Technical Study

IMPLEMENTATION OF
TODDLERS’ HEIGHT
MEASUREMENT
ACTIVITIES AND I N T
E G R A T E D
STUNTING DATA
MANAGEMENT IN
INDONESIA
Technical Study

IMPLEMENTATION OF
TODDLERS’ HEIGHT
MEASUREMENT ACTIVITIES
AND INTEGRATED STUNTING
DATA MANAGEMENT
IN INDONESIA
1
Implementation of Toddlers’ Height
Measurement Activities and Integrated
Stunting Data Management in
Indonesia

Published in Indonesia 2019 by

Center for Indonesia’s Strategic

Development Initiatives

Jalan Cut Nyak Dien No. 5 Blok B, Menteng

Jakarta Pusat 10359 Indonesia

www.cisdi.org
CISDI

Cover design by Rudra Ardiyase copyrights protected.

Unless otherwise stated, all contents of this report are protected

in Creative Commons Attribution-NonCommercial 4.0 International
License.

Some rights are retained.

How to cite:
(CISDI, 2019)
Center for Indonesia’s Strategic Development Initiatives.
2019. Implementasi Kegiatan Pengukuran Tinggi Badan
Balita dan Manajemen Data Stunting Terintegrasi di
Indonesia. Jakarta:
Center for Indonesia’s Strategic Development Initiatives,
Abbot Laboratory – White Rook Advisory.
 1
FOREWORD
This technical study was prepared by a
research team led by Zakiyah and consisted of
Yurdhina Meilissa, Olivia Herlinda, Yenuarizki, Sri
Nuraini, Siska Verawati, Rayssa Anggraeni Putri, and
Egi Abdulwahid. Diah Satyani Saminarsih gave
general direction to build a scenario framework and
led the consultation of limited expert resource
persons.
The Research Team also received guidance
from an Advisory Panel consisting of Akmal Taher,
Fasli Jalal, Wicaksono Sarosa, Ani Rahardjo, and
Christian P. Somali. Yurdhina Meilissa edited the end
of the Indonesian version. Yenuarizki, Rudra Ardiyase
and Naufal Randhika managed the layout of this
report.
During the study, the research team received
support from a number of nutrition practitioners
from various backgrounds of participating
organizations through various discussions and
interviews. We are grateful for their willingness to
share their experiences and in-depth knowledge that
enriches this technical study. We appreciate expert
speakers who provided input both verbally and in
writing to this study, namely: Brian Sriprahastuti
(KSP), Agus Suprapto (Kemenko PMK), Atmarita
(PERSAGI), Halik Sidik (ADINKES), Erna Mulati
(Directorate of Public Welfare, Ministry of Health),
Elvina Karyadi (World Bank), Akim Dharmawan (World
Bank), Guruh Hari Wibowo (Nganjuk District Health
Office), Dakhlan Choeron (Directorate of Community
Nutrition, Ministry of Health), Octoviana Carolina S
(DKI Jakarta Provincial Health Office), Annisa Harpini
(Pusdatin, Ministry of Health), Iing Mursalin (TNP2K),
Foreword
Eti Rohati (Depok City Health Department), Sudikno
(Research Center for Public Health Efforts, Ministry of
Health), Winne Widiantini (Pusdatin, Ministry of
Health), Hasnani Rangkuti (BPS), Ade Wahid (TP2AK),
Aman B Pulungan (IDAI), and Giri Wurjandaru
(Directorate of Community Nutrition, Ministry of
Health).
This technical study does not provide a simple
solution to improve the implementation of activities
for measuring toddlers’ height and integrated
stunting data management in Indonesia. However,
the research team believes that this technical study
represents diverse perspectives and brings together
debates about the best way to achieve the ultimate
goal.
This technical study was funded by the Abbot
Laboratory - White Rook Advisory and carried out by
the Center for Indonesia’s Strategic Development
Initiatives (CISDI), Jakarta. CISDI is fully responsible
for the findings, conclusions and recommendations
written in this technical study, without the influence
of funders.
 2
CISDI

TABLE OF CONTENTS
FOREWORD
2
TABLE OF CONTENTS
3
LIST OF TABLES
4
EXECUTIVE SUMMARY
11
CHAPTER 1. IMPLEMENTATION OF TODDLERS’ HEIGHT MEASUREMENT AND INTEGRATED
DATA MANAGEMENT ACTIVITIES: AN INTRODUCTION
15
18
WHY THIS ISSUE IS IMPORTANT?
19
TARGET OF STUDY
19
QUESTIONS AND RESEARCH DESIGN
20
REPORT STRUCTURE
CHAPTER 2. CONDITIONS OF POSSIBILITIES: REGULATION FRAMEWORK, GOVERNANCE,
AND FINANCING
21
23
REGULATION FRAMEWORK
23
GLOBAL AGENDA
24
NATIONALIZING GLOBAL AGENDA
26
GOVERNANCE FRAMEWORK
31
FINANCING FRAMEWORK
CHAPTER 3. TODDLERS’ HEIGHT MEASUREMENT IMPLEMENTATION AND QUALITY
ASSURANCE
35
37
HEIGHT MEASUREMENT AS A STANDARD OF MONITORING GROWTH OF TODDLERS 40
DELIVERY ARRANGEMENT
43
QUALITY OF GROWTH MEASURE PLATFORM
43
STRUCTURE/INPUT
CHAPTER 4. INTEGRATED STUNTING INFORMATION SYSTEM: IMPLEMENTATION AND
QUALITY ASSURANCE
65
 67
DATA GENERATION: AVAILABILITY OF QUALITY
69
DATA INTEGRATION FOR ANALYSIS AND SYNTHESIS
72
DATA UTILIZATION
CHAPTER 5. SYNTHESIS, IMPLICATION, AND RECOMMENDATION
89
SYNTHESIS AND IMPLICATION
91
REGULATION FRAMEWORK, GOVERNANCE, AND FINANCING
91
TODDLERS’ BODY HEIGHT MEASUREMENT; IMPLEMENTATION AND QUALITY
ASSURANCE
94
INTEGRATED STUNTING INFORMATION SYSTEM: IMPLEMENTATION AND QUALITY
ASSURANCE
98
RECOMMENDATION
104
REFERENCES
126

3
Table of Contents

APPENDIX 1. POLICIES RELATING TO HIGH MEASUREMENT OF TODDLERS AND INTEGRATED

128
STUNTING DATA PUBLICATION
APPENDIX 2. INTERVIEW: PROTOCOL AND INSTRUMENTS
130
APPENDIX 3. FOCUS GROUP DISCUSSION: PROTOCOL AND INSTRUMENTS
135
APPENDIX 4. LIST OF RESPONDENTS / SPEAKER IN
138
APPENDIX 5. LIST OF DISCUSSION EXPERT SPEAKERS
141
APPENDIX 6. LIST OF DISSEMINATION OF EXPERT SPEAKER STUDY RESULTS
143
APPENDIX 7. LIST OF EXPERT SPEAKERS THAT GIVES WRITTEN INPUT
144
 4
CISDI

LIST OF FIGURES
Figure 1. Figure 2. Figure 3. Figure 4. 32
Integration of various Toddlers’ Growth Measurement
Figure 5. Figure 6. Platforms in Indonesia

Figure 7.

Figure 8. Figure 9.

Figure 10. Figure 11.

Eight Actions of Integration

18
Action Plan for the Resolution of WHA 65.6
41
23 Adaptation of the Donabedian Model to the Evaluation
Main Strategy for Gernas PPG of Growth Measurement Platform

24
Structure Task Force for the Acceleration of Nutrition
Improvement based on Perpres No. 42 of 2013

26
Governance Structure of PforR World Bank

43
The relationship between stunting prevalence analysis
and analysis of program / activity availability

27
Coordination based on the National Strategy for the
Prevention of Stunting Prevention

27
Framework for Financing the Stunting Program in
Indonesia (Source: Stranas Stunting 2018- 2024)
70 73
Integrated Stunting Data Management Flow

5
List of Figures & Tables

LIST OF TABLES
Table 1. Table 2. Table 3. Table 4. Table 5. Table 6. Structure / Input
Table 7. Table 8.

Table 9. Table 10. Table 11. 44

The Profession Involved in the Measurement Process
Table 12. Table 13.

Comparison of Structures among Regulations

29 50
Categories and Thresholds for Child Nutrition Status Evaluation of Growth Monitoring Platforms according
Based on Index to Process Dimensions

38
Evaluation of Growth Measurement Platform based on
53 100
Household Surveys and Surveillance Related to Recommendations for Improving the Regulatory,
Stunting Governance and Financing Framework

74
Indicators and Data Sources Related to Stunting

107
77 Recommendations for Improvement of
Synthesis of Findings in the Regulatory, Governance Implementation of Height Measurement
and Financing Framework

93
Synthesis of Findings on Implementation of Height
Measurement

112
Recommendations for Improvement of Integrated
Stunting Data Management 117

96
Synthesis of Findings in Integrated Stunting Data
Management
 6
CISDI

LIST OF ABBREVIATIONS
1.000 HPK : Children Aged Under Two Years
ASI : Children Under Five Years Old
Baduta : Regional Development Planning Agency
Balita : National Development Planning Agency
Bappeda : Weight according to Body Length
Bappenas : Weight according to Height
BB / PB : Weight by Age
BB / TB : Under the Red Line
BB / U : Toddler Family Development
BGM : Toddler Weighing Month
BKB : Social Security Organizing Body
BPB : Independent Practice Midwife
BPJS : Statistics Indonesia
BPM : Center for Indonesia’s Strategic Development
BPS Initiatives : Data Arrives per Target at Posyandu
CISDI : Special Allocation Fund
D/S : Health Service
DAK : Disbursement-Linked Indicator.
Dinkes : Donor and UN Country Network on Nutrition
DLI : Community-Based Nutrition Reporting and Nutrition
DUNCNN Reporting : Focus Group Discussion
PPGBM : First Level Health Facility
FGD : National Movement for the Acceleration of Nutrition
FKTP Growth
Gernas PPG GMP Nutrition Improvement GOBI
: Growth Monitoring and Promotion
IAKMI : Growth Monitoring, Oral Rehydration Therapy,
IDI Breastfeeding, Immunization
IFPRI : Association of Indonesian Public Health Experts :
BMI / U Indonesian Doctors Association
Jabodetabek JKN : International Food Policy Research Institute
K/L : Body Mass Index by Age
: First 1,000 Days of Life : Jakarta, Bogor, Depok, Tangerang, Bekasi
: Mother’s Milk : National Health Insurance
: Ministry or State Institution

7
Kemenkeu Kepmenkes MCH Mendigbud Menkes : Upper Arm Circle Lokmin
KMS Menkeu Puskesmas: Mini Puskesmas
KPM : Ministry of Finance Workshop
KRPL : Decree of the Minister of Health : Cross-Sector Mini Workshop
LB : Maternal and Child Health : Maternal and Child Health
LB1 : Card Towards Health : Minister of Religion
LB3 : Human Development Cadres : Minister of Trade
: Sustainable Food Home Area : Minister of Home Affairs
LB4 : Monthly Reports : Minister of Villages, Disadvantaged
Litbangkes LILA : Monthly Data on Illness Report Regions and Transmigration
: Monthly Report on Nutrition, KIA, : Minister of Education and Culture
Lokmintor MCH Immunization and Observation of : Minister of Health
Menag Infectious Disease Data : Minister of Finance
Mendag : Monthly Report on Puskesmas List of Abbreviations
Mendagri Activity Data : Health Research and
Mendes PDTT Development

Menko PMK Menkominfon Menperin GDP

Mensos PDGMI
Mentan : Coordinating Minister for Human Development and
Menteri PPPA MP-ASI Culture : Minister of Communication and Information
MTBS : Minister of Industry
OPD : Minister of Social Affairs
PB / U : Minister of Agriculture
: Minister of Women Empowerment and Child : Body Length according to Age
Protection : ASI Complementary Food : Gross Domestic Product
: Integrated Management of Toddler Sickness : : Indonesian Medical Nutrition Doctors Association
Regional Apparatus Organization

8
CISDI : Regulation of the Minister of Health
: Presidential Regulation
: Indonesian Nutritionists Association
: Program-for-Results
: Family Health Information
: Healthy Indonesia Program with a Family Approach :
Family Hope Program
: Provision of Additional Food
: Prevention of HIV Transmission From Mother to
Child : Village Maternity Hospital
: Integrated Service Post
Permenkes Perpres : Government regulations
PERSAGI PforR : Family Health Profile
Pinkesga PIS-PK : Data and Information Center
PKH : Community Health Centers
PMT : Supporting Puskesmas
PPIA : Local Area Monitoring
Polindes : Quantitative Service Delivery Surveys
Posyandu PP : National Action Plan for Food and Nutrition
Prokesga Pusdatin Puskesmas Pustu : Food and Nutrition Action Plan
PWS : Basic Health Research
QSDS : Government Work Plan
RAN-PG : National Medium Term Development Plan
RAPG : Hospital
Riskesdas RKP : Standard Deviation
RPJMN : Sustainable Development Goals
RS : Early Childhood Growth and Stimulation, Detection
SD and Intervention
SDGs : Human Resources
SDIDTK : Cabinet Secretariat
: Vice President’s Secretariat
SDM : Application of Independent Practice Midwife
Setkab Information System
Setwapres SIBIMA : Regional Health Information System
: Puskesmas Management Information System :
SIKDA Puskesmas Integrated Recording and Reporting
SIMPUS System
SP2TP
 9

Health SPM SSGBI WHA : Height according to age

Stranas : Minimum Service Standards for : National Team for the Acceleration
Stunting Health of Poverty Reduction : Nutrition
: Indonesian Toddler Nutrition Workers
SUN Status Survey : United Nations Emergency
Susenas TB / U Children’s Fund : Effort to Improve
TNP2K : National Strategy for the Family Nutrition
TPG Acceleration of Prevention of : Law
UNICEF Stunting : World Health Assembly
UPGK : Scaling Up Nutrition List of Abbreviations
UU : National Socio-Economic Survey
 10
CISDI

EXECUTIVE SUMMARY
2020 will be the first year of the implementation of the This technical study found 3 main challenges that
2020-2024 National Medium-Term Development Plan significantly marked the dynamics of height / length
(RPJMN). The Indonesian government directs measurement for toddlers in Indonesia and required the
development priorities on human resources to strengthen attention and response of the Government in 2019-2024.
the foundation of competitiveness towards the developed These structural challenges include:
country phase which is expected to occur in 2036-2044.
The government translates this political vision, one of Challenges related to the regulatory, governance and
which, through improving the quality of public health. financing framework
that
The government has strengthened the integration of the this
stunting program to realize an optimistic scenario of techni
cal
reducing prevalence by 2-2.5% per year. The study
implementation of integrated stunting reduction repres
interventions needs to be supported by accurate, current, ents a
integrated and accountable height measurements. A variet
reliable stunting information system is an important y of -
prerequisite so that measurement data is easily accessed perspectives and brings together debates regarding the
and shared as a basis for case management and evidence- implementation of height measurement for toddlers and
based policy making). integrated stunting data management.

