Gap between expected and invested efforts to improve

Maternal and Child Health & Nutrition in Indonesia:

a challenge for the Indonesian Government

Dr. Harriet Torlesse

Chief Nutrition
Gap between expected and invested efforts to improve
Maternal and Child Health & Nutrition in Indonesia:
a challenge for the Indonesian Government

① Expected efforts

② Invested efforts

③ Bridging the gap

 No progress in reducing malnutrition

Source: Basic Health Research Survey, 2007, 2010, 2013

Prevalence in Indonesia is similar to countries
in Africa and South Asia (2013/2014 surveys)
 Indonesia ranks in top five countries for
number of children affected
5th highest in
the world

4th highest in
the world

Source: UNICEF calculations based on 2013 RISKESDAS nutrition data and BPS population projects for 2013
Indonesia accounts for one-third of the
stunting burden in South East Asia

6
World Health Assembly targets for nutrition
Global target 1 40% reduction of the global number of children
under five who are stunted
Global target 2 50% reduction of anaemia in women of
reproductive age.

Global target 3 30% reduction of LBW

Global target 4 No increase in childhood overweight

Global target 5 Increase the rate of exclusive breastfeeding in

the first six months up to at least 50%.
Global target 6 Reduce and maintain childhood wasting to less
than 5%.

Indonesia is currently “on track” for only Global Target 5

① What are the “expected efforts”
in nutrition globally?
Essential interventions according to the
2013 Lancet nutrition series
Paper 2, Bhutta et al
Essential interventions according to the
2013 Lancet nutrition series

Pregnant women
• Multiple micronutrient supplements (replacing iron-folate)
• Calcium supplements for women at risk of low calcium intake
(prevents pre-eclampsia)
• Maternal balanced protein-energy supplements
• Universal salt iodization
Essential interventions according to the
2013 Lancet nutrition series

Children <5 years

• Promotion of exclusive breastfeeding for six months, and
continued breastfeeding for 2 years
• Education on appropriate complementary feeding;
complementary food supplements in food insecure populations
• Vitamin A supplements twice yearly (6-59 months)
• Preventative zinc supplements (12-59 months)
• Supplementary feeding for children with moderate acute
malnutrition (moderate wasting)
• Therapeutic feeding for children with severe acute malnutrition
Essential interventions according to the
2013 Lancet nutrition series

Impact of 10 interventions delivered at 90% coverage could

result in
• 15% reduction in child deaths (including deaths due to
diarrhea, pneumonia and measles)
• 20% reduction in stunting
• 60% reduction in wasting
• Achievement of WHA nutrition targets for 2025
② What are the “invested efforts”
in nutrition in Indonesia?
What is the coverage of essential nutrition
interventions in Indonesia?
Pregnant women Children under five
Multiple micronutrient Promotion exclusive breastfeeding.
supplements. Continued breastfeeding for
two years.
Calcium supplements.
Education on complementary
Balanced protein-energy feeding.
supplements. Complementary food supplements
Universal salt iodization. in food insecure areas.
Vitamin A supplements.
Preventative zinc supplements.
Supplementary feeding for
moderate acute malnutrition.
Therapeutic feeding for severe
acute malnutrition.
Multiple micronutrient supplements (MMS)
• Current policy is to give iron-folic acid (IFA) supplements to pregnancy
women, but allows for MMS
• Pregnant women should consume at least 90 supplements
• In 2013, only 33% pregnant women consumed >90 IFA supplements

80.0

60.0

33.2
40.0

20.0

18.0
0.0
Sumbar
Lampung

Sumut

Bengkulu

Jatim
Sulut

NTT
Kalteng

Sulteng

Malut

DKI
NTB

DIY
Sulsel
Kalsel
Sultra
Sumsel
Kaltim

Banten
Jabar

Bali
Aceh
Maluku

Riau

Kep.Riau
Jambi

INDONESIA

Jateng
Sulbar

Papua

Kalbar
Pabar

Babel
Gorontalo

2010 2013
 Calcium supplements during pregnancy
2012 Cochrane review of 15 RCTs showed that calcium
supplementation during pregnancy:
• Reduces incidence of gestational hypertension by 35%,
pre-eclampsia by 55% and preterm births by 24%
• Increases birth weight by 85g.
Effect was mainly in populations with low calcium intake.
WHO (2013) recommends pregnant women take 1.5 to 2 g
of calcium every day in populations with low calcium intake.

