IMPLEMENTATION OF TODDLERS’ HEIGHT ......Implementation of Toddlers’ Height Measurement...

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IMPLEMENTATION OF TODDLERS’ HEIGHT M E A S U R E M E N T ACTIVITIES AND I N T E G R A T E D STUNTING DATA MANAGEMENT IN INDONESIA

Technical Study

Technical Study

IMPLEMENTATION OFTODDLERS’ HEIGHTMEASUREMENT ACTIVITIESAND INTEGRATED STUNTINGDATA MANAGEMENTIN INDONESIA

Implementation of Toddlers’ Height Measurement Activities and Integrated Stunting Data Management in Indonesia

Published in Indonesia 2019 by

Center for Indonesia’s Strategic Development Initiatives

Jalan Cut Nyak Dien No. 5 Blok B, Menteng Jakarta Pusat 10359 Indonesia

www.cisdi.org

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Cover design by Rudra Ardiyase copyrights protected.

Unless otherwise stated, all contents of this report are protected inCreative Commons Attribution-NonCommercial 4.0 International License.

Some rights are retained.

How to cite:(CISDI, 2019)Center for Indonesia’s Strategic Development Initiatives. 2019. Implementasi Kegiatan Pengukuran Tinggi Badan Balita dan Manajemen Data Stunting Terintegrasi di Indonesia. Jakarta: Center for Indonesia’s Strategic Development Initiatives, Abbot Laboratory – White Rook Advisory.

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This technical study was prepared by a research team led by Zakiyah and consisted of Yurdhina Meilissa, Olivia Herlinda, Yenuarizki, Sri Nuraini, Siska Verawati, Rayssa Anggraeni Putri, and Egi Abdulwahid. Diah Satyani Saminarsih gave general direction to build a scenario framework and led the consultation of limited expert resource persons.

The Research Team also received guidance from an Advisory Panel consisting of Akmal Taher, Fasli Jalal, Wicaksono Sarosa, Ani Rahardjo, and Christian P. Somali. Yurdhina Meilissa edited the end of the Indonesian version. Yenuarizki, Rudra Ardiyase and Naufal Randhika managed the layout of this report.

During the study, the research team received support from a number of nutrition practitioners from various backgrounds of participating organizations through various discussions and interviews. We are grateful for their willingness to share their experiences and in-depth knowledge that enriches this technical study. We appreciate expert speakers who provided input both verbally and in writing to this study, namely: Brian Sriprahastuti (KSP), Agus Suprapto (Kemenko PMK), Atmarita (PERSAGI), Halik Sidik (ADINKES), Erna Mulati (Directorate of Public Welfare, Ministry of Health), Elvina Karyadi (World Bank), Akim Dharmawan (World Bank), Guruh Hari Wibowo (Nganjuk District Health Office), Dakhlan Choeron (Directorate of Community Nutrition, Ministry of Health), Octoviana Carolina S (DKI Jakarta Provincial Health Office), Annisa Harpini (Pusdatin, Ministry of Health), Iing Mursalin (TNP2K),

Eti Rohati (Depok City Health Department), Sudikno (Research Center for Public Health Efforts, Ministry of Health), Winne Widiantini (Pusdatin, Ministry of Health), Hasnani Rangkuti (BPS), Ade Wahid (TP2AK), Aman B Pulungan (IDAI), and Giri Wurjandaru (Directorate of Community Nutrition, Ministry of Health).

This technical study does not provide a simple solution to improve the implementation of activities for measuring toddlers’ height and integrated stunting data management in Indonesia. However, the research team believes that this technical study represents diverse perspectives and brings together debates about the best way to achieve the ultimate goal.

This technical study was funded by the Abbot Laboratory - White Rook Advisory and carried out by the Center for Indonesia’s Strategic Development Initiatives (CISDI), Jakarta. CISDI is fully responsible for the findings, conclusions and recommendations written in this technical study, without the influence of funders.

FOREWORD

Foreword

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FOREWORD TABLE OF CONTENTS LIST OF TABLES EXECUTIVE SUMMARY CHAPTER 1. IMPLEMENTATION OF TODDLERS’ HEIGHT MEASUREMENT AND INTEGRATED DATA MANAGEMENT ACTIVITIES: AN INTRODUCTION

CHAPTER 2. CONDITIONS OF POSSIBILITIES: REGULATION FRAMEWORK, GOVERNANCE, AND FINANCING

CHAPTER 3. TODDLERS’ HEIGHT MEASUREMENT IMPLEMENTATION AND QUALITY ASSURANCE

CHAPTER 4. INTEGRATED STUNTING INFORMATION SYSTEM: IMPLEMENTATION AND QUALITY ASSURANCE

CHAPTER 5. SYNTHESIS, IMPLICATION, AND RECOMMENDATION

REFERENCES

TABLE OF CONTENTS23411

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212323242631

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WHY THIS ISSUE IS IMPORTANT? TARGET OF STUDY QUESTIONS AND RESEARCH DESIGN REPORT STRUCTURE

REGULATION FRAMEWORK GLOBAL AGENDA NATIONALIZING GLOBAL AGENDA GOVERNANCE FRAMEWORK FINANCING FRAMEWORK

HEIGHT MEASUREMENT AS A STANDARD OF MONITORING GROWTH OF TODDLERS DELIVERY ARRANGEMENT QUALITY OF GROWTH MEASURE PLATFORM STRUCTURE/INPUT

DATA GENERATION: AVAILABILITY OF QUALITY DATA INTEGRATION FOR ANALYSIS AND SYNTHESIS DATA UTILIZATION

SYNTHESIS AND IMPLICATION REGULATION FRAMEWORK, GOVERNANCE, AND FINANCINGTODDLERS’ BODY HEIGHT MEASUREMENT; IMPLEMENTATION AND QUALITY ASSURANCE INTEGRATED STUNTING INFORMATION SYSTEM: IMPLEMENTATION AND QUALITY ASSURANCERECOMMENDATION

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APPENDIX 1. POLICIES RELATING TO HIGH MEASUREMENT OF TODDLERS AND INTEGRATED STUNTING DATA PUBLICATION APPENDIX 2. INTERVIEW: PROTOCOL AND INSTRUMENTS APPENDIX 3. FOCUS GROUP DISCUSSION: PROTOCOL AND INSTRUMENTS APPENDIX 4. LIST OF RESPONDENTS / SPEAKER IN APPENDIX 5. LIST OF DISCUSSION EXPERT SPEAKERS APPENDIX 6. LIST OF DISSEMINATION OF EXPERT SPEAKER STUDY RESULTS APPENDIX 7. LIST OF EXPERT SPEAKERS THAT GIVES WRITTEN INPUT

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Table of Contents

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LIST OF FIGURESEight Actions of Integration Action Plan for the Resolution of WHA 65.6 Main Strategy for Gernas PPG Structure Task Force for the Acceleration of Nutrition Improvement based on Perpres No. 42 of 2013 Governance Structure of PforR World Bank Coordination based on the National Strategy for the Prevention of Stunting Prevention Framework for Financing the Stunting Program in Indonesia (Source: Stranas Stunting 2018- 2024)Integration of various Toddlers’ Growth Measurement Platforms in Indonesia Adaptation of the Donabedian Model to the Evaluation of Growth Measurement Platform The relationship between stunting prevalence analysis and analysis of program / activity availability Integrated Stunting Data Management Flow

Figure 1. Figure 2.Figure 3.Figure 4.

Figure 5.Figure 6.

Figure 7.

Figure 8.Figure 9.

Figure 10.

Figure 11.

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LIST OF TABLESComparison of Structures among RegulationsCategories and Thresholds for Child Nutrition Status Based on IndexEvaluation of Growth Measurement Platform based on Structure / InputThe Profession Involved in the Measurement ProcessEvaluation of Growth Monitoring Platforms according to Process DimensionsHousehold Surveys and Surveillance Related to StuntingIndicators and Data Sources Related to StuntingSynthesis of Findings in the Regulatory, Governance and Financing Framework Synthesis of Findings on Implementation of Height Measurement Synthesis of Findings in Integrated Stunting Data Management Recommendations for Improving the Regulatory, Governance and Financing FrameworkRecommendations for Improvement of Implementation of Height Measurement Recommendations for Improvement of Integrated Stunting Data Management

Table 1. Table 2.Table 3.Table 4.Table 5.Table 6.Table 7.Table 8.

Table 9.Table 10.Table 11.

Table 12.

Table 13.

29384450537477

9396100

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112117

List of Figures & Tables

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LIST OF ABBREVIATIONS1.000 HPKASIBadutaBalita BappedaBappenasBB / PBBB / TBBB / U BGM BKBBPB BPJS BPM BPS CISDI D / S DAK Dinkes DLI DUNCNN PPGBM FGD FKTP Gernas PPG GMP Nutrition ImprovementGOBI

IAKMI IDI IFPRI BMI / U Jabodetabek JKN K/L

: First 1,000 Days of Life: Mother’s Milk: Children Aged Under Two Years: Children Under Five Years Old: Regional Development Planning Agency: National Development Planning Agency: Weight according to Body Length: Weight according to Height: Weight by Age: Under the Red Line: Toddler Family Development: Toddler Weighing Month: Social Security Organizing Body: Independent Practice Midwife: Statistics Indonesia: Center for Indonesia’s Strategic Development Initiatives: Data Arrives per Target at Posyandu: Special Allocation Fund: Health Service: Disbursement-Linked Indicator.: Donor and UN Country Network on Nutrition: Community-Based Nutrition Reporting and Nutrition Reporting: Focus Group Discussion: First Level Health Facility: National Movement for the Acceleration of Nutrition Growth

: Growth Monitoring and Promotion: Growth Monitoring, Oral Rehydration Therapy, Breastfeeding, Immunization: Association of Indonesian Public Health Experts: Indonesian Doctors Association: International Food Policy Research Institute: Body Mass Index by Age: Jakarta, Bogor, Depok, Tangerang, Bekasi : National Health Insurance: Ministry or State Institution

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Kemenkeu Kepmenkes MCH KMS KPM KRPL LB LB1 LB3 LB4 Litbangkes LILA

Lokmintor MCH Menag Mendag Mendagri Mendes PDTT

Mendigbud Menkes Menkeu Menko PMK MenkominfonMenperin Mensos Mentan Menteri PPPAMP-ASI MTBSOPDPB / UGDPPDGMI

: Ministry of Finance: Decree of the Minister of Health: Maternal and Child Health: Card Towards Health: Human Development Cadres: Sustainable Food Home Area: Monthly Reports: Monthly Data on Illness Report: Monthly Report on Nutrition, KIA, Immunization and Observation of Infectious Disease Data: Monthly Report on Puskesmas Activity Data: Health Research and Development: Upper Arm Circle Lokmin Puskesmas: Mini Puskesmas Workshop: Cross-Sector Mini Workshop: Maternal and Child Health: Minister of Religion: Minister of Trade: Minister of Home Affairs: Minister of Villages, Disadvantaged Regions and Transmigration : Minister of Education and Culture: Minister of Health: Minister of Finance: Coordinating Minister for Human Development and Culture : Minister of Communication and Information: Minister of Industry: Minister of Social Affairs: Minister of Agriculture: Minister of Women Empowerment and Child Protection : ASI Complementary Food: Integrated Management of Toddler Sickness: Regional Apparatus Organization: Body Length according to Age: Gross Domestic Product: Indonesian Medical Nutrition Doctors Association

List of Abbreviations

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Permenkes Perpres PERSAGI PforR Pinkesga PIS-PK PKH PMT PPIA Polindes Posyandu PP Prokesga Pusdatin Puskesmas Pustu PWS QSDS RAN-PG RAPG Riskesdas RKP RPJMN RS SD SDGs SDIDTK

SDM Setkab Setwapres SIBIMA SIKDA SIMPUS SP2TP

: Regulation of the Minister of Health: Presidential Regulation: Indonesian Nutritionists Association: Program-for-Results: Family Health Information: Healthy Indonesia Program with a Family Approach: Family Hope Program: Provision of Additional Food: Prevention of HIV Transmission From Mother to Child: Village Maternity Hospital: Integrated Service Post: Government regulations: Family Health Profile: Data and Information Center: Community Health Centers: Supporting Puskesmas: Local Area Monitoring: Quantitative Service Delivery Surveys: National Action Plan for Food and Nutrition: Food and Nutrition Action Plan: Basic Health Research: Government Work Plan: National Medium Term Development Plan: Hospital: Standard Deviation: Sustainable Development Goals: Early Childhood Growth and Stimulation, Detection and Intervention: Human Resources: Cabinet Secretariat: Vice President’s Secretariat: Application of Independent Practice Midwife Information System: Regional Health Information System: Puskesmas Management Information System: Puskesmas Integrated Recording and Reporting System

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: Minimum Service Standards for Health: Indonesian Toddler Nutrition Status Survey

: National Strategy for the Acceleration of Prevention of Stunting: Scaling Up Nutrition: National Socio-Economic Survey: Height according to age: National Team for the Acceleration of Poverty Reduction: Nutrition Workers: United Nations Emergency Children’s Fund: Effort to Improve Family Nutrition: Law: World Health Assembly

Health SPM SSGBI Stranas Stunting

SUN Susenas TB / U TNP2K TPG UNICEF UPGK UU WHA

List of Abbreviations

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EXECUTIVE SUMMARY2020 will be the first year of the implementation of the 2020-2024 National Medium-Term Development Plan (RPJMN). The Indonesian government directs development priorities on human resources to strengthen the foundation of competitiveness towards the developed country phase which is expected to occur in 2036-2044. The government translates this political vision, one of which, through improving the quality of public health.

The government has strengthened the integration of the stunting program to realize an optimistic scenario of reducing prevalence by 2-2.5% per year. The implementation of integrated stunting reduction interventions needs to be supported by accurate, current, integrated and accountable height measurements. A reliable stunting information system is an important prerequisite so that measurement data is easily accessed and shared as a basis for case management and evidence-based policy making).

This technical study provides a framework for thinking, synthesis of findings, and recommendations for follow-up on the implementation of activities for measuring toddlers’ height and integrated stunting data management in Indonesia. This technical study was compiled based on a literature review, policy analysis, field visits, interviews, and limited consultations with various expert speakers. The research team believes that this technical study represents a variety of perspectives and brings together debates regarding the implementation of height measurement for toddlers and integrated stunting data management.

This technical study departs from a systemic scanning process regarding events and trends surrounding the measurement of height / length of toddlers in Indonesia. Specifically, scanning of events and trends involves stakeholders to answer three questions. First, the extent to which regulatory, governance, and budget support has established enabling conditions for good practices in height measurement and integrated stunting data management. Second, whether height measurements in Indonesia have been carried out

with high technical soundness and the extent to which integration between measurement platforms has taken place? Third, to what extent has the measurement data been used as a basis for clinical decision making and policy improvement?

This technical study then brings together and processes the results of the scan through limited consultation with experts (Delphi Method). The consultation phase has three main objectives, namely: (1) gathering opinions and findings in the field based on the accumulation of expert knowledge and experience; (2) determining the structural challenges (drivers) that underlie these findings; (3) designing a number of possible scenario (scenario building) structuring and the necessary stages (roadmap). Thus, this technical study takes into account all aspects of ‘what’ and “why “ according to various points of view, and brings together debates on “how” does the implementation of toddlers’ height measurement and integrated stunting data management.

This technical study found 3 main challenges that significantly marked the dynamics of height / length measurement for toddlers in Indonesia and required the attention and response of the Government in 2019-2024. These structural challenges include:

Regulatory frameworks that support efforts to reduce stunting are available at various levels, but translating and implementing them at subnational levels remains a challenge.

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Challenges related to the regulatory, governance and financing framework

Overlapping governance both at the level of coordinating agencies and implementing agencies

A regulatory framework for meaningfully involving non-governmental actors is not yet available

The unavailability of accountability mechanisms and the effectiveness of financing efforts to

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Challenges related to the implementation of height measurements in the field

Inconsistencies in regulations and standards regarding the target age group, and frequency of height measurements

The business process of monitoring growth has not focused on aspects of data interpretation, counseling, and referral to subsequent services after measurement. The behavioral change communication component has not been included in the growth monitoring service package

Debate about the duties and functions of cadres in measuring height, especially regarding whether Posyandu cadres are allowed to carry out toddlers’ height measurements at posyandu

Health workers who take measurements are not available in all places with an adequate numbers

Growth monitoring service platforms are fragmented and not interconnected with referral services

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Challenges related to data management, including processing, analyzing, and accessing data

Data on height to detect the nutritional status according to TB / U and BB / TB is not caught in the health information systems in many District / City because of the limited availability of measuring instruments and measuring competence

Data obtained often does not meet quality data qualifications. This will cause a weak basis for the preparation of regulations and subsequent programs

Data fragmentation because each information system has a database that stands alone

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From these structural challenges through a limited consultation process with experts (Delphi), the following priorities for improvement are formulated:

Priority improvements related to the regulatory, governance and financing framework

Designing a regulatory framework based on needs assessments and gaps in the field that involve various stakeholder elements

The establishment of a governance structure that is quite simple, effective and agreed upon by all parties is complemented by a clear division of roles and functions of coordination

Encouraging the immediate enactment of the regulatory framework that forms the umbrella of stunting stranas, one of which includes a meaningful involvement of multi-sector stakeholders and their roles and functions clearly

Increasing the efficiency and effectiveness of stunting program funding through the budget tagging and tracking mechanism to the village level

Encourage local government performance evaluation mechanisms

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Priority for improving the implementation of measurements in the field

Harmonization of standards, governance and operational definitions

In conditions that are not ideal where there are no trained health workers available, it is important to increase the capacity of posyandu cadres regarding height measurement and counseling ability and interpretation of data.

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reduce stunting to the regional level. Accessing data and information from cross-units in the Ministry of Health and across sectors is still difficult because of the unavailability of standards and protocols

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Executive Summary

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Incorporate components and conduct behavioral change communication training in growth service packages

Internet-based remote health workforce training (e-learning) about growth monitoring and communication of behavioral changes to puskesmas

Designing a regulatory framework stating that trained cadres are allowed to measure height in conditions where health workers are not available

Increase the availability of nutrition workers in each Puskesmas

Procurement of measurement and reporting logistics according to the standards required at Posyandu Integration of various toddlers’ height measurement services from posyandu to district / city level

Increased coverage and quality of PIS PK to ensure and educate every family with a toddler to go to the posyandu.

The Ministry of Health includes the height measurement component in the growth monitoring service standards at posyandu and health facilities

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In conditions where health workers are not available, the puskesmas must validate the measurement results by the cadre and ensure that the referral system from the posyandu to the nearest health service runs according to the procedure, i.e.:

Cadres only monitor toddlers’ body weight every month and refer toddlers to health workers at the puskesmas if they are indicated to have nutritional problems or fixed weight, or the weight does not increase after two consecutive measurements.

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Challenges related to the implementation of height measurements in the field

Increasing the capacity of posyandu cadres and puskesmas nutrition officers to record and report, as well as to utilize data

Simplification of posyandu information systems and integration of KPM score cards (eHDW) to Posyandu information systems as well as ePPGBM

Increasing coverage on the use of e-PPGBM accompanied by an increase in the capacity of officers related to surveillance - the process of gathering - analyzing - action based on analysis, also taking into account regional limitations in infrastructure and human resources. The implementation of SSGBI by BPS and Litbangkes is carried out routinely once a year to find out the current prevalence of stunting toddler

Integration of prevalence data and programs related to stunting prevention in the Mhealth platform developed by the Pusdatin Ministry of Health

Add a National Health Information System Roadmap related to the inclusion of clear roles among stakeholders and the development of national and regional SIK integration plans

Strengthening the National Health Information System through the use of appropriate technology and improving system interoperability

Develop guidelines for implementing e-government for nutritional problems in Indonesia

Incorporate a nutrition agenda, especially stunting, into the village planning agenda, such as through the Village Community Conference (MMD), to communicate and discuss data at the community level

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Involve civil organizations and individuals to carry out social monitoring)

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These three priorities are proposed to be operationalized through 19 targets whose achievements can be measured through 23 indicators, as stated in this technical study.

Jakarta, 14 December 2021

Writer Team

Executive Summary

01.Implementation of Toddlers’

Body Height Measurement and Integrated Stunting Data

Management in Indonesia:An Introduction01

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Stunting is a condition of failure to thrive in children under five years old (toddlers) due to chronic malnutrition and psychosocial stimulation, as well as repeated exposure to infections especially in the period of the First 1,000 Days of Life (1,000 HPK), namely from the fetus to the two-year-old child [1]. The child is classified as stunting if the length or height is below minus two of the standard deviation (-2SD) the length or height of the child of his age [2]. One thousand (1,000) HPK is the golden period for children’s growth. In this period, the baby’s brain and body are developing rapidly. Proper nutrition interventions in this period will result in higher quality Indonesian human resources that will become investments in cost-effective development [3].

Stunting is still one of the biggest nutritional problems of toddlers in the world although in the last two decades it has decreased from 32.6% in 2000 to 22.2% in 2017 [4]. The 2018 Global Nutrition Report notes that the prevalence of stunting in Indonesia is far worse than countries with similar economic levels in Southeast Asia: Thailand (16%), Malaysia (17.5%), and Vietnam (23%) [5]. Although the Basic Health Research (Riskesdas) 2018 shows a decrease in the prevalence of stunting for children under five from 37.2% (2013) to 30.8% (2018), the proportion of children under two years old (baduta) short and very short is still at 29, 9% or higher than the 2015-2019 Medium Term Development Plan (RPJMN) target of 28% [6] [7] [8]. The prevalence of stunting in Indonesia occurs in all regions and also across income groups. Some health indicators in 2018 also indicate the need for immediate improvement, such as anemia in pregnant women (48.9%) and babies born with low birth weight (6.2%).

The technocratic design of the RPJMN 2020-2024 places the target of reducing stunting in toddlers to 19% by 2024 as one indicator of basic service fulfillment [9]. Financial Note for Fiscal Year 2020 places stunting as a strategic issue that receives priority budget allocation through the convergence of physical Special Allocation Funds (DAK), non-physical DAK, K / L expenditure, village funds, and grants to 260 priority areas [10].

This political commitment is expected to drive the acceleration of stunting prevalence in toddles to 27.1% according to the Government Work Plan (RKP) of 2020 [10] to get closer to the 2025 Global Nutrition target in reducing stunting in toddlers by 40% [11].

The government’s effort to reduce the prevalence of stunting confirms the link between the stunting reduction program and Indonesia’s efforts to become a medium-high income country. Various studies have shown that stunting that occurs at 1,000 HPK risks hindering physical growth, increasing children’s vulnerability to disease, creating barriers to cognitive development that reduce children’s intelligence and productivity in the future. Stunting will also increase the risk of degenerative diseases in adulthood. Economic losses due to stunting are estimated to reach 2-3% of Gross Domestic Product (GDP) per year, equivalent to 300 trillion rupiah [12].

Stunting prevention interventions are prioritized targeting children under two years of age because in that period they are considered to be more sensitive to the impact of an intervention than children over two years old. [13] [14]. The main problems that cause high stunting rates in Indonesia are a combination of policies that have not been integrated in providing support for stunting prevention, logistical limitations and competency of measuring staff, availability of quality data, as well as communication problems and behavioral changes that occur both at the individual level, community level and health service level.

CHAPTER 1. Implementation of Toddlers’ Height Measurement Activities and Integrated Stunting Data Management: An Introduction

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Chapter 1

National Strategy for the Acceleration of Prevention of Stunting 2019-2024 (Stranas Stunting) establishes specific and sensitive nutrition interventions that will be delivered to priority groups in priority locations. Stranas stunting is useful as a sign of government in handling stunting because: (1) Arranged based on evidence, good practice, and experience of Indonesia and globally; (2) Aiming to ensure that all resources are directed and allocated to support and finance priority activities to improve the coverage and quality of 1,000 HPK household nutrition services; (3) Arranged so that all parties at all levels can work together to accelerate the prevention of stunting, and (4) Arranged so that it involves and describes the roles of ministries / institutions, academics, professional organizations, civil society, business world, and development partners / donors

Why is this issue important?

