Stephen J Atwood and Roger Shrimpton

UNICEF´S Comparative Advantage in Supporting Interventions to Address Overnutrition, Non-Communicable Diseases and Adolescent Health and Nutrition in Indonesia

By

Stephen J Atwood and Roger Shrimpton

Public Health Solutions Limited

Table of Contents

Acronyms 2

1. Executive Summary 4

2. Introduction 9

3. Overnutrition and non-communicable diseases 9

Evidence of the problem and strategies employed to address them 9

Mapping of stakeholders working in the field including closely related work streams 15

Evidence based interventions and state of implementation, and delivery platforms employed 17

Assessment of links with UNICEFs current engagement and comparative advantage 19

Effective Advocacy 19

Service delivery 20

Capacity development 22

Communication for development 23

Strategic partnerships 23

South-South and Triangular Cooperation 23

4. Adolescent Health And Nutrition 23

The missing adolescent in UNICEF programming 23

The rising emphasis on the adolescent 24

Significant adolescent health problems in Indonesia 27

Significant adolescent nutrition approaches in Indonesia 29

Adolescent vulnerability: Barriers to adequate adolescent health and nutrition. 31

Out of school barriers 31

In-school barriers 32

Institutional barriers 32

Barriers in the home 33

Barriers in the Health System 34

Barriers in the Legal System 36

Barriers in the Community 36

Strategies and entry points to overcome the barriers 37

Priority 1: Overcoming barriers that lead to adolescent pregnancies 37

Priority 2: Working with the health system to reach the ‘invisible’ adolescent 39

Priority 3: Improve the visibility of adolescents by strengthening data collection on health and nutrition of this age group 40

Priority 4: Multisectoral initiatives to provide indirect support to adolescents 40

Applications to UNICEF Program Planning 42

Advocacy 42

Capacity development 43

Service delivery 43

Strategic partnerships 43

5. Summary and Conclusions 44

6. Recommendations 46

Recommendations on minimal UNICEF CSD involvement 49

Annex 1: Itinerary 50

References 52

Acronyms

AHN: Adolescent health and nutrition

AIDS: Acquired Immunodeficiency Syndrome

APEC: Asian Pacific Economic Cooperation

ASEAN: Association of Southeast Asian Nations

BAPPEDA: Regional body for planning and development

BAPPENAS: Ministry of National Development Planning

BKKBN: National Family Planning Coordinating Board

BMI: Body mass index

BPJS: Universal social security system

CIP: Comprehensive Implementation Plan

CSD: Child Survival and Development section

CSR: Corporate Social Responsibility

CVD: Cardiovascular disease

DALY: Disability adjusted life year

DBM: Double burden of malnutrition

DFAT: Department of Foreign Affairs and Trade (Australia)

DHS: Demographic and Health Survey

DM: Diabetes mellitus

EBF: Exclusive breastfeeding

EPI: Expanded programme on immunization

EPODE: “Together for prevention of obesity in children” program

FCTC: Framework Convention on Tobacco Control

G20: Group of 19 countries and the European Union, with representatives of the International Monetary Fund and the World Bank

GAVI: Global Alliance for Vaccines and Immunizations

GDP: Gross domestic product

GOI: Government of Indonesia

HIV: Human immunodeficiency Virus

HPK: National movement to accelerate the reduction in undernutrition in Indonesia during the first 1000 days of life

