The first 1,000 days between conception and a child's second birthday is the most crucial window of opportunity for interventions. (Antara Photo/Maulana Surya)

Preventing Stunting: What Works and What Doesn't


NOVEMBER 07, 2019

President Joko "Jokowi" Widodo has stated that starting in 2019, the government would focus on improving the quality of Indonesia's human resources. To accomplish that vision, the health sector has become one of the priorities of his second-term government. 

The 2020 State Budget allocates Rp 132 trillion ($9.4 billion) for health care, increasing 13 percent from this year. 

This puts pressure on the Health Ministry to tick off many still-to-be-accomplished items on its bucket list.

Among its priorities is to strengthen early childhood health programs to reduce the prevalence of stunting.

Stunting reared its head to become a national issue during campaigning in the last presidential election.

Preventing it has become one of Jokowi's nine main agendas in his second term.

Stunting is a condition of chronic malnutrition that occurs during critical periods of growth and development starting from the fetus.

In Indonesia, an estimated 30 percent of children under five years old suffer from stunting.

This makes it the country with the fifth-highest burden of stunting in the world.

In its 2020-2024 National Medium-Term Development Plan, the government vows to act more aggressively in preventing stunting and reduce its prevalence rate to 19 percent.

The government plans to expand its stunting prevention programs to 260 districts or cities in 2020, up from 160 districts or cities in 2019. 

Newly appointed Health Minister Terawan Agus Putranto has said that the causes of stunting vary from areas to areas.

Consequently, there's no cookie-cutter solution for stunting. Efforts to prevent it must be applied sector by sector, but so far Terawan has not announced any specific plan.

"[The root causes of stunting] must be researched carefully because each region has its own unique causes. Our budget must be expended on target, on time and in the right direction," Terawan said shortly after the inauguration of the new cabinet.

Good Strategy, Bad PR

Has the current strategy from the Health Ministry to reduce the rate of stunting been effective?

The National Strategy for the Acceleration of Stunting Prevention (Stranas Stunting) includes programs such as the Supplementary Food Program (PMT) to provide nutritious food for pregnant women and toddlers and a village fund program where village-level administrations receive a budget of Rp 100 million ($7,100) to tackle stunting in their areas. 

The strategy is holistic and well-planned, but there are serious problems with the way it is being promoted.

The government still has to clear up a lot of misconceptions on the basic facts of stunting.

Sadly, the large billboard we now see in front of the Health Ministry headquarters on Jalan Rasuna Said in South Jakarta is not going to help. 

Captioned "Preventing Stunting Is Important," the poster is illustrated with the pictures of two children in elementary school uniforms. Standing next to each other in front of a height ruler, one child is clearly much shorter than the other.

Only three points are highlighted in the poster: prevent stunting by improving sanitation, improving access to clean water and healthy latrines and washing hands with soap.

Several things need to be straightened out in the poster. First, the elementary school uniform is misleading. Stunting is defined as a condition that afflicts children aged 0 to 59 months (0-6 years, Indonesian children generally don't start elementary school until they are seven) whose height for their age is two standard deviations below the median in a standard growth chart (moderate and severe stunting) or three standard deviations below (severe stunting).

The first 1,000 days between conception and a child's second birthday is the most crucial window of opportunity for interventions. Loss of height resulting from stunting is irreversible after this period. Suggesting that interventions should start in elementary school, as the poster suggests, is misguided.

Gubernur Jawa Barat Ridwan Kamil (kiri) bersama Ketua Tim Penggerak PKK Provinsi Jawa Barat Atalia Praratya (kedua kanan) menunjukan tangannya yang berlumuran cat saat deklarasi pencegahan stunting di Lapangan Gasibu, Bandung, Jawa Barat, Minggu (18/11/2018). Deklarasi tersebut dilakukan sebagai salah satu program kerja Gubernur Jawa Barat menuju Jawa Barat bebas Stunting pada 2023. ANTARA FOTO/Raisan Al Farisi/aww.
West Java Governor Ridwan Kamil, left, wears a t-shirt with the same design as the Health Ministry's stunting prevention poster. (Antara Photo/Raisan Al Farisi)

Second, highlighting only three methods to prevent stunting in the poster paints a very narrow picture of the condition. Stunting arises from multi-faceted biological, social and environmental causes that are often interlinked at various levels.

Although it may help to prevent stunting, WASH (water, sanitation and hygiene) interventions are not the most critical. Poor WASH may cause stunting but it would take a long time and need a lot of interactions with other stunting determinants.

Nutrition is Key

If there is one point that must be highlighted in stunting prevention, it is nutrition intervention.

Although stunting is related to multi-factor causes, evidence suggests that nutrition-specific evidence-based interventions could reduce stunting by 20 percent.

These interventions include supplementary feeding for pregnant women, exclusive breastfeeding promotion, appropriate complementary feeding for infants and other interventions involving pregnant women and children under five years old.

Improving awareness by delivering clear information on stunting is pivotal. The wrong message can lead to the wrong efforts being made, leading to millions of dollars spent on useless programs.

One of these is a program initiated by the Bandung district government. They organize a routine morning exercise for elementary school students that they say will help to prevent stunting since the condition is caused by a lack of vitamin D.

This is why the students need to do their morning exercise to get at least 30 minutes of sunlight exposure every day. 

This is a great example of a misconception of stunting leading to a totally useless program.

Another ineffective anti-stunting campaign involves providing mung bean porridge and milk for elementary school students.

This program has been adopted by several regional governments, including Jakarta.

To be clear, nutritional interventions to prevent stunting should be given during the first 1,000 days of a child's life. Doing them when your children are already in elementary school is close to being useless. 

A successful anti-stunting program requires not only impeccable planning but also the delivery of accurate information to communities. 

Under the leadership of the new Health Minister, let's hope the government's anti-stunting program will, at last, be delivered on target, on time and in the right direction.

Nadhira Nuraini Afifa is completing her master's degree in public health at Harvard University. She researches stunting in developing countries.