Executive Summary
Stunting Reduction and Acceleration Program in Indonesia: An Evaluation
Developed by: CHPM, UGM
Supported by: JICA Indonesia
October, 2022
Background
As one of the leading economic in the region, Indonesia have done some quite significant improvement in poverty rates and some of key health indicator. Unfortunately, the nutrition problem still appear to be one of the important problem. Recent National Basic Health Survey (Riskesdas 2018) found that more than 30% of children under-5 are stunted (shorter for their age), more than 19% are wasted (low weight for age), and 11% are either overweight or obese. Indonesia is rank among low performed countries in the regional and income peers. As a respond to the situation, the Government of Indonesia (GoI) introduced a promising National Strategy to Accelerate Stunting Prevention/StraNas Stunting (2018-2024) with ambitious target of reducing stunting to 14% in 2024.
StraNas Stunting has 5 key pillars which refer to the Vice President Decision in National Stakeholder meeting about stunting on August, 9th 2017. Those pillars are: 1) national leadership and commitments; 2) national campaign and behavioral change; 3) convergence of national, regional, and village programs; 4) nutritional food security; 5) monitoring and evaluation. In 2024, the StraNas stunting will come to an end of the implementation and need a picture of how its implementation for better planning for next strategy. In order to get a picture of the implementation of stunting reduction and acceleration program Japan International Cooperation Agency (JICA) work together with Center for Health Policy and Management (CHPM) conducted a data collection survey for nutrition improvement to the stunting reduction. This survey aims to understand the situation of nutrition intervention to accelerate the stunting reduction as well as the progress toward the target. The findings from this case study is important for all parties including Government of Indonesia, development partners, academicians, and local government to get the overview of the national strategies to accelerate stunting reduction which can be used to enrich the existing monitoring and evaluation in order to design and plan for the improvement of the program.
Methodology
The survey used an explanatory research that combine multiple approach to answer “why” and “what” questions through scooping review, comparative case study with mixed-method approached, and Non-Government Organization (NGO) analysis. The survey has done in 3 months from August-October in 3 selected provinces: West Java, Bali, and Nusa Tenggara timur (NTT). Those 3 provinces has been selected to represent the high and low performing province in stunting reduction and acceleration program.
Findings
a. Situation of stunting and its determinant factors
Stunting prevalence in Indonesia shows a quite significant declining since the introduction of StaNas Stunting from more than 30% in 2018 to 24% in 2021. Unfortunately, there are no reliable annual monitoring system for this rate. The road for Indonesia to achieve the agreed target of 14% in 2024 based on National Medium-Term Development Plan (RPJMN) is not easy given the current declining rate. Recent National Nutritional Status Study (SSGI) in 2021 found only 4 out of 34 provinces in green category (prevalence <20%) according to WHO standard.
Although some key nutrition specific indicator has shown improvement, some other important indicators especially in preventive actions show a stagnation even declining during these 3 years. Those indicators are iron and folic acid supplementation for adolescence girls, exclusive breastfeeding, basic immunization, and under-5 access to Posyandu. Some key indicators in nutrition sensitive intervention also struggle to meet the target like family planning access, access to subsidize rice and conditional cash transfer (for priority households), and health insurance for pregnant women and under-5 children. Comparative case study in selected districts from 3 provinces shows that low-prevalence districts just performing better in achieving key indicators compared to high-prevalence districts. Important indicators like iron and folic acid supplementation for pregnant women, food supplementation for pregnant women with chronic energy deficiency, etc. in Garut, West Java and Timor Tengah Selatan, NTT are far behind other districts. Nevertheless, some other key indicators like exclusive breastfeeding, infant and young child feeding (IYCF), and promotion and counselling of exclusive breastfeeding could not analyze appropriately due to availability and validity of the data.
