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Nutrition and Health Status and Program

of Infants and Young Children in Indonesia

DODDY IZWARDYDirector of Nutrition

Directorate General of Nutrition and Maternal and Child HealthMinistry of Health

Jakarta, August 13, 2014

Outline

Development of nutritional problems in Indonesia

What causes undernutrition in Indonesia

Policies and Programs on Nutrition Improvement

National Movement on Accelerating Nutrition Improvement within the Framework of The First Thousand Days of Life

Formulation of Policy Recommendations for the Next National Midterm Plan/RPJMN 2015 - 2019

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Development of nutritional problems in Indonesia

Progress on Nutritional Problem

Controlled ProblemsVAD and IDD

un-finished problemsStunting, underweight, IDA

Emerging problemsOverweight

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Vitamin A Deficiency

% Xerophthalmia (X1B)1978-1992

% retinol < 20 µg/DL1992-2007

54

14.6

0

10

20

30

40

50

60

1992 2007

Public health

problem 0.5 %

Public health

problem15 %

Source: - 1978 national survey of Vita A - 2007 national survey of micro nutrition- 1992 national survey of Vita A 5

Iodine Deficiency Disorders

IndicatorPublic health

problems2002/03 2007 2013

Median UIE of school age children(µg/L)

100-299 229 224 215

% UIE < 100 µg/L

≤ 20% 16,3 12,9 14,9

Source data: 2002 – Survai GAKI; 2007 – Riskesdas; 2013 - Riskesdas

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Prevalence of Iron Deficiency Anemia in year 1995-2013

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51.558.0

40.2

25.0 28.1

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

1995 (SKRT) 2001 (SKRT) 2004 (SKRT) 2006 (SUR GZMIKRO)

2013 (Riskesdas)

Public health problems

20 %

In U-5 Children

Pregnant women

Insufficient maternal nutrition as a main cause of undernutrition problem in children

Proportion of Chronic Energy Deficiency is high enough especially in adolescent

High rates of low birth weight showed poor maternal nutrition

Nutritional Status 1989-2013

31 28.2

21.6 18.4

17.9

19.6

12.8

8.4 5.4

4.9

5.7

0

5

10

15

20

25

30

35

40

1989 1995 2000 2007 2010 2013

underweight wasting

U-5 Nutritional Status 2010- 2013 Trend of Nutritional Status 1989-2013

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Malnutrition in Indonesia is high compared to other countries in Southeast Asia

Stunting is an issue in every province

Prevalence of stunting

40+

30-39

20-29

<20 Source: BKP/WFP using RISKESDAS 2007 data11

Rising inequities in stunting

Source: RISKESDAS 2007 & 2010

Reduction in stunting in

children in highest wealth

quintile

Increase in stunting in

children in lowest wealth quintile

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13

12.214.2 13.9 14.8

19.7

32.9

0

5

10

15

20

25

30

35

U-5(2007)

U-5(2010)

U-5(2013)

Men2007

Women2007

Men2013

Women2013

Proportion of Obese in Children and Adult

(Riskesdas)

14.011.9

“Overweight” needs serious attention

Overweight children under five has decline eventhough the prevalence still high (RISKESDAS)

Overweight (BMI> 25) increased in Female Adult > 18 years

2010 2013

Hipertensi (%) 7.6 9.5

Diabetes (%) 1.1 2.1

Stroke (per 1000 pop) 8.3 12.1

NCD increades in Adult Group

Riskesdas 2013

What causes undernutrition in Indonesia

What causes undernutrition in Indonesia?

• Only 36% children 6-23 months consume a “minimum acceptable diet” (IDHS, 2012)

• 14% of children have suffered diarrhea in the last 2 weeks (IDHS, 2012)

• 24% defecated in the open (JMP, 2013)

• 14% do not have access to an improved water source (JMP, 2013)

• Only 42% children less than 6 months are exclusively breastfed (IDHS, 2012)

• 12% are below the national poverty line (SUSENAS, 2012)

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T a r g e t s

• The targets are through all Life Cycles

• The priorities targets are The First 1000 Days of Life: Pregnant Women Children Under Two years old

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Growth Body Massand Body Composition

Glucose, Lipids, Protein

Hormon / Receptor/GenMetabolic

Brain Development

Cognitive and Educational Performance

Immune Capacity

Diabetic, Obesity,Cardiovascular, Cancer

Stroke, and Disability of Elderly

Nutrition in The First1000 Days of Life

(fetal and children under two years)

Short term impact Long term impact

Death

Sumber: Short and long term effects of early nutrition (James et al 2000)

Why The First 1000 Days of Life?

