Lessons Learned from other countries
Experience on reducing stunting has been confirmed in certain countries. An integrated and convergent approach of multi-sectors in tackling stunting can be effective. Lessons learned from various countries involving different combinations of nutrition interventions are considered to have been effective.
Studies referred to by the World Bank (such as one on Bangladesh), demonstrated a 55 percent decline in stunting rates over 15 years, through improved household income, better sanitation coverage, parental education and improved utilization of health services in cutting fertility rates. Thailand lowered stunting to less than 20 percent from 50 percent with an “army” of well-trained dedicated community volunteers visiting homes and providing interpersonal counselling, agricultural investments and local commitment.
Significant involvement in multi-sectoral commitment was conducted in Senegal, where stunting was cut from 33 to 19 percent in less than two decades, with a high level of sustained multi-sector commitment, a results-based approach and an excellent data monitoring system. In addition, Peru successfully lowered stunting rates by almost half over a decade, from around 28 to 13 percent, from 2008 to 2016.
Peru seems the best example of stunting reduction efforts, taking into account the holistic approach. The key factors of Peru’s success were supported by political will and commitment from multi-sector policy makers from the highest through lower levels; hence, public officials and parents were made aware of the stunting consequences over generations. There was support in alignment of incentives for households, health facilities and local government.
Other key factors launched in Peru included a nationwide communication campaign, along with clear and achievable targets of program monitoring-evaluation, embedded in the information system of the Peruvian nutrition program. Community-based Growth Promotion Programs (CBGP) were implemented in those successful countries and others (also in Indonesia) through regular growth measurement of weight and length in toddlers.
Stunting and National Strategy
The Indonesian target to reduce stunting to just 14 percent by 2024 is ambitious. This goal was set in 2013, through Presidential Decree Number 42/2013, subject to acceleration of nutrition improvement through National action of the First Thousand Days of Life (1000 HPK). Furthermore, the newest commitment to stunting prevention came down in August 2018, as Presidential Decree number 83/2018. It introduces a national strategy to accelerate stunting prevention, through a multi-sectoral approach. The new StraNas approach aims to reduce stunting prevalence nationally, through better coordination of national, regional and community programs.
The strategy has set its sights on improving the allocation of funding across programs, better coordination, convergence evidence-based interventions, monitoring and performance. It strengthens governance and management capacity as well as results-based planning and budgeting, as depicted in Graph 2.
This strategy also plans to use resources efficiently for the highest-burden areas, and scale up successful intervention. The StraNas covers five pillars: 1) Leadership commitment and vision, 2) mass campaign on behavior change and interpersonal communication, 3) convergence of the national, regional and village program, 4) food and nutrition policy, 5) monitoring and evaluation. Integrated nutrition intervention in its implementation is categorized as a specific and sensitive manner, with the target priority of pregnant women, and toddler age of 0-23 months in the first thousand days of life.
Implementation of intervention is based on the success of other countries, and through literature studies. Stunting reduction will be more effective when carried out in an manner integrating specific and sensitive interventions. In addition, the success of an integrated approach is subject to target priority in the intervention locus. The intervention locus was gradually set, beginning at 8 districts/municipalities in 2017 as a pilot. It replicates in 2018 for 100 more loci. A further 160 loci were distributed in 2019, and all 514 districts and municipalities are expected to be covered by 2020-2024 (Graph 3).
The Indonesian health system in a decentralization era implemented all directly under local government (the district and municipalities). Nevertheless, coordination is inseparable from the Central Government through the Province level. This coordination is important to convince all that the policy achieved results according to the national policy as stated in the RPJMN.
The specific intervention in reducing stunting is technically focused on health intervention, but for the sake of sector integration, some intersecting programs are also carried out by other sectors; for example, a mass campaign to reduce stunting, that should be announced at any sector, sharpening on the specific intervention depicted in Graphs 4 and 5.
As mentioned earlier, the Indonesian government focuses on evidence-driven and strategic spending to improve food security, sanitation, health care, and caring practices for mothers and children. When this strategic planning is well-implemented, it could prevent an estimated two million young children from becoming stunted between 2018 and 2022.
An encouraging quote from World Bank President Jim Yong Kim: “Indonesia has the key ingredients to succeed: strong leadership and sustained commitment, financial and human resources at all levels of government, and perhaps most importantly ambitious targets—and a concrete plan to achieve them”.