Scaling up child wasting prevention and treatment in the context of stunting prevention in Indonesia
Leveraging efforts for joint wasting and stunting programming in Indonesia
This article outlines how wasting treatment was integrated into stunting prevention programmes in Indonesia.
Blandina Rosalina Bait works for UNICEF, Jakarta, Indonesia.
Angela Kimani is a Food Systems and Nutrition Consultant at OptimAdept Consult.
David Colozza works for UNICEF, Jakarta, Indonesia.
Julia Suryantan works for UNICEF, Jakarta, Indonesia.
Dhian Dipo works at the Ministry of Health, Government of Indonesia.
Pungkas Bahjuri Ali works at the Ministry of National Development Planning, Government of Indonesia.
Sidayu Ariteja works at the Ministry of National Development Planning, Government of Indonesia.
Nurul Azma Ahmad Tarmizi works at the Ministry of National Development Planning, Government of Indonesia.
Evi Fatimah works at the Ministry of Health, Government of Indonesia.
Yuni Zahraini works at the Ministry of Health, Government of Indonesia.
Jee Hyun Rah works for UNICEF, Jakarta, Indonesia.
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Key messages:
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Background
Despite tremendous progress in reducing malnutrition in Indonesia, the challenge of undernutrition in children under five years of age remains. Stark differences are noted between provinces with the prevalence of stunting ranging from 42.6% in East Nusa Tenggara (NTT) (provinces shown in Figure 1) to 17.6 % in Jakarta, and that of wasting from 14.4% in West Nusa Tenggara (NTB) to 4.6% in North Kalimantan (National Basic Health Research, 20181). However, a recent annual study by the Government of Indonesia (SSGI) showed that stunting and wasting prevalence reduced to 24% and 7% respectively.
Sources of information for the facts summarised in this article come from a range of sources, including key informant interviews, summarised in Box 1.
Figure 1. Map of Indonesia
Source: World Health Organization. (2017). State of health inequality: Indonesia. World Health Organization. https://apps.who.int/iris/handle/10665/259685
Government policies and strategies
The Government of Indonesia (GoI) has committed to tackling stunting and wasting simultaneously, as outlined in the 2017 National Strategy to Accelerate Stunting Prevention which includes plans to scale up child wasting prevention and treatment. Subsequently, indicators and annual targets for both forms of undernutrition have been developed and are included in the National Medium-Term Development Plan 2020–2024 with ambitious targets to reduce the prevalence of stunting to 14% and wasting to 7% by 2024. Reflecting on these targets, the Ministry of Health (MoH) set a goal of at least 60% of primary healthcare centres providing integrated management of acute malnutrition (IMAM) services by 2024. Additionally, a Presidential decree (no. 72) on stunting reduction acceleration was launched in 2021 and included a target to provide treatment to 90% of severely wasted children by 2024. Furthermore, in 2021, the GoI developed its country-level Global Action Plan (GAP) on Child Wasting Roadmap with support from UNICEF and other United Nations (UN) partners.
Box 1: Sources of information for key facts and figures in this article
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The National Stunting Prevention programme
The 2017 national strategy to accelerate stunting prevention established a nationwide programme to ensure that this would be incorporated into existing policy and institutional frameworks. Following the launch of the programme, the GoI solidified its commitment to scaling up action against stunting by leveraging multiple funding sources to support the programme at all levels. Between 2018 and 2020, more than USD7.5 billion was allocated to support the scale-up of nutrition-specific and nutrition-sensitive interventions at the national level and an additional USD596 million was used to support the acceleration of stunting prevention at the sub-national level. Furthermore, the GoI channelled approximately USD307 million to villages to support evidence-based nutrition actions (Secretariat of the Vice President of Indonesia, 2021).
The stunting reduction programme is multi-sector in nature involving stakeholders across sectors at both national and sub-national levels with different coordination structures and focus for each. The programme targets interventions within the first 1,000 days of life including pregnant and lactating women and adolescent girls.