Critical period of fetal

development

All of fetus formation were happened in the

first 8 week conception

Policies and Programs on Nutrition Improvement

CurativePreventivePromotive

Concept and Programs of Nutrition Services in Indonesia

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Caring

Malnourished

ChildUnderweight Child

by giving

Complementary

Feeding for

Recovery• Growth Monitoring

• Counseling BF/IYCF

• Giving Vit A Capsul

• Giving IFA tablet

• Promoting Iodized salt

• Active screening

• Giving TABURIA

• PMT pregnant women CEM

Local vs Instant

Impatient vs Outpatient

No Weight Gain/

Wasting

Malnourised

Spesific Nutrition Intervention

Pregnant Mother

Lactating Mother

Children Under

Five

School Children

Adolescent

Elderly

Folate Suplementation

Supl. Feeding Malnourished Pregnant Mother

De-worming prevention

Calcium supl.

Breastfeeding promotion

Breastfeeding counseling

Growth monitoring

Vit.A Suplementation

Iodization

Supl.feeding

Fortification

Zinc diarrhea management

De-worming prevention

• Imunization • School Health Program• Supl.feeding• Promotion healthy

street food

• Reproductive health

• Nutr.Counseling• Fe Suplementation

• Nutr.counseling• Nurt. servicess

Multi Sectoral Nutrition Development Mainstream

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Food and Nutrition Security

National Health

Insurance

Poverty alleviation

Family Planning

Water supply and sanitation

Female adolescent

Community nutrition education

Sensitive Nutrition Intervention

Nutrition Policies

Health Law No.36/2009 establish nutrition development target to achieve individual and community nutritional status by:

•Improve food comsumption patterns that suitable with balanced nutrition;

•Improve nutrition awareness, physical activity, clean and healhty life behaviour (PHBS);

•Increase acces and nutrition serveces level that suitable with science and technology advances.

Nutrition Strategies

1. Implementing the Presidential Decree No.42/2013 on National

Movement to Accelerate Nutrition Improvement

2. Developing nutrition education integrated to national education

system

3. Developing coordination to provide nutrition supplementation

and optimizing utilization of BOK

4. Developing of nutrition services integrated to mother and child

health systems

5. Strengthening health worker capacity

6. Strengthening nutrition surveillance

Challenges and Opportunities

• Increasing of the purchasing power, the poor vs rich

• Changing of demographic structure, urbanization vs proportion of elderly

• Changing of life style, unbalanced diet vs food safety

• Double burden problems, stunting vs obese

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Strategies

• Nutrition education improvement through development EIC (Education Information communication) material and campaign

• Providing nutrition supplementation through strengthening local and central resources

• Capacity building of health staffs

• Providing of complementary feeding for underweight children U5 and supplementary feeding for pregnant women

• Integrating nutrition service for pregnant women through ANC

• Implementing Nutrition surveillance in all districts

• Strengthening collaboration of multi sectors, professionals, private sectors and donor agencies

• Developing policy and regulation of nutrition services (NSPK)

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National Movement on Accelerating Nutrition Improvement within the

Framework of The First Thousand Days of Life

• Presidential Decree No. 42/2013 on National Movement to Accelerate Nutrition Improvement within the Framework of the First 1000 Days of Life

– Provide authority to the Coordinating Ministry of People’s Welfare to oversee the coordination of the SUN Movement in Indonesia

– Identify coordinating structures to convene multiple stakeholders and sectors at national and sub national level

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Putting Policies in Place

• Policy Framework for the first 1,000 daysmovement is the central policy document forSUN movement. It identifies six nutritiongoals that cover stunting, wasting, overweight, low-birth weight and exclusivebreastfeeding

• Guidelines for Program Planning is areference for stakeholders for planning andbudgeting as well as for implementing,monitoring and evaluating the progress ofSUN movement

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• Food and Nutrition Action Plan 2011-2015 (National& Provinces)

– Developed as a guideline and direction inimplementing food and nutrition development atnational, provincial, district levels, not only forgovernment but also for other related parties involvedin the food and nutrition improvement.

– All relevant ministries such as the ministry of health,agriculture, industry, home affairs, education, religiousaffairs, food and drug control, marine and fisheries,and bappenas (developmen & planning agency) areready and are committed to act

– In progress: aligning indicators with SUN PolicyFramework (specific and sensitive nutritionintervention)

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1000 Days of Life Movement Target at the end of 2025

• Reduce the proportion of stunted children under five by 40%

• Reduce the proportion of wasted children under five to less than 5%

• Reduce the proportion of low birth weight infants by 30%

• No increase in the proportion of overweight children under five

• Reduce the proportion of anemia among reproductive-aged mothers by 50%

• Increase the exclusive brastfeeding rate in the first six month at least by 50%

