in other takeaways from this book. When an enabling countries, such as Peru, political commitment to environment - including local regulations, improving health and wellbeing of mothers and funding sources, adequate platforms and trained children in the first 1,000 days of life has been human resources for coordination, as well critical to success. Children who eat adequate as convergence - is created, the districts are nutritious food, have access to good healthcare, well placed to offer local solutions to tackle a clean water, and sanitation, and are given proper nationwide challenge. care and early stimulation face much lower risk MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 115 ⃣ Sustainability, Support & Scale: Small initiatives gains in poverty reduction, cutting the poverty rate by can only have a big impact when they are more than half since 1999, to 9.78% in 2020 (World supported. They must be supported to achieve Bank, 2021). sustainability and scale, including by the national government, development partners, Prior to the COVID-19 crisis, Indonesia was able to academia, civil society organizations, local maintain consistent economic growth, qualifying the communities, and businesses. They must be part country to reach upper middle income status between of an integrated and systemic approach to make July 2020 to June 2021. Despite the challenges of a lasting difference. At the end of the day, scale COVID-19, Indonesia’s commitment to driving down matters, no matter how successful individual rates of stunting remains undiminished. In 2000 initiatives are locally. around 40% of children in Indonesia were stunted. By 2019 this had fallen to just over 27%. The goal now is This book is about local heroes, from midwives and to accelerate current reductions as also mandated in healthcare workers to district and central government Presidential Decree No. 72/2021 on Acceleration of officials. But it is also the story of a nation. The Stunting Reduction. Indonesia aims to reach all 514 largest economy in Southeast Asia, Indonesia – a districts in the country by 2022 through a convergent diverse archipelago nation of more than 300 ethnic approach as part of a drive to tackle stunting in groups – has charted impressive economic growth provinces, districts, and villages across Indonesia. since overcoming the Asian financial crisis of the late 1990s. Today, Indonesia is the world’s fourth most Indonesia is moving forward. With each step, it moves populous nation, the world’s 10th largest economy in closer to reducing stunting rates to levels almost terms of purchasing power parity, and a member of inconceivable a decade ago. Indonesia can do it! the G-20. Furthermore, Indonesia has made enormous 116 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING REFERENCES Alderman, H., Behrman, J., & Puett, C. (2017). Big Numbers about Small Children: Estimating the Economic Benefits of Addressing Undernutrition. 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Human capital index and components. https://www.worldbank.org/en/data/ interactive/2018/10/18/human-capital-index-and-components-2018 World Bank. (2018b). Indonesia Investing in Nutrition and Early Years (Project Appraisal Document Report No. PAD2796). World Bank. (2019). Prevalence of stunting, height for age (% of children under 5). https://data.worldbank.org/ indicator/SH.STA.STNT.ZS?locations=ID World Bank. (2020a). Indonesia Economic Prospects: The Long Road to Recovery. The World Bank Indonesia Office. http://documents1.worldbank.org/curated/en/804791594826869284/pdf/Indonesia-Economic- Prospects-The-Long-Road-to-Recovery.pdf World Bank. (2020b). Spending better to reduce stunting in Indonesia: Findings from a public expenditure review. The World Bank Indonesia Office. World Bank. (2021). Overview. The World Bank in Indonesia. https://www.worldbank.org/en/country/indonesia/ overview World Food Programme. (2009). Food Security and Vulnerability Atlas 2009. World Health Organization. (2004). Clinical management of acute diarrhea (WHO/UNICEF). World Health Organization. World Health Organization. (2018). Building the primary health care workforce of the 21st century. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 121 122 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING ANNEX 1: STUNTING PROJECTIONS FOR INDONESIA 1. INTRODUCTION Investment in nutrition in the early years is key to HCI of 0.67 and 0.6, respectively (Alderman et al., improving human capital. Nutrition investments 2017; Hoddinott et al., 2013; Horton et al., 2010; particularly in the first 1,000 days of a person’s life are World Bank, 2018a, 2020b). cost-effective and promise high economic returns. Stunting is considered a good proxy for measuring Stunting reduction is a high priority for the cumulative nutritional deprivation that begins in the Government of Indonesia and motivates the launch womb. Indonesia’s under five stunting rate of 30.8% of Indonesia’s ambitious National Strategy to in 2018 is high relative to comparator countries in the Accelerate Stunting Prevention (StraNas Stunting) region and by income as depicted in Figure 21. For with a multi-sectoral and coordinated approach its level of per capita income, we could expect the at the national, regional and community level. stunting rate to be about 15%, closer to Sri Lanka’s This chapter explains the methodology adopted 13%. This is also reflected in its Human Capital Index in modeling projections of stunting in Indonesia.43 (HCI),42 a representation of a country’s productivity The details refer to the national level model and add potential. Indonesia’s HCI score of 0.53 indicates reference to calculations at the district level.44 The that the productivity of Indonesia’s future workforce district-level model serves as a hypothetical case will be just above 50% of what it could be given the and the calculations use national level assumptions right inputs. It falls below Vietnam’s and Thailand’s in the absence of district-level data.45 42 HCI captures five indicators of health and education – probability of child survival till age 5, expected years of school, quality of learning (harmonized test scores and learning-adjusted years of school), proportion of under five not stunted, and adult survival rate. 43 A version of the model incorporating the impact of COVID-19 has also been prepared and is currently being updated. This chapter has accompanying excel files for modelling national projections and an experimental template for district projections. For more information regarding the accompanying files and template, please contact the World Bank Office Jakarta. 44 The national level model was described in “Aiming High: Indonesia’s Ambition to Reduce Stunting”(Rokx et al., 2018). 45 The district chosen for the example is Timor Tengah Selatan (TTS) in East Nusa Tenggara or Nusa Tenggara Timur (NTT) Province. The district has a stunting rate of 58.7% in the under fives in 2019 according to the most recent BPS Statistics published in 2020 (the data for under two stunting is not available) and a population of 465,477. Given its relatively large population, the sample of households with children under the age of two covered for TTS in the Riskesdas survey is sufficient to generate statistically reliable estimates. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 123 Figure 21: Stunting rate in Indonesia relative to comparator countries Stunting prevalence (%), latest year available vs GNI per capita (USD) 2017 Stunting prevalence (%), latest year available vs GNI per capita (USD) 2017 60 Papua New Guinea 50 Nigeria % Stunting among children under-5 40 Ethiopia India Philippines Cambodia Djibouti Mali Indonesia 30 Myanmar Vietnam Malaysia Ghana 20 Sri Lanka Thailand 10 China 0 0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000 GNI per capita (Atlas method) Source: World Bank, 2020b; Based on World Development Indicators data for 2019; Indonesia value from Riskesdas 2018 (NIHRD, 2018). 2. TARGET AREAS AND SCENARIOS The Government’s strategy prioritized 100 districts The baseline stunting rate assumed is the 2019 with high stunting rates in its first phase in 2018. under two national stunting rate of 26.6% (NIHRD, The model’s base year is 2019 when the number of 2018, 2019).46 The projected stunting estimates are districts targeted were increased to 160 reaching the calculated for the period 2020-203047 focusing on the national coverage of 514 districts by 2022. Modeling first 1,000 days of a child’s life under three scenarios: projections of stunting form an important tool in Business as Usual Baseline (BAU Baseline), National tracking progress in achieving the goals set out. Strategy Realistic (StraNas Realistic) and National Strategy Optimistic (StraNas Optimistic). 46 Riskesdas 2018 reports the under two stunting rate of 29.9% and an under five rate of 30.8%. SSGBI-SUSENAS 2019 reports the under five rate at 27.7%. Our team calculated the 2019 under two stunting rate of 26.6% by applying the ratio of the under five and under two rate to the under five rate. 47 The projections consider interventions to take effect in the subsequent year. Thus, any interventions rolled out in 2019 will take effect in 2020. 124 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING The Baseline scenario projects stunting based on 3. INTERVENTIONS TO REDUCE the trend in stunting decline from 2000 to 2018 of an STUNTING average of 1.52% annually (see Table 4).48 This decline is based on the assumption that the Government The nutrition specific interventions cover one does not employ any additional interventions or step antenatal intervention – iron and folic acid (IFA) up its current coverage to reach a larger fraction supplementation - focusing on pregnant mothers, of the population. The Realistic scenario assumes and four interventions for the 0-2 year olds – additional coverage of 5% for a set of interventions exclusive breastfeeding (BF) counseling, zinc as identified in Table 5.49 The Optimistic scenario adjunct therapy, vitamin A supplementation, and assumes the same set of interventions as the complementary feeding counseling. The nutrition Realistic scenario with a 10% increase in coverage. A sensitive interventions include conditional cash complete list of interventions is presented in Table 5. transfers, food assistance using the impact of having an egg a day on stunting, and behavioral changes in water and sanitation hygiene. Table 4. Stunting decline calculations for Business as Usual Scenario Under 5 stunting rate in 2000a 42.4% Under 5 stunting rate in 2007b 36.8% Under 5 stunting rate in 2013b 37.2% Under 5 stunting rate in 2018b 30.8% Number of years of decline 18 Percentage point decline from 2000-2018 = Stunting rate in 2018 - Stunting rate 11.6 in 2000 Percentage change from 2000 to 2018 = Percentage point decline from 2000 to 27.4% 2018/Stunting rate in 2000 Per year stunting decline = Percentage change in stunting over 2000-2018/No. of 1.52% years World Bank, 2019; bRiskesdas (NIHRD, 2007, 2013, 2018) a 48 We use the time series for the national under five stunting rate rather than under two since the data for the latter was not available. However, the pattern of decline for the two age groups is expected to be the same over the period. 49 There was a 15% increase in IFA coverage over two years from 33% in 2016 (NIHRD, 2016) to 38.1% in 2018 (NIHRD, 2018). We take a conservative approach and assume an optimistic increase of 10% and a realistic increase of 5% for the different interventions. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 125 Table 5. Interventions identified for the model and current coverage Interventions Impact identified in the literature Current coverage Nutrition-specific Decline in stunting due to 38% 90+ IFA tablets, -9 to -6 reduction of low birthweight months (pregnancy) (NIHRD, 2018) (Peña-Rosas et al., 2012) Decline in stunting due to a decline 4% Exclusive breastfeeding in diarrhea incidence (Black et al., counseling, 0-6 months (World Bank, 2018b) 2013; Lamberti et al., 2011) Zinc as adjunct Decline in stunting due to a decline 37% therapy during in subsequent episodes of diarrhea diarrhea episodes (Baqui et al., 2002; Black et al., 2013) (Statistics Indonesia et al., 2017) Decline in stunting due to a decline 76% Vitamin A in diarrhea incidence (Bhutta et supplementation (NIHRD, 2016) al., 2013; Black et al., 2013) Decline in stunting as a direct effect of 36% Complementary feeding improved nutrition from complementary (World Bank, internal education counseling feeding practices (Lassi et al., 2013) communication) Nutrition-sensitive Decline in stunting indirectly 10% Conditional cash due to better purchasing power (Government of Indonesia; World transfers (Cahyadi et al., 2018) Bank, internal communication) Decline in stunting due to direct effects Egg-a-day of micronutrients in eggs (Iannotti, Poorest 25% of the population Lutter, & Stewart, 2017; Ilman, 2019) Water, sanitation, and Decline in stunting due to decline in hygiene behavioral diarrhea incidence (Black et al., 2013; Proxied by WASH infrastructure counseling Waddington & Snilstveit, 2009) We assume that nutrition-specific interventions Since we consider the impact of zinc on diarrhea as are mutually exclusive. The antenatal interventions an adjunct therapy in the treatment of diarrhea and are independent of all the other interventions as not as a regular supplement, we do not incorporate the period of intervention is different. Exclusive the synergistic effect of zinc on vitamin A. Zinc breastfeeding impact is also independent of the deficiency can limit the bioavailability of vitamin other two impacts in the 0-2 year old period as the A, thus zinc supplements are also given to aid in intervention is restricted to the 0 to 6-month period, resolving vitamin A deficiencies (see, for example, different from zinc and vitamin A supplementation, (Rahman et al., 2002)). If zinc is used as a regular which takes effect after the age of 6 months. supplement, it would also invoke the synergistic 126 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING effect of zinc on vitamin A. Children receiving zinc currently in effect in Indonesia.51 Following Black are those who are treated for diarrhea, as an adjunct et al., 2013 we assume that 20% of all stunting therapy and is not given as a regular supplement in is attributed to intra-uterine growth retardation, Indonesia. It is worth noting that there is negligible resulting in low birthweight or small for gestational zinc deficiency in Indonesia because the Indonesian age babies. This is the proportion of babies that will soil is rich in zinc and likely also because wheat flour be stunted pre-intervention. We apply the benefit from and some other foods are fortified with zinc (Diana et IFA supplementation to this percentage, resulting in a al., 2017). 