Indonesia is home to more than 250 million people. It is a trillion-dollar economy and boasts four of ASEAN’s 7 start-up unicorns. However, 9 million (37%) Indonesian children under 5 are stunted*.
Poor nutrition, poor maternal health, inadequate healthcare and poor access to clean water can all cause stunting. Stunted children are prone to learning difficulties, illness and poverty. At a national level, high stunting rates can decrease a country’s economic growth and increase inequality.
The Government of Indonesia has launched an ambitious stunting prevention strategy (2018-2021) to strengthen the nation’s human capital investments. Through the national strategy, the government will spend US$14.6 billion to reach 48 million beneficiaries in 514 districts and 75,000 villages.
The Investing in Nutrition and Early Years (INEY) Program aims to increase the simultaneous use of nutrition interventions by 1,000-day households in priority districts. The convergence of basic services is at the heart of INEY.
INEY is led by the Vice President of Indonesia and provides the management tools and incentives to execute the national strategy.
It is implemented by 10 national agencies because services in five sectors must converge to prevent stunting. The five sectors are health, water and sanitation, social protection, nutrition, as well as early childhood education and development.
INEY Results Areas:
Strengthening national leadership. Strengthen national leadership and ensure the effective national coordination and accountability mechanisms that are critical for the sustained and high-quality implementation of the national strategy.
Strengthening delivery of national sector programs. Support the improved design and delivery of national sector programs that have been identified as the significant gaps in the current mix of programming (i.e. ECED for children 0-2, nutrition sensitivity of food assistance and interpersonal communication).
Strengthening convergence of district activities. Strengthen the management and implementation of nutrition activities implemented at the district level and reduce financial fragmentation.
Converging village service delivery. Support activities that will converge delivery of priority interventions on all 1,000-day households in villages, incentivize villages to allocate additional budget from Village Funds to priority nutrition-specific and nutrition-sensitive interventions.
Human Development Worker (HDW) Program
As part of the Government of Indonesia’s stunting prevention strategy (2018-2021), The World Bank and the government launched the Human Development Worker (HDW) pilot in 2018 by engaging 3,105 HDWs in 31 districts in nine provinces.
The HDWs have three key tasks:
Diagnose. Using community- and household mapping, the HDWs identify risks, human capital gaps, and service availability for families and children in the village. The HDWs then develop targets and checklists to fill the human capital gaps and service needs, working closely with facilities and existing programs.
Treat. Based on the diagnosis, HDWs prioritize interventions and deliver and monitor a package of key services to address malnutrition and promote early childhood development in the village. Households with children who are, or are at risk to become stunted are targeted for additional intervention, including home visits and monitored growth promotion. The HDWs also work with the village leadership to ensure that village plans and budgets prioritize human development services.
Monitor and Adjust. The HDWs use household and village level checklists and scorecards to continuously monitor performance and results. They use regular growth monitoring (height and weight) to track progress. A quarterly village convergence forum will feed baseline and service delivery monitoring data to district service providers, review implementation and impacts of village-financed nutrition activities, and seek feedback from beneficiaries.
*Riskesdas (Indonesia Basic Health Research), 2013
The prevalence of stunting in young Indonesian children has caused alarm at the highest levels of government. In 2013, 37.2 percent of Indonesian children under 5 years of age (almost 9 million children) were stunted, 19.6 percent were underweight, and 11.9 percent were either overweight or obese. Stunting is caused by chronic malnutrition and repeated illnesses in childhood. It can be measured by comparing young children’s heights with the WHO Growth Chart Standard.
The government launched a National Strategy to accelerate Stunting Prevention in August 2017 and as part of this initiative, the Human Development Workers pilot. HDWs support villages and local service providers to bring together stunting-reduction services in the health, water and sanitation, social protection and early education sectors for households with pregnant women and children under two years old.
Public awareness of stunting and its causes is still low. Salmiah, a mother of three in Central Lombok, was devastated to learn that her 2-year-old daughter was stunted. She recalled how her pregnancy was difficult and that she didn’t have access to nutritious food.
“Due to a lack of healthy food during my pregnancy, my daughter was born underweight and at the age of two she was stunted,” said Salmiah, a teacher at an Islamic elementary school.
