the landscape analysis indonesian country assessment

Landscape Analysis Country Assessment

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The Landscape Analysis

Indonesian Country

Assessment

Final Report

6 September 2010


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The Landscape Analysis - Indonesian Country

Assessment

Table of Contents

Executive Summary ................................................................................................... 4 1. Introduction ........................................................................................................... 6

2. The Landscape Analysis Country Assessment Process ........................................... 8 3. The Nutrition Situation in Indonesia .................................................................... 10

Nutrition and Health Situation of Children in Indonesia ....................................... 10 Nutrition and Health Situation of Women in Indonesia ......................................... 12

Maternal and Infant and Young Child Feeding in Indonesia ................................. 14 4. Findings of the Landscape Analysis Country Assessment and analysis ................ 20

Perception of the problem .................................................................................... 20 Nutrition policies and activities currently practised .............................................. 21

Nutrition Coordination ......................................................................................... 23 Human Resources for Nutrition ............................................................................ 24

Planning, Budget and Funding ............................................................................. 26 Nutrition Information System ............................................................................... 27

Summary of Findings ........................................................................................... 28 5. Recommendations ................................................................................................ 29

Overall Objective ................................................................................................. 29 Nutrition Coordination & Responsibilities ............................................................ 29

Budget and Funding ............................................................................................. 29 Planning and Design of Programmes .................................................................... 30

Human Resources ................................................................................................ 31 Service Provision ................................................................................................. 33

Nutrition Information System ............................................................................... 33 6. Next Steps ........................................................................................................... 36

Appendix 1. The Country Assessment methodology ................................................ 38 Appendix 2. Indonesia’s nutrition oriented poverty reduction programmes ........... 104

Cluster 1 - Social Assistance and Protection Programmes ................................... 105 Raskin Programme ......................................................................................... 106

Cash Transfers ............................................................................................... 107 Health Insurance ............................................................................................ 108

Cluster 2 - Community Empowerment Programmes ........................................... 109 PNPM Mandiri (National Programme on Community Empowerment) ........... 109

PNPM Generasi (Community Cash Transfer for Health and Smart Generation)110 Micro and Small Business Empowerment....................................................... 111

Appendix 3. Essential Nutrition Interventions Policy and Programme framework . 112 Appendix 4. WFP Food Security and Vulnerability Mapping ............................... 119


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Figures and Table

Figure 1: The timing of growth faltering in children under five in developing countries

.................................................................................................................................. 6 Figure 2: The UNICEF Nutrition Conceptual Framework .......................................... 8

Figure 3: Functions of the Nutrition System which help define Commitment and

Capacity ................................................................................................................... 10

Figure 4: Underweight Prevalence in children under five years of age in Indonesia .. 11 Figure 5: Stunting and wasting by province in Indonesia (Riskesdas 2007) .............. 11

Table 1: Coverage of the Lancet Nutrition Interventions in Indonesia....................... 18


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Executive Summary

Despite the gross national income having grown five fold since the eighties, progress in

nutrition has been limited with 37% of Indonesian children still being stunted.

Concerned about the situation of stunting and the need for an adequate assessment of

the capacity of the government nutrition system in the new decentralized administration,

the National Planning Agency and the Ministry of Health of the Government of

Indonesia (GOI) decided to carry out the Landscape Analysis Country Assessment

process in order assess their “readiness” to act to accelerate the reduction of maternal

and child undernutrition.

An analysis of the nutrition situation reveals that although child underweight prevalence

has been reduced in Indonesia and the Mid-Term Development and the Millennium

Development Goals for hunger reduction have been achieved, Indonesia continues to

have serious stunting and wasting problems among young children. Considerable

maternal undernutrition exists, which is contributing to the relatively high level of low

birth weight as well as stunting. Programme coverage of existing nutrition programmes

is reasonable for some activities, but much higher coverage needs to be achieved of the

more preventive essential nutrition interventions that can help accelerate the reduction

of maternal and child undernutrition, including promotion and counselling on

breastfeeding and complementary feeding, iron folate supplementation of women,

deworming of women and children, protein and energy supplementation of poor

pregnant women, treatment of diarrhoea with zinc, and improved coverage of food

fortification and home fortification programmes.

The findings of the Country Assessment are that although the commitment to act for

nutrition is reasonably strong, the capacity to act for nutrition still needs to be

strengthened. The existing strong commitment to act for nutrition is misdirected at

trying to resolve acute nutrition problems rather than putting into place systems and

interventions to prevent children and women becoming malnourished, largely because

the latter is not generally recognized as a problem. Commitment to resolving the

problem of stunting is growing at the national level, but at the provincial and district

levels where all the action is decided and implemented, the nutrition problem is still

largely equated with severe undernutrition (Gizi Buruk) and/or to a lack of food.

Mechanisms for policy coordination, identification of priorities and setting of goals and

targets are weak or non-existent at all levels. The capacity to act for nutrition needs to

be strengthened if stunting reduction is to be achieved. Service provision largely

revolves around child growth monitoring and is misdirected to the under-five year olds

rather than focused on children under two years where nutrition interventions can have a

greater effect. Less priority is given to preventive activities related to counseling of

mothers on infant and young child feeding than to the curative function of detecting and

treating wasting. Inter-sectoral coordination of implementation needs to be reinforced.

Although sufficient nutritionists are being trained their curricula is outdated or

incomplete. They are under employed in the system, and especially in the

implementation of service delivery. Little or no in-service training in nutrition occurs.

The use of monitoring data for decision making or of evaluation data to learn from

programme experience is very uncommon.

Recommendations are made concerning the areas of: Nutrition Coordination and

Responsibilities; Budget and Funding; Planning and Design of Programmes; Human


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Resources; Service Provision; Nutrition Information System. In summary, priority

should be given to creating mechanisms which promote the development of harmonized

Food and Nutrition Action Plans at Province and District level based on the national

plan, decree and guidelines, as well as to developing inter-sectoral coordination

mechanisms to oversee and monitor their implementation. In order to increase cost-

effectiveness of funding, guidance and incentives should be provided to districts for

them to prioritize evidence-based interventions targeted at vulnerable groups of pre-

pregnant, pregnant and lactating women and children under two-years of age. Length of

children under two and maternal anemia should be given increasing emphasis and

prioritized for measuring the effectiveness of both nutrition as well as poverty reduction

programmes at all levels. In parallel to this, job descriptions need to be updated to

reflect new program directions (i.e., measurement of stunting and maternal

health/anemia) for all staff involved in nutrition at all levels of the system. A human

resource map for nutritionists and other health workers should be developed in order to

identify deployment gaps and competencies, and develop a national plan for a training

approach to teach nutritional competencies for volunteers, nurses and midwives, and to

provide technical updates for doctors in the nutrition sciences. In parallel to this the

implementation at scale (as appropriate depending on local conditions), of the package

of Essential Nutrition Interventions (ENI) should be progressively implemented starting

in a few districts and provinces and gradually expanding so that within five years most

mothers and children are covered by ENI as a continuum of care from pre-conception,

conception to two years of age. Monitoring and evaluation guidelines should be

modified to reflect new programme focus and relevant indicators.


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1. Introduction

While the Indonesian economy has grown impressively over the last four decades, child

malnutrition rates although reduced, still remain stubbornly high. The gross national

income has grown five fold since the eighties, but child underweight rates have little

more than halved in the same period, and 18% of Indonesian children are still so

affected. Perhaps the most worrying aspect of this however, is that 37%1 of Indonesian

children are stunted. Child stunting is widely accepted as one of the best predictors of

the quality of human capital, influencing potential academic performance and future

earning capability of a nation2.

Stunting is equally caused by deficiencies in the intrauterine environment of the foetus

as well as the child’s health and nutrition during early post natal life. As can be seen in

Figure 1 below, in countries affected by maternal and child undernutrition, length

growth faltering is already established at birth, and then occurs every month from birth

to two years3. After two years of age children from all countries grow the same, such

that height at two years of age largely determines adult height4.

Figure 1: The timing of growth faltering in children under five in developing countries

In the last decade Indonesia has been transformed from one of the most centralized to

one of the most decentralized governments in the world. Decentralization was achieved

by a series of regulations that came into effect in 2001 and transferred the responsibility

for the delivery of public services to district or municipality. Indonesia’s 1999

decentralisation law permitted the division of provinces, districts and sub-districts into

smaller units in the interests of better service delivery, more equitable resource

distribution and more representative government. With decentralization the number of

districts is reported to have increased from 292 in 1998 to 497 in early 2009 and it is

still increasing. Areas of competence which were maintained at the central level

1 Basic Health Research (Riskesdas) 2007 2 Victora CG, Adair L, Fall C, Hallal PC, Martorell M, Richter L, Sachdev HS for the Maternal and Child Undernutrition Study Group (2008) Maternal and child undernutrition: consequences for adult health and human capital. The Lancet 37: 340-357 3 Victora CG, de Onis M, Hallal PC, Blössner M, Shrimpton R. 2010 Worldwide timing of growth faltering: revisiting implications for interventions. Pediatrics. 125(3):e473-80. 4 Cole T. 2000. Secular trends in growth. Proc. Nut Soc. 59:317-324.


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included Foreign Affairs, Defence, Fiscal and Monetary, Justice and Religion. For the

remaining areas including Health, Agriculture and Education, the role of central level of

government is restricted to that of setting standards and norms, monitoring and

evaluation and controlling, while that of the provincial government is one of supervision

and facilitation5.

Furthermore it would seem that the lack of improvement in child undernutrition since

around the turn of the century, which was related initially to the economic crisis, has

since been associated with a deterioration of nutrition programme service delivery

capacity caused by decentralization. Between 1995 and 2006, the number of health

providers such as medical doctors and specialists, midwives and nurses has, however,

risen significantly but the focus seems to have been on multiplying the numbers of

workers, with quality given less attention. The preliminary results of the WHO/GoI

report on hospital assessment of quality of child care conducted in six provinces6show

that the percentage of standard achievement of case management of undernutrition was

30% on average or less than 60%, a cut-off figure that suggests a strong need for

improvement. The lowest achievement was observed in East Java (23%) and the highest

achievement in NTT (43%). A further causal analysis of these figures is required to

uncover the full extent and nature of the deficiency, as well as to assess the prevailing

current knowledge and practices of nutritional care by health and nutrition professionals

in the community.

Just as the district government struggled to match human resource skills with its newly

attained authority, so did provincial and central level planners and policy makers face

the new challenges of coordination, monitoring and standardization. The end result

during this transition has been that the shortage of nutrition capacity at the district level

combined with the challenges to coordination and leadership at the provincial and

central levels has resulted in a deterioration of nutrition programmes in general.7

Concerned about the situation of stunting and the need for an adequate assessment of

the capacity of the government nutrition system in the new decentralized administration,

the National Planning Agency and the Ministry of Health of the Government of

Indonesia (GOI) decided to carry out the Landscape Analysis Country Assessment

process that has been developed by the UN and other international agencies under the

leadership of WHO8. The Country Assessment (CA) aims to help countries assess their

“readiness” to act to accelerate the reduction of maternal and child undernutrition.

Readiness is recognized to be a function of both “commitment” and “capacity” and

influenced by factors operating at all levels of causality as depicted in the UNICEF

Nutrition Conceptual Framework (See Figure 2 below). Commitment can be measured

by the existence of policies and the amounts of resources applied to the problem, while

capacity is reflected at the underlying level in terms of adequacy of service delivery.

5 Suwandi M 2001. Top down versus bottom up approaches to decentralization (the Indonesian experience). Jakarta: Ministry of Home Affairs and Regional Autonomy. 6 The assessment was done in three hospitals each in Jambi, Southeast Sulawesi, East Java, NTT, North Maluku and Central Kalimantan. The results have also shown that the management of cases of diarrhoea, fever and cough/difficult breathing was also below 60% (WHO, 2009. Report of hospital assessment on quality of child health care in 6 provinces, February) 7 Friedman J, Heywood PF, Marks G, Saaday F, Choi Y. 2006.Health Sector Decentralization and Indonesia’s Nutrition Programs: Opportunities and challenges. Report No. 39690-IND. Washington: World Bank. 8 Nishida, N Shrimpton R, Darnton-Hill I 2009. Landscape Analysis on countries readiness to accelerate action in nutrition. SCN News 37: 4-9. Geneva: SCN.


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Figure 2: The UNICEF Nutrition Conceptual Framework

2. The Landscape Analysis Country Assessment Process

The overall objective of the CA is to assist in the creation of greater capacity and

commitment for improving the nutrition situation in order to accelerate the reduction of

maternal and child undernutrition. To this end, with the support provided by the main

UN agencies involved, a national team was created with representatives from the

Ministry of Health as well as from the BAPPENAS together with provincial level

representatives from the planning boards and health offices of the three provinces where

the CA was undertaken. The Micronutrient Initiative, Helen Keller International, and

academic institutions including the University of Indonesia were also involved. The full

methodology together with questionnaires, the schedule of interviews and the people

interviewed are contained in Appendix 1, and the process is further summarized here.

The overall rationale guiding the CA process is derived from the understanding agreed

at the UN Standing Committee on Nutrition 35th Session

9. It was recognized that the

effective targeting of mothers and children from conception to two years of age (the

‘window of opportunity’) of the set of interventions coming from the Lancet Nutrition

Series (LNS)10

on how to accelerate the reduction of maternal and child undernutrition

could prevent at least a quarter of child deaths under 36 months of age and reduce the

prevalence of stunting by about a third in the short term.

The assessment methodology used for the Indonesian CA was a qualitative one.

Questionnaires derived from those provided by WHO Geneva were translated into

Indonesian and further refined by the national team to meet Indonesian requirements for

decision making at national, provincial and district levels. Stakeholders interviewed at

9 SCN 2008. Recommendations from the SCN 35th Session: "ACCELERATING THE REDUCTION OF MATERNAL AND CHILD UNDERNUTRITION" Available at http://www.unscn.org/Publications/AnnualMeeting/SCN35/35th_Session_Recommendations.pdf (Accessed 09/07/09) 10 The Lancet Series on Maternal and Child Undernutrition 2008. Available at URL: http://www.theLancet.com/series/maternal-and-child-undernutrition (Accessed 05/11/09)

http://www.unscn.org/Publications/AnnualMeeting/SCN35/35th_Session_Recommendations.pdf

http://www.thelancet.com/series/maternal-and-child-undernutrition


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the central level included officials from ministries of planning, health, home affairs,

industry, agriculture, education, social welfare, as well as representatives from

parliament, donor agencies, international and national non-government organizations

and universities. The national interview team was divided to visit three provinces, and

included members coming from provincial offices of home affairs, health, agriculture,

various other state offices and NGOs. Stakeholders interviewed at the provincial level

were the same as at national level, but at the district level the heads of health centers and

nutritionists as well as village midwives and posyandu cadres were also included.

The timing of the various Landscape Analysis activities was as follows:

11 – 13 March: Preparation of the logistics of the various field visits as well as

training the interviewers in the use of the questionnaires;

13 March: National Launch of the Landscape Analysis Country Assessment;

15 March: Provincial level launches and interviews with stakeholders in Aceh,

Jawa Tengah and NTT;

16 – 18 March: Meetings and interviews with District level stakeholders in Aceh

Timur, Aceh Besar, Kota Semarang, Banyumas, Sikka and Belu;

19 March: Provincial level feedback sessions;

22 – 23 March: National level interviews;

24 March: Consolidation of the results from the district, provincial and national

level interviews;

25 March: Development of the draft findings and recommendations;

26 March: Presentation and discussion of the draft findings and

recommendations with national level stakeholders.

The first step in the analysis of the questionnaires was to summarize the responses of

the national, provincial and district level interviewees using the headings that grouped

the various questions. An analytical matrix, derived from that used in other Country

Assessments11

, showing the various indicators of “commitment” as well as those of

“capacity” to act, was also used to help further summarize the questionnaires results.

This matrix included the four elements of the nutrition system as proposed in the Lancet

Nutrition Series (LNS)12

(see Figure 3 below), where “Commitment to Act” is related to

the Stewardship and Resources functions and “Capacity to Act” is related to the

Capacity and Service Provision functions.

11 Chopra M, Pelletier D, Witten C, Dietrich M. 2009. Assessing countries’ readiness: Methodology for in-depth country assessment. SCN News 37:17-22 12 Morris SS, Cogill B, Uauy R, et al Effective international action against undernutrition: why has it proven so difficult and what can be done to accelerate progress? Lancet. 371(9612):608-21.


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CO

MM

ITT

ME

NT

CA

PA

CIT

Y

---------------------------------------------------------------------------------------------------

Figure 3: Functions of the Nutrition System which help define Commitment and Capacity

Not all of these four functions are fully operational at all levels. The Service Provision

function is only present at the District level, whereas the Stewardship and Capacity

functions are more those performed at national and provincial levels. Resources are

essentially applied at all levels, although control of them in Indonesia is now

predominantly at the district level.

3. The Nutrition Situation in Indonesia13

Nutrition and Health Situation of Children in Indonesia The child nutrition situation in Indonesia, as measured by underweight, has improved

significantly. In 1989 the prevalence was 31% and latest data from 200714

indicate that

it is now 18.4%. This is a decline of almost 13% over 18 years; about 0.7% points per

year. As shown in the Figure 4 on underweight prevalence below, the decline was

particularly marked in the 1990s, during which time it fell by about 10%. However,

there was then a period of stagnation, even a slight rise in prevalence between 2000 and

2005. Between 2005 and 2007 there was a very rapid decline of just over 6 percentage

points. This dramatic decline in underweight may reflect a genuine reduction in the

prevalence of underweight or a difference in survey methodology between the Susenas

2005 and Riskesdas 2007, even though both surveys used the same sampling frame. The

MDG target of 18.5% has already been achieved by RISKESDAS in 2007 since the

target was a 50% reduction of 37.5 % underweight in 1989. The medium term

development plan target was also achieved.

13 The most recent available data is used throughout this review, which in most cases was from the

Riskesdas 2007 survey. 14 1989 data from Susenas and 2007 data from Riskesdas, all by WHO standard.


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Figure 4: Underweight Prevalence in children under five years of age in Indonesia

In contrast, however, child undernutrition as measured by child stunting and wasting

remains a significant problem. Representative data on child stunting is limited, with

Susenas 1995 reporting a prevalence of 46.9% stunting based on the NCHS growth

reference. In 2007 the RISKESDAS found 36.8% of all children under five in

Indonesia were stunted using the new WHO growth standard as a reference and

furthermore 13.6% were wasted. These national data reflect significant provincial

variations as shown in Figure 5 below for stunting and wasting by Province.

Figure 5: Stunting and wasting by province in Indonesia (Riskesdas 2007)

Trend in Underweight Prevalence of Under Five Children

6,37,2

11,610,5

8,17,5

6,3

8,0 8,3 8,6 8,8

5,4

31,2

28,3

20,019,0

18,317,1

19,8 19,3 19,2 19,6 19,2

13,0

37,5

35,5

31,6

29,5

26,4

24,6

26,127,3 27,5

28,2 28,0

18,4 2018,5

0,0

10,0

20,0

30,0

40,0

1989 1992 1995 1998 1999 2000 2001 2002 2003 2004 2005 2007 2009 2012 2015

Pe

rce

nt

Severe Maln. Moderate Maln Malnourished Target

Target RPJM 2009

Target MDG 2015

Source : Susenas(1989-2005), Riskesdas 2007 (WHO standard)

Stunting and Wasting by Province in Indonesia (Riskesdas 2007)

0

5

10

15

20

25

30

35

40

45

50

Aceh

N S

umatra

W S

umatra

Riau

Jambi

S S

umatra

Bengkulu

Lampung

Bangka

Kepulauan R

iau

DK

I Jakarta

W Java

C Java

DI Y

ogyakarta

E Java

Banten

Bali

W N

usa Tenggara

E N

usa Tenggara

W K

alimantan

C K

alimantan

S K

alimantan

E K

alimantan

N S

ulawesi

C S

ulawesi

S S

ulawesi

SE

Sulaw

esi

Gorontalo

W S

ulawesi

Maluku

N M

aluku

W P

apua

Papua

%

Stunting

Wasting


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East Nusa Tenggara (NTT) is the province with the highest prevalence of stunting in

Indonesia with 46.7%, and there are nine provinces with stunting prevalence over 40%,

categorized by WHO as ‘very high’. Wasting rates are also high, since a prevalence of

over 15% it is considered an emergency situation with requirements for supplementary

feeding programmes. Eighteen of Indonesia’s 33 provinces have a wasting prevalence

above 15%. Moreover nationally, 6.2% of children are severely wasted which puts

them at high risk of death.

Child illness still remains a problem that compromises nutritional status in Indonesia.

Diarrhoea and ARI remain the two main causes of death for infants and children under

five.15

Prevalence of these illnesses is also high. 11% and 31% of children had ARI and

a fever respectively in the two weeks preceding the DHS 2007 and for only 65.9% was

treatment or advice sought from a health facility or provider. 13.7% of children had

diarrhoea in the previous two weeks of the DHS and 60.9% received some form of oral

rehydration. Immunization rates are also low – only 46.2% of children 12-23 months

were found to have completed their vaccinations (Riskesdas 2007). It seems likely that

the high rates of infectious illness will be contributing to the high rates of wasting in

young children, and most probably are a reflection of the poor infant feeding practices

and poor hygiene conditions that are discussed further below.

Overall therefore, while underweight prevalence has been reduced in Indonesia and the

Mid-Term Development and the Millennium Development Goals have been achieved,

Indonesia continues to have serious stunting and wasting problems, with an almost two

fold difference in prevalence seen across the provinces. The high stunting and wasting

rates are accompanied by high rates of infection disease among children under five

years of age

Nutrition and Health Situation of Women in Indonesia WHO notes that weight of the child at birth is directly influenced by the general level of

health and nutrition of the woman before and during pregnancy16

, and that while

prematurity is the main cause of low birth weight in industrialized societies, in

developing countries it is predominantly caused by intra-uterine growth retardation17

.

Riskesdas 2007 data indicates that 13.6% of women have chronic energy deficiency as

measured by mid-upper arm circumference <23.5 cm. This represents a decline in

prevalence from the 2003 level of 16.7%. Nevertheless, prevalence remains greater than

15% in eight provinces. According to WHO18

, a prevalence between 10-19% is

considered as a medium prevalence indicating a poor nutrition situation.

Data on birth weight although limited does suggest that there is a problem. Although

only about half of babies are weighed at birth, 11.5% of these have birth weight below

2.5kg19

. Although data from the 2007 DHS indicate a much lower proportion of low

15 Riskesdas 2007 16 Kramer M 1987. Determinants of low birth weight: methodological assessment and meta-analysis.

Bulletin of the World Health Organization 65: 663-737 17 Villar J and Belizan JM. 1982. The relative contribution of prematurity and foetal growth retardation to

low birth weight in developing and developed societies. Am J Obstetrics & Gynaecology 143: 793-798 18 Physical status: the use and interpretation of anthropometry. Report of a WHO Expert Committee.

Technical Report Series No. 854. 1995. URL:

http://www.who.int/childgrowth/publications/physical_status/en/index.html. (accessed 17 June 2010) 19 Riskesdas 2007

http://www.who.int/childgrowth/publications/physical_status/en/index.html


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birth weight children (5.5%), it seems that around 35% of newborn birth weights were

gathered from the child health cards during the DHS, while the cards were used as a

source of information for around 50% of children during the Riskesdas 2007.