Measuring body length or height included in the Stimulation, Detection and Early Intervention Program for Child Growth and Development (SDIDTK) is the foundation of Stranas Stunting. Therefore, the Guidelines for the Implementation of Integrated Stunting Reduction Interventions in Districts / Cities [15] place the measurement and publication of stunting figures as one of the eight Integration Actions..

Integrated planning, implementation, evaluation, and control of Stranas Stunting, need to be supported by data that are accurate, current, integrated, accountable, easily accessed, and shared, and managed carefully, integrated, and sustainably. Measurement of toddlers’ height and an in-sequence stunting data publication routinely will sharpen the implementation of Integration Action through improvement of: (1) Quality of analysis of data-based situations and factual information; (2) Accuracy in determining service targets, efficiency in allocating resources, being the basis for determining policy (evidence-informed policy) and advocating for program integration support in the stunting conference; (3) Reliability of the data management system to support performance studies; and (4) Accurate diagnosis so that health workers can find out the nutritional status of children under five as a basis for integrated follow-up efforts and family-based counseling.

However, the availability of technical studies on toddlers’ height measurement and integrated stunting data management is very limited in Indonesia. The Nutrition Capacity Assessment Report in Indonesia and the Background Paper for the Health Sector Study provide a big picture of the provision of nutrition services in Indonesia, but need to be enriched with technical studies with sufficient depth of analysis to improve policy operationalization [16] [17].

Mengidentifikasi sebaran prevalensi stunting, ketersediaan program, dan praktek manajemen layanan di kab/kota

Bappeda (koordinator) dan OPD lain

Pertemuan lintas OPD dan masyarakat untuk memastikan terjadinya konvergensi program/ kegiatan dan pembiayaan


Memberikan kepastian hukum yang digunakan sebagai rujukan oleh desa untuk merencanakan, mengangarkan program/ kegiatan

Membina kader pembangunan yang berasal dari kader posyandu, guru PAUD, dan kader lainnya di tingkat desa

Dinas PMD/BPMD

Pengelolaan data di tingkat kabupaten/kota hingga desa yang akan digunakan untuk mendukung pelaksanaan intervensi gizi spesifik dan sensitif

Bappeda (koordinato) dan OPD lain

Dinas Kesehatan

Mengukur dan mempublikasikan angka prevalensi stunting tingkat desa hingga kabupaten/kota

Penilaian Pemerintah Kab/Kota terkait pencegahan stunting selama 1 tahun terakhir

Sekda dan Bappeda (koordinator) dan OPD

Dinas PMD/BPMD

Tindak lanjut kab/kota untuk merealisasikan hasil rekomendasi dari tahap analisis situasi


1 2 3 4 5 6 7 8AnalisisSituasi

RencanaKegiatan

RembukStunting

Perbup/Perwalitentang Peran

Desa

Pembinaan KaderPembangunan

Manusia

Sistem Manajemen

Data

Pengukuran danPublikasi Data

Stunting

Reviu KinerjaTahunan

Figure 1. Eight Actions of Integration

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Targets of Study

Center for Indonesia’s Strategic Development Initiatives (CISDI) conducted this technical study to support the government’s efforts to improve the implementation of height measurements and their relation to the reliability of integrated stunting data. Broadly speaking, we divided the technical study discourse into three broad clusters: (1) Politics - the process by which policies are formulated and determined; (2) Polity - the institutional framework for how policies are formulated and implemented, and (3) Policy - concerns the content and substance, as well as the desired mechanism of change.

Specifically, this technical study will: (1) Explore the roles of stakeholders and their governance; (2) Checking program / activity gaps related to height measurement, publication, and utilization of integrated stunting data; and (3) Propose recommendations for improvement based on the accumulation of Indonesian knowledge and experience to obtain collaborative work commitments among ministries / institutions, academics, professional organizations, civil society, business world, and development partners / donors.

Research questions and design

This technical study aims to answer the following group of questions:

1. Are the available regulatory, governance and financing frameworks adequate to encourage the implementation of good measurement?

2. “Has the height measurement activity and integrated stunting data management been adequately designed?”

3. “Are there components of the program or activity for height measurement and management of integrated stunting data that are missing?”

4. “Does the program person responsible for the program possess the capacity for planning, implementing and monitoring?”

5. “Is there an integrated system to monitor the results or intermediate results of the success of height measurement activities and integrated stunting data management?”

To answer these questions, we used a combination of several research methods and instruments. In the first phase of research, we analyze secondary data and explore data sources from national surveys, special studies, and various other scientific literature. Next, we went a step further by conducting a series of semi-structured interviews involving 22 key informants with diverse backgrounds at national and subnational levels (see appendix 4) to obtain detailed, nuanced, and in-depth findings. This data collection process took place in the July-September 2019 period.

On October 14, 2019, CISDI brought a preliminary version of this technical study into a focus group discussion (FGD) involving 28 experts (see Appendix 5). CISDI applies the Delphi approach in the FGD. The Delphi approach was chosen to, systematically, facilitate and capture different perspectives from stakeholders who come from different backgrounds and expertise.

In the period of December 3-16, CISDI conducted an individual consultation with 15 experts (see appendix 6) in order to report the results of the synthesis of FGD findings and ask for input related to policy studies. Next, CISDI synthesizes inputs and finalizes policy studies.

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Chapter 1

The focus of the study that CISDI set might limit the breadth and depth of the analysis.

Limited access to expert sources during the analysis period might limit the diversity of opinions on findings, analysis and recommendations. Data retrieval, which is mostly carried out in Jabodetabek area, might affect the diversity of contexts, thus it is not representative of the entire territory of Indonesia.

Structure of Report

Chapter One gives a description of the strategic relevance of this study along with questions and research designs. Chapter Two explains the policy framework related to stunting, as well as governance including available financing mechanisms. Chapter Three explains the implementation and quality assurance of toddlers’ height measurement in the form of toddlers’ growth assessment standards and various toddlers’ height measurement platforms in terms of technical soundness. Chapter Four will dig deeper into the data and indicators used to monitor the progress and architecture of integrated stunting data management. Chapter Five will close this study by presenting a study synthesis, submitting conclusions along with a number of policy recommendations.

02.Enabling Conditions:

Regulatory Framework, Governance, and Financing02

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Stunting is a condition of failure to thrive in children The regulatory, governance and financing framework provides direction and space for relevant stakeholders to form enabling conditions so that a program / activity can run. Enabling conditions is an ecosystem that needs to be organized, managed, given resources, and regulated in institutional arrangements. This ecosystem must be able to encourage cross-sector stakeholders to collaborate, exchange knowledge, and promote evidence-based policies.

Specifically, this chapter will map the power relations between stakeholders, examine their role in mobilizing allocative and authoritative resources, and how these actions shape practices in policy implementation. In this study, good governance is a prerequisite for the key to the success and sustainability of the implementation of toddlers’ height measurement activities and integrated stunting data management in Indonesia, such as: a) Continued commitment and support from the highest leadership; (b) Integration of evidence-based specific and sensitive nutrition interventions; (c) Nutrition education and communication to change behavior; (d) Social monitoring and community-based programs / activities; and (e) Integrated data system.

Regulatory Framework

Global Agenda

In 2011, the Scaling-Up Nutrition (SUN) movement called for a nutritional improvement approach in every country to be proven cost effective, promoting cross-sectoral cooperation both government and non-governmental, and focusing on 1,000 HPK interventions. Furthermore, in 2012, WHO through the World Health Assembly (WHA) Resolution approved the Comprehensive Implementation Plan on Maternal, Infant, and Young Children Nutrition [18]. The Resolution of WHA 65.6 encourages member countries and international partners to carry out five actions in the local context (see Figure 2).

Figure 2. Action Plan for the Resolution of WHA 65.6

Through these five actions, WHA is committed to achieving the target of reducing nutritional indicators by 2025, namely: 1) a 40% reduction in the prevalence of short and very short toddlers; 2) a 50% reduction in anemia in fertile women; 3) a 30% reduction in babies born with LBW; 4) increase in exclusive breastfeeding to at least 50%; and 6) reduce and maintain wasting in toddlers less than 5%.

The relevance of this resolution is maintained in the Sustainable Development Goals (SDGs). The world is committed to eliminating all forms of malnutrition by 2030. SDGs as a comprehensive global policy, encouraging development policies at the national level by uniting the state of mind and logic of thinking about development planning and implementation needed to achieve the expected targets. This implementation requires a policy framework and architecture for development at the national level to ensure SDGs are implemented in ministries, institutions and local governments.

Action #1Creating a supportive environment for the

implementation of comprehensive food and nutrition policies

Action #2Includes all effective health interventions needed to have an impact on the national nutrition action plan

Action #3Stimulate development policies and programs outside

the health sector that include nutrition

Action #4Provide sufficient human and financial resources for

the implementation of nutrition interventions

Action #5Monitor and evaluate the implementation of policies

and programs

CHAPTER 2. Enabling Conditions: Regulatory Framework, Governance, and Financing

24

Chapter 2

Nationalizing the Global Agenda

To coordinate food and nutrition, Law No. 18/2012 on Food mandates the government to prepare a food and nutrition action plan. Five years later, the preparation, implementation, monitoring and evaluation, as well as the reporting procedures for the National Action Plan for Food and Nutrition (RAN-PG) are regulated in Presidential Regulation No. 83 of 2017 concerning the Strategic Policy for Food and Nutrition.

Referring to the Strategic Food and Nutrition Policy (KSPG), at the central level a National Action Plan for Food and Nutrition (RAN-PG) is developed in line with the 2015-2019 National Medium-Term Development Plan (RPJMN). To facilitate the organization of the sectors that contribute to the Food and Nutrition Action Plan, grouping is needed in the form of pillars: 1) improving people’s nutrition; 2) increasing accessibility of diverse foods; 3) food quality and safety; 4) clean and healthy life behavior; 5) coordination of food and nutrition development.

The government also issued Presidential Regulation No. 42 of 2013 concerning the National Movement for the Acceleration of Nutrition Improvement (Gernas PPG) to accelerate the improvement of nutrition for the priority communities in the first 1,000 days [19]. By using the issue of stunting as an entry point, Perpres Gernas PPG provides a sharpening of the nutritional program policy targets, which focus on pregnant women, breastfeeding mothers, and children aged 0-2 years, excluding young women from the priority of efforts to improve nutrition mandated by Law No. 36 of 2009 concerning health. Perpres Gernas PPG links nutrition improvement efforts to be accompanied by broader, but highly related development programs such as poverty alleviation, food security, water supply and sanitation.

Furthermore, Bappenas issued a Policy Framework and Planning Guidelines in the same year to guide the implementation of Gernas PPG. In 2017, these two documents were updated in the form of a Roadmap for the Implementation of the 2017-2019 Gernas PPG

which later became the reference for the Secretariat of Gernas PPG in order to support the Technical Team in the implementation of.

Figure 3. Main Strategy for Gernas PPG

In 2018, Bappenas launched Stranas Stunting to ensure the prevention of stunting is a priority of governments and communities at all levels until 2024. Stranas Stunting consists of five pillars, each of which has objectives, achievement strategies, and implementation instruments to target priority groups in priority locations (see figure 6). With increased efforts in implementing the coordination scheme and various technical implications and funding from Stranas Stunting, a moderate scenario projected that the stunting rate of baduta could fall by 1.5-2% per year and could achieve the WHA and SDGs target.

One of the things that deserves attention is the fact that there are no regulations that raise the strategy of the sustainability of efforts and progress in reducing stunting in Indonesia. It is has become a debate whether when the focus of the government has switched, financing and cross-sectoral efforts that have been established will also end. For this reason, the strategy of maintaining the sustainability of the results that have been pursued must become one of the government’s priorities in the next few years.

Pillar #1Making improvements

in nutrition as the main stream of human resource development, social, and

culture economy

Pillar #2Increasing capacity and competence of human

resources in all sectors, both government and

private

Pillar #3Increasing evidence-

based interventions that are effective on different existing order in society

Pillar #4Increased community

participation for the ap-plication of social norms that support nutritional

awareness behavior

25

CISDI

Appendix 1 summarizes all available policy frameworks at various levels along with the technical implications and visions of synergy between various stakeholders at all levels of government

The availability of regulations at the national level is considered sufficient, but translating it to the subnational and village level in terms of regulation and implementation is still a challenge. At present, only about 20% of regions have a Perbup / Perwali explaining the use of village funds for stunting. One instrument that can be used to ensure national standards and targets is through the implementation of Minimum Service Standards (SPM). The implementation of SPM itself has been encouraged and supported by Law 23/2014 regarding Regional Government, PP 2/2018 regarding Minimum Service Standards, Permendagri 100/2018 regarding SPM implementation, and Permenkes 4/2019 on Technical Standards for the Fulfillment of Basic Service Quality in SPM in the health sector.

SPM includes service standards and targets that must be met in terms of quality and quantity to be considered to have already reached the minimum service levels. District / City Governments must

meet 12 SPM in the health sector, which includes one of them, namely toddler health services. It was stated that “District / City Governments must provide health services for toddlers in their working areas according to standards within one year”. These provisions include weighing at least 8 times a year, and measurement of length / height at least 2 times a year.

SPM is considered as the standard minimum basic requirement for citizens. Thus, all communities are targeted to have to obtain minimum health services (100%), or are considered “not meeting SPM achievements”. Even in budgeting, SPM must be prioritized before meeting other budgets. Unfortunately, there are no sanctions / disincentives in the implementation if the SPM is not met.

Finding 1

Political commitment for the efforts to improve community nutrition is strong enough in the form of Laws, Government Regulations (PP), Presidential Regulations (Perpres), Ministerial Regulations (Permen), and Regional Regulations (Perda), but the implementation gap at regional levels is still a challenge. In addition, the sustainability strategy of efforts to reduce stunting must begin to be

prioritized in its planning and implementation

*

26

Chapter 2

Governance Framework

The institutional architecture at the national level was formed to orchestrate the implementation and recapitulation of community nutrition improvement achievements at the national level. At the legislative level, there is the DPR RI Health Caucus which consists of members of the DPR RI across factions and between commissions to support community nutrition programs in the context of legislation, budgeting, and supervision.

At the executive level, the government established the Gernas PPG Task Force (see Figure 3) led by Menko Kesra (now Menko PMK) to monitor the implementation of Perpres across K / L. Bappenas, in particular the Deputy for Human Resources as the Chairperson of the Technical Team, has the authority to orchestrate planning and budget allocation.

In building and enhancing partnerships with non-governmental organizations, Gernas PPG, among others, is guided by: (1) UN Standing Committee on Nutrition; (2) WHO guidelines in cooperation with private parties; (3) Global Strategy for Toddlers and Child Feeding; (3) UNICEF Guidelines and manuals in working with the business community; (4) Guidelines from the International Pediatric Association (IPA) in working with industry.

The main activities of K / L and partners are divided into short-term (18 months) and mid-term (36 months) activities aimed at supporting the collection of key Gernas PPG performance indicators. Monitoring of input indicators and processes is carried out every semester, while monitoring of outputs is carried out annually to three years [20].

Figure 4. Structure Task Force for the Acceleration of Nutrition Improvement based on Perpres No. 42 of 2013

KetuaMenko Kesra

Wakil Ketua IMendagri

AnggotaBappenas

AnggotaMenkominfo

AnggotaMenag

AnggotaMentan

AnggotaMentri PPPA

AnggotaSetkab

AnggotaMendikbud

AnggotaMensos

AnggotaMenperin

AnggotaMendag

AnggotaMentri Kelautan dan Perikanan

SekretarisDeputi bidang SDM dan Kebudayaan Bappenas

Wakil Ketua IIMenteri Kesehatan

TIM PENGARAH

KetuaDeputi Bidang SDM dan Kebudayaan Bappenas

Wakil Ketua IDeputi Bidang Koordinasi

Kesehatan, Kependudukandan KB Kemenkokesra

SekretarisDirektur Kesehatan dan Gizi

Masyarakat Bappenas

SekretarisDirektur Bina

Gizi Kemenkes

Wakil Ketua IIDirjen Bina Gizi dan KIA

Kemenkes

TIM TEKNIS

27

CISDI

The available governance framework based on Perpres No. 42 of 2013 is considered not effective in guiding policies and encouraging cross-sectoral coordination and implementation [20]. In addition, decentralization presents challenges for planning systems between government levels and fiscal transfers. In fact, national programs are very dependent on the facilitation process at the District / City level and service delivery at the village level.

Therefore, the World Bank established the Secretariat of the Vice President (Setwapres) as the highest leadership authority to manage the PforR program to accelerate the reduction in stunting prevalence ‘Investing in Nutrition and Early Years’ 2018-2022 (see Figure 5). In addition to becoming the executing agency, Setwapres also plays a role in several key functions: (1) held a summit stunting; (2) synchronizing planning and budgeting with Bappenas and the Ministry of Finance; (3) reviewing the progress of implementing PforR together with the Ministry of Home Affairs; (4) coordinate with BPKP as an independent verification agent [21].

In carrying out its functions, the Secretariat is supported by TNP2K which makes the stunting reduction program one of the acceleration policies [20]. Specifically, the TNP2K Secretariat in this structure serves to provide technical support to the Setwapres, Menko PMK, Bappenas, and the Ministry of Finance to encourage the implementation of the annual cycle, accountability and learning which includes five main functions, namely (1) annual targets and commitments, (2 ) allocation of costs and fiscal transfers based on the results of interventions, (3) coordination of national and subnational implementation, (4) monitoring interventions and data consolidation, and (5) performance reviews and adjustments.

Figure 5. Governance Structure of PforR World Bank

On the other hand, Stranas Stunting also developed a coordination structure as shown in Figure 6. This structure consists of a Steering Committee chaired by the Vice President and supported by the TNP2K Secretariat / Setwapres, the Steering Committee, and a Technical Team supported by the Secretariat of the SUN Bappenas.

Figure 6. Coordination based on the National Strategy for the Prevention of Stunting Prevention

Sekretariat TNP2K

Program Leadership Committee

Ketua I: Wakil PresidenKetua II: Menko PMK

Program Executing Agency

Sekretariat Negara/Sekretariat Wakil Presiden

Program Steering Committee

Program Enabling Agencies

Bappenas Kemenkeu

Program Implementing Agencies

Menkes BPS Mensos Mendes

MendikbudMendagri

Pemerintah Kabupaten

Pemerintah Desa

Komite PengarahKetua : Wakil PresidenWakil Ketua : Menko PMK

Anggota : Menteri dan Ketua lembaga dari:

1. KemenkoPMK2. Kemendagri3. Kemenkeu4. Kementan5. Kemendikbud6. Kemenkes7. Kemenag8. Kemensos9. Kementerian Kelautan dan Perikanan10. Kementerian PUPR11. Kemenperin12. Kemenkominfo

13. Kementerian PPPA14. Kementerian PPN/Bappenas15. BPOM16. Kemendes PDTT17. BKKBN18. Kemenristek19. Kemendag20. Kementerian KUKM21. BPS22. Sekretaris Kabinet23. Sekretaris Wakil Presiden

Ketua : 1. Deputi bidang Dukungan Kebijakan Pembangunan Manusia dan Pemerataan Pembangunan, Sekretariat Wakil Presiden2. Deputi bidang Koordinasi Peningkatan Kesehatan, MenkoPMK3. Deputi bidang Pembangunan Manusia, Masyarakat dan Kebudayaan, Kementerian PPN/Bappenas

Anggota : Pejabat eselon I dari 23 Kementerian/lembaga yang disebutkan dalam Komite Pengarah yang ditunjuk oleh Menteri dan Ketua Lembaga

Komite Pengendali

Sekretariat TNP2K/Setwapres

Sekretariat SUN Bappenas

Ketua : 1. Direktur Kesehatan dan Gizi, Bappenas2. Direktur Bina Gizi, Kemenkes3. Direktur SUPD III, Kemendagri

Anggota : Pejabat eselon I dari 23 Kementerian/lembaga yang disebutkan dalam Komite Pengarah yang ditunjuk oleh Menteri dan Ketua Lembaga

Tim Teknis

28

Chapter 2

The three coordinating and governance structures (Figures 4, 5, and 6) are then compared, especially some important components in the structure to see changes between one structure to another as shown in Table 1. In the aspect of leadership hierarchy, structure 1 is chaired by Coordinating Minister for People’s Welfare, structure 2 by Vice President and Menko PMK, and structure 3 by Vice President. Structure 3 also shows that more K / L are involved than structures 1 and 2.

29

CISDI

Table 1. Comparison of Structures among Regulations

Indicator Gernas PPG (1) PforR World Bank Program (2)

Stranas Stunting (3)

Main leadership hierarchy

The Coordinating Minister for People’s Welfare leads the Task Force responsible for the President

Vice President and Menko PMK

Vice President

K/L involved 15 12 23

Legal Basis Perpres No 42 of 2013 n/a n/a

Organization structure

Steering team, technical team and working group

Program leadershipcommittee, program steering committee

Steering committee, control committee and technical team

Role and function

The task force coordinates and synchronizes Gernas PPG between K / L. The division of roles between structures or K / L is not mentioned in detail

The division of roles between structures or K / L can be found in detail in the document

In the OPD Official Handbook, it lists the roles and functions of each K / L at the national level, also the Provincial, District / City and Village Governments, and non-governmental Institutions

Reporting The Chair of the Task Force reports directly to the President at least once a year or at any time if necessary.Governor, Regent / Mayor reports to the Chair of the Task Force at leastonce a year or at any time if necessary

Implementing agencies report to coordinating agencies (Setwapres, Bappenas, Ministry of Finance, and BPS)

• The Secretariat of TNP2K / Setwapres prepares a Report on the Acceleration of Prevention of Stunting (PPS) every semester 1 and annually in collaboration with related Ministries / Agencies.

• The Vice President shall submit an annual national PPS report to the Vice President who will forward it to the President

Confidential – for internal circulation only

30

Chapter 2

Indicator Gernas PPG (1) PforR World Bank Program (2)

Stranas Stunting (3)

Coordination The Task Force holds meetings at least once every three months

The leadership committee program holds meetings every three months

• The Vice President leads a quarterly meeting

• The TNP2K / Setwapres Secretariat coordinates the annual leadership forum of the regional government

• The Steering Committee holds regular quarterly meetings

• The technical team holds planning meetings at least twice a year

Implementa-tion in the region

Involving regional government Involving regional government

The elaboration is carried out at the village level

Monitoring and evalua-tion function

Task Force TNP2K Secretariat is leading the monev process

TNP2K will lead the monitoring of the Stranas Stunting with related K / L

Involvement of partners outside the government sector

Provincial and District / City Local Governments form task forces that draw up work plans and programs with reference to national policies. The task force members consist of the government, universities, professional organizations, community organizations, religious organizations, business world, and `community member.

Encourage multi-sectors involvement to target the main determinants of stunting, but does not describe in detail the potential role of each stakeholder

Stranas Stunting outlines the roles and functions of potential partners outside the government sector

Source of funding

APBN, APBD, and other legal and non-binding sources in accordance with the legislation

APBN, APBD, and other sources up to loans from the World Bank can be disbursed when the DLI target is reached.

APBN, APBD, village funds, and other legitimate sources of income, and are encouraged to explore other sources of funding outside the government sector


31

CISDI

The involvement of many K / Ls certainly becomes a challenge for coordination and division of roles. From the document review, Table 1 shows that structure 1 does not describe in detail the division of tasks between structures or K / L, while structure 2 in the PforR document clearly states the expected role for each K / L and incentives related to performance indicators ( disbursement linked indicators). For structure 3, the OPD Official Handbook lists the roles and functions of each K / L at the national level, also the Provincial, District / City and Village Governments, and non-governmental Institutions.