This technical study provides a framework for thinking,

synthesis of findings, and recommendations for follow-
up on the implementation of activities for measuring
toddlers’ height and integrated stunting data
This
management in Indonesia. This technical study was techni
compiled based on a literature review, policy analysis, cal
field visits, interviews, and limited consultations with study
various expert speakers. The research team believes depar
with high technical soundness and the extent to which ts
from a
integration between measurement platforms has taken syste
place? Third, to what extent has the measurement data mic -
been used as a basis for clinical decision making and scanning process regarding events and trends
policy improvement? surrounding the measurement of height / length of
toddlers in Indonesia. Specifically, scanning of events and
This technical study then brings together and processes trends involves stakeholders to -
the results of the scan through limited consultation with answer three questions. First, the extent to which
experts (Delphi Method). The consultation phase has regulatory, governance, and budget support has
three main objectives, namely: (1) gathering opinions and established enabling conditions for good practices in
findings in the field based on the accumulation of expert height measurement and integrated stunting -
knowledge and experience; (2) determining the structural data management. Second, whether height
challenges (drivers) that underlie these findings; (3) measurements in Indonesia have been carried out
designing a number of possible scenario (scenario
building) structuring and the necessary stages (roadmap). Regulatory frameworks that support efforts to reduce
Thus, this technical study takes into account all aspects of stunting are available at various levels, but translating
‘what’ and “why “ according to various points of view, and and implementing them at subnational levels remains
brings together debates on “how” does the implementation a challenge.
of toddlers’ height measurement and integrated stunting
data management. Overlapping governance both at the level of
coordinating agencies and implementing agencies
 A regulatory framework for meaningfully involving The unavailability of accountability mechanisms and
non-governmental actors is not yet available the effectiveness of financing efforts to

11
Executive Summary

reduce stunting to the regional level. Accessing data and information from cross
-
units in the Ministry of Health and across sectors
Challenges related to the implementation of height Posyandu cadres are allowed to carry out toddlers’
measurements in the field height measurements at posyandu
is still difficult because of the unavailability of
standards and protocols

-
Inconsistencies in regulations and standards
regarding the target age group, and frequency of
height measurements

-
The business process of monitoring growth has not -
focused on aspects of data interpretation,
-
From these structural challenges through a limited
Health workers who take measurements are not
consultation process with experts (Delphi), the following
available in all places with an adequate numbers
priorities for improvement are formulated:
-
Priority improvements related to the regulatory,
Growth monitoring service platforms are fragmented
governance and financing framework
and not interconnected with referral -
counse services
ling,
Designing a regulatory framework based on needs
and
assessments and gaps in the field that involve various
referr
stakeholder elements
al to
subse
The establishment of a governance structure that is
quent
quite simple, effective and agreed upon by all parties
servic
is complemented by a clear division of roles and
es -
after measurement. The behavioral change functions of coordination
communication component has not been included in
Encouraging the immediate enactment of the
the growth monitoring service package
regulatory framework that forms the umbrella of
stunting stranas, one of which includes a meaningful
involvement of multi-sector stakeholders and their
roles and functions clearly

- Increasing the efficiency and effectiveness of stunting

program funding through the budget
-
Debate about the duties and functions of cadres in Challenges related to data management, including
measuring height, especially regarding whether processing, analyzing, and accessing data
 tagging and tracking mechanism to the village level preparation of regulations and subsequent

-
-
Data on height to detect the nutritional status -
according to TB / U and BB / TB is not caught in the programs
Encourage local government performance evaluation
mechanisms -
Data fragmentation because each information system
health information systems in many District / City has a database that stands alone
because of the limited availability of measuring Harmonization of standards, governance and
instruments and measuring competence operational definitions
Priority for improving the implementation of
measurements in the field In conditions that are not ideal where there are no
trained health workers available, it is important to
- increase the capacity of posyandu cadres regarding
- height measurement and counseling ability and
Data obtained often does not meet quality data interpretation of data.
qualifications. This will cause a weak basis for the

12
CISDI

- -
Incorporate components and conduct behavioral
change communication training in growth service -
packages Increase the availability of nutrition workers in each
Challenges related to the implementation of height Puskesmas
measurements in the field
-
- Procurement of measurement and reporting logistics
- according to the standards required at Posyandu
Internet-based remote health workforce training (e- Integration of various toddlers’ height measurement
learning) about growth monitoring and communication services from posyandu to district / city level
of behavioral changes to puskesmas

-
Designing a regulatory framework stating that trained
cadres are allowed to measure height in conditions
where health workers are not available
 - -
- available, the puskesmas must validate the
Increased coverage and quality of PIS PK to ensure measurement results by the cadre and ensure that the
and educate every family with a toddler to go to the referral system from the posyandu to the nearest
posyandu. health service

-
The Ministry of Health includes the height

-
measurement component in the growth monitoring
service standards at posyandu and health facilities

In conditions where health workers are not

-
runs according to the procedure, i.e.:
Increasing the capacity of posyandu cadres and
puskesmas nutrition officers to record and report, as
well as to utilize data

Simplification of posyandu information systems and

integration of KPM score cards (eHDW) to Posyandu
information systems as well as ePPGBM

Increasing coverage on the use of e-PPGBM

accompanied by an increase in the capacity of officers
related to surveillance - the process of gathering -
analyzing - action based on analysis, also taking into
account regional limitations in infrastructure and
human resources. The implementation of SSGBI by
BPS and Litbangkes is carried out routinely once a
year to find out the current prevalence of stunting
toddler

Integration of prevalence data and programs related

to stunting prevention in the Mhealth platform
developed by the Pusdatin Ministry of Health

Add a National Health Information System Roadmap

 related to the inclusion of clear roles among -
stakeholders and the development of national and
regional SIK integration plans
Strengthening the National Health Information System
through the use of appropriate technology and
improving system interoperability
Develop guidelines for implementing e-government
for nutritional problems in
-
Cadres only monitor toddlers’ body weight every
month and refer toddlers to health
workers at the puskesmas if they are indicated to
have nutritional problems or fixed weight, or the
weight does not increase after two consecutive
measurements.
Indonesia
Incorporate a nutrition agenda, especially stunting, into
the village planning agenda, such as through the Village
Community Conference (MMD), to communicate and
discuss data at the community level

13
Executive Summary

-
Involve civil organizations and individuals to
carry out social monitoring)

These three priorities are proposed to be

operationalized through 19 targets whose
achievements can be measured through 23
indicators, as stated in this technical study.

Jakarta, 14 December 2021

Writer Team
 1
14

An Introduction

01.
Implementation of Toddlers’
Body Height Measurement
and Integrated Stunting Data
Management in Indonesia:
CISDI

CHAPTER 1. Implementation of Toddlers’ Height

Measurement Activities and Integrated Stunting Data
Management: An Introduction
Stunting is a condition of failure to thrive in children Financial Note for Fiscal Year 2020 places stunting as a
under five years old (toddlers) due to chronic strategic issue that receives priority budget allocation
malnutrition and psychosocial stimulation, as well as through the convergence of physical Special Allocation
repeated exposure to infections especially in the period Funds (DAK), non-physical DAK, K / L expenditure, village
of the First 1,000 Days of Life (1,000 HPK), namely from funds, and grants to 260 priority areas [10].
the fetus to the two-year-old child [1]. The child is This political commitment is expected to drive the
classified as stunting if the length or height is below minus acceleration of stunting prevalence in toddles to 27.1%
two of the standard deviation (-2SD) the length or height of according to the Government Work Plan (RKP) of 2020 [10]
the child of his age [2]. One thousand (1,000) HPK is the to get closer to the 2025 Global Nutrition target in
golden period for children’s growth. In this period, the reducing stunting in toddlers by 40% [11].
baby’s brain and body are developing rapidly. Proper
nutrition interventions in this period will result in higher The government’s effort to reduce the prevalence of
quality Indonesian human resources that will become stunting confirms the link between the stunting
investments in cost-effective development [3]. reduction program and Indonesia’s efforts to become a
medium-high income country. Various studies have
Stunting is still one of the biggest nutritional problems of shown that stunting that occurs at 1,000 HPK risks
toddlers in the world although in the last two decades it hindering physical growth, increasing children’s
has decreased from 32.6% in 2000 to 22.2% in 2017 [4]. vulnerability to disease, creating barriers to cognitive
The 2018 Global Nutrition Report notes that the prevalence development that reduce children’s intelligence and
of stunting in Indonesia is far worse than countries with productivity in the future. Stunting will also increase the
similar economic levels in Southeast Asia: Thailand (16%), risk of degenerative diseases in adulthood. Economic
Malaysia (17.5%), and Vietnam (23%) [5]. Although the losses due to stunting are estimated to reach 2-3% of
Basic Health Research (Riskesdas) 2018 shows a decrease Gross Domestic Product (GDP) per year, equivalent to 300
in the prevalence of stunting for children under five from trillion rupiah [12].
37.2% (2013) to 30.8% (2018), the proportion of children
Stunting prevention interventions are prioritized
under two years old (baduta) short and very short is still at
29, 9% or higher than the 2015-2019 Medium Term targeting children under two years of age because in
Development Plan (RPJMN) target of 28% [6] [7] [8]. The that period they are considered to be more sensitive to
prevalence of stunting in Indonesia occurs in all regions the impact of an intervention than children over two
and also across income groups. Some health indicators in years old. [13] [14]. The main problems that cause high
2018 also indicate the need for immediate improvement, stunting rates in Indonesia are a combination of policies
such as anemia in pregnant women (48.9%) and babies that have not been integrated in providing support for
born with low birth weight (6.2%). stunting prevention, logistical limitations and competency
of measuring staff, availability of quality data, as well as
The technocratic design of the RPJMN 2020- 2024 communication problems and behavioral changes that
places the target of reducing stunting in toddlers to 19% occur both at the individual level, community level and
by 2024 as one indicator of basic service fulfillment [9]. health service level.

17
National Strategy for the Acceleration of Prevention of
Stunting 2019-2024 (Stranas Stunting) establishes
specific and sensitive nutrition interventions that will be
delivered to priority groups in priority locations. Stranas
stunting is useful as a sign of government in handling
stunting because: (1) Arranged based on evidence, good
practice, and experience of Indonesia and globally; (2)
Aiming to ensure that all resources are directed and
allocated to support and finance priority activities to
improve the coverage and quality of 1,000 HPK household
nutrition services; (3) Arranged so that all parties at all
levels can work together to accelerate the prevention of
stunting, and (4) Arranged so that it involves and describes
the roles of ministries / institutions, academics,
professional organizations, civil society, business world,
and development partners / donors
Why is this issue important?
Integrated planning, implementation, evaluation, and
control of Stranas Stunting, need to be supported by
data that are accurate, current, integrated, accountable,
easily accessed, and shared, and managed carefully,
integrated, and sustainably. Measurement of toddlers’
height and an in-sequence stunting data publication
routinely will sharpen the implementation of Integration
Action through improvement of: (1) Quality of analysis of
data-based situations and factual information; (2)
Accuracy in determining service targets, efficiency in
allocating resources, being the basis for determining
policy (evidence-informed policy) and advocating for
program integration support in the stunting conference;
(3) Reliability of the data management system to support
performance studies; and (4) Accurate diagnosis so that
health workers can find out the nutritional status of
children under five as a basis for integrated follow-up
efforts and family based counseling.

Measuring body length or height included in the
Stimulation, Detection and Early Intervention Program
for Child Growth and Development (SDIDTK) is the
foundation of Stranas Stunting.
Therefore, the Guidelines for the Implementation of
Integrated Stunting Reduction Interventions in Districts /
Cities [15] place the measurement and publication of
stunting figures as one of the eight Integration Actions.
.
Chapter 1
However, the availability of technical studies on toddlers’
height measurement and integrated stunting data
management is very limited in Indonesia. The Nutrition
Capacity Assessment Report in Indonesia and the
Background Paper for the Health Sector Study provide a
big picture of the provision of nutrition services in
Indonesia, but need to be enriched with technical studies
with sufficient depth of analysis to improve policy
operationalization [16] [17].

12345678
Analisis Dinas
Situasi PMD/BPMD
Sistem
Manajemen
Data

Mengidentifikasi sebaran prevalensi

stunting,
ketersediaan Pengelolaan data di tingkat
program, dan kabupaten/kota hingga desa yang
praktek akan digunakan untuk mendukung
manajemen pelaksanaan
layanan di intervensi gizi spesifik dan
kab/kota sensitif
Rencana Pengukuran dan Publikasi Data
Kegiatan Stunting

Mengukur dan mempublikasikan

angka prevalensi stunting tingkat
Tindak lanjut
desa hingga
kab/kota untuk merealisasikan
kabupaten/kota Dinas Kesehatan
hasil rekomendasi dari tahap
analisis situasi Reviu Kinerja Tahunan

Bappeda
(koordinator) dan
Rembuk
Stunting

Penilaian
Pemerintah
Kab/Kota terkait pencegahan
stunting selama 1 tahun terakhir

Pertemuan lintas Sekda dan

OPD dan Bappeda
masyarakat untuk (koordinator) dan
memastikan
terjadinya
konvergensi
program/ kegiatan
dan pembiayaan

Bappeda
Perbup/Perwali tentang Peran
Desa

Memberikan
kepastian hukum yang digunakan
sebagai rujukan oleh desa untuk
merencanakan, mengangarkan
program/ kegiatan
Pembinaan Kader
Pembangunan Manusia

Membina kader
pembangunan
yang berasal dari kader posyandu,
guru PAUD, dan
kader lainnya di
tingkat desa
OPD lain (koordinator) dan OPD lain Bappeda
Bappeda (koordinato) dan
OPD Dinas
(koordinator) dan OPD lain
PMD/BPMD
OPD lain

Figure 1. Eight Actions of Integration

18
CISDI 3. “Are there components of the program or activity for
height measurement and management of integrated
stunting data that are missing?”
4. “Does the program person responsible for the program
possess the capacity for planning, implementing and
monitoring?”

Targets of Study
Center for Indonesia’s Strategic Development Initiatives
(CISDI) conducted this technical study to support the
government’s efforts to improve the implementation of
height measurements and their relation to the reliability of
integrated stunting data. Broadly speaking, we divided the 5. “Is there an integrated system to monitor the results or
technical study discourse into three broad clusters: (1) intermediate results of the success of height
Politics - the process by which policies are formulated and measurement activities and integrated stunting data
determined; (2) Polity - the institutional framework for management?”
how policies are formulated and implemented, and (3)
Policy - concerns the content and substance, as well as To answer these questions, we used a combination of
the desired mechanism of change. several research methods and instruments. In the first
phase of research, we analyze secondary data and
Specifically, this technical study will: (1) Explore the roles explore data sources from national surveys, special
of stakeholders and their governance; (2) Checking studies, and various other scientific literature. Next, we
program / activity gaps related to height measurement, went a step further by conducting a series of semi-
publication, and utilization of integrated stunting data; structured interviews involving 22 key informants with
and (3) Propose recommendations for improvement based diverse backgrounds at national and subnational levels
on the accumulation of Indonesian knowledge and (see appendix 4) to obtain detailed, nuanced, and in-depth
experience to obtain collaborative work commitments findings. This data collection process took place in the
among ministries / institutions, academics, professional July-September 2019 period.
organizations, civil society, business world, and
development partners / donors. On October 14, 2019, CISDI brought a preliminary version
of this technical study into a focus group discussion
(FGD) involving 28 experts (see Appendix 5). CISDI applies
Research questions and design the Delphi approach in the FGD. The Delphi approach was
chosen to, systematically, facilitate and capture different
This technical study aims to answer the following group of perspectives from stakeholders who come from different
questions: backgrounds and expertise.

1. Are the available regulatory, governance and financing In the period of December 3-16, CISDI conducted an
frameworks adequate to encourage the individual consultation with 15 experts (see appendix 6)
implementation of good measurement? in order to report the results of the synthesis of FGD
2. “Has the height measurement activity and integrated findings and ask for input related to policy studies. Next,
stunting data management been adequately CISDI synthesizes inputs and finalizes policy studies.
designed?”
 19
Chapter 1

The focus of the study that CISDI set might limit

the breadth and depth of the analysis.

Limited access to expert sources during the

analysis period might limit the diversity of opinions
on findings, analysis and recommendations.
Data retrieval, which is mostly carried out in
Jabodetabek area, might affect the diversity
of contexts, thus it is not representative of the
entire territory of Indonesia.