In Indonesia health facilities in some districts give pregnant women

15-20 tablets/month comprising 0.5 g calcium but:
• No coverage data available
• Dose/frequency much lower than WHO recommendations, and
geared towards “improving bone growth” not prevention of
pregnancy/birth complications
17
 Balance protein-energy supplements
• There is a lack of clear international guidance on
balanced protein-energy supplements in non-emergency
settings.
• In Indonesia some pregnant women with LILA <23.5 cm
receive the “sandwich biscuit” but coverage is unknown
 Universal salt iodization
• Salt iodization is mandatary in Indonesia and iodized salt is
promoted through the health sector
• In 2013, 92% of the population consumed iodized salt but
laboratory results indicate that only 47% consumed
adequately iodized salt.
• Median urinary iodine concentration of pregnant women is in
the optimal range (150-249 g/L) but only just (163 g/L)
Promotion of exclusive breastfeeding and
continued breastfeeding for two years
 Promotion of exclusive breastfeeding and
continued breastfeeding for two years
• Health sector give excellent attention to exclusive breastfeeding
(EBF) but less to continued breastfeeding.
• 2009 Health Law and Government Regulations 33/2012 on EBF
protects EBF for six months but not continued breastfeeding for
two years.
• National strategy to support breastfeeding (2010) exists, as well as
guidelines, training materials and job aids for health workers and
community-based workers.
• Health sector does not collect data on coverage of breastfeeding
counselling services for mothers.
 Education on complementary feeding and
Complementary food supplements
in food insecure areas.
• National strategy to support complementary feeding (2010) exists,
as well as guidelines, training materials and job aids for health
workers and community-based workers.
• Health sector does not collect data on coverage of complementary
feeding counselling services for mothers.
 Vitamin A supplements (6-59 months)
• VAS is included in the Minimum Health Service Standards (SPM)
• In 2013 coverage of VAS was 75.5%
• Significant delays in reporting VAS coverage to national level
100.0
75.5
80.0

60.0
71.5

40.0

20.0

0.0
Banten
Sumut

Sulteng

NTT

Lampung

Jatim
Kalteng

Sumbar

Jambi

Sulut

NTB
Bengkulu

Bali
Malut

Sulsel

Kalsel
Sultra

Kaltim

DIY
Riau

Indonesia

Jabar
Kep.Riau
Babel

Aceh

DKI
Maluku

Sumsel
Papua

Pabar

Jateng
Sulbar

Kalbar

Gorontalo
2007 2013
 Preventative zinc supplements

• Zinc is included in the Micronutrient Powders (MNP or taburia)

• Coverage of MNPs is unknown.
 Supplementary feeding for children with
moderate acute malnutrition

• Guidelines exists for treatment of moderate underweight (not

moderate acute malnutrition)
• Coverage data is not available.
 Therapeutic feeding for children with
severe acute malnutrition

Considerable gap between estimated

number of SAM cases and the reported
number of children who were treated

Treatment data from SMS Gateway

Burden and Incidence form Nutridash global database (Riskesdas 2013)
 At a glance:
Intervention Coverage
MMS for pregnant women 33% consumed at
least 90 tablets
Calcium supplementation for pregnant women No data
Balanced protein-energy supplements No data
Iodized salt
Promotion EBF and continued breastfeeding No data

Education on complementary feeding No data

Vitamin A supplements 75% children

Preventative zinc supplements/Micronutrient No data
Powders
Supplementary food for moderate acute malnutrition No data

Therapeutic feeding for severe acute malnutrition <2% according to

SMS gateway data
③ How to bridge the gap between
expected and actual efforts?
How to bridge the gap?