HPV: Human papilloma virus

ICN2: Second International Conference on Nutrition

IDA: Iron deficiency anaemia

ILO: International Labour Organization

ISPCAN: International Society for Prevention of Child Abuse and Neglect

IT: Information technology

LBW: Low birth weight

LMIC: Lower middle-income country

MCA: Millennium Challenge Account

MCA/CHN: Millennium Challenge Account / Child Health and Nutrition

MCC: Millennium Challenge Corporation

MCU: Maternal and child undernutrition

MDG: Millennium Development Goal
UNFPA: United Nations Population Fund

MMR: Measles, mumps and rubella vaccine

MOH: Ministry of Health

MOHA: Ministry of Home Affairs

MUAC: Mid-upper arm circumference

NAP: National Action Plan on NCDs

NCD: Non-communicable disease

NFSI: Nutrition friendly school initiative

PERKENI: Indonesian Society of Endocrinology

PERSADIA: Indonesian Heart Foundation

PNPM Generasis: Block grants for reduction of poverty and MCU

PNPM Rural: National community empowerment program in rural areas

PUGS: Indonesia guide to a healthful diet

RAD-PG: Provincial food and nutrition action plan

RAN-PG: National plan of action on food and nutrition

RISKESDAS: National Basic Health Survey

RPJMN: National medium-term development plan

SRH: Sexual and reproductive health

STD: Sexually transmitted disease

STI: Sexually transmitted infection

SUN: Scaling up nutrition

TB: Tuberculosis

Tdap: Tetanus, diphtheria and pertussis vaccine for adolescents and adults

UKS: Indonesia School Health Programme

UNICEF: United Nations Children’s Fund

USAID: US agency for International Development

UTI: Urinary tract infection

WASH: Water, sanitation and hygiene

WB: World Bank

WC: Waist circumference

WFP: World Food Programme

WHA: World Health Assembly

YLL: Years of life lost

1. Executive Summary

Indonesia’s rapid epidemiological transition has made non-communicable diseases (NCDs) dominant in the overall disease burden in the country. From 1990 to 2010 the morbidity and mortality in the country from NCDs increased from 37% to 58%; an increase that will continue as the country continues to age. NCDs are chronic and complicated and can lead to an enormous financial burden on the health systems of even developed countries. At the root of most NCDs is malnutrition, the double burden malnutrition (DBM), of both undernutrition (stunting, anaemia) and overnutrition (overweight and obesity), often co-existing in the same communities, households, and even in individuals.

The prevention of NCDs begins in pregnancy where the health and nutrition of the pregnant woman from conception onward influences foetal development and where deficiencies can lead to stunting and later to obesity and other adult-onset diseases, most of them non-communicable. Because the peri-conception period and the first months of pregnancy are important, the problems start and must be addressed before women enter pregnancy. This is why the health and nutrition of adolescents becomes a key factor in the prevention of both undernutrition and overnutrition leading to NCDs as a consequence. Furthermore, it is now clear that treatment of obesity is difficult and often unsuccessful (i.e., recidivism to pre-diet weight within five years is as high as 90% in some studies). Prevention is absolutely essential if the economic and human consequences of the DBM are to be avoided.

UNICEF Indonesia has not worked in the areas of overnutrition and NCDs, nor has it been intensively involved in adolescent health and nutrition (AHN). However, one of the outcomes of the Mid-term Review of the current country programme was to “…explore the potential for future UNICEF technical collaboration” around emerging NCDs and obesity. This has led to an examination of the potential role of the Child Survival and Development (CSD) Section in the next country program in support of efforts to reduce the prevalence of these conditions, through interventions that improve AHN.

This review presents a situational analysis of the DBM in Indonesia and its role in the transition to non-communicable diseases. It includes the prevalence of non-communicable diseases, their cost to the country in economic terms as well as the burden to the health system of expensive and chronic care. It shows that most of the disease burden in the country is related to diet and nutrition and not to infectious diseases. In preventing later NCDs, the relationship between low birth weight, stunting and the metabolic syndrome and later onset of cardiovascular disease, diabetes, hypertension and stroke is of great significance.

With regard to NCDs themselves, five points are of significance: (i) stroke is the largest disease burden and increasing (by 46% from 2007 – 2013), (ii) diabetes is largely undiagnosed and also rapidly increasing (from 10.2% in 2007 to 36.6% in 2013 = 259% increase), (iii) blood lipid levels population wide in Indonesia are significantly elevated making cardiovascular disease and stroke a great concern, (iv) overweight and obesity are high in adults and children and rising fastest among wealthier populations and women, (v) relevant to this, the BMI measure of obesity and overweight (BMI = wt/ht2) may be using cut-off figures (30 for obesity and 25 for overweight) that are too high for a population that has a high prevalence of stunting. If lower cut-off values were used (i.e., 27 and 21), the rates would significantly increase in the country, (vi) the population has become increasingly sedentary, particularly in urban areas, (vii) household diets are changing rapidly with increased consumption of meat and processed foods, and with little consumption of fruits and fresh vegetables, (viii) despite the worsening nutrition in the country and the World Health Association resolutions calling for national and international action to reduce the impact of marketing of nutritionally dangerous processed foods on children, advertisements for processed foods (and cigarettes) are commonplace throughout the country on billboards, newspapers, and magazines.

The capacity in the country to deal with malnutrition is limited. Although there is a National Plan of Action on Food and Nutrition that provides a results framework to reduce undernutrition based on community nutrition, food availability, quality and safety, a clean and healthy diet, and the development of food and nutrition institutions, fewer than 10 % of 500 districts have developed a similar plan and are therefore without a road-map to address undernutrition. Overnutrition is presently absent from all plans. There is, however, a national multisectoral plan for NCDs coordinated by the MOH.