It is notable that according to DHS 2007 more than 90% of women have their weight

monitored during pregnancy, although it is not clear if specific support and advice is

given to ensure that women gain sufficient weight during pregnancy. Total weight gain

during pregnancy has been found to be insufficient in around 80% of mothers in a

population based study in rural Central Java20

, suggesting that more might be done to

improve weight gain. Trials of food supplementation during pregnancy in Java, besides

improving birth weight, subsequently led to a 20% reduction in stunting in under-five

year old children21

.

Although nationally representative data on anaemia in women is limited and dated,

anaemia still seems to be a problem. The National Household Health Survey in 2001

indicated that 27.9% of reproductive age women and 40.1% of pregnant women were

anaemic. Riskesdas 2007 data indicates that in urban areas 19.7% of reproductive age

women are anaemic, and 24.5% are anaemic in pregnancy. There is other evidence that

iron status is limiting, such that during the time of the 1997/8 financial crisis mothers

were the first ones to show signs of undernutrition as reflected in increased wasting and

levels of anaemia associated with reduced consumption of high quality food22

. A more

recent study has suggested that 20% of early neonatal deaths in Indonesia could be

attributed to a lack of iron and folic acid supplementation during pregnancy23

.

Considerable information exists on maternal health practices during pregnancy and

around delivery, which are far from being limited in their content. Riskesdas 2007

reported that 84.5% of women receive some form of pregnancy check up, and even in

rural areas and amongst the poorest economic quintile almost 80% of women have a

pregnancy check up. 97.1% of these women report receiving three or more

interventions during their visit. The majority of women receive blood pressure

measurements, fundal height examination, tetanus toxoid immunization and weight

measurement. However only 33.8% receive a haemoglobin test and only 36.4% a urine

test. DHS 2007 also has data on the type of maternal care during pregnancy: 93.3% of

women receive ANC from a trained provider and 75.3% of women have their first ANC

visit at less than four months, with the result that the average duration of pregnancy of

first visit is 2.7 months. 81.5% of women have more than four visits in total and only

4.2% of women have no visit. 46.1% of women deliver in a health facility, the majority

in a private facility, and 53% of women deliver at home. 79.4% are delivered by a

skilled provider, the majority by a nurse, midwife or village midwife. Nevertheless

maternal mortality remains high in Indonesia and is not improving.

Despite the high ANC coverage the treatment of anaemia during pregnancy doesn’t

seem to be very effective. Although most mothers receive supplements they don’t take

20 Winkvist A, Stenlund H, Hakimi M, Nurdiati DS, and Dibley MJ. 2002. Weight-gain patterns from prepregnancy until delivery among women in Central Java, Indonesia. Am J Clin Nutr 75:1072–7. 21 Kusin JA, Kardjati S, Houtkooper JM, Renqvist UH. 1992. Energy supplementation during pregnancy and postnatal growth. Lancet 340(8820):623-6. 22 Block SA , Kiess L, Webb P, Kosen S, et al. 2004. Macro shocks and micro-outcomes: child nutrition during Indonesias crisis. Ecn Hum Biol 2(1):21-24. 23Titaley CR, Dibley MJ, Roberts CL, Hall J & Aghod K 2009. Iron and folic acid supplements and reduced early neonatal deaths in Indonesia. Bull World Health Organ 87: 1–23.


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enough of them. Riskesdas 2007 found that 92.2% of women received iron and folic

acid supplementation during the last pregnancy which is slightly different from DHS

2007 which reports that only 79.3% of women received iron supplements during

pregnancy. More importantly is that Riskesdas reports that only 29.2% of women

consumed the 90+ tablets during the last pregnancy as recommended24,

Fertility in Indonesia has dropped to only 2.6 births per woman though it remains

significantly higher in some provinces such as NTT and Maluku. Median age at first

birth is 21.5 years with little variation, though it is slightly lower in rural areas (20.6

yrs), among those with no education (19.6 yrs) and those from the lowest wealth

quintile (20.7 yrs). As a result, the percentage of teenagers who have begun child

bearing (15-19 years) is relatively low at only 8.5%. The low fertility rate is at least

partially due to the fact that 61% of currently married women were using some form of

family planning (57.4% were using a modern method) at the time of the data

collection25

with an unmet need for family planning of only 9.1% amongst currently

married women.

We can conclude that despite the limited information available, there is considerable

maternal undernutrition which is likely to be contributing to the relatively high level of

low birth weight as well as stunting. While it appears that women receive reasonable

health care during pregnancy and delivery if measured in terms of timing of first visit,

frequency of visits and delivery by a skilled attendant, the “nutrition” oriented

interventions could be improved. Visits earlier in the first trimester would be preferable,

as would more blood tests and urine tests done to identify risk factors such as anaemia

and urine infections. Also, too few women consume the required number of iron folate

tablets in pregnancy to protect them from anaemia.

Maternal and Infant and Young Child Feeding in Indonesia Infant and young child feeding practices in Indonesia are far from adequate. According

to the DHS 2007, only 32.4% of children less than six months of age are exclusively

breastfed. This represents a net decrease from the 40% rate in 2002 and is likely

attributed to the sharp increase of bottle-feeding practices from 17% to 28% among

children under-six months of age during the same period. Susenas data indicate the

same trend regarding the practices of breastfeeding. In the worst off provinces (i.e.,

Riau Islands, Jakarta and Bali) exclusive breastfeeding benefits less than 15% of

children. As breastmilk is the optimal source of nutrition for children, this puts young

children at a severe disadvantage both nutritionally and for the prevention of illness.

Added to this is the fact that only 43.9% of children start breastfeeding within an hour

of birth and 64.6% receive a prelacteal feed. Young children in Indonesia are also

receiving complementary foods too early: at 4-5 months of age more than half (52.9%)

are receiving some form of solid or semi-solid foods, and even below two months,

33.4% are receiving infant formula. Complementary feeding should start from about six

months and children should receive three or more food groups a minimum number of

times according to their age group in addition to breastmilk. DHS 2007 data indicate

that only 52.5% are optimally fed in this way.

The main area of weakness in infant and young child feeding is frequency of feeding

(only 67% offer complementary foods the minimum times per age group per day in

24 Riskesdas 2007 25 DHS 2007


15

addition to breastmilk) but only 75% consume sufficient number of food groups, i.e., a

diversified diet.26

These poor feeding practices: insufficient exclusive breast feeding,

excessive use of infant formula, early complementary feeding and poor quality and

frequency of complementary feeding after six months, are undoubtedly contributing to

wasting and stunting. Poor feeding practices are also contributing to micronutrient

deficiencies. Only 87.4% and 69.7% of 6-35 month old children were reported to have

received vitamin A and iron rich foods in the past 24 hours, according to the DHS

(2007).

Few data are currently available on maternal food consumption except DHS 2007 data,

which reports that about 75% of women with an under-three year old child ate meat or

fish within the previous 24 hours; consumption of iron rich foods is similar.

National recommendations for carbohydrate and protein consumption, established in

2004 for the general population by the National Workshop on Food and Nutrition VIII

(WKNPG), are for 2,000 kilo-calories per capita per day for carbohydrates and 52

grams per capita per day for protein. On a national level 1,735 kilocalories of

carbohydrate and 55.5 grams of protein are consumed per day per capita27

. Only East

Java meets the national recommendation for carbohydrate consumption at a provincial

level. However, all but six provinces meet or exceed the national requirements for

protein indicating, in general, a food secure environment for women and children.

The consumption of fruits and vegetables is considered to be inadequate for the general

population. Riskesdas found 93.6% of the population does not consume ‘enough’ fruits

and vegetables, i.e., they consume less than five portions daily. This indicates that the

consumption of fruits and vegetables is likely below the 400 g per day recommended by

WHO28

for the prevention of diet-related chronic diseases such as obesity, diabetes,

cardiovascular diseases and cancer.

In conclusion, maternal and infant and young child feeding practices are generally poor,

with low levels of exclusive breastfeeding in the first six months and inadequate

complementary feeding among young children. While food consumption of the general

population is largely adequate from a quantitative perspective it is poor qualitatively.

Poor feeding practices, including insufficient amounts of nutrient dense foods among

mothers and their children contribute to the consumption of micronutrient deficient diets.

Nutrition and Nutrition-related Programmes in Indonesia Nutrition is an important component of the central government programme. The total

budget for community nutrition is Rupiah 244 billion (about US$ 26 million) from

central government and a further 148 billion is available from special funds including

loans. 60% of this funding is maintained at central level and the remainder is provided

to provinces as de-concentration budget based on population and prevalence of

underweight.29

26 DHS 2007 Table 14.5, page 176 27 Riskesdas 2007 28 WHO, 2002. Diet, Nutrition and the prevention of chronic diseases. Report of a joint WHO/FAO expert

consultation. Geneva. 29 Pangaribuan R. 2010 Description of Health System Delivery and Nutrition Policies, Programs and

Initiatives in Landscape Analysis Preparation. Report prepared for UNICEF Jakarta


16

At district level, funding for nutrition comes from district funding (APBD II), provincial

health offices - from province budget (APBD II) and passing on funding from central

level (APBN) - and special grants. Proposals are submitted for activities for which

funding is required but the process of review of these proposals is lengthy and

convoluted and nutrition activities may be dropped from the district plan due to budget

limitations or if representatives of the District Health Office are not able to justify them

to the decision makers of the district budget – Bappeda, DPRD and District Health

Office. A similar process takes place at provincial level.

Since decentralization was adopted in 1999, responsibility for delivery of public health

services has been devolved to district level. However Minimum Service Standards

(SPM) have been issued under the Ministry of Home Affairs’ Regulation on Technical

Guidance on Formulating and Establishing Minimum Service Standards for

Government Departments. The SPM ensure that local governments provide basic

services and ensure consistency between districts. The 2008 MOH Regulation on

Obligatory Minimum Service Standards specifies the following basic services and

require local authorities to monitor whether the standards are being met.

Coverage of ANC for pregnant women (at least four visits), including iron and

folic acid supplementation: 95% by 2015

Coverage of postpartum health services, including vitamin A supplementation:

90% by 2015

Universal child immunization: 100% by 2010

Coverage of infant health services, including vitamin A supplementation: target

90% by 2010

Coverage of child health services, including vitamin A supplementation and

growth and development monitoring): target 90% by 2010

Coverage of supplementary feeding of 6-24 month old children from poor

families: 100% by 2010

Coverage of treatment of severely malnourished children: 100% by 2010

Due to the above SPM and traditions of nutrition interventions in Indonesia, the main

intervention implemented to address these high levels of undernutrition is community

(versus facility) based growth monitoring in integrated health posts – the posyandu.

The policy is that all children under five should be regularly weighed at the posyandu,

preferably once per month30

, that the weight is plotted on the “Road to Health” (Kartu

Menuju Sehat or KMS) growth charts or in the chart in the KIA (mother and child

health) book and that mothers of faltering children should be counselled. In addition,

children from poor families are given supplementary food at the posyandu in the form

of fortified blended food for those aged 6-11 months and fortified biscuits for those

aged 12-23 months. If a child has not gained weight for the previous two consecutive

months or has fallen below -3SD (fallen below the red line) they should be referred to

the local health facility. The health facility should provide further examination,

including weight-for-height assessment to confirm severe acute malnutrition and

medical check-up. Based on the results, they should be provided with treatment: either

supplementary feeding or therapeutic feeding.

30 According to the Nutrition Plan of Action at Central Level (Rencana aksi pembinaan gizi masyarakat,

2010-2014), 80% of all preschoolers are to be weighed at Posyandu.


17

In reality, however, in 2007 only 45.4% of children under five were weighed at least 4

times in the six months prior31

. In some provinces such as NTT and Yogyakarta the

percentage was much higher (i.e., above 65%) but in others such as North Sumatera and

Jambi it was only 30% or below. 25.5% of children under five had not been weighed at

all in the last six months. Moreover, it has been observed that very few mothers whose

children are growth faltering received counselling. At its best, a community based

growth monitoring approach is more curative than preventive. As practiced in

Indonesia, the focus is very much on weighing and not on the preventative and

supportive interventions that are intended to actually address the problem of

undernutrition.

Another major nutrition intervention is vitamin A supplementation. Under

decentralization, all districts are meant to purchase adequate supplies of vitamin A

supplements for children 6-59 months and post partum women. The supplements for

children are meant to be distributed through posyandu in February and August with the

necessary mobilization and socialization activities to take place before the distribution

to encourage attendance on the distribution day. Children who do not attend are to be

followed up in their homes. According to DHS 2007 only 68.5% reportedly received a

vitamin A capsule within the past six months. Riskesdas 2007 reported a similar figure

of 71.5%. Women are to receive a vitamin A supplement after delivery during a post

partum visit or when they take their newborn for immunization. However, the DHS

2007 found that only 44.6% of women had received the supplement.

The final main maternal nutrition intervention is iron and folic acid supplementation of

pregnant women. As reported above however, only about 30% of women received 90+

tablets as intended; compliance is not recorded.

Several other interventions related to maternal health and child health impact upon

nutritional status, as does, for example, access to water and sanitation and food security.

Indonesia also operates several major poverty reduction programmes which could be

expected to have a significant impact on child and maternal undernutrition. For

example, a programme called RASKIN distributes subsidized rice to the poor and a

programme of conditional cash transfers (PKH – Program Keluarga Harapan) aims to

reduce maternal and child mortality by providing cash transfers to families on condition

of accessing services such as antenatal and postnatal care, pregnancy iron

supplementation, assisted delivery, child immunization, growth monitoring and vitamin

A supplementation. The PKH works with another programme PNPM Generasi which

provides block grant to villages to help them improve access to health and education

services. A more complete description of these nutrition oriented poverty reduction

programmes is contained in Appendix 2.

In 2008 a major analysis by the Lancet32

identified 14 feasible and effective

interventions for which there was sufficient evidence for implementation in all 36

countries with 90% of stunted children, including Indonesia. The Lancet also identified

a further 10 interventions, for which there was sufficient evidence for implementation in

specific, situational contexts. Table 1 below summarizes the coverage in Indonesia of

these ‘essential nutrition interventions’, A more detailed analysis showing the current

31 Riskesdas 2007 32 The Lancet Series on Maternal and Child Undernutrition 2008. Available at URL: http://www.theLancet.com/series/maternal-and-child-undernutrition (Accessed 05/11/09)



18

policy and legislation for each of these interventions is included in Appendix 3. The

data indicate that there are several ‘essential interventions’ where much higher

coverage needs to be achieved including promotion and counselling on breastfeeding

and complementary feeding, iron folate supplementation of women, deworming of

women and children, protein and energy supplementation of poor pregnant women,

treatment of diarrhoea with zinc, and improved coverage of food fortification and home

fortification programmes.

The Lancet recommends both iron folate supplementation and multiple micronutrient

supplementation, without indicating which to use in the package of interventions.

Indonesian national policy is to provide iron folate supplements to all pregnant women,

but the multiple micronutrients are being piloted in two provinces. Trials of the multiple

micronutrient as compared with iron folate supplements carried out in Indonesia have

shown them to be as effective as iron folate in improving anaemia status 33

and to reduce

90-day infant mortality by nearly 20% as compared with iron folate supplements34

.

Table 1: Coverage of the Lancet Nutrition Interventions in Indonesia

Interventions with sufficient evidence for implementation in all 36 countries

Intervention

Current

Coverage in

Indonesia

References and Notes

Maternal and birth outcomes

Iron folate supplementation 29.2% DHS 2007- 90+ days

Maternal supplements of multiple

micronutrients 0%

Policy in Indonesia is to give iron and folate during pregnancy. MNS are being piloted in two provinces with UNICEF support.

Maternal iodine through iodized salt 62.8% Riskesdas - no of households consuming adequately iodized salt (titration)

Interventions to reduce tobacco

consumption and indoor air pollution 97%

DHS - % of women who do not use tobacco. However on 87.8% of men use tobacco. Data on indoor air pollution is not available

Newborn babies

Promotion of breastfeeding (individual

and group counselling) N/A

Infants and children

Promotion of breastfeeding (individual

and group counselling) N/A

Behaviour change communications for

improved complementary feeding N/A

Zinc in management of diarrhoea N/A It is policy but data not available on coverage.

Vitamin A supplementation 68.5% - 71.5%. DHS 2007 and Riskesdas 2007

Universal salt iodization 62.8% Riskesdas - no of households consuming adequately iodized salt (titration)

33 Sunawang, Utomo B, Hidayat A, Kusharisupeni, Subarkah. 2009. Preventing low birthweight through maternal multiple micronutrient supplementation: a cluster-randomized, controlled trial in Indramayu, West Java. Food Nutr Bull. 30 (4 Suppl):S488-95 34 Supplementation with Multiple Micronutrients Intervention Trial (SUMMIT) Study Group, Shankar AH, Jahari AB, Sebayang SK, Aditiawarman, Apriatni M, Harefa B, Muadz H, Soesbandoro SD, Tjiong R, Fachry A, Shankar AV, Atmarita, Prihatini S, Sofia G. 2008. Effect of maternal multiple micronutrient supplementation on fetal loss and infant death in Indonesia: a double-blind cluster-randomised trial. Lancet. 371(9608):215-27.


19

Handwashing or hygiene interventions 23.2% and

71.1%

Riskesdas - % of population over 10

years with correct behaviour in handwashing and defecating

Treatment of severe acute malnutrition N/A

Interventions with sufficient evidence for implementation in specific, situational

contexts


Maternal supplements of balanced

energy and protein** 0% Not policy in Indonesia

Maternal deworming in pregnancy 0% The Indonesian policy does not allow for mass deworming in pregnancy.

Maternal calcium supplementation N/A No policy exists although there is some implementation

Intermittent preventative treatment of

malaria* N/A

Planned in the new Mid-Term Development Plan but not yet implemented

Insecticide treated bednets* 2.3% DHS - % of pregnant women who

slept under an insecticide-treated net the night before the survey

Newborn babies

Neonatal vitamin A supplementation 0% Not yet a WHO recommendation

and no policy in Indonesia

Delayed cord clamping 0% No policy in Indonesia

Infants and children

Conditional cash transfer programmes

(with nutritional education)** 0.1%

In 2009 the conditional cash transfer programme covered 72,000 households.

Deworming*** 0%

The national policy recommends

deworming for children aged two to five years old and school-aged children depending on prevalence: >50% -- mass deworming 2x/yr 20 – 50% -- mass deworming 1x/yr <20% -- targeted deworming However, coverage data is scarce.

Iron fortification and supplementation

programmes*** 100%

Flour fortification with iron is

mandatory in Indonesia and close to 100% of all flour is fortified although it is not known how much flour young children consume.

Insecticide-treated bednets* 3.3% DHS - % of children under 5 who slept under an insecticide-treated net the night before the survey

*In areas with malaria

** For women and children from poor families

*** In areas with high worm infestation and/or anaemia

In summary although child underweight prevalence has been reduced in Indonesia and

the Mid-Term Development and the Millennium Development Goals have been

achieved, Indonesia continues to have serious stunting and wasting problems among

young children. There is considerable maternal undernutrition which is likely to be

contributing to the relatively high level of low birth weight as well as stunting. The

programmes coverage indicates that much higher coverage needs to be achieved of the

essential nutrition interventions that can help accelerate the reduction of maternal and

child undernutrition, including promotion and counselling on breastfeeding and

complementary feeding, iron folate supplementation of women, deworming of women

and children, protein and energy supplementation of poor pregnant women, treatment of


20

diarrhoea with zinc, and improved coverage of food fortification and home fortification

programmes.

4. Findings of the Landscape Analysis Country Assessment

and analysis 35

Perception of the problem The general perception in the provinces and districts is that the nutrition problem is that

of severe wasting. There is little recognition of stunting or maternal undernutrition as

being problems. At the national level there is a more widespread and growing

understanding of the stunting problem. At the sub-national level, stunting as small

stature is commonly attributed to genetics as it affects most of the population.

This perception is understandable: over the last two decades, awareness and advocacy

on nutrition has mainly focused on severe wasting. The nationwide advocacy in 1998

during the first Asian economic crisis had an impact on the continued programme of

management of severe acute malnutrition at all levels. This concept has been carried

forward over the years as reflected in current nutrition policies and strategies: the

Presidential Decree no. 741 issued in 2008, which provides guidance on the minimum

health services standards 36

(SPM) to be achieved by 2015, gives rehabilitation of 100%

of children affected by severe underweight as one of the main nutrition targets for the

districts. This guidance is reflected in the objectives of the current health and nutrition

programme of some provinces (RPJMD 2009-2013) such as NTT which contains an

objective on the elimination of severe starvation. In regard to maternal nutrition, the

Decree no. 741 recommends that 95% of pregnant women be covered with 4 antenatal

care visits, including 90+ iron folate tablets. The SPM do not include any requirements

for prevention of general child or maternal malnutrition such as counselling on infant

feeding or nutrition during pregnancy.

There is agreement at national level that food availability is not a major cause of

undernutrition, though many think that poverty is constraining access to adequate,

quality food in some communities. The GOI/WFP Food Security and Vulnerability

Atlas of Indonesia indicate that food availability37

is really only in deficit in Papua,

Maluku, Riau, Jambi, Bengka Belitung, Sumatera Barat and Kalimantan Tengah. On

the other hand when access is taken into account, due to poverty or lack of infrastructure

for example, vulnerability to food security increases significantly. Overall, taking food

availability, access and utilization into account, the analysis identified 100 districts, out

of 346 for which there was data, as being high priority (priority 1, 2 and 3). These 100

districts are home to some 25 million people. The 20 priority 1 districts are concentrated

in Papua, NTT and Papua Barat. Therefore, while people often attribute undernutrition

to food security, especially at district level, in reality, food access due to poverty is more

often the cause, rather than actual deficits in food availability. A more detailed

discussion on Food Security and its surveillance is described in Appendix 4.

35 The findings relate mainly to the three provinces visited which, though offering a representative

overview of three different environments and situations, cannot be considered as representing the full

diversity of Indonesia. 36 The SPM are the reference used to define planning programme targets at district and kota levels. 37 As measured by ratio of per capita normative consumption to net cereal production. Map 2.1. Page 35.

GOI and WFP. A Food Security and Vulnerability Atlas of Indonesia, 2009


21

Micronutrient deficiencies are not well recognized by respondents outside the national

level. This is impacting, for example, on district budget allocation to purchase vitamin

A capsules for young children. However, although it was not specifically mentioned as

a major nutrition problem by those interviewed, iron deficiency is acknowledged as of

public concern by some nutrition stakeholders at sub-national level. During the Country

Assessment, iron/folic acid tablets were found in most of the visited puskesmas. For

instance, in Aceh province, all puskesmas and posyandu visited during the LA had

stocks of iron folate tablets. At puskesmas level, micronutrient fortified supplementary

foods were also found. Iodine deficiency has been given little attention over the last few

years outside the national level possibly because people assume that Indonesia has

achieved universal salt iodization. Riskesdas 2007 showed that an estimated 92% of

households consume iodized salt. However, only 63% consume adequately iodized salt

(>15ppm iodine).

Obesity was not perceived as a problem at any level reflecting the fact that overweight

and obesity only emerged recently in Indonesia. Yet, in the current National Plan on

Food and Nutrition (2006-2010), there is a pillar on improvement of healthy living

pattern which includes activities to address overweight and obesity. The

implementation of activities related to that component is limited.