3.8% decline in stunting. The effect of WASH works through a different Effective coverage: The effective coverage of channel - water, sanitation, and hygiene, independent pregnant women consuming IFA, not just receiving of the channel with which vitamin A and exclusive BF it, is 38.1% (NIHRD, 2018). Thus, the discrepancy in are delivered. However, we assume (incorporated in effective coverage is 62%. Assuming there is a 5% the final calculations in the model) that due to the increase in coverage in the first year, the increment simultaneous delivery of a number of interventions, would be 5%*62% = 3.1%. The discrepancy in there is a ‘convergence’ effect and a greater decline coverage would now be 62%-3.1% = 58.8%. In the next in stunting in areas with synchronized interventions year, with new pregnancies, the target would be to (see, for example, (Levinson & Balarajan Y with reduce the discrepancy by another 5%, thus making Alessandra Marini for Peru, 2013; World Bank, the cumulative incremental coverage equal to: 3.1% + 2017b)). The LIST and Optima models subtract the 58.8%*5% = 6%, and so on till the year 2030, reaching possible overlapping effects from their calculations a cumulative incremental coverage of 30.1%. The (see Pearson et al., 2018; N. Walker et al., 2013; total coverage would thus be 38.1% (from before) Winfrey et al., 2011). Thus, for example, they would plus 30.1% or approximately 68% under the realistic subtract the possible effect of zinc and vitamin A scenario. Assuming a 10% incremental increase together, which would be the products of decline in under the optimistic scenario in effective coverage stunting times the coverage for zinc and vitamin A.50 would result in total coverage of 84% by 2030. We We don’t subtract these for the reasons given above. cap the coverage at 70% for the realistic scenario and Instead, we add the effect on a decline in stunting 85% for the optimistic scenario. These limits are not due to convergence, explained further below. reached for either scenario. 3.1 IRON AND FOLIC ACID (IFA) Adjusting for additional coverage the decline in stunting for the incremental group will be 3.1% SUPPLEMENTATION (calculated above) times the cumulative incremental Intervention period: -9 to 0 months coverage for each year. Thus, in the first year, for this incremental group of the target population Assumptions from literature: Supplementation by the stunting decline will be the decline in stunting iron during pregnancy had been found to reduce low attributed to IFA supplementation of 3.8% times birthweight (LBW) by 19% and the results are similar 3.1% = 0.12%. Assuming the rest of the targeted for iron and folic acid supplementation (Bhutta et population will receive the same benefits as before, al., 2013; Peña-Rosas et al., 2012), the intervention we assume a decline in stunting at the same rate as 50 Winfrey et al., 2011 consider the total impact R as: R = 1 – (1 – R1) * (1 – R2). R1, R2 are the impacts of individual interventions such as zinc or vitamin A. 1-R1, or 2 is the probability of that event not occurring. 1 indicates the P(occurrence) + P(non-occurrence) of all events, the entire set. The product of the ‘R’ events not occurring is the simultaneous non-occurrence of everything else. 1 less this product is then the probability of the events R occurring. This happens to be same as P(R1) + P(R2) – P(R1 and R2) to avoid double counting, visualizing these as intersecting Venn diagrams. However, we do not need to subtract P(R1 and R2) if we consider the events mutually exclusive, as we have done in our model. 51 Note that antenatal micronutrient supplement (includes IFA and other micronutrients including vitamin A), on the other hand, reduces LBW between 11-13%. We could use this lower estimate instead of IFA but since the Indonesia program uses IFA, we have employed the estimate for IFA reported in the Cochrane review by Peña-Rosas et al., 2012. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 127 the BAU scenario of 1.52% annually. We assume that group at the national level the estimate is 440,154- only 20% of this decline is attributed to interventions 1,027 = 439,126 and for TTS it is 7,255. at this stage of a child’s life. Thus, the decline in stunting is 38%*1.52%*20% = 0.12% for the first year Next, we calculate the number of stunted in the non- of intervention. Adding this to the decline attributed target pregnant population at the national level.54 to incremental coverage, we get a total decline of This is the product of total non-targeted pregnancies 0.1% + 0.1% = 0.24% for the realistic scenario in the times the baseline stunting rate or 973,840. Assuming first year of intervention. In the second year, it is 20% of BAU decline of 1.52%, the number of stunted 0.3% and reaches 1.3% by 2030 under the realistic cases averted will be: Total stunted in non-target and 2% under the optimistic scenario with increased pregnant population in 2018 *BAU decline*20% or coverage.52 2,960. Subtracting this number from the total stunted in the non-target group gives us total stunted post- Scale: The model starts with interventions for intervention. Adding this number to the number pregnancies in 2019 with effects realized in 2020. stunted in targeted pregnant population we have The number of children born stunted in 2020 will be number stunted at the end of the period, 1,412,967. In the product of the baseline stunting percentage and 2019, the total pregnancies nationally were 5,256,483. number of pregnancies. The percentage stunted is calculated as the total stunted at the end of the period/Total national At the national level assuming a baseline stunting pregnancies 1,581,351/5,291,143 or 26.8% under the percentage of 26.9% and given 1,636,25953 targeted realistic scenario, indicating a 0.02 of a percentage pregnancies in 2019, the number of children born point decline in stunting by the end of the first period stunted in the target group will be the product of due to antenatal IFA intervention. these two terms, equal to 440,154. The Timor Tengah Selatan (TTS) stunting rate is 58.7% and there are For the following year, we follow the same process, 12,348 new pregnancies. We assume that everyone is assuming the baseline stunting of 26.9% to remain targeted in the district. Thus, the number stunted pre- unchanged rather than feed the end of previous year intervention will be 7,242. The percentage reduction stunting. We assume that new pregnancies in the in stunting estimated using assumptions from the following year will not have any positive externalities literature (previous paragraph) is 0.2% for the realistic from interventions in the previous year. However, we scenario, thus number of stunted cases averted relax this assumption in the mid-term by the year are the number stunted pre-intervention times the 2025 and use the stunting percentage from the end reduction in stunting due to IFA supplementation. of the previous year. In 2030, the stunting is 25.1% At the national level for the target group this is: implying a 1.8 percentage point decline in stunting 440,154*0.2% or 1,027 cases and for TTS district it relative to the baseline of 26.9% as a result of IFA is approximately 17 cases. The total stunted at the supplementation. The corresponding decline for the end of gestation is then calculated as the difference optimistic scenario is 2.7 percentage points by 2030. between number stunted pre-interventions less than number of stunted cases averted. For the target 52 It may be argued that the exercise could be conducted using only the secular decline and assuming increase in coverage. This, however, will not be able to separate the effects of the different interventions and the impact and contribution of each intervention on the total along with the increase in coverage required for each intervention. 