Structure of Report
Chapter One gives a description of the strategic
relevance of this study along with questions and
research designs. Chapter Two explains the policy
framework related to stunting, as well as governance
including available financing mechanisms. Chapter
Three explains the implementation and quality
assurance of toddlers’ height measurement in the
form of toddlers’ growth assessment standards and
various toddlers’ height measurement platforms in
terms of technical soundness. Chapter Four will dig
deeper into the data and indicators used to monitor
the progress and architecture of integrated stunting
data management. Chapter Five will close this study by
presenting a study synthesis, submitting conclusions
along with a number of policy recommendations.
2
20
Governance, and Financing

02.
Enabling Conditions:
Regulatory Framework,
CISDI

CHAPTER 2. Enabling Conditions: Regulatory

Framework, Governance, and Financing
Stunting is a condition of failure to thrive in children The Creating a supportive environment for the
regulatory, governance and financing framework implementation of comprehensive food and nutrition
provides direction and space for relevant stakeholders policies
to form enabling conditions so that a program / activity
Action #2
can run. Enabling conditions is an ecosystem that needs Includes all effective health interventions needed to have
to be organized, managed, given resources, and regulated an impact on the national nutrition action plan
in institutional arrangements. This ecosystem must be
able to encourage cross-sector stakeholders to
collaborate, exchange knowledge, and promote evidence- Action #3
based policies. Stimulate development policies and programs outside the
health sector that include nutrition
Specifically, this chapter will map the power relations
between stakeholders, examine their role in mobilizing Action #4
allocative and authoritative resources, and how these Provide sufficient human and financial resources for the
actions shape practices in policy implementation. In this implementation of nutrition interventions
study, good governance is a prerequisite for the key to the
success and sustainability of the implementation of
toddlers’ height measurement activities and integrated Action #5
Monitor and evaluate the implementation of policies and
stunting data management in Indonesia, such as: a)
programs
Continued commitment and support from the highest
leadership; (b) Integration of evidence-based specific and
sensitive nutrition interventions; (c) Nutrition education Figure 2. Action Plan for the Resolution of WHA 65.6
and communication to change behavior; (d) Social
monitoring and community based programs / activities; Through these five actions, WHA is committed to
and (e) Integrated data system. achieving the target of reducing nutritional indicators by
2025, namely: 1) a 40% reduction in the prevalence of
short and very short toddlers; 2) a 50% reduction in
Regulatory Framework anemia in fertile women; 3) a 30% reduction in babies born
with LBW; 4) increase in exclusive breastfeeding to at
Global Agenda
least 50%; and 6) reduce and maintain wasting in toddlers
less than 5%.
In 2011, the Scaling-Up Nutrition (SUN) movement called
for a nutritional improvement approach in every country to
The relevance of this resolution is maintained in the
be proven cost effective, promoting cross-sectoral
Sustainable Development Goals (SDGs). The world is
cooperation both government and non-governmental, and
committed to eliminating all forms of malnutrition by
focusing on 1,000 HPK interventions. Furthermore, in
2030. SDGs as a comprehensive global policy, encouraging
2012, WHO through the World Health Assembly (WHA)
development policies at the national level by uniting the
Resolution approved the Comprehensive Implementation
state of mind and logic of thinking about development
Plan on Maternal, Infant, and Young Children Nutrition [18].
planning and implementation needed to achieve the
The Resolution of WHA 65.6 encourages member
expected targets. This implementation requires a policy
countries and international partners to carry out five
framework and architecture for development at the
actions in the local context (see Figure 2).
national level to ensure SDGs are implemented in
Action #1 ministries, institutions and local governments.

23

Nationalizing the Global Agenda Chapter 2

To coordinate food and nutrition, Law No. 18/2012 on
Food mandates the government to prepare a
which later became the reference for the Secretariat of implementation of.
Gernas PPG in order to support the Technical Team in the

food and nutrition action plan. Five level a National Action Plan for Food Pillar #3
years later, the preparation, and Nutrition (RAN-PG) is developed in Increasing evidence based interventions
implementation, monitoring and line with the 2015-2019 National that are effective on different existing
evaluation, as well as the reporting Medium-Term Development Plan order in society
procedures for the National Action Plan (RPJMN). To facilitate the organization Pillar #2
for Food and Nutrition (RAN of the sectors that contribute to the Increasing capacity and competence of
PG) are regulated in Presidential Food and Nutrition Action Plan, human resources in all sectors, both
Regulation No. 83 of 2017 concerning grouping is needed government and private
the Strategic Policy for Food and
Pillar #1
Nutrition. Making improvements in nutrition as the Pillar #4
main stream of human resource Increased community participation for the
Referring to the Strategic Food and development, social, and culture economy ap plication of social norms that support
Nutrition Policy (KSPG), at the central nutritional awareness behavior

in the form of pillars: 1) improving people’s nutrition; 2) Implementation of the 2017-2019 Gernas PPG
increasing accessibility of diverse foods; 3) food quality Figure 3. Main Strategy for Gernas PPG
and safety; 4) clean and healthy life behavior; 5)
coordination of food and nutrition development. In 2018, Bappenas launched Stranas Stunting to ensure
the prevention of stunting is a priority of governments
The government also issued Presidential Regulation No. and communities at all levels until 2024. Stranas Stunting
42 of 2013 concerning the National Movement for the consists of five pillars, each of which has objectives,
Acceleration of Nutrition Improvement (Gernas PPG) to achievement strategies, and implementation instruments
accelerate the improvement of nutrition for the priority to target priority groups in priority locations (see figure 6).
communities in the first 1,000 days [19]. By using the With increased efforts in implementing the coordination
issue of stunting as an entry point, Perpres Gernas PPG scheme and various technical implications and funding
provides a sharpening of the nutritional program policy from Stranas Stunting, a moderate scenario projected
targets, which focus on pregnant women, breastfeeding that the stunting rate of baduta could fall by 1.5-2% per
mothers, and children aged 0-2 years, excluding young year and could achieve the WHA and SDGs target.
women from the priority of efforts to improve nutrition
mandated by Law No. 36 of 2009 concerning health. One of the things that deserves attention is the fact that
Perpres Gernas PPG links nutrition improvement efforts there are no regulations that raise the strategy of the
to be accompanied by broader, but highly related sustainability of efforts and progress in reducing
development programs such as poverty alleviation, food stunting in Indonesia. It is has become a debate whether
security, water supply and sanitation. when the focus of the government has switched, financing
and cross-sectoral efforts that have been established will
Furthermore, Bappenas issued a Policy Framework and also end. For this reason, the strategy of maintaining the
Planning Guidelines in the same year to guide the sustainability of the results that have been pursued must
implementation of Gernas PPG. In 2017, these two become one of the government’s priorities in the next few
documents were updated in the form of a Roadmap for the years.

24
CISDI
 *
Appendix 1 summarizes all available policy frameworks at
various levels along with the technical implications and
visions of synergy between various stakeholders at all levels
of government

The availability of regulations at the national level is have already reached the minimum service levels.
considered sufficient, but translating it to the District / City Governments must
subnational and village level in terms of regulation and meet 12 SPM in the health sector, which includes one of
implementation is still a challenge. At present, only about them, namely toddler health services. It was stated that
20% of regions have a Perbup / Perwali explaining the use “District / City Governments must provide health services
of village funds for stunting. One instrument that can be for toddlers in their working areas according to standards
used to ensure national standards and targets is through within one year”. These provisions include weighing at
the implementation of Minimum Service Standards (SPM). least 8 times a year, and measurement of length / height
The implementation of SPM itself has been encouraged at least 2 times a year.
and supported by Law 23/2014 regarding Regional
Government, PP 2/2018 regarding Minimum Service SPM is considered as the standard minimum basic
Standards, Permendagri 100/2018 regarding SPM requirement for citizens. Thus, all communities are
implementation, and Permenkes 4/2019 on Technical targeted to have to obtain minimum health services
Standards for the Fulfillment of Basic Service Quality in(100%), or are considered “not meeting SPM
SPM in the health sector. achievements”. Even in budgeting, SPM must be
prioritized before meeting other budgets. Unfortunately,
SPM includes service standards and targets that must be there are no sanctions / disincentives in the
met in terms of quality and quantity to be considered to implementation if the SPM is not met.

Finding 1

Political commitment for the efforts to improve community nutrition is strong enough in the form
of Laws, Government Regulations (PP), Presidential Regulations (Perpres), Ministerial Regulations
(Permen), and Regional Regulations (Perda), but the implementation gap at regional levels is still a
challenge. In addition, the sustainability strategy of efforts to reduce stunting must begin to be
prioritized in its planning and implementation

25
Governance Framework In building and enhancing partnerships with non
governmental organizations, Gernas PPG, among others, is
The institutional architecture at the national level was guided by: (1) UN Standing Committee on Nutrition; (2)
formed to orchestrate the implementation and WHO guidelines in cooperation with private parties; (3)
recapitulation of community nutrition improvement Global Strategy for Toddlers and Child Feeding; (3) UNICEF
achievements at the national level. At the legislative Guidelines and manuals in working with the business
level, there is the DPR RI Health Caucus which consists of community; (4) Guidelines from the International Pediatric
members of the DPR RI across factions and between Association (IPA) in working with industry.
commissions to support community nutrition programs in
the context of legislation, budgeting, and supervision. The main activities of K / L and partners are divided into
short-term (18 months) and mid term (36 months)
At the executive level, the government established the activities aimed at supporting the collection of key
Gernas PPG Task Force (see Figure 3) led by Menko Gernas PPG performance indicators. Monitoring of input
Kesra (now Menko PMK) to monitor the implementation indicators and processes is carried out every semester,
of Perpres across K / L. Bappenas, in particular the while monitoring of outputs is carried out annually to three
Deputy for Human Resources as the Chairperson of the years [20].
Technical Team, has the authority to orchestrate planning
and budget allocation.
Chapter 2

TIM PENGARAH Sekretaris

Deputi bidang SDM dan
Kebudayaan Bappenas

Ketua
Menko Kesra

Wakil Ketua I
Mendagri

Wakil Ketua II
Menteri Kesehatan

Anggota Anggota Anggota Anggota Anggota Anggota

Bappenas Anggota Anggota Mentri PPPA Anggota Anggota
Menag Anggota Setkab Mensos
Mendag
Wakil Ketua I
TIM TEKNIS Ketua Wakil Ketua II
Menkominfo
Mentan Deputi Bidang SDM dan Kebudayaan Bappenas
Mentri Kelautan Mendikbud
dan Perikanan
Menperin
Deputi Bidang Koordinasi Dirjen Bina Gizi dan KIA
Kesehatan, Kependudukan Kemenkes
dan KB Kemenkokesra

Sekretaris
Sekretaris Direktur Bina
Direktur Kesehatan dan Gizi Gizi Kemenkes
Masyarakat Bappenas

Figure 4. Structure Task Force for the Acceleration of Nutrition

Improvement based on Perpres No. 42 of 2013

26
CISDI policies and encouraging cross- manage the PforR program to
sectoral coordination and accelerate the reduction in
implementation [20]. In addition, stunting prevalence ‘Investing in
decentralization presents challenges Nutrition and Early Years’ 2018-2022
for planning systems between
(see Figure 5). In addition to
government levels and fiscal transfers.
becoming the executing agency,
In fact, national programs are very
dependent on the facilitation process atSetwapres also plays a role in
the District / City level and service several key functions: (1) held
delivery at the village level.

Therefore, the World Bank

The available governance framework established the Secretariat of the
based on Perpres No. 42 of 2013 is Vice President (Setwapres) as the
considered not effective in guiding highest leadership authority to
Sekretariat TNP2K Program Leadership Committee Program Enabling Agencies Bappenas Kemenkeu

Ketua I: Wakil Presiden

Ketua II: Menko PMK Program Implementing Agencies

Program Steering Committee Menkes BPS Mensos Mendes Mendagri Mendikbud

Program Executing Agency

Sekretariat Negara/ Pemerintah Kabupaten
Sekretariat Wakil Presiden
Pemerintah Desa

a summit stunting; (2) synchronizing planning and technical support to the

budgeting with Bappenas and the Ministry of Figure 5. Governance Structure of PforR World Bank
Finance; (3) reviewing the progress of implementing
PforR together with the Ministry of Home Affairs; (4) On the other hand, Stranas Stunting also developed a
coordinate with BPKP as an independent verification coordination structure as shown in Figure 6. This
agent [21]. structure consists of a Steering Committee chaired by the
Vice President and supported by the TNP2K Secretariat /
In carrying out its functions, the Secretariat is supported Setwapres, the Steering Committee, and a Technical
by TNP2K which makes the stunting reduction program Team supported by the Secretariat of the SUN Bappenas.
one of the acceleration policies [20]. Specifically, the Komite Pengarah
TNP2K Secretariat in this structure serves to provide Ketua : Wakil Presiden
Wakil Ketua : Menko PMK

Anggota : Menteri dan Ketua lembaga dari:

Setwapres, Menko PMK, cycle, accountability and

Sekretariat 13. Kementerian PPPA
14. Kementerian PPN/Bappenas 15. BPOM
TNP2K/Setwapres 16. Kemendes PDTT
1. KemenkoPMK 17. BKKBN

Bappenas, and the Ministry of learning which includes five

2. Kemendagri 18. Kemenristek
3. Kemenkeu 19. Kemendag
4. Kementan 20. Kementerian KUKM

Finance to encourage the main functions, namely (1)

5. Kemendikbud 21. BPS
6. Kemenkes 22. Sekretaris Kabinet
7. Kemenag 23. Sekretaris Wakil Presiden
8. Kemensos

implementation of the annual annual

9. Kementerian Kelautan dan Perikanan 10. Kementerian PUPR
11. Kemenperin
12. Kemenkominfo

targets and commitments, (2 ) consolidation, and (5) performance

Sekretariat SUN Bappenas

Komite Pengendali
allocation of costs and fiscal transfers reviews and adjustments. Ketua : 1. Deputi bidang Dukungan Kebijakan Pembangunan Manusia dan Pemerataan Pembangunan, Sekretariat Wakil Presiden

based on the results of interventions,

2. Deputi bidang Koordinasi Peningkatan Kesehatan, MenkoPMK
3. Deputi bidang Pembangunan Manusia, Masyarakat dan Kebudayaan,
Kementerian PPN/Bappenas

(3) coordination of national and

Anggota : Pejabat eselon I dari 23 Kementerian/lembaga yang disebutkan dalam Komite Pengarah yang ditunjuk oleh Menteri dan Ketua Lembaga

subnational implementation, (4) Tim Teknis

monitoring interventions and data

Ketua : 1. Direktur Kesehatan dan Gizi, Bappenas
2. Direktur Bina Gizi, Kemenkes
3. Direktur SUPD III, Kemendagri
Anggota : Pejabat eselon I dari 23 Kementerian/lembaga yang disebutkan dalam Komite Pengarah yang ditunjuk oleh Menteri dan Ketua Lembaga

Figure 6. Coordination based on the National

Strategy for the Prevention of Stunting Prevention

27
Chapter 2

The three coordinating and governance structures

(Figures 4, 5, and 6) are then compared, especially
some important components in the structure to see
changes between one structure to another as shown
in Table 1. In the aspect of leadership hierarchy,
structure 1 is chaired by Coordinating Minister for
People’s Welfare, structure 2 by Vice President
and Menko PMK, and structure 3 by Vice President.
Structure 3 also shows that more K / L are involved
than structures 1 and 2.
 28
CISDI

Confidential – for internal circulation only

Table 1. Comparison of Structures among Regulations

Indicator Gernas PPG (1) PforR World Bank Stranas Stunting (3)
Program (2)

Main The Coordinating Vice President and Vice President

leadership Minister for People’s Menko PMK
hierarchy Welfare leads the
Task Force
responsible for the
President

K/L 15 12 23
involved

Legal Basis Perpres No 42 of 2013 n/a n/a

Organizati Steering team, Program leadership Steering committee,

on technical team and committee, control committee and
structure working group program steering technical team
committee

Role and The task force The division of roles In the OPD Official Handbook, it
function coordinates and between structures or lists the roles and functions of
synchronizes Gernas K / L can be found in each K / L at the national level,
PPG between K / L. The detail in the document also the Provincial, District / City
division of roles and Village Governments, and
between structures or non governmental Institutions
K / L is not mentioned
in detail

Reporting The Chair of the Task Implementing • The Secretariat of

Force reports directly agencies report to TNP2K / Setwapres
to the President at coordinating prepares a
least once a year or at agencies Report on the Acceleration
any time if necessary. (Setwapres, of Prevention of Stunting
Governor, Regent / Bappenas, Ministry (PPS) every semester 1 and
Mayor reports to the of Finance, and BPS) annually in collaboration
Chair of the Task with related Ministries /
Force at least Agencies.
once a year or at
any time if • The Vice President shall submit
an annual national PPS report to
necessary
the Vice President who will
forward it to the President

29
Chapter 2
 Confidential – for internal circulation only
Indicator Gernas PPG (1) PforR World Stranas Stunting (3)
Bank Program
(2)

Coordination The Task Force holds meetings The leadership • The Vice President leads a
at least once every three committee quarterly meeting
months program holds
meetings • The TNP2K / Setwapres
every three Secretariat coordinates the
months annual leadership forum of
the regional government

• The Steering Committee

holds regular quarterly
meetings

• The technical team holds

planning meetings at
least twice a year

Implemen Involving regional government Involving The elaboration is carried out

ta tion in regional at the village level
the government
region

Monitoring Task Force TNP2K TNP2K will lead the monitoring

and evalua Secretariat is of the Stranas Stunting with
tion function leading the related K / L
monev process

Involveme Provincial and District / City Encourage Stranas Stunting outlines the
nt of Local Governments form multi-sectors roles and functions of potential
partners task forces that draw up involvement to partners outside the
outside the work plans and programs target the government sector
governme with reference to national main
nt sector policies. The task force determinants
members consist of of stunting, but
the government, does not
universities, professional describe in
organizations, community detail the
organizations, potential role
religious organizations, of each
business world, and stakeholder
`community member.