Nutrition policies and activities currently practiced Nutrition activities are focused on growth monitoring (for identification of growth

faltering), treatment of undernutrition or Gizi Buruk, and, to a lesser extent, on

supplementary feeding. This finding was expected given the guidance provided by the

Presidential Decree No 741 mentioned above on minimal standards for health services

(SPM); it lists only micronutrient supplementation, growth monitoring, supplementary

feeding and treatment of severely malnourished children as basic services for nutrition.

One of the required basic services is coverage of health services, including vitamin A

supplementation and growth and development monitoring. The data used to report on

this indicator (i.e., the proportion of children receiving health services) does not

necessarily reflect the implementation of all components. In order to calculate the

coverage of health services of balita (12-59 months children), one needs only to

measure the total number of children who have attended growth monitoring at least

eight times during a certain time in one area and divide this number by the total number

of babies born during the same period. Thus, the limited (or absence of) implementation

of some nutrition interventions such as nutrition education or counselling may be

attributed to the fact that there is no need to specifically report on them. If not measured

or reported upon, they may be perceived as not essential or necessary to implement.

The Ministry of Health is solely responsible for micronutrient supplementation (i.e.,

iron folate for pregnant women and vitamin A supplementation for children 6-59

months and post-partum women) and complementary feeding. However the MOH

shares responsibility for other nutrition related interventions with other ministries as

follows: fortification of food - MoHA, BPOM, MoI); nutrition education -MoE, MONE,

MWE and others; promotion of exclusive breastfeeding - Ministry of Women

Empowerment and Child Protection and food programmes - MoHA and Ministry of

Social Affairs. The posyandu itself is under the Ministry of Home Affairs. Thus, many

“nutrition activities” are implemented or controlled outside of the health sector and

targeting, implementation and coordination aspects may not be happening optimally in

order to achieve the best nutrition outcome.


22

The concepts of “packages of interventions” and of a “continuum of care” from

conception to two years of age are not well understood in spite of the fact that the

minimum standards and the technical guidelines represent a valuable effort to provide

such guidance and knowledge in that direction. The guidelines provide indications of

health services to be given during pregnancy, the neonatal period, the first year of life

and the period from 12-59 months. It is likely that the rationale for the minimum

standards and the technical guidelines are not fully understood by the potential users.

This may explain why, although policies, protocols, manuals and guidelines for the

implementation of nutrition interventions are available in health structures such as

puskesmas, they are not fully implemented. There is a new effort to include a

continuum care for mother and child into the ‘Buku KIA’, which is used in posyandu

and puskesmas, but it seems that the use of this book is not optimal.

Another bottleneck to implementation of a package of effective nutrition interventions

through a continuum of care concept seems to be the lack of awareness by health

providers of its importance and effectiveness. (Human resources will be discussed in

another section.)

Many health facilities are not able to treat severely wasted children or even severely

underweight children. For example, the supplementary feeding is provided for a fixed

period of time, usually 90 days, regardless of whether the child’s nutrition status has

improved adequately or not. There also seems to be little understanding of the

difference in importance, causes and treatment of severe underweight compared to

severely wasted.

The National Plan for Development 2010-2014 (RPJMN) is focused on stunting and the

Essential Nutrition Intervention package from the Lancet Nutrition Series. Although

provinces and districts plans are supposed to refer to the RPJMN when defining their

own plans, there is a disconnect between planning processes at central and sub-national

levels. Consequently, although some targets are defined in the new RPJMN or even in

the recent Ministerial Decree no. 741 on the SPM and Ministerial Decree no. 838 in the

technical guidelines, given the different planning periods between central (2010-2014)

and sub-national levels (2009-2013 for NTT; 2007-2012 for Aceh; 2008-2013 for

Central Java), the targets and indicators set up at central, province or district levels may

be different. For example, in the current RPJMN, one objective is to reduce underweight

from 18% to less than 15% by 2015. In the NTT RPJMD, the aim is to reach 13% by

2013, while it is less than 15% by 2012 in the Aceh RPJMD. Moreover, the Central

Java RPJMD does not include any target for underweight and focuses only on the

reduction of severe wasting to less than 0.82% . Another example relates to the

technical guidelines on the implementation of the minimum health services standards. In

that document, it is stated that 95% of pregnant women shall received four antenatal

visits by 2015. Since this includes the iron folate supplementation, one would assume

that coverage of supplementation would also be set at 95%. Yet, the NTT target for iron

folate supplementation coverage is 90% by 201338

while the target is set at 85%39

in

Aceh and 80% in Central Java40

.

38 RPJMD NTT 2009-2013 39 RPJMD Aceh 2008-2012, Bab II 40 Central Java Province Health Office Strategic Plan 2008-2013


23

The National Action Plan for Food and Nutrition (RANPG) for the five year period

2011-2015 is currently under development. It will be based on the actual National

RPJMN at both national and provincial level. Its main objective is to reduce stunting by

five percent in the next five years (from 37% to 32%).

Clearly, there has been considerable political commitment on nutrition at national level

in Indonesia over the past decades, as evidenced in policy documents such as the current

RPJMN. Nutrition and nutrition-related programme plans at District level are also found

as part of the Provincial Development Plan (RPJMD 2009-2013 of NTT province,

RPJMD 2007-2012 of Aceh province, RPJMD 2008-2013 of Central Java province)

including health, education and agriculture. However, despite the existence of these

national and provincial plans, large scale nutrition programmes at both province and

district level in Health Strategic Plan (Renstra) are not adequately funded. As

mentioned earlier, the lack of knowledge of the sector planners on the causes and

implications of undernutrition and its importance as a determinant of health and human

development is likely a barrier.

The examination of all nutrition-related programs in-country also showed that many

nutrition-related activities are carried out by the non-health sector. For example, the

education sector distributes food to preschool children as a part of the early child care

development programme (PAUD). The Food Security Agency has complementary

feeding programmes in some of its project sites in NTT. Snacks at schools (PMT-AS)

are provided to increase enrolment and prevent school drop-outs of girls in particular,

and to improve the learning process. There is strong commitment from national

government to increase the coverage and impact of this program.

Programmes like the unconditional cash transfer programme (PKH) and other pro-poor

programs have the potential to significantly improve nutrition. These programmes could

be very synergistic with direct nutrition interventions, if implemented in a coordinated

way, with common objectives and indicators. However, if they are disjointed they risk

squandering financial resources that could be used more effectively if targeted at the

root causes of nutrition problems in the country. For example, if the RASKIN

programme could be better targeted to those with actual food availability and access

issues, some of the undernutrition caused by food insecurity, could be addressed.

Similarly, if the conditional cash transfers programme requires families to access

services and practice behaviours that have been identified as essential interventions by

the RANPG, and if systems are in place to ensure the necessary conditions are met

before the cash transfer is made, coverage of essential interventions would likely

significantly increase. At the same time, the MOH must work in collaboration with the

PKH programme to ensure that the services specified in the PKH are available at high

quality in the programme areas.

Nutrition Coordination There is a widespread and strong feeling that coordination is lacking for improving

nutrition across sectors, within sectors, at all levels of government, and in the UN. At

government level, this might be due to the fact that nutrition is under Health and has

been given a lower priority in terms of coordination. At national level coordination is

needed for strategy and policy development, while at sub-national levels (district and

sub-district) coordination is needed for implementation.


24

At central level, BAPPENAS makes a lot of effort to ensure the coordination of the

health and nutrition programmes through an established Directorate of Health and

Nutrition which oversees activities under UNICEF-GoI cooperation. There is also a

Food Security Council chaired by the President, Republic of Indonesia (RI) with

ministers from the related ministries as members. A similar Board exists at sub-national

level chaired by the Governor and Bupati. Moreover, several Task Forces/Committees

have been created for the purpose of improving coordination. As such, there is a

Nutrition task force under the Food Security Council at central, province and district

levels. However, it seems that there is no clear definition of roles and responsibilities

among these various bodies. The absence of a work plan creates a challenge that limits

their efficiency. This is in contrast to the good collaboration between local governments

and NGO/INGOs working in nutrition activities at all levels.

At district level, it is felt that there is a vacuum of local nutrition leadership and

governance. Although different efforts have been made, it seems that there is no strong

coordination mechanism to enhance the coordination of activities of sectors and partners

leading to a fragmentation of activities and effect. For instance, although 79.4% of birth

deliveries are assisted by skilled birth attendants, early initiation of breastfeeding is

practiced by mothers in only 44% of cases. Furthermore, only 45% of post-partum

women receive vitamin A capsules during the first 42 days after delivery.

Although MOH is seen to have the lead role in nutrition, questions were raised on

whether or not it should be the coordinator. This may be due to the fact that the nutrition

problem is still perceived by many as related to the lack of food. From this perspective,

other ministries (e.g., the Ministry of Agriculture in charge of food security) are seen as

having a larger role to play thus diminishing the relative authority of the Ministry of

Health as the coordinator. It is also often difficult for one sector to ‘coordinate’ others;

this role might need to be taken by someone ‘above’ the individual sectors.

Provincial or district Food and Nutrition Action Plans do not exist in every province and

district; nor are there consistent nutrition targets in the existing Plans. There are

exceptions: in NTT province as well as in Belu District, nutrition activities and targets

are present in the health strategic plans which cover the 2009-2013 period; the

provincial Aceh programme on nutrition has nutrition targets such as reduction of

prevalence of underweight and improvement of exclusive breastfeeding to name a few.

The Central Java province strategic plan has targets for reduction of IDD, anemia

among pregnant and postpartum women, severe wasting, and chronic energy

malnutrition among pregnant women. It is likely that efforts to improve nutrition

through the on-going partnerships between UNICEF, other agencies and NGOs with the

Government in these provinces (and in some districts) have had an impact on planning

and budget for nutrition.

Human Resources for Nutrition Though data suggest that a sufficient number of nutritionists are trained in Indonesia,

they are not employed nor effectively deployed, especially ‘in the field’: thus only 30%

of puskesmas or health centers have a 3-year Diploma (D3) nutritionist. Most

nutritionists are trained by one of the 33 accredited Academies of Nutrition spread

throughout the country and supervised by the Government. On an annual basis, over a

thousand nutritionists graduate from these academies. In addition to the Academy-

graduates, medical doctors can also undertake nutrition training (2-4 additional years to

their curriculum) to become clinical nutritionists or community dieticians. After their


25

pre-service training, nutritionists and dieticians apply for jobs wherever they want. As in

other countries, most prefer to work in urban areas given the improved living conditions

in such settings. Consequently, as for other health professionals, the geographical

distribution of nutritionists is inequitable in Indonesia. In 2007, there were 1.7

nutritionists per puskesmas in Yogyakarta while in Papua and NTT, the ratio was 0.2

and 0.5 per puskesmas respectively. Moreover, as pointed out by the World Bank41

, the

actual approach for staff allocation at district level is based on national staffing

standards which do not necessarily match with district needs.

Nutritionists are often responsible for other programmes. It is likely that the lack of a

clear job description (the job-description for nutritionist at puskesmas was developed

over a decade ago) leads to nutritionists having difficulties in interpreting their job or

prioritising their responsibilities. Moreover, even though several nutrition activities are

to be implemented at district level as indicated by the SPM, it is noteworthy that

nutritionists are rarely mentioned as responsible for the implementation of nutrition

interventions as opposed to midwives and medical doctors. In fact, the practice is to

refer to a nutritionist only when facing problems related to the rehabilitation of severely

undernourished children, for supplementary feeding for children of poor families, and

logistic management of nutrition supplies. There is no mention of the need to refer to a

nutritionist either for counseling on breastfeeding and complementary feeding or for

micronutrient supplementation of children and women.

This may explain why other health professionals such as the midwives and nurses have

more responsibilities in terms of nutrition interventions although they may lack relevant

technical knowledge and expertise. For example, the curricula of pre-service training for

midwives in Aceh includes only 12 hours on nutrition out of the six semesters and the

majority of these 12 hours are dedicated to the “balanced nutrition of children” (pre- and

school-age). In addition, six hours are spent on post-partum care, which includes

breastfeeding, general nutrition, vitamin A supplementation, and baby hygiene. This is

inadequate training, though it leads some to question the usefulness of recruiting a

nutritionist in the field or assigning nutritionists as responsible for programmes. It likely

also explains why District Health Officers often struggle to convince the Bupati to

employ nutritionists.

Added to the problem with deployment of nutritionists, is the challenge of inadequately

qualified nutritionists even among those trained. The quality of pre-service nutrition

training (D3) is not consistent in all Academies. There are some that still use the 1997

curricula which emphasises theory compared to the 2003 curricula which has a stronger

component on practice. In 2009, the curriculum was up-dated but is still not

consistently used for pre-service training. Based on a review of the curriculum of the

Nutrition Academy in Aceh, it seems that there is no specific component on infant and

young child feeding practices nor on maternal nutrition. Actually, approximately 70%

of the content of the Academy curriculum is standardized, leaving the introduction of

new topics such as infant and young child feeding practices or maternal nutrition to the

discretion of each institution to fill the remaining 30%. The Aceh province training

center for health workers will be the first to add IYCF into the nutrition curriculum. In

addition to the Academy, there are private institutions that could implement the new

curriculum. The quality of the pre-service training in these institutions likely varies,

41 World Bank/GoI, 2009. Indonesia’s doctors, midwives and nurses: Current stock, increasing needs,

future challenges and options. January, World Bank, Jakarta, Indonesia.


26

though it has never been assessed. Moreover, as an example of the quality of the

nutritionist training, even though puskesmas has nutritionist, the prevalence of

undernutrition may still be of concern and this, in spite of an adequate quantity of staff.

For example, in Semarang city most puskesmas (14/18) have a nutritionist, but nutrition

indicators are still poor, eg 38% stunting.

Finally, as explained above, other factors such as the limited knowledge of nutrition

among other health professionals and the unequal geographical distribution of

nutritionists also contribute to the lack of adequate qualified human resources in

nutrition, particularly in remote areas.

In addition to the weaknesses described in pre-service training, the Country Assessment

also found that in-service training on nutrition was insufficient. Most health staff

interviewed during the CA admitted that they have received no in-service training in the

last two years.

There is enthusiasm among district authorities for more involvement of community

volunteers. More than two million volunteers or “cadres” serve 260,000 posyandu in

480 districts. The cadres are members of the Family Empowerment for Welfare (PKK)

organization, the most popular women’s organization in Indonesia. The capability and

competency of these volunteers vary and depend on the attention of local governments

for training and re-training.

Lack of monitoring and supervision also jeopardizes the motivation of human resources

and the quality of services. Finally, as for other health professionals such as the

midwives and nurses, the accreditation process of nutritionists may not be aligned with

international standards of independence, credibility and transparency to the public,

which also impacts on the quality of the staff.

Planning, Budget and Funding As highlighted in the previous section on nutrition and nutrition-related

programmes/activities, there are significant resources allocated for nutrition and

nutrition-related activities at central level, including major poverty reduction and safety

net programmes. Yet, most of these resources are not under the responsibility of the

Ministry of Health.

Numerous sources of funding are available for food and nutrition related activities at the

district level but are complicated by restrictions and time constraints. In addition, the

complex processes between budget allocation, approval and implementation due to

bureaucratic restrictions and earmarking often delayed the implementation of nutrition

interventions.

Despite the potential availability of funds, very little funding actually gets included in

nutrition budgets at sub-national level and what exists may not be appropriate for the

nutrition targets included in the Province and District workplans. For example, in Belu

district of NTT province, one of the workplan objectives is to reduce the prevalence of

malnutrition from 40% in 2008 to 20% in 2012, yet only 18% of the district health

budget goes to nutrition activities. Furthermore, particularly at lower levels, most of the

budget goes toward to administration (salaries) and infrastructure, with very limited

funds for programme activities: in NTT 70% of the 2009 budget (APBD II) goes to

salaries and allowances -- the remaining 30% goes to all sectors with 8% to health and


27

half of that for infrastructure. In the budget of one district in Aceh province, of a total of

Rp 53,120,000,000 going to health, only 0.2% was for nutrition. The low allocation on

nutrition is clearly linked to the perception that nutrition is not a major concern.

Moreover, more than 65% (of this 0.2%) was allocated to food for pregnant women and

children under five and to the rehabilitation of severely undernourished children. A low

allocation to nutrition was also observed in Kota Semarang in Central Java, where the

nutrition comprises merely 2% of the total health budget. Most of the funds are spent

on supplementary feeding and treatment of severe wasting. In Banyumas District, the

local district budget suffered an effective 70% cut due to a sudden increase in salaried

positions, as staff previously paid honoraria were moved to formal salary lines. This left

almost nothing for the health and nutrition programs. This disconnect between planning

and budget approval and allocation is observed at all levels.

There is a general culture of budget-based planning rather than coverage/results-based

planning.

Available funding is not being allocated to the most effective interventions. The

planning, budget and funding going to nutrition programmes and activities are in line

with the perceptions of the nutrition problem as well as with the existing content of

policies, strategies and guidelines to address the situation and the current planning

process. Given the widespread and growing understanding of nutrition (including the

stunting problem at national level) it also explains why many more resources are

allocated at national rather than sub-national level on nutrition and nutrition-related

activities, including major poverty reduction and safety net programmes. It also

highlights the disconnect with nutrition activities at District level. Nutrition programmes

such as those for vitamin A are perceived to be a central level responsibility.

Consequently, budget for the procurement of vitamin A capsules is not always included

in sub-national budgets. Even in those instances where development partners are

financing various nutrition programmes, funds are not always spent on the most

effective interventions.

Nutrition Information System Large amounts of data are available, including from routine reports and national

surveys. However, information on certain basic indicators is not available on a regular

basis, nor is available data always complete and accurate (e.g., anaemia data on

pregnant women is not routinely collected or reported).

The SKDN data (S=children under five that exist at that posyandu, K=those that have a

growth card, D=those that came to be weighed last month, and N=those that grew) are

collected routinely at posyandu level and sent upwards. Although large amounts of staff

time appear to be spent collecting this information and reporting it up, it is seldom used

for programme improvement, targeting, evaluation etc. One reason is that the

denominator is often not reported up with the numerator. Another is that there are no

triggers for action (e.g. take action if prevalence exceeds x%) and it is not clear what

action to take on the basis of this data.

Data on breastfeeding, consumption of iodized salt, vitamin A capsules supplementation

and nutritional status among “nutritionally aware families” are collected through the

Sistem Kewaspadaan Pangan dan Gizi or SKPG (food and nutrition surveillance

system). Data on iron / folate supplementation of pregnant women are also gathered.


28

These sets of data are sent to the Puskesmas on a monthly basis. However, it is unclear

how all the above data are used for decision making and/or in supervisory discussions.

Survey data are used quite well for advocacy at national and province level. For

example, given the high prevalence of stunting as shown by the 2007 Riskesdas and

given its recognized impact on development, the government has decided to address the

problem over the next five years. As such, the reduction of stunting prevalence has

become an important target of the RPJMN 2010-2015 and the main objective of the

2011-2015 National Plan on Food and Nutrition.

The SPM is intended to guide districts on what basic interventions they must provided

and to provide targets they should achieve and report on. For the most part however the

SPM indicators are not used for monitoring. Yet, there are exceptions. In Central Java,

the SPM is fully used. This includes indicators on (i) Severe Acute Malnutrition cases

treated, (ii) coverage of MP-ASI distribution and use, (iii) coverage of vitamin A, and

(iv) coverage of iron / folate. However, the limitation of monitoring only these four

indicators is that the emphasis of the district nutrition programs is only on the associated

interventions.

There are an insufficient number of programme evaluations; there is insufficient data to

indicate whether the efforts being made are having the expected impact – for example

are iron folate supplements being consumed and if so are they improving iron status in

pregnant women or is flour fortification contributing to improvements in micronutrient

status. Funding for monitoring and evaluation is a duty and responsibility of local

government in charge of the budget. It appears that low priority is given to supervision,

monitoring and evaluation of nutrition programmes.

Summary of Findings Commitment to act for nutrition is reasonably strong, but misdirected at trying to

resolve acute nutrition problems rather than putting into place systems and interventions

to prevent children and women from becoming malnourished. Commitment to resolving

the problem of stunting is growing at the national level, but at the provincial and district

levels where all the action is decided and implemented, the nutrition problem is largely

equated with severe undernutrition (Gizi Buruk) and/or to a lack of food. In some

districts (e.g., in Aceh and Central Java) nutrition is no longer thought to be a big

problem. Considerable amounts of resources appear to be expended on food distribution

due to confusion about the extent of food availability and to address poverty. In reality

food distribution may be a common intervention because it is politically popular, rather

than to address any actual problems of poverty, food availability or nutrition.

Mechanisms for policy coordination, identification of priorities and setting of goals and

targets are weak or non-existent at the national level.

Capacity to act for nutrition needs to be strengthened. Service provision largely revolves

around child growth monitoring and is misdirected to the under-five year olds rather

than focused on children under two years where nutrition interventions can have a

greater effect. Less priority is given to preventive activities related to counseling of

mothers on infant and young child feeding than to the curative function of detecting and

treating wasting. When counseling is done it is by minimally trained community based

posyandu cadres. Attention to maternal nutrition is limited to iron/folate tablet

distribution with little priority or promotion. Inter-sectoral coordination of

implementation needs to be reinforced. Although sufficient nutritionists are being


29

trained their curricula is outdated or incomplete. They are under-employed in the system,

and especially in the implementation of service delivery. Little or no in-service training

in nutrition occurs. The use of monitoring data for decision making or evaluation data to

learn from programme experience is very uncommon.

5. Recommendations42

Overall Objective

To accelerate the reduction of maternal and child undernutrition and contribute

to the achievement of MDGs 1, 4, 5 and 6.

The first section below presents the recommendations that could be prioritized in terms

of implementation over the next few years. Other recommendations that could also be

implemented but not considered as priorities are also suggested in the second section.

Recommendations in bold font are considered as innovative. For all recommendations, a

timeframe is suggested.

Suggested recommendations to be prioritized on a Medium-Term

Nutrition Coordination & Responsibilities

1. At Sub-national level: Harmonize the Food and Nutrition Action Plans at Province

and District level based on the national plan, decree and guidelines, and develop

intersectoral coordination mechanisms to oversee and monitor their implementation.

This complements the decentralized structure of decision making at the

Province and District, while at the same time retaining the unifying

objectives and overall strategies that are presented in the National

Plan. Intersectoral inputs are needed to reflect and organize the inputs

of the various stakeholders in nutrition security.

2. At National level: Approve a Government Regulation, that puts into effect the

principles of the International Code of Marketing of Breastmilk Substitutes to

control the marketing of breastmilk substitutes and develop a mechanism for

monitoring and enforcement

Control of the marketing of breastmilk substitutes requires a national

effort because of the importance of the problem and the scope of

resources being channeled into the marketing of infant formula and

other substitutes. This recommendation draws attention to the

alarming decline in EBF rates, and calls for defining ways to monitor

and enforce the Regulation.

Budget and Funding

1. At all levels: Increase cost-effectiveness of funding by choosing evidence-based

interventions targeted at vulnerable groups of pre-pregnant, pregnant and

42 Recommendations are prioritized under each heading so that those given first (in bold) are the most

important, and should be considered for immediate implementation. (In the case of Human Resources,

the first two are prioritized.) Second and third recommendations are also important, and are to be

implemented over the medium or long -term.