In Structure 1, 2, and 3 show quite different leadership and coordination structures. The existence of new structure 2 and 3 (Figures 5 and 6) do not negate the structure of the Gernas Task Force (Figure 4). This difference has the potential to cause confusion and overlapping work, for example in structure 1 (Figure 4) where Bappenas acts as the coordinator of the implementing technical team, while in structure 2 (Figure 5) Setwapres becomes the coordinator of the PforR Governance Structure and Structure 3 (Figure 6) Bappenas, Ministry of Health, and Ministry of Home Affairs become the coordinator of Stranas Stunting.

Clear division of roles is very important to ensure that efforts do not overlap and coordination and communication can work well across agencies and ministries. Ministry of Health and Ministry of Health PDTT which has a role and many technical programs in the field must have a significant role in the structure of the technical team. However, currently the Ministry of PDTT has positions as members in structures 1 and 3.

The plan to involve partners outside the government sector has also been included in every document even though it is not directly involved in all structures. Structure 1 and 2 also do not regulate the role of academics, professional organizations, civil society,

Finding 2

Potential for overlapping governance

business community, and other development partners / donors in detail. Only structure 3 that explains in more detail the potential roles and functions of each partner. A broader Task Force, which allows the involvement of business networks, civil society alliances, and donors (DUNCNN) under the coordination of the Scaling Up Nutrition Movement technical team may be needed.

Financing Framework

The general scheme of funding sources for stunting programs in Indonesia is to use APBN (K / L budget), Special Allocation Funds, APBD 1 (Province), APBD 2 (Regency / City), village funds (APBDesa), and other legal sources. In 2018, the Ministry of Finance estimates the need for a budget allocation for nutrition of Rp 141.9 trillion annually to be consistent with the target of stunting reduction in the 2015-2019 RPJMN [22].

In accordance with the reconciliation results of the Ministry / Institution Work Plan (Renja K / L) and the Ministry / Agency Work Plan and Budget (RKA K / L) 2019, the 2019 budget allocation in the relevant APBN to support stunting reduction was Rp 29 trillion. The Ministry of Health managed Rp 3.6 trillion for specific nutrition interventions with macro and micro nutrient supplementation outputs, training in Infant and Child Feeding (PMBA), growth monitoring training, strengthening integrated nutrition information, and updating nutritional surveillance, and immunization. With an increase in total health function expenditure allocations in 2020 of Rp 1.4 trillion and an increase in BOK funds of Rp 475.9 billion for handling stunting in 260 regions, it can be estimated that the commitment to increase the mobilization of government funding sources for nutrition programs is very high [23].

Finding 3

A regulatory framework for meaningfully engaging SUN Network / non-government actors

is not yet available

32

Chapter 2

Village funds can be an important source of funding for stunting. Transfers to the regions and the Village Fund in 2020 as a whole are planned to reach Rp. 856 billion (34%). Village funds cover 10 potential categories and 48 subcategories. Upon approval taken through a village meeting, the Village Fund can finance issues that are appropriate to potential categories and subcategories. In addition, the issue must also be in line with village development goals, and government priorities at national and subnational levels. Within these categories, some are important determinants that contribute to

stunting prevention, such as access to clean water and sanitation, health promotion, growth monitoring, and nutrition of pre-school and school-aged children. [24]. The Permendesa PDTT 11/2019 concerning Priority for the Use of Village Funds in 2020 also includes stunting as a priority for the use of village funds. In its implementation, this regulation has not been well socialized to all village officials to understand that village funds can be used for stunting prevention programs. Only around 20% of Regent / Mayor have made regional regulations regarding the use of village funds for stunting programs.

Figure 7. Framework for Financing the Stunting Program in Indonesia (Source: Stranas Stunting 2018- 2024)

APBN

Belanja Pemerintah

(Pusat)

Kementerian/Lembaga Mendanai Kewenangan 6

Urusan (Mutlak)Dana Vertikal

Program/Kegiatan Pusat (K/L)

Dana sektorial:Dikerjakan oleh K/L/UPT

Dana Dekonsentrasi Dilimpahkan ke Gubernur

Subsidi

Dana Tugas Pembantuan: Dilimpahkan ke

Gub/Bupati/Walikota

Dana Otsus dan Keistimewan DIY

Dana Perimbangan

Block Grant

Specific Grant,Penggunaannya di-earmark

untuk bidang tertentu

Mendanai kebijakan tertentu Pemerintah (misal: Infrastruktur)

APBDes Program/Kegiatan

Desa

Dana Insentif Daerah

Dana Desa

Alokasi Dana Desa

Kementirian/Lembaga Mendanai Kewenangan Di

luar 6 Urusan

Transfer ke Daerah dan Dana

Desa (TKDD)

APDB

Anggaran nol K/L

Masuk dalam APDB

DAU

DBH

DAK

DesaIntervensi Sasaran Ibu HamilIntervensi Sasaran Ibu Menyusui dan Anak 0-6 bulan ...dst...Intervensi Air BersihSanitasiEdukasi...dst..

1.

2.

3.4.5.6.7.

33

CISDI

Efforts to prevent stunting are also encouraged to explore other sources of funding that come from businesses and donors given the limited government funding. One of the major international funding sources for nutrition in Indonesia is the World Bank funding scheme. The World Bank provides loans to Indonesia with a results-based financing scheme (Performance for Results) that depends on achieving indicators / targets set (Disbursement Linked Indicators).

With the amount of resources spent on reducing stunting, the Government realizes the importance of starting to focus on the resulting impact. As part of the convergence effort on handling stunting, the Government has begun to implement a Tagging and Tracking system to finance specific and sensitive stunting programs, as well as assistance, coordination, and technical support, where the budget has been marked and allocated specifically for programs that can be traced its utilization and targets achieved . This system also makes it easier for the Government to conduct planning and performance evaluations, as well as to ensure the accountability of each K / L. The tagging process is not optimal because the thematic stunting marking on Renja and RKA K / L TA 2019 was only effectively implemented in October 2019. Unfortunately, this system has only been implemented for financing by the central government, but its use has not been traced to local budgets and village funds.

Finding 4

The amount of funding allocated for the stunting program needs to be encouraged for its efficiency and effectiveness. One method used

is through a budget tagging and tracking system as a tool to measure impact and encourage

accountability in the use of funds.

The regulatory, governance and financing framework is an important component that drives and enables programs / interventions to reduce stunting. These components will greatly affect the coordination, accountability, implementation, reporting, and especially the expected outputs. In the next chapter, the focus of the study will highlight the process of measuring and recording from various aspects of regulation to monitoring.

34

Chapter 2

03.Toddlers’ Height Measurement:

Implementation and Quality Assurance03

37

CISDI

Toddler growth monitoring is an effort to obtain data on nutritional status of toddlers and indicators related to nutrition at the scale of posyandu, puskesmas and district services. This monitoring is carried out in stages to find out individual level progress, increase parental participation, and the community to maintain optimal toddler growth, as well as provide follow-up and counseling tools for behavior change.

At the policy making level, growth monitoring is useful for increasing the effectiveness of service targets and resource allocation. In addition, this monitoring is also able to encourage problem solving and planning at the village to district level. In related units in the village government, monitoring is also useful to support advocacy for program integration.

This chapter will examine the toddlers’ height measurement platforms available in Indonesia. Specifically, this chapter will highlight service standards, availability of resources, delivery arrangements for each platform, and integration between platforms.

Height measurement as a standard for monitoring Toddlers’ growth

The medical community began to introduce growth measurement practices in developing countries since the 1960s. Soon after, in the 1970s, the use of growth charts became standard practice. Scientific publications at the time linked much to growth monitoring with nutrition education and counseling. The measurement practice outside the building grew to become part of the activities of the primary health care community. World Health Organization (WHO) in 1978 included Growth Monitoring in the GOBI package (growth monitoring, oral rehydration therapy, breastfeeding, immunization) in the Child Survival Development Revolution program. This concept continued to evolve into Growth Monitoring and Promotion (GMP) in the mid 1980s.

The GMP includes the counseling component and links the measurement results to follow-up actions that must be taken afterwards [25]. This aspect of promotion aims to increase: (1) awareness of child growth; (2) parenting practices; (3) demand for related services, so it is becoming the key in family-level decisions for integrated nutrition services.

Indonesia adopted the GMP program and made it a component of the Family Nutrition Improvement Efforts (UPGK) since the 1970s through the Integrated Service Post (Posyandu). Posyandu was launched in 1986 and has become the main platform for GMP in Indonesia. At that time weight was still the main indicator of toddler growth.

Minister of Health Decree (Kepmenkes) No. 1995 / Menkes / SK / XII / 2010 set anthropometric standards for assessing children’s nutritional status. This anthropometric standard refers to the WHO Growth Standards 2005 [26]. WHO developed anthropometric standards through the WHO Multicenter Growth Reference Study which was also adopted by 159 other countries in the world. Categories and thresholds for children’s nutritional status are determined based on the index as shown in table 2.

CHAPTER 3. Measurement of Toddlers’ Body Height: Implementation and Quality Assurance

38

Chapter 3

Table 2. Categories and Thresholds for Child Nutrition Status Based on Index

Index Nutrition Status Category Threshold

Body weight based on Age (BB/ U)Children aged 0-6 months

Bad nutritionLess nutritionGood nutritionOver nutrition

< -3 SD-3 SD up to <-2 SD

-2 SD up to 2 SD>2 SD

Length of body based on age (PB/ U)

Children aged 0 – 60 months

Very shortShort

NormalHigh

<-3 SD-3 SD upt to <-2 SD


Body weight based on body length (BB/ PB)

OrBody weight based on body

Height (BB/ TB)Children aged 0 – 60 months

LeanNormal

Fat

<-3 SD up to <-2 SD-2 SD up to 2 SD

>2 SD

Body mass index based on age (IMT/ U)


Very leanLean

NormalFat

-3 SD -3 SD up to <-2 SD


Body mass index based on age (IMT/ U)


Very leanLean

NormalFat

Obesity

<-3 SD-3 SD up to <-2 SD

-2 SD up to 1 SD> 1 SD up to 2 SD

>2 SD

Measuring body length or height measures included in the Stimulation, Detection and Early Intervention Program for Child Growth and Development (SDIDTK). Specific regulations governing the monitoring of growth, development, and developmental disorders of children regulating the goals, frequency, and scope of services are contained in two regulations, namely Minister of Health Regulation (Permenkes) No. 25 of 2014 concerning child health efforts and Permenkes No. 66 of 2014. Specifically, what is regulated in both regulations are:

1. Growth monitoring is a package of health services for infants, toddlers and preschoolers carried out in children aged 0 (zero) to 72 months. Weighing is done every month, measuring length / height every three months, and measuring head circumference according to schedule, namely at the age of 15, 21, 30, 42, 54, and 66 months.

2. Early detection of growth deviations is based on weight classification for height (BB / TB) by trained health workers.

39

CISDI

Permenkes No. 66 of 2014 defines a height below -2SD as short stature or short stature, in contrast to the WHO definition that a child is classified as stunting if the length or height is below minus two of the standard deviation (-2SD) the length or height of a child of his age [2].

Both Permenkes mention growth monitoring targeting infants, toddlers and preschoolers aged 0 (zero) to 72 months, in contrast to the Stranas Stunting priority targets which refer to children 0-23 months as priority targets and children aged 24-59 months as important targets. The measurement frequency listed in Permenkes No. 66 of 2014 is also different from Permenkes No.4 of 2019 regarding Technical Standards for Fulfillment of Basic Service Quality in Minimum Service Standards in the Health Sector. Minister of Health Regulation 66/2014 states that measurements of height every three months in children aged 0-12 months and every six months in children aged 12-72 months, while Permenkes 4/2019 regulates that measurements of length / height are carried out at least 2 times / year on children aged 0-59 months.

However, although both Permenkes insisted that this growth monitoring must be carried out comprehensively, counseling points after measurement are not explicitly written. In fact, counseling is an important component after the measurements made to provide an explanation and follow-up that must be carried out by the child’s guardian based on the measurement results. The counseling component for mothers is only listed in the management chart of children with malnutrition without details on the points that must be delivered according to the measurement results [27].

Finding 5

There are different definitions, target age groups, and recommended measurement

frequencies

Finding 6

The communication component of behavior change, especially aspects of interpersonal

communication escapes the growth monitoring service package

Box 1. Indonesian National Synthetic Growth Charts

In an article entitled “Indonesian National Synthetic Growth Charts” published in the ACTA

Scientific Paediatrics journal volume 1 issue 1, August 2018, Pulungan, A et.al. recommend

the use of Synthetic Growth Chart in Indonesia which were developed based on the 2013

Riskesdas data sample. Researchers consider this national growth to be more representative of

the nutritional status and growth of Indonesian children. WHO, PERSAGI, PDGMI, IDI, and IAKMI

in their official recommendations advise Indonesia to continue using the 2005 WHO

Growth Standards for children 0-59 months. The standard is designed to control genetic and

environmental factors and consider secular trends in the population. At the November 2019

meeting chaired by the Ministry of Health, it was agreed by all parties to continue using the 2005

WHO Growth Standards.

Finding 7

Agreement to use WHOGrowth Standard 2005 in Indonesia according to

Kepmenkes No.1995 / 2010

40

Chapter 3

Delivery Arrangement

Posyandu is the backbone of monitoring infant growth in Indonesia that operates at least one (1) time a month at the hamlet level. The village midwife, PKK cadre and Posyandu cadre are the posyandu organizers. One cadre accompanies 10-20 target families.

Posyandu, which is implemented through a 5-table system, is expected to provide GMP services and other integrated nutrition (MCH, KB, Immunization, and diarrhea prevention). The success of Posyandu is reflected through the SKDN coverage: (a) D/S: community participation indicators (access) and (b) N / D: indicators of success (service quality). Using the BB / U indicator, the posyandu refers the child to the Puskesmas if in two measurements the body weight does not go up or fall below the red line (BGM) curve in the KMS. In certain conditions, if growth disorders are caused by comorbid diseases that cannot be treated at the Puskesmas, children are referred to the District / City Hospital.

There is still debate about whether Posyandu cadres can take measurements. In the National Strategy, it is said that ideally monitoring the growth and development of children in the posyandu is routinely conducted every month by health workers assisted by KPM and posyandu cadres, but for length / height measurements, it can be done at least once every three months. There are no standards / regulations that say that posyandu cadres are tasked with measuring height.

Anecdotal findings indicate that height measurements at posyandu are carried out by cadres. Measurements are made using a length board or microtoise anthropometry measuring device. Children who are detected with stunting will be referred to the puskesmas for validation of measurements by a nutritionist or midwife and further examination by a doctor.

A home visit by a companion cadre is carried out if a toddler is not present at the Posyandu. In areas with limited resources that do not allow the accompanying cadre to make regular home visits, sweeping is done twice a year by utilizing the Toddler Weighing Month (BPB). Follow-up after measurements in the Toddler Weighing Month are carried out through the same mechanism by the posyandu. Meanwhile, toddlers living in urban areas have alternative measurement platforms such as a doctor’s clinic or an independent hospital.

The Healthy Indonesia Program with the Family Approach (PIS-PK) can be used to ensure and educate every family that has a toddler to bring toddlers to the posyandu. One PIS-PK indicator verifies whether a toddler is weighed every month or not. If toddlers / parents are not present at the posyandu, counseling is done through home visits. The Healthy Family Index (IKS) can guide health center personnel to recognize patterns of health problems at the family level that contribute to stunting.

If anthropometric measurement tool is not yet available or limited, growth mat can be used temporarily as an early detection tool for stunting risk. In Posyandu with limited tools that are priority areas of the Smart Healthy Generation (GSC) program, together with posyandu cadres, midwives or other puskesmas workers, the Human Development Cadre (KPM) facilitates height measurement with growth mat.

KPM ensures the convergence of stunting handling at the village level. KPM conducts monthly monitoring of the implementation of the convergence of 5 stunting handling service packages. Monitoring is carried out by following the implementation of posyandu activities, PAUD activities, and visits to target homes.

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Determination of the prevalence of stunting at the national, provincial and district level is carried out by the Basic Health Research (Riskesdas) and the Indonesian Toddler Nutrition Status Survey (SSGBI). Riskesdas is conducted every 5 years and will be carried out again in 2023, while SSGBI is held once a year. Weight and height data are collected based on measurements by enumerators.

The integration of various Toddlers’ Growth Measurement Platforms in Indonesia can be seen in Figure 8.

Figure 8. Integration of various Toddlers’ Growth Measurement Platforms in Indonesia

Confidential – for internal circulation onlyDo not duplicate or distribute without written permission from CISDI

RUMAH TANGGA DESA KECAMATAN KABUPATEN

BPB

Pengukuran BB dan TB Konseling Imunisasi

Tikar Pertumbuhan

Balita stunting dirujuk

Kunjungan kader karena balita

tidak ke posyandu

PIS-PIK tidak diukur, diminta ke Posyandu



Rujuk karena butuh penanganan dr. SpA

Pelaporan data

Posyandu

PUSKESMASPEMBANTU

PIS -PK

Apakah balita mendapatpemantauan pertumbuhan?

SUSENAS SSGBI

RSUD

RS.SWASTA

KLINIK SWASTA/BPM

RISKESDAS

Ukur ulang BB dan TB PMT Pemulihan Konseling

dan Pemantauan

PUSKESMAS

Puskesmas Dinkes Kabupaten

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Quality of growth measure platform

The model used as a reference frame for assessing the quality of growth platforms is the system evaluation model from Donabedian [28]. This model highlights three dimensions in quality assessment, namely: structure / input, process, and outcome (output)).

Based on this framework, this study uses a regulatory framework, governance and financing, availability and quality of human resources, as well as tools for measuring height and stunting data management as an important input or component to enable measurement of toddler height. In this study, the process component will focus on the frequency and quality of the measurement process, data interpretation, counseling and referral, as well as the process of recording and reporting data that will influence the expected output, namely quality data and integrated data systems.

Structure/ Input

Quality assessment of each platform based on structure / input is listed in table 3

Figure 9. Adaptation of the Donabedian Model to the Evaluation of Growth Measurement Platform

Confidential – for internal circulation onlyDo not duplicate or distribute without written permission from CISDI

Structure/Input Process Output

Regulation framework, govermance and fundingAvailablility and quality of human resources and tools

Measurement processData interpretation, counselling and referalRecording and raporting

Quality dataIntegrated stunting data system

1.

2.

1.2.

1.2.

3.

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Table 3. Evaluation of Growth Measurement Platform based on Structure / Input

Platform Governance Measurement Tool Human Resources Funding

1. Posyandu • Governance at the national level is complicated. It is still debating whether the Ministry of Home Affairs, PKK, Ministry of Health PDTT, or Ministry of Health are responsible

• At the district level, posyandu management is the authority of the district head and is reduced to the village head’s responsibility.

• The health sector (ministry of health, health offices, puskesmas) is responsible for ensuring health service logistics in posyandu (immunization, family planning, etc.) and providing assistance to cadre.

• BB measuring devices are available in all posyandu

• TB measuring devices are limited at posyandu

• Posyandu found with TB measuring instrument not according to the standard

• Posyandu management is carried out by posyandu cadres

• Puskesmas health workers provide health technical support

• Cadre refreshing training is conducted by village midwives / TPG puskesmas

• Posyandu management competency and TB measurement are minimum

• Government, sourced from APBN, Provincial APBD, Regency / City APBD funds,

• BOK dinkes / puskesmas

• Village funds

• Posyandu user / visitor fees

• Village funds are insufficient


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2. Puskesmas • Ministry of Health handles at national level

• Health Office handles coordination at the district level

• TPG puskesmas handles nutrition data reporting at the village level, data managed by the village midwife then collected to TPG puskesmas.

• BB (standardized tread scale) and TB (microtoise and length board) scales are available at the puskesmas

• High TPH workload – mostly for administrative functions

• Competence is lacking, in-service training [29]

• Detection of stunting cases is also done by general practitioners when handling patients with MTBS and immunization. TB measurements in MTBS polyclinics and general treatment are performed by nurses.

• If a stunting case is found, the doctor will refer to a nutritionist for further examination.

• Originated from BOK, DAK, etc.


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3. Private first-level health facilities (FKTP)

• Individual medical personnel, such as: Independent Practitioner Doctor (DPM) or Independent Practice Midwife (BPM))

• Weight scales

• The majority do not have standardized length measurements

• Increased competence and standards depend on individuals and professional organizations. Assistance from the health department is still low. The majority of private FKTP do not measure body length, only measure body weight

• Payment of out of pocket patients, capitation funds (if already registered with BPJS)

4. Hospital • The Ministry of Health regulates hospital regulations at the national, public and private levels

• Hospital governance is the responsibility of each hospital management

• TB, BB, and head circumference measured*

• Measuring tools according to the standard, carried out annual calibration*

*Depends on the type of hospital and the availability of equipment at the hospital

• Competency improvement is held by the dinkes and professional organizations

• Toddler nutrition cases handled by pediatricians and / or clinical nutrition specialists

• Local Goverment (provincial), funded by Regional Government Budget (APBD)

• If not through the referral process, the costs are borne by the family (out of pocket)


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5. PIS-PK • The ministry of Health through the Director General of Health and the Director of Primary Health Care is responsible at the national level

• The health office is responsible at the City/ District level

• The implementation is carried out by puskesmas officers

• Not measuring BB and TB, just asking the mother if the toddlers get monthly growth monitoring

• Puskesmas staff must visit all houses within the puskesmas working area (total sampling). Often puskesmas staff also have basic tasks and other programs at the puskesmas, making it difficult to collect PIS-PK data.

• BOK Puskesmas funds

6. BPB • The Ministry of Health through the Director General of Health and the Director of Primary Health Care is responsible at the national level

• The health office is responsible at the City / District level

• The implementation is carried out by puskesmas staff and cadres

• BW and TB measured

• Measuring tools using the puskesmas’ property are subject to availability

• Need anthropometric training for cadres and TPG

• There needs to be personnel who re-check to ensure the validity of measurements

• Large amounts of human resources for home visits to toddlers who do not come to weighing

• BOK puskesmas


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7. KPM • Ministry of PDTT handles at national level

• The village head manages it at the village level

• Screening for stunting toddlers using growth mats at home, PAUD, or at the Posyandu

• Not all KPM come from posyandu cadres

• The quality of detection with a mat will determine the competence of KPM. KPM training is needed to equalize quality

• Village funds

8. Riskesdas • RI Ministry of Health, through Litbangkes, manages at the national level

• Performed every 5 years

• Measuring TB and BB and percentage of growth monitoring coverage

• A trained enumerator who has obtained anthropometric training

• APBN

9. SSGBI • Research and Development Ministry of Health of the Republic of Indonesia cooperates with BPS

• Performed once a month

• Measuring TB and BB

• A trained enumerator who has obtained anthropometric training

• BPS and Litbangkes budget


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In terms of governance, most of the existing measurement platforms are managed by the Ministry of Health. Some platforms such as growth mats, posyandu, and SSGBI are managed in collaboration with other Ministries. However, the platform still needs support from the Ministry of Health in its implementation in the field. Most of the funding on the platform managed by the Ministry of Health comes from BOK. In terms of funding, the measurement platform managed by the Ministry of Health is mostly sourced from the BOK puskesmas. Other sources of funds are village funds, APBN, APBD, and medical services paid by patients.

Based on table 2, the most ideal platform for growth measurement is posyandu. This is in view of the regular implementation of posyandu, which is once a month. However, posyandu governance at the central level is complicated because it must be managed by 4 different institutions (Ministry of Health, Ministry of Home Affairs, Ministry of Villages, and PKK driving teams). Height measurements are also not carried out every three months, only 2 times per year during BPB implementation. The limited availability of measuring instruments and the lack of cadre competence in measurement poses a posyandu constraint.