Source of APBN, APBD, and other legal APBN, APBD, APBN, APBD, village funds, and
funding and non-binding sources in and other other legitimate sources of
accordance with the sources up to income, and are encouraged to
legislation loans from the explore other sources of
World Bank can funding outside the
be government sector
disbursed
when the DLI
target is
reached.

30
CISDI The involvement of many K / Ls certainly becomes a
challenge for coordination and division of roles. From the
document review, Table 1 shows that structure 1 does not
describe in detail the division of tasks between structures
or K / L, while structure 2 in the PforR document clearly
states the expected role for each K / L and incentives
related to performance indicators ( disbursement linked
indicators). For structure 3, the OPD Official Handbook
lists the roles and functions of each K / L at the national
level, also the Provincial, District / City and Village
Governments, and non-governmental Institutions.
In Structure 1, 2, and 3 show quite different leadership
and coordination structures. The existence of new
structure 2 and 3 (Figures 5 and 6) do not negate the
structure of the Gernas Task Force (Figure 4). This
difference has the potential to cause confusion and
overlapping work, for example in structure 1 (Figure 4)
where Bappenas acts as the coordinator of the
implementing technical team, while in structure 2 (Figure
5) Setwapres becomes the coordinator of the PforR
Governance Structure and Structure 3 (Figure 6)
Bappenas, Ministry of Health, and Ministry of Home Affairs
become the coordinator of Stranas Stunting.
Finding 2
Potential for overlapping governance
Clear division of roles is very important to ensure that
efforts do not overlap and coordination and
communication can work well across agencies and
ministries. Ministry of Health and Ministry of Health PDTT
which has a role and many technical programs in the field
must have a significant role in the structure of the
technical team. However, currently the Ministry of PDTT
has positions as members in structures 1 and 3.
The plan to involve partners outside the government
sector has also been included in every document even
though it is not directly involved in all structures.
Structure 1 and 2 also do not regulate the role of
academics, professional organizations, civil society,
31
Village funds can be an important source of funding for
stunting. Transfers to the regions and the Village Fund in
2020 as a whole are planned to reach Rp. 856 billion (34%).
Village funds cover 10 potential categories and 48
subcategories. Upon approval taken through a village
business community, and other development partners /
donors in detail. Only structure 3 that explains in more
detail the potential roles and functions of each partner. A
broader Task Force, which allows the involvement of
business networks, civil society alliances, and donors
(DUNCNN) under the coordination of the Scaling Up
Nutrition Movement technical team may be needed.
Finding 3
A regulatory framework for meaningfully engaging SUN
Network / non-government actors is not yet available
Financing Framework
The general scheme of funding sources for stunting
programs in Indonesia is to use APBN (K / L budget),
Special Allocation Funds, APBD 1 (Province), APBD 2
(Regency / City), village funds (APBDesa), and other legal
sources. In 2018, the Ministry of Finance estimates the
need for a budget allocation for nutrition of Rp 141.9
trillion annually to be consistent with the target of
stunting reduction in the 2015- 2019 RPJMN [22].
In accordance with the reconciliation results of the
Ministry / Institution Work Plan (Renja K / L) and the
Ministry / Agency Work Plan and Budget (RKA K / L) 2019,
the 2019 budget allocation in the relevant APBN to
support stunting reduction was Rp 29 trillion. The
Ministry of Health managed Rp 3.6 trillion for specific
nutrition interventions with macro and micro nutrient
supplementation outputs, training in Infant and Child
Feeding (PMBA), growth monitoring training,
strengthening integrated nutrition information, and
updating nutritional surveillance, and immunization. With
an increase in total health function expenditure
allocations in 2020 of Rp 1.4 trillion and an increase in BOK
funds of Rp 475.9 billion for handling stunting in 260
regions, it can be estimated that the commitment to
increase the mobilization of government funding sources
for nutrition programs is very high [23].
meeting, the Village Fund can finance issues that are
appropriate to potential categories and subcategories. In
addition, the issue must also be in line with village
development goals, and government priorities at national
and subnational levels. Within these categories, some are
important determinants that contribute to stunting prevention, such as access to clean water and
sanitation, health promotion, growth monitoring, and
nutrition of pre-school and school aged children. [24]. The
Kementerian/Lembaga Permendesa PDTT 11/2019 concerning Priority for the Use
Mendanai Kewenangan 6
Urusan (Mutlak) of Village Funds in 2020 also includes stunting as a priority
for the use of village funds. In its implementation, this
Belanja
Pemerintah regulation has not been well socialized to all village
(Pusat) officials to understand that village funds can be used for
Kementirian/Lembaga stunting prevention programs. Only around 20% of
Mendanai Kewenangan Di
luar 6 Urusan
Regent / Mayor have made regional regulations regarding
the use of village funds for stunting programs.
Chapter 2

Dana Vertikal

Program/Kegiatan Pusat
(K/L)

Dana sektorial:
Dikerjakan oleh K/L/UPT

Dana Dekonsentrasi
Dilimpahkan ke Gubernur

APBN
Daerah dan Dana Desa Dana Perimbangan Alokasi Dana Desa DAK Specific Grant, 2.
(TKDD) Dana Tugas Pembantuan: Penggunaannya di-earmark
Dilimpahkan ke untuk bidang tertentu
Gub/Bupati/Walikota
3. 4. 5. 6. 7.
Masuk dalam APDB APDB Mendanai kebijakan
tertentu Pemerintah (misal:
Desa
Infrastruktur) Intervensi
Subsidi Sasaran Ibu Hamil Intervensi
Sasaran Ibu
Menyusui dan Anak 0-6
APBDes bulan ...dst...
Anggaran nol K/L Dana Insentif Daerah Dana Program/Kegiatan Intervensi Air Bersih
Sanitasi
Desa
Edukasi

DAU DBH
Block Grant ...dst..
Desa 1.
Transfer ke Dana Otsus dan
Keistimewan DIY

Figure 7. Framework for Financing the Stunting Program in Indonesia

(Source: Stranas Stunting 2018- 2024)

32
CISDI Efforts to prevent stunting are also encouraged to
explore other sources of funding that come from
businesses and donors given the limited government
funding. One of the major international funding sources
for nutrition in Indonesia is the World Bank funding
scheme. The World Bank provides loans to Indonesia with
a results-based financing scheme (Performance for
Results) that depends on achieving indicators / targets set
(Disbursement Linked Indicators).
With the amount of resources spent on reducing effectiveness. One method used is through a budget
stunting, the Government realizes the importance of tagging and tracking system as a tool to measure
starting to focus on the resulting impact. As part of the impact and encourage accountability in the use of
convergence effort on handling stunting, the Government funds.
has begun to implement a Tagging and Tracking system to
finance specific and sensitive stunting programs, as well
as assistance, coordination, and technical support, where
the budget has been marked and allocated specifically for
programs that can be traced its utilization and targets
achieved . This system also makes it easier for the
Government to conduct planning and performance
evaluations, as well as to ensure the accountability of
each K / L. The tagging process is not optimal because the
thematic stunting marking on Renja and RKA K / L TA 2019
was only effectively implemented in October 2019.
Unfortunately, this system has only been implemented for
financing by the central government, but its use has not The regulatory, governance and financing framework is
been traced to local budgets and village funds. an important component that drives and enables
programs / interventions to reduce stunting. These
components will greatly affect the coordination,
Finding 4 accountability, implementation, reporting, and especially
the expected outputs. In the next chapter, the focus of the
The amount of funding allocated for the stunting study will highlight the process of measuring and
program needs to be encouraged for its efficiency and recording from various aspects of regulation to
monitoring.
33
Chapter 2
3
34

03.
Toddlers’ Height Measurement: Implementation
and Quality Assurance
CISDI

CHAPTER 3. Measurement of Toddlers’ Body Height:

Implementation and Quality Assurance

Toddler growth monitoring is an effort to obtain data on nutritional status of toddlers and indicators related to
nutrition at the scale of posyandu, puskesmas and
district services. This monitoring is carried out in stages
to find out individual level progress, increase parental
participation, and the community to maintain optimal
toddler growth, as well as provide follow-up and
counseling tools for behavior change.
At the policy making level, growth monitoring is useful
for increasing the effectiveness of service targets and
resource allocation. In addition, this monitoring is also
able to encourage problem solving and planning at the
village to district level. In related units in the village
government, monitoring is also useful to support
advocacy for program integration.
This chapter will examine the toddlers’ height
measurement platforms available in Indonesia.
Specifically, this chapter will highlight service
standards, availability of resources, delivery
arrangements for each platform, and integration
between platforms.
Height measurement as a standard for
monitoring Toddlers’ growth
The medical community began to introduce growth
measurement practices in developing countries since
the 1960s. Soon after, in the 1970s, the use of growth
charts became standard practice. Scientific publications
at the time linked much to growth monitoring with
nutrition education and counseling. The measurement
practice outside the building grew to become part of the
37
activities of the primary health care community. World
Health Organization (WHO) in 1978 included Growth
Monitoring in the GOBI package (growth monitoring, oral
rehydration therapy, breastfeeding, immunization) in the
Child Survival Development Revolution program. This
concept continued to evolve into Growth Monitoring and
Promotion (GMP) in the mid 1980s.
The GMP includes the counseling component and links
the measurement results to follow-up actions that must
be taken afterwards [25]. This aspect of promotion aims
to increase: (1) awareness of child growth; (2) parenting
practices; (3) demand for related services, so it is
becoming the key in family level decisions for integrated
nutrition services.
Indonesia adopted the GMP program and made it a
component of the Family Nutrition Improvement Efforts
(UPGK) since the 1970s through the Integrated Service
Post (Posyandu). Posyandu was launched in 1986 and has
become the main platform for GMP in Indonesia. At that
time weight was still the main indicator of toddler growth.
Minister of Health Decree (Kepmenkes) No. 1995 /
Menkes / SK / XII / 2010 set anthropometric standards
for assessing children’s nutritional status. This
anthropometric standard refers to the WHO Growth
Standards 2005 [26]. WHO developed anthropometric
standards through the WHO Multicenter Growth Reference
Study which was also adopted by 159 other countries in
the world. Categories and thresholds for children’s
nutritional status are determined based on the index as
shown in table 2.
Chapter 3
 Table 2. Categories and Thresholds for Child Nutrition Status Based on Index
Index Nutrition Status Category Threshold

Body weight based on Age (BB/ Bad nutrition < -3 SD

U) Children aged 0-6 months Less nutrition -3 SD up to <-2 SD
Good nutrition -2 SD up to 2 SD
Over nutrition >2 SD

Length of body based on age Very short <-3 SD

(PB/ U) Short -3 SD upt to <-2 SD
Children aged 0 – 60 months Normal -2 SD up to 2 SD
High >2 SD

Body weight based on Lean <-3 SD up to <-2 SD

body length (BB/ PB) Normal -2 SD up to 2 SD
Or Fat >2 SD
Body weight based on
body Height (BB/ TB)
Children aged 0 – 60 months

Body mass index based on Very lean -3 SD

age (IMT/ U) Lean -3 SD up to <-2 SD
Children aged 0 – 60 months Normal -2 SD up to 2 SD
Fat >2 SD

Body mass index based on Very lean <-3 SD

age (IMT/ U) Lean -3 SD up to <-2 SD
Children aged 5 – 18 months Normal -2 SD up to 1 SD
Fat > 1 SD up to 2 SD
Obesity >2 SD

Measuring body length or height measures included in

the Stimulation, Detection and Early Intervention
Program for Child Growth and Development (SDIDTK).
Specific regulations governing the monitoring of growth,
development, and developmental disorders of children
regulating the goals, frequency, and scope of services are
contained in two regulations, namely Minister of Health
Regulation (Permenkes) No. 25 of 2014 concerning child
health efforts and Permenkes No. 66 of 2014.
Specifically, what is regulated in both regulations are:
1. Growth monitoring is a package of health services for
infants, toddlers and preschoolers carried out in
children aged 0 (zero) to 72 months. Weighing is done
every month, measuring length / height every three
months, and measuring head circumference according
to schedule, namely at the age of 15, 21, 30, 42, 54, and
66 months.

2. Early detection of growth deviations is based on weight

classification for height (BB / TB) by trained health
workers.

CISDI
Permenkes No. 66 of 2014 defines a height below -2SD as
short stature or short stature, in contrast to the WHO
definition that a child is classified as stunting if the
length or height is below minus two of the standard
deviation (-2SD) the length or height of a child of his age
[2].
Both Permenkes mention growth monitoring targeting
infants, toddlers and preschoolers aged 0 (zero) to 72
months, in contrast to the Stranas Stunting priority
targets which refer to children 0-23 months as priority
targets and children aged 24-59 months as important
targets. The measurement frequency listed in Permenkes
No. 66 of 2014 is also different from Permenkes No.4 of
2019 regarding Technical Standards for Fulfillment of Basic
Service Quality in Minimum Service Standards in the Health
Sector. Minister of Health Regulation 66/2014 states that
measurements of height every three months in children
aged 0-12 months and every six months in children aged 12-
72 months, while Permenkes 4/2019 regulates that
measurements of length / height are carried out at least 2
times / year on children aged 0-59 months.
Finding 5
There are different definitions, target age
groups, and recommended measurement
frequencies
However, although both Permenkes insisted that this
growth monitoring must be carried out comprehensively,
counseling points after measurement are not explicitly
written. In fact, counseling is an important component
after the measurements made to provide an explanation
and follow-up that must be carried out by the child’s
guardian based on the measurement results. The
38
counseling component for mothers is only listed in the
management chart of children with malnutrition without
details on the points that must be delivered according to
the measurement results [27].
Finding 6
The communication component of behavior change,
especially aspects of interpersonal communication
escapes the growth monitoring service package
Box 1. Indonesian National Synthetic Growth Charts
In an article entitled “Indonesian National Synthetic
Growth Charts” published in the ACTA Scientific
Paediatrics journal volume 1 issue 1, August 2018,
Pulungan, A et.al. recommend the use of Synthetic
Growth Chart in Indonesia which were developed based
on the 2013 Riskesdas data sample. Researchers
consider this national growth to be more representative
of the nutritional status and growth of Indonesian
children. WHO, PERSAGI, PDGMI, IDI, and IAKMI in their
official recommendations advise Indonesia to continue
using the 2005 WHO Growth Standards for children 0-59
months. The standard is designed to control genetic
and environmental factors and consider secular trends
in the population. At the November 2019 meeting
chaired by the Ministry of Health, it was agreed by all
parties to continue using the 2005 WHO Growth
Standards.
Finding 7
Agreement to use WHO
Growth Standard 2005 in Indonesia according to
Kepmenkes No.1995 / 2010
 39
Delivery Arrangement
Posyandu is the backbone of monitoring infant growth in
Indonesia that operates at least one (1) time a month at
the hamlet level. The village midwife, PKK cadre and
Posyandu cadre are the posyandu organizers. One cadre
accompanies 10-20 target families.
Posyandu, which is implemented through a 5-table
system, is expected to provide GMP services and other
integrated nutrition (MCH, KB, Immunization, and
diarrhea prevention). The success of Posyandu is
reflected through the SKDN coverage: (a) D/S:
community participation indicators (access) and (b) N / D:
indicators of success (service quality). Using the BB / U
indicator, the posyandu refers the child to the Puskesmas
if in two measurements the body weight does not go up or
fall below the red line (BGM) curve in the KMS. In certain
conditions, if growth disorders are caused by comorbid
diseases that cannot be treated at the Puskesmas,
children are referred to the District / City Hospital.
There is still debate about whether Posyandu cadres can
take measurements. In the National Strategy, it is said
that ideally monitoring the growth and development of
children in the posyandu is routinely conducted every
month by health workers assisted by KPM and posyandu
cadres, but for length / height measurements, it can be
done at least once every three months. There are no
standards / regulations that say that posyandu cadres are
tasked with measuring height.
Anecdotal findings indicate that height measurements
at posyandu are carried out by cadres. Measurements
are made using a length board or microtoise
anthropometry measuring device. Children who are
detected with stunting will be referred to the puskesmas
for validation of measurements by a nutritionist or
midwife and further examination by a doctor.
Chapter 3
A home visit by a companion cadre is carried out if a
toddler is not present at the Posyandu. In areas with
limited resources that do not allow the accompanying
cadre to make regular home visits, sweeping is done
twice a year by utilizing the Toddler Weighing Month
(BPB). Follow-up after measurements in the Toddler
Weighing Month are carried out through the same
mechanism by the posyandu. Meanwhile, toddlers living in
urban areas have alternative measurement platforms such
as a doctor’s clinic or an independent hospital.
The Healthy Indonesia Program with the Family
Approach (PIS-PK) can be used to ensure and educate
every family that has a toddler to bring toddlers to the
posyandu. One PIS-PK indicator verifies whether a
toddler is weighed every month or not. If toddlers /
parents are not present at the posyandu, counseling is
done through home visits. The Healthy Family Index (IKS)
can guide health center personnel to recognize patterns
of health problems at the family level that contribute to
stunting.
If anthropometric measurement tool is not yet available
or limited, growth mat can be used temporarily as an
early detection tool for stunting risk. In Posyandu with
limited tools that are priority areas of the Smart Healthy
Generation (GSC) program, together with posyandu
cadres, midwives or other puskesmas workers, the Human
Development Cadre (KPM) facilitates height measurement
with growth mat.
KPM ensures the convergence of stunting handling at
the village level. KPM conducts monthly monitoring of
the implementation of the convergence of 5 stunting
handling service packages. Monitoring is carried out by
following the implementation of posyandu activities,
PAUD activities, and visits to target homes.
 40
CISDI Chapter 3