30

lactating women and children under two-years of age. The recent data from the

World Bank calculations43

on the costs of effective nutrition and health

interventions can likely be used as a reference for that exercise. Moreover,

accompanying central level funds with clear and mandatory guidelines on how

to use them.

In keeping with the strategy of the Lancet Nutrition Series, this is to

support local decision makers who want to ‘do the right thing’ and stop

paying for other interventions that are without evidence of effectiveness.

Targeting vulnerable groups (i.e., pre-pregnant, pregnant and lactating

women, and children under two-years of age) will increase the impact of

funding as these are the groups with the highest rates of malnutrition.

2. At Central level: Work with MoH and BAPPENAS to set guidelines for

calculating the proportion of budget to be dedicated to nutrition based on a

newly defined ‘Maternal and Child Undernutrition Index’ (i.e., using stunting

and anemia in pregnant women as indicators).

This recommendation acknowledges that the main problem of funding of

nutrition-related interventions is not the absence or lack of sufficient

financial resource, but their allocation at the Provincial and District

levels. The development of an ‘Index’, using the values for two key

indicators, will allow local governments to make informed decisions on

where to allocate funds to the areas of greatest need for the greatest

impact. It will also focus attention on the problems of stunting and

anaemia which currently receive insufficient recognition.

Planning and Design of Programmes

1. At all levels: Measure length of all children <2 years of age every six months

during vitamin A distribution months; Measure anemia in pregnant women as

a part of ANC; Continue measuring weight of children regular activity of the

posyandu but prioritize weighing on children under 2 years of age.

Length does not need to be measured as frequently as weight since the

increments of change are less and are less obvious on a month- to-

month basis. Community measuring sessions should only be done

periodically (every six months) making it feasible for a trained team from

the Puskesmas to do the measuring and thereby reduce inaccuracies. If

there is good socialization before hand, this should include all children,

especially as it will be linked with vitamin A distribution. The data will

provide strong evidence of the success of community based interventions

directed at reducing stunting.

Anemia in pregnancy is an indicator of a mother’s nutritional status, her

access to quality health care (i.e., intercurrent infections like urinary

infections, tuberculosis, gastro-intestinal parasites, or malaria can also

cause anaemia), and her status in the family and the community as a

reflection of how well she is cared for. This should be done in every

pregnancy.

43 Horton, S., Shekar, M., McDonald, C., Mahal, A., brooks, J.K. 2010. Scaling up nutrition: What will it

cost? The World Bank. Washington, D.C., USA.


31

Weighing of children can continue as a popular and important part of

posyandu activities but the cadres should focus their attention on

children <2 years of age as this is the age when most faltering occurs.

2. At National level: Target nutrition programs at all pregnant women and

infants and young children 0 – 2 years old in order to (i) focus on the ‘window

of opportunity’, (ii) to use fewer resources more efficiently, and (iii) to increase

the time to counsel mothers of young children and pregnant women.

The shift to targeting children under 2 years of age and pregnant women

throughout their pregnancy will free up time spent in weighing older

children (where the potential to impact on their nutrition is less) and

allow the health worker to focus more on teaching and counseling

mothers and women, especially pregnant women and those planning a

pregnancy, in the Puskesmas and posyandu.

3. At all levels: Develop advocacy materials for members of non-health sectors on the

importance of nutrition for social, economic, cognitive, and physical development.

MOH/MOHA to develop nutrition advocacy materials to influence the campaigns of

Bupatis running for election/re-election.

There are many non-health sectors involved in nutrition but not all of

them are fully informed about the impact of evidence-based interventions,

or the full importance of nutritional improvement. Furthermore, Bupatis

are sometimes constrained by campaign promises to support activities

that are outside of nutrition. By making sure that nutritional goals

become a part of the Bupati’s campaign, there is a greater likelihood

that these goals will be pursued after election.

Human Resources

1. Update existing job descriptions and include new program directions (i.e.,

measurement of stunting and maternal health/anemia) for all staff involved in

nutrition in each ministry/department

Job descriptions, where they exist, are outdated and do not always

reflect the skills and practices that are necessary in a changing

environment. Adjustment of the nutritionist’s job to meet the new

nutrition goals and interventions is necessary.

2. Develop a human resource map for nutritionists and other health workers in order to

identify deployment gaps and competencies. This map is to be used for advocacy

with senior level decision makers. (e.g., President, Governor, Bupati) and Ministries

(e.g., PAN). Use this resource map to develop a national plan for a training

approach to teach nutritional competencies for Volunteers, Nurses and Midwives,

and to provide technical updates for doctors in the nutrition sciences.

As mentioned in the Country Assessment, many nutrition positions in the

Districts are not filled by qualified nutritionists (D3). Knowing where the

resources are needed is the first step in filling those gaps. As the

geographic gaps are being assessed, efforts should be made to ascertain

competency gaps as well. All health workers should be included in this

assessment.


32

3. Expand incentives now being offered to doctors to include nutritionists for working

in underserved areas.

Staff members need incentives to work in more challenging

environments; this is recognized in the placement of doctors. In

recognition of the importance of nutrition for health and development,

the same incentives are necessary to attract and retain qualified

nutrition staff in challenging areas, which are often those in greatest

need.

4. Establish accreditation requirements and procedures (including training

qualifications for nutritionists at all levels) to be recognized and implemented by the

Association of Nutritionists (PERSAGI) with recognition from other professional

associations.

This links with revised and updated job descriptions (mentioned above)

as a means of increasing the professional profile of nutritionists and of

standardizing their knowledge and performance around the evidence-

based interventions outlined in the literature.

5. Nutrition Academies and Universities to standardize and update curriculum,

competencies and accreditation for pre-service and in-service training of public

health nutritionists, including new program emphasis on stunting and maternal

nutrition; Add or reinforce nutrition to pre-service training on nutrition to all

Doctors, Bidans, Nurses;

Nutrition education needs to be updated and expanded to include new

concepts and recent research in the pre-service training of all health and

nutrition professionals; academic institutions are also important in

providing in-service training.

6. Ensure the provision of a continuum of health and nutrition care from conception

through to two years of age, through appropriately organized facility based, periodic

outreach and ongoing community based delivery of services44

.

Stunting is a perfect example of an undesirable nutrition outcome that is

the equal result of deficiencies in intrauterine life and post-natal

conditions. Failing to approach the problem from a continuum of care

perspective will not reduce stunting, as is evident from its persistence

over the past decades that reflects approaches that targeted children

when they were already stunted; no attention was paid to the intrauterine

causes of the problem. Furthermore, if pregnant women are to be

targeted in the first trimester, attention must be paid to the young woman

before she becomes pregnant, (and to the adolescent girl whose own

growth must be protected from a premature pregnancy.)

Nutrition Information System

1. Update the SPM to reflect new programme focus and relevant indicators.

44 Kerber KJ, de Graft-Johnson JE, Bhutta ZA, Okong P, Starrs A, Lawn JE. 2007 Continuum of care for maternal, newborn, and child health: from slogan to service delivery. Lancet 370: 1358–69


33

The standard indicators should be brought in line with current

programme goals and objectives if progress is to be made and

measured toward new goals like stunting and maternal nutrition.

2. NIS to measure indicators listed in the Food and Nutrition Action Plan that can be

used to assess performance and for supervision.

Indicators are to be measured and used in decision making more than

is the present practice. Measuring the output and outcome of practices

in the field will allow supervisors to identify individuals and facilities

that are doing high quality work. These facilities would be eligible for

performance rewards. Those who are not performing well could be

directed to participate in continuing education classes to upgrade their

skills, knowledge, and practice.

Suggested recommendations to be prioritized on a long-term

Service Provision

1. Implement at scale (as appropriate depending on local conditions), the package of

Essential Nutrition Interventions (ENI) effectively targeted to mothers and children

from conception to two years of age.

Packaging key interventions assures that all components necessary for a

healthy and nutritious life are being provided at the same time and in the

same place in a way that will lead to the best outcome. Implementation

of individual interventions separately and in different places (e.g., giving

Vitamin A without giving deworming tablets) is wasteful as well as

ineffective since neither is as effective if used alone. Implementation of

this package could prevent at least a quarter of child deaths under 36

months of age, and reduce the prevalence of stunting by about a third in

the short term45

46

.

Nutrition Information System

1. As a longer term objective, create a working group, chaired by BPS, to consider how

the number of national surveys (eg. RISKESDAS, DHS, IFLS) can be reduced and

rationalized.

Surveys are expensive though their cost is often outweighed if they are

used for critical decision making regarding program focus, targeting

populations, and so on. There are, however, a large number of

national surveys that collect data that is sometimes duplicative. These

should be rationalized so that only one or two surveys are needed to

provide all the information that decision makers need for improving

program performance. The first step in doing this is to define the

actual decisions that need to be taken, the data needed to make those

decisions, the sources of those data, and the methods for collecting

them.

45 The Lancet Series on Maternal and Child Undernutrition 2008. Available at URL: http://www.theLancet.com/series/maternal-and-child-undernutrition (Accessed 31/03/10) 46 SCN 2008. Recommendations from the SCN 35th Session: "ACCELERATING THE REDUCTION OF MATERNAL AND CHILD UNDERNUTRITION" Available at http://www.unscn.org/Publications/AnnualMeeting/SCN35/35th_Session_Recommendations.pdf (Accessed 09/07/0)


http://www.unscn.org/Publications/AnnualMeeting/SCN35/35th_Session_Recommendations.pdf


34

Other recommendations that could be implemented on a medium-term

Nutrition Coordination & Responsibilities

1. At National level: Create a national level coordination mechanism to oversee and

coordinate implementation of the National Food and Nutrition Action Plan by

changing the name of the existing National Food Security Council to the National

Food and Nutrition Council, or by creating a new body with the designated

responsibility of national nutrition coordination.

By adding the words “…and Nutrition”, Food Security is recognized

as a vital part of the greater goal of Nutrition Security. The Council is

then mandated to implement the National Food and Nutrition Plan,

which is aimed at achieving Nutrition Security through many

approaches, one of which is Food Security. This Council will therefore

fulfill the much needed role of coordinating nutrition security actions

which is very much missing currently. NB. If the scope of the Council is

expanded to include also nutrition security, it may be necessary to

place the Council under President’s office in recognition of the greater

scope.


1. At National level: Develop and implement a strategy for reaching pre-pregnant

women in the age group 18-24 years with a package of health and nutrition

services by working with staff involved in family planning and community

religious leaders during pre-marital visits, etc. Establish a surveillance or

monitoring system to monitor coverage of pre-pregnant women with this

package. The first trimester is now recognized as of key importance for fetal

growth in length and in brain growth, and the micronutrient status

around conception is key for preventing some birth defects. Most women

do not come to the Bidan until their second trimester. Therefore to make

sure that their protein, energy, and micronutrient nutrition is adequate

and that they are free from diseases that compete for nutrients in the first

trimester, they need to be reached before they become pregnant or as

early as possible after conception.

2. At National level: Strengthen national food fortification programs by updating

fortification standards for wheat, making oil fortification mandatory, and improving

the enforcement of the salt fortification law.

National food fortification programmes are an effective, cost efficient

and important way to increase the micronutrient status of the population

consuming the food vehicle. They can improve micronutrient intake in

women before they become pregnant, in adolescents and in men; all

groups not commonly targeted or able to be reached by other

micronutrient interventions such as supplementation. The effectiveness

of the wheat flour fortification programme needs to be increased by

updating the SNI in line with global WHO recommendations, oil

fortification is happening but needs to be made mandatory in order to

have optimal impact on public health and enforcement of the salt


35

fortification law is needed to ensure all salt is iodized and that quality

assurance systems are improved.

Human Resources

1. Use high achievements in reducing stunting, anemia in pregnancy, and improvements

in early and exclusive breastfeeding as basis for additional performance rewards to

puskesmas and posyandu.

Performance incentives may be in the form of financial or non-financial

rewards. When awarded to well-performing facilities (rather than to

individuals) they can stimulate improved teamwork, efficiency, and

community service.

Other recommendations that could be implemented on a long-term

Budget and Funding

1. At all levels: Implement a process to identify ways to strengthen poverty reduction

programmes for increased impact on child and maternal undernutrition.

Under the auspices of the National Team for Accelerated Poverty

Reduction” (TNP2K), chaired by the Vice President, initiate a process to

review each of the poverty-reduction programmes to identify how they

can be adapted to contribute to improvements in nutrition priorities and

interventions in line with the National Medium Term Development Plan

and the National Food and Nutrition Plan. Implement these changes

through the TNP2K at provincial and district level. If not already there,

include a nutrition indicator such as prevalence of child stunting as an

impact indicator of the programmes in recognition of the close link

between poverty and child nutrition.


1. Focus the objective of school feeding programs on increasing school enrolment and

retention, and, if resources are a limiting factor, prioritize the program to secondary

schools in poorer areas as an incentive for girls to stay in school.

School-age children are not the most nutritionally vulnerable; hence they

do not benefit significantly from school feeding programmes. School

feeding can however provide an incentive, in certain situations, to

increase enrolment and retention of children in schools. Where this

becomes of great importance is in the adolescent girl who will be

pressured to stop her schooling prematurely, particularly in families

without sufficient finances. In these cases, food becomes an economic

supplement more than a nutritional one, although the nutritional impact

will be felt if girls stay in school longer since this is associated with a

later age of marriage, and a later age (beyond adolescence) of first

pregnancy.


36

Human resources

1.Provide technical assistance in the development of distance learning modules for in-

service training of nutrition staff linked to accreditation and performance rewards for

successful completion of training and achievement of higher scores.

Distance learning with rewards for achievements offers a less expensive

way to maintain the training and knowledge of staff in the field. New

techniques that ensure confidentiality and monitor participation allow

courses to be run inexpensively in a secure environment.

6. Next Steps

Obtaining final approval of the LA report from MoH at Central level and, in

particular, from the department of Community Nutrition.

Translation of the LA report in Bahasa Indonesia

Design and printing of the LA report in both languages (English and Bahasa

Indonesia)

Organization of a meeting at MoH at Central level between all relevant

departments namely Community Nutrition, Maternal Health and Child

Health to disseminate the LA report. This meeting can be organized by the

Director General of Community Health at MoH.

Dissemination of the LA report by MoH/Bappenas at Central level to all

relevant partners including donors, ministries, UNs agencies, NGOs, etc.

Integration of the prioritized recommendations in the 2011-2015 National

Food and Nutrition Action plan. This could be done through the process of

the development of the National plan which will be ongoing up to December

210. Moreover, using the prioritized recommendations of the Landscape

Analysis Country Assessment, identify short term actions that can already be

acted on for 2011, and longer term activities that will require new laws and

regulations, etc.

Present the results of the Landscape Analysis Country Assessment at the

province level. Use this opportunity to start the process of harmonization of

objectives and targets between national and sub-national levels as well as to

advocate for more nutrition budget at sub-national levels.

Initiate the implementation of the National Food and Nutrition Action Plan

in one (or two) districts of each of the three provinces and further refine and

focus the posyandu system following the recommendations. This will

include Bidans and Kadres working more with groups of mothers preparing

them to get pregnant with no anaemia, etc. This will include equipping the

puskesmas to do the necessary measurements and working on procedures,

etc, developing the IEC material, etc.

In summary, the recommendations are made concerning the areas of: Nutrition

Coordination & Responsibilities; Budget and Funding; Planning and Design of

Programmes; Human Resources; Service Provision; Nutrition Information System.

Priority should be given to creating mechanisms which promote the development of

harmonized Food and Nutrition Action Plans at Province and District level based on the

national plan, decree and guidelines, as well as to develop inter-sectoral coordination

mechanisms to oversee and monitor their implementation. In order to increase cost-


37

effectiveness of funding, guidance and incentives should be provided to districts for

them to prioritize evidence-based interventions targeted at vulnerable groups of pre-

pregnant, pregnant and lactating women and children under two-years of age. Length of

children under two and maternal anemia should be given increasing emphasis and

prioritized for measuring the effectiveness of both nutrition as well as poverty reduction

programmes at all levels. In parallel to this job descriptions need to be updated to reflect

new program directions (i.e., measurement of stunting and maternal health/anemia) for

all staff involved in nutrition at all levels of the system. A human resource map for

nutritionists and other health workers should be developed in order to identify

deployment gaps and competencies, and develop a national plan for a training approach

to teach nutritional competencies for volunteers, nurses and midwives, and to provide

technical updates for doctors in the nutrition sciences. In parallel to this the

implementation at scale (as appropriate depending on local conditions), of the package

of Essential Nutrition Interventions (ENI) should be progressively implemented starting

in a few districts and provinces and gradually expanding so that within five years most

mothers and children are covered by ENI as a continuum of care from conception to two

years of age. Monitoring and evaluation guidelines should be modified to reflect new

programme focus and relevant indicators.


38

Appendix 1. The Country Assessment methodology

Scope of Country Assessment of the landscape analysis

Overall Vision: District government and health authorities have the commitment and capacity to ensure high coverage of effective nutrition interventions in order to accelerate the reduction of maternal and child undernutrition. Effective nutrition interventions are those identified by the Lancet Nutrition Series. District government commitment and capacity will be ensured by central level guidance to district government and health authorities on the effective nutrition interventions and building their capacity to undertake microplanning to achieve high coverage and quality implementation. Provincial government and health authorities will provide supervision and quality assurance support. Effective nutrition interventions will be implemented through existing health systems and be supported by and synergistic with national level policies and initiatives on health, nutrition, agricultural development, poverty alleviation and safety nets, that are successfully articulated at the local level At all levels the Country Assessment will focus on identifying weaknesses and opportunities for improvement on the following seven challenges identified by the Lancet Series:

1. Putting nutrition on the national agenda, 2. Doing the right things, 3. Not doing the wrong things, 4. Doing things at scale, 5. Reaching those in need, 6. Using data for nutrition decision-making, 7. Building strategic and operational capacity.

At district level the Country Assessment will focus on the following:

1. How to improve the capacities of districts to microplan and implement essential nutrition interventions

2. How national policies and guidance is delivered to and utilized by districts 3. How district implementation of essential nutrition interventions can be facilitated and

supported by provincial authorities 4. How funding mechanisms and resources can be better accessed and used for improving

coverage and quality of essential nutrition interventions 5. How national programmes and initiatives including safety net and pro-poor programmes can

be more synergistic with and better support district implementation of essential nutrition interventions

6. What data is needed and how it can be better used at district level to facilitate quality implementation at high coverage of essential nutrition interventions.


39

List of team members for the country assessment in each province and district

Aceh Province Central Java Province NTT Province

Roger Shrimpton Stephen Atwood Karen Codling

Sonia Blaney (UNICEF) Anna Winoto (UNICEF) Ninik Sukotjo (UNICEF)

Rufina Pardosi (UNICEF) Armunanto (UNICEF) Helena S Ndolu (UNICEF)

Rachmi Untoro (MoH Expert) Ineu (MoH) Dini Latief (MoH Expert)

Darmiati (Bappeda) Yazid (PHO) Henny Tomasoa (PHO)

Setyawati, SKM, MPH Budi Setiana (Bappeda) Djoese (Bappeda)

Arifin Ahmad (Poltekkes Gizi) Diah Utari (FKM-UI) Maria Catharina (WFP)

Sugeng Irianto (WHO) Elviyanti Martini (HKI) Rosnani (local consultant)

Eko Prihastono (MoH) Yosi Tresnawati (Bappenas) Eman Sumarna (MoH)

Mardewi (FKM-UI) Bariadi (MoH) Ichwan Arbie (MoH)

District interviews

Aceh Besar Aceh Timur Kota Semarang Banyumas Sikka Belu

Roger Sonia Anna Steve Rosnani Karen Codling

Rufina Setyawati Elvi Armunanto Helena Ninik

Arifin Darmiati Yazid Budi Setiana Henny Djoese

Mardewi Eko Ineu Arbie Maria

Bariadi

Province interviews Province interviews Province interviews

Rachmi Untoro Yosi Dini Latief

Sugeng Diah Eman Sumarna


40

Jadwal pelaksanaan “Landscape Analysis” atau

Kajian dan Analisa Pemetaan Program Gizi dan Program Terkait Lainnya

11 s/d 26 Maret 2010

Hari pertama: Jakarta, 11 Maret 2010

Venue: Jasmine Room, Intercontinental Hotel

08.30 – 08.35 Sambutan Depkes DR Minarto, Direktur Bina

Gizi Masyarakat

08.35 – 08.50 Latar belakang

Pengalaman pelaksanaan LA di negara lain

Roger Shrimpton, UNICEF

08.50 – 09.10 Rencana pelaksanaan Landscape Analysis di

Indonesia

DR Minarto, Direktur Bina

Gizi Masyarakat

09.10 – 09.30 Metodologi

Analisa/pelaporan

Roger Shrimpton, UNICEF

09.30 – 10.00 Hasil telaah awal Rosnani Pangaribuan

10.00 – 10.30 Diskusi/Tanya jawab

10.30 – 10.45 Rehat kopi

10.45 – 11.00 Pembagian kelompok (berdasarkan daerah)

11.00 – 11.45 Review kuesioner 1 & 2 (diskusi kelompok)

11.45 – 12.15 Diskusi pleno International team

12.15 – 13.15 Makan siang




15.15 – 15.30 Rehat kopi


16.00 – 17.00 Finalisasi kuesioner

Hari ke-2: Jakarta, 12 Maret 2010

Venue: Jasmine Room, Hotel Intercontinental

08.30 – 09.00 Registrasi

09.00 – 09.05 Sambutan UNICEF Kepala Perwakilan UNICEF Indonesia

09.05 – 09.20 Pengarahan dan pembukaan Direktur Jenderal Bina

Kesehatan Masyarakat, Depkes

09.20 – 09.35 Prioritas program gizi dalam RPJMN 2010-

2014

Deputi SDM dan Kebudayaan,

Bappenas

09.35 – 09.45 Kebijakan program gizi di Indonesia Direktur Bina Gizi Masyarakat, Depkes

09.45 – 10.15 Latar belakang dan pengalaman pelaksanaan

Landscape Analysis di negara lain

Roger Shrimpton

UNICEF

10.15 –10.30 Rehat kopi

10.30 – 11.15 Diskusi & tanya jawab Moderator: Direktur Bina Gizi Masyarakat

11.15 – 11.30 Penutupan Direktur Bina Gizi

Masyarakat


13.00 – 17.00 Review kuesioner


41

Hari ke-3: Jakarta, 13 Maret 2010

Venue: Jasmine Room, Hotel Intercontinental

08.30 – 09.30 Pelaksanaan pengumpulan data di

lapangan

Rosnani Pangaribuan

09.30 – 12.00 Praktek wawancara Ninik Sukotjo


13.00 – 17.00 Persiapan akhir untuk kunjungan

lapangan

Anna Winoto

Hari ke-4-10: Kunjungan Lapangan, 14 – 20 Maret 2010

Hari ke-4

(14 Maret)

Perjalanan tim ke propinsi terpilih

Hari ke-5 (15 Maret)

Pertemuan propinsi dengan seluruh stakeholders (termasuk kabupaten) untuk

mempresentasikan tujuan kajian;

dilanjutkan dengan wawancara kepada stakeholder di tingkat propinsi

Propinsi

Hari ke-6

(16 Maret)

Perjalanan ke Kabupaten

Hari ke-7 - 8 (17-18 Maret)

