President Joko “Jokowi” Widodo has said he was now focusing on improving Indonesia’s human resources in his second and last term. To help accomplish that vision, the budget allocation for health care is projected to increase by 13 percent to Rp 132.2 trillion (US$9.4 billion) in 2020.

Among the priorities of the Health Ministry are to strengthen early childhood health programs to fight the prevalence of stunting.

Stunting is a condition of chronic malnutrition that occurs during critical periods of growth and development starting from the fetus. An estimated 30.2 percent of Indonesia’s children under the age of five suffer from stunting. Indonesia is also a country with the fifth-highest prevalence of stunting in the world.

In the 2020-2024 National Medium-Term Development Plan (RPJMN), the government plans to act more aggressively in suppressing the country’s stunting rate by targeting a 19 percent reduction. The government also plans to expand the scope of its stunting program to 260 cities and regencies in 2020, from last year’s 160 regencies and cities.

Terawan stated that the causes of stunting vary and general effort could not be applied to address stunting. Instead, the efforts should be applied sector by sector.

“[The root causes of stunting] must be checked carefully because each region has its own different causes. The budget must be on target, on time and in the right direction,” Terawan was quoted as saying after the Cabinet inauguration ceremony.

So, was the last Health Ministry program on stunting effective? The National Strategy for Acceleration of Stunting Prevention (Stranas Stunting) has several leading programs, such as providing supplementary food for pregnant women and toddlers, as well as village funds of Rp 100 million per village to tackle stunting.

Despite the government’s apparently holistic and well-developed plans, misconceptions about stunting remain. One instance is a large billboard right in front of the Health Ministry building.

Bearing a message that reads, “Preventing stunting is important”, the poster features two children in elementary school uniforms. Standing next to a height chart, one child looks much shorter than the other. The poster highlights three ways to prevent stunting: improving sanitation, improving access to clean water and healthy latrines and washing hands with soap.

Obviously, several things need to be straightened out in the poster. First, stunting is defined as children aged 0 to 59 months, whose height for their age is below minus two standard deviations (moderate and severe stunting) and minus three standard deviations (severe stunting) from the standard growth chart.

The first 1,000 days between conception and a child’s second birthday is the most crucial window of opportunity for intervention. The loss of height resulting from stunting is irreversible after this period, making intervention for school-age children completely useless.

Second, the three stunting prevention points emphasized on the poster are not quite right. Stunting arises from multifactorial biological, social and environmental causes that are often interlinked. Although it does have a connection to stunting, water, sanitation and hygiene (WASH) interventions are not the most critical efforts in addressing stunting. In fact, poor sanitation and hygiene would require a very long period with interaction with other determinants to be able to contribute to stunting.

One point that must be highlighted to prevent stunting should be nutrition intervention. Although stunting is related to many causes, evidence suggests that nutrition-specific evidence-based intervention could reduce stunting by 20 percent. These interventions include supplementary feeding for pregnant women, exclusive breastfeeding promotion, appropriate complementary feeding for infants and other interventions involving pregnant women and under-5 children.

Delivering clear information on stunting is pivotal. In fact, incorrectly delivered messages can lead to ineffective efforts, leading to the waste of millions of dollars on useless programs.

For example, a program initiated by Bandung regency in West Java revolved around routine morning exercises in dozens of elementary schools as an effort to prevent stunting.

Regency officials said stunting was caused by a lack of vitamin D, so students needed to do morning exercises and sunbathe for at least 30 minutes per day. This is an example of a real misconception in the field, leading to futile programs.

Another inefficient effort to reduce stunting is the distribution of free mung bean porridge and milk to elementary school students, including in Jakarta. Again, nutritional intervention to prevent stunting should be given during the first 1,000 days of life. Intervention efforts for elementary school children are hardly fruitful.

Successful stunting programs, therefore, not only require impeccable planning but also correct information that must be conveyed well to communities. Under the leadership of Health Minister Terawan, let us hope that stunting programs will be implemented on target, on time and in the right direction.

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Master of Public Health student at Harvard University, currently involved in research on stunting in developing countries.

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