Determination of the prevalence of stunting at the national, provincial and district level is carried out by the Basic
Health Research (Riskesdas) and the Indonesian Toddler Nutrition Status Survey (SSGBI). Riskesdas is conducted
every 5 years and will be carried out again in 2023, while SSGBI is held once a year. Weight and height data are collected
based on measurements by enumerators.
Confidential – for internal circulation only
Do not duplicate or distribute without written permission from CISDI

RUMAH TANGGA DESA KECAMATAN KABUPATEN

The integration of various Toddlers’ Growth Measurement Platforms in Indonesia can be seen in Figure 8.
PIS -PK

Apakah balita mendapat

pemantauan pertumbuhan?

Kunjungan kader
PUSKESMAS
PEMBANTU

PIS-PIK tidak diukur, diminta ke Posyandu

Posyandu
Balita stunting dirujuk
Balita stunting dirujuk
Ukur ulang BB dan TB PMT Pemulihan Konseling dan Pemantauan

PUSKESMAS

SUSENAS SSGBI

RSUD

Rujuk karena butuh

penanganan dr. SpA

Pelaporan data

karena balita
tidak ke posyandu

BPB
Pengukuran BB dan TB Konseling Imunisasi Tikar Pertumbuhan

Balita stunting dirujuk

Dinkes Kabupaten
Puskesmas

RS.SWASTA

KLINIK
SWASTA/BPM

RISKESDAS

Figure 8. Integration of various Toddlers’ Growth Measurement Platforms in Indonesia

41 42
CISDI

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Do not duplicate or distribute without written permission from CISDI

Quality of growth measure platform

The model used as a reference frame for assessing
the quality of growth platforms is the system
evaluation model from Donabedian [28]. This model
highlights three dimensions in quality assessment,
namely: structure / input, process, and outcome
(output)).

Structure/Input Process Output

1. Regulation framework, resources and tools Measurement process 1. Integrated stunting data
govermance and 1. Data interpretation, 2. system
2. funding Availablility and 2. 3. counselling and referal Quality data
quality of human Recording and raporting

Figure 9. Adaptation of the Donabedian Model to the Evaluation of Growth Measurement Platform

Based on this framework, this study uses a

regulatory framework, governance and financing,
availability and quality of human resources, as well
as tools for measuring height and stunting data
management as an important input or component to
enable measurement of toddler height. In this study,
the process component will focus on the frequency
and quality of the measurement process, data
interpretation, counseling and referral, as well as
the process of recording and reporting data that will
influence the expected output, namely quality data
and integrated data systems.

Structure/ Input

Quality assessment of each platform based on

structure / input is listed in table 3
43
Chapter 3

Confidential – for internal circulation only

Table 3. Evaluation of Growth Measurement Platform based on Structure / Input

Platform Governance Measurement Tool Human Funding
Resources

1. Posyandu • Governance at • BB measuring • Posyandu • Government,

the national devices are management sourced
level available in all is carried out from APBN,
is complicated. posyandu by posyandu Provincial
It is still debating cadres APBD, Regency
whether the • TB measuring / City APBD
Ministry of Home devices are • Puskesmas funds,
Affairs, PKK, limited at health workers
Ministry of Health posyandu provide health • BOK dinkes /
PDTT, or Ministry technical puskesmas
of Health are • Posyandu support
responsible found with • Village funds
TB measuring • Cadre
• At the district instrument not refreshing • Posyandu user
level, posyandu according to training is / visitor fees
management is the standard conducted
the authority of by village • Village funds
the district head midwives / TPG are
and is reduced to puskesmas insufficient
the village head’s
responsibility. • Posyandu
management
• The health sector competency
(ministry of health, and TB
health offices, measurement
puskesmas) is are minimum
responsible for
ensuring health
service logistics
in posyandu
(immunization,
family planning,
etc.) and
providing
assistance to
cadre.
 44
CISDI

Confidential – for internal circulation only

2. Puskesmas • Ministry of Health • BB • High TPH • Originated from
handles at (standardized workload – BOK, DAK, etc.
national level tread scale) mostly for
and TB administrative
• Health Office (microtoise functions
handles and length
coordination at board) scales • Competence
the district level are available at is lacking,
the puskesmas in
• TPG puskesmas service
handles training [29]
nutrition
data reporting at • Detection of
the village level, stunting
data managed by cases
the village is also done
midwife then by general
collected to practitioners
TPG puskesmas. when handling
patients with
MTBS and
immunization.
TB
measurements
in MTBS
polyclinics
and general
treatment are
performed by
nurses.

• If a stunting
case is
found,
the doctor
will refer to a
nutritionist
for further
examination.

45
Chapter 3

Confidential – for internal circulation only

 3. Private • Individual medical • Weight scales • Increased • Payment of
first level personnel, such competence out of pocket
health as: Independent • The majority and standards patients,
facilities Practitioner do not depend on capitation
(FKTP) Doctor (DPM) have individuals and funds (if
or Independent standardized professional already
Practice Midwife length organizations. registered with
(BPM)) measurements Assistance BPJS)
from the health
department is
still low. The
majority of
private FKTP
do not measure
body length,
only measure
body weight

4. Hospital • The Ministry of • TB, BB, • Competency • Local

Health and head improveme Goverment
regulates circumference nt (provincial),
hospital measured* is held by the funded by
regulations at the dinkes and Regional
national, public • Measuring professional Government
and private levels tools organizations Budget (APBD)
according to
• Hospital the standard, • Toddler • If not through
governance is carried nutrition cases the referral
the responsibility out annual handled by process, the
of each hospital calibration* pediatricians costs are borne
management and / or clinical by the family
*Depends on the nutrition (out of pocket)
type of hospital specialists
and the
availability of
equipment at
the hospital

46
CISDI

Confidential – for internal circulation only

5. PIS-PK • The ministry of • Not measuring • Puskesmas • BOK
Health through BB and TB, staff must Puskesmas
the Director just asking the visit all houses funds
General mother if the within the
of Health and toddlers get puskesmas
the Director of monthly working
Primary Health growth area (total
Care is monitoring sampling).
responsible at Often
the national puskesmas
level staff also have
basic tasks
• The health office is and other
responsible at programs at
the the
City/ District level puskesmas,
making it
• The difficult to
implementation collect PIS-PK
is carried out data.
by puskesmas
officers

6. BPB • The Ministry of • BW and TB • Need • BOK

Health through measured anthropometr puskesmas
the Director ic training for
General • Measuring cadres and TPG
of Health and tools using the
the Director of puskesmas’ • There needs to
Primary Health property are be personnel
Care is subject to who re-check
responsible at availability to ensure the
the national validity of
level measurements

• The health office is • Large amounts

responsible at of human
the resources for
City / District level home visits to
toddlers who
• The do not come to
implementation weighing
is carried out by
puskesmas staff
and cadres

47
Chapter 3

Confidential – for internal circulation only

 7. KPM • Ministry of PDTT • Screening • Not all KPM • Village funds
handles at for stunting come from
national level toddlers using posyandu
growth mats at cadres
• The village head home, PAUD, or
manages it at at the Posyandu • The quality
the of detection
village level with a mat will
determine the
competence
of KPM. KPM
training is
needed to
equalize quality

8. Riskesdas • RI Ministry of • Performed • A trained • APBN

Health, through every 5 years enumerator
Litbangkes, who has
manages at the • Measuring TB obtained
national level and BB and anthropometr
percentage ic training
of growth
monitoring
coverage

9. SSGBI • Research and • Performed • A trained • BPS and

Development once a month enumerator Litbangkes
Ministry of Health who has budget
of the Republic • Measuring TB obtained
of Indonesia and BB anthropometr
cooperates with ic training
BPS

48
CISDI In terms of governance, most of the existing
measurement platforms are managed by the Ministry of
Health. Some platforms such as growth mats, posyandu,
and SSGBI are managed in collaboration with other
Ministries. However, the platform still needs support from
the Ministry of Health in its implementation in the field.
Most of the funding on the platform managed by the
Ministry of Health comes from BOK. In terms of funding,
the measurement platform managed by the Ministry of
Health is mostly sourced from the BOK puskesmas. Other
sources of funds are village funds, APBN, APBD, and
medical services paid by patients.

Based on table 2, the most ideal platform for growth

measurement is posyandu. This is in view of the regular
implementation of posyandu, which is once a month.
However, posyandu governance at the central level is
complicated because it must be managed by 4 different
institutions (Ministry of Health, Ministry of Home Affairs,
Ministry of Villages, and PKK driving teams). Height
measurements are also not carried out every three
months, only 2 times per year during BPB implementation.
The limited availability of measuring instruments and the
lack of cadre competence in measurement poses a
posyandu constraint.
Finding 8
Posyandu is the most ideal platform for
monitoring growth. However, measurement at
Posyandu is constrained by the availability of
measuring instruments and measurement
competencies.
Although posyandu is the most ideal measurement
platform, not all toddlers are examined for growth at
posyandu. Nationally, Posyandu D / S coverage is 80.6%
[7]. This shows that as much as 19.4% of toddlers are not
brought to the posyandu. In addition, not all posyandus do
body length measurements. As much as 46.8% toddlers
have not received body length measurements in the last 12
months [7]. Ideally, toddlers who are not present at
However, the 2016 QSDS data found that only 35% of
cadres visited homes [30].
The problem of the absence of toddlers to posyandu can
ideally be overcome by sweeping the weighing of
toddlers twice a year which is done during the weighing
month of toddlers and providing education through
home visits PIS-PK. At PIS-PK, health workers ask
whether a toddler is weighed in a posyandu or a health
facility in the past month. This indicator can be a
complement and driver of the social accountability
mechanism of the D / S posyandu indicator. However, the
coverage of PIS PK in 2019 was only 56%. In addition,
awareness raising through PIS-PK has not been
implemented well. Home visits were only used for data
collection on Family Health Profile (prokesga).
Based on the FGD with Puskesmas and hospital service
providers in Jakarta, the Puskesmas and resource
hospitals have an adequate measuring platform. The
standard of equipment used at the puskesmas refers to
the standards of the Ministry of Health and the
Department of Health. At the hospital, the tools used refer
to the Ministry of Health’s standards and are part of the
hospital accreditation assessment. Tool calibration is
carried out annually to ensure measurement accuracy.

In terms of HR, cadres become important actors in

measuring height at posyandu and weighing months for
toddlers. The TPG and the village midwife control the
quality of height measurements made by cadres at the
puskesmas, and also become health workers who
measure the growth of children in poly nutrition at the
puskesmas. In the scope of MTBS and puskesmas
immunization services, height measurements are carried
out by nurses before the patient meets the doctor. The
posyandu get a home visit by the cadre. During home doctor will re measure if extreme measurement data are
found. Identification of HR involved in the measurement
visits, cadres take measurements of growth and provide
process is in table 4.
counseling about the growth and nutrition of children.

49
Chapter 3

Confidential – for internal circulation only

Table 4. The Profession Involved in the Measurement Process

Human Resources Measurement Platform Measurement Competence Things Needed
 Cadres of • Posyandu Depending on the training Assistance from
Posyandu • Weighing Month for provided and not through TPG and village
Toddlers formal schooling. Training midwives when
is provided by the TPG or measuring at
village midwife. posyandu

Based on the Pencerah

Nusantara study [31], cadres
have limited competence
even though they have
received repeated training;
one of the factors is due to
age and education.

Village Weighing Month for Height measurements In service training

midwives and Toddler and included in the growth and the urgency of
midwives Maternity Clinic and development height
practice modules are taught in measurement
indipendently midwife education

TPG • Posyandu Height measurements In service training

• Weighing Month for included in the
Toddlers anthropometry module
• Puskesmas taught in nutritionist
education

Midwives • Puskesmas, before Height measurements In service training

patients receive included in the growth and the urgency of
doctor services and development height
• Hospital, before module are taught in measurement
patients get nurse education
specialist services

General • MTBS poly Taught in medical education Refreshing training

practitioners puskesmas and and the urgency of
posyandu services height measurement
• Independent
practice clinic

Pediatrician • Hospital Taught in the education Urgency of height

of doctors and measurement
pediatricians

CISDI
Based on table 4, different handling is needed for each
health worker in terms of height measurement. As the
50
only non-health worker in the measurement process,
posyandu cadres need intensive assistance from TPG
and village midwives at table 3 posyandu.
For village midwives, nurses and TPG, in-service training
is needed to ensure the three health workers measure
accurately and according to standards while keeping
abreast of developments in science. At present, there is
no standardized in-service training to improve the
competency of nutrition workers. The Unicef study [29]
found a lack of pre-service training for nutrition workers
in puskesmas. Therefore, in service training is needed to
close the competency gap.
In physicians and pediatricians, no study was found
regarding the lack of pre-service training in height
measurement. Based on FGDs and interviews with a
number of doctors and pediatricians from Jakarta, the
majority of children’s height measurements were carried
out by nurses before the patient was examined by a
doctor or pediatrician. Thus, very few cases of growth
measured directly by the doctor.
51
Process
Increased physician awareness about the urgency of
height measurements is needed to ensure that children
with extreme measurement results are comprehensively
re-measured by doctors, therefore early detection of
stunting can be done. In addition, the ability of doctors to
conduct post-measurement counseling and
communication of behavioral changes needs to be
improved. Through counseling, mothers get the right
information about stunting and other health problems so
that the mother’s excessive worries can be overcome.
Therefore, it is necessary to ensure that the doctor has
good counseling skills so that the information is
conveyed appropriately.
Chapter 3
 After a toddler is measured, the measurement data
will be recorded in the patient register. The method
of recording is different on each platform. For
example, measurement results at the posyandu are
recorded in the weighing register, but in the PIS-PK
the findings are recorded in the Family Health Profile
(prokesga) and Healthy Family Application. After the
data is recorded, the measurement officer provides
counseling to the toddler mother. If a toddler is
found to be experiencing nutritional problems, a
toddler will be referred to the next level of health
care. Quality assessment of each platform based on
the process dimensions is shown in table 4.