Pelaksanaan Wawancara di tingkat Kabupaten; dan konsolidasi hasil

wawancara- hari terakhir

Kabupaten

Hari ke-9

(19 Maret)

Perjalanan kembali ke Propinsi;

Pertemuan Propinsi untuk diseminasi draft hasil kajian

Propinsi

Hari 10

(20 Maret)

Perjalanan tim Pusat ke Jakarta

Hari ke-12 - 16: Jakarta, 22 – 26 Maret 2010

Hari 12-13

(22-23 Maret)

Wawancara Stakeholders di tingkat

Pusat

Tim akan berkumpul di kantor

UNICEF pada pukul 08.00

setiap pagi sebelum melaksanakan wawancara

(Alamat: Wisma Metropolitan

II Lt. 12)

Hari 14

(24 Maret)

Konsolidasi hasil wawancara/kajian di

tiga propinsi di tingkat pusat,

penyusunan kesimpulan dan

rekomendasi awal oleh tim kecil

Kantor UNICEF

Wisma Metropolitan II Lt. 12

Hari 15

(25 Maret)

Tim Kecil menyusun draft awal dan

presentasi power point

Kantor UNICEF

Wisma Metropolitan II Lt. 12

Hari 16

(26 Maret)

Diseminasi hasil Kajian dan Analisa

Pemetaan Program Gizi dan Program Terkait Lainnya yang dihadiri oleh

seluruh tim Pusat dan Propinsi dan

Kabupaten terpilih

Jasmine Room,

Intercontinental Hotel


42

LA interviews Schedule at Central Level

22 March 20010

23 March 2010


43

List of interviewees

Aceh province, Aceh Timur and Aceh Besar Districts

No Name Title Institution Remarks

1 Jamil Rusaleh Bidang Pelayanan dan Rehabilitasi

Sosial

Dinas Sosial Aceh Province

2 Khairani Staf Pelayanan Anak Dinas Sosial Aceh Province

3 dr. Hasnani Kasie KIA dan Gizi Dinas Kesehatan Aceh Province

4 drg. Efi Syafrida Kabid Pembinaan Kesehatan Dinas Kesehatan Aceh Province

5 dr.Yani Kepala Dinas Dinas Kesehatan Aceh Province

6 Azhari Kabid Pendidikan Dasar Dinas Pendidikan Aceh Province

7 M. Yunus Ilyas, SE, M.Si Sekretaris Fraksi Komisi F DPRA Province

8 Nasir Kabid Industri Kimia Agro Dinas Perindustrian, Perdagangan,

Koperasi & UKM Aceh

Province

9 Dewi Mutia Kasie Kimia Afro Dinas Perindustrian, Perdagangan,

Koperasi & UKM Aceh

Province

10 Isnaidi Kasie Logam Mesin Dinas Perindustrian, Perdagangan,

Koperasi & UKM Aceh

Province

11 Parabi Kabid Anak Badan Pemberdayaan Perempuan

dan Perlindungan Anak Aceh

Province

12 M. Nur Kabid Ketahanan Pangan Mukim

dan Gampong

Dinas Pemberdayaan Masyarakat

Aceh

Province

13 Ellya Kasubbid Motivasi dan Swadaya Dinas Pemberdayaan Masyarakat

Aceh

Province

14 Buchari Kasubbid Pengembangan Sumber

Daya Tradisi dan Budaya

Dinas Pemberdayaan Masyarakat

Aceh

Province

15 Aripin Ahmad Kajur Gizi Poltekes Aceh Poltekes NAD Province

16 Ir. Rusli Kepala Bidang Konsumsi &

Keamaanan Pangan

Badan Ketahanan Pangan Aceh Province

17 Cut Sumarni Kepala Bidang Distribusi Badan Ketahanan Pangan Aceh Province

18 Erisna Bagian Keanekaragaman Konsumsi

Pangan

Badan Ketahanan Pangan Aceh Province

19 Kabid Tanaman Pangan Dinas Pertanian Aceh Besar District Aceh Besar

20 Sekretaris Dinas Pertanian Aceh Besar District Aceh Besar

21 Kasie Tanaman Pangan Dinas Pertanian Aceh Besar District Aceh Besar

22 Kepala Bidang Penguatan

Kelembagaan Masyarakat

Badan Pemberdayaan Masyarakat

dan Gampong Aceh Besar

District Aceh Besar

23 Kepala Badan Badan Ketahanan Pangan dan

Penyuluhan Aceh Besar

District Aceh Besar

24 Kabid Ketahanan Pangan Badan Ketahanan Pangan dan


District Aceh Besar

25 Sekretaris Badan Ketahanan Pangan dan


District Aceh Besar

26 Kepala Bappeda Aceh Besar District Aceh Besar


44

27 Hasanudin Kasubbid Pengembangan SDM &

Keistimewaan Aceh

Bappeda Aceh Besar District Aceh Besar

28 Kepala Dinas Dinas Kesehatan Aceh Besar District Aceh Besar

29 Program Officer KIA Dinas Kesehatan Aceh Besar District Aceh Besar

30 Program Officer P2P Dinas Kesehatan Aceh Besar District Aceh Besar

31 Komisi E DPRK Aceh Besar District Aceh Besar

32 Kepala Puskesmas Puskesmas Indrapuri District Aceh Besar

33 Tenaga Pelaksana Gizi Puskesmas Indrapuri District Aceh Besar

34 Bidan Koordinator Puskesmas Indrapuri District Aceh Besar

35 Bidan Desa Puskesmas Indrapuri District Aceh Besar

36 Kader Posyandu Puskesmas Indrapuri District Aceh Besar

37 Kepala Puskesmas Puskesmas Darul Imarah Aceh

Besar

District Aceh Besar

38 Tenaga Pelaksana Gizi Puskesmas Darul Imarah Aceh

Besar

District Aceh Besar

39 Bidan Desa Lheu Blang Puskesmas Darul Imarah Aceh

Besar

District Aceh Besar

40 Kader Posyandu Lheu Blang Puskesmas Darul Imarah Aceh

Besar

District Aceh Besar

41 Kepala bidang BPMG (Badan

Pemberdayaan Masyarakat

Gampong)

Kantor BPM-PKS District Aceh Timur

42 DPRK, Komisi E Kantor DPRK District Aceh Timur

43 Dr Hambali, Agustina and

Marlita

Kepala Puskesmas, TPG dan Bidan

Koordinator

Puskesmas Bireum Bayeun District Aceh Timur

44 Bupati Aceh Timur dan

Bpk. Syanfanmur

Bupati dan Sekretaris Kantor Bupati Distritc Aceh Timur

45 Ir. Irham, MT Kepala Bappeda Kantor Bappeda District AcehTimur

46 Bidan Desa dan Kader Posyandu of Desa Alue Buloh District Aceh Timur

47 Ayubi, SKM dan Amir,

SKM

Kepala Dinas Kesehatan, Kepala

Bidang Pelayanan Kesehatan

Dinas Kesehatan District Aceh Timur

48 Kabid Hortikultura Dinas Pertanian District Aceh Timur

49 Badan Ketahanan Pangan Kantor Ketahanan Pangan District Aceh Timur

50 BPM-PKS Kepala Pemberdayaan

Masy, Perempuan & Keluarga

Sejahtera

Kantor BPM-PKS District Aceh Timur

51

Bidan Desa dan Kader Posyandu Camar Laut-Desa Blang

Qlumpang

District Aceh Timur

52

Kepala Puskesmas, TPG dan Bidan

Koordinator

Puskesmas Idi Rayeuk District Aceh Timur


45

Central Java province, Kota Semarang and Banyumas district

No Name, Title Institution Remarks

1 Bambang Setyobudi (Kabid), Dwi Arminingsih (staf), Ratna Widyarini (staf)Bidang Kesra Province

2 Dr. Mardiyatmo, SP RAD (Kepala Dinas) Dinas Kesehatan Province

3 Dr. Retno Budiastuti (Kasubdit Yankes) Dinas Kesehatan Province

4 Dr. Djoko Mardijanto, Mkes (Kabid. P2PL) Dinas Kesehatan Province

5 Dr. Yuswanti (Kasie Kesga Gizi) Dinas Kesehatan Province

6 Achmad Syaifudin (Ka.Perencanaan) Dinas Kesehatan Province

7 Dr. Messy Widiastuti, MARS (Komisi E) DPRD Province

8 Ir. Suyatno, Mkes (Wadek III, staf Jur. Gizi) FKM Undip bagian gizi Province

9 Ir. Basuki Sigit (Ka. Jur) Poltekkes Gizi Province

10 Surati Dinas Pendidikan Province

11 Drs. Ali Yahya, MPd Bapermas Province

12 Mery Zuliana (anggota Pokja IV) PKK Province

13 Munawir, SH (Bid. Kemandirian Pangan, bid. Ketersediaan Pangan)Badan Ketahanan Pangan Province

14 Hari Sutjahyo (Sie. Industri Kimia Bid. Industri Agro Kimia dan Hasil Hutan)Dinas Perindag Province

15 F. Himawan E.W. (Kasie. Pengembangan SDM & Kelembagaan)Dinas Pertanian Province

16 Moch Junaedi (Kasie. Potensi Sumber Kesejahteraan Sosial)Dinas Sosial Province

17 Dra. Diana Susilowati (Kasubid. Perlindungan Anak bid. Kesejahteraan dan Perlindungan Anak)BP3AKB Province

18 Dyah Siti Sundari (Diklat) BKKBN Province

19 Hernowo Budi Luhur (Kabid Perencanaan Sosbud)Bidang Sosbud Kota Semarang

20 Dr. Tatik Suyarti (Kadinkes) Dinas Kesehatan Kota Semarang

21 Dr Susi Herawati (Kasubdit Kesga) Dinas Kesehatan Kota Semarang

22 Dr Widoyono (Kabid P2ML) Dinas Kesehatan Kota Semarang

23 Purwanti (Kasie Gizi) Dinas Kesehatan Kota Semarang

24 Drg Lusi Suryani (Kasie Perencanaan Subbag) Dinas Kesehatan Kota Semarang

25 Tenaga Gizi Puskesmas Pandanaran Kota Semarang

26 Retno (bidan) Posyandu Setialsulu Kota Semarang

27 Ismoyowati, Ani (kader) Posyandu Setiasulu Kota Semarang

28 Kepala Puskesmas Puskesmas Srondol Kota Semarang

29 Bidan Puskesmas Srondol Kota Semarang

30 Ahli gizi Puskesmas Srondol Kota Semarang

31 Drs Hidayatullah (Kasie TS SD) Dinas Pendidikan Kota Semarang

32 Dra. Hayu & Lilik Haryanto Bapermas Kota Semarang

33 Dra. Wijayanti (Pokja IV) TP PKK Kota Semarang

34 S. Kiswanti (Kasie Konsumen & Ketahanan Pangan) & Diana Hidayati (staff)Badan Ketahanan Pangan Kota Semarang

35 Agus Guntoro (Seksi Agro Kimia & Hasil Hutan) Dinas Perindag Kota Semarang

36 Ir Komara Irawati (Kasie Agroindustri Pangan & Hortikultura)Dinas Pertanian Kota Semarang

37 Dra Dahlia Gombiarti MSI (Kabid PMKS) Dinas Sosial Kota Semarang

38 Mardjoko (Bupati) Bupati Kab Banyumas

39 Ir Wahyu Budi Saptono M.Si (Kepala) Bappeda Kab Banyumas

40 Ir Achmad Wahyudi (Kabid Pemb.) Bappeda Kab Banyumas

41 Bagus Abimanyu (Kasubid Kesmas) Bappeda Kab Banyumas

42 dr Widayanto (Kadinkes) Dinas Kesehatan Kab Banyumas

43 dr Supraptini (Kabid Yankes) Dinas Kesehatan Kab Banyumas

44 Baharudin SKM (Seksi Gizi) Dinas Kesehatan Kab Banyumas

45 Suwanseno (Kasie Palawija) Dinas Pertanian Kab Banyumas

46 Puji Rahardjo (Seksi pengendalian mutu) Dinas Pendidikan Kab Banyumas

47 Suwarno (Kasie Bappeluh) Badan Ketahanan Pangan Kab Banyumas

48 Suharyanto (Bidang kelembagaan) Bapermades Kab Banyumas


46

NTT province, Sikka and Belu districts No Title Institution Remarks

1 Representative DPRD Province

2 Representative Dinas Sosial Province

3 Representative Badan Ketahanan Pangan and Penyuluhan Province

4 Representative BPMPD Province

5 Representative AusAid - AIPMNH project Province

6 Representative Bappeda Province

7 Representative Lembage Perlindungan Anak Province

8 Representative Dinas Kesehatan Province

9 Representative Dinas Pendidikan, Permuda and Olahraga Province

10 Representative Dinas Perindustrian and Perdagangan Province

11 Representative Dinas Pertanian and Perkebunan Province

12 Representative Biro Pemberdayaan Perempuan Province

13 Bupati Kabupaten District Sikka

14 Representative DPRD District Sikka

13 Head of Office BAPPEDA SIKKA Sikka District

14 Head of social politic unit Sikka District

15 Head of survey Sikka District

16 Vice Bupati District Government of Sikka Sikka District

18 Kepala Badan Pemberdayaan Masyarakat Daerah (BPMD) Sikka District

Community Empowerment

19 Kepala Badan Pemberdayaan Perempuan dan KB (BP2&KB) Sikka District

20 Kepala of Family planning unit Women Empowerment and Family Planning Sikka District

21 Kepala of family welfare unit Sikka District

22 Kepala of women empowerment and child protection Sikka District

23 Staff of planning section Education Sikka District

24 Kepala Trade and Industry Sikka District

25 Secretary Social and work force Sikka District

26 Kepala Badan Ketahanan Pangan dan Penyuluhan Sikka District

27 Kepala District Health Office Sikka District

28 Staff of Puskesmas Puskesmas Waipare Sikka District

29 Village Midwife and BF Counselor Village Midwife Post of Geliting - Puskesmas Waipare Sikka District

30 Acting head of Puskesmas Puskesmas Kopeta Sikka District

31 Village Midwife and BF Counselor Village Midwife Post of Nangamarang - Puskesmas Kopeta Sikka District

32 Bupati District Government of Belu Belu District

33 Representative Dinas Sosial Belu District

34 Representative Badan Ketahanan Pangan dan Penyuluhan Belu District

35 Representative BPMPD Belu District

36 Representative LSM Lokal (PPSE and Yaspem) Belu District

37 Representative Bappeda Belu District

38 Representative Lembaga Perlindungan Anak Belu District

39 Representative Dinas Kesehatan Belu District

40 Representative Dinas Pendidikan, Pemuda and Olahraga Belu District

41 Representative Dinas Perindustrian and Perdagangan Belu District

42 Representative Dinas Pertanian and Perkebunan Belu District


47

Questionnaires

Preface

Overview of the Landscape Country Assessment Tool

The Landscape Analysis Country Assessment Tool consists of eight main

questionnaires and checklists for assessing commitment and capacity to accelerate

actions to reduce maternal and child undernutrition at national and various sub-national

levels. In Indonesia, only questionnaires 1 to 6 were used for the country assessment.

Questionnaire 2 was used for the NGOs interviews instead of questionnaires 7 and 8.

Core package of questionnaires and checklists includes:

Level Existing tools:

National 1. Semi-structured interview tool for national level stakeholders

(government agencies and other stakeholders such as UN

agencies, donors and NGOs)

Regional /

Provincial

2. Semi-structured interview tool for provincial level stakeholders

(provincial government agencies and regional based NGOs and

other organizations)

District 3. Semi-structured interview tool for district level management staff

Facility 4. Semi-structured interview tool for the facility manager and

nutrition responsible

5. Facility checklist

6. Structured questionnaire for health workers in posyandu,

puskesmas and polindes

Field 7. Semi-structured interview tool for manager of implementing

NGOs

8. Semi-structured interview tool for nutrition coordinator in NGOs

The original tools were have been developed by the Medical Research Council of Cape

Town, South Africa for the WHO Department of Nutrition for Health and Development

and adapted throughout the first six Landscape Assessments in Madagascar, Burkina

Faso, Ghana, Guatemala, Peru and South Africa. Each of these countries has further

enhanced the tools, adapting them to their respective national situations. A major

revamp was done by the South African country team to allow a nation-wide large scale

assessment where a total of almost 1,000 questionnaires were completed. To facilitate

computer based analysis of this amount of questionnaires, coding fields were added.

Due to the high focus on nutrition and HIV in South Africa, an additional set of tools

were developed for use in the ARV clinics (Forms 9 and 10).

Preparations

As part of the preparations for the Landscape Analysis Country Assessment, the country

team has reviewed the tools, select which ones to use and adapt them to the national

situation. The country team also determined the scope of the assessment, including

scheduling interviews and planning field visits. The Word document questionnaires can


48

be obtained from WHO Department of Nutrition for Health and Development, by

contacting [email protected].

mailto:[email protected]

Landscape Analysis Country Assessment Tools Form 1. National level stakeholders

49

Form 1. National level stakeholders

Semi-structured interview for government agencies and other stakeholders (e.g. UN agencies, donors, NGOs) at national level

ID:___

Completed by:

Code

Agency:

Code

Respondents: Name: Position:

Code

Name: Position:

Code

Name: Position:

Code

Date of

visit

d d m m y y y y


50

Section 1. Nutrition situation and priorities 1.1 What do you perceive as the three major nutrition problems in the country?

(List according to importance)

1. Code

2. Code

3. Code

1.2 Do you feel these identified problems are adequately addressed in the national nutrition

policy, strategy and/or action plan?

1 Yes

0 No

98 Don’t know if they

are addressed

99 Don't know of any national nutrition

policy

Code

Justify:

1.3 What do you perceive as the most important causes of these nutrition problems?


1. Code

2. Code

3. Code

1.4 What do you perceive as the major barriers for scaling-up nutrition actions? (List

according to importance)

1. Code

2. Code

3. Code


51

1.5 What do you perceive as the major opportunities for scaling-up nutrition actions? (List according to importance)

1. Code

2. Code

3. Code

Section 2. Nutrition coordination system 2.1 What do you perceive as the major strengths of the current system/mechanism for

coordinating nutrition actions in the country? (List according to importance)

1. Code

2. Code

3. Code

4. Code

5. Code

2.2 What do you perceive as the major aspects of the coordination of nutrition actions that

should be improved? (List according to importance)

1. Code

2. Code

3. Code

4. Code

5. Code


52

Section 3. Agency nutrition activities and policies 3.1 What specific actions, if any, does your agency/department/unit support in the area of

nutrition?

Code

3.2 Please describe your agency/department/unit actions and support at the different levels:

Level Actions and support Code

National

Provincial

District

Community

3.3 Are there any policies in your agency/department/unit that support these actions?

1 Yes

0 No

99 Don’t know

Code

If yes, please describe:

3.4 What do you feel are the important nutrition strategies and actions that should be scaled

up?

Code

3.5 How does your agency/department/unit provide this support in the area of nutrition?

Code


53

Section 4. Budget and funding 4.1 Could you estimate the annual budget of your agency/department/unit that is dedicated to

nutrition actions?

Current year:

Code

Last year:

Code

4.2 Approximately what percentage of your agency/department/unit total annual budget does

this represent?

Current year: % Code

Last year: % Code

4.3 What are the sources of funding for nutrition activities implemented by your

agency/department/unit?

1 %

Code

2 %

Code

3 %

Code

4 %

Code

5 %

Code

4.4 Do you feel there is adequate funding to tackle the nutrition situation in the country?

Justify.

Code

4.5 If no, do you have any specific plans or ideas for increasing funding?

Code


54

Section 5. Human resources for nutrition 5.1 Do you think that there are enough nutritionists at the different levels (national, regional,

district, community) in the country?

Code

5.2 If no, what do you think should be done to strengthen nutrition capacity in the country?

Code

5.3 Does your agency/department/unit have staff dedicated part-time or full-time to the

implementation of the nutrition activities?

1 Yes

0 No

99 Don’t know

Code

5.3.1 If yes, please indicate how many: and the approximate

number of staff at full-time or part-time at different levels.

Level Full-Time Code Part-Time Code

National

Provincial

District

Community

5.3.2 How many of them have degrees in nutrition (equivalent of D3)?

Code

5.4 Could you describe about any in-service, short-, or longer term training programmes that

your staff have participated in over the last two years?

Level Number of staff trained Topic of training Code

International

Regional

National

5.5 If no staff have participated in training during the two past years, why not?

Code


55

Section 6. Nutrition information system 6.1 What types of information/data on nutrition do you use regularly?

Code

6.2 How are these data collected and collated and by whom? Probe: surveys, routine, data, etc.

Code

6.3 How does your agency/department/unit use these data and how do you share

results/data with provincial and district levels and other stakeholders in nutrition?

Code

Section 7. Nutrition and the food price crisis 7.1 Which three groups (e.g. urban vs. rural; people who are net consumers vs. net

producers; specific regions of the country, etc.) do you perceive to be most badly affected by the rise in food prices?

1. Code

2.

3.

7.2 What actions are national/regional/local governments taking to mitigate the effects of the

crisis?

Code


56

Section 8. Nutrition in emergencies (e.g natural disasters) 8.1 Which groups do you perceive to be most badly affected by natural disasters?

1. Code

2.

3.

8.2 What actions are national/regional/local governments taking to mitigate the effects of emergencies?

Code

Section 9. Advocacy and scaling-up 9.1 In your experience, what information or specific messages that could facilitate working

together among nutrition partners in the country?

Code

9.2 Have you used the Millennium Development Goals (MDG) in this effort?

1 Yes

0 No

99 Don’t know

Code


9.3 Have you used the Convention on the Rights of the Child (CRC) or UU23/2002 in this

effort?

1 Yes

0 No

99 Don’t know

Code


9.4 Have you used any other advocacy tools/presentations?

1 Yes

0 No

99 Don’t know

Code


9.5 Which type of intervention or support could your agency/department/unit provide to

support scaling-up of nutrition actions?

1. Code


57

2. Code

3. Code

9.6 If your agency/department/unit could do only one thing at scale to improve nutrition –

what would that be?

Code

Section 10. Concluding questions 10.1 In your opinion, what are the top three priority needs of this province in order to

accelerate reduction of malnutrition? Do NOT prompt for options listed, rank as mentioned by interviewee

Rank (1, 2, 3) Code

Human resources (more staff, better salaries, high staff turn over)

Training (more training, better training modules or trainers)

Supplies (better drug and supply systems)

Infrastructure (more space, better equipment)

Financial resources (larger budget, more external funding)

Others

10.2 Is there anything else that you think you should tell us to have a better understanding

about the nutrition situation in the country?

Code

Landscape Analysis Country Assessment Tools Form 2. Provincial level stakeholders

58

Form 2. Provincial level stakeholders

Semi-structured interview for government agencies and other stakeholders (e.g. UN agencies, donors, NGOs) at provincial level

ID:___

Completed by:

Code

Province:

Code

Agency:

Code

Respondents: Name: Position:

Code

Name: Position:

Code

Name: Position:

Code

Date of

visit

d d m m y y y y


59

Section 1. Nutrition situation and priorities 1.1 What do you perceive as the three major nutrition problems in your province?


1. Code

2. Code

3. Code

1.2 Do you feel these identified problems are adequately addressed in the national or any

provincial nutrition policy, strategy and/or action plan?

