Indonesia has one of the world’s highest prevalence of stunting, a sign of nutritional deficiency that starts in early childhood. With the help of international donors and health organizations, the country is taking giant leaps to combat this health problem. The Jakarta Post’s Wahyoe Boediwardhana takes a closer look at these measures.

Stunting is a condition of impaired growth in children under 5. Based on the parameters issued by the Health Ministry, a child suffers from stunting when their height-for-age is more than two standard deviations under the threshold defined by the World Health Organization.

Stunting is largely the result of chronic malnutrition, repeated infections and inadequate psychosocial stimulation in the First 1,000 Days of Life (HPK), starting from conception until the age of 23 months.

According to data from the Health Ministry’s Basic Health Survey (Riskesdas) in 2013, 37.2 percent of Indonesian children under the age of 5 were considered stunted or around 9 million children. A total of 228 regencies and cities had a stunting prevalence rate of above 40 (a very high category).

The figure declined to about 30.8 percent in the 2018 Riskesdas but was still comparatively high, which prompted then-vice president Jusuf Kalla to convene a ministerial meeting to stress the importance of stunting prevention efforts in July 2017.

The meeting detailed the five pillars of stunting prevention: the importance of top government leaders’ commitment and vision; the need to conduct national campaigns and communicate behavioral changes; the need for the convergence, coordination and consolidation of central, regional and village programs; the importance of nutrition and food resilience; and the importance of monitoring and evaluating these programs across the country.

The state of stunting in Indonesia has drawn the attention of the Global Alliance for Improved Nutrition (GAIN), an NGO based in Switzerland that is financed by the Netherlands.

The NGO focuses among other things on the sufficient nutritional intake for infants and children and introduced a method called Emotion Demonstration (Emo-Demo) that was successful in encouraging and changing the behavior of parents and babysitters in feeding babies and toddlers.

“We want our program to support the government’s strategy in changing the nutritional behavior in society, certainly from the aspect of health. That’s why GAIN is cooperating with the Health Ministry’s Public Nutrition Directorate General,” GAIN Indonesia country director Ravi K. Menon said while monitoring the program’s implementation in Probolinggo regency, East Java, on Oct. 28.

Sufficient nutritional intake, according to Menon, constitutes one of the important assets to reduce stunting among children.

From the moment of conception, ample amounts of ATIKA, an acronym for chicken, liver, eggs and fish, should be consumed. Babies should later exclusively be fed breast milk (ASI) for 6 months after birth and then nutrition-rich foods until the age three.

“This is the golden age for babies, called the 1,000 HPK. It should be optimally maintained,” Menon said.

The public, especially mothers and expectant mothers, initially lacked awareness about the importance of a sufficient nutritional intake for their infants and children under 5.

GAIN, whose pilot projects in Indonesia were located in Malang and Sidoarjo, East Java, from 2014 to 2017, divided the Emo-Demo method into specific themes. The first theme began with an explanation about sufficient breastfeeding, followed by a guideline promoting the mother-and-child emotional bond.

The second theme offered a demonstration on child feeding schedules, nutritious snacks and food portions. The third theme underlined the types of foods to avoid, except ASI, for infants up to 6 months of age and a game showing the correct way to breastfeed. The fourth featured mothers expressing their hopes, a demonstration on washing hands with soap and the expectations of different villages.

“This method helps mothers gain a better understanding and increase their awareness so that they will do as they have been instructed without being told. So, we touch them emotionally to make them realize that what they do is for the benefit of their own children,” Menon added.

After being introduced for the first time in Malang and Sidoarjo, GAIN also carried out intervention programs in public health centers in four other regencies and a city in East Java starting in 2018, namely Probolinggo, Bondowoso, Jember, Trenggalek regencies and the city of Surabaya.

In the early stages, only seven health officers were trained. They then trained 143 masters of trainers in the other regencies and cities, who later passed their knowledge and skill on to others. At present, the program has 1,539 trainers spread across various regions.

These trainers have communicated the Emo-Demo method to around 8,000 members of integrated health services posts (Posyandu), early childhood education (PAUD) centers, Family Welfare Movement (PKK) and social organizations in East Java.

Today, a total of 200,000 mothers with children under the age of 5 have been acquainted with this method.