b. Organization and governance of stunting reduction program
The organizational and governance of the stunting reduction is a little bit complex with the involvement of a wide range of stakeholder from national (government ministries/agencies), subnational (local government in provincial, district, and village), government partners (NGO and donors), academicians, media, and private sectors. Recent President Law No 72/2021 has mandated the establishment of Stunting Reduction Acceleration Team (TPPS) which stretch from national, provincial, district, sub-district to village level. Government partner work hand in hand with the government in national and subnational level to strengthen the implementation of the program including providing technical input, testing and cascading promised innovation, contributing in policy and regulation development, supporting meetings and coordination, etc. In district level, the organizational and governance of stunting has been established long before the President Law TPPS in form of Stunting Task Force/Working Group with convergence action as the guidelines for implementation. The presence of TPPS in already established coordination system with Working Group/Task Force would need more time to adjust and potentially bring disharmonization between the stakeholders in the district level. All stakeholders in the district level did not get clear information about the establishment of TPPS including their role and function in the team to support the stunting reduction and acceleration program.
c. Policies and regulations for stunting program
Since the introduction of StraNas Stunting in 2018, the stunting issue has transformed the policy and regulatory framework in all ministries/agencies. Some adjustment in the system need to be put in place to support the implementation of stunting reduction and acceleration program including tagging system for monitoring budget allocation, convergence scorecard to monitor village performance, various capacity building requirements, prioritization for social protection scheme, and planning and budgeting regulation for local government. Stunting also included in National Mid-term Development Plan (Rencana Pembangunan Jangka Menengah/RPJMN) for 2019-2024 which followed-up in Ministry of Health (MoH) strategic plan. The recent policy that hopefully can accelerate the program achievement is The National Action Plan for Stunting Reduction and Acceleration in Indonesia (RAN PASTI). In district level, Bupati/Mayor regulations also issued to expound the national regulation as well as to emphasize local innovations in form of decree or law.
d. Nutrition service delivery
Nutrition services that lead to acceleration of stunting reduction mostly deliver by sub-national level through Puskesmas or public offices in the district level. However, most of the inputs including vaccines, vitamin A, food supplement, anthropometric kits are provided by national government. Each district has different approaches to deliver nutrition services to all the targeted population. Most of the innovations in district level were aimed to increase knowledge and awareness about stunting, its determinant factors, and increase interventions coverage. All selected districts in this study have similar challenges in deliver the nutrition-related services. Puskesmas have limited resources to maintain all the services to reach targeted population. Nutrition staffs in Puskesmas are limited and not all have received adequate training. Cadre as the main resources in the community level work with low incentives and poor capacities. Not all Posyandu have standardized anthropometric kit which prolonged and threaten the data collection process. Community awareness interventions like health education and promotion is hard to conduct with heavy workload of the staff and minimum community outreach program.
e. Health information system
Health information system for stunting received a quite upgraded with electronic data collection system. Yet, the introduction of electronic data collection has not responded by readiness of the supply side in the lower level. Lack of infrastructure and equipment like computer, smartphone, internet connection as well as low capacity of cadre have a huge impact for the sustainability of the system. Local staff has overwhelmed to maintain many database and surveys resulting in poor usability of the data for program improvement. In district level, there is an ongoing debate about the SSGI vs e-PPBGM data to be used as the stunting prevalence data source not to mention other data sources like Riskesdas, Susenas, Aplikasi Satu Data Kesehatan (ASDK), Sigizi Terpadu, mHealth, Pendataan Keluarga, etc. Moreover, the selection of indicators in the monitoring and evaluation plan of the StraNas stunting and most of the data sources still far from measuring quality of the nutrition services with mostly use coverage rather than effective coverage recommended by WHO.
f. Financing of stunting reduction program
The financing of the stunting reduction and acceleration program is complex and involve multiple source of funding managed by multiple agencies. Since the introduction of StraNas Stunting in 2018 there was a significant increase in financing in national and subnational level. However, national government still dominating with different type of fiscal transfer to the subnational level. The efficiency in allocation and use of the resources still a big problem with inhibiting factors like weak data management and information, lack of competent staff in planning and budgeting process, complicated bureaucracy and timeline for different funding proposal, and lack of staff capacity in the field to deliver the program.
Conclusion and recommendation
The findings from this data collection survey shows that there are some works that need to do to escalate the reduction rate and make the program more sustainable. All parties need to work together effectively in solving the specific issues in the system to ensure the implementation of the program can run in the right direction including improving the health information system, provide clear strategic planning and budgeting guidelines, improve the quality of nutrition services, and strengthen the organizational and governance of the stunting reduction team.
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