1 Yes

0 No

99 Don’t know

Code

Justify:

1.3 What do you perceive as the most important causes of these nutrition problems?


1. Code

2. Code

3. Code

1.4 What do you perceive as the major barriers for scaling-up nutrition actions? (List according to

importance)

1. Code

2. Code

3. Code

1.5 What do you perceive as the major opportunities for scaling-up nutrition actions? (List

according to importance)

1. Code


60

2. Code

3. Code

Section 2. Nutrition coordination system 2.1 What do you perceive as the major strengths of the current system/mechanism for

coordinating nutrition actions in your province? (List according to importance)

1. Code

2. Code

3. Code

4. Code

5. Code

2.2 What do you perceive as the major aspects of the coordination of nutrition actions that

should be improved? (List according to importance)

1. Code

2. Code

3. Code

4. Code

5. Code


61

Section 3. Agency nutrition activities and policies 3.1 What specific actions, if any, does your agency/department/unit support in the area of

nutrition?

Code

3.2 Please describe your agency/department/unit actions and support at the different levels:

Level Actions and support Code

Provincial

District

Community

3.3 Are there any policies in your agency/department/unit that support these actions?

1 Yes

0 No

99 Don’t know

Code


3.4 What do you feel are the important nutrition strategies and actions that should be scaled

up?

Code

3.5 How does your agency/department/unit provide this support in the area of nutrition?

Code


nutrition actions?

Current year:

Code

Last year:

Code


62

4.2 Approximately what percentage of your agency’s total annual budget does this represent?

Current year:

Code

Last year:

Code

4.3 What are the sources of funding for nutrition activities implemented by your agency?

1 %

Code

2 %

Code

3 %

Code

4 %

Code

5 %

Code

4.4 Do you feel there is adequate funding to tackle the nutrition situation of your province?

Justify.

Code


Code

Section 5. Human resources for nutrition 5.1 Do you think that there are enough nutritionists at your institution?

Code

5.2 If no, what do you think should be done to strengthen nutrition capacity in your institution?

Code


63

5.3 Does your agency/department/unit have staff dedicated part-time or full-time to the implementation of the nutrition activities?

1 Yes

0 No

99 Don’t know

Code


number of staff at full-time or half-time at different levels.


National

Provincial

District

Community

5.3.2 How many of them have degrees in nutrition D3?

Code

5.4 Do you think that there are enough nutritionists at the different levels (provincial, district,

community) in your province?

Code

5.5 If no, what do you think should be done to strengthen nutrition capacity in your province?

Code




International

Regional

National


Code


64

Section 6. Nutrition information system 6.1 What types of information/data on nutrition do you use regularly?

Code

6.2 How are these data collected and collated and by whom? Probe: surveys, routine, data, etc.

Code

6.3 How does your agency/department/unit use these data and how do you share

results/data with other stakeholders in nutrition??

Code

Section 7. Nutrition and the food price crisis 7.1 Which three groups (e.g. urban vs. rural; people who are net consumers vs. net

producers; specific regions of the country, etc.) do you perceive to be most badly affected by the rise in food prices in your province?

1. Code

2.

3.


crisis in your province?

Code

Section 8. Nutrition in emergencies (natural disasters) 8.1 Which groups do you perceive to be most badly affected by natural disasters?

1. Code

2.

3.


65

8.2 What actions are national/regional/local governments taking to mitigate the effects of emergencies?

Code

Section 9. Advocacy and scaling-up 9.1 In your experience, what information or specific messages that could facilitate working

together among nutrition partners in your province?

Code

9.2 Have you used the Millennium Development Goals (MDG) in this effort?

1 Yes

0 No

99 Don’t know

Code


9.3 Have you used the UU 23/2002 in this effort?

1 Yes

0 No

99 Don’t know

Code


9.4 Have you used any other advocacy tools/presentations, such as “PROFILES”?

1 Yes

0 No

99 Don’t know

Code


9.5 Which type of intervention or support could your agency/department/unit provide to

support scaling-up of nutrition actions?

1. Code

2. Code

3. Code


66

9.6 If your agency/department/unit could do only one thing at scale to improve nutrition – what would that be?

Code

Section 10. Concluding questions 10.1 In your opinion, what are the top three priority needs of this province in order to


Rank (1, 2, 3) Code






Others

10.2 Is there anything else that you think you should tell us to have a better understanding

about the nutrition situation in your province?

Code

Landscape Analysis Country Assessment Tools Form 3. District level management staff

67

Form 3. District level management staff Semi-structured interview

ID:___

Completed by:

Code

Province:

Code

District:

Code

District office: 1 District Department of Health 2 District Department of Food and Agriculture 3 District Department of Women and Child Welfare 77 Other:

Code

Respondent: 1 District manager 2 Nutrition programme officer 3 Maternal-Child Health programme officer 4 Community Health Worker 5 Volunteers / Lay counsellors 77 Other: _____________________________

Code

Date of

visit

d d m m y y y Y


68

Section 1. Nutrition programme and activities 1.1 Which key nutrition activities are included in the current district action plan?

Code

1.2 What community based nutrition related activities are implemented in your district to

promote

1.2.1 Maternal nutrition : Code

1.2.2 Breastfeeding:

Code

1.2.3 Complementary feeding (including distribution of fortified foods):

Code

1.2.4 Prevention of micronutrient deficiencies (e.g vitamin A among children and post-partum women, MMN for pregnant women and children, salt iodization):

Code

1.2.5 Identification and management of severe or moderate malnutrition:

1.2.6 Prevention and care for children with diarrhoea:

1.2.7 Breastfeeding in the context of HIV/AIDS:

1.2.8 Healthy eating and physical activity to prevent overweight:

1.2.9 Prevention of intestinal parasites for children and pregnant women (e.g. hygiene promotion, deworming)


69

1.2.10 Prevention of malaria for children and pregnant women (e.g. intermittent treatment, bednet)

1.2.11 Prevention of communicable diseases for children and women (immunization)

1.2.12 Family planning

1.2.13 Other:

1.3 Which three groups (e.g. urban vs. rural; people who are net consumers vs. net

producers; specific regions, etc.) do you perceive to be most badly affected by the rise in food prices in your district?

1. Code

2.

3.


crisis in your district?

Code

1.5 In what ways does the district enforce the International Code of Marketing of Breast-milk

Substitutes?

Code

1.6 How many facilities in the district are certified BFHI (Baby-Friendly Hospital Initiative)?

Code

1.7 How many facilities are preparing to become certified BFHI?

Code


70

1.8 Are nutrition messages communicated at the community level for the following issues:

If Yes, who is and how are the messages communicated?

Code

1.9.1 Maternal anaemia reduction 1

Yes

0 No

1.9.2 Exclusive breastfeeding 1

Yes

0 No

1.9.3 Optimal complementary feeding

1 Yes

0

No

1.9.5 Zinc supplementation for diarrhoea management

1 Yes

0

No

1.9.6 Vitamin A supplementation for children

1 Yes

0

No

1.9.7 Vitamin A supplementation for post-partum women

1 Yes

0

No

1.9.8 Consumption of iodized salt 1

Yes

0 No

1.9.9 Management of moderate malnutrition

1 Yes

0

No

1.9.10

Management of severe malnutrition

1 Yes

0

No

1.9.11 Prevention and care for children with diarrhoea

1 Yes

0

No

1.9.12 Breastfeeding in the context of HIV/AIDS

1 Yes

0

No

1.9.13 Healthy eating and physical activity to prevent overweight

1 Yes

0

No

1.9.14 Other: _____________ 1

Yes

0 No

Section 2. Responsibilities and coordination

2.1 Within the district team, who has the main responsibility for nutrition?

Code

1 District manager 1

Yes 0

No 99

Don’t know

2 Nutrition programme officer 1

Yes 0

No 99

Don’t know

3 Maternal-Child Health programme officer 1

Yes 0

No 99

Don’t know

4 Community Health Worker 1

Yes 0

No 99

Don’t know

5 Volunteers / Lay counsellors 1

Yes 0

No 99

Don’t know

77 Other: _____________________________ 1

Yes 0

No 99

Don’t know


71

2.2 What nutrition training does this person have?

Code

2.2 What other, if any, non-nutrition related responsibilities does this person have?

Code

2.3 Within the government, who are the other players working in nutrition within your district? Please specify what nutrition activities they undertake or contribute to.

Code

2.4 How are nutrition activities coordinated in the district? What are the institutional

arrangements/platforms and how often are meetings held?

Code

2.5 Who develops the nutrition strategy and plan in district and is this developed?

Code


nutrition actions?

Current year:

Code

Last year:

Code


72

3.2 Approximately what percentage of your agency’s total annual budget does this represent?

Current year:

Code

Last year:

Code

3.3 What are the sources of funding for nutrition activities implemented by your agency?

1 %

Code

2 %

Code

3 %

Code

4 %

Code

5 %

Code

3.4 Do you feel there is adequate funding to tackle the nutrition situation of your province? Justify.

Code


Code

Section 4. Human resources for nutrition 4.1 Do you think that there are enough nutritionists at your institution?

Code

4.2 If no, what do you think should be done to strengthen nutrition capacity in your institution?

Code


73

4.3 Does your agency/department/unit have staff dedicated part-time or full-time to the implementation of the nutrition activities?

1 Yes

0 No

99 Don’t know

Code


number of staff at full-time or half-time at different levels.


National

Provincial

District

Community

4.3.2 How many of them have degrees in nutrition D3?

Code

4.4 Do you think that there are enough nutritionists at your district?

Code

4.5 If no, what do you think should be done to strengthen nutrition capacity in your district?

Code




International

Regional

National


Code


74

Section 5. Training

5.1 What nutrition related training have there been in your district in the past two years?

A. Trainings (title, organizing institution)

B. Participants (number of participants and their

affiliations) Code

5.2 How is training monitored or followed-up? Probe for existence of refresher training and on site

training

Describe:

Code

Section 6. Information management systems 6.1 What are the most important nutrition indicators that are routinely collected and/or

collated at district level?

Code

6.2 How do you use this information?

Code

6.3 Have you ever received feedback on the information on nutrition that you send to the

provincial or national level?

1 Yes

0 No

99 Don’t know

Code


75

6.4 If yes, is this feedback useful? And how do you use this feedback?

Code

Section 7. Management systems, supervision and support

7.1 How often does the person in charge of nutrition get to visit facilities and/or communities

to provide nutrition programme support?

1 Everyday

2 Every week

3 Every month

4 Less often

Code

7.2 In relation to nutrition activities, how does the district office communicate

7.2.1 With partners (government and non-government) in the district:

Code

7.2.2 With the provincial or national office:

Code

7.3 What support has your district received during the last two years to enable the nutrition team to undertake nutrition programming, planning and implementation?

Probe for training, budget support, research, dialogue, field visits.

Code

Section 8. Concluding questions

81 In your opinion, what are the top three priority needs of your District in order to accelerate

reduction of malnutrition? Do NOT prompt for options listed, rank as mentioned by interviewee

Rank (1, 2, 3) Code






Others


76

8.2 Is there anything else that you think you should tell us to have a better understanding about nutrition situation in the district?

Code

Landscape Analysis Country Assessment Tools Form 5. Facility checklist

77

Form 4. Facility manager and nutrition responsible

Semi-Structured Group* Interview

ID:___

Completed by:

Code

Province:

Code

District:

Code

Facility: 1 District Hospital 2 Secondary Hospital 3 Tertiary/Provincial Hospital 4 Primary Health Care Centre/Clinic 5 Community Health Centre 6 Maternity/Birthing Unit 7 Health post Posyandu 77 Other:

Code

Unit: 1 Out-Patient Department 2 Maternity/Birthing Unit 3 Children’s ward 77 Other:

Code

Respondents: 1) Facility manager 1 Present 0 Not

present Code

2) Responsible for nutrition programme

Present: 1 Facility manager 2 Physician 3 Nurse 4 Auxiliary nurse 5 Midwife 6 Nutritionist / Dietitian 7 Nutrition counsellor adviser / Nutrition officer 8 Other programme officer

0 Not present

Code

* It is desirable to have both the Facility Manager and the person responsible for the nutrition programme

together for this group interview. Where this is not possible, please conduct two interviews in order to

capture both viewpoints.

Date of

visit

d d m m y y y y


78

9 Community Health Worker 10 Volunteers / Lay counsellors 11 Administrator / clerk 77 Other: _________________________

1.1 What are the key / main nutrition-related activities at the facility?

Code

1.2 Does your facility provide any of the following nutrition interventions?

Code

1.2.1. Maternal iron-folate supplementation 1

Yes 0

No

99 Don’t know

1.2.2. Maternal multiple micronutrients supplementation

1 Yes

0 No

99 Don’t know

1.2.3. Maternal calcium supplementation 1

Yes 0

No

99 Don’t know

1.2.4. Breastfeeding promotion 1

Yes 0

No

99 Don’t know

1.2.5. Complementary feeding promotion 1

Yes 0

No

99 Don’t know

1.2.6. Vitamin A supplementation to children 1

Yes 0

No

99 Don’t know

1.2.7. Vitamin A supplementation to post-partum women

1 Yes

0 No

99 Don’t know

1.2.8. Child multiple micronutrients supplementation

1 Yes

0 No

99 Don’t know

1.2.9. Distribution of fortified foods to children 1

Yes 0

No

99 Don’t know

1.2.10 Distribution of fortified foods to pregnant women

1 Yes

0 No

99 Don’t know

1.2.11. Zinc supplementation to children (regular and/or during diarrhoea)

1 Yes

0 No

99 Don’t know

1.2.12. Promotion of iodized salt 1

Yes 0

No

99 Don’t know

1.2.13. Growth monitoring and promotion 1

Yes 0

No 99

Don’t

Section 1. Nutrition activities and integration into other

programmes


79

know

1.2.14. Management of moderate malnutrition 1

Yes 0

No

99 Don’t know

1.2.15. Management of severe malnutrition 1

Yes 0

No

99 Don’t know

1.2.16. Feeding of the sick child 1

Yes 0

No

99 Don’t know

1.2.17. Hand washing promotion 1

Yes 0

No

99 Don’t know

1.2.18. Deworming (children or pregnant mothers)

1 Yes

0 No

99 Don’t know

1.2.19. Promotion of insecticide-treated bednets 1

Yes 0

No

99 Don’t know

1.2.20 Presumptive treatment for pregnant women for malaria

1 Yes

0 No

99 Don’t know

1.2.21. Breastfeeding in the context of HIV/AIDS 1

Yes 0

No

99 Don’t know

1.2.22.Healthy eating and physical activity for prevention of overweight

1 Yes

0 No

99 Don’t know

1.2.23 Family planning 1

Yes 0

No

99 Don’t know

1.2..24. Other: __________________________ 1

Yes 0

No

99 Don’t know

1.3 How is nutrition integrated into other primary health care programs or activities?

Probe: How nutrition is integrated into IMCI, maternal health, adolescent health, HIV/AIDS, etc.

Code

1.4 Describe how nutrition education takes place in the health centery

Probe: Who is responsible, when and where does it take place

Code

1.5 How do you think nutrition could be improved at the health center?

Code


80

1.6 Who are usually providing nutrition services at the facility on a day-to-day basis (not

asked one be one, ask overall)? Code

1. Facility manager 1

Yes 0

No

99 Don’t Know

2. Physician 1

Yes 0

No

99 Don’t Know

3. Nurse 1

Yes 0

No

99 Don’t Know

4. Auxiliary nurse 1

Yes 0

No

99 Don’t Know

5. Midwife 1

Yes 0

No

99 Don’t Know

6. Nutritionist / Dietitian 1

Yes 0

No

99 Don’t Know

7. Nutrition counsellor / Nutrition officer 1

Yes 0

No

99 Don’t Know

8. Other programme officer 1

Yes 0

No

99 Don’t Know

9. Community health worker 1

Yes 0

No

99 Don’t Know

10. Volunteers / Lay counsellors 1

Yes 0

No

99 Don’t Know

11. Administrator / Clerk 1

Yes 0

No

99 Don’t Know

77. Other:________________________ 1

Yes 0

No

99 Don’t Know

Section 2. Training, materials and resources

2.1 Which staff categories in this facility have received nutrition-related training (overall) last

two years? Code

1. Facility manager 1

Yes 0

No

99 Don’t Know

2. Physician 1

Yes 0

No

99 Don’t Know

3. Nurse 1

Yes 0

No

99 Don’t Know

4. Auxiliary nurse 1

Yes 0

No

99 Don’t Know


81

5. Midwife 1

Yes 0

No

99 Don’t Know

6. Nutritionist / Dietitian 1

Yes 0

No

99 Don’t Know

7. Nutrition counsellor / Nutrition officer 1

Yes 0

No

99 Don’t Know

8. Other programme officer 1

Yes 0

No

99 Don’t Know

9. Community health worker 1

Yes 0

No

99 Don’t Know

10. Volunteers / Lay counsellors 1

Yes 0

No

99 Don’t Know

11. Administrator / Clerk 1

Yes 0

No

99 Don’t Know

77. Other:________________________ 1

Yes 0

No

99 Don’t Know

2.2 How many of the above staff who have received nutrition training are still at the facility?

1 All

2 Most

3 Some

4 None

77 Other

99 Don’t know

Code

2.3 For each of the following areas have any of the facility staff have received training and/or

provided training to others. Code

2.3.1 Maternal nutrition 1

Received

2 Provide

d

3 Both

0 None

2.3.2 Breastfeeding counselling 1

Received

2 Provide

d

3 Both

0 None

2.3.3 Training on breastfeeding counseling

1 Receive

d

2 Provide

d

3 Both

0 None

2.3.4 Complementary feeding counselling

1 Receive

d

2 Provide

d

3 Both

0 None

2.3.5 Zinc supplementation for diarrhoea management

1 Receive

d

2 Provide

d

3 Both

0 None

2.3.6 Vitamin A supplementation for children

1 Receive

d

2 Provide

d

3 Both

0 None


1 Receive

d

2 Provide

d

3 Both

0 None

2.3.8 Child multiple micronutrients supplementation

1 Receive

d

2 Provide

d

3 Both

0 None

2.3.9 Maternal micronutrients supplementation

1 Receive

2 Provide

3 Both

0 None


82

d d

2.3.10

Growth monitoring and promotion

1 Receive

d

2 Provide

d

3 Both

0 None

2.3.11

Management of moderate malnutrition

1 Receive

d

2 Provide

d

3 Both

0 None

2.3.12

Management of severe malnutrition

1 Receive

d

2 Provide

d

3 Both

0 None

2.3.13

Prevention and care for children with diarrhoea

1 Receive

d

2 Provide

d

3 Both

0 None

2.3.14 Breastfeeding in the context of HIV/AIDS counselling

1 Receive

d

2 Provide

d

3 Both

0 None


1 Receive

d

2 Provide

d

3 Both

0 None

2.3.16 Prevention of intestinal parasites

1 Receive

d

2 Provide

d

3 Both

0 None

2.3.17 Prevention of communicable diseases

1 Receive

d

2 Provide

d

3 Both

0 None


Received

2 Provide

d

3 Both

0 None

2.3.19 Prevention of malaria 1

Received

2 Provide

d

3 Both

0 None

2.3.20 Other: __________________ 1

Received

2 Provide

d

3 Both

0 None

2.4 Is there any system for follow-up or monitoring of training, such as on-site or refresher

training?

1 Yes

0 No

Code

If Yes, please describe:

Section 3. Community support 3.1 How does the facility work with communities to improve: Ask one by one

Probe: role of volunteers, husbands, TBAs, community leaders etc.

3.2.1 Maternal nutrition (including distribution of fortified foods) ; Code


83

3.2.2 Breastfeeding:

Code

3.2.3 Complementary feeding (including distribution of fortified foods): Code

1.2.4 Prevention of micronutrient deficiencies (e.g. vitamin A among children and post-partum women, MMN for pregnant women, salt iodization)

Code

1.2.5 Identification and management of moderate malnutrition

1.2.6 Identification and management of severe malnutrition:

1.2.7Prevention and care for children with diarrhoea:

1.2.8 Breastfeeding in the context of HIV/AIDS:

1.2.9 Healthy eating and physical activity to prevent overweight:

1.2.10 Prevention of intestinal parasites for children and pregnant women (e.g. hygiene promotion, deworrming):

1.2.11 Prevention of malaria for children and pregnant women (e.g. intermittent treatment, bednet):

1.2.12 Immunization for children and women:

1.2.13 Family planning


84

1.2.10 Other:

3.2 Has the facility participated in other community beside posyandu?

Code

3.3 In your opinion, how could the community better support breastfeeding? Probe: role of volunteers, husbands, TBAs, community leaders etc.

Code

Section 4. Support 4.1 How often are meetings held with the district nutrition programme staff?

1 Everyday

2 Every week

3 Every month

4 Less often

5 Almost never

Code

4.2 Do you feel that you receive adequate support from the district/provincial nutrition

programme staff?

1 Yes

0 No

Code

4.2a If Yes, please describe:

Code

4.2b If No, why not and what could be done to improve this situation? Give specific

examples:

Code


85

Section 5. Management of the nutrition programme 5.1 Who is in charge of nutrition in the facility?

1 Facility manager 2 Physician 3 Nurse 4 Auxiliary nurse 5 Midwife 6 Nutritionist / Dietitian 7 Nutrition counsellor adviser / Nutrition officer 8 Other programme officer 9 Community Health Worker 10 Volunteers / Lay counsellors 11 Administrator / clerk 77 Other:

Code

5.2 What proportion of his/her time is spent on counselling patients on nutrition in the health

center over the last month?

Proportion: % 99

Don’t know

Code

5.3 Has this person graduated/has received formal training on nutrition over the last two

years?

1 Yes

0 No

Code

5.4 If yes, what nutrition formal training has he or she attended?

Code

Section 6. Referral and nutrition counselling 6.1 Who performs nutrition counselling at this facility?

1 Staff trained in nutrition

2 Staff not formally trained in nutrition

99 Don't know

Code

If answered either 1 or 2, please specify:

6.2 Is there a dedicated nutrition counselling room/space?

1 Yes

0 No

Code


86

6.3 Is there a particular day in the week or month when nutrition counselling services can be booked?

1 Yes

0 No

Code

6.4 What is the average number of patients per month booked for nutrition counselling?

Code

6.5 What are the most common cases for referral?

Code

Section 7. Concluding questions 7.1 In your opinion, what are the top three priority needs of your health center in order to


Rank (1, 2, 3) Code

Human resources (more staff, better salaries, less staff turn over)





Others

7.2 Is there anything else that you would like to add regarding the nutrition services in this

health center?