Although posyandu is the most ideal measurement platform, not all toddlers are examined for growth at posyandu. Nationally, Posyandu D / S coverage is 80.6% [7]. This shows that as much as 19.4% of toddlers are not brought to the posyandu. In addition, not all posyandus do body length measurements. As much as 46.8% toddlers have not received body length measurements in the last 12 months [7]. Ideally, toddlers who are not present at

Finding 8

Posyandu is the most ideal platform for monitoring growth. However, measurement

at Posyandu is constrained by the availability of measuring instruments and measurement

competencies.

posyandu get a home visit by the cadre. During home visits, cadres take measurements of growth and provide counseling about the growth and nutrition of children. However, the 2016 QSDS data found that only 35% of cadres visited homes [30].

The problem of the absence of toddlers to posyandu can ideally be overcome by sweeping the weighing of toddlers twice a year which is done during the weighing month of toddlers and providing education through home visits PIS-PK. At PIS-PK, health workers ask whether a toddler is weighed in a posyandu or a health facility in the past month. This indicator can be a complement and driver of the social accountability mechanism of the D / S posyandu indicator. However, the coverage of PIS-PK in 2019 was only 56%. In addition, awareness raising through PIS-PK has not been implemented well. Home visits were only used for data collection on Family Health Profile (prokesga).

Based on the FGD with Puskesmas and hospital service providers in Jakarta, the Puskesmas and resource hospitals have an adequate measuring platform. The standard of equipment used at the puskesmas refers to the standards of the Ministry of Health and the Department of Health. At the hospital, the tools used refer to the Ministry of Health’s standards and are part of the hospital accreditation assessment. Tool calibration is carried out annually to ensure measurement accuracy.

In terms of HR, cadres become important actors in measuring height at posyandu and weighing months for toddlers. The TPG and the village midwife control the quality of height measurements made by cadres at the puskesmas, and also become health workers who measure the growth of children in poly nutrition at the puskesmas. In the scope of MTBS and puskesmas immunization services, height measurements are carried out by nurses before the patient meets the doctor. The doctor will re-measure if extreme measurement data are found. Identification of HR involved in the measurement process is in table 4.

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Table 4. The Profession Involved in the Measurement Process

Human Resources Measurement Platform Measurement Competence Things Needed

Cadres of Posyandu

• Posyandu• Weighing Month for

Toddlers

Depending on the training provided and not through formal schooling. Training is provided by the TPG or village midwife.

Based on the Pencerah Nusantara study [31], cadres have limited competence even though they have received repeated training; one of the factors is due to age and education.

Assistance from TPG and village midwives when measuring at posyandu

Village midwives and midwives practice indipendently

Weighing Month for Toddler and Maternity Clinic

Height measurements included in the growth and development modules are taught in midwife education

In service training and the urgency of height measurement

TPG • Posyandu• Weighing Month for

Toddlers• Puskesmas

Height measurements included in the anthropometry module taught in nutritionist education

In service training

Midwives • Puskesmas, before patients receive doctor services

• Hospital, before patients get specialist services

Height measurements included in the growth and development module are taught in nurse education

In service training and the urgency of height measurement

General practitioners

• MTBS poly puskesmas and posyandu services

• Independent practice clinic

Taught in medical education Refreshing training and the urgency of height measurement

Pediatrician • Hospital Taught in the education of doctors and pediatricians

Urgency of height measurement


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Based on table 4, different handling is needed for each health worker in terms of height measurement. As the only non-health worker in the measurement process, posyandu cadres need intensive assistance from TPG and village midwives at table 3 posyandu. For village midwives, nurses and TPG, in-service training is needed to ensure the three health workers measure accurately and according to standards while keeping abreast of developments in science. At present, there is no standardized in-service training to improve the competency of nutrition workers. The Unicef study [29] found a lack of pre-service training for nutrition workers in puskesmas. Therefore, in-service training is needed to close the competency gap.

In physicians and pediatricians, no study was found regarding the lack of pre-service training in height measurement. Based on FGDs and interviews with a number of doctors and pediatricians from Jakarta, the majority of children’s height measurements were carried out by nurses before the patient was examined by a doctor or pediatrician. Thus, very few cases of growth measured directly by the doctor.

Increased physician awareness about the urgency of height measurements is needed to ensure that children with extreme measurement results are comprehensively re-measured by doctors, therefore early detection of stunting can be done. In addition, the ability of doctors to conduct post-measurement counseling and communication of behavioral changes needs to be improved. Through counseling, mothers get the right information about stunting and other health problems so that the mother’s excessive worries can be overcome. Therefore, it is necessary to ensure that the doctor has good counseling skills so that the information is conveyed appropriately.

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Process

After a toddler is measured, the measurement data will be recorded in the patient register. The method of recording is different on each platform. For example, measurement results at the posyandu are recorded in the weighing register, but in the PIS-PK the findings are recorded in the Family Health Profile (prokesga) and Healthy Family Application. After the data is recorded, the measurement officer provides counseling to the toddler mother. If a toddler is found to be experiencing nutritional problems, a toddler will be referred to the next level of health care. Quality assessment of each platform based on the process dimensions is shown in table 4.

Finding 9

Variations in the quality and availability of measurements due to logistical limitations,

calibrations, measuring competencies, and lack of proper governance, SOP, and non-compliance

with standards.

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Table 5. Evaluation of Growth Monitoring Platforms according to Process Dimensions

No. Platform SOP Measurement Obstacle Data Obstacle Recording Counseling Obstacle Handling and Referal Obstacle

1. Posyandu Measurement

• Growth monitoring is carried out once a month

• Routine BB Weighing every month• Most Posyandus measure TB every 6

months at BPB

Data Recording

• The results of weighing are recorded in the baby’s weighing register.

• KIA Handbook: body weight filled in the BB / U chart, height filled in the TB / U chart. The officer checks whether BB / U and TB / U fit the standard curve for toddler growth

Counseling

• Counseling is done after recording data. Officers provide feedback by explaining the meaning of growth graphs on KMS / KIA books and giving advice on feeding children according to their age group. Cadres also invite mothers to come to the posyandu every month

Handling and referral

• If the child’s BB does not increase 2 times (T2) or remains below the red line (BGM), the officer asks questions and takes notes on health complaints and toddler eating habits.

• After that, the officer explains the possible causes of the child’s BB not going up and gives advice on child feeding

The officer then refers the child to a health facility

• TB measurements vary. The majority does not take measurements every 3 months

• Cadre measurement competency is low

• Baby weighing register: must include NIK, many mothers do not carry ID cards or do not have ID cards.

• KIA Handbook: TB charts are not filled by cadres, only BB charts are filled.

• ePPGBM: not all cadres can operate computers, there are no computers / laptops available at the posyandu, there is no ePPGBM training for cadres

The focus of counseling is only on the child’s BB.There is no mechanism for case finding and stunting case counseling at posyandu

• It is uncertain toddlers who are stunting referred to a health facility. There needs to be a follow-up on home visits by officers for toddlers detected by BGM

• Detection of new cases of BGM. There is no detection mechanism for toddler stunting, so the toddler stunting referral system is not yet operational.


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2. Puskesmas Measurement

• BB and TB are measured in puskesmas as part of MTBS

Recording patient’s data

• Weighing results are recorded in a toddler cohort register and reported using ePPGBM

• KIA Handbook: Body weight is filled in the BB / U graph, height is filled in the TB / U chart, The officer checks whether the BB / U and TB / U matches the standard curve for toddler growth

Data collection from posyandu

• Cadres collect toddler weighing registers and posyandu information system documents a week after posyandu activities

Counseling

• Counseling is done after data recording. Officers provide feedback by explaining the meaning of growth graphs according to the plotting BB / U and TB / U children. The officer also provides a referral for baby feeding

Handling and refferal

• Toddler stunting and malnutrition receive a 90-day recovery PMT and receive a home visit from a health worker to monitor the increase in weight

If there is no improvement, the toddler will be referred to the hospital

In some cases, the coverage of toddlers measurement is little, because toddlers are only measured if they are sick or come to immunization services

• Baby registers and posyandu information systems: Delayed collection from posyandu

• e-PPGBM: Takes a long time to enter data from Posyandu. Inadequate time, lack of technical assistance from the health department

If the nutrition officer does not have a background and understanding of nutrition, then counseling is not optimal

In some rural settings, the distance from the puskesmas to the RSUD is far, thus in order to go to the hospital, the patient’s parents must pay non-health costs such as transportation and lodging costs. Meanwhile, parents’ financial capacity


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3. Private first-level health facilities (FKTP)

Measurement

• Private FKTP often only measures toddlers’ BB


• Using a patient medical record card

Counseling

• Some private FKTPs do not provide growth counseling; FKTP only provides disease counseling.


• FKTP refers patients to the hospital

• TB is not measured. There are no regulations governing private FKTP to measure TB.

• There are no measurement tools.

• Patient medical record: the mechanism of reporting cases to the health department is not working

There is no growth counseling

The distance from the puskesmas to the RSUD is far, that in order to go to the hospital, the patient’s parents must pay non-health costs such as transportation and lodging costs.

4. Hospital Measurement

• Performed at a specialist growth and development clinic or children’s clinic


• The hospital records using the patient’s medical record

Counseling

• Pediatricians provide counseling


• The hospital referred back the patients who have improved to the puskesmas / posyandu

• Standards and quality vary

• Patient medical record: the mechanism of reporting cases to the health department is not working

The competence of specialist doctors is adequate, but the community has limited access to specialist doctors because of distance and cost

The absence of a mechanism that ensures referral back to the running puskesmas thud the growth of toddle can be monitored by the puskesmas.


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5. PIS-PK Measurement

• No measurement taken


• Use the Prokesga application

Counseling

• Done using pinkesga


• Toddlers who do not get growth monitoring are educated to come to the posyandu

Does not measure BB and TB

• The limitations of the internet network limit the maximum use of the Prokesga application and the Healthy Family application in some puskesmas; KS web application access is difficult / slow

Abandoned because officers focused on filling the Prokesga application

There is no monitoring mechanism whether in the following month the mother will bring her children to the posyandu. A follow-up visit should have been made, but the scope is still small.

6. BPB Measurement

• Puskesmas do BB and TB measurements. If a toddler is absent, a health worker makes a home visit


• Use the BPB register

Counseling

• None


• BPB refers to cases of malnutrition found in puskesmas

• Availability of measuring devices

• Prone to measurement errors due to too many home visits

• BPB Registers: Officers collect large amounts of data, but the availability of time to fill in registers is limited

None The absence of a mechanism to ensure nutrition problems toddlers come to meet the referral to the puskesmas


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7. KPM Measurement

• Early detection of stunting with growth mat


• Convergence score card

• Growth mats are not yet available in all districts / cities

• Potential for overlapping and confusion at the level of implementation between posyandu cadres and KPM, as well as reporting and using different indicators

• Village Scorecard: Convergence service monitoring activities have not been done much, flow of reporting is different from puskesmas

Have not run well The absence of a mechanism to ensure nutrition problems toddlers come to puskesmas

8. Riskedas Measurement


Data Recording

• Counseling

Questionnaire (None)

Handling and referral (None)

It is necessary to ensure the enumerator’s competence in measurement

Questionnaire None None

9. SSGBI Measurement


Data Recording

• Counseling

Questionnaire (None)

Referral (None)

It is necessary to ensure the enumerator’s competence in measurement

Questionnaire None None


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Based on table 5, height measurements have not been routinely measured at posyandu so the stunting case finding has not yet taken place. Village cadres and midwives who work at the posyandu have not consistently filled the TB/ U charts in the KIA handbook. This has caused early detection and education of stunting cases not yet fulfilled.

The ability of cadres in KMS chart/ KIA book interpretation and counseling is low. Based on the findings of Pencerah Nusantara [31] the TB/ U graphs were not filled in the KIA book because: (1) height measurement tools were not available; (2) cadres’ inability to take measurements; (3) cadres ignorance regarding TB / U content charts, (4) the number of tasks that must be carried out by cadres during posyandu; and (5) there is no height measurement form that must be reported to the puskesmas. This is in line with the results of monitoring and evaluation conducted by the Ministry of Health related to the use of KIA books in 9 Districts / Cities. This study showed that only 18% of KIA books were filled in with the highest level of occupational health care during pregnancy and newborns [10].

Besides filling in by cadres, KIA book ownership is also still a problem. Based on 2018 RISKESDAS data, 24.9% of pregnant women do not have KIA books, while the level of ownership of KIA books in toddlers is 65.9%. In fact, according to Riskesdas 2013 and Sirkesnas 2016, there was a link between the ownership of the KIA Handbook and the utilization of maternal and child health services [10]. Based on the findings of the FGD, parents’ awareness of bringing

Finding 10

The TB / U graphs are not filled in the KIA book due to: (1) the unavailability of height

measurement tools, (2) the limited ability of cadres to measure; (3) ignorance of cadres

filling TB / U charts; (4) lack of cadres in charge at posyandu; and (5) there is no height

measurement form that must be reported to the puskesmas.

KIA books when coming to the posyandu or to health services is also still low. Health workers often meet parents who do not carry a KIA book and do not know the urgency of recording and health information in the KIA book.

On most platforms, recording problems occur due to the lack of time, ignorance of officers, manual recording mechanism not yet running, and application technical issues (for example on ePPGBM and Healthy Family Application).

In the recording application, the recording officer requires training and technical support in the form of assistance, the availability of tools, and internet access. Technical constraints such as loss of data after entry also sometimes occur due to the lack of user understanding of the application. Limited internet access must be addressed with the presence of offline applications that can be used. Slow application access requires adequate data server support.

The results of recording the height become the cadre counseling / health workers to mothers of toddlers. Anecdotal findings suggest that mothers have excessive worries if stunting is detected by a toddler, that she will be labeled as a bad mother. Therefore, a proper understanding of stunting must be given by cadres / health workers after measurement and height recording.

Information about stunting can be conveyed well if several important components such as early detection of stunting, the ability of cadres and health workers in communicating behavior change, and the availability of a wide range of information media. First, stunting screening at posyandu and health facilities must be carried out as an early detection and entry point for providing appropriate information about stunting. A proper understanding of stunting can also be given when cadres make home visits in an effort to ‘pick up the ball’ for mothers who do not bring toddlers to the posyandu. Secondly, cadres and health workers must have good skills in conveying behavioral change communication.

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Therefore, the Ministry of Health needs to ensure training and material regarding communication on behavior change related to stunting is given to cadres. Third, media is needed as a tool to spread accurate information about stunting. This can be accommodated through national stunting campaigns and public service announcements coordinated by the Ministry of Health.

Based on table 5, counseling activities are carried out on 5 platforms, namely posyandu, puskesmas, hospitals, PIS-PK, and BPB. Most counseling is carried out by posyandu cadres and TPG. However, the QSDS study found that only 45% of posyandus carried out post-measurement counseling and only 39% of posyandu cadres had the ability to provide counseling to toddlers’ mothers [30]. Counseling activities did not go well because: (1) cadres’ ability to translate KMS graphics into counseling messages was still limited; (2) the cadre’s ability to provide counseling if a problem with limited nutritional status was found; (3) weak supervision and guidance of health workers in counseling sessions; and (4) lack of cadre’s ability to communicate behavior change. This shows the function of counseling and competence of cadres in providing counseling was still low.

In private health services, the flow of data reporting to the health department is not yet qualified. Data reporting by private FKTP to health centers and the health department was still voluntary and has not become an obligation. Field findings from the City of Depok explained the mechanism of reporting hospitals to the health department built through online discussion groups using Whatsapp application and an internal application called SIBIMA. However, this mechanism has not been applied yet in all districts / cities.

For the referral process, the initial referral to the stunting case was carried out at the puskesmas. The management of cases of toddlers with nutritional problems needs to be clarified. The provision of PMT recovery cannot be the only intervention for stunting toddlers. At the hospital, referral was made to the

hospital after the recovery of the patient. Growth monitoring is important so that children do not experience recurrent nutritional problems.

Ideally, stunting data from posyandu and puskesmas are then reported on the ePPGBM application. This application has the potential as a source of reference data for district / city governments. If the data collection mechanism with ePPGBM works well, this platform can provide monthly stunting prevalence. This platform can also act as an early warning system for stunting toddler cases to be followed up by puskesmas and health offices. Intervention in stunting toddler can also be done directly because data by name by address stunting toddler is available on the ePPGBM application.

However, the potential for ePPGBM applications is still constrained by the quality of the input and measurement processes that are still problematic. Poor posyandu and puskesmas data resulted in invalid height measurements. This caused the validity and reliability of the stunting prevalence data taken to be doubtful thus the effectiveness of the determination of service targets, program planning, and allocation of resources for overcoming stunting was not on target.

Finding 11

Counseling activities are not going well because of the limited ability of cadres to translate data

into counseling messages and in communication of behavior change, as well as weak monitoring

and training of health workers.

04.Integrated Stunting Data

Management: Implementation and Quality Assurance04

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Technical studies on this dimension depart from the basic assumption that measurement data are only meaningful if they can be used as a basis for improving policy making and clinical decision making. Measurement information will only be of little value if it is not available in a format that meets the needs of many users and is not delivered in a timely manner.

Stunting information systems collect data from the health sector and other related sectors and turn it into information for decision making. Integration of planning, implementation, evaluation, and control of stunting interventions needs to be supported by data that are accurate, current, integrated, can be accounted for, easily accessed, and shared, and is managed carefully, integrated, and sustainably.

Communication is an important attribute in the use of stunting information systems. Information will be of little value if it is not available in a format that meets the needs of many users and is not delivered in a timely manner. A good stunting information system ensures that all users have access to reliable, understandable and comparable data.

The issue of the availability of quality and timely data is still a major problem in integrated stunting information systems. This is caused by two fundamental problems: (1) the availability of quality data, especially in various measurement platforms due to implementation constraints as explained in chapter 3; (2) the flow and openness of data access.

This chapter will describe integrated data management efforts that are used to help manage programs / or activities related to reducing stunting at the national to village level. Specifically, this chapter will dissect about: (1) data availability and quality, (2) data integration and system interoperability for analysis and synthesis; and (3) use of data related to stunting in the framework of one data policy. Furthermore, the strategic issues that will be discussed in this chapter will lead to efforts to arrange data transactions in health service facilities as a source of data to improve the quality

and access to health data and information.

Data Generation: Availability and Quality

The measurement and publication of stunting numbers is a joint responsibility between the Regional Government and the Central Government. District / City Health Offices are responsible for collecting data at the individual level and individual health facility level data. The central government has the duty to collect data at population level and surveillance. Next is the division of roles of each actor involved:

1. Puskesmas, as the Technical Implementation Unit (UPT) of the District / City Health Office, carries out quality control over the implementation of the measurement platform and ensures information flow runs from the individual to the District / City level. Puskesmas is tasked with arranging schedules and preparing the human, logistical and financial resources needed for measurement according to the available platform options. Puskemas coordinate with Puskesmas Pembantu, Polindes, Poskesdes, Posyandu, clinics, hospitals in their working area to take measurements and ensure information flow enters the Puskesmas Information System. Puskesmas is also responsible for carrying out quality control by re-measuring randomly in the time close to the previous measurement day.

Puskesmas are the main users of data at the individual and family level. Puskesmas use measurement data to show that a child is growing and developing normally, at risk, or has problems that must be dealt with. At the family level, Puskesmas utilize measurement data to show patterns of health problems at the family level that contribute to stunting.

2. District / City Health Offices must build a tiered stunting information system as part of the Regional Health Information System (SIKDA).

CHAPTER 4. Integrated Stunting Information System: Implementation and Quality Assurance

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Chapter 4

This information system contains the results of measurements of growth and development of toddlers, especially height and weight, in stages from Posyandu to a higher level, both manually and online. These data must be kept up to date so that they are always up to date and in accordance with the changes that occur in toddlers encountered when measured at the toddler growth and development monitoring platform. The District / City Health Office is responsible for providing feedback on Puskesmas reports and validating data entered into the Data Communication Application and then sent to the Ministry of Health database server to enter the centralized National Health Information System (SIKNAS).

District / City Health Office processes the measurement data to assess progress at the village / hamlet / subdistrict level. This processing is used to analyze risk factors in the community and guide the determination of priority intervention locations, as well as resource allocation. Data can be analyzed based on trends, demographics and geography, comparability and relationships between programs / activities.

3. The Central Government, in this case the Ministry of Health and BPS, is responsible for conducting household surveys and surveillance. Both are often the main references for information related to stunting in locations where data at the health facility level is not reliable. Comparison between various household surveys and nutrition related surveillance and challenges in its management can be seen in table 6.

Many findings indicate the limitations of measurement coverage due to capacity constraints of program holders and the availability of logistics for data collection. The World Bank’s QSDS research (2016) states that only 61% of Puskesmas have received training in monitoring child growth and development and only 47% of cadres have received the same training in the last 12 months. Posyandu readiness is at the forefront of data collection due to

logistical sufficiency: only 30% have lengthboards.

This combination causes stunting problems not to be captured in health information systems in many districts / cities. As a result, growth monitoring at the grassroots level still relies on Toddler BGM data, the scope of case finding is also limited. Riskesdas said the number of children under five who had not been weighed in the past 6 months increased from 25.5% (2007) to 34.3% (2018). The low coverage of e-PPGBM (49.6%) causes household survey and surveillance to be the main source of stunting data.

Anecdotal findings, which were confirmed through interviews with experts, also indicated several problems in data quality, which includes: (1) data not collected (for example, there were toddlers who were not brought to Posyandu and were not recorded in the monitoring system (completeness); (2) data were collected according to protocols which can change depending on who and when the data was collected (precision and reliability), (3) Data was collected, but distortion occured in transmission (for example: there is a change in data in the transfer of notes in the Posyandu to the Puskesmas report to the Health Service report) so that it does not reflect what actually happened (validity); (4) Data was collected using more than one format with different elements, not integrated, and stored by more than one system with low interoperability (interoperability); (5) Data storage is carried out by individual managers with low interagency coordination mechanisms (ex: lack of coordination of data collected between the Ministry of Health and Ministry of Health); and (6) data reporting delays (timeliness) because the recording and reporting system takes time, capacity limitations, geographical and infrastructure challenges, and so on

Finding 12

Problems in data quality, including: (1) completeness of data (completeness), (2) Reliability and accuracy

of data (precision and reliability), (3) Data validity, (4) system interoperability, (5) coordination between data

managers, ( 6) timeliness of data (timeliness).

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Data Integration for analysis and synthesis

Stranas Stunting establishes specific and sensitive nutrition intervention groups to guide program implementers in converging programs amid limited resources. By adopting the Conceptual Framework of Determinants of Child Undernutrition (UNICEF, 2013), The Underlying Drivers of Malnutrition (IFPRI, 2016), and the Factors that Cause Nutrition Problems in the Indonesian Context (Bappenas, 2018), Stranas Stunting sets priority specific nutrition intervention groups, supporters, and priorities according to certain conditions. In addition, Stranas Stunting also stipulates sensitive nutrition interventions carried out through various programs and activities outside the Ministry of Health.

The establishment of the intervention group also guides program implementers to carry out analysis and synthesis of data related to stunting. To provide information for strategic decisions, an analysis of the situation of a stunting reduction program is not only done by identifying the distribution of stunting prevalence, but also gathering data on the situation of related service availability (see table 6. Only in this way, the stunting prevalence rate can be given a “meaning”. , if there are areas with programs related to priority nutrition interventions that are relatively complete, service coverage is relatively adequate, but the prevalence of stunting is still high, then the analysis needs to be sharpened by looking at the quality of specific nutrition services and access to sensitive nutrition services.

