Challenges for Indonesia in addressing malnutrition in all its forms

I just returned from a trip to Jakarta to meet with GAIN’s key partners.  Indonesia is one of our most interesting offices: a large decentralised country struggling with a double burden of malnutrition, with a thriving business community, a government that is clearly motivated to address malnutrition in all its forms and with development partners slowly but surely exiting the country as it enters middle income status.

Indonesia is on track for only one of 8 WHA nutrition targets (Exclusive BF)

I first gave a talk at the National Nutrition Day, highlighting some of the Global Nutrition Report (GNR) 2016 findings.  This was great because Nila Moeloek, the Minister of Health (and a supporter of the GNR) was right there in the audience while the GNR was painting a challenging picture of nutrition progress (one out of eight indicators is on track to meet WHA targets—exclusive breastfeeding rates--although it is close to meeting two others –women’s anemia and under 5 overweight).  

Some very new data were presented by the Government showing stunting rates of 27-29%--very good news indeed if they hold up to further stress tests, although the very rapid decline (7 percentage points in 2-3 years) is hard for some to fathom. 

Minister Moeloek, DG Anung, and Ravi Menon

Ravi Menon, the GAIN country director also presented Minister Moeloek with the “emo-demo” behaviour change module (involving games and interactions with mothers on changing complementary feeding practices) pioneered by GAIN and partners. 

In the afternoon I presented the Global Panel Foresightreport on food systems and diets at the Agricultural University at Bogor.  The nutrition and agriculture students asked me great questions (about compliance with laws and codes, food labelling, adolescent diet choices, GMOs, decentralisation). Tough.

Bogor Agricultural University Students and Faculty

The next day we hosted two roundtables with GAIN partners: NGOs/CSOs and Donors/Businesses.  The topic here was key challenges faced by the partners in addressing malnutrition in Indonesia and what role could/should GAIN play. 

My main takeaways from the visit:

1.     Since my last visit in Feb 2015 the issue of overweight and obesity has really emerged on the government radar.  The toll that these outcomes take on health, productivity and health care is becoming clearer to policymakers.  The challenge for them now is what to do about it when there is so little positive experience from elsewhere.  But because it is becoming more and more artificial to separate the different expressions of malnutrition from root causes, now is the time for the Government to try some things that are at least plausibly effective, particularly the double duty actions identified by the GNR (interventions such as breastfeeding promotion, school based healthy diet education and food system transformation).

2.     Decentralisation of responsibility and funding for preventing malnutrition to the more than 500 districts has made the need for capacity development at this level ever more evident. In a sense decentralisation has forced a frank assessment of capacity. From the Ministry of Health maps (did I mention the fabulous data resources the government has?) it is clear that some districts are doing well in meeting their outcome targets while others, seemingly similar, are not.  Just why some are and some are not would make for a great piece of analysis.  Capacity and governance, I suspect, will make a big difference.

3.     The withdrawal of development partners from the country when one third of under 5’s are stunted is a real challenge and opportunity for the government. Obviously the loss of funding will be felt. Although aid is not a significant source of overall funding for health, it is a catalyst for change and trying something new.  Indonesian foundations, businesses and the government will have the opportunity—and the responsibility--to step into this gap.

4.     Attitudes to the potential role of business in improving nutrition outcomes are opening up, but caution abounds. Given the existing context this is understandable.  Until we have clear processes for surfacing and managing conflicts of interest, for registering PPPs, for tracking the conduct of businesses, and credible impacts of the effects of business engagement in nutrition, this context will persist and will hold back the leveraging of resources and know how to improve nutrition.  GAIN, together with its partners, aims to contribute to strengthening the enabling environment for informed engagement with responsible businesses. 

5.     The biggest question of all, however, is how to drive changes in consumer demand and the food environment towards healthier diets.  How, for example can fish consumption be made more attractive?  With our partners, we are trying public service TV commercials (highlighted by the Minister of Health and the Health Director General in keynote speeches) and public health “emo-demo” approaches (designed with and for adolescents in urban environments). But my guess is that some of the advertising guile used in making us want junk food needs to be diverted to making us find healthy diets more attractive and aspirational.  Just how that can happen is the big, big question and one GAIN will be trying to address in the future.

The consultations on GAIN’s strategy identified some key comparative advantages: a focus on making safe and affordable foods more available, accessible and affordable, bringing public and private actors together, working throughout the food system, developing tools for scaling, and speaking truth to power--whether in the public or business spheres. 

Some GAIN partners--NGOs, CSOs and academics

Some GAIN partners--development partners and businesses

I really enjoyed meeting the relatively small GAIN team (only 7 people) and celebrating their successes (including helping to develop the first ever national food composition table), sharing their frustrations and helping them strengthen ties with government, CSOs, academia and businesses. 

Even though it has relatively few development partners, experiences in Indonesia will give us some foresight into how other countries—who are behind in the nutrition transition-- should or should not manage the double burden.  Development partners and other governments would do well to keep a close watch on what happens in this nation of thousands of islands.