Code


87

Form 5. Health center Checklist ID:___

Completed by:

Code

Province:

Code

District:

Code

Facility: 1 District Hospital 2 Secondary Hospital 3 Tertiary/Provincial Hospital 4 Primary Health Care Centre/Clinic 5 Community Health Centre 6 Maternity/Birthing Unit 7 Health post 77 Other:

Code


Code

Respondent: 1 Facility manager 2 Physician 3 Nurse 4 Auxiliary nurse 5 Midwife 6 Nutritionist / Dietitian 7 Nutrition counsellor adviser / Nutrition officer 8 Other programme officer 9 Community Health Worker 10 Volunteers / Lay counsellors 11 Administrator / clerk 77 Other:

Code

Date of

visit

d d m m y y y Y


88

Section 1. Availability of nutrition programme materials (to

be seen)

Item

Availability

Comments Code

1.1 Protocol for maternal supplementation of iron-folate

1 Yes

0 No

1.2

Protocol for maternal supplementation of multiple micronutrients

1 Yes

0 No

1.3 Protocol for maternal supplementation of calcium

1 Yes

0 No

1.4 Protocol for breastfeeding support and counselling

1 Yes

0 No

1.5 Ten Steps to Successful Breastfeeding

1 Yes

0 No

1.6 Protocol for counselling on complementary feeding

1 Yes

0 No

1.7 Protocol for vitamin A supplementation for children

1 Yes

0 No

1.8 Protocol for vitamin A supplementation for post-partum women

1 Yes

0 No

1.9 Protocol for zinc supplementation to children (regularly or during diarrhoea)

1 Yes

0 No

1.10 Protocol for Growth Monitoring and Promotion

1 Yes

0 No

1.11 Protocol for management of moderate malnutrition

1 Yes

0 No

1.12 Protocol for management of severe malnutrition

1 Yes

0 No

1.13 Record for management of severe malnutrition

1 Yes

0 No

1.14 Protocol for feeding of the sick child

1 Yes

0 No

1.15 Integrated Management of Childhood Illness (IMCI) manual

1 Yes

0 No

1.16 Protocol for infant feeding in the context of HIV/AIDS

1 Yes

0 No

1.17 Food based dietary guidelines 1

Yes 0

No


89

1.18 Monthly health information report

1 Yes

0 No

1.20 Other:: ___________________ 1

Yes 0

No

Section 2. Availability of nutrition IEC materials (poster or

pamphlet, to be seen)

Item

Availability Comments Code

2.1 Nutrition during pregnancy 1

Yes 0

No

2.2 Reduction of maternal anaemia 1

Yes 0

No

2.3 Exclusive breastfeeding 1

Yes 0

No

2.4 Optimal complementary feeding 1

Yes 0

No

2.5 Vitamin A supplementation for children

1 Yes

0 No

2.6 Vitamin A supplementation for post-partum women

1 Yes

0 No

2.7 Zinc supplementation to children (regularly or during diarrhoea)

1 Yes

0 No

2.8 Child multiple micronutrients supplementation

1 Yes

0 No

2.9 Consumption of iodized salt 1

Yes 0

No

2.10 Buku KIA 1

Yes 0

No

2.11 Management of moderate malnutrition

1 Yes

0 No

2.12 Management of severe malnutrition

1 Yes

0 No

2.13 Feeding of the sick child 1

Yes 0

No

2.14 Hand washing 1

Yes 0

No

2.15 Deworming (children or pregnant mothers)

1 Yes

0 No

2.16 Use of insecticide-treated bednets

1 Yes

0 No


90

2.17 Breastfeeding in the context of HIV/AIDS

1 Yes

0 No

2.18 Healthy eating and physical activity to prevent overweight

1 Yes

0 No

2.19 Food guide and other nutrition education material

1 Yes

0 No

2.20 Family planning 1

Yes 0

No

2.21 Immunization of children and women

1 Yes

0 No

2.22 Other: ____________________ 1

Yes 0

No

Section 3. Availability of drugs and other supplies

Item

Availability

Comments (e.g., type, dosage,

insufficient quantity, expiry date,

adequately and appropriately stored/kept or maintained) Code

3.1 Iron-folic acid tablets 1

Yes 0

No

3.4 Multiple micronutrients tablets for

PW and post-partum women

1 Yes

0 No

3.5 Multiple micronutrients powders

for children under-five 1

Yes 0

No

3.4 Calcium tablets 1

Yes 0

No

3.5 Vitamin A capsules 100,000IU 1

Yes 0

No

3.6 Vitamin A capsules 200,000IU 1

Yes 0

No

3.7 Zinc tablets 1

Yes 0

No

3.8 Functioning baby weighing scale 1

Yes 0

No

3.9 Functioning adult weighing scale 1

Yes 0

No

3.10 Length measuring board 1

Yes 0

No

3.11 Height measure board 1

Yes 0

No

3.12 Growth charts or health cards with growth curves/Buku KIA

1 Yes

0 No

3.13 MUAC tapes 1

Yes 0

No

3.14 Therapeutic food F-75 (Starter Formula)

1 Yes

0 No


91

Item

Availability

Comments (e.g., type, dosage,

insufficient quantity, expiry date, adequately and appropriately

stored/kept or maintained) Code

3.15 Therapeutic food F-100 (Catch-up formula)

1 Yes

0 No

3.16 Ready-to-Use Therapuetic Food (RUTF)

1 Yes

0 No

3.17 MP-ASI porridge (biscuits and porridge)

1 Yes

0 No

3.18 Supplementary food packages (e.g., take home food pack)f

1 Yes

0 No

3.19 Oral Rehydration Solution (ORS) 1

Yes 0

No

3.20 Other: __________________ 1

Yes 0

No

Landscape Analysis Country Assessment Tools Form 6. Health worker

92

Form 6A. Health staff (Village Midwife)

Structured questionnaire interview for all clinic staff providing services to pregnant women or children

ID:___

Completed by:

Code

Province:

Code

District:

Code


Code


Code


Code

Date of

visit

d d m m y y y y


93

Section 1. Background and training 1.1 Have you have any training in the t he last two years have, if yes what (Do not go one

by one): Code


Yes 0

No


Yes 0

No

1.1.3 BFHI training (breastfeeding management and support)

1 Yes

0 No

1.1.4 Complementary feeding counselling 1

Yes 0

No

1.1.5 Zinc supplementation for diarrhoea management 1

Yes 0

No

1.1.6 Vitamin A supplementation for children 1

Yes 0

No


1 Yes

0 No

1.1.8 Child multiple micronutrients supplementation 1

Yes 0

No

1.1.9 Maternal micronutrients supplementation 1

Yes 0

No

1.1.10

Growth monitoring and promotion 1

Yes 0

No

1.1.111

Management of moderate malnutrition 1

Yes 0

No

1.1.12

Management of severe malnutrition 1

Yes 0

No

1.1.13

Prevention and care for children with diarrhoea 1

Yes 0

No


1 Yes

0 No


1 Yes

0 No

1.1.16 Prevention of intestinal parasites 1

Yes 0

No

1.1.17 Prevention of communicable diseases 1

Yes 0

No


Yes 0

No


Yes 0

No

1.1.20 Other: __________________ 1

Yes 0

No


94

Section 2. Knowledge of nutrition protocols

2.1 What micronutrient supplement should pregnant women receive?

1 None

2 Iron-Folat

3 Calcium 4 MMN

5 Others

99 Don’t know

Code

2.2 How soon after delivery should a baby be put to the breast?

1 Within 1

hour

2 Within 6

hours

3 Within 24

hours

4 After the

mother has recovered

99 Don’t know

Code

2.3 When should breastfed children start receiving complementary foods?

1 At 4-6

months of age

2 At 6 months

of age

3 At 8 months

of age

4 When the

child has got teeth

99 Don’t know

Code

2.4 When should infants receive vitamin A supplements?

1 Every month

until age 6 months

2 Every six months

from birth

3 Every six months

from age 6 months

until age 5 years

4 Once a

year

5 When sick

99 Don’t know

Code

2.6 Zinc supplements should be given to all children who have diarrhoea

1 True

2 False

99 Don’t know

Code

2.7 All children in all countries have the same potential to grow from birth until 5 years

1 True

2 False

99 Don’t know

Code

2.8 A severly malnourrished child has micronutrient deficiencies and should therefore immediately receive iron and other vitamin and mineral supplements.

1 True

2 False

99 Don’t know

Code

2.9 Exclusively breastfeed infants who get diarrhoea may need some water to replace loss of fluids.

1 True

2 False

99 Don’t know

Code

2.10 HIV-infected women who breastfeed should gradually stop breastfeeding over several

months when their child is about 6 months

1 True

2 False

99 Don’t know

Code


95

2.11 How soon after delivery should a baby’s umbilical cord be clamped?

1 Straight

away

2 After one minute

3 After 3

minutes

4 After 1 hour

99 Don’t know

Code

Section 3. Programme implementation (Direct observations

at posyandu level) Please select only one response in this section. Direct observations 3.1 How relevant is the training you have received to your current nutrition tasks?

1 Not relevant

at all

2 Partly

relevant

3 Relevant

4 Very

relevant

88 Not

applicable

Code

3.2 How confident do you feel when implementing the nutrition actions in your facility?

1 Not

confident at all

2 Confident

about some aspects

3 Confident

about most aspects

4 Confident

about every aspect

88 Not

applicable

Code

3.3 How confident do you feel about advising and supporting a mother to breastfeed

exclusively for 6 months?

1 Not

confident at all

2 Confident

about some aspects

3 Confident

about most aspects

4 Confident

about every aspect

88 Not

applicable

Code

3.4 How confident do you feel about advising on complementary feeding?

1 Not

confident at all

2 Confident

about some aspects

3 Confident

about most aspects

4 Confident

about every aspect

88 Not

applicable

Code

3.6 How confident do you feel about interpreting growth charts?

1 Not

confident at all

2 Confident

about some aspects

3 Confident

about most aspects

4 Confident

about every aspect

88 Not

applicable

Code

3.7 How confident do you feel about treating severely malnourished children?

1 Not

confident at all

2 Confident

about some aspects

3 Confident

about most aspects

4 Confident

about every aspect

88 Not

applicable

Code

3.8 How confident do you feel about counselling on the feeding for lactating women?

1 Not

confident at all

2 Confident

about some aspects

3 Confident

about most aspects

4 Confident

about every aspect

88 Not

applicable

Code


96

3.9 How confident do you feel about counselling HIV-infected women on infant feeding practices?

1 Not

confident at all

2 Confident

about some aspects

3 Confident

about most aspects

4 Confident

about every aspect

88 Not

applicable

Code

3.10 Is your posyandu/polindes ever received infant formula/poster/leaflet/block-note from

infant formula company?

1 Yes

2 No

99 don’t know

Code

Explain if yes:

Section 4. Breastfeeding support

4.1 How often do you counsel a mother on breastfeeding?

1 Everyday

2 Every week

3 Every month

4 Less often

5 Never

99 Don’t know

Code

4.2 How often do you counsel HIV-infected mothers about infant feeding?

1 Everyday

2 Every week

3 Every month

4 Less often

5 Never

99 Don’t know

Code

4.3 Has your posyandu/polindes ever received any posters/pamphlets/free formula milk

samples or paper pads/pens by formula manufacturing companies?

1 Yes

0 No

99 Don’t know

Code


Section 5. Community involvement and support groups 5.1 Are there any breastfeeding support groups or volunteers based at your clinic or in the

local community? E.g. BFHI support groups

1 Yes

0 No

99 Don’t know

Code

5.2 How often do they meet?

1 Everyday

2 Every week

3 Every month

4 Less often

5 Never

99 Don’t know

Code


97

Section 6. Suggestions to improve

6.1 In your opinion, how can the nutrition programme be improved in your area?

Code

6.2 Are there any areas in nutrition which you feel that you need more training?

1 Yes

0 No

Code

If Yes, please describe the type of training:

Section 7. Support 7.1 Who do you consult if you need technical support regarding nutrition? (Technical support

includes help with difficult counselling cases, information about recent advances in nutrition)

Code

7.2 Do you have adequate time to carry out your nutrition duties?

1 Yes, sometimes

2 Yes, always

0 Never

Code

7.3 Is there anything else that you would like to add regarding the implementation of nutrition

services?

Code


Form 6B. Health staff (Village Health Volunteer)

Structured questionnaire interview for all clinic staff providing services to pregnant women or children

ID:___

Completed by:

Code

Province:

Code

District:

Code


Code


Code


Code

Date of

visit

d d m m y y y y

Landscape Analysis – Indonesian Country Assessment

Draft Report 27 June 2010

99

Section 1. Background and training

1.1 Have you have any training in the t he last two years have, if yes what (Do not go

one by one): Code


Yes 0

No


Yes 0

No

1.1.3 BFHI training (breastfeeding management and support)

1 Yes

0 No

1.1.4 Complementary feeding counselling 1

Yes 0

No

1.1.5 Zinc supplementation for diarrhoea management 1

Yes 0

No

1.1.6 Vitamin A supplementation for children 1

Yes 0

No


1 Yes

0 No

1.1.8 Child multiple micronutrients supplementation 1

Yes 0

No

1.1.9 Maternal micronutrients supplementation 1

Yes 0

No

1.1.10

Growth monitoring and promotion 1

Yes 0

No

1.1.111

Management of moderate malnutrition 1

Yes 0

No

1.1.12

Management of severe malnutrition 1

Yes 0

No

1.1.13

Prevention and care for children with diarrhoea 1

Yes 0

No


1 Yes

0 No


1 Yes

0 No

1.1.16 Prevention of intestinal parasites 1

Yes 0

No

1.1.17 Prevention of communicable diseases 1

Yes 0

No


Yes 0

No


Yes 0

No

1.1.20 Other: __________________ 1

Yes 0

No

Section 2. Knowledge of nutrition protocols

2.1 What micronutrient supplement should pregnant women receive?



100

1 None

2 Iron-Folate

3 Calcium 4 MMN

5 Others

99 Don’t know

Code

2.2 How soon after delivery should a baby be put to the breast?

1 Within 1

hour

2 Within 6

hours

3 Within 24

hours

4 After the

mother has recovered

99 Don’t know

Code

2.3 When should breastfed children start receiving complementary foods?

1 At 4-6

months of age

2 At 6 months

of age

3 At 8 months

of age

4 When the

child has got teeth

99 Don’t know

Code

2.4 When should infants receive vitamin A supplements?

1 Every month

until age 6 months

2 Every six months

from birth

3 Every six months

from age 6 months

until age 5 years

4 Once a

year

5 When sick

99 Don’t know

Code

2.6 Zinc supplements should be given to all children who have diarrhoea

1 True

2 False

99 Don’t know

Code

2.7 All children in all countries have the same potential to grow from birth until 5 years

1 True

2 False

99 Don’t know

Code

2.8 A severly malnourrished child has micronutrient deficiencies and should therefore immediately receive iron and other vitamin and mineral supplements.

1 True

2 False

99 Don’t know

Code

2.9 Exclusively breastfeed infants who get diarrhoea may need some water to replace loss of fluids.

1 True

2 False

99 Don’t know

Code

2.10 HIV-infected women who breastfeed should gradually stop breastfeeding over several

months when their child is about 6 months

1 True

2 False

99 Don’t know

Code

2.11 How soon after delivery should a baby’s umbilical cord be clamped?

1

Straight away

2

After one minute

3

After 3 minutes

4

After 1 hour

99

Don’t know

Code



101

Section 3. Programme implementation (Direct observations

at posyandu level)

Please select only one response in this section. Direct observations

3.1 How relevant is the training you have received to your current nutrition tasks?

1 Not relevant

at all

2 Partly

relevant

3 Relevant

4 Very

relevant

88 Not

applicable

Code

3.2 How confident do you feel when implementing the nutrition actions in your facility?

1 Not

confident at all

2 Confident

about some aspects

3 Confident

about most aspects

4 Confident

about every aspect

88 Not

applicable

Code

3.3 How confident do you feel about advising and supporting a mother to breastfeed

exclusively for 6 months?

1 Not

confident at all

2 Confident

about some aspects

3 Confident

about most aspects

4 Confident

about every aspect

88 Not

applicable

Code

3.4 How confident do you feel about advising on complementary feeding?

1 Not

confident at all

2 Confident

about some aspects

3 Confident

about most aspects

4 Confident

about every aspect

88 Not

applicable

Code

3.6 How confident do you feel about interpreting growth charts?

1 Not

confident at all

2 Confident

about some aspects

3 Confident

about most aspects

4 Confident

about every aspect

88 Not

applicable

Code

3.7 How confident do you feel about treating severely malnourished children?

1 Not

confident at all

2 Confident

about some aspects

3 Confident

about most aspects

4 Confident

about every aspect

88 Not

applicable

Code

3.8 How confident do you feel about counselling on the feeding for lactating women?

1 Not

confident at all

2 Confident

about some aspects

3 Confident

about most aspects

4 Confident

about every aspect

88 Not

applicable

Code



102

3.9 How confident do you feel about counselling HIV-infected women on infant feeding practices?

1 Not

confident at all

2 Confident

about some aspects

3 Confident

about most aspects

4 Confident

about every aspect

88 Not

applicable

Code

3.10 Is your posyandu/polindes ever received infant formula/poster/leaflet/block-note from infant formula company?

1 Yes

2 No

99 don’t know

Code

Explain if yes:

Section 4. Breastfeeding support

4.1 How often do you counsel a mother on breastfeeding?

1 Everyday

2 Every week

3 Every month

4 Less often

5 Never

99 Don’t know

Code

4.2 How often do you counsel HIV-infected mothers about infant feeding?

1 Everyday

2 Every week

3 Every month

4 Less often

5 Never

99 Don’t know

Code

4.3 Has your posyandu/polindes ever received any posters/pamphlets/free formula milk

samples or paper pads/pens by formula manufacturing companies?

1 Yes

0 No

99 Don’t know

Code


Section 5. Community involvement and support groups 5.1 Are there any breastfeeding support groups or volunteers based at your clinic or in the

local community? E.g. BFHI support groups

1 Yes

0 No

99 Don’t know

Code

5.2 How often do they meet?

1 Everyday

2 Every week

3 Every month

4 Less often

5 Never

99 Don’t know

Code



103

Section 6. Suggestions to improve

6.1 In your opinion, how can the nutrition programme be improved in your area?

Code

6.2 Are there any areas in nutrition which you feel that you need more training?

1 Yes

0 No

Code

If Yes, please describe the type of training:

Section 7. Support 7.1 Who do you consult if you need technical support regarding nutrition? (Technical support

includes help with difficult counselling cases, information about recent advances in nutrition)

Code

7.2 Do you have adequate time to carry out your nutrition duties?

1 Yes, sometimes

2 Yes, always

0 Never

Code

7.3 Is there anything else that you would like to add regarding the implementation of

nutrition services?

Code



104

Appendix 2. Indonesia’s nutrition oriented poverty

reduction programmes

There are several methods used to identify Indonesia’s poor. One of the most

commonly used systems is as follows. In 2005 the central government, helped by

BPS, held a census to map poor families in urban and rural areas. The census was

called the Sosial Ekonomi Penduduk 2005 (PSE05). Households are categorized by

14 criteria. Once identified as poor, the household receives an Energy Compensation

Card (Kartu Kompensasi –KKB). At the same time, several programmes include a

process by which poor households are identified by local village authorities based on

the same 14 criteria (see below). Once identified by the village, the list is reviewed

and verified by local BPS agents. It is the local BPS office that approves the final list

of beneficiaries to any programme. The numbers and lists of poor generated by this

‘bottom-up’ process are used primarily by poverty reduction programmes to identify

recipients and participants to the programmes.

In addition, the annual Social and Economic Survey (Susenas) measures levels of

poverty. This data is used by national government and international agencies for

monitoring the levels of poverty in Indonesia and developing macro social and

economic strategies.

The national income poverty line is about PPP US$1.55. Indonesia’s poverty rate has

been steadily declining since the political and social upheavals of the 1990s. A large

increase was seen between 1993 and 1998 due to the Asian Financial Crisis and a

change in the way poverty was measured. It has since declined again to a level of

14.18% in 2009 that is almost equivalent to the pre-crisis level of 13.7% in 1993. The

decline has been steady except for a small increase between 2005 and 2006 as a result

of rice price increases in February 2005 as a result of a rice import ban.47

However,

with 32 million people in poverty, Indonesia still has a huge burden of poor. In

47 Although fuel prices increased significantly in October 2005, poverty rates did not increase due to

the programme of unconditional cash transfers (see below in document).



105

addition, a large portion of the population is clustered just above the national poverty

line. Susenas 2006 data indicates that whereas only 16.7% lived below the national

poverty line of PPP US$1.55 per day, as many as 49% lived below PPP US$2 per day

meaning that vulnerability to poverty is very high in Indonesia and that poverty

programmes really need to target the poor and near poor.

Indonesia’s poverty reduction programmes can be divided into three clusters: i. Social assistance and protection programmes. These provide staple food, housing,

health and educational assistance to targeted poor households. This cluster includes

programmes such as Food scheme programme of subsidized food package (Raskin),

School Operational Assistance (BOS), health insurance schemes and the unconditional (BLT) and conditional cash transfer programmes (PKH). Each year the

Central Bureau of Statistics (BPS) verifies and updates the data on targeted

households. In 2007 there were 19.1 million targeted households; in 2008 and 2009 the target fell to 18.5 million and 17.1 million households respectively.

ii. Community empowerment programmes. This is basically a community-based

programme, which is provided through the National Programme for Community

Empowerment (PNPM). It provides block grants to community council at village level to be used for productive investment. PNPM Mandiri is the National

Programme on Community Empowerment. It is a set of programmes aiming to

increase income and capacity of poor communities and to accelerate achievement of the Millennium Development Goals (MDGs). The PNPM group of programmes also

includes PNPM Urban and PNPM Rural.

iii. Micro and small economic activity empowerment. This provides micro credit to small and medium size creditors.

Since 2005 these programmes are being implemented under the National Strategy on

Poverty Reduction (SNPK) which formed the basis for the National Mid-Term

Development Plan 2005-2009. The SNPK reflected a fundamental paradigm shift of

recognizing the poor as a social asset whose rights should be met and who should be

empowered rather than a passive recipient. The Strategy also aims for better

coordination between the various poverty reduction programmes for increased

efficiency and effectiveness. Based on the SNPK, in 2005, the National Team for

Poverty Reduction Coordination (TKPK) was established within the Office of

Coordinating Ministry for Peoples Welfare (Menkokestra). The TKPK consists of 22

ministries and heads of central institutions with programmes related to poverty

reduction. The TKPK was initially chaired by the Coordinating Minister for People’s

Welfare but as of February 2010, the Vice President became the chair and the

coordination national team was renamed the National Team for Accelerated Poverty

Reduction (TNP2K). The TNP2K is managed daily by a Secretariat. The role of the

TNP2K is to monitor implementation of poverty reduction policies and to strengthen

coordination in policy and at programme level. Similar bodies have also been

established at provincial and local (districts/municipalities) level.

In addition to Indonesia’s efforts to reduce poverty, under a new Social Security Law,

the government envisages a system of mandatory universal health insurance coverage

and in future pensions and other social security mechanisms. The process to ensure

universal health insurance coverage has already started.

Cluster 1 - Social Assistance and Protection Programmes



106

Raskin Programme48

The Raskin programme is a national programme aimed at helping poor households to

fulfill their food needs and reduce financial burdens by providing subsidized rice. It

was established in 1997 during the Asian Financial Crisis to cushion the effects of

rising prices and declining employment. At the same time the programme enables the

government to buy up surplus rice in order to maintain rice prices and maintain a

buffer stock for use in emergencies. In 2007 the total cost of the programme was Rp

6.28 trillion (approximately US$ 690 million). Under the programme poor

households are intended to receive 10 kg of rice per month at a subsidized price of Rp

1,000 per kg. The State Logistics Agency (Bulog) is responsible for the distribution of

rice to the distribution points, while local government is responsible for distributing

the rice to poor households form the distribution points. In the sense that the

programme provides subsidized rice to poor households, it could be expected that the

Raskin programme could contribute to the prevention of undernutrition of both

women and children. The strategy should be particularly effective at achieving this

goal if women and children in poor households are undernourished because of

inability to purchase adequate food due to poverty. In reality however it appears that

the Raskin programme is widely seen as been ineffective as a safety net and

inefficient in use of resources. Some issues of concern are:

Although the targeted number of beneficiaries rises each year, it is still less

than the total number of poor households (RTM). As a result local

governments have a hard time distributing the rice as intended as they do not

have enough. In response, some RTM do not receive any rice, all beneficiaries

get less than intended or the rice is simply distributed to all with no focus on

the poor at all. Thus, Susenas data indicate that poor households (quintiles 1

and 2) only account for 53% of all beneficiaries; ie there is a 53% leakage to

non-poor households.