53 The number of pregnancies and number of children 0-2 year old targeted were calculated using the estimates of population growth rate from BPS. 54 For the district model, we assume that all pregnant women are covered, thus this part of the calculation does not apply in our district example. However, as mentioned, the model is experimental and hypothetical for the district level and actual values of coverage and scale of operation in terms of beneficiaries can be incorporated into the model as data becomes available. 128 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 3.2 EXCLUSIVE BREASTFEEDING55 2013). Thus, 58.3% are not exclusively breastfed. We COUNSELING assume all of these are partially breastfed (although some might be predominantly breastfed as well). A Intervention period: 0 to 6 months 20% increase in exclusive BF would mean percentage exclusively BF post intervention is: Assumptions from literature: In a recent meta analyses (Lamberti et al., 2011) find that infants Percentage exclusively BF pre-intervention + who are partially breastfed,56 relative to those who (Percentage not exclusively BF*increase in rate of are exclusively breastfed (EBF), up to the age of 6 exclusive BF) = 41.7% + (58.3%*20%) = 53.4%. months are at an additional risk of diarrhea incidence expressed as a relative risk ratio (RR) of 1.68 or a 68% Thus, the percentage point decline in those not higher risk. Thus, a move from partial to exclusive exclusively BF is 53.4% less 41.7% or 12 percentage breastfeeding would reduce diarrhea incidence by points or 12/41.7% = 28% change. 68%. The RR for predominant relative to exclusive breastfeeding is lower at 1.28. We use the RR of As noted earlier, the impact of breastfeeding on 1.68 for our model, but discount it further by 50% for stunting works through its impact on reducing Indonesia, thus assuming a decline of 34% in the risk diarrhea incidence. Assuming a 34% decline in of diarrhea due to a move from partial to exclusive diarrhea incidence risk and applying it to the breastfeeding. percentage increase in exclusive BF we get: 34%*28% = 9.5% decline in diarrhea incidence. The number of The next question then is how would the shift come diarrhea episodes per 0-6 months old infant each about and what percentage of nursing/breastfeeding year in Indonesia is estimated to be 2.6 (IHME, 2016; (BF) mothers can be expected to move to exclusive Statistics Indonesia et al., 2017)57. Translating the BF from partial BF? Sinha et al. (2015) review studies diarrhea decline into number of episodes: Number on antenatal or postnatal interventions to influence of episode * Decline = 2.6*9.51% = 0.25. The average breastfeeding through different settings including episodes after intervention is then 2.6 – 0.25 = 2.35 health systems and services; home and family (one per child per year. The number of diarrhea episodes on one counseling through home visits or over the for TTS is 3.1 episodes. telephone) and the community (group counseling, meetings, social mobilization, mass media or social Twenty five percent of stunting is attributable to media). A combination of counseling methods has a previous five episodes of diarrhea (Black et al. higher impact on increasing excusive BF rates. We, 2013). Thus, stunting attributable to diarrhea pre- however, use the relative risk ratio of 1.2 (95% CI 1.03- intervention at the national level would be 25%/5 1.39) in a community setting. In a combined home and * 2.6 = 13% and post-intervention it will attribute: community setting the impact is greater at 1.42 (95% 25%/5*2.35 = 11.8%. Thus, the percentage point CI 1.21-1.66). Thus, we can expect a 20% increase decline in stunting due to diarrhea reduction from in exclusive BF rates due to community counseling. switch to exclusive breastfeeding is 13% - 11.8% = 1.2 Currently, 41.7% of Indonesian infants under the percentage points. age of 6 months are exclusively breastfed(NIHRD, 55 Exclusive breastfeeding is the feeding of breast milk only and no other liquids or solids except medicines. 56 Partial breastfeeding is the consumption of breastmilk along with other liquids or solids/semi-solids including milk and non-milk products. Predominant breastfeeding is different from exclusive in that it includes water and other drinks but does not include solids/semi-solids or other liquids including milk other than breastmilk. 57 We use a lower incidence of diarrhea than that reported in IDHS 2012 of 3 episodes per child (11.6% children under 6 months get diarrhea in the last two weeks, thus in 52 weeks (one year) = 11.6%* 52/2 = 11.6%*26 = 3 episodes per child per year. The Global Burden of Disease reports 1.6 episodes per child per year under five years for Southeast Asia. We, thus, use an average of the two numbers, which is 2.6 episodes per child per year. Note that the lower estimate we use, the more conservative our assumptions are; there is that much less stunting to reduce and hence lower declines in stunting in the model. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 129 Effective coverage: The current interpersonal percentage points (see details of calculations under counseling coverage in Indonesia is estimated at 4% exclusive breastfeeding). (World Bank, 2018b). Thus, discrepancy in coverage is 96%. We assume a 5% increase every year under Effective coverage: The diarrhea incidence among realistic and 10% under the optimistic scenario with a 6-23 months old children is estimated at 20%. Eighty cap of 70% on total coverage in the former and 85% in percent of those who have diarrhea report to the the latter. Using these assumptions, the incremental health center. Of these, only 37.3% receive zinc for coverage reaches 47% by 2030 in the realistic and treatment (Statistics Indonesia et al., 2017). Thus, the 72% under the optimistic scenario. The decline in current coverage in terms of the proportion of those stunting is then calculated as the product of the receiving zinc is 20%*80%*36% = 6.1%. To calculate effective coverage in that year times the percentage the discrepancy in coverage, however, we refer to the point decline. For the first year when the incremental proportion given zinc at the health center, which is coverage is 4.8% (96% * 5%) the percentage point currently 37.3%. The incremental coverage of zinc for decline is 1.24 % points * 4.8% = 0.06 percentage treatment is then