Indonesia’s stunting challenges, Can it be overcome?

stunting kids
Illustration: LEONARDO A. PUTONG

IO – Stunting or shortness of stature (height below average for age) resulting from chronic malnutrition in the under-five year old children has become a major public health concern in Indonesia. Historically, the prevalence of this condition was stagnant from 2013 to 2017, at around 37 percent. By way of reference, the WHO indicates a prevalence of stunting above 20 percent as a serious public health concern. From 2018, Indonesia has achieved significant improvement in this area, with the prevalence dipping to 30.8 percent, according to the Indonesian Basic Health Survey (Riskesdas). This number implies that about one in every three children, or about 9 million in total, are afflicted with stunting, while the overall economic growth of the country is rising, with meaningful poverty reduction.

Root problem and Consequences of Stunting
As a symptom of chronic malnutrition, stunting has multi-related factors, as a downstream impact of national development. UNICEF 1990 classified the multi-factorials of stunting as basic causes or as distance determinants, covering socio-economic, political or other potential phenomena. Such determinants tend to affect the underlying causes or intermediate determinants, such as inadequate access to food, inadequate care of women and children along with insufficient availability of health services and an unhealthy environment. These causes intersect with one another, exerting an influence on the immediate causes; a direct determinant, such as inadequate dietary intake or disease reciprocally manifests into malnutrition, including stunting.

Unfortunately, national economic improvement is not necessarily accompanied by betterment of the overall health status of the community; impacts from economic improvement tend to vary; for example, the rising prevalence of non-communicable diseases may lead to increasing malnutrition, or conversely obesity.

The first thousand days of life (1000 HPK) is postulated as the “window of opportunity” in the effort to prevent stunting, starting from conception through the first two years of life: these are critical for the future for both people and the country. In this period, growth rates and neuroplasticity of the brain are at their peak and thus nutritional deficiencies can exert their most devastating impact (Black, 2008). Mother’s nutrition during pregnancy can be an indicator of the nutritional status of the newborn. Chronic malnutrition and suboptimal weight gain during pregnancy, in addition to the factor of early age pregnancy, could pose a risk of intrauterine growth retardation of the fetus, resulting in low birth weight (less than 2500 grams), and or lack of height (baby is less than 48 cm long).

Root causes of stunting in Indonesia

Stunting at birth is not the only risk of linear growth, while the most important aspect is how stunting might affect brain development. Stunted children are at risk of morbidity at an early age, and having lower cognitive capacity results in a lack performance in school, even meaning being left behind, compared to their counterparts. Longterm developmental risks of stunted children include being prone to obesity and developing non-communicable diseases such as heart trouble, hypertension and diabetes mellitus in adulthood. Last but not least, their reproductive potential may be affected, especially when they come from a poor family that may deprive them, a feature of structural poverty, similarly to the intergenerational effects of stunting itself.

The framework of causes of stunting in Indonesia is described by the National Development Board ‘Bappenas’, and is adapted from UNICEF 1997 and IFRI 2016. Stunting reduction focuses on addressing the causes of nutritional problems, such as factors related to food security, social environment for food and parenting, access to health care to prevent morbidity, and the availability of clean water and sanitation. All of these factors influence nutritional intake and health status, and vice versa, as can be seen from Graph 1.

Human Resources Quality in Demographic Bonus
Indonesia, according to IFRI (2015) ranks 108th of 132 countries for stunting problems; it is indexed at the third level among ASEAN countries, after Timor Leste and Laos. Stunting related to the quality of human resources brings economic consequences. Bappenas in 2018 estimates the economic loss related to stunting without proper intervention may reach up to three percent of Gross Domestic Product, amounting to some IDR 300 hundred trillion (based on 2017 GDP). This amount includes the cost of tackling stunting and the potential loss of income as a result of the low productivity of the population, with a stunting prevalence of 37%. Compared to their counterparts, stunted adults on average earn 20 percent less income than their non-stunted counterparts.

The latest Survey shows that stunting prevalence in 2019 was 27.7% (SSGBI, 2019). This decline is inseparable from the Government’s increasingly focused and synergistic efforts. The National mid-term Development Plan (RPJMN) 2020-2024 has set stunting reduction by 14 percent, as a national strategy to raise the quality of human resources.

Stunting not only curbs individual potential, but affects the human capital of a nation as well. Achievements of development targets related to the quality of human resources in 2015-2019 included the reduction of the stunting prevalence to 27.7%, maternal mortality rate (from 346 to 305 per 100,000 live births), and total fertility rate (from 2.41 to 2.28) supposed to exert a significant impact on human resources quality through suppression of stunting.

Based on a World Economic Forum (WEF) 2017 report, Indonesia’s human capital index is at a 65th position among over 130 countries, lagging behind Malaysia (33rd), Thailand (40th)’ and Vietnam (64th). Although the productivity of the Indonesian workforce has increased from 2017 to 2018 from 81.9 to 84.07 million Rupiah per capita in 2018, it is lacking compared to figures for Singapore and Malaysia.

Planning and Budgeting Concept

Stunting threatens the much-heralded demographic bonus. The rate of population growth that cannot be suppressed between 1980 to 2010 shifted the population pyramid to an adult age group in the following decade. The peak of the demographic bonus in Indonesia will occur in 2030. If efforts to accelerate stunting reduction are not properly enforced, the target and hopes of a “Golden Generation” by 2045 may fail.

The Covid-19 pandemic in March 2020 seriously burdened the health system. The Covid-19 outbreak has stopped nutritional and health intervention efforts. Integrated weighing posts or Posyandu to monitor toddlers’ nutrition status have been curtailed, resulting from restrictions on crowding and social distancing. However, the Ministry of Health came up with a solution to home visit children for nutrition, in addition to child immunization to prevent morbidity, given directly in health care facilities or Puskesmas.

The Covid-19 pandemic did not deter the Government’s determination to achieve the stunting reduction target of 24 percent by 2024. Amid the Covid-19 pandemic, the Indonesian President has ordered the National Family Planning Board (BKKBN) to work as the Ministry in charge of stunting reduction. A family approach is the strategy taken, so that the accelerated target can be achieved. This strategy broadens, to not only include pregnant women and toddlers, but also at-risk teenagers and brides-to-be.