Nutrition Message for all ages

Pregnant Mother

Lactating mother

Under five -

mother

School Children

Adolescent

Elderly

community

eat 1 serving more Regular pregnancy check

Eat 1,5 serving more Exsclusive

brestfeeding

Breasfeed continue until 2 years

Growth monitoring

Breakfast habit Handwashing with

soap Growth monitoring

Food diversity Avoid cigarette,

alcohol, narcotic Regularly physical

activity

Food diversity Regularly physical

activity Pertahankan BB ideal

Food diversity Regularly physical

activity Regularly weighing Avoid cigarette,

alcohol, narcotic

Major opportunities in Indonesia

• Extensive community network of cadres and posyandu to reach childrenand women close to where they live

• Social protection platforms that target the most vulnerable children andwomen are in the process of being scaled-up and can be designed in waythat impact more effectively on nutrition:

– PNPM (National Program for Community Empowerment) Generasiand MCA Indonesia in 11 provinces, 64 districts, 499 sub-districts,5206 villages

– PKH Prestasi (Conditional Cash Transfer)

– National Insurance Program coverage

• Thriving business sector which can contribute enormously, if harnessedappropriately and in-line with government regulations to protectchildren’s rights to breastfeed.

• Parent’s desire for their children to do well at school – parents are ourmost important ally but need to understand how important nutrition is inearly life.

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Formulation of Policy Recommendations for the Next National Midterm

Plan/RPJMN 2015 - 2019

Improve access to quality nutrition services, with focus on adolescent girls, pre-pregnant women, pregnant women,

breastfeeding women and children under two years.

• Support the delivery of a package of integrated health and nutrition services to improve dietary intake and prevent and treat diseases that precipitate malnutrition.

• Establish delivery system to reach the adolescent girls and pre-pregnant for nutrition services

• Enhance service delivery models, including delivery through posyandus, with a focus on more effectively reaching vulnerable and marginalized groups.

• Strengthen the management of nutrition services by provincial and district government.

• Ensure health facilities have essential logistic supplies, including anthropometric and hemoglobin detection equipment, to assess the essential nutritional status.

• Raise public demand for services and promote behavior change

Implement the following essential Package of Interventions to Improve Nutrition with a full coverage of the priority targets

Adolescent girls and pre-pregnant women:

•Iron-folic acid (IFA) ormultiple micronutrient supplements (MMS)

Pregnant and postpartum women

•IFA or MMS during pregnancy and for 40 days postpartum

•Postpartum vitamin A supplementation (2 doses)

•Calcium supplementation

•Counseling on appropriate diet during pregnancy and breastfeeding

•Balanced protein-energy supplements for undernourished pregnant women

Children (Focus to U-2 children)

•Monthly growth monitoring for children 0-23 months and twice-yearly height measurement for children 6-36 months

•Promotion of early and exclusive breastfeeding for six months and continued breastfeeding for up to 2 years

•Education on appropriate complementary feeding

•Twice-yearly vitamin A supplements for children 6-59 months

•Micronutrient powders for children 6 -24 months

•Deworming for children 12-59 months

•Management of moderate and severe acute malnutrition

•Zinc supplementation for children with diarrhea

Update and standardize course curricula, core competencies, nutrition service standards and job descriptions for nutritionists.

Monitor the deployment and nutritionists

• Review the nutrition component of the health information system, including selection of indicators, age groups, periodicity, and reporting, based on information needs for policy and programme decisions.

• Strengthen the capacity of health workers at all levels to generate, analyse and utilize nutrition data for decision-making through training, mentoring and data reviews.

• Explore opportunities for real-time data collection using mobile phone technologies, building on the experiences of the SMS gateway, to automate data collection, validation and analysis

• Include relevant indicators in the SPM to reflect new programme focus on undernutrition (including stunting) and overnutrition.

Strengthen the production, analysis, dissemination and use of reliable and timely nutrition information by decision-makers at all level of the health system, both

on a regular basis and in emergencies

•Strengthen the design, implementation and monitoring of laws, regulations and standards for nutrition: Update, implement and monitor nutrition-related laws, regulations and standards, particularly in the areas of Breastmilk Substitutes, processed foods and fortified foods.

MULTISECTOR

Improve nutrition governance through effective leadership, coordination bodies and transparent accountabilities

•Strengthen multi-sector and multi-stakeholder coordination and planning for nutrition at national and subnational level.

•Establish clear accountabilities for nutrition across all relevant sectors and reflect in sector-specific strategies and plans.

•Institutionalize the Multi Sector Formulation of District Food and Nutrition Planning (RAD-PG) as the only basis for budget allocationfor all nutrition-specific and nutrition-sensitive activities

Improve health promotion and community empowerment with emphasize on behavior change

Strengthen community-based processes aimed at enabling community members to support adolescent girls, pre-pregnant women, pregnant women, postpartum mothers and children under two to receive adequate quality nutrition services

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THANK

YOU