lessons learnt program penurunan stunting di negara-negara...
TRANSCRIPT
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SEAMEO-TROPMED Regional Center for Community Nutrition University of Indonesia
Lessons learnt program penurunan stunting
di negara-negara Asia Tenggara
Dr. Umi Fahmida
Southeast Asian Ministers of Education Organization
Regional Center for Food and Nutrition (SEAMEO RECFON)
Pusat Riset Pangan dan Gizi – Universitas Indonesia
Jakarta, 23 Mei 2018
Outline
1. Indonesia vs negara Asia Tenggara
1. Trend status gizi
2. Pendanaan untuk gizi
3. Cakupan program
2. Lessons learnt dari SMILING Study
3. Lessons learnt dari Thailand
4. Kesimpulan
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Global Nutrition Report (2014): Indonesia adalah 1 dari 17 negara dengan 3 masalah gizi;
1 dari 47 negara dengan prevalensi stunting dan anemia WUS yang tinggi
Propinsi dengan angka kemiskinan 12.0% - 30.0% (Sumber: BPS, 2014)
PROFIL INDONESIA
34 propinsi 17.504 pulau
514 kab/kota 237.641.326 orang
(BPS 2010 & 2015)
PROFIL GIZI
37.2% stunting, 12.1% wasting,
11.9% underweight
Prevalensi stunting: Indonesia vs negara Asia Tenggara
Sumber: Rembug Stunting, Bappenas (2018)
Sumber: Riskesdas (2013)
Stunting vs GDP: Indonesia vs negara Asia Tenggara
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Global Nutrition Report 2017: Anggaran gizi spesifik dan gizi sensitive (%total anggaran)
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Global Nutrition Report 2017: Anggaran gizi spesifik vs gizi sensitif
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Global Nutrition Report 2017: Cakupan program MCN
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Vietnam: 3 dari 4 WHA target”on progress” (stunting, wasting, anemia WUS)
SMILING Study: Multiple Criteria Mapping (MCM)
Peringkat berdasarkan penilaian stakeholders:
1. “Fortifikasi Pangan” untuk bumil
dan WUS
• impact, feasibility, efficacy
1. “Suplementasi”
1. Suplementasi IFA – effectiveness, feasibility, resources,
sustainability
2. “MNP Baduta” – Ranked 2nd for impact, efficacy, resources
3. “MNP WORA” – Ranked 2nd for effectiveness
2. “Food-based recommendation”
• Impact, efficacy
0 10 20 30 40 50 60 70 80 90 100
Food fortification for pregnant women and WORA (C)
Daily Iron folic acid supplementation for pregnant and postpartum women
(C)
MNP for 6-23 months infants and children 24-59 months (C)
Weekly MMN supplementation for WORA (C)
(RULED OUT BY SOME #1) Regularly updated food composition
database (C)
Food-based recommendations for children and WORA (C)
All participants in Indonesia
MCM: Ranking by stakeholders
MCM: usulan lainnya
0 10 20 30 40 50 60 70 80 90 100
Supplementation of MMN syrup for children aged 6-59 months (D)
Intrapersonal counseling for IFA (D)
Intervention for children 5-13 years with MNP in water (D)
Daily MMN supplementation for pregnant women (D)
Strengthening nutrition in school curriculum through dailiy practice (D)
Repositioning Nutrition as indicator for development (D)
Weekly MMN supplementation for pre-pubesant girls (D)
Policy process for calcium supplementation during pregnancy (D)
Strengthening local human resources at community level (D)
Strengthening policy on healthy foods and environment (D)
Nutrition education for policy maker (D)
Develop the link between sensitive interventions to improve specific intervention (D)
Discretional options for all participants in Indonesia
SMILING
Study (Sustainable
Micronutrient
Interventions
to ControL
Deficiencies
and Improve
Nutritional
status and
General
Health in
Asia)
Fe Zn Ca B3
6-8mo
Cambodia x x x
Indonesia x x x x
Lao PDR x x x
Thailand x x x
Vietnam x x
9-11 mo
Cambodia x x x
Indonesia x x
Lao PDR x x x
Thailand x x x
Vietnam x
12-23mo
Cambodia x x x
Indonesia
Lao PDR x
Thailand
Vietnam
“Success story” Thailand
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Faktor pendukung peningkatan status gizi: 1. Pertumbuhan
ekonomi 2. Peningkatan
akses terhadap pelayanan kesehatan
3. Program gizi berbasis masyarakat yang efektif
Trend malnutrisi di Thailand (1987 - 2006)
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From: Winichagoon P (2013). Asia Pac J Clin Nutr 22(1): 6-15.