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Chapter 4

Figure 10. The relationship between stunting prevalence analysis and analysis of program / activity availability

Analisi sebaran prevalansi stunting dalam wilayah kabupaten/kota

Pertanyaan Kunci:Bagaimana pola sebaran prevalensi stunting dalam wilayah kabupaten/kota

Pertanyaan Kunci:Bagaimana ketersediaan program & kesenjangan cakupan pada setiap intervensi gizi prioritas

Pertanyaan Kunci:Apa yang menjadi kendala penyedia layanan dalam penetapan Rumah Tangga 1.000 HPK sebagai target penerima manfaat

Keputusan 3:Upaya perbaikan manajemen untuk memastikan Rumah Tangga 1.000 HPK menjadi target penerima manfaat layanan

Keputusan 2:Program yang alokasinya perlu diprioritaskanJenis sumber daya yang diperlukanRealokasi atau menambah alokasi program

1.

2.

3.

Keputusan 1:Jumlah analisis situasiLokasi-lokasi fokus penurunan stunting

1.2.

1.

Analisis ketersediaan program & kesenjangan cakupan layanan

2.

Analisis situasi penyampaian layanan pada rumah tangga 1.000 HPK

3.

Stunting information systems still have problems with system integration in both the health and non-health sectors. At the district / city Health Office level, there are at least 11 separate Public Health Center Information System reporting forms that track the scope of activities and programs related to stunting. This results in overlaps in data collection and processing and there is still repeated data collection by different units. Fragmented data because each program has a database that stands alone creates obstacles when users need composite information that must correlate two or more databases. This condition also results in an administrative burden ratio at health service facilities become large which have an impact on the disruption of the performance of public services.

Finding 13

A fragmented information system where there is difficulty in exchanging data between one system

and another due to system interoperability limitations

Each district / city also has its own Puskesmas Information System (SIMPUS) and e-Puskesmas which have not been integrated with the Regional Health Information System (SIKDA). Each of these information systems tends to collect as much and direct data as possible from the lowest health care facilities using their own programming languages. As a result, development efforts tend to create their own health information systems and pay less attention to the sustainability of the system and the concept of system integration for efficiency.

Human resources play an important role in the successful implementation of health information systems. However, current conditions both at central and regional levels are still limited both in terms of the quantity and quality of health information system management personnel. So far, in some areas, data and information managers are generally workers who hold concurrent positions or other tasks, which in reality are unable to fully work in managing data and information due to inappropriate incentives. Many of them choose part time jobs elsewhere. This weakness is compounded by the lack of skills

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and knowledge of data managers in the field of information, particularly information technology and its use. During this time, there have been functional positions for data and information managers, such as computer institutions, statistics, epidemiologists, information security, but have not been fully utilized.

The mechanism of monitoring and evaluation is still low. The weaknesses and various problems in the implementation of information system of health of course can be identified with the mechanism of monitoring and evaluation as well as audit of information system of health. Unfortunately, the mechanism of monitoring and evaluation has not been coordinated and implemented well.

In the Ministry of Health, data management functions related to fragmentation are fragmented between Data and Information Centers (Pusdatin), Information Centers in each technical Directorate and Health Research and Development Department (Litbangkes). The results of the health information system assessment from the Health Metric Network (2012) indicated that the six components of the implementation of the health information system are inadequate, especially for the management component. The results of the e-health assessment using the 2013 Commission on Information and Accountability (COIA) assessment tool also showed that the six components of e-health implementation (policies, infrastructure, applications, standards, governance, and security) were available, but did not meet standard. Close coordination between sub-units is needed to collect, check validity, and publish it in a national health database.

The weak condition of the current health information system is inseperabale of the weak role of Pusdatin in developing the system of recording and reporting. In principle, information system in the main unit must be able to communicate with integrated application in the Data and Information Center (data communication and data warehouse). However, every main unit in the Ministry of Health has the support of reporting application that are varied in order to manage data and information. Internally,

the main unit still faces hard times to perform data integration. In addition, the mechanism/ procedures related to one-door information has not been available. This has become the cause of the occurance of duplication of data and become one of the factors that become a constraint in building health information system in areas integrated with national health information system.

To facilitate the level of coordination between Ministries, various national information systems and e-government governance policies have been formulated, including Information and Communication Technology Strategy, Presidential Instruction number 3 of 2003 concerning e-Government Development, Law number 14 of 2008 concerning Information and Electronic Transactions, Government Regulation number 82 of 2012 concerning the Implementation of Electronic Transactions and Systems, Government Regulation number 46 of 2014 concerning Health Information Systems, and Presidential Regulation number 96 of 2014 concerning Indonesian Broadband Plans. Republic of Indonesia Presidential Regulation (Perpres) No. 39 of 2019 concerning One Data Indonesia provides a policy framework for standardization of data collection and preparation of evidence-based policies. The data management system includes data from each indicator from data stunting to the scope of specific and sensitive nutrition interventions. However, the national policy has not significantly had a positive impact on the implementation of the health information system, both at the regional and central levels.

In fact, the one data stunting policy has a number of important objectives. Among these are the structuring of regulations and the institutionalization of data management, and the integration of data from Ministries / Institutions, regional governments and state institutions into one data portal so as to produce an open data set. The hope is that there is a big data for stunting generated, managed and stored by the Government and can be utilized by any organization, including within the government itself. Thus, every policy, program and development

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activity is based on a shared database that can be accounted for.

The challenges to building cross-sectoral networks are very large, even though the one data policy and open data stunting are very important for managing the main database. The existence of government policies in strengthening e-government will depend on the interoperability of all system components. The unavailability of standards and protocols in the implementation of information systems in each ministry / institution results in unclear “rules of the game”. Data and information access from cross-units in the Ministry of Health and across sectors is still difficult because networks to strengthen the availability of valid and accurate data cannot be optimally carried out. The need to calculate health indicators does not only come from one source of data only, but from several data sources. For example, to measure or calculate the scope of success of a health program it requires data outside the health sector, such as population data as a denumerator from the Central Statistics Agency (BPS). From these conditions, it can be seen that the availability of protocols to build networks and establish standards supported by legal aspects is one of the challenges that must be immediately intervened.

Data Utilization

In addition to being weak in the the coverage of program, follow-up post measurement is often unavailable. GMP in Indonesia is established with low encouragement on the use of growth information obtained to educate betterment of eating patterns and children care patterns. Anecdotal finding identified that although some of the Puskesmas Program Holder’s time is spent collecting and

Finding 14

Ketidaktersediaan standar dan protokol penyelenggaraan sistem informasi di setiap Kementerian/Lembaga maupun lintas K/L

reporting information, data is rarely used to improve policy and implementation. Forums to share and discuss relevant data in each and between sectors are also not available at all levels.

Unreliable integrated data of stunting results in a weak basis for drafting regulations and integrated action plans (see figure 11). Integrated stunting data management is carried out throughout the fiscal year to support the overall budgeting process, as well as monitoring and evaluating the implementation of convergence actions to reduce stunting. Weak data management systems will cause the following Integration Actions that require integrated data for stunting: action # 1 (Situation Analysis), action # 2 (Action Plan), action # 7 (Measurement and Publication of Stunting), and action # 8 related to Review of Annual Performance does not have sufficient input.

Finding 15

Inadequate data causes a weak basis for the preparation of regulations and programs and can

reduce community control mechanisms

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Figure 11. Integrated Stunting Data Management Flow

Tingkatan

PusatTNP2K

BappenasKementerian

Manajemen Data Stunting

Perencanaan Monitoring

Evaluasi


Evaluasi


Evaluasi


Evaluasi

Aksi #7:Pengukuran

dan Publikasi

Aksi #1:Analisis Situasi

Aksi #2:Rencana Kegiatan

Aksi #8:Reviu Kinerja

Manajemen Data Stunting

Pengelolaan

Data Desa/Kelurahan

Posyandu BPSPAMS Pusat

Data StuntingData Manajemen

Data KIAData Air Minum & Sanitasi

Data PAUD

BappedaOPD terkait

BappedaOPD terkait

Kecamatan Puskesmas

Perangkat Desa HDW Fasilitator

Provinsi

Kabupaten

Kecamatan

Desa/Kelurahan

PenanggungJawab

Proses Monitoring Penggunaan Data

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Chapter 4

Table 6. Household Surveys and Surveillance Related to Stunting

Type Institution Frequency Method and type of data collected Reporting and challenges

Basic Health Research

Health Research and Development Agency, Ministry of Health

5-yearly A cross-sectional survey of around 300,000 households. Nutrition Indicator:i. antropometri (anak <5 tahun)ii. breastfeedingiii. micronutrient intake (TTD &

vitamin A pregnant women, children <5 years vitamin A)

iv. treatment (for diarrhea & zinc supplementation)

v. iodized salt (urine samples collected in 2007 & 2013)

Information is widely used for planning and for measuring impact.

Indonesian Demographic and Health Survey

Indonesian Central Statistics Agency

3- yearly A cross-sectional survey of around 45,000 households. Nutrition Indicator:i. PMBA (breastfeeding practices

and complementary feeding)ii. micronutrient intake (mother &

child <5 years)iii. management of diarrhea (with

oral rehydration fluids and zinc supplementation)

National Socio-Economic Survey (Susenas)

Indonesian Central Statistics Agency

Twice per year

A cross-sectional survey of around 300,000 households in March and 75,000 households in September. Household consumption / expenditure data is collected. Nutrition indicators collected include: i. practice of breastfeeding

Used to calculate poverty levels and as a monitoring tool for development.

Total Diet Study

Health Research and Development Agency, Ministry of Health

One time survey

One-time survey (cross-sectional) of 191,524 individuals from 51,127 households, including:i. consumption of individual foodii. chemical contamination analysis

of food ingredients

Used to determine patterns of food consumption and nutritional adequacy of the diet, food processing, and cooking techniques.

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Nutrition surveillance

Directorate of Community Nutrition, Ministry of Health

Annual One-time survey (cross-sectional) through 30 clusters sampling techniques at the district level. Data collected was data of children <5 years and pregnant women. In total there were 15 nutritional indicators collected including:i. anthropometric indicators of

children <5 yearsii. breastfeeding practicesiii. iron supplementation for mothersiv. vitamin A supplementation for

childrenv. children and pregnant women

with malnutrition who receive biscuits

vi. LILA women of childbearing agevii. Testing of iodized salt

Used to monitor the nutritional status of pregnant women and chil-dren for planning and monitoring.

Routine health surveillance system

Ministry of Health

Monthly Data is collected through public health service facilities. Indicators include:i. growth monitoring (body weight

per age only)ii. treated cases of acute

malnutritioniii. vitamin A supplementation for

childreniv. iron supplementation for mothersv. exclusive breastfeedingvi. consumption of iodized salt

There is no obligation for districts to report indicators. Thus, not all public health facilities report. Data compilation and feedback are very slow.

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SMS-Gateway (Real time nutrition case reporting system - acute malnutrition)


Launched in 2011, real-time reporting for acute malnutrition is reported by Puskesmas staff via mobile devices. Reports are received by the server to be entered into a database which is then displayed via the internet in real time

(http://gizi.depkes.go.id/sms-gateway/)

Low response rate. Anecdotal evidence that district authorities do not want to report a high number of cases.

Electronic system for reporting nutritional indicators (E-PPGBM)


E-PPGBM is an application to record and report the nutritional status of children and pregnant women quickly, accurately, regularly, and continuously for the preparation of nutritional policy planning and formulation. Nutritional indicators include:i. anthropometryii. exclusive breastfeedingiii. vitamin A, TTD and PMT coverage

There is no evaluation of the effectiveness of this application

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Table 7. Indicators and Data Sources Related to Stunting

No Indicator Operation

Definition

Numerator Denominator OPD Person in

Charge

Data Source

of Monitoring

System

Data Source

of Database

System

Frequency

Collecting Reporting

1. Pregnant Women CoverageKEK obtainingPMT recovery

Percentage of KEK Pregnant Women who received recovery PMT against all KEK Pregnant Women in the same time period

Number of KEK Pregnant Women who received recovery PMT

The total number of KEK Pregnant Women in the region within the same one year period

Health Department

Nutrition Report

Puskesmas Information System

Continue Monthly

2. Coverage of Pregnant Women receiving IFA (TTD) of at least 90 tablets during pregnancy

The percentage of pregnant women receiving a TTD of at least 90 tablets during pregnancy for all pregnant women in the same time period

The number of pregnant women receiving a TTD of at least 90 tablets during pregnancy

The number of all pregnant women in the area within the same one year

HealthDepartment

Nutrition Report


Continue Monthly

3. Coverage of classes for pregnant women (mothers attending nutrition and health counseling)

Percentage of pregnant women who take a class of pregnant women to the number of all pregnant women

The number of pregnant women attending the pregnant mothers class

The number of all pregnant women within the same one year

HealthDepartment

Nutrition Report


Continue Monthly

4. Coverage of families participating in the Toddler Family Development Program

Percentage of families who took the BKB to all Family with toddlers

The number of families with toddlers joining BKB

The number of all families with toddlers in one period of the same year

Office in charge of family affairsplanned

Family Health Report


Continue Monthly

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Definition


Charge

Data Source

of Monitoring

System

Data Source

of Database

System

Frequency


5. Coverage of skinny toddlers who receive PMT

Percentage of underweight toddlers who receive PMT

The number of skinny toddlers who receive PMT recovery

The total number of skinny toddlers in the region in the same one year

Health Department

Nutrition Report

e-PPGBM Continue Monthly

6. Coverage of attendance at posyandu (ratio of incoming to total targets)

The average percentage of children aged 0-5 years who attend per month at the posyandu for all children aged 0-5 years in the posyandu working area

The total number of children aged 0-5 years who attend per month at the posyandu

Number of children aged 0-5 years in posyandu working areas

HealthDepartment

Health promotion Report


Continue Monthly

7. Coverage of Pregnant Women-K4

Percentage of pregnant women who receive antenatal care at least 4 times during pregnancy with a schedule once in the first trimester, once in the second trimester, and twice in the third trimester of all pregnant women in the same period

Number of pregnant women receiving K4 services in health care facilities

The number of all pregnant women in the region within the same one year

HealthDepartment



Continue Monthly

8. Coverage of children 6-59 months receiving Vitamin A

Percentage of number of toddlers aged 6-59 months receiving Vitamin A to all toddlers aged 6-59 months

Number of children aged 6-59 months receiving Vitamin A in the months of February and August

Number of babies 6-59 months of that year

Health Department

Nutrition Report


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Definition


Charge

Data Source

of Monitoring

System

Data Source

of Database

System

Frequency


9. Coverage of children 12-23 months has been fully basic immunized

Percentage of children 12-23 months receiving basic and complete immunizations against all toddlers aged 0-11 months

Number of children aged 12-23 months receiving basic and complete immunizations

Number of all babies aged 0-11 months in the same period of one year

Health Department

Immunization Report


Continue Monthly

10. Coverage of toddlers with diarrhea receiving zinc supplementation

Percentage of toddlers with diarrhea receiving zinc supplementation

The number of toddlers with diarrhea receiving zinc supplementation

The total number of toddlers with diarrhea in that one year period

Health Department

MTBS Report Puskesmas Information System P-care BPJS

Continue Monthly

11. Coverage of young women obtaining TTD

Percentage of young women (13-18 years) obtaining TTD

Number of young women receiving TTD

Number of young women in the period of the same year

HealthDepartment

Nutrition Report


Continue Monthly

12. Coverage of households that use drinking water sources is feasible

Percentage of households that have access to improved drinking water sources to all households

Number of households with access to adequate drinking water sources

Number of households in that year

Health Department Office of Public Works

STBM- SMART Continue Monthly

13. Coverage of households that use proper sanitation

Percentage of households that have used proper sanitation to all households

Number of households that have used proper sanitation

Number of households in that year

Health Department

STBM- SMART Continue Monthly

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Definition


Charge

Data Source

of Monitoring

System

Data Source

of Database

System

Frequency


14. Coverage of JKN / Jamkesda participant households

Percentage of population that has become JKN / Jamkesda participants of all residents

Number of residents who have participated in JKN / JamKesda

Number of population in that year

Health Department

BPJSHealth

PCare Continue Monthly

15. Coverage of KPM PKH obtaining FDS nutrition and health

Percentage of KPM PKH participating in the Family and Capacity Building Meeting (P2K2) / FDS nutrition and health for all KPM PKH

Number of PKH KPM participating in the Family and Capacity Building Meeting (P2K2) / FDS nutrition and health

Number of KPM PKH Social Department

- - -

16. Coverage of parents who take parenting classes

Percentage of pregnant women and parents with under two million attending the parenting class

Number of pregnant women and parents with baduta children who attend parenting class

Number of pregnant women and children under two years

Department of Education and Culture

- - - -

17. Coverage of children aged 2-6 years registered (students) in PAUD

Percentage of children aged 2-6 years registered (students) in PAUD against the number of all children aged 2-6 years

Number of children aged 2-6 years registered (students) in PAUD

Number of children aged 2-6 years

Department of Education and Culture

- - - -

18. Coverage of 1000 HPK poor families as BPNT recipients

Percentage of 1000 poor families’ HPK as recipients of BPNT against the total number of families of 1000 poor households

Number of families of 1000 HPK poor group as recipients of BPNT

Number of families of 1000 HPK poor group

Social Department

- - - -

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Definition


Charge

Data Source

of Monitoring

System

Data Source

of Database

System

Frequency


19. Village coverage applies KRPL

Percentage of villages that apply KRPL to total villages

Total number of villages implementing KRPL

Total number of villages Department of Agriculture

- - - -

20. Postpartum Mothers service coverage

Percentage of postpartum mothers getting postnatal care at least 3 times for all postpartum mothers in the same time period

Number of postpartum mothers who receive postnatal care at least 3 times

Number of all postpartum mothers in the region within the same period of that year

Health Department



Continue Monthly

21. Coverage of toddlers suffering from malnutrition handled (BGM)

Percentage of malnourished toddlers handled in all cases of malnourished toddlers

Number of malnourished toddlers (BGM) handled

Total number of cases of malnutrition toddlers (BGM) within the same period of the same year

Puskesmas Nutrition Report


22. Coverage of Puskesmas capable of administering MTBS

Percentage of number of Puskesmas capable of administering MTBS to all Puskesmas in the District / City all Puskesmas in the District / City

Number of Puskesmas capable of managing MTBS

Total number of Puskesmas in the district / city

Health Department

- - - -

23. Coverage of 1000 HPK families and poor groups as PKH recipients

The percentage of 1000 HPK poor families as PKH recipients to the total number of families of 1000 poor households

Number of 1000 HPK families of poor group as PKH recipients

The total number of 1000 HPK families of poor group

Social Department

- - - -

24. Coverage of babies with birth certificates

The percentage of baduta who have birth certificates for all baduta

The number of baduta who have birth certificates

The total number of baduta in the same year

Dukcapil Office

- - - -

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Definition


Charge

Data Source

of Monitoring

System

Data Source

of Database

System

Frequency


25. Coverage of toddlers suffering from malnutrition handled (BGM)

The percentage of malnourished toddlers handled in all cases of malnourished toddlers

The total number of malnutrition toddlers handled

The total number of cases of malnourished toddlers in the period of the same year

Puskesmas Nutrition Report


26. Coverage of Pregnant women use mosquito nets in endemic areas

The percentage of pregnant women who use mosquito nets against all pregnant women

Total number of pregnant women using mosquito nets

The total number of pregnant women

Puskesmas - - - -

27. Coverage of HIV positive pregnant women

Receive Mother to Child Transmission Prevention (PPIA: Prevention of Mother to Child Transmission)

Percentage of HIV positive pregnant women getting PPIA services against all HIV positive pregnant women

The total number of HIV positive pregnant women getting PPIA services

The total number of pregnant with positive HIV

Puskesmas - - - -

28. Coverage of toddlers (12-59 months) who receive worm medicine

Percentage of toddlers (12-59 months) who receive worm medication for all toddlers

Total number of toddlers (12-59 months) receiving worm medicine

The total number of toddlers

Puskesmas MTBS Report Puskesmas Information System

P-care BPJS

Continue Monthly

05.Synthesis and Implementation of

Study Results05

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As explained in the previous chapter, this technical study has: (1) identified gaps and explored the role of regulations, governance, and related stakeholders; and (2) checking program / activity gaps related to the practice of measuring, collecting, publishing and utilizing integrated data on stunting.

In the first part, this chapter presents a synthesis of various findings (gaps from ideal conditions) identified through literature and policy studies; interviews with various expert speakers and field visits to see good practices in handling stunting at the district level.

In the second part, this chapter proposes a number of recommendations as a result of in-depth conceptualization of the analysis of findings, the implications of the findings, and the causes underlying the findings (drivers). Recommendations are submitted in the form of a road map that takes into account allegations about possible scenarios in the future (scenarios).

Synthesis and Implications

Regulatory Framework, Governance and Financing

Technical studies on this dimension depart from the basic assumption that good governance will encourage good practices in program implementation. This study will focus on the regulatory, governance and financing framework as enabling factors that shape good governance. The combination of these three elements will provide direction and space for stakeholders to collaborate, exchange information and promote evidence-based policies.

a. Regulation Framework

Nutrition improvement efforts have become a global concern and are on the global development agenda. In 2012, WHO through the World Health Assembly (WHA) Resolution endorsed and

encouraged member countries and international partners to implement a Comprehensive Implementation Plan on Maternal, Infant and Young Children Nutrition. Nutrition improvement targets in the Millennium Development Goals (MDGs) agenda were then continued and entered the Sustainable Development Goals (SDGs) agenda with the aim of eliminating all forms of malnutrition by 2030. Each member country has a moral responsibility to translate them into a national policy framework.

In 2018, the Government launched the National Strategy for the Acceleration of Prevention of Stunting (Stranas) which was the Government’s response to a weak integration program aimed at key targets in priority locations. The National Strategy also provides an overview of the work plan and the role of each party to reduce the national stunting rate.

The regulatory framework is available at the national level at various levels but translating and applying it to the subnational level is still a challenge. Stunting has entered the national priority and implemented 23 K / L. The government has issued a strategy to install it implemented at the top level, one of which is through the measurement of length / height that is included as part of the Minimum Service Standards (SPM) indicators. However, licensing and implementation are still being considered regarding cross-sectoral cooperation, even regulations that have not been harmonized.

b. Governance

The government designed an institutional architecture to divide the roles among ministries / institutions at the national level, regulate central-regional authority, facilitate policy implementation, and monitor the achievements of improving community nutrition. From the results of the policy analysis, this study compares the three governance structures at the national level listed in the key document:

CHAPTER 5. Synthesis and Implementation of Study Results

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(1) Framework for Implementation of the 2013 National Movement for Nutrition Improvement Acceleration, (2) World Bank Performance for Results Financing (PforR) in 2018, (3) National Strategy for the Acceleration of Prevention of stunting 2018-2024.

The three documents show different leadership and coordination structures. The governance structure carried by the 2nd and 3rd documents does not annul the institutional architecture of the 1st document. This difference creates confusion and overlapping work, for example in the first document the implementing / technical team is coordinated by Bappenas, while in the second document it is coordinated by the Secretariat of the Presidential Secretariat while the third document is by three Ministries, namely Bappenas, Ministry of Health and the Ministry of Home Affairs. At the implementing agency level, the main measurement platforms such as Posyandu are directly and indirectly managed by four different institutions, namely the Ministry of Health, Ministry of Home Affairs, Ministry of Villages, and PKK driving team which do not have a joint implementation guidance document.

c. Funding Framework

The Government is committed to ensuring the availability of adequate and sustainable sources of financing for efforts to reduce the prevalence of stunting. The general scheme of government funding sources for stunting programs in Indonesia is using the APBN (K / L budget), Special Allocation Funds, APBD 1 (Province), APBD 2 (District / City), village funds (APBDesa), and other sources that is legitimate. In addition, there are also sources of non-government funds that can come from legal entities / businesses, donors, or individuals / groups of people.