Finding 9

Variations in the quality and availability of

measurements due to logistical limitations,
calibrations, measuring competencies, and lack
of proper governance, SOP, and non-compliance
with standards.

52
CISDI Chapter 3 Confidential – for internal circulation only

Table 5. Evaluation of Growth Monitoring Platforms according to Process Dimensions

No Platform SOP Measurement Obstacle Data
.
 1. Posyandu Measurement • TB measurements • Bab
vary. The m
• Growth monitoring is carried out once a majority m
month does not take c
• Routine BB Weighing every month • measurements n
Most Posyandus measure TB every 6 every 3 months c
months at BPB • Cadre measurement • KIA
competency is low ch
Data Recording c
c
• The results of weighing are recorded in • eP
the baby’s weighing register. can
• KIA Handbook: body weight filled in the ther
BB / U chart, height filled in the TB / la
U chart. The officer checks whether the
BB / U and TB / U fit the standard n
curve for toddler growth f

Counseling

• Counseling is done after recording data.

Officers provide feedback by explaining
the meaning of growth graphs on KMS /
KIA books and giving advice on feeding
children according to their age group.
Cadres also invite mothers to come to
the posyandu every month

Handling and referral

• If the child’s BB does not increase 2 times

(T2) or remains below the red line (BGM),
the officer asks questions and takes
notes on health complaints and toddler
eating habits.
• After that, the officer explains the possible
causes of the child’s BB not going up
and gives advice on child feeding
The officer then refers the child to a
health facility

53 54
CISDI Chapter 3 Confidential – for internal circulation only

No Platform SOP Measurement Obstacle Data

.
 2. Puskesmas Measurement In some cases, the • Bab
coverage of p
• BB and TB are measured in puskesmas as toddlers i
part of MTBS measurement is s
little, because c
Recording patient’s data toddlers are only p
measured if they • e-P
• Weighing results are recorded in a toddler are sick or come to t
cohort register and reported using immunization services f
ePPGBM I
• KIA Handbook: Body weight is filled in the tim
BB / U graph, height is filled in the TB / U as
chart, The officer checks whether the h
BB / U and TB / U matches the standard
curve for toddler growth

Data collection from posyandu

• Cadres collect toddler weighing registers

and posyandu information system
documents a week after posyandu
activities

Counseling

• Counseling is done after data recording.

Officers provide feedback by explaining
the meaning of growth graphs
according to the plotting BB / U and TB
/ U children. The officer also provides a
referral for baby feeding

Handling and refferal

• Toddler stunting and malnutrition receive

a 90-day recovery PMT and receive
a home visit from a health worker
to monitor the increase in weight

If there is no improvement, the toddler will

be referred to the hospital

55 56
CISDI Chapter 3 Confidential – for internal circulation only

No Platform SOP Measurement Obstacle Data

.
 3. Private first- Measurement • TB is not • Pat
level health measured. There t
facilities • Private FKTP often only measures are no regulations re
(FKTP) toddlers’ BB governing private h
FKTP to measure n
Recording patient’s data TB. • There are no
measurement tools.
• Using a patient medical record card

Counseling

• Some private FKTPs do not provide

growth counseling; FKTP only
provides disease counseling.

Handling and referral

• FKTP refers patients to the hospital

4. Hospital Measurement • Standards and • Pat

quality vary t
• Performed at a specialist growth and re
development clinic or children’s h
clinic n

Recording patient’s data

• The hospital records using the patient’s

medical record

Counseling

• Pediatricians provide counseling

Handling and referral

• The hospital referred back the patients

who have improved to the
puskesmas / posyandu

57 58
CISDI Chapter 3 Confidential – for internal circulation only

No Platform SOP Measurement Obstacle Data

.
 5. PIS-PK Measurement Does not measure • The
BB and TB i
• No measurement taken l
t
Recording patient’s data t
a
• Use the Prokesga application a
F
Counseling i
pu
• Done using pinkesga ap
d
Handling and referral

• Toddlers who do not get growth

monitoring are educated to come to
the posyandu

6. BPB Measurement • Availability of • BPB

measuring devices c
• Puskesmas do BB and TB measurements. • Prone to o
If a toddler is absent, a health worker measurement a
makes a home visit errors due to too fi
many l
Recording patient’s data home visits

• Use the BPB register

Counseling

• None

Handling and referral

• BPB refers to cases of malnutrition found

in puskesmas

59 60
CISDI Chapter 3 Confidential – for internal circulation only

No Platform SOP Measurement Obstacle Data

.
 7. KPM Measurement • Growth mats are not • Villa
yet available in all Co
• Early detection of stunting with growth districts / cities m
mat • Potential for h
overlapping m
Recording patient’s data and confusion r
at the level of f
• Convergence score card implementation p
between posyandu
cadres and KPM, as
well as reporting
and using different
indicators

8. Riskedas Measurement It is necessary to Ques

ensure the
• BW and TB measured enumerator’s
competence in
Data Recording measurement

• Counseling

Questionnaire (None)

Handling and referral (None)

9. SSGBI Measurement It is necessary to Ques

ensure the
• BW and TB measured enumerator’s
competence in
Data Recording measurement

• Counseling

Questionnaire (None)

Referral (None)

61 62
CISDI midwives who work at the posyandu have not consistently
filled the TB/ U charts in the KIA handbook. This has
caused early detection and education of stunting cases
not yet fulfilled.

The ability of cadres in KMS chart/ KIA book interpretation

and counseling is low. Based on the findings of Pencerah
Nusantara [31] the TB/ U graphs were not filled in the KIA
book because: (1) height measurement tools were not
available; (2) cadres’ inability to take measurements; (3)
cadres ignorance regarding TB / U content charts, (4) the
number of tasks that must be carried out by cadres during
Based on table 5, height measurements have not been posyandu; and (5) there is no height measurement form
routinely measured at posyandu so the stunting case that must be reported to the puskesmas. This is in line
finding has not yet taken place. Village cadres and with the results of monitoring and evaluation conducted
by the Ministry of Health related to the use of KIA books in urgency of recording and health information in the KIA
9 Districts / Cities. This study showed that only 18% of KIA book.
books were filled in with the highest level of occupational
health care during pregnancy and newborns [10]. On most platforms, recording problems occur due to the
lack of time, ignorance of officers, manual recording
Finding 10 mechanism not yet running, and application technical
issues (for example on ePPGBM and Healthy Family
The TB / U graphs are not filled in the KIA book due to: Application).
(1) the unavailability of height measurement tools, (2)
the limited ability of cadres to measure; (3) ignorance In the recording application, the recording officer
of cadres filling TB / U charts; (4) lack of cadres in requires training and technical support in the form of
charge at posyandu; and (5) there is no height assistance, the availability of tools, and internet access.
measurement form that must be reported to the Technical constraints such as loss of data after entry also
puskesmas. sometimes occur due to the lack of user understanding of
the application. Limited internet access must be
addressed with the presence of offline applications that
Besides filling in by cadres, KIA book ownership is also can be used. Slow application access requires adequate
still a problem. Based on 2018 RISKESDAS data, 24.9% of data server support.
pregnant women do not have KIA books, while the level of
ownership of KIA books in toddlers is 65.9%. In fact, The results of recording the height become the cadre
according to Riskesdas 2013 and Sirkesnas 2016, there counseling / health workers to mothers of toddlers.
was a link between the ownership of the KIA Handbook Anecdotal findings suggest that mothers have excessive
and the utilization of maternal and child health services worries if stunting is detected by a toddler, that she will
[10]. Based on the findings of the FGD, parents’ awareness be labeled as a bad mother.
of bringing Therefore, a proper understanding of stunting must be
given by cadres / health workers after measurement and
height recording.

Information about stunting can be conveyed well if

several important components such as early detection
of stunting, the ability of cadres and health workers in
communicating behavior change, and the availability of a
wide range of information media. First, stunting
screening at posyandu and health facilities must be
carried out as an early detection and entry point for
providing appropriate information about stunting. A
proper understanding of stunting can also be given when
KIA books when coming to the posyandu or to health cadres make home visits in an effort to ‘pick up the ball’ for
services is also still low. Health workers often meet mothers who do not bring toddlers to the posyandu.
parents who do not carry a KIA book and do not know the Secondly, cadres and health workers must have good skills
in conveying behavioral change communication.

63

Therefore, the Ministry of Health needs to ensure training
and material regarding communication on behavior
change related to stunting is given to cadres. Third, media
is needed as a tool to spread accurate information about
stunting. This can be accommodated through national
stunting campaigns and public service announcements
coordinated by the Ministry of Health.
Based on table 5, counseling activities are carried out on
5 platforms, namely posyandu, puskesmas, hospitals,
PIS-PK, and BPB. Most counseling is carried out by
posyandu cadres and TPG. However, the QSDS study found
that only 45% of posyandus carried out post- hospital after the recovery of the patient. Growth
measurement counseling and only 39% of posyandu monitoring is important so that children do not experience
cadres had the ability to provide counseling to toddlers’ recurrent nutritional problems.
mothers [30]. Counseling activities did not go well
because: (1) cadres’ ability to translate KMS graphics into Finding 11
counseling messages was still limited; (2) the cadre’s
ability to provide counseling if a problem with limited Counseling activities are not going well because of the
nutritional status was found; (3) weak supervision and limited ability of cadres to translate data into
guidance of health workers in counseling sessions; and (4) counseling messages and in communication of
lack of cadre’s ability to communicate behavior change. behavior change, as well as weak monitoring and
This shows the function of counseling and competence of training of health workers.
cadres in providing counseling was still low.
Ideally, stunting data from posyandu and puskesmas are
In private health services, the flow of data reporting to then reported on the ePPGBM application. This
the health department is not yet qualified. Data reporting application has the potential as a source of reference data
by private FKTP to health centers and the health for district / city governments. If the data collection
department was still voluntary and has not become an mechanism with ePPGBM works well, this platform can
obligation. Field findings from the City of Depok explained provide monthly stunting prevalence. This platform can
the mechanism of reporting hospitals to the health also act as an early warning system for stunting toddler
department built through online discussion groups using cases to be followed up by puskesmas and health offices.
Whatsapp application and an internal application called Intervention in stunting toddler can also be done directly
SIBIMA. However, this mechanism has not been applied because data by name by address stunting toddler is
yet in all districts / cities. available on the ePPGBM application.

For the referral process, the initial referral to the
stunting case was carried out at the puskesmas. The
management of cases of toddlers with nutritional
problems needs to be clarified. The provision of PMT
recovery cannot be the only intervention for stunting
toddlers. At the hospital, referral was made to the
Chapter 3
However, the potential for ePPGBM applications is still
constrained by the quality of the input and measurement
processes that are still problematic. Poor posyandu and
puskesmas data resulted in invalid height measurements.
This caused the validity and reliability of the stunting
prevalence data taken to be doubtful thus the
effectiveness of the determination of service targets,
program planning, and allocation of resources for
overcoming stunting was not on target.

64
Quality Assurance

04.
Integrated Stunting Data
Management: Implementation and
CISDI
4
CHAPTER 4. Integrated Stunting Information System:
Implementation and Quality Assurance

Technical studies on this dimension depart from the policy making and clinical decision making. Measurement
basic assumption that measurement data are only information will only be of little value if it is not available in
meaningful if they can be used as a basis for improving a format that meets the needs of many users and is not
delivered in a timely manner.
Stunting information systems collect data from the
health sector and other related sectors and turn it into
information for decision making. Integration of planning,
implementation, evaluation, and control of stunting
interventions needs to be supported by data that are
accurate, current, integrated, can be accounted for, easily
accessed, and shared, and is managed carefully,
integrated, and sustainably.
Communication is an important attribute in the use of involved:
stunting information systems. Information will be of little
value if it is not available in a format that meets the needs 1. Puskesmas, as the Technical Implementation Unit (UPT)
of many users and is not delivered in a timely manner. A
good stunting information system ensures that all users
have access to reliable, understandable and comparable
data.
The issue of the availability of quality and timely data is
still a major problem in integrated stunting information
systems. This is caused by two fundamental problems: (1)
the availability of quality data, especially in various
measurement platforms due to implementation
constraints as explained in chapter 3; (2) the flow and
openness of data access.
This chapter will describe integrated data management
efforts that are used to help manage programs / or
activities related to reducing stunting at the national to
village level. Specifically, this chapter will dissect about:
(1) data availability and quality, (2) data integration and
system interoperability for analysis and synthesis; and (3)
use of data related to stunting in the framework of one
data policy. Furthermore, the strategic issues that will be
discussed in this chapter will lead to efforts to arrange
data transactions in health service facilities as a source of
data to improve the quality
and access to health data and information.
67
This information system contains the results of
measurements of growth and development of
toddlers, especially height and weight, in stages from
Posyandu to a higher level, both manually and online.
These data must be kept up to date so that they are
always up to date and in accordance with the changes
that occur in toddlers encountered when measured at
Data Generation: Availability and
Quality
The measurement and publication of stunting numbers is
a joint responsibility between the Regional Government
and the Central Government. District / City Health Offices
are responsible for collecting data at the individual level
and individual health facility level data. The central
government has the duty to collect data at population level
and surveillance. Next is the division of roles of each actor
of the District / City Health Office, carries out quality
control over the implementation of the measurement
platform and ensures information flow runs from the
individual to the District / City level. Puskesmas is
tasked with arranging schedules and preparing the
human, logistical and financial resources needed for
measurement according to the available platform
options. Puskemas coordinate with Puskesmas
Pembantu, Polindes, Poskesdes, Posyandu, clinics,
hospitals in their working area to take measurements
and ensure information flow enters the Puskesmas
Information System. Puskesmas is also responsible for
carrying out quality control by re-measuring randomly
in the time close to the previous measurement day.
Puskesmas are the main users of data at the individual
and family level. Puskesmas use measurement data to
show that a child is growing and developing normally,
at risk, or has problems that must be dealt with. At the
family level, Puskesmas utilize measurement data to
show patterns of health problems at the family level
that contribute to stunting.
2. District / City Health Offices must build a tiered stunting
information system as part of the Regional Health
Information System (SIKDA).
the toddler growth and development monitoring
platform. The District / City Health Office is
responsible for providing feedback on Puskesmas
reports and validating data entered into the Data
Communication Application and then sent to the
Ministry of Health database server to enter the
centralized National Health Information System
 (SIKNAS).
District / City Health Office processes the
measurement data to assess progress at the village /
hamlet / subdistrict level. This processing is used to
analyze risk factors in the community and guide the
determination of priority intervention locations, as
well as resource allocation. Data can be analyzed
based on trends, demographics and geography,
comparability and relationships between programs /
activities.
3. The Central Government, in this case the Ministry of
Health and BPS, is responsible for conducting
household surveys and surveillance. Both are often the
main references for information related to stunting in
locations where data at the health facility level is not
reliable. Comparison between various household
surveys and nutrition related surveillance and
challenges in its management can be seen in table 6.
Many findings indicate the limitations of measurement
coverage due to capacity constraints of program holders
and the availability of logistics for data collection. The
World Bank’s QSDS research (2016) states that only 61% of
Puskesmas have received training in monitoring child
growth and development and only 47% of cadres have
received the same training in the last 12 months. Posyandu
readiness is at the forefront of data collection due to
Chapter 4
logistical sufficiency: only 30% have lengthboards.
CISDI
Data Integration for analysis and
synthesis
This combination causes stunting problems not to be
captured in health information systems in many
districts / cities. As a result, growth monitoring at the
grassroots level still relies on Toddler BGM data, the scope
of case finding is also limited. Riskesdas said the number
of children under five who had not been weighed in the
past 6 months increased from 25.5% (2007) to 34.3%
(2018). The low coverage of e-PPGBM (49.6%) causes
household survey and surveillance to be the main source
of stunting data.
Anecdotal findings, which were confirmed through
interviews with experts, also indicated several problems
in data quality, which includes: (1) data not collected (for
example, there were toddlers who were not brought to
Posyandu and were not recorded in the monitoring system
(completeness); (2) data were collected according to
protocols which can change depending on who and when
the data was collected (precision and reliability), (3) Data
was collected, but distortion occured in transmission (for
example: there is a change in data in the transfer of notes
in the Posyandu to the Puskesmas report to the Health
Service report) so that it does not reflect what actually
happened (validity); (4) Data was collected using more than
one format with different elements, not integrated, and
stored by more than one system with low interoperability
(interoperability); (5) Data storage is carried out by
individual managers with low interagency coordination
mechanisms (ex: lack of coordination of data collected
between the Ministry of Health and Ministry of Health); and
(6) data reporting delays (timeliness) because the
recording and reporting system takes time, capacity
limitations, geographical and infrastructure challenges,
and so on
Finding 12
Problems in data quality, including: (1) completeness of data
(completeness), (2) Reliability and accuracy of data
(precision and reliability), (3) Data validity, (4) system
interoperability, (5) coordination between data managers, ( 6)
timeliness of data (timeliness).
68
 Stranas Stunting establishes specific and sensitive
nutrition intervention groups to guide program
implementers in converging programs amid limited
resources. By adopting the Conceptual Framework
of Determinants of Child Undernutrition (UNICEF,
2013), The Underlying Drivers of Malnutrition (IFPRI,
2016), and the Factors that Cause Nutrition Problems
in the Indonesian Context (Bappenas, 2018), Stranas
Stunting sets priority specific nutrition intervention
groups, supporters, and priorities according to
certain conditions. In addition, Stranas Stunting also
stipulates sensitive nutrition interventions carried
out through various programs and activities outside
the Ministry of Health.