1962
1967
1972
1977
1982
1987
1992
1997
2002
2007
2012
1st NEDP
2nd NEDP
3rd NEDP
4th NESDP
5th NESDP
6th NESDP
7th NESDP
8th NESDP
9th NESDP
10th NESDP
11th NESDP
2017
: Economic Infrastructure, Sectoral Plans
: + Poverty Alleviation Plan (PAP) + Integrated and implemented PHC
+ FNP and Basic Minimum Needs (BMN) Indicators in rural/urban communities
: + Social Plan + Food and Nutrition Plan (FNP) + Primary Health Care (PHC)
: Improvement of Agriculture, Infrastructure
: 1992 + School Lunch Program (SLP) + School Milk Program (SMP)
1960 - Anaemia in preg: 57%;
- B1 deficiency: 23%;
- B2 deficiency: 47%;
- Low serum retinal: 38%;
- Goitre in school children: 29%
1981 - PEM (Wt/Age of U 5): > 50%
1986 - PEM (Wt/Age of U 5): 30%
1995 - B1 deficiency: < 1%;
- B2 deficiency: < 1%
1989 - Goitre in school children: 19%
1996 - PEM3 (Wt/Age of U 5): 15%
- Anaemia in preg5: 13%; - Goitre in school children4: 4%
2003 - Goitre in school children: 1%
2006 - PEM (Wt/Age of U 5): 9%
2007 - UI in preg8 < 150 µg/L: 61%; - Low serum retinal9: 16%
2008 - UI in preg < 150 µg/L: 56% 2010 - UI in preg < 150 µg/L: 43% 2012 - PEM (Wt/Age of U 5): 7%
1991 - Anaemia in preg: 18%
: 2008 + National Food Committee Act
: 2010 + Strategic Framework for Food Management (SFFM) approved by cabinet
: Integration of the SFFM and the 11th NESDP : Promote cooperation and integration of all relevant sectors, academia, business and NGOs to strengthen national food and nutrition security
: 2010- Triferidine tablet (iron+folate+iodine) : 2010 - Universal salt iodisation (USI)
2005 - Anaemia in preg: 10%
Nutrition Situation Thailand’s Development Plans Policies and Strategies
Milestones of Thailand’s National Social and Economical Development Plan related to food and nutrition Courtesy from Prof.Dr.Kraisid Tontisirin
Kebijakan terkait gizi di Thailand (1960 – 2012)
16 From: Winichagoon P (2013). Asia Pac J Clin Nutr 22(1): 6-15.
1992: National School Lunch Programme (SLP) & School Milk Programme (SMP)
2008: National Food Committee Act
Thai’s nutrition-specific interventions: life-course approach*
1. ANC-quality (5 times) + Safe motherhood hospital & Baby friendly initiative “ANC Anywhere, All Free” (2013 dst)
2. Primary Health Care (PHC) oleh VHWs (1 VHW : 10 HH) + Universal Health Coverage (UHC) scheme plus IFA (60mg Fe, 2.8mg folat)
3. MTV + 3 supplementations (besi, yodium, folat) untuk bumil dan buteki (0-6bln)
4. ASI & MP-ASI plus pemantauan pertumbuhan dengan “pink book” WHO Optifood (2015), INMU sebagai focal point
5. School milk program, school lunch program (TK sd SD kelas 6)
6. Global Nutrition Targets sebagai indikator kinerja
7. 1,000HPK sebagai program nasional
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*Personal communication: Dr.Napaphan Viriyautsahakul (Director Bureau of Nutrition, Dept.Health, Min.Public Health, Thailand)
Thai’s village health volunteers (VHWs)
• 1 kader (VHW) per 10 KK:
– Diseleksi dari masyarakat, dilatih di masyarakat
– Sukarela (tidak dibayar), namun menerima pelayanan kesehatan gratis untuk kader dan keluarganya
– Tugas:
1. membantu nakes memberikan pesan gizi dan kesehatan,
2. mendorong ibu untuk menghadiri ANC,
3. mempromosikan supplementary feeding (local snacks) untuk bumil, ASI ekslusif, MP-ASI,
4. membantu pemantauan pertumbuhan
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Intervensi anak malnutrisi: 1. Resep tinggi energi-protein untuk baduta dari pangan lokal (beras,
kacang-kacangan, wijen) 2. Dipantau sampai pulih dari malnutrisi 3. Dana desa dalam bentuk ‘revolving fund’ untuk membeli beras, kacang-
kacangan, wijen
“Success story” Thailand: Komponen utama
1. Agenda nasional, kerjasama multi-sektor, investasi pemerintah
2. Mobilisasi massa, partisipasi masyarakat
3. Indikator dasar gizi pada identifikasi masalah, penetapan tujuan (goal setting), MonEv outcome & impact
4. Indikator pelayanan minimum/dasar bidang kesehatan, pendidikan, pertanian dipandu oleh “local service providers” dalam hal perencanaan dan implementasi di tingkat masyarakat
5. “Corrective actions” untuk mempromosikan kebiasaan makan yang sehat dan mengentaskan masalah gizi.
