Indonesia, Southeast Asia's most populous nation (over 240 million), is one of the world's great emerging economies. It has been growing at 4-6% per year for the last 10 years; few countries have posted better results over this very difficult decade. A recent McKinsey Global Institute Report expects that it will be the world's 7th largest economy by 2030. New roads, office buildings, hospitals are all under construction throughout the major cities. Indonesia looks and feels prosperous.
But shocking gaps remain. One out of every two people still lack access to safe drinking water and sanitation. Malnutrition is still a major problem in Indonesia and one that has not improved much over the last decade. The percentage of underweight among under-five children has remained stagnant at 18% since 2007. Indonesia also has the world's fifth largest population of stunted children. As the UN puts it:
"'Stunting' (or stunted growth) is what happens to a child’s brain and body when they don’t get the right kind of food or nutrients in their first 1,000 days of life. The damage is irreversible. That child will never learn, nor earn, as much as he or she could have if properly nourished in early life."Children who are stunted are less likely to learn well in school, or even complete school. Stunting literally robs individuals, their communities, and indeed their country, of a future. This is why Plan emphasizes nutrition in much of its country programming.
Addressing stunting is both straightforward and challenging. Straightforward because we know what nutrients the infant requires to help ensure healthy growth. And Indonesia is well-endowed with the key elements required to produce these nutrients: abundant rainwater, rich soils, oceans of fish and seafood. But addressing the problem in a sustainable manner requires getting information to the mothers and getting the mothers to act on that information; it requires behavior change. And getting people to change behaviors is always hugely challenging.
Plan's work takes place in Sumbawa, a poorer island of 1.4 million inhabitants, with much more limited economic prospects; most of its inhabitants either work in agriculture or migrate to Malaysia or elsewhere in search for work. And within Sumbawa we work in Dompu District, population 220,000, targeting those villages where, according to the latest health surveys, more than 30% of infants are underweight.
There are many approaches to improving nutritional status. Plan starts with the mothers. And it focuses on information, education and communication efforts to get young mothers to breast feed their babies from birth, and to supplement the breast milk with locally-sourced porridge (made with mung bean or brown rice and mixed with vegetables) starting at 6 months. Such solutions are cheaper and more likely to be sustainable than relying on nutritional supplements which tend to be imported.
Plan's approach is based on peer-to-peer communication. Expectant and new mothers are organized into Kelompok Pendukung Ibu (KP-Ibu) or Mothers' Support Groups (MSG). I saw several of these in action while in Sumbawa. The mothers work with the cadres (local women leaders who volunteer to be the KP-Ibu facilitators, and have been trained by Plan) and midwives. They learn as a group, sharing their experiences, their frustrations and successes, mentoring and encouraging each other. They continue with the KP-Ibus because they see results.
A young mother of two, who had her new baby girl with her told me that her infant daughter is already doing much better than her older child, more alert and lively. She credits the MSG and what she learned about the early breast feeding. She is telling others.
What has been interesting for me in Jambu and other Dompu villages visited in this trip has been to see how Plan is learning and adapting its program as it gathers data and evaluates results. Specifically, our monitoring and evaluation efforts in this program have helped us understand that our work on nutrition must start well before pregnancy and that simply improving breast feeding and young child feeding practices is not enough. If the mother-to-be is not well nourished and does not know how to take care of herself, or is having babies too young, even good breast feeding practices will not help.
So Plan is now moving to incorporate adolescent sexual reproductive health initiatives into the maternal and child nutrition programs. These efforts are also based on peer-to-peer communication. In this case, we work through youth volunteers (girls and boys, mostly between 16 and 19 years of age) to spread messages about the advantages of delaying marriage and pregnancy and completing school. The young volunteers use a variety of approaches including social media, to spread the word. We will now be measuring and evaluating whether and how this additional program element affects children's nutritional status in these villages.
Plan is also working with the district health office (DHO) to increase access to more varied protein sources for the mothers and children. Plan and the DHO are exploring with the district Fisheries office whether and how to link their local fish farming initiative to the KP-Ibus in the villages. This idea is still under development, but what is great to see is how the communities and the district government search for solutions to infant nutrition problems together.
The other interesting thing about Jambu village, where Plan has also been working for about 15 years, is how much support local authorities give these community-based initiatives started by Plan; the district health office, the district and sub-district political authorities lend their premises for the meetings, incorporate Plan's programs into their budgets, use Plan's approach for their midwives training. In essence, the local authorities, and village elders have made these Plan programs their own.
Plan intends to leave Jambu and other villages in the district at the end of 2013, though it will continue to monitor the maternal and child nutritional effort. Jambu and other Dampu communities haven't solved all the young child under-nutrition problems. But the mothers, children, families and cadres in these communities have the structures, confidence and relationships to continue to work the problem together with local authorities. Developing these relationships at the district, sub-district and village level requires patience and trust. This is what local ownership and sustainable development is all about. And it is made possible through the long-term support of Plan's donors.