The various themes of the Emo-Demo method are expected to change the behavior of infant and child feeding (PMBA) because stunting does not only refer to dwarfism but also a child’s brain development and other relevant factors during the 1,000 HPK.

In Probolinggo regency, one of the program’s targets, the method presented by GAIN has produced a great impact on children and mothers, according to Regent Puput Tantriana Sari.

“Something seems to raise the spirits of residents. A significant change is felt by expectant and breastfeeding mothers. Emo-Demo has had a major influence on women who are pregnant, about to give birth and taking care of their babies,” Puput said.

Stunting in Probolinggo, she indicated, had in the last five years remained at the rate of 49 percent and could be reduced by 10 percent through this Emo-Demo approach.

“I hope such a good program won’t cease halfway so it can be replicated throughout the regency. We will expand it in Probolinggo to cover five more Puskesmas [community health post] funded by the regency budget. I’ve asked participating health officers and they feel confident about the Emo-Demo method,” added the regent.

In October alone, 31,381 women joined Emo-Demo, exceeding the target of 30,824 pregnant mothers and those with children under 5, she explained. One of the advantages of Emo-Demo is the presentation of simple simulations by using familiar subjects.

One of the subjects taught is the difference between ASI and formula milk. Infants consuming ASI will fully absorb their mothers’ milk while formula milk will leave fat residues. In the demo, two transparent glasses were used to show the difference, which made breastfeeding mothers more aware about the importance of ASI.

Probolinggo Health Agency head Anang Budi said stunting was more than just impaired growth, but was also related to a child’s mental development, beginning from pregnancy until the age of 8.

“So, the brain is already formed in the womb. Expectant and breastfeeding mothers should often visit Posyandu so as to understand the great benefit of ASI and nutritional intake,” Anang added.

East Java Governor Khofifah Indar Parawansa earlier said that the stunting rate in the province was 32.81 percent, higher than the average national rate of around 30 percent.

“Whether it’s due to our youths’ changed lifestyle, there should be some research on it. Stunting can’t be ascertained from when the fetus is in the womb," said Khofifah while opening the National Scientific Meeting on Independent Village Development Acceleration in Malang on Sept. 3.

Based on data from the East Java Health Agency, electronic records and reports on community based nutrition (EPPGBM) on July 20 put the province’s prevalence of stunting among children under 5 at 36.81 percent. According to EPPGBM, the highest rates were scored by Malang at 51.7 percent, Probolinggo regency with 50.2 percent and Pasuruan regency with 47.6 percent.

Outside East Java, GAIN has also popularized the Emo-Demo method for behavioral change in community nutrition in several other provinces, like West Sumatra, East Kalimantan, Bali, South Sulawesi and Central Sulawesi.

“The Emo-Demo program has also been introduced to a number of higher learning institutions in Indonesia as study and educational material,” Menon said.

For greater stunting prevention, the government has designated three priority program. First, the 100 regencies and cities fixed as program targets for 2018 were increased to 160 in 2019, 260 in 2020 and all regencies and cities in Indonesia by 2024.

Second, priority targets involve pregnant mothers, breastfeeding mother and infants aged zero to 23 months (1,000 HPK families). Third, priority interventions are made up of specific nutrition interventions and sensitive nutrition interventions.

Stunting has been one of the country’s most spotlighted health issues. Research in 2013 showed that the prevalence of stunting among children under 5 in Indonesia reached 37.2 percent, similar to the stunting rate in Ethiopia. Indonesia had the highest score among Group of 20 countries.

Thanks to the interministerial coordination under then-vice president Jusuf Kalla, the rate dropped to 27.67 percent in 2019. Meanwhile, the WHO has asked Indonesia to further lower the rate to 20 percent.

The Health Ministry cooperating with Statistics Indonesia (BPS) has conducted research on 84,000 children to produce the Result of Nutritional Status Study of Indonesian Children Under 5 (SSGBI). The research calculated the prevalence of underweight, stunted and wasted or thin children under 5.

The SSGBI has revealed that the prevalence of underweight or undernourished children under 5 in 2019 is at 16.29 percent, down by 1.5 percent from last year, while wasted or thin children under 5 was at 7.44 percent, down by 2.8 percent from last year.

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