1. Use bottleneck analysis to understand why nutrition

services are not reaching children and women
2. Set clear expectations for managing and delivering
nutrition services.
3. Ensure compliance with procedures and standards.
4. Collect and use appropriate data to monitor what is
happening.
 Use bottleneck analysis
Determinants
Social Norms
Enabling Environment
Legislation/Policy
Budget/Expenditure
Management
/Coordination
Availability of Essential
Commodities/Inputs
Supply
Access to Adequately
Staffed Services, Facilities
and Information
Financial Access
Demand
Social and Cultural
Practices and Beliefs
Timing & Continuity of Use
Definitions
Widely followed social rules of behaviour
Adequacy of laws and policies
Allocation & disbursement of required
resources
Roles and Accountability/ Coordination/
Partnership
Essential commodities/ inputs required to
deliver a service or adopt a practice
Physical access (services, facilities,
information)
Direct and indirect costs for
services/practices
Individual/ community beliefs, awareness,
behaviors, practices, attitudes
Completion/continuity in service, practice
 Example: iron-folate supplements
Determinants
Social Norms
Enabling Environment
Legislation/Policy
Budget/Expenditure
Management /Coordination
Availability of Essential
Commodities/Inputs
Supply
Access to Adequately Staffed
Services, Facilities & info
Financial Access
Social and Cultural Practices
Demand
and Beliefs
Timing & Continuity of Use
Definitions
Not a bottleneck – no social norms that interfere
Not a bottleneck – policy/guideline exist
No budget to design counselling materials on IFA
Poor coordination between health centres & community-based
health posts -> opportunities missed to distribute IFA
Sufficient iron-folate at the health centre, but village midwives
often run out
Health staff and community-based works lack knowledge, skills
and counselling materials to counsel mothers on side-effects
Not a bottleneck
Mothers are concerned that iron-folate may increase birth
weight and likelihood of complicated delivery. Mothers dislike
side effects
Women visit ANC late in preg & make insufficient ANC visits
Set clear expectations for managing and
delivering nutrition services
• Ensure the SPM guidelines (NSPK) include the full package of
essential nutrition interventions and performance targets are
set.
• Assign clear roles and responsibilities for managing and
delivering nutrition services to
• Managers (in DHO, hospitals and health centres)
• All relevant service providers (doctors, midwife
coordinator, nurses, nutritionists, bidan desa, kader, etc).
Ensure compliance with procedures and
standards
• Equip managers and service providers with the knowledge and
tools to deliver nutrition services
• Strengthen supportive supervision of health workers and kaders
Collect and use appropriate data to monitor
what is happening
Urgent need to update the nutrition component of the health
management information system so it is “fit for purpose”:
• Review the nutrition indicators collected at posyandu and
health facility level to ensure they include all essential services
• New international guidance on a minimum set of nutrition
indicators is being developed and can be shared
• Review how data are analysed at facility and DHO level
• Review procedures for reporting of data to province and
national level
• Consider a “district/province score card” to monitor coverage at
subnational level
Summary
 Summary
Coverage of essential nutrition interventions among women and
children is far below optimal levels and/or data are not available.

Recommendations:
1. Use bottleneck analysis to understand why services are not
reaching children and women
2. Ensure the SPM guidelines (NSPK) include the full package of
essential nutrition interventions.
3. Assign clear roles and responsibilities for managing and
delivering nutrition services to managers and all relevant
service providers.
4. Ensure compliance with procedures and standards through
appropriate training and supportive supervision.
5. Update the nutrition component of the health management
information system so it is “fit for purpose”:
 Terima kasih

htorlesse@unicef.org