calculated as an increment to this points under the realistic scenario and 0.12% for the percentage. Under the realistic scenario, we assume optimistic scenario. a 5% increase and for the optimistic scenario, a 10% rise capping coverage at 70% and 85% for the 3.3 ZINC AS ADJUNCT THERAPY FOR respective scenarios. The rest of the calculations to arrive at stunting decline incorporating coverage DIARRHEA remain the same as in the other interventions. The 6-23 months stunting decline is 0.06 percentage point in the first year and reaches 0.6 in 2030 for the realistic Assumptions from literature: The next intervention scenario and 0.12 and 0.88 percentage points for the we consider is using zinc as adjunct therapy in the optimistic scenario. treatment of diarrhea, along with Oral Rehydration Salts (ORS). WHO and UNICEF (World Health 3.4 VITAMIN A SUPPLEMENTATION Organization, 2004) recommend a 10-14 days zinc treatment for diarrhea in children under five on the Intervention period: 6-23 months grounds that zinc shortens diarrhea episodes, reduces its severity as well as the risk of future diarrhea. The Assumptions from literature: Vitamin A importance of supplementing with zinc during and supplementation in the 6-23 months age group after an episode of diarrhea is also realized due to reduces diarrhea incidence by 15% (Bhutta et al., the loss of zinc during a diarrhea episode, which 2013). The current coverage of vitamin A in Indonesia compromises a child’s immunity further (Black et al., is 76% (NIHRD, 2016). We assume a cap of 85% in 2013; Larson et al., 2008). A randomized control trial coverage for the realistic scenario and 95% for the in Bangladesh found that administering 20mg of zinc optimistic scenario for vitamin A. The coverage rates for 14 days for diarrhea treatment therapy resulted in are high already and the incremental increase may a 15% reduction in diarrhea (Baqui et al., 2002). We need to target the marginalized. The calculations use this lower estimate rather than the 19% reduction to arrive at stunting decline incorporating in prevalence mentioned by (Walker & Black, 2010) coverage increase are the same as in the exclusive based on a meta analyses. Applying the 15% reduction breastfeeding and zinc intervention, resulting in a to the number of episodes of diarrhea assumed at 2.6 stunting decline of 0.02 percentage points in the first per child per year (see above), we get 2.21 episodes year and 0.18 by 2030 under the realistic scenario post-intervention. Since a quarter of all stunting is and 0.05 for the optimistic scenario in the first year attributable to previous five episodes of diarrhea, the and 0.34 percentage points in 2030. decline in stunting from zinc treatment would be 2 130 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING As noted above, we consider the effects of these three 3.6 CONDITIONAL CASH TRANSFERS nutrition-specific interventions affecting stunting through diarrhea incidence, exclusive breastfeeding 0-2 years old households counseling, zinc, and vitamin A, mutually exclusive and, thus, add the stunting effects adjusted for Cahyadi et al. (2018) find that after six years of incremental coverage without subtracting interaction conditional cash transfers through the Government’s terms.58 Program Keluarga Harapan (PKH/Family Hope Program) to poor families, there is a significant decline in stunting between 9 and 11 percentage points. The 3.5 COMPLEMENTARY FEEDING program was initiated in 2007 and provides quarterly EDUCATION cash transfers to very poor households with children Intervention period: 6-23 months or pregnant and/or lactating women. A part of the transfer is ‘conditional’ on meeting specified health Assumptions from literature: Complementary feeding and education related decisions. (CF) education works towards helping caregivers feed nutritious foods beyond the period of exclusive We assume a 10 percentage point reduction in breastfeeding, along with promoting breastfeeding. stunting for the realistic pre-crisis model and an 11 Since this period is critical to the growth of a percentage point reduction under the optimistic child, getting good quality and quantity of food is scenario rolled out to the poorest 40% of the essential in providing the high demand for nutrients households. The Government of Indonesia reports at this stage. A pooled analysis of five studies from that a total of 9.2m people receive PKH from families food secure and insecure populations finds that with pregnant or lactating mothers or children in the CF education brings about a significant decline in age group of 0-2 years or 1,000-day families. This is stunting with a relative risk ratio of 0.71 (95% CI: 0.60, 10% of the total population of the -9 to 24 months old 0.76) or a 29% decline in stunting, with caregivers age group. The stunting decline per year is calculated incorporating recommended foods in feeding the as the average of 10 percentage points over six years children (Lassi et al., 2013). We use the lower bound or 1.7 percentage points for the realistic scenario. of the confidence interval and, hence, 0.76 or a 24% Multiplying this with 10% coverage gives us a stunting stunting decline. Given pre-intervention stunting of decline of 0.17 percentage points for each year under 26.9%, this translates into a 6.5 percentage point the realistic scenario and using a 15% coverage, 0.18 decline. We assume further that only half of this is of a percentage points for the optimistic scenario. realized in the Indonesian context, to be conservative, thus a 3.2 percentage point decline. Currently 36% 3.7 EGG-A-DAY THROUGH FOOD of the caregivers are receiving CF education (World ASSISTANCE Bank, 2018b). We assume once again that coverage increases by 5% each year under a realistic scenario 6-12 months and 10% for the optimistic scenario with a cap of 70% for realistic and 85% for the optimistic scenario. Introducing eggs early in complementary feeding The realistic percentage point decline in stunting is can contribute to improving nutrition and reducing 0.1 for the first year and one percentage point for the stunting due to their rich micronutrient content, final year. The corresponding values for the optimistic particularly choline, betaine, vitamin B12, and vitamin scenario are 0.2 and 1.5 percentage points. A. Although other sources of protein also provide 58 For those who are already covered and fall in the target population, we calculated the secular decline. We assumed that these three 0-2 year old interventions considered at this stage contribute to a fourth of the total secular decline (of 1.52%). Further, we assumed that each of these interventions contributes equally. Thus, the secular decline taking into account the coverage for each component is: (25%*1/3*1.52%)* existing coverage for that intervention. This yields a very low percentage decline for each intervention and we did not include it in the final calculations. Not including these also presents a more conservative decline. We, however, keep the calculations made for IFA since it involves fewer assumptions on the distribution across the interventions for the 0-2 year old interventions. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 131 key micronutrients, eggs are locally available, are consumption calculated for this model and get a affordable, and are easy to store and prepare. A stunting decline of 0.06%*47% = 0.9 percentage of a randomized control trial of introducing an egg a day point for the realistic and one percentage point for among children 6-9 months old in five rural parishes the optimistic scenario.60 in Ecuador, with a baseline stunting rate of 38%, found a significant reduction in stunting by 47%. The 3.8 WATER, SANITATION, AND trial was carefully monitored with weekly visits to the HYGIENE (WASH) BEHAVIORAL 83 households in the treatment group covered over COUNSELING a period of 6 months to distribute and ensure egg intake (Iannotti et al., 2014; Iannotti, Lutter, & Stewart, 6-24 months 2017; Iannotti, Lutter, & Waters, 2017). A review of impact evaluations covering 35 low- Indonesia’s Non-Cash Food Subsidy (Bantuan Pangan and middle-income countries finds a 32% reduction Non-Tunai or BPNT) program provides a food voucher in diarrhea morbidity due to water, sanitation, and of IDR 110,000 to the poorest 25% families accounting hygiene behavioral interventions (Waddington & for about 15% of their monthly income. The assistance Snilstveit, 2009). In our model, we assume that is provided with the aim of encouraging the purchase decline due to behavioral change is 50% of the stated of nutritious foods particularly rice and eggs. Other decline under a realistic scenario and 75% under the nutritious food groups including vegetable, legumes, optimistic scenario, thus a 16% and 24% decline in and fruits were added later to the program in 2020. diarrhea morbidity under the two scenarios. The The program is also referred to as BNPT Sembako impact would be seen in terms of a reduction in (Sembilan Bahan Pokok) referring to a bundle of the number of diarrhea episodes per child per year. nine primary commodities: rice, corn, wheat, soya However, we assume that the decline will only come bean, meat, milk, sugar, cooking oil (coconut oil) and about where there is ‘WASH’ infrastructure. Currently, iodized-salt. (Ilman, 2019; Mu’minah et al., 2012). 74% of Indonesian children in the 0-2 years age group have access to improved drinking water, 68% have A study conducted in Sumba Island, East access to improved sanitation and 71% are open Nusa Tenggara finds an on average household defecation free (SUSENAS (2017) and NIHRD (2013) in consumption of 12.43 eggs per capita per month. World Bank, 2018b)). Thus, we calculate the ‘average’ The introduction of the BPNT/Sembako increases of these as the access to WASH infrastructure, the consumption by 7.5 eggs per person per month which is 71%. The decline in diarrhea is discounted or 0.25 eggs per person per day (Ilman, 2019). We by this percentage. For the realistic scenario it will assume this increase for the realistic scenario and be 16%*71% = 11.4% and for the optimistic scenario, an additional 15% for the optimistic scenario. Since 24%*71% =17%. Using these declines, we arrive at the program focuses on the poorest 25%, we assume the number of diarrhea episodes post-intervention that the increase is applicable only for this fraction of and calculate post-intervention stunting decline the population and will be 0.25*25% = 0.06 per person as for vitamin A, Zinc, and EBF interventions. The per day for the realistic and 0.07 for the optimistic percentage point decline is 1.5 for realistic and 2.2 scenario. We apply a discounted decline in stunting for the optimistic scenario throughout the period rate of 13.7%59 instead of the 47% in the Ecuador since we do not make any assumptions on changes study and apply it to the fractional increase in egg in coverage for the nutrition-sensitive interventions. 59 The Ecuador study baseline stunting rate was 38% whereas the baseline stunting rate in Indonesia at 26.9% is 29% lower. We assume a proportionately lower decline in stunting for Indonesia or 26.9%*47% = 13.7%. Note that for the district model where we use Timur Tengah Selatan as an example, the baseline stunting rate of 59% is much higher than that of Ecuador. We, therefore, do not apply the reduction equivalent to the percentage difference in the baseline stunting rates and instead assume half the stunting decline of the Ecuador study following a conservative approach since the Ecuador study was carefully controlled for egg intake among participants. 60 Percentage point reduction in stunting: [Baseline stunting rate] – [Post intervention stunting rate] where Post intervention stunting rate = [Baseline stunting rate – Percentage decline in stunting]. 132 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING The final decline in stunting due to the entire set of As new districts are added in subsequent years, we 0-2 years old nutrition-specific (four interventions – apply the baseline stunting percentage of 26.9% EBF, zinc, vitamin A, CF) and nutrition-sensitive (CCTs, to the fraction of new districts. Of the repeated Egg-a-Day, WASH) interventions is the sum total of districts, the 1-2 years olds in the current year all interventions. In the first year, the decline is 2.7 would have received the 0-1 year old interventions percentage points for realistic and 3.9 for optimistic in the previous year. Also, the 0-1 year olds received and in 2030, 4.7 and 6.9, respectively. antenatal interventions in the previous period. Thus, we assume that of the repeated districts those who Scale: Number of 0-2 years old targeted in 2019 received -9 to 0 month interventions the previous year (results materialize in 2020) is 4,392,482. Applying and are now 0-1 year old will have externalities and the baseline stunting percentage of 26.6% the these children would have acquired the new stunting number stunted pre-intervention is 1,181,578. With rate. Therefore, we use the new stunting rate but only a 2.8 percentage point reduction calculated for the a third of it since this age group is about a third of the realistic scenario and baseline stunting of 26.9%, target population.61 We could assume that the 0-1 stunting post intervention will be 24.2% or a 10.2% year old also acquire the new stunting rate as they decline. Thus, number of stunted cases averted I the have received one year of the program interventions. target population is: Number stunted pre-intervention But we use a conservative approach and assume * Stunting decline = 1,181,578*10.2% = 120,696. The that this group still has baseline stunting. Thus, the number of stunted post-intervention is then number adjusted stunting percentage is: stunted pre-intervention less the number stunted cases averted or 1,060,882. The total 0-2 years old (Baseline stunting % * % districts not repeated) + population in 2019 is 14,110,850. The total stunted, (Previous year stunting % * % districts repeated * 1/3 using the baseline stunting rate would be 3,795,819. for -9 to 0 month olds who are now 0-1 year old) + Of the total, 9,718,368 are not targeted. For this (Baseline stunting % * % districts repeated * 2/3) part of the 0-2 years old population, the number of stunted using baseline stunting rate is 2,614,241 The number of stunted pre-interventions calculated and stunting will decline at the BAU rate. We assume from the second year until the end of the period that 80% of the decline is from interventions at