Other non-communicable diseases are also problems: for example, tobacco consumption (the country is one of only 15 out of 194 countries that has yet to sign the Framework Convention on Tobacco Control), road accidents (the third highest cause of untimely death in 2010), domestic and other forms of violence, mental health and depression.

The consultants met with a number of stakeholders from UN Agencies (e.g., WHO, UNFPA, WFP) bilateral donor agencies (e.g., DFAT, USAID, World Bank), the private sector, civil society and various government departments, directorates, and sub-directorates. Almost all were familiar with the growing problem of NCDs, but few had any knowledge of AHN or of its importance in pre-pregnancy preparation as a means of preventing stunting and overweight. Yet, when the topic was raised and discussed, all expressed a new interest in it.

In considering the response to the DBM, the report emphasizes the primary importance of addressing stunting as the first step (and most advanced) in the prevention of DBM and NCDs. This is the focus of the Scaling Up Nutrition (SUN) movement, of which UNICEF CSD Section is the convener in Indonesia. SUN, which has been adopted by the government, defines the 1000 days concept of maximum vulnerability to undernutrition as the period between conception and the child’s second birthday. Although multi-sectoral and multi-stakeholder forums needed to implement the interventions of the 1000 days have been defined none are yet functional. This underlines the persistent problem of gaining and maintaining multisectoral involvement to address undernutrition let alone the DBM and AHN – the concept is accepted by many but is very difficult to put into practice. Other interventions are mentioned: the use of cash transfers, nutrition education for adults, the Indonesian School Health Programme, taxes to reduce the consumption of tobacco (and possibly other imported foods), and so on. Each has its strengths, but reach is limited (education of the community is hampered by the capacity of the health system to deliver), the evidence for impact of cash transfers is limited, the school health program is considered “in suspended animation”, and taxes are not high enough to reduce tobacco consumption as much as desired.

It is pointed out that UNICEF will need to use its role as donor convener of SUN and as the leading nutrition agency among the donor community to expand the SUN mandate to include overnutrition and the health and nutrition of pre-pregnant women, particularly adolescents. This was reiterated by many of the interviewed stakeholders, who felt that the 1000 day focus had become too limiting, particularly in light of growing problems with teenage pregnancies, the DBM and NCDs.

Each of these observations indicates that a new approach is needed, and that there has not been sufficient attention paid to the period preceding pregnancy; and to the key interventions essential for pregnancy preparedness.

The analysis and comments on programs to prevent NCDs and the DBM casts a new light on the adolescent, previously left out of primary UNICEF programming where early child survival was of greater and more immediate importance. With improvements in IMR and U5MR, however, the shift is occurring to look more at the second decade of childhood as the key period for improving the health of both the present as well as the next generation.

In addition, youth between the ages of 15-24 are now 27% of the population in Indonesia and represent the cohort that should be most productive over the next twenty years – part of the demographic dividend that occurs in countries that have reduced fertility and do not yet have a significantly aged population. However, for the dividend to be collected, the work force needs to be well educated, skilled, healthy and well nourished. There is evidence that the present generation of adolescents and youth may not be, and that this could blunt the bonus the country should have in productivity and economic gain between now and 2030. This adds another direct reason to attend to AHN.

Adolescents face problems with their sexual and reproductive health that arise from lack of knowledge (discussing sexual organs is considered pornographic; there are no comprehensive life-skills education courses in schools), lack of access to services (there are legal constraints to purchasing contraceptives if not married), and early marriages (the law permits marriage of a 16 year old girl). Other problems that face adolescents are vehicle accidents, tuberculosis, HIV and other STDs including HPV infection, mental health problems like depression and suicide, domestic and other forms of violence.

Many of these problems are because adolescents – particularly those who are in institutions or who have dropped out of school – are largely invisible to society. This makes them more vulnerable to abuse and/or neglect. Outside of the classroom, there are few non-family members who see them on a daily basis, who can monitor their physical and mental status or respond to their needs. They are essentially unknown to the health system, as they are believed to have low rates of mortality and morbidity. Efforts to bring them into contact with health workers would improve this situation.

Institutionalized adolescents (and younger children in some cases) are of particular concern. It is estimated that more than 500,000 children are in institutions, the majority of which are privately run so their whereabouts, situation or services provided are completely outside of government supervision or regulation. In most cases, their parents have voluntarily institutionalized them because of poverty, behavior problems, or because parents thought it would be a good way to guarantee a secondary education. In many instances, they are not seen by anyone outside the institution for many years (parents may not visit for 2-3 years.) It is unclear what their health and nutrition status is as the data is lacking.