In 2018, the Ministry of Finance estimated that a budget allocation for nutrition needed was Rp 141.9 T annually to meet the stunting reduction target in the 2015-2019 RPJMN. Based on the

evaluation of the Ministries / Institutions Work Plans (Renja K / L) and the Ministries / Institutions Work and Budget Plans (RKA K / L) 2019, the relevant 2019 APBN budget allocation to support stunting reduction was recorded at Rp 29 trillion.

Recognizing the limited resources to fund innovation programs related to stunting, the Government has been exploring other funding sources that come from businesses and donors. One source of international funding for stunting in Indonesia is the World Bank funding scheme. In 2018, the World Bank provided soft loans to Indonesia with a performance-based financing scheme (Performance for Results) that depends on the achievement of the indicators / targets set (Disbursement Linked Indicators). The PforR mechanism seeks to bridge the Government budget deficit.

Another potential source of funding is the Village Fund. The Minister of Village’s Regulation concerning Priority in Using Village Funds in 2020 makes stunting a priority. In practice, the regulation is still in the stage of socialization. Only around 20% of Bupatis / Mayors have made regional regulations regarding the use of village funds for stunting programs. This also shows the commitment of the regional government in funding the stunting program, one of which is related to cadre fees, where there are still many imbalances in honorariums.

Starting in 2020, the Ministry of Finance will implement new provisions on Regional Incentive Funds (DID), as stated in PMK no. 141/2019. DID have the opportunity to provide incentives to the regions depending on the achievement of the main criteria and predetermined performance categories. One of the measured performances is public services in the health sector, which include stunting handling efforts. This policy has the opportunity to encourage regional governments to make optimal efforts to deal with stunting.

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The large allocation of funding for the stunting program has also begun to encourage the Government of Indonesia to increase the efficiency and effectiveness of its use. One method used is through the budget tagging and tracking system as a tool to measure the impact, performance and encourage accountability in

the use of funds. Unfortunately, this method has not yet been used to the village level. In addition, the absence of a national policy framework that includes a clear division of roles for stunting financing between the central, provincial, and district / city governments is a problem to ensure efforts are implemented properly.

Table 8. Synthesis of Findings in the Regulatory, Governance and Financing Framework

Dimension 1:Regulatory Framework, Governance and Financing

Ideal Condition Current Condition Need

Targeted strategic policies are based on the needs, data and available evidence

The policy framework for the acceleration of stunting prevention programs already exists at various levels and sectors which should be sufficient to encourage the realization as targeted. However, the implementation gap at the subnational level is still a challenge, especially due to the unavailability of a sustainability strategy

• Encouraging the implementation at the regional level is carried out according to policy.

• In-depth policy review especially about the impact on the community.

• The legal umbrella that underlies the National Strategy, is recommended in the form of Perpres / PP.

The existence of a supreme leadership hierarchy that has the authority to coordinate all K / Ls involved.

Simple and effective governance structure to ensure the flow goes in good coordination and communication across K / L.

Clear division of roles and functions between line ministries and other relevant stakeholders

The potential of overlapping in the governance and effectiveness of the coordination flow from the many ministries involved.

• Meetings are more routine than those set.

• An agreement of one K / L who holds the highest leadership to coordinate and manage.

• There is a clear division of roles and functions between line ministries and other relevant stakeholders that is stated in a policy umbrella.

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A comprehensive regulatory framework covers the involvement of multi-sector stakeholders, especially those incorporated in Scaling Up Nutrition (SUN) network.

A comprehensive regulatory framework covers the involvement of multi-sector stakeholders, especially those incorporated in the Scaling Up Nutrition (SUN) network.

A comprehensive regulatory framework covers the involvement of multi-sector stakeholders, especially those incorporated in the Scaling Up Nutrition (SUN) network.

The use of funds can be accounted for and have an impact as expected (costeffective)

The use of stunting program funds is not yet fully accountable for its efficiency and effectiveness

Budget tagging and tracking system down to the village level

Toddler Height Measurement: Implementation and Quality Assurance

The technical study on this dimension departs from the basic assumption that technical validity / height soundness measurement on various platforms and integration between services will enable the availability of height measurement data that are accurate, current, integrated, and accountable. Measurement data becomes a tool to identify nutritional problems in children as early as possible. At the policy making level, measurement data are useful for increasing the effectiveness of planning and determining service targets and resource allocation, as well as problem solving and monitoring at the village to district level.

a. Measurement Standards

The concept of Growth Monitoring has developed over the past few decades and has become a basic component of primary health care. In its development, this concept was transformed into Growth Monitoring and Promotion (GMP) which emphasized aspects of post-measurement counseling and referral governance.

This technical study captures several strategic issues regarding standard measurement practices in Indonesia. First, there are differences of opinion regarding the accuracy of Growth Standards used in Indonesia. Minister of Health Decree (Kepmenkes) No. 1995 / Menkes / SK / XII / 2010 set anthropometric standards used to refer to the 2005 WHO Growth Standard as long as Indonesia does not yet have a valid National Growth Chart Standard.

Second, there are differences in the target age groups and recommended measurement frequencies in several regulatory frameworks in Indonesia. Third, the differences in interpretation of measurement results in relation to operational definitions of nutritional status. Permenkes No. 66 of 2014 defines height below -2SD as short stature or short stature that can occur due to normal variations. This is different from the definition used by WHO: A child is classified as stunting if the length or height is below minus two of the standard deviation (-2SD) of the length or height of a child at his age. Fourth, the communication component of behavior change, especially aspects of counseling, including interpersonal communication aspects, escapes the growth monitoring service package.

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There is still debate about whether Posyandu cadres can take measurements. In the National Strategy, it is said that ideally monitoring the growth and development of children in the posyandu is routinely conducted every month by health workers assisted by KPM and posyandu cadres, but for length / height measurements, it can be done at least once every three months. There are no standards / regulations that say that posyandu cadres are tasked with measuring height.

In reality, health workers are not available in all places equally and often they have too much workload, so cadres often become the backbone of body measurements. For this reason, regulatory support is needed which states that trained cadres are allowed to measure height in conditions where health workers are not available.

b. Technical Soundness

Posyandu is the backbone of monitoring the growth of toddlers in Indonesia but is constrained by the availability of standardized measurement tools, the availability of nutrition workers at the puskesmas and measuring competence of both posyandu cadres and health workers. The results of the World Bank’s QSDS research (2016) mention that only 61% of Puskesmas have received training in monitoring child growth and development and only 47% of cadres have received the same training in the last 12 months. Posyandu readiness is at the forefront of data collection due to logistical sufficiency: only 30% have lengthboards. With the unavailability of standardized measurement tools and limited measuring competence, the opportunity to prevent stunting and detect early cases may be lost.

The workflow / business process for monitoring growth has not focused on aspects of data interpretation, counseling and referral to subsequent services after measurement. Field

findings indicate that Posyandu services stop at the measurement table due to high workloads and limited capacity of posyandu cadres and the availability of health workers. As a result, the management of cases of toddlers with nutritional problems in practice does not run according to the service standards set.

This combination causes height data to detect nutritional status according to TB / U and BB / TB not caught in health information systems in many districts / cities. As a result, growth monitoring at the grassroots level still relies on Toddler BGM data, the scope of case finding is also limited. Riskesdas said the number of children under five who had not been weighed in the past 6 months increased from 25.5% (2007) to 34.3% (2018). The low coverage of e-PPGBM (49.6%) causes household surveys (co: Susenas, Riskesdas, SSGBI) and surveillance is still the main source of stunting data [30]. This is due to the fact that there are still many areas that are still constrained by problems such as network limitations and manpower capacity to conduct manual input and integration with other reporting systems.

c. Inter-service Integration

The success of Posyandu as the backbone of monitoring toddlers’ growth can be achieved if the system is connected to the network of other Puskesmas activities / programs. To reach targets that do not have access to Posyandu, sweeping is done twice a year through the Toddler Weighing Month. The Healthy Indonesia Program with the Family Approach (PIS-PK) is also a means to analyze risk factors at the family level. The Early Childhood Development, Detection and Intervention Program (SDIDTK) is also an important intervention to monitor the growth and development of children by involving community, school and health personnel involvement.

For people who live in urban areas, measurements are often carried out on clinical platforms and private hospitals. Private clinics and

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independent practice help provide services to the community level. However, not all services do height / length measurements, and only do weight measurements. Health service providers are expected to carry out height measurements according to standards as part of basic services provided to toddlers.

Anecdotal findings, confirmed through interviews and field visits, indicate that the existing service platforms are still fragmented and not interconnected within the framework of the referral efforts. One of them is because there is no interconnected information / data system or enables data exchange between health services among the public and public-private sectors.

The Human Development Cadre (KPM) was initiated to encourage social monitoring

mechanisms at the village level. KPM ensures stunting services to 1,000 HPK families using growth mats and convergence score cards as an education and risk factor detection tool. KPM conducts monthly monitoring of the implementation of the convergence of 5 stunting handling service packages through the implementation of posyandu activities, PAUD activities, and visits to target homes. This social monitoring system is under the coordination of the Ministry of Villages, Disadvantaged Regions and Transmigration (Kemendes PDTT), but unfortunately it has not been well integrated into the Ministry of Health’s monitoring system. This also created confusion due to the presence of posyandu cadres and KPM.

Table 9. Synthesis of Findings on Implementation of Height Measurement

Dimension 2:Height Measurement


Uniform legal guidelines regarding operational definitions of nutritional status, target age groups, and frequency of height measurements

There are differences in operational definitions of nutritional status, target age groups and recommended measurement frequencies based on Permenkes No. 66 of 2014, Stranas Stunting, and 2016 edition of the KIA book

Harmonization of regulations to equalize standards / references used

The use of guaranteed growth standards, methods, validity, and reliability of HR measurement has an adequate number and competence

There is debate about the accuracy of Growth Standards used in Indonesia. HR problems on each platform: lack of competency in measuring staff, excessive workload, and lack of incentives.

Agreement and common perception of all actors to use one reference

Increasing the capacity of cadres and health workers

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Puskesmas have a sufficient number of TPG. One TPG is the program implementer and 1 person handles data recording and reporting

TPG receives regular training in anthropometric measurements.

Standardized height measurement are available at the posyandu at the stunting priority locus

The logistical limitations of measuring height are adequate, standardized, and calibrated

The Ministry of Health and the local government ensure that each posyandu has a standardized height measurement tool

Spot check of height measurement at posyandu by the health department.

Integration of one measurement platform to another in terms of schedule, frequency, data, and follow-up

The existing height measurement platform is not yet integrated (ex: posyandu, BPB, PIS PK, independent practice doctors, etc.)

K / L involved conduct harmonizing cross-platform mechanisms

Periodic height measurements at posyandu

Due to differences in guidelines and logistical limitations and competency of measuring staff, height measurements are not carried out regularly during posyandu

Incorporating height measurement components into growth and growth monitoring service standards at posyandu and health facilities

The availability of standards for recording and reporting that are well socialized to officers in the field through training

Most of the recording constraints are the unavailability of time, ignorance of officers, application technical issues (for example in e-PPGBM and Healthy Family Applications), not yet functioning recording mechanisms, and the absence of standards for recording and reporting height for toddlers at the level of posyandu to the district / city level

Simplification of the posyandu information system that must be reported by cadres.

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Behavioral change communication education

The unavailability of the communication component of behavior change in the growth service package

Technical guidelines and behavioral change communication training for posyandu cadres and TPG.

Integrated Stunting Information System: Implementation and Quality Assurance

The technical study on this dimension departs from the basic assumption that measurement data are only meaningful if they can be used as a basis for improving policy making and clinical decision making. Measurement information will only be of little value if it is not available in a format that meets the needs of many users and is not delivered in a timely manner. A good stunting information system ensures that all users have access to reliable, understandable and comparable data. Thus, the growth measurement functions for broader purposes; such as providing early warning, supporting service facility management, improving the quality of program planning and resource allocation, stimulating the emergence of new research, and encouraging evidence-based policies.

a. Data Generation: Availability and Quality

The measurement and publication of stunting numbers is a joint responsibility between the Regional Government and the Central Government. The District Health Office is responsible for collecting data at the individual level and at the health facility level data. The Health Research and Development Agency (Balitbangkes) and the Central Statistics Agency (BPS) are tasked with collecting data at the population level data and surveillance.

Anecdotal findings, confirmed through interviews with experts, indicate several problems in data quality. First, data is not

collected (completeness), for example, there are toddlers who are not brought to Posyandu and are not recorded in the monitoring system. Second, data is collected according to protocols that can change depending on who and when the data was collected (precision and reliability). Third, data is collected, but distortions occur in transmission (for example: measurement errors occur; data changes occur in the transfer of records in the Posyandu to Puskesmas reports and to the Health Office due to human error or data manipulation, etc.) so it does not reflect what actually happened (validity). Fourth, data is collected using more than one format that is not integrated and in systems with low interoperability. Fifth, data storage is carried out by individual managers with low coordination mechanisms between managers; and (6) timeliness is not reported.

b. Data integration for analysis and synthesis

Stunting information systems still have problems with system integration in both the health and non-health sectors. At the district / city Health Office level, there are at least 11 separate Puskesmas Information System reporting forms that track the scope of activities and programs related to stunting. This causes an overlap in data collection and processing which is still repeated by different units. Fragmented data because each program has a database that stands alone creates obstacles when users need composite information that must connect two or more databases. This condition also causes the ratio of administrative burden in health service facilities to be large which has an impact on the disruption of public service performance.

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Each district / city also has its own Puskesmas Information System (SIMPUS) and e-Puskesmas which have not been integrated with the Regional Health Information System (SIKDA). Each of these information systems tends to collect as much and direct data as possible from the lowest level of health care facilities using their own programming languages. As a result, development efforts tend to create health information system silos and pay less attention to the sustainability of the system and the concept of system integration for efficiency.

The weak condition of the current health information system is inseparable from the weak role of Pusdatin in developing the recording and reporting system. In principle, the information system in the main unit must be able to communicate with integration applications in the Data and Information Center (data communication and data warehouse). However, each main unit in the Ministry of Health has varied application and recording support for managing data and information. In the era of one data, the challenge is on the ability of Pusdatin to integrate data from the main unit. In addition, mechanisms / procedures related to one-door information are not yet available. This is the cause of data duplication and is one of the factors in the difficulty of building health information systems in regions that are integrated with national health information systems.

c. Data integration for analysis and synthesis

Stunting information systems still have problems with system integration in both the health and non-health sectors. At the district / city Health Office level, there are at least 11 separate Puskesmas Information System reporting forms that track the scope of activities and programs related to stunting. This causes an overlap in data collection and processing which is still repeated by different units. Fragmented data because each program has a database that stands alone creates obstacles when users need

composite information that must connect two or more databases. This condition also causes the ratio of administrative burden in health service facilities to be large which has an impact on the disruption of public service performance.

Each district / city also has its own Puskesmas Information System (SIMPUS) and e-Puskesmas which have not been integrated with the Regional Health Information System (SIKDA). Each of these information systems tends to collect as much and direct data as possible from the lowest level of health care facilities using their own programming languages. As a result, development efforts tend to create health information system silos and pay less attention to the sustainability of the system and the concept of system integration for efficiency.

The weak condition of the current health information system is inseparable from the weak role of Pusdatin in developing the recording and reporting system. In principle, the information system in the main unit must be able to communicate with integration applications in the Data and Information Center (data communication and data warehouse). However, each main unit in the Ministry of Health has varied application and recording support for managing data and information. In the era of one data, the challenge is on the ability of Pusdatin to integrate data from the main unit. In addition, mechanisms / procedures related to one-door information are not yet available. This is the cause of data duplication and is one of the factors in the difficulty of building health information systems in regions that are integrated with national health information systems.

The challenges to building cross-sectoral networks are enormous, even though the one data policy and the stunting data openness are very important for managing the main database. Perpres No. 39 of 2019 concerning Indonesian One Data provides a policy framework for standardization of data collection and

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compilation of an integrated evidence-based policy. The existence of government policies in strengthening e-government will depend on the interoperability of all system components. The unavailability of standards and protocols in the implementation of information systems in each ministry / institution results in the unclear “rules of the game”. Accessing data and information from cross-units in the Ministry of Health and across sectors is still difficult.

d. Data Utilization

In addition to being weak in terms of program coverage, post-measurement follow up is often not available. Monitoring toddlers’ growth in Indonesia is carried out with little emphasis on the use of growth information obtained to educate the improvement of eating patterns and parenting. Anecdotal findings indicate that although part of the Puskesmas Program Holder’s time is spent gathering and reporting information, data is rarely used for policy improvement and implementation. Forums to share and discuss relevant data in each and between sectors are also not available at all levels. Regular forums are held only at the central level. Data analysis is not immediately carried out (or not even done), so if there is a case of stunting in the community it is not followed up immediately (early detection).

The communication methods used to communicate measurement results and interpretations related to nutrition are still limited. Health workers in the field have not been equipped with guidelines to encourage behavior change, especially in terms of following up on post-measurement.

Limited understanding of the importance of monitoring growth and development, also triggers the Mother and Child Health Book (MCH Handbook) in many cases is often not used optimally. Whereas the KIA Handbook can be a media or data reference and good progress for parents / caregivers to monitor their children’s health and development.

Unreliable integrated data of stunting results in a weak base for drafting regulations and integrated action plans. Integrated stunting data management is carried out throughout the fiscal year to support the overall budgeting process, as well as monitoring and evaluating the implementation of convergence actions to reduce stunting. Weak data management systems will lead to Integration Actions that require integrated data stunting, namely: action # 1 (Situation Analysis), action # 2 (Action Plan), action # 7 (Measurement and Publication of Stunting), and action # 8 related to Annual Performance Review does not have sufficient input.

Table 10. Synthesis of Findings in Integrated Stunting Data Management

Dimension 3:Integrated Stunting Data Management


Available quality data that is accurate and up to date based on the needs of the main units, both in the form of individual data levels, health facility data levels, and population level data.

(1) Data is not collected (for example, there are toddlers who are not brought to the posyandu and are not recorded in the monitoring system) (completeness);

• Increasing the capacity of providers to carry out clear, accurate and simple recording systems

• Simplification of the Posyandu and Puskesmas Information System

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(2) Data is collected according to protocols that can change depending on who and when the data is collected (precision and reliability);

(3) Data is collected, but there is a distortion in the transmission (for example, there is a change in data in the transfer of notes in the posyandu to the puskesmas report to the health department report) that it does not reflect what actually happened (validity);

(4) Data is collected using more than one format that has different elements, is not integrated and is stored by more than one system with low interoperability;

(5) Data storage is carried out by individual managers with very low coordination mechanisms between managers; and

(6) Data is not reported in time (timeliness)).

Availability of a database with high interoperability within the Ministry of Health.

Data within the Ministry of Health has limitations to be exchanged with each other (integrase and interoperability) because it is developed based on the logic and preferences of each developer.

• Strategic plans for the integration of national and regional health information systems

Communication support and data exchange systems between ministries and institutions are available.

The unavailability of standards and protocols in the administration of information systems in each ministry / institution results in ambiguity of “rules”

• Guidelines for implementing e-government

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Effectiveness of social monitoring.

The community does not actively participate in overseeing the programs and performance of health workers and related stakeholderslainnya.

Mechanisms for involvement of civil society organizations and individuals to carry out social monitoring.

Designing a Repair Scenarios

Rationale for Scenario Design

After mapping the situation and measurement challenges and their relation to stunting data management, this section develops scenario planning. The scenarios are based on a literature review and a group discussion with expert speakers focusing on the issue of height measurement and integrated data management considering three dimensions, namely (1) regulatory, governance and financing frameworks, (2) implementation of measurements, (3) management of data. The scenario design is built based on the input received by the writers from a literature review, interview, and consultation of expert sources using the Delphi method.

Current Condition

Based on the analysis taken from the synthesis in Table 7, the number and types of regulatory frameworks currently available are considered sufficient at each level of government. However, gaps in the level of implementation and harmonization of central and regional policies remain the biggest challenges. Unclear coordination functions can also cause miscoordination that causes confusion in the implementation in the field. The absence of a regulatory framework involving cross-sectoral stakeholders will be a problem in involving more parties in the acceleration and sustainability strategies of reducing stunting.

With the large amount of financial resources flowing into the stunting program, the pressure to increase

the efficiency and effectiveness of the use of funds also increased. At the central level, there is a budget tagging and tracking system that is used to evaluate the use of funds. Unfortunately, this system cannot be used until at the village level which also has a special allocation for stunting from village funds. With less bias the effectiveness of the use of funds and performance can account for opening gaps in corruption and misuse of funds.

Table 8 shows regulations that are still inconsistent in a number of ways such as standards, definitions and governance. This triggers confusion on the ground and results in the inaccurate measurements - a serious gap because it can lead to missed detection of cases of stunting and other malnutrition that can actually be prevented or avoided. The challenges of limited capacity of measuring staff and the availability of logistics and information systems that have not been qualified also complicate the problem of measurement and recording in the field. Inaccurate measurement process will produce data not in good quality.

Data management conditions shown in Table 9 show that the data produced does not meet aspects of completeness, precision and reliability, validity, interoperability, cooperabiity and timeliness. Inadequate data results in a weak base for drafting regulations and integrated action plans to reduce stunting. This also has an impact on the inefficiency of the use of funds and the ineffectiveness of the program being implemented which will become a cycle that will not ultimately make much change. The efforts made will be difficult to make a significant impact. The World Bank estimates that the current effort may only reduce about 1% of stunting prevalence annually.

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Ideal Condition

Based on the mapping of the current situation, synthesis of the problem, as well as input from expert speakers, scenarios with ideal conditions depend on the existence of the following elements:

1. The existence of a strategic policy that is right on target based on the needs, data, and available evidence to minimize implementation gaps.

2. There is a clear function and flow of coordination, where there is a main coordinator with a governance structure that can be quite simple and effective to ensure good coordination and communication flow across ministries / institutions.

3. The existence of a clear division of roles and functions between K / L and other relevant stakeholders also becomes an important force. It must also be complemented by a comprehensive regulatory framework regarding the involvement of stakeholders outside government which will ultimately encourage more actors, especially civil society groups, young people, and the media to be involved in accelerating the reduction of stunting from various lines.

4. The existence of an accountability mechanism for the use of funds to the lowest level, such as budget tagging and tracking to the village level, is important to ensure good governance, as well as efforts made to achieve the expected targets. If these conditions are realized, then cross-ministerial coordination and convergence will go well, where accountability and transparency of the use of funds can also be accounted for.

Good governance will encourage the development of process improvements in the field. Harmonization and consistency of regulations will make it easier for officers in the field to have the same understanding and improve measurement accuracy. The availability of tools, logistics, and qualified measuring staff will encourage periodic height measurements that are in

accordance with standards and procedures. Aside from being equipped with measurement capabilities, the posyandu cadre is expected to also have the ability to interpret data, conduct counseling, and nutrition education based on behavior change.

If the ideal conditions are met, then the data can be recorded and reported properly from the posyandu level to the highest level. The mother group is well educated and informed about their health and their children well so that cases of stunting and other malnutrition can be detected early and empowered to understand and take steps to be taken. A good measurement process will also have an impact on the production of more reliable and quality data.

The availability of accurate and up-to-date quality data based on the needs of the main unit, both in the form of individual data to the level of health facilities and population, can encourage evidence-based policies and programs that are more effective and targeted. Program coverage and beneficiaries also increased from the efficiency and effectiveness of the use of funds. Having quality data must be supported by an integrated information system across programs and even across ministries to facilitate data access and integration in decision making and policy making.

