Indonesia has achieved remarkable progress in women's and children’s health over the past decade. Yet, malnutrition is still a major concern and stunting has remained stubbornly high despite considerable government efforts to address the problem. An ambitious national strategy is ensuring that households with pregnant women or children under age two can access a package of diverse services essential to prevent stunting. The strategy aims to benefit 48 million mothers and children in 514 districts across the country and allow children to grow to their full potential. The Global Financing Facility (GFF) is providing catalytic support to the government to strengthen political commitment, coordination and accountability at all levels, scale up innovative information systems, and adopt the health financing reforms needed to accelerate impact.
Aligning Sectors towards a Single Goal
Over the past decade, Indonesia has made significant progress in health outcomes. Between 1990 and 2017 mortality of children under 5 declined dramatically by 67 percent and life expectancy increased from 63 years in 1990 to 69 years in 2015. Though the government has invested substantially in nutrition for mothers and young children, one out of three children under five were stunted in 2018; almost 18 percent were underweight; and 10 percent had a low weight-for-height ratio. These indicators have serious implications for the country’s potential to build its human capital, increase productivity and promote economic growth.
Experience and global lessons show that stunting requires leadership across multiple sectors and all levels of government. Based on this, the government made a high-level political commitment with the launch of an ambitious US$14.6 billion national strategy to accelerate stunting reduction. Led by Indonesia’s president and vice president, the strategy coordinates 23 ministries across sectors such as health, water and sanitation, early childhood education, social protection, and food security. The aim is to ensure that every household in the country has access to a core package of services proven to be effective in reducing stunting. The program started by targeting the 100 worst-affected districts and will scale up rapidly to reach all of Indonesia’s 514 districts by 2024. As of 2019, the program already covered an estimated 3.9 million mothers and 10.6 million children under age two.
Catalyzing Change through Political Commitment and Capacity Building
To bolster the national stunting reduction strategy, the GFF has committed US$20 million linked to a US$400 million project financed by the World Bank -- Investing in Nutrition and Early Years Program for Results. The GFF support is focused on specific catalytic actions including strengthening national coordination and accountability, scaling up specific interventions to close gaps in service delivery, and reforming health financing. For example, the GFF supports a series of ‘Stunting Summits’ in the 100 priority districts to secure political commitments from district leaders, which have led to concrete action plans and coordinated resource mobilization efforts to achieve the program’s goals. In addition, the GFF has supported the vice president’s office to establish a data-driven performance monitoring system and improve the availability of key health and nutrition outcome data, which helps flag and respond to bottlenecks and promote government accountability.
GFF-funded technical assistance is also supporting the scale-up of specific interventions to close gaps in health and nutrition service delivery. In order to better understand current gaps and challenges, the GFF is helping local governments to strengthen the capacity of their human development workforce, who go door-to-door to map households with women and children under two, identify service gaps, share information on nutrition, and incentivize families to access services. As a result of national scale up, from 2018 to 2019 the number of workers employed by the program grew 20-fold from about 3,500 to almost 73,000 workers, covering 97 percent of all villages, and 95 percent of these workers had been trained in relevant nutrition areas. Building on an existing scorecard system to monitor results, the GFF has helped Indonesia roll out innovative technology solutions such as a digital application that will enable real-time results monitoring in all 75,000 villages. To date, 39 percent of all villages have already implemented this digital application.
The GFF is also supporting behavior change communications on nutrition, early childhood stimulation, and sanitation and hygiene practices for vulnerable families. In 2019, 72 priority districts had implemented locally adapted behavior change communication activities. Almost 2,000 teachers have been trained in early childhood health and 843 teachers were certified.
Moreover, the GFF is supporting programs to ensure food security for households. In 2019, vitamin-rich and protein source food was introduced in the food assistance program and has been delivered to 15.2 million beneficiaries nationally.
Increased Resources and Spending Efficiency Helped Align Services
To promote more integrated service delivery, the GFF has supported the Ministry of Finance to pass a new regulation that requires local governments to align their planning and budgeting process with the national strategy’s priorities. The GFF also worked with the government to introduce a new budget transfer instrument, a significant reform which makes it easier at the district level to coordinate service provision across sectors. In 2019, using this new budget transfer model, the government made available US$88 million to local governments. In addition, as part of Village Fund – a special budget transfers to villages, the average share of spending on nutrition in villages increased to 17 percent in priority districts. Overall, national spending on stunting-specific interventions rose from US$8.4 per capita in 2017 to US$12.3 per capita in 2018.
The GFF has also supported the establishment of smarter systems to track resources and performance. In 2019, the Ministry of Finance published a review that links nutrition spending to achievements and shows how the budget was spent. This has enabled the government to improve coordination and ensure the best use of resources.
Successful Implementation Yields Positive Outcomes
Early indications suggest that Indonesia’s strategy, supported by the catalytic role of the GFF and other partners, is yielding positive results for women, children and adolescents.
Progress in maternal and child health and nutrition services
- Between 2018 and 2019, the stunting rate for children under five declined from 30.8 to 27.7 percent and wasting decreased from 10.2 to 7.4 percent.
- Between 2017 and 2019, the number of infants (0-6 months) who were exclusively breastfed increased significantly from 60.2 percent to 66.7 percent. The initiation of breastfeeding within one hour of birth rose from 42.7 percent in 2016 to 58.2 percent in 2018.
- The percentage of babies aged 6-23 months who were fed a minimum acceptable diet rose from of 56.2 percent in 2018 to 58.2 percent in 2019 nationally, and in the 100 priority districts from 52.6 percent in 2017 to 55.9 percent in 2019.
- The number of children aged 1-3 years receiving complete immunizations increased nationally from 37.3 to 47 percent between 2017 and 2019 and from 39.2 to 48 percent in the 100 priority districts.
- Coverage of iron supplementation (more than 90 iron tablets over the course of pregnancy) during pregnancy increased from 35.5 to 37.7 percent between 2016 and 2018.
Improved access to clean water, sanitation
- Between 2017 and 2019, the percentage of households with children under two with access to improved drinking water rose from 70 to 72 percent at the national level, and from 65.3 to 69 percent in the 100 priority districts.
- The percentage of households with access to improved sanitation rose from 62.4 to 66.6 percent at the national level, and from 54.3 percent to 58 percent in the 100 priority districts.
Increase in birth registration
- The percentage of children under five issued a birth certificate increased from 69.5 to 71.7 percent at the national level, and from 62.9 to 65 percent in the 100 priority districts