Although Salmiah has been a member of her local integrated health service post (posyandu) since 2000, she decided to learn from about stunting after learning that her daughter was stunted. She found that in her village, 25 percent of children under five, or 225 children, were stunted. In 2017, she became a Human Development Worker (HDW) for Generasi Sehat dan Cerdas (Healthy and Smart program), a program initiated by the Government of Indonesia and the World Bank.
“I know about stunting now and I am determined to provide good, nutritious food and maintain a clean environment, so that my daughter can grow optimally,” Salmiah said.
"As an HDW, it is my duty to ensure that pregnant mothers have regular prenatal check-ups at the posyandu, take Iron supplements, consume healthy, nutritious food and have access to clean water”.
Salmiah met fellow Human Development Workers in Jakarta at a training organized by the Central government and the World Bank – an experience that made her more determined to help her community fight stunting. She and fellow HDWs were also trained to use the Length Mat, a simple and innovative tool to detect stunting early.
"Upon my return from the training, I shared more information about stunting with the community, particularly its impacts and how to overcome it. I spoke to community members, religious leaders and village leaders. I am grateful that 30 percent of the Village Fund is now allocated to prevent stunting,” Salmiah said.
Salmiah works closely with other facilitators and village representatives from the health post, early childhood center, the conditional cash transfer program for families (Program Keluarga Harapan or PKH) as well as from the water and sanitation program (Pamsimas). By strengthening coordination between these service providers, she wants to ensure that all targeted beneficiaries receive the complete service delivery package. Salmiah developed a village convergence social map which helped identify 11 households with stunted children which are operating without latrines and clean water. She worked with water and sanitation facilitators to ensure that clean water and latrines are provided to these households in 2018.
The challenge, however, is to convince families who are in denial that their children are stunted. “It takes great effort,” Salmiah said, “to raise awareness on supplementary nutrition, and good sanitation practices.”
Salmiah’s hardwork has paid off already. In the past 15 months, the number of stunted children aged two or less decreased from 86 to 58.
“Insya Allah (God willing), there will be no poor families and every child in our village will grow to be tall and smart,” Salmiah said.
Source of data: 2013 National Health Survey (RISKESDAS) and interviews.
The atmosphere was festive as staff at the Permata Bunda integrated health post (posyandu) in Manahan, Surakarta awaited Vice President Jusuf Kalla on Monday, 12 March. The posyandu is a key component of the national stunting prevention program led directly by President Joko Widodo and Vice President Jusuf Kalla. The one in Manahan serves 42 under-five-years-old children and four pregnant women.
At Permata Bunda health post, Vice President Kalla witnessed the launch of an innovative tool -- a portable “Length Mat” -- initiated by Generasi, the Ministry of Health and the Ministry of Villages, Disadvantaged Regions and Transmigration to measure the height of children under two years of age.
Between 6-15 February 2018, this innovative tool was trialed in 13 villages in four priority districts – Cianjur, Gorontalo, Maluku Tengah, and Ketapang. The trial involved 232 people, including parents of children under two years of age, health post workers, and human development workers. Generasi and the Ministry of Villages will expand the pilot to 3,105 villages in 31 districts in 2018.
Height, a critical benchmark of child growth, must be measured every three months for children less than two years old. The Length Mat gives health workers and parents a visual cue to see if a child is the right height for her/his age, and can be used to differentiate between female and male children. It is used by posyandu to detect stunting early and rapidly identify children who need special attention.
The Length Mat is made from durable plastic and is practical as it can be carried door to door by community health workers in remote areas, making it easier for them to detect stunting, and promote better health and nutrition practices. The mat is expected to motivate caregivers to change behaviors to promote child growth. Since community level height measurements may not be highly accurate, measurements taken with the length mat should primarily be used to raise awareness for behavioral change, not as hard data.
The length mat has been introduced in stunting prevention initiatives in Bolivia, Guatemala, Zambia and Cambodia. The use of growth charts in Zambia has reportedly helped reduce stunting by 22 percent over a one year period. Initial reviews of length mat use in Cambodia and Guatemala showed that mothers felt the height visualization on the mat has helped them understand their children’s growth.