Sumber: ASEAN/UNICEF/WHO (2016). Regional Report on Nutrition Security in ASEAN, Volume 2.
Bangkok; UNICEF.
“Success story” Vietnam (1)
• Penurunan kemiskinan dan perkembangan social ekonomi: – Angka kemiskinan: 58% (1990-an) 9% (2012)
– Produksi pangan meningkat 64% antara 1990-2004; dari importer menjadi leading exporter beras
– Antara 1985-2013: Underweight turun 70%, Stunting turun 60% (~2-3%/tahun), Under-five mortality turun 52%, Infant mortality turun 50%, Maternal mortality turun 64%
• Kelembagaan & kebijakan: – 1980: National Institute of Nutrition (NIN), di bawah koordinasi Kemenkes
untuk mengkoordinasikan kebijakan, penelitian dan implementasi program gizi. • 2012: NIN, international development partner agencies, the Women’s Union dan Institute of
Legislative studies (iLS) menghasilkan kebijakan: (10 cuti melahirkan dari 4 ke 6 bulan, (2) larangan pemasaran susu formula untuk baduta
– 2009: Nutrition Cluster Partnership Group (NCPG), terdiri atas NIN & mitra pembangunan pertemuan setiap 4-6 minggu untuk mendiskusikan isu gizi serta mengidentifikasi kerjasama untuk penanggulangan malnutrisi.
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“Success story” Vietnam (2)
• Komitmen: – 2015: bergabung dengan “UN Zero Hunger challenge”
– ‘food systems’ approach to eliminate hunger by 2025
• 1 dari 5 pilar adalah “zero stunting” pada 2025 (Note: target WHA hanya penurunan sebanyak 40%)
• Strategi “gizi spesifik” (PMBA, management of acute malnutrition, Pendidikan dan konseling gizi) dan “gizi sensitive”
• 2009: Vietnam’s Social Health Insurance programme (SHI) untuk semua anak <6tahun, manula, keluarga miskin
• Produk lokal: – Hebi (RUTF untuk balita kurus): beras, kedelai, kacang hijau (NIN,
Unicef, IRD)
– Bibomix (MNP): dijual melalui Public Health System (GAIN)
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Sumber: RESULTS UK, Concern Worldwide, and University of Westminster (2015).
What Works for nutrition? Stories of success from Vietnam, Uganda and Kenya
Kesimpulan
1. Prevalensi stunting tidak semata-mata ditentukan oleh pendapatan negara (e.g. Vietnam, Filipina) – Anggaran untuk gizi spesifik & sensitive dari total anggaran – Proporsi gizi spesifik dari total anggaran gizi
2. Pembelajaran dari Thailand & Vietnam: – Komitmen pemerintah (mis: Zero Stunting in 2025) – Kelembagaan (mis: NIN, NCPG) – Kebijakan (mis: Universal Health Coverage) – Keterlibatan masyarakat:
• Rasio kader/VHVs terhadap rumah tangga (dasawisma); apresiasi terhadap kader/VHVs • Dana Desa untuk “Gizi Spesifik” local service providers
– Potensi pangan lokal untuk menguatkan food-based recommendation mendapat prioritas tinggi
– Upaya preventif pendidikan gizi dan asupan gizi di masyarakat & sekolah (school milk dan school lunch)
3. Kerjasama akademisi dan pengampu program, serta pihak terkait diperlukan untuk implementasi optimasi diet dan gizi spesifik (selain gizi sensitive) di masyarakat.
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