At the national level, 19 ministries and institutions coordinate the programme together with other relevant stakeholders such as civil society, development partners, academics, the private sector and the media. Efforts are focused on delivering a set of evidence-based nutrition-specific and nutrition-sensitive interventions with high coverage and quality. At the sub-national level, intensive efforts are being made to support programme convergence through strengthening multi-sector coordination and the capacity of local government authorities, healthcare and non-health workers and frontline workers. Box 2 provides a case study from East Nusa Tenggara province.
Addressing child wasting in the context of the stunting reduction programme
A set of evidence-based nutrition-specific and nutrition-sensitive interventions was selected to be scaled up across the country to support the national stunting prevention programme. Specifically, the prevention and treatment of moderate and severe child wasting were included as two of the eight critical nutrition-specific interventions prioritised. The nutrition-sensitive interventions included various areas such as home food gardening and improvements in water and sanitation services.
Accordingly, the IMAM programme was scaled up across all 514 districts in 34 provinces. To facilitate the scale-up, the MoH, with support from UNICEF, developed and disseminated national IMAM guidelines and an accompanying training curriculum (adapted in light of the COVID-19 pandemic). IMAM services were also institutionalised including community screening in all provinces and integrating screening and treatment data into the national health and nutrition information system.
Furthermore, since 2019, the GoI and UNICEF have been working to support the local production of ready-to-use therapeutic food (RUTF) in collaboration with the Scaling Up Nutrition (SUN) Business Network. The first-ever acceptability and efficacy study of local RUTF recipes was conducted through this partnership and completed in December 2021. The results will guide government efforts to ensure the availability of local RUTF to treat severely wasted children and thus to support the scale-up efforts.
Box 2: Scaling up lifesaving integrated management of acute malnutrition (IMAM) within the stunting reduction programme in East Nusa Tenggara (NTT) province
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Background Stunting and wasting are persistent problems in NTT province. According to the National Basic Health Research (Riskesdas) survey data, as of 2018, the province had the highest stunting prevalence in the country (42.6%) and one of the highest levels of wasting prevalence (12.8%). How was the programme implemented? The provincial technical team leads the implementation of interventions prioritised in the different national policies and oversees the budget allocations for stunting and wasting interventions. The Stunting Task Force (led by a representative from a non-governmental institution) works under the provincial technical team to support the implementation of the interventions at a more local level. Between 2018 and 2021, key IMAM activities were scaled up including IMAM training for healthcare workers, ready-to-use therapeutic food (RUTF) procurement, the expansion of the IMAM programme to 21 districts and one municipality and the procurement of mid-upper-arm circumference (MUAC) tapes. This shows the integrated approach in the performance of the stunting reduction programme that covers both nutrition-specific interventions (that includes treatment of child wasting) and nutrition-sensitive interventions. As an example of implementation at the village level, in Manulai 1 the sub-village team meets annually to discuss priority activities and budgets. At this meeting, village stakeholders such as village authorities, community health volunteers and women’s empowerment organisations conduct mapping activities and develop joint work plans and budgets based on the village situation analysis. Some community activities implemented by the cadres in the village include supplementary feeding for children under five years of age and pregnant and lactating women, home visits for nutritionally vulnerable households and growth monitoring follow-up appointments as well as recording and reporting back to village heads. By the end of 2020, IMAM services had been scaled up in all 22 districts of NTT. The screening protocol for severe wasting was introduced in local posyandu (integrated health posts) and puskesmas (public health centres) and family-based MUAC screening was introduced in several districts. A women’s empowerment organisation in NTT has supported IMAM service implementation in its 22 model villages across all 22 districts since 2020, allocating budget for capacity building, monitoring and supervision as well as the procurement of RUTF and MUAC tapes. The Stunting Task Force at provincial level developed the Field Operational Guideline that has been used since 2020 to train villages authorities and support them in planning, implementing and monitoring stunting interventions at the village level. These stunting interventions include the treatment of child wasting. Government leaders from all sub-national levels have generally committed to continually implement nutrition actions to prevent and manage child stunting that also address child wasting. |
Successes, challenges, and lessons learned
Successes
At the national level, there have been deliberate efforts to strengthen the joint implementation of child stunting and wasting programmes. There is currently an enabling environment for integration through the changes at policy level as exemplified in the recent Presidential decree and the substantial increase in budget allocations for nutrition interventions. In the Tokyo Nutrition for Growth (N4G) Summit 2021, Indonesia also emphasised this financial commitment as one of the country’s goals. There is substantial support from national level to sub-national authorities in designing interventions for stunting reduction that also include the management of wasting. This has been further supported by the institutionalisation of IMAM services into the existing health system and improvements to national nutrition data management systems.