The establishment of the intervention group also

guides program implementers to carry out analysis
and synthesis of data related to stunting. To provide
information for strategic decisions, an analysis of
the situation of a stunting reduction program is not
only done by identifying the distribution of stunting
prevalence, but also gathering data on the situation
of related service availability (see table 6. Only in this
way, the stunting prevalence rate can be given a
“meaning”. , if there are areas with programs related
to priority nutrition interventions that are relatively
complete, service coverage is relatively adequate,
but the prevalence of stunting is still high, then the
analysis needs to be sharpened by looking at the
quality of specific nutrition services and access to
sensitive nutrition services.

69

1. Analisi sebaran Pertanyaan Kunci: Keputusan 1:

Chapter 4
prevalansi stunting dalam wilayah
kabupaten/kota
Bagaimana pola sebaran prevalensi
stunting dalam wilayah kabupaten/kota
1.
2.
Jumlah analisis situasi Lokasi-lokasi fokus
penurunan stunting

2.
Analisis ketersediaan
Pertanyaan Kunci:
Keputusan 2:
program &
kesenjangan cakupan layanan
Bagaimana ketersediaan program &
kesenjangan cakupan pada setiap
intervensi gizi prioritas
1.

2. 3.

Program yang alokasinya perlu diprioritaskan

Jenis sumber daya yang diperlukan
Realokasi atau menambah alokasi program

3.
Analisis situasi penyampaian
layanan pada rumah tangga 1.000
HPK
Pertanyaan Kunci:
Apa yang menjadi kendala penyedia layanan
dalam penetapan Rumah Tangga 1.000
HPK sebagai target penerima manfaat
Keputusan 3:
Upaya perbaikan
manajemen untuk
memastikan Rumah Tangga 1.000 HPK
menjadi target penerima manfaat layanan
 Figure 10. The relationship between stunting prevalence analysis and analysis of program / activity availability

Finding 13

A fragmented information system where there is

difficulty in exchanging data between one system and
another due to system interoperability limitations

Stunting information systems still have problems with

system integration in both the health and non health
sectors. At the district / city Health Office level, there are
at least 11 separate Public Health Center Information
System reporting forms that track the scope of activities
and programs related to stunting. This results in overlaps
in data collection and processing and there is still
repeated data collection by different units. Fragmented
data because each program has a database that stands
alone creates obstacles when users need composite
information that must correlate two or more databases.
This condition also results in an administrative burden
ratio at health service facilities become large which have
an impact on the disruption of the performance of public
services.
Each district / city also has its own Puskesmas
Information System (SIMPUS) and e-Puskesmas which
have not been integrated with the Regional Health
Information System (SIKDA). Each of these information
systems tends to collect as much and direct data as
possible from the lowest health care facilities using their
own programming languages. As a result, development
efforts tend to create their own health information
systems and pay less attention to the sustainability of the
system and the concept of system integration for
efficiency.

Human resources play an important role in the successful

implementation of health information systems. However,
current conditions both at central and regional levels are
still limited both in terms of the quantity and quality of
health information system management personnel. So far,
in some areas, data and information managers are
generally workers who hold concurrent positions or other
tasks, which in reality are unable to fully work in managing
data and information due to inappropriate incentives.
Many of them choose part time jobs elsewhere. This
weakness is compounded by the lack of skills
 70
CISDI the main unit still faces hard times to perform data
integration. In addition, the mechanism/ procedures
related to one-door information has not been available.
This has become the cause of the occurance of
duplication of data and become one of the factors that
become a constraint in building health information system
in areas integrated with national health information
system.

To facilitate the level of coordination between Ministries,

various national information systems and e-government
governance policies have been formulated, including
and knowledge of data managers in the field of Information and Communication Technology Strategy,
information, particularly information technology and its Presidential Instruction number 3 of 2003 concerning e-
use. During this time, there have been functional positions Government Development, Law number 14 of 2008
for data and information managers, such as computer concerning Information and Electronic Transactions,
institutions, statistics, epidemiologists, information Government Regulation number 82 of 2012 concerning the
security, but have not been fully utilized. Implementation of Electronic Transactions and Systems,
Government Regulation number 46 of 2014 concerning
The mechanism of monitoring and evaluation is still low. Health Information Systems, and Presidential Regulation
number 96 of 2014 concerning Indonesian Broadband
The weaknesses and various problems in the
Plans. Republic of Indonesia Presidential Regulation
implementation of information system of health of course
(Perpres) No. 39 of 2019 concerning One Data Indonesia
can be identified with the mechanism of monitoring and
provides a policy framework for standardization of data
evaluation as well as audit of information system of
collection and preparation of evidence-based policies.
health. Unfortunately, the mechanism of monitoring and
The data management system includes data from each
evaluation has not been coordinated and implemented
indicator from data stunting to the scope of specific and
well.
sensitive nutrition interventions. However, the national
policy has not significantly had a positive impact on the
In the Ministry of Health, data management functions
implementation of the health information system, both at
related to fragmentation are fragmented between Data
the regional and central levels.
and Information Centers (Pusdatin), Information Centers in
each technical Directorate and Health Research and
In fact, the one data stunting policy has a number of
Development Department (Litbangkes). The results of the
important objectives. Among these are the structuring of
health information system assessment from the Health
regulations and the institutionalization of data
Metric Network (2012) indicated that the six components
management, and the integration of data from Ministries /
of the implementation of the health information system
Institutions, regional governments and state institutions
are inadequate, especially for the management
into one data portal so as to produce an open data set. The
component. The results of the e-health assessment using
hope is that there is a big data for stunting generated,
the 2013 Commission on Information and Accountability
managed and stored by the Government and can be
(COIA) assessment tool also showed that the six
utilized by any organization, including within the
components of e-health implementation (policies,
government itself. Thus, every policy, program and
infrastructure, applications, standards, governance, and
development
security) were available, but did not meet standard. Close
coordination between sub units is needed to collect, check
validity, and publish it in a national health database.

The weak condition of the current health information

system is inseperabale of the weak role of Pusdatin in
developing the system of recording and reporting. In
principle, information system in the main unit must be
able to communicate with integrated application in the
Data and Information Center (data communication and
data warehouse). However, every main unit in the Ministry
of Health has the support of reporting application that are
varied in order to manage data and information. Internally,

71
activity is based on a shared database that can be obtained to educate betterment of eating patterns and
accounted for. children care patterns. Anecdotal finding identified that
although some of the Puskesmas Program Holder’s time is
The challenges to building cross-sectoral networks are spent collecting and
very large, even though the one data policy and open data Chapter 4
stunting are very important for managing the main
database. The existence of government policies in
strengthening e-government will depend on the
interoperability of all system components. The
unavailability of standards and protocols in the
implementation of information systems in each ministry /
institution results in unclear “rules of the game”. Data and
information access from cross units in the Ministry of
Health and across sectors is still difficult because
networks to strengthen the availability of valid and
accurate data cannot be optimally carried out. The need to
calculate health indicators does not only come from one reporting information, data is rarely used to improve
source of data only, but from several data sources. For policy and implementation. Forums to share and discuss
example, to measure or calculate the scope of success of relevant data in each and between sectors are also not
a health program it requires data outside the health available at all levels.
sector, such as population data as a denumerator from the
Central Statistics Agency (BPS). From these conditions, it Unreliable integrated data of stunting results in a weak
can be seen that the availability of protocols to build
basis for drafting regulations and integrated action plans
networks and establish standards supported by legal
(see figure 11). Integrated stunting data management is
aspects is one of the challenges that must be immediately
carried out throughout the fiscal year to support the
intervened.
overall budgeting process, as well as monitoring and
evaluating the implementation of convergence actions to
Finding 14 reduce stunting. Weak data management systems will
cause the following Integration Actions that require
Ketidaktersediaan standar dan protokol integrated data for stunting: action # 1 (Situation
penyelenggaraan sistem informasi di setiap Analysis), action # 2 (Action Plan), action # 7
Kementerian/Lembaga maupun lintas K/L (Measurement and Publication of Stunting), and action # 8
related to Review of Annual Performance does not have
sufficient input.
Data Utilization
Finding 15
In addition to being weak in the the coverage of
program, follow-up post measurement is often Inadequate data causes a weak basis for the
unavailable. GMP in Indonesia is established with low preparation of regulations and programs and can
encouragement on the use of growth information reduce community control mechanisms
 72
CISDI Tingkatan
Penanggung

Jawab Proses Monitoring Penggunaan Data

Bappenas Manajemen Data Stunting

PusatTNP2K Kementerian Perencanaan Monitoring Evaluasi

Provinsi Kabupaten Manajemen Data Stunting Monitoring

Bappeda OPD terkait Evaluasi

Aksi #7:
Pengukuran
dan Publikasi
Pengelolaan
Aksi #2:
Bappeda Perencanaan
OPD terkait Data Stunting Data Manajemen Analisis Situasi Aksi #8:
Aksi #1: Reviu Kinerja
Rencana Kegiatan

Kecamatan Kecamatan Data KIA Posyandu BPSPAMS Pusat

Puskesmas Data Air Minum & Sanitasi Data Perencanaan Monitoring
PAUD Evaluasi

Desa/
Perangkat Desa HDW Fasilitator Data Desa/Kelurahan Perencanaan Monitoring
Kelurahan
Evaluasi

Figure 11. Integrated Stunting Data Management Flow

73
Chapter 4

Table 6. Household Surveys and Surveillance Related to Stunting

Type Institution Frequency Method and type of data collected Reporting and
challenges
 Basic Health 5-yearly A cross-sectional survey of Information is
Health Research around 300,000 households. widely used for
Research and Nutrition Indicator: planning and for
Developme i. antropometri (anak <5 tahun) measuring
nt ii. breastfeeding impact.
Agency, iii. micronutrient intake (TTD
Ministry of & vitamin A pregnant
Health women,
children <5 years vitamin A)
iv. treatment (for diarrhea &
zinc supplementation)
v. iodized salt (urine samples
collected in 2007 & 2013)

Indonesian Indonesian 3- yearly A cross-sectional survey of

Demograph Central around 45,000 households.
ic and Statistics Nutrition Indicator:
Health Agency i. PMBA (breastfeeding practices
Survey and complementary feeding)
ii. micronutrient intake (mother
& child <5 years)
iii. management of diarrhea
(with oral rehydration fluids
and zinc supplementation)

National Indonesian Twice A cross-sectional survey of Used to

Socio Central per around 300,000 households in calculate
Economic Statistics year March and 75,000 households in poverty levels
Survey Agency September. Household and as a
(Susenas) consumption / expenditure data is monitoring tool
collected. Nutrition indicators for
collected include: development.
i. practice of breastfeeding

Total Diet Health One time One-time survey (cross- Used to

Study Research survey sectional) of 191,524 individuals determine
and from 51,127 households, patterns of food
Developme including: consumption
nt i. consumption of individual food ii. and nutritional
Agency, chemical contamination analysis adequacy of
Ministry of of food ingredients the diet, food
Health processing,
and cooking
techniques.

74
CISDI
Type Institution Frequency Method and type of data collected Reporting and
challenges
Nutrition Directorate Annual One-time survey (cross-sectional) Used to
surveillance of through 30 clusters sampling monitor the
Community techniques at the district level. nutritional
Nutrition, Data collected was data of status of
Ministry of children <5 years and pregnant pregnant
Health women. In total there were 15 women and chil
nutritional indicators collected dren for
including: planning and
i. anthropometric indicators of monitoring.
children <5 years
ii. breastfeeding practices
iii. iron supplementation for
mothers iv. vitamin A
supplementation for children
v. children and pregnant women
with malnutrition who
receive biscuits
vi. LILA women of childbearing
age vii. Testing of iodized salt

Routine Ministry of Monthly Data is collected through public There is no

health Health health service facilities. obligation for
surveillan Indicators include: districts to
ce i. growth monitoring (body weight report
system per age only) indicators.
ii. treated cases of acute Thus, not all
malnutrition public
iii. vitamin A supplementation health
for children facilities
iv. iron supplementation for report. Data
mothers v. exclusive breastfeeding compilation and
vi. consumption of iodized salt feedback are
very slow.