Household Socio Economic Survey Data (BPS) is meant to be used to verify

poor households at village level through village meetings to finalize the list of

beneficiaries. The process of doing this however is varied and non-transparent

creating opportunities for corruption and contributing to mis-targetting.

Beneficiaries frequently pay more than Rp 1,000/kg as they are charged for

transport costs etc. This is because national budget for the programme only

covers the cost of transporting the rice to primary distribution centres. Local

governments have to cover the cost of distributing the rice from primary to

secondary distribution centres and for local administration.

Finally the programme appears to be highly inefficient; in 2003, only 18% of

Raskin’s budget benefited poor households, 52% benefit non poor households

and 30% was used for operational expenses and Bulog’s profit. In the same

year, it only cost Bulog Rp2,790/kg to procure the rice while they sold it to the

government for up to Rp 3,343/kg.

Putting these weaknesses aside, a new opportunity has arisen for Raskin to benefit

nutrition; in 2009 the ADB and the Government of Japan approved a grant of US$ 2

million for food fortification in Indonesia. The grant will be used to assess the

feasibility, cost and impact of providing iron fortified rice through Raskin. If Raskin

rice can indeed be fortified, and can be targeted as intended to the poor and the food

48

The Effectiveness of the Raskin Program. SMERU Research Institute. February 2008



107

insecure, it will be a highly cost effective way to improve iron intake in the most

vulnerable segments of society.

Cash Transfers In October 2005, the government raised the price of fuel by 85% to safeguard the

national budget. In order to off-set the impact on the poor, a programme of

unconditional cash transfers to households of poor and near poor families (Bantuan

Tunai Langsung – BLT) was started. In the first round of the scheme some 60 million

people in 15.5 million households (28% of the population) were targeted and in the

second round, May 2008 when the gas price was again increased, by 33.3%, the target

was extended to 70 million people in 19.2 million households. Grants of Rp 100,000

per month (US$ 10) are provided; in the first round it was provided from October

2005 to March 2006 after which it was suspended. The poor are initially identified by

local authorities and classified by economic level on the basis of 14 criteria develop

by the Central Bureau of Statistics (BPS)49

. Village authorities produce list of poor

households and these households are then visited by a BPS enumerator to help them

fill out an assessment form. The forms are reviewed by the local BPS office and a

final list is produced. The approved list is given to the Post Office which issues

entitlement cards and provides cash transfers in quarterly lump sums to the poor

household. In the first year, 2005, the government allocated 4.6 trillion for the

programme (US$ 500 million). The funds are taken from the partial cut of gas subsidy,

essentially transferring the gas subsidy into a household subsidy. An evaluation,

coordinated by the University of Indonesia,50

found that 90% of recipients used the

transfer for purchasing rice, just under 80% on purchasing oil and about 40% on debt

repayment and health costs. Only about 5% used it for gasoline purchase. Although

the programme was considered to be successful in the sense that it curtailed a rise in

poverty which would otherwise have occurred, the programme was converted into a

conditional cash transfer programme to empower poor communities.

The conditional cash transfers (Program Keluarga Harapan – PKH) was started in

2007 and targeted the same households as the BLT but with additional criteria for

eligibility. The objectives of the PKH are to (i) reduce maternal mortality, (ii) reduce

child mortality, (iii) ensure universal coverage of basic education, (iv) reduce child

labour and encourage children to go to school. Eligible households must have a

pregnant woman, children 0-6 years or children of primary or high school age (6-17).

The cash transfers are given to households on the condition that they meet the below

12 conditions. The funds are given to the mother (or another adult woman) in the

household every three months. Beneficiaries may participate for a maximum of 6

years and there is recertification of eligibility every 3 years. The PKH is implemented

by the Ministry of Social Affairs (DepSos) and will run until 2015 in line with the

MDGs. The PKH programme was implemented in 7 provinces in 2007 as a pilot. It

has since been expanded and in 2009 covered a total of 720,000 households.

49 Criteria include things like size of house, flooring and wall material of house, access to water and

sanitation, source of light, kind of fuel used for cooking, how many times per week the family buys

meat/chicken/milk, how many times per day the family eats and possession of specified assets. 50 Widjaja. An Economic and Social Review on Indonesian Direct Cash Transfer Program to Poor

Families Year 2005.



108

Health indicators:

Indicators for pregnant mothers: (i) four prenatal care visits during pregnancy, (ii)

take iron supplements during pregnancy, (iii) have a delivery assisted by a trained

professional, (iv) two postnatal care visits;

Indicators for under-five children: (v) complete childhood immunization, (vi) monthly

growth monitoring of children under 3 and quarterly thereafter (1-6 years), (vii)

monthly weight gain of infants, (viii) vitamin A every six months for under fives.

Education indicators: (i) all children aged 6-12 enrolled in primary school, (ii) minimum attendance rate of

85% for all primary school-aged children, (iii) all children aged 13-15 enrolled in

junior secondary school, (iv) minimum attendance rate of 85% for all junior

secondary school-aged children.

Problems experienced with the programme include beneficiary selection, in

particularly targeting errors (inclusion) and the transparency of the selection process,

interagency coordination in relation to financial arrangements and information flow,

insufficient socialization and insufficient monitoring and verification. There are also

issues with insufficient training of the facilitators and their workload, and problems

with the payment system.51

Overall however the programme is considered a success

and some concrete improvements have been measured as noted below.

Health Insurance52

In 2004, the Indonesia government made a commitment to provide its entire

population with health insurance coverage through a mandatory public health

insurance scheme. In principal this should be contributing substantially to improving

nutritional status in that it should ensure access to essential health services including

antenatal care, delivery care, micronutrient supplementation, treatment of childhood

illness and preventative services and nutritional counselling. In addition to ensuring

insurance coverage for all, inefficiencies in the health system and overall low quality

of service provision need to be addressed in order to improve the supply of basic

health services. Health financing since decentralization has become more

complicated and health service delivery appears to be worsening. As a result, half of

all health spending is private, largely out of pocket (OOP) and almost half of all those

who are ill actually seek health services from private providers.

In order to provide health insurance to everyone, the government established Asuransi

Kesehatan Masyarakat Miskin (Health Insurance for Poor Population) or Askeskin in

2004 and expanded it into Jaminan Kesehatan Masyarakat (Health Insurance for the

Population) or Jamkesmas in 2008. Meanwhile civil servants and their dependents are

covered under the Askes programme and Jamsostek covers private sector employees

in firms with 10 or more employees. Susenas 2007 indicates that 26% of the

population is covered by health insurance, the majority by Jamkesmas (14.3%). This

means that 73.9% remain uninsured. The government estimates however that by 2008

the proportion covered had increased to 48% mostly as a result of expansion of

Jamkesmas. The government vision is that coverage for the poor will be financed by

the government and financing for the remainder of the population will be through a

51 Karin Schelzig Bloom. Conditional Cash Transfers: Lessons from Indonesia’s Program Keluarga

Harapan. July 2009. ADB 52

Health Financing in Indonesia: A Reform Road Map. World Bank, 2009



109

contributory scheme. The legislation envisages existing health insurance carriers

converting to non-profit status and all carriers merging under a mandatory, universal

system under the national social security council. Problems will be in how the

government will identify additional fiscal space to finance coverage for the poor

(about 70 million people) and how the huge informal sector53

of some 60 million

people will be covered as they are difficult to identify and it will be difficult to obtain

contributions from this segment of the population.

Cluster 2 - Community Empowerment Programmes

PNPM Mandiri (National Programme on Community Empowerment) PNPN Mandiri was launched in April 2007. It is formed by the merging of two

community driven development approach programmes, the Kecematan Development

Programme (KDP) and the Urban Poverty Programme (UPP), which had themselves

been started in 1998 and 1999. In the PNPM Mandiri these two programmes have

been scaled up; in 2009 all sub-districts in the country were covered (6,408 sub-

districts).

The general objective of PNPM Mandiri is to improve the welfare of poor

communities. Specific objectives include (i) increasing participation of community

members, (ii) improving capacity of community institutions, (iii) improving local

government capacity to provide public services, (iv) increasing synergy between

communities, local government and other pro-poor stakeholders, (v) enhancing

capacity and capability of the community and local government and (vi) increasing

innovation and use of appreciate technology, information and communication in

community development.

PNPM Mandiri programmes can be categorized into: Core PNPM and Supporting

PNPM. The core PNPM programme consists of community based empowerment

programme and activities such as Rural PNPM Mandiri, Urban PNPM Mandiri,

PNPM Mandiri for Disadvantaged Areas, PNPM Mandiri for Rural Infrastructure, and

PNPM Mandiri for Regional Socio-Economic Infrastructure. The Supporting PNPM

programme consists of sector based, region based, and special community

empowerment designed to support poverty reduction related to the achievement of

specific targets such as PNPM Generasi, Green PNPM (PNPM Hijau), and PNPM

Smallholder Agribusiness Development Initiative (SADI).

The component of activities in PNPM Mandiri includes (i) community development,

(ii) strengthening local governance and partnership, (iii) community block grant and,

(iv) technical assistance for programme management and development. The PNPM

Mandiri works by providing Community Block Grants to poor community groups

including women’s groups. The community groups have been or are being

empowered and supported by almost 40,000 facilitators. The programme is planned to

continue until 2015, the deadline for the MDGs.

53 Some 85% of all workers are in firms of fewer than five workers and 38% are in firms of only one

worker.



110

Most of PNPM Mandiri’s source of fund comes from government annual budget

(APBN), regional funds (APBD), private/community contributions and also grants or

loans from various donor.

PNPM Generasi (Community Cash Transfer for Health and Smart

Generation) As noted above, PNPM Generasi is a component programme of PNPM Mandiri. It is

mentioned here because it contributes specifically to health and education goals and is

synergistic with the PKH. The PNPM Generasi aims to increase access of poor

households to health and education services. Through the PNPM Generasi the local

community can build infrastructure or procure equipment to enable them to access

basic services eg. Build community health centre, purchase standard equipment,

renovate facilities, build bridges or roads. The programme builds on the experiences

of the Kecamatan Development Project (KDP) and is implemented as part of the

PNPM Mandiri. The programme covers 3.1 million beneficiaries or 8.4% of total poor

people in Indonesia.

Under the programme, poor communities self-identify problems and seek solutions to

meet the same 12 conditions of the PKH. Community participation in PNPM Generasi

is conditional upon their commitment to meet the 12 conditions. All participating

villages receive facilitation or technical assistance in the form of facilitators and

training, and an average village block grant of US$ 8,400. Assisted by facilitator,

communities follow a cycle of socialization, village planning, village implementation

and performance measurement. A cycle takes 12 months with village implementation

taking 9 months. In the first year of operation, 2007, 56% of funds were used for

education activities vs 44% for health activities. Within health activities funds were

used as follows: supplementary feeding for underweight and malnourished children

(40%), financial assistance for pregnant women and mothers to access health services

(30%), infrastructure (13%), facilities and equipment (11%), socialization and training

(3%) and incentives for health workers (3%). An evaluation by the World Bank found

improvement in coverage of health services, in particular participation in

immunization coverage. The evaluation also noted an improvement in child

underweight under 3% (25% before and 21% after in Jakarta).54

It is clear that the PKH and Mandiri Generasi have significant potential to contribute

to improvements in nutrition, and some results in this area have been reported.

However as presently implemented, a significant proportion of the effort has gone on

interventions that are not the most effective at reducing maternal and child

undernutrition such as increasing participation in monthly weighting and

supplementary feeding programmes. The conditions for the PKH are in line with the

national strategy for nutrition in the sense that they include a focus on maternal health

and on young children (growth monitoring is stipulated to be monthly only for under

1 children for example) but even more emphasis could be placed on improving

maternal nutrition and on strengthening child nutrition services (such as breastfeeding

and complementary feeding counseling, or vitamin A supplementation) as opposed to

growth monitoring for example.

54 Karin Schelzig Bloom. Conditional Cash Transfers: Lessons from Indonesia’s Program Keluarga

Harapan. July 2009. ADB. It appears that these impacts have been achieved through a combination of

the PKH and PNPM Generasi.



111

Micro and Small Business Empowerment The People’s Business Credits (Kredit Untuk Rakyat – KUR) provides soft credit to

develop micro and small businesses. The credits use public funds managed by banks

but they are guaranteed by the government. Since its launching in November 2007,

until 2008, the programme has provided Rp13 trillion (US$1,417 million) to 1.7

million creditors.


Appendix 3. Essential Nutrition Interventions Policy and Programme framework

Interventions with sufficient evidence for implementation in all 36 countries Intervention Policy / legislation Supporting guidelines Target Implementation

status

Current

Coverage

in

Indonesia

References and

Notes

Maternal and

birth outcomes

Iron folate

supplementation

National Action Plan for

Food & Nutrition 2006-

2010

Plan of Action on

Community Nutrition

(2010-2014)

Operational guidelines

for family nutrition

awareness in alert

village (desa Siaga)

(MOH decree:

747/MOH/SK/VI/2007)

Counseling guideline

book to achieve family

nutrition awareness

2007 Guideline book of IEC

strategy for family

nutrition awareness

program 2007

85% (2014) National 29.2% DHS 2007- 90+

days

Maternal

calcium

supplementation

None None N/A Not implemented N/A

Maternal

supplements of

multiple

micronutrients

None None N/A Sub-national; Piloted

in NTB and NTT

provinces

Lombok

Tengah:

84,5%

(2008)

and 71,1%

(2009) of

women

Landscape Analysis – Indonesian Country Assessment Draft Report 27 June 2010

113

have

received

MMN

tablets

Maternal iodine

through iodized

salt



2010

Decree No: JM 03 03/BV/2195/09

Accelerated intervention

of non-iodized salt 2009

Plan of Action on

Community Nutrition

(2010-2014)

Operational guideline


awareness in alert

village (desa Siaga) (MOH decree:

747/MOH/SK/VI/2007



nutrition awareness

2007

Guideline book of IEC

strategy for family

nutrition awareness

program 2007

Monitoring guideline of

iodized salt in the community 2001

90% (2014) National 62.8% Riskesdas - no of

households

consuming

adequately iodized salt (titration

methodology)

Interventions to

reduce tobacco

consumption

and indoor air

pollution



2010

Council of Ulemas

(MUI), 2010 Fatwa

forbidding all muslims

from smoking in public

places

Ministry of Finance No

2003/PMK 001/2008

Cigarette Tax Increment

Health regulation No 36,

chapter 113, 114,115 on

N/A N/A Sub-national 97% DHS - % of

women who do not

use tobacco.

However on 87.8%

of men use

tobacco. Data on

indoor air pollution

is not available


114

security of addictive

substances

Newborn

babies

Promotion of

breastfeeding

(individual and

group

counseling)



2010

Minimum Health

Service Standard 2008 Ministerial decree on

exclusive breastfeeding

Ministerial decree on

marketing of breastmilk

substitutes

BPOM regulation on

labelling

Health regulation No 36,

chapter 128, 129, 200

about EBF 2010

Supervision decree of

International code 2009 Plan of Action on

Community Nutrition

(2010-2014)



awareness in alert


(MOH decree: 747/MOH/SK/VI/2007



nutrition awareness

2007


strategy for family

nutrition awareness

program 2007

National strategy in

increasing breastfeeding

and complementary feeding 2010

Counseling material of

early initiation of

breastfeeding 2009

Code in formula milk

labeling 2003

80% (2014)

National Data not

available

on

coverage

of IYCF counselin

g services

In 2007

32%

infants 0-6

months

exclusivel

y

breastfed;

41%

children

6-23 months

receive

timely and

appropriat

e

compleme

ntary

feeding

Infants and

children

N/A

Promotion of

breastfeeding

(individual and group

As above As above As above As above As above As above


115

counseling)

Behaviour

change

communications

for improved

complementary

feeding



2010



awareness in alert


(MOH decree:

747/MOH/SK/VI/2007

Counseling guideline book to achieve family

nutrition awareness

2007


strategy for family

nutrition awareness

program 2007

None National N/A National target

only available for

distribution of

commercial

fortified

complementary

food to children in poor families

Zinc in

management of

diarrhoea

Departemen Kesehatan

RI dalam Keputusan

Menteri Kesehatan

Republik Indonesia

Nomor: 1216 /

MENKES / SK /XI / 2001 tentang Pedoman

Pemberantasan Penyakit

Diare edisi ke-5, tahun

2007

Guidelines are under

development.

None National N/A

Vitamin A

supplementation



2010

Minimum Health

Service Standard 2008

Plan of Action on

Community Nutrition

(2010-2014)



awareness in alert


(MOH decree:

747/MOH/SK/VI/2007


book to achieve family nutrition awareness

2007

85% (6-59

months

children,

2014)

National 68.5% -

71.5%.

DHS 2007 and

Riskesdas 2007


116

Management guideline

of vit A

supplementation 2009

Universal salt

iodization

Same as above on

maternal iodine through

iodized salt

Same as above on

maternal iodine through

iodized salt

90% National 62,8% Riskesdas - no of

households

consuming

adequately iodized

salt (titration)

Handwashing or hygiene

interventions

National Action Plan for Food & Nutrition 2006-

2010

Minimum Health


Decree No

852/MOH/SK/IX/2008

National Decree (2008)

on Community Based

Sanitation

No guidelines 100% National 23.2% and 71.1%

Riskesdas - % of population over 10

years with correct

behavior in

handwashing and

defecating

Treatment of

severe acute

malnutrition



2010 Minimum Health


National plan of action

for severe malnutrition

prevention and

intervention 2005-2009

Plan of Action on

Community Nutrition

(2010-2014)

Severe malnutrition

screening guideline

2009 Management of severe

malnutrition 2009

Monitoring book for

management of severe

malnutrition 2009

100% of

children with

Gizi buruk (2014)

National N/A National policies

and guidelines

currently being updated

Interventions with sufficient evidence for implementation in specific, situational contexts


Maternal

supplements of

None None N/A Not

implemented,

0% Supplementary

feeding of pregnant


117

balanced energy

and protein**

yet women will be

initiated in 2010

Maternal

deworming in

pregnancy

None None N/A Not

implemented

N/A No policy or

program, yet

Maternal

calcium

supplementation

None None N/A Not

implemented

mandatorily

N/A Implemented

inconsistently as it is

not mandated by

national policy or program

Intermittent

preventative

treatment of

malaria*

Mid-term Development

Plan 2010-2014

Malaria Case

Management Guideline

in Indonesia, CDC

MOH 2009

N/A N/A

Insecticide

treated bednets*

Mid-term Development

Plan 2010-2014

Ministerial Decree no.

293/MENKES/SK/IV/2

009

Why do we need to use

ITN bednets, CDC

MOH 2008 (Booklet)

ITN Bednet CDC, MOH

2007

80% (of total

population)

2.3% DHS - % of pregnant

women who slept

under an insecticide-

treated net the night

before the survey

Newborn

babies

Neonatal

vitamin A

supplementation

None None N/A Not

implemented

N/A Not yet a WHO

recommendation

Delayed cord clamping

None None N/A N/A Not specified in the APN

Infants and

children

Conditional

cash transfer

programmes

(with nutritional

education)**

None None N/A Sub-national N/A Implemented in

selected areas, but

coverage data is not

available.

Deworming*** None on pregnant

women and children

None N/A Sub-national N/A Scarcity of data on

prevalence limits


118

under-five implementation of

this

policy/programme

Iron

fortification and

supplementation

programmes***



2010

Decree No

1452/MOH/SK/X/2003 Flour Fortification

None All flour National 100% Flour fortification

with iron is

mandatory in

Indonesia and close

to 100% of all flour is fortified although

it is not known how

much flour young

children consume.

Insecticide-

treated bednets*

Same as above Same as above 3.3% DHS - % of children

under 5 who slept

under an insecticide-

treated net the night

before the survey

*In areas with malaria

** For women and children from poor families *** In areas with high worm infestation and/or anaemia


Appendix 4. WFP Food Security and Vulnerability

Mapping

There has been a constant need for the Government of Indonesia to improve

geographical targeting of more vulnerable areas for food and nutrition security related

interventions. In 2003 the Food Security Council (FSC), chaired by the President of

Indonesia, whose Secretariat is the Food Security Agency (FSA), collaborated with

WFP to develop the national Food Insecurity Atlas (FIA) for Indonesia. The first FIA

was developed and launched in 2005 and covered 265 rural districts in 30 provinces.

More than US $32 million were allocated by the Government to 100 districts

identified as food insecure and interventions began in 2006-2007. The second Atlas,

with a new title “Food Security and Vulnerability Atlas (FSVA)” covering 346 rural

districts in 32 provinces, was signed off by the President of Indonesia in March 2010

and will be launched in May 2010, and it has already been fully integrated into annual

government work plans and budgetary allocations. WFP has been providing technical

and financial support towards the development and implementation of the FIA and

FSVA since 2003.

Like the FIA 2005, the FSVA 2009 serves as an important tool for decision making

in targeting and developing recommendations for responding to food insecurity

at the provincial and district levels.

The FSVA analyzed 13 indicators related to food security, based on officially issued

secondary data of the period 2004-2007, and developed a composite of 9 of them to

derive a Composite Food Security Index that allows the FSVA to answer three key

questions related to food security and its vulnerability: Where are the higher

vulnerable to food insecurity (by province, district); How Many are they (estimated

population); and Why are they higher vulnerable (main underlying causes of food

insecurity)?

Indicators used in Composite Food Security Index provide information on the three

food security pillars of food availability, household food access and individual food

utilization, as shown below.

Food Availability Food and Livelihoods

Access

Food Utilization

Per capita normative

consumption to net ‘rice +

maize + cassava + sweet

potato’ availability ratio

Percentage of people

below the poverty line

Life expectancy at birth

Percentage of villages with

inadequate connectivity to

4 wheeled vehicles

Children underweight

Percentage of households

without access to

electricity

Female illiteracy


without access to


120

improved drinking water


living more than 5km

away from health facilities

NB. For food utilization, data on direct indicators such as food consumption, was not

available at district level. Hence, indirect indicators that may be affected by food

utilization or may influence food utilization, and for which data was available at

district level, were used instead. In reality therefore, none of the indicators used

under food utilization can be said to be indicators of food utilization; rather they are

indicators of vulnerability to food and even nutritional security.

Using the composite index, 346 districts which had complete datasets, were ranked

and mapped. Among them, 100 were ranked as Priority 1 (30 districts), Priority 2 (30

districts) and Priority 3 (40 districts) with a total estimated population of 25 million

people. The remaining 246 districts are classified as Priorities 4-6. Higher attention

should be paid to districts of Priorities 1-3 in addressing food security and

vulnerability.

The FSVA provides information tools for decision makers to quickly identify the

more vulnerable areas where investments in different services, human development

and infrastructure related to food security will have more impact on livelihood, food

and nutrition security of the people.

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