Strengthening the role of the Ministry of Health Pusdatin as a reference for the management and use of dashboard stunting and improving the function of the Central Statistics Agency as the main reference for development statistics is needed. The strengthening of these two institutions will reduce the cross-confusion that has occurred in the formulation of policies, program implementation, and execution of activities that result in inefficiencies. The work of sharing data (data sharing) for the internal interests of institutions / ministries or between organizations is needed to make data as the backbone of open government. Anyone who needs can take advantage of data that is readily available and can be accessed easily. In the end, all elements of this improvement increase the credibility of the government through appropriate development policies. Such policies

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must be based on evidence and data, not merely political considerations, let alone the mere intuition of policy makers.

Recommendation

Recommendations are proposed to guide the stakeholders to decide on the steps to be taken immediately in the domain of their respective tasks and tasks, as well as in collaboration between sectors. In this section, it is mapped the needs and priorities of the government in the future.

1. Recommendations for Strengthening the Regulatory, Governance and Financing Framework

The following recommendations are addressed to Ministries / Institutions with coordination functions (Setwapres / Bappenas / Kemenko PMK)

• Design a regulatory framework based on needs assessments and gaps in the field that involve various stakeholder elements

• The establishment of a governance structure that is quite simple, effective and agreed upon by all parties is complemented by a clear division of roles and functions of coordination

• Encouraging the immediate enactment of the regulatory framework that forms the umbrella of the stranas stunting, one of which includes a meaningful involvement of multi-sector stakeholders and their roles and functions clearly

• Increasing the efficiency and effectiveness of stunting program funding through the budget tagging and tracking mechanism to the village level

• Encourage local government performance evaluation mechanisms

2. Recommendations for Improvement of Implementation of Height Measurement

This recommendation is intended for Ministries / Institutions with a coordination function and a technical implementation function (Ministry of Health and Bappenas)

• Harmonization of standards, governance and operational definitions

• In conditions that are not ideal where there are no trained health workers available, it is important to increase the capacity of posyandu cadres regarding height measurements and the ability to counsel and interpret data.

• Incorporate components and conduct behavioral change communication training in growth service packages

• Internet-based remote health workforce training (e-learning) on monitoring growth and communicating behavioral changes to puskesmas

• Design a regulatory framework stating that trained cadres are allowed to measure height in conditions where health workers are not available

• Increase the availability of nutrition workers in each Puskesmas

• Procurement of measurement and reporting logistics according to the standards required at Posyandu Integration of various toddler height measurement services from posyandu to district / city level

• Increased coverage and quality of PIS PK to ensure and educate every family that has a toddler to go to the posyandu.

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• Increased coverage and quality of PIS PK to ensure and educate every family that has a toddler to go to the posyandu.

In conditions where health workers are not available, the puskesmas must validate the measurement results by the cadre and ensure that the referral system from the posyandu to the nearest health service runs according to the procedure, i.e.:

• Cadres only monitor toddlers body weight every month and refer toddlers to health workers at the puskesmas if indicated to have nutritional problems or fixed weight, or do not increase after two consecutive measurements.

Recommendations for stunting data management

Specifically, the team underscored the importance of the realization of big data stunting being produced, managed and stored by the Government for use by any organization, including within the government itself. This is in line with the one data policy (Perpres No. 39 of 2019) which has a number of important objectives, including structuring regulations and institutionalizing data management, and integrating data of Ministries / Institutions, local governments and state institutions into one data portal resulting in an open data set.

To ensure that the direction of policies issued by the government, programs and development activities based on shared data that can be accounted for, the writing team formulates specific recommendations for K / L with monitoring and evaluation functions (Pusdatin Ministry of Health, BPS, TNP2K and the Ministry of Villages)

• Increase the capacity of posyandu cadres and puskesmas nutrition officers to record and report, as well as to utilize data

• Simplified posyandu information system and integration of KPM score cards to Posyandu information systems as well as ePPGBM

• Increase coverage of the use of e-PPGBM accompanied by an increase in the capacity of officers related to surveillance - the process of collecting - analyzing - action based on analysis, by also considering regional limitations in infrastructure and human resources capacity. The implementation of SSGBI by BPS and Litbangkes is done routinely annually to know the updated prevalence of stunting toddlers

• Integration of prevalence data and programs related to stunting prevention in the Mhealth platform developed by the Ministry of Health Pusdatin

• Add a National Health Information System Roadmap related to the inclusion of clarity of roles among stakeholders and the development of national and regional SIK integration plans

• Strengthening the National Health Information System through the use of appropriate technology and improving system interoperability

• Develop guidelines for implementing e-government for nutrition issues in Indonesia

• Incorporate a nutrition agenda, especially stunting, into the village planning agenda, such as through the Village Community Conference (MMD), to communicate and discuss data at the community level

• Involving civil society organizations and individuals to carry out social monitoring

However, given the handling of stunting requires a national orchestration involving stakeholders outside the government; the role of civil society, the private sector, academia and the media to ensure broad public engagement is urgently needed. In this study, the writing team has mapped out the actions

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expected of each stakeholder group in the complete document to develop and carry out various actions to reduce national stunting rates. In this brief document, the writing team attempts to describe the role of actors in general, as follows:

• CivilsThe spread of civil society groups, including youth groups, to the village level is an advantage for them to be an extension of the government, especially in terms of bridging access and monitoring targets that are not affordable by the Government. In addition, they can also oversee the process and provide technical assistance through the studies needed to inform policy making and encourage the involvement of vulnerable and marginalized groups in the process. Civil society groups also have the flexibility to innovate.

• AcademicsAcademics are encouraged to be involved in the process of study and regulation design by providing input and other technical assistance needed through studies and research.

In accordance with the tri darma of higher education, academics are also expected to be able to fill the implementation gap through community service activities at the village level.

• Profession OrganizationsProfessional organizations are expected to be able to ensure that health care providers under the professional association can carry out health services, ranging from height / body length measurements as well as counseling and other follow-up, according to standards and procedures established. OP is expected to play an active role in maintaining the quality of services, by being involved in quality assurance and supervision. The Ministry of Health, the private sector and other actors need to work closely with the OP and HCP in setting standards for height and weight measurements, including monitoring programs.

• Private SectorsThe private sector is an important actor in development. The private sector can help in the form of cash assistance, technical assistance, supply assistance to fill gaps that cannot be resolved by the government and community organizations.

Besides helping to mobilize resources, with its great potential, the private sector can also support the government through innovative approaches and with advanced technology and research.

• MediaThe role of the media is no less important to be involved, the media can conduct oversight of the government through critical reporting and voice honest findings on the ground. In addition, the media can socialize and help educate the public about stunting and its impact on health.

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Table 11. Synthesis of Findings on Implementation of Height Measurement

RecommendationsMain Action

Target IndicatorGoverment Inter Sectors

Improving the regulatory framework based on the needs and gaps study in the field involving various elements of stakeholders

Bappenas coordinates the needs review and harmonization of regulations across K / L

Bappenas

Encourage ratification of the stunting strategy within a specific regulatory framework

Ministry of Home Affairs

Encourage a district / mayor level regulatory framework regarding the formation of district / city level teams in stunting prevention and handling efforts

Regional government:

Designing authority regulations to the village level and disseminating practical steps to prevent and reduce stunting based on the potential and local wisdom of the village

CSO: Encourage inclusiveness and involvement of the poor, marginal and disability groups to be involved in all processes

Guide the process through the studies needed to inform policy making

Private sector, academics and professional organizations: contribute / be involved in the review process and draft regulations by providing input and other technical assistance needed

Media: Oversee the government through critical and honest reporting of the truth found in the field

Harmonized and sustainable stunting regulatory framework

There is a regulatory framework for preventing and reducing stunting to the village level

There are no overlapping regulations regarding stunting before 2024

100% local government has a regulatory framework for prevention and stunting reduction before 2024

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Establishing a governance structure that is quite simple, effective and agreed upon by all parties complemented by a clear division of roles to ensure the flow of coordination

The President / Vice President decides the main structure of governance that is used

Chairperson / Coordinator:• Coordinate and

set meetings with frequency as needed

• Coordinating the distribution of roles and functions of each K / L in detail

Local Government:

Performing detailed roles and functions across agencies and programs.

CSO, private, academic, and professional organizations: Provide input and technical assistance to ensure good governance and coordination and communication channels

Governance structure with clear flow of coordination and division of roles for each K / L and partners involved

The presence of governance and coordination structure to accelerate the reduction of national stunting led by Bappenas with clarity on the division of roles of stakeholders involved

Encourage the immediate endorsement of the regulatory framework that forms the umbrella of the stranas stunting, especially those that include one of them concerning the meaningful involvement of multisector stakeholders

The Chairperson / Coordinator encourages the ratification of the stranas stunting considering that in the National Strategy the framework for multisector involvement is stated. Manuscripts can be included in the revised Perpres or new Perpres specifically stunting (subject to final agreement)

CSO, private, academic, and professional organizations: Provide input and technical assistance when needed

The enactment of the Perpres stranas stunting

The National Regulation on the National Strategy includes meaningful multi-sector stakeholder engagement

The regulatory framework includes multi-sector involvement to reduce stunting

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Increase the efficiency and effectiveness of the use of stunting program funds

Central Government:Central Government:

• Implement a tagging and tracking system for financing programs / activities for preventing and reducing stunting from the central to the village level

• There is a regulatory framework up to the regional level regarding the implementation of the budget tagging and tracking system

• The existence of a national regulatory framework / NSPK (Norms, Standards, Procedures and Criteria) that clearly divides the roles related to financing between central, provincial and district / city level stakeholders.

Local Government

Ensuring that there is a budget allocation for stunting, including a decent cadre honorarium budget

CSO, academics, professional organizations and the media:

• Guard and encourage transparency and accountability

• Encourage greater allocation of public health budgets than individual health

• Conduct studies to help evaluate the performance of the use of funds

The implementation of a budget tagging and tracking system for financing up to the village level

Regulatory framework regarding the application of budget tagging and tracking

The budget tagging and tracking system is implemented at the village level

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Encourage local government performance evaluation mechanism

Kemendagri:Kemendagri:

• Ensuring that SPM is implemented as a key indicator of local government performance with a reward and punishment system

• Establish an indicator of work performance as a mechanism of reward and punishment for local governments. Example: promotion, increase in budget and reduction of funds from the center to the regions

Kemendagri and Kemendesa PDTT

• Encourage the existence of district / city derived from PDTT permendesa no 11/2019 for priority village funds for stunting

• Encourage stunting consultation to determine funding priorities in each village prior to

CSO

Oversee the process, provide inputs and technical assistance needed

Private:

Supporting through an innovative approach, the idea of resource mobilization and resource support donates approval of the Presidential Regulation

Exit strategies and sustainability plans (co: SPM, village funds, etc.) efforts to prevent and reduce stunting after stunting is not a priority issue

• Incentive and disincentive mechanisms for local governments that reach the MSS / other performance targets

• Minimum allocation of village funds ..% for stunting in all villages before 2024

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the Musrembang implementation

• Encourage stunting consultation to determine funding priorities in each village prior to the Musrembang implementation

Bappenas and Kemenkeu

Make plans to mobilize domestic resources and exit strategies from foreign financing dependencies

Local Government:

Ensuring sustainability strategies in the Regional Action Plans and Work Plans

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Table 12. Recommendations for Improvement of Implementation of Height Measurement



Harmonization of regulations regarding operational definitions, target age groups, and frequency of height measurements

The Ministry of PPN / Bappenas facilitates the regulatory harmonization process

The Directorate of Nutrition of the Ministry of Health establishs an expert working group to jointly develop and provide recommendations regarding definitions, target age groups and height measurements to Bappenas

CSO, private, academic and professional organizations: involved in working groups providing the necessary input and technical assistance

Health professional organizations: Assisting and providing technical assistance, especially relatedguidelines and standards

One standard regarding definitions related to stunting, target age group for intervention and frequency of height measurements

Revised guidelines for implementing toddlers growth monitoring

Ensuring the availability of trained personnel to carry out height measurements at posyandu and puskesmas

The Ministry of Health organizes socialization, training and technical guidance for the regions

Strengthen the surveillance system with the aim of early detection of nutritional problems with a follow-up response that immediately involves village stakeholders

The regional government allocates funding to

CSO, private sector, academics and professional organizations: expanding the capacity building process by conducting capacity building and mentoring health workers and posyandu cadres

Posyandu cadres and qualified health workers

All posyandu cadres, midwives and nutrition program holders are trained in 2024

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increase the capacity of posyandu cadres and health workers through regional budget / village funds

Ensuring the availability of adequate, standardized and calibrated height measurements to each posyandu at the stunting priority locus

The Ministry of Health ensures that each posyandu at the stunting priority locus has adequate, standardized, and calibrated height measurement tools

Perform quality control in e-catalog for quality and reliability testing

Developing a standarized body length measurement tool that is easy for cadres to use for education and risk factors

Local governments/village heads allocate funds for joint height measurement instruments at posyandu

CSO advocate fund allocated for measuring instruments at Posyandu

Business sector channel CSR allocation for measurement procurement

Develop measurement instrument that is more innovative and simpler to be utilized by health cadres

CSO, academics and professional associations: monitor the availability of instruments that are sufficient, standardized, and callibrated

Professional association: encourage practicioners to use standardized height measurement instruments

The availability of sufficient, standardized, and calibrated height measurement instruments in every Posdyandu in the prioritized stunting locus

100% Posyandu has standardized height measurement practice

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Integrating height measurement platform services

Bappenas facilitate the coordination and role sharing among Kemenkes, Kemendagri, Kemendesa dan PKK mengenai posyandu

Kementerian Kesehatan make improvements, harmonization, and integration of mechanisms, coverage, and data collection of home visits in the PIS PK program, post-posyandu home visits and Toddler Weighing Month

Improve coverage and quality of PIS PK to ensure and educate every family that has a toddler to go to the posyandu

CSO, business sectors, academics, and professional associations: provide input and technical assistance needed

Conduct studies, help monitor and evaluate the implementation of PIS PK, Posyandu, and BPB

Posyandu interventions and programs and other platforms that do not overlap

Revised guidelines for the implementation of growth and development monitoring with a focus on harmonizing the measurement platform

Ensure routine height measurement practice in posyandu and other health facilities

Kementerian Kesehatan conduct socialization regarding the integration of height measurements at posyandu and health facilities according to Permenkes No.4 of 2019.

incorporate height measurement components into the standard of growth and development monitoring services at posyandu and health facilities

CSO, business sectors, academics, and professional associations provide input and technical assistance in the preparation of standards and materials / modules for monitoring growth and development services at posyandu and health facilities

conduct training, training of trainers, capacity building and assistance to health workers and posyandu cadres

The standard of growth and development monitoring service in the posyandu is equipped with height measurements

Increased coverage of Posyandu that has implemented minimum service standards

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Develop materials / modules on technical monitoring of the growth of children under five in posyandu

Encourage the use of buku KIA to record Height to Age

Health-related professional association: carry out standardized height measurement as a basic service given to toddlers

Improve mechanisms for reporting toddlers’ height in posyandu and health facilities

Ministry of Health develops and disseminates standards for recording and reporting height for toddlers from posyandu level to district / city level

Regional Government

The District Health Office monitors the weight results until S = K-D-N is reached

CSO, academics and professional organizations provide input in the preparation of growth and development monitoring service standards at posyandu and health facilities

Health professional organizations: Carrying out recording and reporting of height according to available and standardized mechanisms

Standards and mechanisms for recording and reporting height at posyandu and health facilities

Issuance of standards for recording and reporting height at posyandu and health facilities

Incorporating components of behavior change communication in the growth service package as stated in Permenkes No. 66 of 2014 concerning Monitoring Child Growth

Local Governments include the behavioral change communication component in regional strategies and action plans

Ministry of Health makes materials / modules on behavior change campaigns

CSOs, private sector, academics and professional organizations:

• Help disseminate educational material on stunting in accordance with national campaign strategies and behavior change

District / City Governments have strategies and action plans with a behavioral change campaign component

Issuance of guidelines for implementing behavioral change communication at the village level and cadre training guidelines

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Ministry of Health organizes socialization and technical guidance on behavior change campaigns for posyandu cadres and health workers

• Monitoring and evaluating behavior change communication strategies

• Encourage and provide input to Local Governments to issue regional policies and strategies on behavioral change communication

• Conducting training, training of trainers, capacity building and assistance to health workers and posyandu cadres

Health professional organization: Accompany the communication module formulation from the perspective of communication and medical counseling

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Table 13. Recommendations for Improvement of Integrated Stunting Data Management



Increase the capacity of health workers and cadres to carry out clear, accurate and simple recording systems through in-service training and supportive supervision

BPPSDM provides a tiered training mechanism and training curriculum for health workers and cadres

Directorate of Nutrition of the Ministry of Health provides the allocation of BOK funds to make it possible for health workers to conduct supportive supervision in the collection process data

CSO: Assist the government to carry out standardized in-service trainings in the target area

Helping the government to carry out supportive supervision in the target area

Private: collaborate with CSR schemes for the provision of ICT-based training facilities

Private clinics / hospitals provide support to conduct supportive supervision in their fostered institutions

Academics and professional health organizations: Provide quality assurance in the training curriculum. Provide support in developing improved measurement technical guidelines

Increased capacity of health workers and cadres to conduct clear, accurate and simple recording and reporting systems

All midwives and nutrition program holders receive refresher training

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Simplify the posyandu and puskesmas reporting systems

The Directorate of Kesga, Primary Services and Health Promotion proposes to simplify the Posyandu and Puskesmas reporting systems

CSO, private sector, academics, professional organizations: Helping the Ministry of Health implement a trial of a new reporting system based on the current effectiveness of reporting studies

A simpler and more efficient Posyandu and Puskesmas reporting system is available

Revised Posyandu and Puskesmas reporting systems

Increase the scope of use of ePPGBM

Ministry of Health organizes socialization, technical guidance, and assistance to TPG puskesmas regarding ePPGBM

Directorate of Community Nutrition forms the ePPGBM technical assistance team

Pusdatin Ministry of Health strengthens ePPGBM applications and servers

Ministry of Communication and Informationimproving network infrastructure in areas that have not yet been achieved

• CSO, academics and supporting professional organizations to TPG puskesmas to carry out recording and follow up on ePPGBM results

Health professional organizations: Assisting officers in the field to use e-PPGBM

Increasing the amount of data reported

All priority districts / cities have 100% ePPGBM coverage

Revise the National Health Information System Roadmap related to:• Inclusion

of clarity of roles between stakeholders

• Development of a strategic plan for the integration of

Pusdatin Kemenkes

• Standardize various software applications made by the main work unit of the Ministry of Health in the form of the Health Data Dictionary

CSO, private sector, academics, professional organizations: participating in working groups providing input to the Ministry of Health to revise the National Health Information System Roadmap

Revised National Health Information System Roadmap


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national and regional health information systems

• Form a working group for the sake of coordination and evaluation of the substance and infrastructure needed

• The working groups across the main work units of the Ministry of Health creates a phasing roadmap that is the basis for setting priorities for regulation, standardization and other policies

• Form a cross-stakeholder and actor working group for inclusion in the National Health Information System Roadmap


Pusdatin Kemenkes

• The community prepares hardware for the development of knowledge platforms

• Together with the Directorate of Public Health develop and test database information systems

CSO, private sector, academics, professional organizations: provide input and technical assistance if needed

Strong and efficient National Health Information System

• Availability of knowledge platform

• Availability of information systems for databases

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• Together with the Directorate of nutrition, ensure the reliability of the nutrition database and knowledge platform

• Develop a data / information system that enables data exchange between public-public and public-private health services

• Integration of prevalence data and programs related to stunting prevention in the MHealth platform developed by the Ministry of Health’s Pusdatin

BPS and Litbangkes

Carry out SSGBI routinely once a year to find out the current prevalence of stunting toddler

Develop e-government manuals on nutrition issues in Indonesia

Bappenas form a cross-K / L working group and actors for the sake of coordination and evaluation of the substance and infrastructure needed

CSO, private, academic and professional organizations:Involved in the working group providing input and technical assistance when needed

Guidelines for implementing e-government for nutritional problems in Indonesia

Issuance of e-government implementation guidelines for nutrition issues in Indonesia

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Develop mechanisms for involvement of CSO and individuals to implement social accountability mechanisms

Bappenas together with working groups across K / L and cross actors develop social monitoring mechanisms in the effort to prevent and reduce stunting

Regional governmentIncorporating nutritional agendas especially stunting into village planning agendas such as through MMD to communicate and discuss data at the community level

CSO, private sector, academics and professional organizations:Involved in working groups to provide input and technical assistance when needed

CSO:Encourage and oversee the process through capacity building and monitoring in the field

Social monitoring mechanism in the prevention and reduction of stunting in Indonesia

Trial of social monitoring in efforts to prevent and reduce stunting in Indonesia in 2020

Increase the capacity of providers to carry out clear, accurate and simple recording systems through in-service training and supportive supervision for health workers and cadres

BPPSDM provides a tiered training mechanism and training curriculum for health workers and cadres

The Directorate of Nutrition of the Ministry of Health provides the allocation of BOK funds to enable health workers to conduct supportive supervision in the data collection process

CSO: Assist the government to carry out standardized in-service trainings in the target area

Helping the government to carry out supportive supervision in the target area

Private: collaborate with CSR schemes for the provision of ICT-based training facilities

Private clinics / hospitals provide support to conduct supportive supervision in their fostered institutions

Academics and health professional organizations: Provide quality assurance in the training curriculum.

Increased capacity of health workers and cadres to conduct clear, accurate and simple recording and reporting systems

All midwives and nutrition program holders receive refresher training

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Provide support in developing improved technical guidelines for measurement

Simplify the posyandu and puskesmas reporting systems

The Directorate of Kesga, Primary Services and Health Promotion proposes to simplify the Posyandu and Puskesmas reporting systems

CSO, private sector, academics, professional organizations: Helping the Ministry of Health carry out system trials of new reporting based on a review of the effectiveness of current reporting

Availability of posyandu and puskesmas reporting systems that is simpler and more efficient

Revised Posyandu and Puskesmas reporting systems

Increase the scope of use of ePPGBM

Ministry of Health organizes socialization, technical guidance, and assistance to TPG puskesmas regarding ePPGBM

The Directorate of Community Nutrition forms the ePPGBM technical assistance team

Pusdatin Ministry of Health strengthens ePPGBM applications and servers

Ministry of Communication and InformationImproving network infrastructure in areas that have not yet been achieved

CSO, academics and professional organizations assisting TPG puskesmas to carry out recording and follow up on ePPGBM results

Health professional organizations: Assisting officers in the field to use e-PPGBM

Increasing the amount of data reported

All priority districts / cities have 100% ePPGBM coverage

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Revise the relevant National Health Information System Roadmap:

• Inclusion of clarity of roles between stakeholders

• Development of a strategic plan for the integration of national and regional health information systems

Pusdatin Kemenkes

• Standardize various software applications made by the main work unit of the Ministry of Health in the form of Health Data Dictionary

• Form a working group for the sake of coordination and evaluation of the substance and infrastructure needed

• The cross-unit work unit of the Ministry of Health creates a National Health Information System Road Map that becomes the basis for setting priorities for regulation, standardization and other policies

• Form a cross-stakeholder and actor working group for inclusion in the National Health Information System Roadmap

CSO, private sector, academics, professional organizations: participating in the working group providing input to the Ministry of Health to revise the National Health Information System Roadmap


The work unit indicators are in accordance with the National Health Information System Road Map

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Pusdatin Kemenkes

• Together with the Directorate of Public Health prepare hardware for the development of knowledge platforms

• Together with the Directorate of Public Health develop and test database information systems

• Together with the Directorate of nutrition, ensure the reliability of the nutrition database and knowledge platform

• Develop a data / information system that enables data exchange between public-public and public-private health services

• Integration of prevalence data and programs related to stunting prevention in the MHealth platform developed by the Ministry of Health’s Pusdatin

CSO, private sector, academics, professional organizations: provide input and technical assistance if needed

Strong and efficient National Health Information System

• Availability of knowledge platform

• Availability of information systems for databases

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BPS and Litbangkes

Carry out SSGBI routinely once a year to find out the current prevalence of toddler stunting

Develop e-government manuals on nutrition issues in Indonesia

Bappenas forms a cross-K / L working group and actors for the sake of coordination and evaluation of the substance and infrastructure needed

CSO, private sector, academics and professional organizations:

Involved in the working group providing input and technical assistance when needed

Guidelines for implementing e-government for nutritional problems in Indonesia

Issuance of e-government implementation guidelines for nutrition issues in Indonesia

Develop mechanisms for involvement of CSOs and individuals to implement social accountability mechanisms

Bappenas together with working groups across K / L and cross actors develop social monitoring mechanisms in the effort to prevent and reduce stunting

Regional government

Incorporating nutritional agendas especially stunting into village planning agendas such as through MMD to communicate and discuss data at the community level

CSO, private sector, academics and professional organizations:Involved in working groups to provide input and technical assistance when needed

CSO:Encourage and oversee the process through capacity building and monitoring in the field

Social monitoring mechanism in the prevention and reduction of stunting in Indonesia

Trial of social monitoring in efforts to prevent and reduce stunting in Indonesia in 2020

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54. Badan Penelitian dan Pengembangan Kesehatan, “Laporan Riskesdas 2013,” Kemenkes RI, Jakarta , 2013.