75
Chapter 4
Type Institution Frequency Method and type of data collected Reporting and
challenges
 SMS- Directorate Launched in 2011, real-time Low response
Gateway of reporting for acute malnutrition is rate.
(Real time Community reported by Puskesmas staff via Anecdotal
nutrition Nutrition, mobile devices. Reports are evidence
case Ministry of received by the server to that district
reporting Health be entered into a database which authorities do
system is then displayed via the internet in not want to
- acute real time report a high
malnutrition) number of
(http://gizi.depkes.go.id/ cases.
sms gateway/)

Electronic Directorate E-PPGBM is an application to There is no

system for of record and report the nutritional evaluation of
reporting Community status of children and pregnant the
nutritional Nutrition, women quickly, accurately, effectiveness
indicators Ministry of regularly, and continuously for the of this
(E-PPGBM) Health preparation of nutritional policy application
planning and formulation.
Nutritional indicators include:
i. anthropometry
ii. exclusive breastfeeding
iii. vitamin A, TTD and PMT coverage

76
CISDI Chapter 4

Table 7. Indicators and Data Sources Related to Stunting

No Indicator Operation Numerator Denominat
 Definition

1. Pregnant Women Percentage of KEK Pregnant Number of KEK The total numb
Coverage Women who received recovery Pregnant KEK Pregnant
KEK obtaining PMT against all KEK Pregnant Women who in the region w
PMT recovery Women in the same time period received the same one y
recovery PMT period

2. Coverage of The percentage of pregnant The number of The number of

Pregnant Women women receiving a TTD of at least pregnant women pregnant wome
receiving 90 tablets during pregnancy for all receiving a TTD the area within
IFA (TTD) of at pregnant women in the same time of at least 90 same one year
least 90 tablets period tablets during
during pregnancy
pregnancy

3. Coverage of Percentage of pregnant women The number of The number of

classes for who take a class of pregnant pregnant women pregnant wome
pregnant women women to the number of all attending the within the sam
(mothers pregnant women pregnant year
attending mothers class
nutrition and
health counseling)

4. Coverage of Percentage of families who took The number of The number of

families the BKB to all Family with families with families with to
participating in toddlers toddlers joining BKB in one period o
the Toddler Family same year
Development
Program

77 78
CISDI Chapter 4
No Indicator Operation Numerator Denominat

Definition
 5. Coverage of skinny Percentage of underweight The number of The total numb
toddlers who toddlers who receive PMT skinny toddlers skinny toddlers
receive PMT who receive PMT the region in th
recovery same one year

6. Coverage of The average percentage of The total number Number of chil

attendance at children aged 0-5 years who of children aged aged 0-5 years
posyandu (ratio of attend per month at the 0-5 years who posyandu wo
incoming to total posyandu for all children aged 0- attend per month areas
targets) 5 years in the posyandu working at the
area posyandu

7. Coverage of Percentage of pregnant women Number of The number of

Pregnant Women- who receive antenatal care at pregnant women pregnant wom
K4 least 4 times during pregnancy receiving K4 the region with
with a schedule once in the first services in health same one year
trimester, once in the second care facilities
trimester, and twice in the third
trimester of all pregnant women
in the same period

8. Coverage of children Percentage of number of toddlers Number of Number of bab

6-59 months aged 6-59 months receiving children aged 6- 59 months of t
receiving Vitamin A Vitamin A to all toddlers aged 6-59 59 months year
months receiving Vitamin
A in the months of
February and
August

79 80
CISDI Chapter 4
No Indicator Operation Numerator Denominat

Definition

9. Coverage of children Percentage of children 12- Number of Number of all b

12-23 months has 23 months receiving basic children aged 12- aged 0-11 mont
been fully basic and 23 months the same perio
immunized complete immunizations against receiving basic one year
all toddlers aged 0-11 months and complete
immunizations
 10. Coverage of toddlers Percentage of toddlers The number of The total numb
with diarrhea with diarrhea receiving zinc toddlers with toddlers with d
receiving zinc supplementation diarrhea receiving in that one yea
supplementation zinc
supplementation

11. Coverage of young Percentage of young women (13- Number of Number of you
women obtaining 18 years) obtaining TTD young women women in the p
TTD receiving TTD of the same ye

12. Coverage of Percentage of households that Number of Number of

households that use have access to improved drinking households with households in
drinking water water sources to all households access to year
sources is feasible adequate
drinking water
sources

13. Coverage of Percentage of households that Number of Number of

households that have used proper sanitation to households that households in
use proper all households have used year
sanitation proper
sanitation

81 82
CISDI Chapter 4
No Indicator Operation Numerator Denomina

Definition

14. Coverage of JKN / Percentage of population Number of Number of pop

Jamkesda that has become JKN / residents who in that year
participant Jamkesda participants of have participated
households all residents in JKN /
JamKesda

15. Coverage of KPM Percentage of KPM PKH Number of PKH Number of KPM
PKH obtaining FDS participating in the Family and KPM
nutrition and health Capacity Building Meeting participating in
(P2K2) / FDS nutrition and health the Family and
for all KPM PKH Capacity Building
Meeting (P2K2) /
FDS nutrition and
health
 16. Coverage of Percentage of pregnant women Number of Number
parents who take and parents with under two pregnant women pregnant wom
parenting classes million attending the parenting and parents with and child
class baduta children under two year
who attend
parenting class

17. Coverage of Percentage of children aged 2-6 Number of Number of chil

children aged 2-6 years registered (students) in children aged 2- aged 2-6 years
years PAUD against the number of all 6 years
registered children aged 2-6 years registered
(students) in PAUD (students) in PAUD

18. Coverage of 1000 Percentage of 1000 poor families’ Number of Number of fam
HPK poor families HPK as recipients of BPNT families of 1000 of 1000 HPK po
as BPNT recipients against the total number of HPK poor group group
families of 1000 poor households as recipients of
BPNT

83 84
CISDI Chapter 4
No Indicator Operation Numerator Denomina

Definition

19. Village coverage Percentage of villages that Total number Total number of
applies KRPL apply KRPL to total villages of villages
implementing KRPL

20. Postpartum Percentage of postpartum Number of Number of all

Mothers service mothers getting postnatal care postpartum postpartum mo
coverage at least 3 times for all mothers who in the region w
postpartum mothers in the same receive the same perio
time period postnatal care at that year
least 3 times

21. Coverage of Percentage of malnourished Number of Total number o

toddlers suffering toddlers handled in all cases malnourished cases of malnu
from of malnourished toddlers toddlers (BGM) toddlers (BGM)
malnutrition handled the same perio
handled (BGM) the same year
 22 Coverage of Percentage of number Number of Total number o
. Puskesmas capable of Puskesmas capable of Puskesmas Puskesmas in t
of administering administering MTBS to all capable of district / city
MTBS Puskesmas in the District / City managing MTBS
all Puskesmas in the District /
City

23 Coverage of 1000 The percentage of 1000 HPK Number of 1000 The total numb
. HPK families and poor families as PKH recipients HPK families of of 1000 HPK
poor groups as to the total number of families poor group as families of poo
PKH recipients of 1000 poor households PKH recipients group

24. Coverage of babies The percentage of baduta who The number of The total numb
with birth have birth certificates for all baduta who have baduta in the s
certificates baduta birth certificates year

85 86
CISDI Chapter 4
No Indicator Operation Numerator Denominat

Definition

25 Coverage of The percentage of The total number The total numb

. toddlers suffering malnourished toddlers of malnutrition cases of
from handled in all cases of toddlers handled malnourished
malnutrition malnourished toddlers toddlers in the
handled (BGM) of the same ye

26 Coverage of The percentage of pregnant Total number of The total numb

. Pregnant women women who use mosquito nets pregnant women of pregnant
use mosquito nets against all pregnant women using mosquito nets women
in endemic areas
 27 Coverage of HIV Percentage of HIV positive The total number of The total numb
. positive pregnant pregnant women getting PPIA HIV positive pregnant with
women services against all HIV positive pregnant women positive HIV
pregnant women getting PPIA
Receive Mother to services
Child
Transmission
Prevention
(PPIA:
Prevention of
Mother to Child
Transmission)

28 Coverage of toddlers Percentage of toddlers (12- Total number of The total numb
. (12-59 months) who 59 months) who receive toddlers (12-59 of toddlers
receive worm worm months)
medicine medication for all toddlers receiving worm
medicine

87 88
Study Results

05.
Synthesis and Implementation of
CISDI
5
CHAPTER 5. Synthesis and Implementation
of Study Results

As explained in the previous chapter, this technical study data on stunting.

has: (1) identified gaps and explored the role of
regulations, governance, and related stakeholders; and (2) In the first part, this chapter presents a synthesis of
checking program / activity gaps related to the practice of various findings (gaps from ideal conditions) identified
measuring, collecting, publishing and utilizing integrated through literature and policy studies; interviews with
various expert speakers and field visits to see good
practices in handling stunting at the district level.
In the second part, this chapter proposes a number of
recommendations as a result of in depth conceptualization
of the analysis of findings, the implications of the findings,
and the causes underlying the findings (drivers).
Recommendations are submitted in the form of a road
map that takes into account allegations about possible
scenarios in the future (scenarios).
Synthesis and Implications
Regulatory Framework, Governance and
Financing
Technical studies on this dimension depart from the
basic assumption that good governance will encourage
good practices in program implementation. This study
will focus on the regulatory, governance and financing
framework as enabling factors that shape good
governance. The combination of these three elements will
provide direction and space for stakeholders to
collaborate, exchange information and promote evidence-
based policies.
a. Regulation Framework
Nutrition improvement efforts have become a global
concern and are on the global development agenda. In
2012, WHO through the World Health Assembly (WHA)
Resolution endorsed and
encouraged member countries and international
partners to implement a Comprehensive
Implementation Plan on Maternal, Infant and Young
Children Nutrition. Nutrition improvement targets in
the Millennium Development Goals (MDGs) agenda
91
(1) Framework for Implementation of the 2013 National
Movement for Nutrition Improvement Acceleration, (2)
World Bank Performance for Results Financing (PforR)
in 2018, (3) National Strategy for the Acceleration of
Prevention of stunting 2018-2024.
The three documents show different leadership and
coordination structures. The governance structure
carried by the 2nd and 3rd documents does not annul
were then continued and entered the Sustainable
Development Goals (SDGs) agenda with the aim of
eliminating all forms of malnutrition by 2030. Each
member country has a moral responsibility to translate
them into a national policy framework.
In 2018, the Government launched the National
Strategy for the Acceleration of Prevention of Stunting
(Stranas) which was the Government’s response to a
weak integration program aimed at key targets in
priority locations. The National Strategy also provides
an overview of the work plan and the role of each party
to reduce the national stunting rate.
The regulatory framework is available at the national
level at various levels but translating and applying it to
the subnational level is still a challenge. Stunting has
entered the national priority and implemented 23 K / L.
The government has issued a strategy to install it
implemented at the top level, one of which is through
the measurement of length / height that is included as
part of the Minimum Service Standards (SPM)
indicators. However, licensing and implementation are
still being considered regarding cross-sectoral
cooperation, even regulations that have not been
harmonized.
b. Governance
The government designed an institutional architecture
to divide the roles among ministries / institutions at
the national level, regulate central-regional authority,
facilitate policy implementation, and monitor the
achievements of improving community nutrition. From
the results of the policy analysis, this study compares
the three governance structures at the national level
listed in the key document:
the institutional architecture of the 1st document. This
difference creates confusion and overlapping work,
for example in the first document the implementing /
technical team is coordinated by Bappenas, while in
the second document it is coordinated by the
Secretariat of the Presidential Secretariat while the
third document is by three Ministries, namely
Bappenas, Ministry of Health and the Ministry of Home
Affairs. At the implementing agency level, the main
measurement platforms such as Posyandu are directly
 and indirectly managed by four different institutions,
namely the Ministry of Health, Ministry of Home
Affairs, Ministry of Villages, and PKK driving team
which do not have a joint implementation guidance
document.
c. Funding Framework
The Government is committed to ensuring the
availability of adequate and sustainable sources of
financing for efforts to reduce the prevalence of
stunting. The general scheme of government funding
sources for stunting programs in Indonesia is using
the APBN (K / L budget), Special Allocation Funds,
APBD 1 (Province), APBD 2 (District / City), village funds
(APBDesa), and other sources that is legitimate. In
addition, there are also sources of non-government
funds that can come from legal entities / businesses,
donors, or individuals / groups of people.
In 2018, the Ministry of Finance estimated that a
budget allocation for nutrition needed was Rp 141.9 T
annually to meet the stunting reduction target in the
2015-2019 RPJMN. Based on the
Chapter 5
evaluation of the Ministries / Institutions Work Plans
(Renja K / L) and the Ministries / Institutions Work and
Budget Plans (RKA K / L) 2019, the relevant 2019 APBN
CISDI
The large allocation of funding for the stunting
program has also begun to encourage the Government
of Indonesia to increase the efficiency and
effectiveness of its use. One method used is through
the budget tagging and tracking system as a tool to
measure the impact, performance and encourage
budget allocation to support stunting reduction was
recorded at Rp 29 trillion.
Recognizing the limited resources to fund innovation
programs related to stunting, the Government has
been exploring other funding sources that come from
businesses and donors. One source of international
funding for stunting in Indonesia is the World Bank
funding scheme. In 2018, the World Bank provided soft
loans to Indonesia with a performance-based
financing scheme (Performance for Results) that
depends on the achievement of the indicators /
targets set (Disbursement Linked Indicators). The
PforR mechanism seeks to bridge the Government
budget deficit.
Another potential source of funding is the Village
Fund. The Minister of Village’s Regulation concerning
Priority in Using Village Funds in 2020 makes stunting
a priority. In practice, the regulation is still in the stage
of socialization. Only around 20% of Bupatis / Mayors
have made regional regulations regarding the use of
village funds for stunting programs. This also shows
the commitment of the regional government in
funding the stunting program, one of which is related
to cadre fees, where there are still many imbalances in
honorariums.
Starting in 2020, the Ministry of Finance will
implement new provisions on Regional Incentive
Funds (DID), as stated in PMK no. 141/2019. DID have
the opportunity to provide incentives to the regions
depending on the achievement of the main criteria and
predetermined performance categories. One of the
measured performances is public services in the
health sector, which include stunting handling efforts.
This policy has the opportunity to encourage regional
governments to make optimal efforts to deal with
stunting.
92
accountability in
the use of funds. Unfortunately, this method has not
yet been used to the village level. In addition, the
absence of a national policy framework that includes a
clear division of roles for stunting financing between
the central, provincial, and district / city governments
is a problem to ensure efforts are implemented
properly.
Table 8. Synthesis of Findings in the Regulatory, Governance and Financing Framework
Regulatory Framework, Governance and Financing
Ideal Condition
Targeted strategic policies
are based on the needs,
data and available
evidence
The existence of a
supreme leadership
hierarchy that has the
authority to coordinate all
K / Ls involved.
Simple and effective
governance structure
to ensure the flow
goes in good
coordination and
communication across K / L.
Clear division of roles
and functions between
line
ministries and other
relevant stakeholders
93
A comprehensive
regulatory framework
covers the
involvement of multi-
sector stakeholders,
especially those
incorporated in Scaling Up
Nutrition (SUN) network.
The use of funds can be
accounted for and have
an impact as expected
(cost effective)
Dimension 1:
Current Condition
The policy framework for the
acceleration of stunting
prevention programs already
exists at various levels and sectors
which should be sufficient to
encourage the realization as
targeted. However, the
implementation gap at the
subnational level is still a
challenge, especially due to the
unavailability of a sustainability
strategy
The potential of overlapping in the
governance and effectiveness of
the coordination flow from the
many ministries involved.
A comprehensive regulatory
framework covers the involvement
of multi-sector stakeholders,
especially those incorporated in
the Scaling Up Nutrition (SUN)
network.
The use of stunting program
funds is not yet fully
accountable for its efficiency
and effectiveness
Need
• Encouraging the
implementation at the
regional level is carried out
according to policy.
• In-depth policy review
especially about the impact
on the community.
• The legal umbrella that
underlies the National
Strategy, is recommended
in the form of Perpres /
PP.
• Meetings are more routine
than those set.
• An agreement of one K / L who
holds the highest leadership
to coordinate and manage.
• There is a clear division of
roles and functions between
line ministries and other
relevant stakeholders that
is stated in a policy
umbrella.
Chapter 5
A comprehensive regulatory
framework covers the
involvement of multi-sector
stakeholders, especially those
incorporated in the Scaling Up
Nutrition (SUN) network.
Budget tagging and tracking
system down to the village
level
Toddler Height Measurement:
Implementation and Quality Assurance
The technical study on this dimension departs from the
basic assumption that technical validity / height
soundness measurement on various platforms and
integration between services will enable the availability of
height measurement data that are accurate, current,
integrated, and accountable. Measurement data becomes
a tool to identify nutritional problems in children as early
as possible. At the policy making level, measurement data
are useful for increasing the effectiveness of planning
and determining service targets and resource allocation,
as well as problem solving and monitoring at the village to
district level.
a. Measurement Standards
The concept of Growth Monitoring has developed over
the past few decades and has become a basic
component of primary health care. In its development,
this concept was transformed into Growth Monitoring
and Promotion (GMP) which emphasized aspects of
post-measurement counseling and referral
governance.
This technical study captures several strategic issues
regarding standard measurement practices in
Indonesia. First, there are differences of opinion
regarding the accuracy of Growth Standards used in
Indonesia. Minister of Health Decree (Kepmenkes) No.
1995 / Menkes / SK / XII / 2010 set anthropometric
standards used to refer to the 2005 WHO Growth
Standard as long as Indonesia does not yet have a valid
National Growth Chart Standard.
Second, there are differences in the target age groups
and recommended measurement frequencies in
several regulatory frameworks in Indonesia. Third, the
differences in interpretation of measurement results
in relation to operational definitions of nutritional
status. Permenkes No. 66 of 2014 defines height below
-2SD as short stature or short stature that can occur
due to normal variations. This is different from the
definition used by WHO: A child is classified as
stunting if the length or height is below minus two of
the standard deviation (-2SD) of the length or height of
a child at his age. Fourth, the communication
component of behavior change, especially aspects of
counseling, including interpersonal communication
aspects, escapes the growth monitoring service
package.
94