this will then be: Number targeted in that year*Adjusted stage (20% came from antenatal IFA intervention) stunting percentage. and is calculated as Number stunted * BAU stunting rate *80% = 31,787. The number of stunted in the The total percentage point reduction in stunting from non-target group at the end of the year is 2,614,241- 0-2 years old interventions obtained in the first year 31,787 = 2,582,453. Thus, total stunted, target and is 2.8%. From the second year onwards, we assume non-target = 2,582,453 + 1,060,882 = 3,643,335. a lower reduction in stunting than the one arrived Dividing this by the total number of children 0-2 gives at. Some of the districts are repeated and in these us an end of year stunting rate for the entire 0-2 years the 1-2 years olds have already received 1 year of old population of 25.5%. For the calculations in the intervention. Thus, we reduce impact of this group next year, we arrive at a weighted average for the by half with the adjusted stunting reduction given stunting rate explained now. by: (Stunting reduction*Percentage districts not targeted before) + (Stunting reduction * Percentage repeated districts * 1/2) 61 A third because we can think of three groups receiving interventions: -9-0 months, 0-1 year, and 1-2 years. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 133 The stunting percentage post intervention in the 4. ADDITIONAL STUNTING target group is the difference in the adjusted stunting DECLINE DUE TO percentage and the percentage point reduction in CONVERGENCE stunting due to 0-2 years old interventions. A recent World Bank report (World Bank, 2017b) The corresponding percentage decline in stunting is investigated the difference in stunting rates for the ratio of the percentage point decline in stunting households with access to at least one versus two, and the adjusted stunting percentage. Thus, the three or four CHEF (care, health, environment and food number of stunted averted in the target group is the security) variables. Adequate care can constitute product of the number of stunted pre-interventions in such measures as breastfeeding practices, mother’s target group and the percentage decline in stunting. knowledge of handwashing practices, smoking We then arrive at the number of stunted post- behavior in the household, and complementary intervention in the target population as the difference feeding practices. Adequate health captures access between number stunted pre-intervention and the and use of health services in antenatal until the post- number of stunted cases averted. natal period and would include IFA supplementation for pregnant mothers and vitamin A supplementation We now calculate the stunting decline for those not for children as well as immunizations. Under in the target group using the BAU stunting decline environment the study uses measures of improved percentage. Total number of stunted children in sanitation, safely managed drinking water, and the non-target 0-2 years old population = Number community sanitation. of children in non-target group * Baseline stunting percentage. The number of stunted cases averted is In 2013, 23% of the households were found to be then calculated as the product of the number stunted without access to any of the CHEF variables. The * Decline in stunting, calculated as the secular rate of difference in stunting between households that decline in stunting times 80% (since we assume that had access to at least one CHEF variable versus 80% of the decline comes at the 0-2 years stage and those that had none was 5.2 percentage points. the remaining from antenatal interventions). Thus, the Likewise, those with access to two versus none had total stunted in non-target 0-2 years olds at the end of 8.9 percentage points lower stunting and as much the year will be the Number stunted at the beginning as 13.4 percentage points with access to three or of the year less the number of stunted cases averted. more. Of the 23% households without any access, Adding this to total stunted in the target population we assume an increase of 15% each year in access gives us the total stunted 0-2 years old population to two CHEF variables under a realistic scenario and in that year. Dividing this by the total number of three under the optimistic scenario. children 0-2 years in that year gives the end of the year stunting percentage. For the following year we Assuming a 15% increase in access to CHEF variables then calculate the adjusted stunting percentage as among the 23% households that had no access explained above, repeating till the year 2030. results in covering nearly 5% of the households previously without any access (15%*23% = 3.45%). In our final step, we incorporate further decline in The discrepancy in access is now: 23%- 3.5% = stunting due to the synergistic effect of the different 19.5%. In the second year the discrepancy is reduced interventions as explained now. to: 19.5% - (19.5%*15%) = 16.6%. The incremental 134 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING coverage of households without access in the first To get the final stunting decline we subtract these year was 3.5%. For the next year the increment in declines due to convergence from the decline households with access to CHEF will be calculated obtained from the interventions detailed above. on the remaining percentage without access that is. Thus, in the second year, the cumulative 5. RESULTS percentage of households with access to CHEF is: 3.5% + (19.5%*15%) = 6.4%. The decline in stunting Figures 22 presents the national projections and each year is then the product of this cumulative Figure 23 presents district projections.62 Starting with increment and the stunting decline. For the first year, a baseline stunting percentage of 26.9%, Indonesia under the realistic scenario the decline is 3.45%*8.9 can reduce its stunting to 22% by 2022 under the percentage points = 0.3 percentage points. For optimistic scenario with a higher incremental the optimistic scenario the decline is 3.45%*13.4 coverage of 10% on average relative to the realistic percentage points or 0.5 percentage points. The level of 5% for all interventions. Under the realistic decline for the respective scenarios in 2030 is 1.8 scenario, Indonesia achieves a 22% stunting rate in and 2.6 percentage points, respectively. 2024. By 2030 the stunting rate is expected to be 19% under the realistic and 15% using optimistic projections. Figure 22: National stunting projections for Indonesia % Cases 800.000 27 26 26 26 25 25 700.000 25 25 25 24 23.8 24 24 23 23 600.000 24 23 23 22 500.000 22 21.1 21 21 20 20 20 19 400.000 20 18 19 300.000 18 17 16 200.000 15 16 16 15 170.224 100.000 12 2018 2020 2022 2024 2026 2028 2030 2032 BAUBaseline StraNasRealistic StraNasOptimistic OptimisticCasesAverted 62 We present the optimistic scenario for the district projections indicative of the decline one can expect. However, these do not reflect the actual reductions one may expect in Timor Tenggah Selatan as the coverage rates used are for the national level with the cap on coverage applied as at the national level. The actual coverage rates are likely much lower in TTS and the data would need to be populated to get the true reductions in stunting. Since the projections are at an experimental stage we also do not consider the COVID-19 impact in the district projections. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 135 Figure 23: Stunting projections for Timor Tengah Selatan % Cases 61 1.800 1.600 58 58 57 56 1.400 55 55 55 54 54 54 1.200 53 53 53 52 52 52 51 51 51 1.000 50 50 50 50 49 49 800 49 49 48 48 47 46 600 46 46 45 44 400 44 43 43 200 40 2018 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 BAUBaseline StraNasRealistic StraNasOptimistic OptimisticCasesAverted 136 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING ANNEX 2: SELECTION CRITERIA CALL FOR EVIDENCE OF The Government of Indonesia’s ambitious strategy SUCCESSFUL LOCAL INITIATIVES and goal was chronicled in Aiming High: Indonesia’s IN REDUCING STUNTING Ambition to Reduce Stunting. The book also tells the story of Indonesia’s nutrition successes, challenges, and ambitions to reduce stunting from a multi- BACKGROUND AND RATIONALE sectoral perspective. Indonesia’s child stunting and malnutrition rates are at crisis levels. According to the 2013 National As Indonesia embarks on the critical agenda, Health Survey (Riskesdas), 37.2 percent of national and local leaders are increasingly aware of Indonesian children under 5 years of age (almost 9 the need to implement stunting reduction strategies million children) were stunted, 19.6 percent were in an evidence-based manner and can benefit from underweight, 12.1 percent were wasted (low weight- lessons-learned drawn from local communities. for-height), and 11.9 percent were either overweight Successful local initiatives that reduce stunting and or obese. The prevalence of stunting in Indonesia improve maternal and child nutrition can serve to both remained virtually unchanged between 2007 and inspire and provide the impetus to trigger knowledge 2013, yet district level analysis shows there are sharing and ‘know-how’ exchange for national and districts that have significantly reduced stunting local leaders. Many such local experiences however, (Rokx et al., 2018). We want to learn how they did remain undocumented or are not documented in a that. manner conducive to effective learning. Recent research highlights the need for a multi- As a follow-up to Aiming High, the World Bank is sectoral approach. Analysis of data from the 2007 and writing a book that will feature successful local 2013 Indonesian Riskesdas found that simultaneous initiatives in reducing stunting, with an emphasis on access to four underlying determinants of nutrition— the ‘how-to’. The World Bank is thus, requesting for food security, access to a safe and hygienic information and data from all nutrition counterparts environment, access to health services, and adequate (including government institutions, academia, care-giving—are associated with a significantly lower non-governmental organizations, civil society probability of being stunted than access to just one organizations, private sectors, and development or two determinants. In 2013, some 23 percent of partners) on local initiatives that are at-scale or children under 3 years of age did not have access to scalable, and have proven to be successful in reducing adequate levels in any of the four drivers of nutrition chronic child malnutrition or stunting. The initiatives in Indonesia; less than 1 percent had simultaneous submitted must be either an on-going program or a access to all four drivers (World Bank, 2017b). program completed in the past 2 years to allow for verification. The Government of Indonesia is tackling the stunting crisis by embarking on an ambitious national strategy AIM which will ensure that high-level commitment, management, and accountability to ensure supply- To document successful local initiatives in reducing and demand-side interventions (both nutrition- stunting for knowledge sharing and to provide specific and nutrition-sensitive) proven to reduce lessons learned for the operationalization of stunting in Indonesia are effectively converged, stunting prevention strategy in Indonesia. delivered, and implemented. MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 137 AREAS OF INTEREST 3. What is the nutrition-related indicator affiliated with your program/project/intervention? Please Nutrition-specific interventions, defined as list all (see examples of nutrition-specific and – interventions addressing the immediate determinants sensitive interventions listed above in Areas of of fetal and child nutrition and development— Interest). adequate food and nutrient intake, feeding, caregiving and parenting practices, and low burden 4. Who are your target beneficiaries and how of infectious diseases. Examples include: adolescent, many beneficiaries are currently enrolled in your preconception, and maternal health and nutrition; program/project/intervention? maternal dietary or micronutrient supplementation; promotion of optimum breastfeeding; complementary 5. Where is the location(s) of your program/project/ feeding and responsive feeding practices and intervention and why was this location chosen? stimulation; dietary supplementation; diversification How big is your program coverage area (i.e. how and micronutrient supplementation or fortification many villages, how many sub-districts, districts)? for children; treatment of severe acute malnutrition; disease prevention and management; nutrition in 6. Please provide an overview of the program emergencies (Bhutta et al., 2013). method/design and monitoring evaluation strategy, including the expected length of time to Nutrition-sensitive interventions, defined as achieve the target results. interventions addressing the underlying determinants of fetal and child nutrition and development—food 7. What challenges do you face in your program security; fortification; adequate caregiving resources implementation? How did you tackle or plan to at the maternal, household and community levels; tackle the challenge of the program and achieve and access to health services and a safe and hygienic the desired goals? environment—and incorporate specific nutrition goals and actions. Examples include: agriculture and food 8. What is the result of your program/project/ security; social safety nets; early child development; intervention so far? How do you ensure maternal mental health; women’s empowerment; transparency and accountability? Is there room child protection; schooling; water, sanitation, and for scalability? hygiene; health and family planning services (Ruel & Alderman, 2013). 9. How long has your program been implemented, and if you have a closing date, what would that GUIDING QUESTION be? What is the sustainability of your program/ project/intervention? 1. What is the name of your program/project/ intervention? Who initiated the program and what 10. Is this something that can be continued by the drives the political commitment? local community, local government or national government? What is the lesson learned for 2. What are the aims and objectives of your replication? program/project/intervention? 138 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING 139 © 2021 International Bank for Reconstruction and Development/The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org 140 MOVING FORWARD: HOW INDONESIA’S DISTRICTS REDUCE STUNTING