55. S. t. Children, “Nutrition in the First 1000 Days: State of the World’s Mothers 2012,” 2012.

56. World Health Organization, “Comprehensive implementation plan on maternal, infant and young child nutrition,” World Health Organization, Geneva, 2014.

57. Kementeriaan Hukum dan HAM RI, “Peraturan Presiden Republik Indonesia Nomor 42 Tahun 2013 Tentang Gerakan Nasional Percepatan Perbaikan Gizi,” Kemenkumham , Jakarta, 2013.

58. World Bank, “Repositioning Nutrition as Center for Development: A Strategy for Large-Scale Action,” WorldBank, Washington DC, 2006.

59. Kementerian Keuangan RI, “Nota Anggaran,” Kemenkeu , Jakarta, 2019.

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Appendix 1. Policies related to Toddlers’ Body Height Measurement and Integrated Stunting Data Publication

No Policy About Note

1 Law No. 36 of 2009 Health Implementation of efforts to improve community nutrition

2 Kepmenkes No. 1995 of 2010

Anthropometric standards for assessing children's nutritional status

The standard refers to the 2005 WHO standard

3 Law No. 18 of 2012 Food The nutritional status of the community is an important component in food development requires central and local governments to prepare a Food and Nutrition Action Plan (RAPG) every five years

4 President Regulation No.83 of 2017

Strategic Food and Nutrition Policy

Compilation, implementation, monitoring, evaluation and reporting of the RAN-PG program

5 President Regulation No. 42 of 2013

Gernas PPG in the framework of 1000 HPK

National Movement for the Acceleration of Nutrition Improvement

6 Permenkes No. 25of 2014

Children’s Health Efforts Set the frequency and target age of monitoring service packs of child growth

7 Permenkes No. 66of 2014

Monitoring the growth, development and developmental disorders of children

Monitoring the growth, development and developmental disorders of children up to age 72 months

The obligation to record and report on children’s DDTK activities

8 RPJMN 2015-2019 National Medium-Term Development Plan 2015-2019

Stunting prevention indicators and targets as national development targets

9 RAN-PG 2015-2019 National Action Plan for Food and Nutrition 2015-2019

Road map in reducing the double burden of nutrition problems at the central and regional levels

10 Stranas penurunanstunting 2018-2024

Acceleration of stunting reduction in 2018-2024

Guidelines for implementing stunting reduction efforts

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11 RPJMN 2020-2024 National Medium-Term Development Plan 2020-2024

Indicators and targets for stunting reduction of up to 22% by 2024

12 Permenkes No. 4Tahun 2019

Technical Standards for Fulfillment of Basic Service Quality on Minimum Service Standards in the Health Sector

Obligations of the District / City to provide weighing services at least 8 times a year, and measure length / height at least 2 times a year

13 Permendesa PDTT No. 11 of 2019

Priority Use of Village Funds for 2020

Contains Stunting as one of the priorities in the utilization of village funds

14 Government Regulation No. 46 of 2014

Health Information System

Regulate types, indicators, collection and storage of health information

15 Law No. 39 of 2019 One Data for Indonesian Policy framework for standardization of data collection and integrated evidence-based policy making

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Appendix 2. Interview: Protocols and Instruments

Reference frameworkInDepth Interview Study of Toddler Development and Monitoring and

Utilization of Integrated Data Stunting Systems in Indonesia”

Purpose of the Study

This study aims to gather input and recommendations related to monitoring and promotion of growth and development of toddlers and integrated data stunting systems in Indonesia.

The results of the discussion will be used as writing material for studies related to monitoring and promotion of child growth and development and an integrated data stunting system in Indonesia.

Time and placeDiscussion period : 6-13 August 2019Duration : ± 60 minutes per speakerLocation of discussion : in favor of the speaker

Discussion TopicEach resource person will be invited to discuss a number of topics, including:1. National Strategy for the Acceleration of Prevention of Stunting, specifically the fifth pillar regarding

monitoring and evaluation2. Standard monitoring and promotion of growth and development of toddlers in Indonesia, covering:

a. Methods and measurement tools for toddler anthropometryb. Urgency of monitoring and promotion of growth and development of toddlers related to the target of

reducing Stunting3. Monitoring and promotion programs for toddlers’ growth in Indonesia, which cover:

a. Posyandub. Mat growth and developmentc. Healthy Indonesia Program with a Family Approach

4. Integrated stunting information system as an effort to monitor and evaluate the growth and development of toddlers at the national levela. Integrated Susenas Study of Indonesian Toddler Nutrition Status (SSGBI)b. Nutrition Status Monitoring (PSG)c. E-PPGBM

Follow-up Plans

The results of discussions with several resource persons will be summarized in a draft study. As a form of follow up, CISDI will hold a Focus Group Discussion (FGD) on October 8, 2019 to discuss the draft study results on Monitoring and Promotion of Toddler Growth and Utilization of the Integrated Data Stunting System in Indonesia. After that, the results of the study will be disseminated to the Ministries, Institutions and relevant stakeholders in November.

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No Topic Sub-Chapter Question Probing

1 Toddlers’ Monitoring and Promotion Standards and their relationship to the National Acceleration of Prevention

1. Anthropometric measuring devices in Indonesia

1. Are there differences in global anthropometric measurement standards with Indonesia?

• Length Board• Microtoise• Growth mat• Technical ability

2. What technical skills are needed by officers in monitoring and promoting activities for toddlers?

• Training• Monitoring

3. How are the availability of resources for monitoring and promotion of Toddler growth and development in Indonesia

• Measuring instrument

• Officer• Location• Financing

4. What are the technical obstacles in measuring the growth and development of infants?

• Availability and quality of tools

• Toddlers cry when measured

• Health workers are not trained

Questions for In-depth Interview

Monitoring and Promotion of Toddler Growth and Development in Indonesia and its Relation to the Integrated Data Stunting System

Speaker : Sugeng Eko Irianto, MPS, PhD

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2. Clinical Perspectives - Relevance Monitoring and promotion of children’s growth and development with stunting prevention programs

1. What happens if the child does not receive monitoring and promotion services?

• Growth faltering

2. What information should officers submit to parents after measurement?

• Media KIE• Officers’ ability

3. How to implement the monitoring and promotion of growth and development that you know and understand at the national, subnational or on the field level?

• Posyandu• Private clinics• PIS PK

3. Policy perspective - Relevance Monitoring and promotion of child development with stunting prevention programs

1. Why is the monitoring and promotion of growth and development an aspect of the national strategy for the Acceleration of Stunting Prevention?

2. What extent to which GMP has a role in achieving the national acceleration of stunting prevention targets?

• Stranas Stunting 5th pillar

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3. Which institutions are responsible for monitoring and promoting the growth and development of toddlers?

4. Does WHO have a strategy / intervention that targets monitoring and promotion of child growth and development and stunting data management?

• Kemenkes• 22 Ministry/

Institution• Role of WHO

5. Are monitoring and promotion activities for toddlers’ growth still an attraction for parents / caregivers?

• Posyandu• Urban Vs Rural

6. Is there a policy regarding monitoring and promotion of child growth and development at the regional level?

• Regional Action Plans

• Regulation of the Regent / Mayor

2 Integrated platform and stunting data system

1. Implementasi 1. Bagaimana implementasi dari sistem manajemen data stunting yang terintegrasi yang Bapak ketahui?

• SUSENAS• RISKESDAS• PSG KEMENKES

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2. Recommendations 2. What can still be improved or changed from the implementation so far related to the monitoring and promotion of growth and development of toddlers and data management systems?

• Ministry and Institution

• Local

3. The role of stakeholders

3. What is the role of relevant stakeholders that must be increased to accelerate the decline in stunting? especially related to growth monitoring and promotion of child growth and development and integrated stunting data

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Appendix 3. Focus Group Discussion: Protocols and Instruments

Terms of Reference for Focus Group Discussions on Toddler Body Height Monitoring and Its Relationship with Integrated Stunting Data

Management in Indonesia

Background

At present, the prevalence of stunting and malnutrition in Indonesia is at a critical level. According to the 2018 Basic Health Research (RISKESDAS), 30.8 percent of Indonesian children under 5 years old (around 7.3 million children) experienced stunting, 10.2 percent underweight, 13.8 percent experienced wasting (low body weight and height), and 11.9 percent overweight or obese.

The government gives a very big focus on reducing the prevalence of stunting and malnutrition. This can be seen from the National Medium-Term Development Plan (RPJMN) 2020-2024, the National Strategy for accelerating stunting reduction in 2018-2024, the National Food and Nutrition Action Plan to innovations in existing programs and services such as the optimization of Integrated Service Posts (Posyandu ), Human Development Cadres with growth mat, and Nutrition Information System (Integrated Nutrition) which includes e-PPGBM and PMT distribution consumption.

Nevertheless, challenges in the form of data utilization that have not been integrated, inequality of access and facilities and data validity in the field are issues that need to be answered. As a first step in this study, CISDI has conducted a literature study and interview with 27 stakeholders across ministries, professional organizations and local governments to further understand the policy direction of the national nutrition program coordinator, implementation by technical ministries and directly study conditions in the field.

Preliminary results of the study show the following findings:1. The current policy framework needs to be improved to address the needs that exist in the field, such

as the division of coordinating roles among the ministries / institutions involved so as not to overlap. In addition, there is no policy framework that regulates the involvement of key actors from various sectors outside the ministry / agency.

2. There are technical challenges in ensuring the implementation and quality of height calculation; related to technical guidelines and standardization of height calculation, availability of infrastructure and resources, and implementation of monitoring and promotion of growth and development. These include differences in operational definitions for interpretation of height calculation results, poor application of behavioral change communication, limitations of adequate measurement and HR tools and weak data integration with available monitoring systems.

3. The low quality of data and the scope of stunting means that the available data cannot be optimized as a basis for policy making.

The initial results of this study can be studied in the attached document and will be explained further in a focus group discussion which also presents 25 expert invitations representing 15 government institutions, professional organizations, and international organizations. Through this discussion, CISDI hopes to gain deeper input related to interim findings and recommendations as a contribution in optimizing an integrated stunting data system to monitor the development of toddlers in Indonesia.

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Purpose of Activity

This group discussion will discuss the draft study results regarding Monitoring and Promotion of Toddler Growth and Utilization of the Integrated Data Stunting System in Indonesia.

Discussion Method

This activity will use the Delphi Method which aims to create a convergence of opinions that can target specific issues. Led by a lead moderator, the Delphi Method of all discussion participants in order to contribute effectively by answering open-ended questions. The opinions and recommendations collected will be structured in accordance with the research findings anonymously / Chatham House Rule. To create a conducive situation and effective discussion, discussion participants will sit at a round table and be facilitated by a co-facilitator.

Time and Place

Day, date : Wednesday, 16 October 2019Time : 08.00 – 13.00 Jakarta TimeLocation : Manhattan Hotel, Jl. Prof. Dr. Satrio, Kuningan, Jakarta 12950

Agenda of Activity

Time Activities Session Speaker Note

07.30 – 08.00 Registration of discussion participants

08.00 – 08.15 Opening speech & introduction to discussions: Interim Study Results

Founder and Chairperson of the CISDI Board of TrusteesDiah Saminarsih

08.15 – 09.00 Discussion session I: Events / trends

Moderator:Diah Saminarsih

Co-facilitator: CISDI

09.00-09.10 Break

09.10-09.55 Discussion session II: Drivers Moderator:Diah Saminarsih


09.55-10.05 Break

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10.05-11.45 Discussion session III: Scenario / Roadmap in GMP

Moderator:Diah Saminarsih


11.45 – 12.00 Closing

12.00 – 13.00 lunch

Framework of questions for discussion

Events/Trends• Noting the current conditions in the policy framework, governance, and financing in reducing stunting;

how are the expert speakers’ opinions about trends that arise in the implementation of height measurement, monitoring and data management systems used?

Drivers• In the view of expert experts, at what point are we (Indonesia) at present, based on mapped trends.• What is the cause of the tendency according to expert opinions / observations?

Scenario/ Roadmap• In planning scenarios for the future, what factors and actions in view of the expertise of expert resource

persons, which must be considered in connection with: - Key stakeholders - Uncertainty factors that must be considered (Politics, Economy, Law) - Sustainability and social impact aspects - Events and trends that are happening now and will continue to occur in the future

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Appendix 4. List of Respondents / Interviewees

No Name Organization/ Affiliation Date of Interview

Mode of Interview

Duration

1 dr. Aman Bhakti Pulungan, Sp.A(K)

Chairperson of IDAI 15 August 2019 Direct 55 Minutes

2 Dr. Sudikno, SKM,MKM PPI (Scientific Advisory Committee) Research and Development Efforts

Public Health Ministry of Health of the Republic of Indonesia

21 August 2019 Direct 67 Minutes

3 Pungkas Bahjuri Ali, STP, MS, Ph.D

Disposition:Dr. Entos Zainal, DCN, SP., MPHM

Bappenas Director of Public Health and Nutrition

Head of Sub Directorate for Community Nutrition Empowerment of Bappenas


4 R. Giri Wurjandaru, SKM, M.Kes

Head of Nutrition PrecautionsMinistry of Health of the Republic of Indonesia

16 August 2019 Joint Interview 62 Minutes

5 Dakhlan Choeron, SKM, MKM

Head of Nutrition Endurance SectionMinistry of Health of the Republic of Indonesia

16 August 2019

6 Gantjang Amanullah, M.A.

BPS Director of People’s Welfare Statistics


7 Sugeng Eko Irianto, MPS, PhD

NPO Nutrition WHO Indonesia


8 Kepala Seksi Gizi, Promkes dan PPSM

Disposition :Staf Seksi Gizi, Promkes dan PPSM

DKI Jakarta Provincial Health Office


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9 Boga Hardhana, S.Si, MM

Head of Information Technology Management

Pusdatin Ministry of Health of the Republic of Indonesia


10 Iing Mursalin Lead program Manager for Stunting TNP2K


11 dr. Erna Mulati, MSc-CMFM

With dr. Iwi dan dr. Widya (Staff)

Family Health DirectorMinistry of Health of the Republic of Indonesia


12 Dr. Elvina Karyadi Co-TTL INEYSenior Health Specialist, WB Indonesia


13 Dr. Minarto, MPS Chairperson of PERSAGI 20 August 2019 Direct 89 Minutes

14 Bito Wikantosa, SS., M.Hum with Mr. Ade Wahyu

Director of Basic Social Services Ministry of PDTT


15 Dr. Nata Irawan, SH, MSi

Disposition:Drs. Budi Antoro, MBAwith Mr. Hari Panji (Staf)

Director General of Village Ministry of Home Affairs Development

Director of Institutional and Village Cooperation Ministry of Home Affairs


16 drg. Agus Suprapto, M.Kes

Disposition:Meida Octarina, MCN

Deputy for Coordination in the Field of Health Improvement of the Ministry of PMK

Assistant Deputy for Nutrition, Mother and Child Health, and Environmental Health Ministry of PMK


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Appendix

17 dr. Ganda Raja Partogi Sinaga, MKMwith Ms. Era (Staff)

Kasubdit PuskesmasMinistry of Health of the Republic of Indonesia


18 drg. Novarita

withdrg. May Haryantiand Eti Rohati, Am.Keb, SKM

Head of Depok City Health Office

Head of Community Health Section Head of Family Health and Nutrition

16 September 2019

Direct 49 Minutes

19 drg. Susi Setiawaty, MARS

Disposition:drg. Iing Ichsan Hanafi, MARS

ARSSI Chairperson

ARSSI Secretary General

17 September 2019

Direct 19 Minutes

20 dr. Krishnajaya, MS

Disposition:Drs. Sawidjan Gunadi, MKes

ADINKES Chairperson

ADINKES Executive Board

18 September 2019

Direct 46 Minutes

21 Head of Department

Head of Community Health Section, Family Resilience and Nutrition, Village Midwives and Cadres

Nganjuk District Health Office

2-3 September 2019

Direct -

22 Denni Puspa Purbasari, M.Sc., Ph.D

Disposition:Dr. dr. Brian Sriprahastuti, MPH

Deputy III for the Study and Management of KSP Strategic Economic Issues

Top Expert Deputy III KSP

26 September 2019

Direct 94 Minutes

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Appendix 5. List of Group Discussion (FGD) Expert Interviewees

Implementation of Toddler Body Height Measuring and Integrated Stunting Data Management in Indonesia

No Name Position Institution

1 Dr. dr. Brian Sriprahastuti, MPH

Top Expert Deputy III Presidential Staff Office (KSP)

2 Guruh Hariwibowo, SKM Head of Public Health Nganjuk District Health Office

3 dr. Erna Mulati, MSc-CMFM

Dispositiondr. Milwiyandia, MARS

Family Health Director

Toddler Subdit StaffDirectorate of Family Health

Ministry of Health of the Republic of Indonesia

4 Gantjang Amanullah, M.A.

DispositionHasnani Rangkuti M.Si, Ph.D

Director of People’s Welfare Statistics

Head of Sub Directorate of Health and Housing Statistics

Central Statistics Agency (BPS)

5 Prof. Dr. dr. Akmal Taher, SpU(K)

Special Staff of the Minister for Health Service Improvement (2014-2019) Advisory Board Member


CISDI

6 Bito Wikantosa, SS., M.Hum

DispositionAde Wahid, S.Pd

Director of Basic Social Services

Monitoring SpecialistTeam for the Acceleration of Prevention of Little Children (Stunting) / TP2AK - Secretariat of the Vice President

Kemendes PDTT

7 Dr. dr. Aman B Pulungan, SpA(K), FAAP, FRCPI (Hon)

Chairman Indonesian Pediatrician Association (IDAI)

8 Dr. Sudikno, SKM, MKM Center for Research and Development of Public Health Efforts


9 dr. Krishnajaya, MS

DispositionHalik Sidik, ME

Chairman

Secretary of the Executive Board

Association of Indonesian Health Services (ADINKES)

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Appendix

10 R. Giri Wurjandaru, SKM, M.Kes

Head of Sub Directorate for Nutrition Alertness Directorate of Community Nutrition


11 Akim Dharmawan, SKM, M.Kes, Ph.D

Consultant World Bank Indonesia

12 Eti Rohati, SKM, MKM Head of the Family Health and Nutrition Section

Depok City Health Department

13 Dr. Minarto, MPS

DispositionDr. Atmarita, Ph.D

Chairman

Vice Chaiman III Research and Development and Publication

Indonesian Nutritionists Association (PERSAGI)

14 Dr. Elvina Karyadi, M.Sc, Ph.D, SpGK

Co-TTL INEY, Senior Health Specialist

World Bank Indonesia

15 dr. Octoviana Carolina S Head of Nutrition Section, Promkes and PPSM

DKI Jakarta Provincial Health Office

16 Prof. dr. Fasli Jalal, Ph.D, Sp.GK

YARSI University Chancellor, Nutrition Expert CISDI Advisory Board Member

CISDI

17 Dr. drh. Didik Budijanto, M.Kes

DisposisiAnnisa Harpini, SKM, MKM

Head of Pusdatin

Data and Information Management Data Center Staff (Pusdatin)


18 Nathaniel Bassa Staff National Team for the Acceleration of Poverty Reduction (TNP2K)

19 Febrida Yulianti, S.STP, M.Si Staff of Health Sub DirectorateDirectorate General of Regional Development

Ministry of Home Affairs

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Appendix 6. List of Dissemination of Results of Expert Resource Review

Implementation of Toddler Body Height Measuring and Integrated Stunting Data Management in Indonesia

No Name Institution Time

1 dr. Erna Mulati, MSc-CMFM Family Health Director of the Ministry of Health of the Republic of Indonesia

Wednesday, 11 December 2019

2 drg. Agus Suprapto, M.Kes Deputy for Coordination in Health ImprovementKemenko PMK


3 Ardhiantie, SKM, MPH First Functional Planner, Directorate of Health and Community Nutrition, Bappenas


4 Dr. Atmarita, MPH Vice Chairman III: Research and Development and PublicationIndonesian Nutritionists Association (Persagi)


5 Dr. Krishnajaya, MS

DispositionHalik Sidik, ME

ChairmanAssociation of Indonesian Health Services (ADINKES)

Secretary of the Executive Board

Thrusday, 5 December 2019

6 Dr. Elvina Karyadi Co-TTL INEY, Senior Health Specialist World Bank Indonesia


7 Dr. dr. Brian Sriprahastuti, MPH

Deputy Chief Expert III of the Presidential Staff Office (KSP)


8 Prof. Dr. dr. Akmal Taher, SpU(K)

CISDI Advisory Board,Professor of the Faculty of Medicine UI,Special Staff of the Minister of Health for Service Improvement (2014-2019)


9 Prof. Dr. H. Muhadjir Effendy, MPA

Coordinating Minister for Human Development and Culture

Friday, 20 December 2019

10 Dr. HC. Ir. H. Suharso Monoarfa

Minister of National Development Planning Agency


Stakeholder Engagement (one-on-one meeting)

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Appendix 7. List of Expert Resources Providing Written Input

No Name Institution Time

1 Iing Mursalin Lead Program Manager for Stunting National Team for the Acceleration of Poverty Reduction (TNP2K)


2 DakhlanChoeron, SKM, MKM

Head of Nutrition Endurance Section of the Ministry of Health of the Republic of Indonesia

Tuesday, 10 December 2019

3 Dr. Sudikno, SKM, MKM Research and Development Center for Public Health Efforts Ministry of Health of the Republic of Indonesia


4 dr. Octoviana Carolina S Head of Nutrition Section, Promkes and PPSM DKI Jakarta Provincial Health Office

Monday, 9 December 2019

5 Guruh Hari Wibowo, SKM Head of the Public Health Sector Nganjuk District Health Office


6 Eti Rohati, SKM, MKM Head of Family Health and Nutrition Section of Depok City Health Office


7 Akim Dharmawan, S K M , M.Kes, Ph.D

Consultant ofWorld Bank Indonesia

Sunday, 15 December 2019

8 Annisa Harpini, SKM, MKM Data and Information Management Staff, Pusdatin, Ministry of Health of the Republic of Indonesia

Tuesday, 17 December 2019

9 Winne Widiantini, SKM, MKM Head of Information Dissemination Sub Division, Pusdatin, Ministry of Health of the Republic of Indonesia

Friday, 3 Januari 2020

2 October 2019draft v.8

IMPLEMENTATION OF TODDLERS’ HEIGHT ......Implementation of Toddlers’ Height Measurement...

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