Thursday, December 6, 2012

Investing in nutrition: A tale of two Indonesian districts

By Dr. Festo P. Kavishe, Deputy Regional Director, UNICEF, EAPRO
When I was asked to participate in a meeting in Jakarta of the  EU/UNICEF project on Maternal and Young Child Nutrition Security Initiative in Asia last month, little did I know it would be such a learning experience. Not only around nutrition, but also on how community-based programmes are being put in place in middle income countries (MIC) with visible results.

While I was in Indonesia, I got to visit Klaten and Brebes districts where improving children’s nutrition is an explicit goal. My visit reminded me of the community programmes I helped organise in the late 1990s in Cambodia and the UNICEF/WHO Joint Nutrition Programmes and the UNICEF supported Child Survival and Development (CSD) Programmes implemented in some countries in the 1980s and 1990s.

©UNICEF Indonesia/Josh Estey
In Klaten district we were briefed by local officials on their policy commitment and plans to reduce stunting; on how to improve community awareness of maternal and child nutrition through participatory action plans; and how to promote infant and young child feeding (IYCF) practices and maternal nutrition. We visited Puskesmas Karangdowo to learn about their advanced health and nutrition information system and support to breastfeeding counselling and then to Pugeran village to learn about their counselling activities.

We also visited Pandes community to learn about their activities on reducing stunting through distributing multiple micrionutrients for pregnant mothers and children, nutrition counselling, growth monitoring and IYCF activities.

Klaten district is located in Central Java with a population of over 1.3 million and is a relatively rich district with poverty rates having declined from 19.7% in 2009 to 15.8% in 2011. Klaten is recognized as a “Child-Friendly District” and has been awarded by the government for their commitment to protect children’s rights. The district believes that “nutrition is a key investment to break the cycle of poverty”. With high levels of commitment by the district authorities, in addition to progress on poverty reduction and economic development, the district has also made tremendous progress in social development with under-fives child mortality decreasing to fewer than 10 per 1,000 live births and an improvement in exclusive breastfeeding from 16% in 2006 to 77% by 2011. The stunting rate of about 30.8% is below the national average of 36% and the plan is to reduce it by 5% to about 25% by 2015.

©UNICEF Indonesia/Josh Estey
In Brebes district, also located in Central Java, we first visited Sawojajar village where we met with moms from a Mother’s and Early Child Development (ECD) Group and learned about a local conditional cash transfer (CCT) project. Cash transfer conditions included increased use of health facilities especially by pregnant mothers, such as for antenatal care, consistent use of growth monitoring of children under five, and school enrolment and high attendance.

Although Brebes, with a population of about 1.74 million, also showed high commitment to make their district child friendly, it was clear their level of social, educational and economic development was much lower than that of Klaten.

UNICEF’s linking of the EU/UNICEF Steering Committee meetings with field visits in the project first started in Nepal last year and has been a great opportunity for getting real-time feedback from mothers, children and local officials on how the project is being implemented, its results, opportunities, challenges and the lessons we can take forward. This also provides critical input into the larger programmes like the Scaled Up Nutrition (SUN) movement.

So what did I take away from these visits? Six things really jumped out at me. First and most glaring is the fact that we clearly saw big disparities in nutrition between the two districts, and differential impacts to-date of the programmes. This points to the fact that middle income countries at sub-national level exhibit both middle-income and low income patterns.

©UNICEF Indonesia/Josh Estey
Secondly, that UNICEF’s catalytic and facilitative role in MICs can be used effectively at community level to model evidence-based approaches that lead to results for children and to feed this back into national policy for scaling up.

Third, the generation and use of evidence and robust information systems are critical for informed individual and community level decisions regarding child survival and development. They also help in showing progress towards reducing disparities, not only at the community level, but also between districts. In essence, UNICEF’s monitoring of results in equity systems (MoRES) starts with community level information systems where determinants can easily be discerned and action immediately taken by individuals and the communities themselves.
©UNICEF Indonesia/Josh Estey

Fourth, community capacity development is crucial not only for community assessment and analysis, but also for taking action including proper monitoring and evaluation as shown in the participatory action plans (PLA) in Klaten district.

Fifth, I noted with concern, that none of the districts had integrated sanitation into their plans to reduce stunting. Given the important link between stunting and sanitation, this must be rectified.

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