Furthermore, in 2021 UNICEF and other UN agencies in Indonesia have supported the GoI to develop and endorse the GAP on Child Wasting and a relevant operational roadmap. The GAP Roadmap will guide the GoI and UN agencies to take a focused, cohesive, coordinated approach to effectively address child wasting. Importantly, given the strong inter-linkage between child wasting and stunting, the Roadmap is also expected to contribute to the reduction of child stunting in Indonesia.
At the sub-national level, particularly in the NTT province, major successes include the increased capacity of sub-national government authorities to implement and monitor the national stunting reduction acceleration programme and the adaptations made for their local context (such as including five additional indicators that were key causal factors for stunting in this context into the broader national monitoring system). There have been increased commitments from other government institutions and community health systems, such as a women’s empowerment organisation, in supporting stunting and wasting interventions. The village government’s capacity has been strengthened to play a leading role in prevention activities at the village level. Local authorities develop activity plans based on the identified causes of stunting and wasting in their specific villages.
Furthermore, advocacy efforts led to the GoI substantially increasing the budget allocations for stunting and wasting treatment and prevention. Between 2017 and 2020, the budget increased from approximately USD979 million to USD2.8 billion. As of 2021, 19 government ministries and institutions had committed a total budget allocation of approximately USD2.5 billion for nutrition-sensitive and nutrition-specific interventions and coordination. Looking forward, sustained advocacy efforts are needed to ensure further budget increases for child wasting prevention and treatment, particularly during the COVID-19 pandemic recovery phase.
Challenges
Despite the progress made to date, challenges remain. Scaling up IMAM in a highly decentralised and culturally diverse country and ensuring that authorities at multiple sub-national levels of government can address both stunting and wasting concurrently remains a key challenge. Data management issues also persist, particularly ensuring sufficient resources to enable quality data management. Health facilities should also be strengthened to fully integrate IMAM services including community mobilisation, local RUTF availability, and monitoring and evaluation. Substantial gaps also remain in integrating and upscaling nutrition-sensitive interventions including home food production, water and sanitation, and social protection. These have been exacerbated by nutrition service disruptions and a reduction in wasting programmes budgets due to the COVID-19 pandemic. There is also a need for more stakeholders to become involved in implementing child wasting services.
Conclusion
Indonesia shows a successful example of how child wasting and stunting can be addressed simultaneously through large-scale programmes that deliver essential nutrition actions including:
- Continued advocacy for sustained political commitment to and awareness of addressing child stunting and wasting simultaneously at all levels.
- Strengthening IMAM services at community and health system level for the early detection, referral, and treatment of children with wasting.
- Prioritising local production of RUTF to improve the supply and affordability of nutrition commodities.
- Strengthening the coordination of nutrition-specific and nutrition-sensitive interventions (and inter-sectoral collaboration) related to the prevention of wasting and stunting.
- Improving the data management capacity of sub-national teams so that there is quality data to track progress and inform decisions.
The national strategy to accelerate stunting prevention and the presidential decree on acceleration of stunting reduction outlines the interventions that can be undertaken to prevent stunting, for example, non-cash food assistance, behaviour change communications campaigns, household food security interventions and early childhood education programmes that incorporate nutrition information. However, further efforts are needed to scale up those stunting prevention measures that also directly contribute to preventing child wasting within communities. This may include empowering the relevant government ministries to actively address nutrition improvement as a key objective in their respective sectors in collaboration with the health sector.
For more information, please contact Blandina Rosalina Bait at bbait@unicef.org
References
National Basic Health Research (RISKESDAS) 2018 Report. Jakarta: Ministry of Health.
Secretariat of the Vice President of Indonesia. (2021). Report on the implementation of the 2018-2020 national strategy to accelerate stunting prevention. Jakarta: Ministry of Health.
Other information sources used to inform the article are listed in Box 1.
1 The RISKESDAS conducted every five years