The VP reiterated the urgency of addressing malnutrition and stunting in Indonesia. “Without sufficient nutrition and a healthy environment, our young generation is in peril,” the Vice President said in a written statement on March 12th. He explained that if the situation persists, it would affect the country’s development performance in economic growth, poverty, and inequality. According to the VP, “Indonesia is in critical situation in terms of stunting, as warned by the WHO. Therefore, people must play (an) active role to protect our children”.
The National Report on Basic Health Research (RISKESDAS) 2013 estimates that almost 9 million children in Indonesia or a third of all children under five years of age are stunted. The Government of Indonesia is committed to reducing the prevalence of stunting through cross-ministerial, national and subnational anti-stunting programs.
The National Report on Basic Health Research (RISKESDAS) 2013 estimates that almost 9 million children in Indonesia or a third of all under-five children are stunted. The Government of Indonesia is committed to reducing the prevalence of stunting through cross-ministerial, national and subnational anti-stunting programs.
Indonesia’s National Development Planning Agency (Bappenas) hosted a two-day Stunting Bootcamp on March 26-27, bringing together 26 district and city governments to reduce rates of stunting to 28 percent by 2019. In an all-out effort to combat stunting, 19 government ministries and institutions came together for the event, as did UNICEF, MCA-I, DFAT and the World Bank. The Stunting Bootcamp is the second of eight planned events to bring the anti-stunting movement to 1,000 villages in 100 districts and cities in 34 provinces. The government plans to expand the coverage to 1,600 villages in 160 districts in 2019.
Through the Bootcamp, the national government aimed to build local governments’ capacity and commitment to plan, implement, monitor and evaluate convergence interventions to reduce stunting. Such interventions would include advocacy campaigns to raise awareness about the importance of reducing stunting and improve interpersonal communication to enhance collaboration across stakeholder groups.
Pungkas Bahjuri Ali, Director of Health and Nutrition at Bappenas, said that local governments were expected to share the national government’s commitment to reduce stunting, and to demonstrate their commitment by planning for and funding anti-stunting programs.
“We will share best practices from global, national, and village experiences, strengthen the coordination between the national and local governments, and improve the effectiveness of the program,” he said in his opening remarks at the Borobudur Hotel in Central Jakarta. He emphasized that adequate nutrition, disease prevention and good parenting were at the core of the movement to reduce stunting. “The role of the ministries and government institutions is focused on those three,” he said.
Subandi Sarjoko, Deputy Minister of Bappenas who also serves as the Head of Human, Community, and Cultural Development, revealed that government mapping initiatives found 19 districts and cities that have launched anti-stunting interventions without success in reducing stunting rates. “It was found that each area does not receive all aspects of the integrated intervention. For example, Village A, provides good nutrition but doesn’t have adequate clean water supply. Village B is the other way around. In fact, all aspects of the integrated intervention should be received by the target communities,” he said.
Villages Minister Eko Putro Sandjojo urged villages to reduce stunting rates by using Village Funds to finance infrastructure such as water and sanitation facilities, health clinics, and early education centers to improve villagers’ quality of life. “We must educate people about stunting. Even wealthy districts have stunting cases due to a lack of knowledge and widespread myths on nutrition,” he said during the Bootcamp. “Only 5 districts across Indonesia are free from open defecation. It affects the stunting rate as it’s not only about nutrition. Villages should build clean water facilities using Village Funds - it’s not expensive.”
The stunting reduction movement has the backing of Indonesia’s highest executive office. President Joko Widodo is committed to reducing stunting as evidenced by the Presidential Instruction No. 1/2017 on Healthy Community Movement (Germas); and Presidential Regulation No. 83/2017 on Strategic Policy on Food and Nutrition. The National Coordination Meeting 2018 for Generasi Sehat Cerdas, the National Village Congress and the Stunting Summit, all held in the week of March 25, further reflect the President’s commitment to accelerate the efforts to reduce stunting.
“Stunting reduction will be included in the government’s work plan every year, in line with the commitment to meet the SDGs by 2030,” Subandi said. “In 2018, the government’s priority is to improve education on nutrition, conduct nutritional surveillance, and provide nutritional food. 12 ministries and institutions directly contribute to interventions against stunting, and these efforts must be synergized.”