Expectant mother Sinta Nurpiani is preparing for the arrival of her second child. She lives in Sumedang district within the vibrant landscapes of West Java province, Indonesia. When she had her first child three years ago, Sinta found support at her local puskesmas, which is a community health center. There, she received medical care in a nurturing environment where dedicated staff members guided her through her pregnancy journey.

Puskesmas play a critical role in supporting antenatal care and the first 1,000 days from conception to a child’s second birthday. They were targeted as one of the key platforms to address a pervasive health issue in the country: childhood stunting.

Now, as she awaits the birth of her second child, armed with additional support and nutritional knowledge, Sinta has increased agency to decide how to best care for her children so they can grow up unburdened by the shadow of stunting.

The need for change

In 2018, almost one out of every three children in Indonesia, or 31%, were stunted, with dramatic variations across provinces. Stunting occurs due to the gradual buildup of irreversible physical and cognitive damage caused by chronic undernutrition, repeated infections and inadequate feeding practices. Stunting has a range of adverse long-term consequences, including poor cognition and school performance, lost productivity and an increased risk of nutrition-related diseases, such as diabetes and obesity. It is also a recognized risk factor for obstetric complications during labour, potentially resulting in injury or death for mothers and their newborns. Due to its health implications within a population, stunting also has an impact on the economy, with the potential to cause economic losses of 2-3% of a country’s yearly Gross Domestic Product.

In 2019, Nutrition International and Save the Children launched the Better Investment for Stunting Alleviation (BISA) project to translate the Government of Indonesia’s national stunting reduction strategy into effective action at the subnational level. It was initiated in four districts across West Java and Nusa Tenggara Timur. Working with the provincial and district health offices, Nutrition International provided technical assistance and advocated for better human and financial resources, stronger policies and accountability mechanisms to improve nutrition before pregnancy and during the critical first 1,000 days.

“Through the BISA project, we integrate a package of interventions that support Indonesia’s government commitment and prioritization on the National Strategy to Accelerate Stunting Prevention.

—Rozy Jafar, Deputy Country Director for Indonesia, Nutrition International

“Through the BISA project, we integrate a package of interventions that support Indonesia’s government commitment and prioritization on the National Strategy to Accelerate Stunting Prevention,” says Rozy Jafar, Deputy Country Director for Indonesia, Nutrition International. “The strategy has a target to reduce stunting to 14% by 2024.”

“Cooperation and coordination are one of the key efforts to reducing stunting,” explains Sumasna, former Head of West Java’s Bappeda, the provincial development planning agency. “We have to make stunting a common enemy in every level of society.”

Located in West Java, the most populous province in Indonesia, Sumedang district has made significant strides in stunting reduction. Commitment from local officials, coupled with BISA’s implementation and the district government’s adoption of innovative and effective strategies, led to a decrease in stunting prevalence from 32.2% in 2018 to 8.27% in 2022, as reported by Indonesia’s national nutrition information system, e-PPGBM. Recognizing these achievements, Sumedang received the prestigious “Best Performing District for Implementing Eight Convergence Actions for Stunting Reduction in West Java” award for three consecutive years in 2020, 2021 and 2022.

Below, we look at how this came to be through strengthening puskesmas, digital innovation and supply chain management.

Strengthening the front line

Previously, health workers in Sumedang faced challenges accessing the necessary training they needed to effectively improve access to quality health and nutrition services. BISA made this possible. “We have never had any training for our staff that is very technical in nature, such as to reduce stunting,” notes Dadang Sulaeman, former Head of Sumedang’s District Health Office. “With BISA, we started discussing the problems we had and then made a joint action plan.”

Addressing stunting starts with quality antenatal care during pregnancy. One fundamental hurdle in Sumedang’s journey was the need to heighten public awareness about the importance of preventing stunting as early as possible. Sumasna notes that despite its prevalence, stunting was initially only understood by heath workers.  To combat this, “we have tried to communicate, disseminate and provide education to every level, from the government to the community,” he says.

At the puskesmas where Sinta receives care, the staff have been equipped to build the knowledge of pregnant women and their families through nutrition education. “Puskesmas play an important role in increasing knowledge, especially in improving nutrition services,” says Siti Nur, Head of Puskesmas Situraja in Sumedang. In addition to routine health checks — including blood pressure, lab tests, ultrasounds and weight monitoring — Sinta also receives counselling on maintaining a balanced, nutritious diet, the importance of adhering to iron and folic acid supplementation and preparation for exclusive breastfeeding.

Innovation through digitization                                                             

In addition to training, Sumedang is leveraging digitization in its stunting reduction initiatives through the development of two innovative digital applications.

The Integrated Stunting Handling Information System — eSimpati — is a pioneering tool that provides comprehensive stunting data in the district, including statistical data on children affected by stunting, prevalence in villages and analytical data on the causes of stunting in specific geographies. Since 2020, all children in Sumedang are weighed and their data input into the application, which is then verified by puskesmas staff under the supervision of the District Health Office.

Using artificial intelligence, eSimpati tailors recommendations to each village’s unique stunting challenges, enabling prompt corrective actions. This not only facilitates closer monitoring by stakeholders, but it also allows the general public and parents to check their children’s nutritional status.

“The system is very effective because stunting is not only known by the ranks of health workers, but now everyone in Sumedang knows what stunting is,” says Dadang of the application’s success in promoting public awareness. “Stunting becomes a social problem. If, for example, a child is stunted, the parents immediately consult with the village and sub-district heads.”

Impressed by the successful implementation of eSimpati in Sumedang, the Ministry of Health is actively replicating the district’s strategy and expanding this electronic-based system nationwide to accelerate stunting management.

Recognizing the vital role of a seamless supply chain system for nutrition commodities, BISA conducted microplanning training to improve the supply chain management skills of health workers. Rita Juwita is the Pharmacy Unit Head of Sumedang’s District Health Office. She said manual forecasting, stock-outs and overstocking created bottlenecks that needed to be addressed.

“A good supply chain is very influential to decrease stunting,” explains Rita. “When micronutrient products are available in all health services, it can be influential in the fast decrease of stunting.” In response, Rita and her pharmacy unit developed ePharmacy, an inventory management application that digitizes the entire commodity inventory and request process, making health care services more accessible. ePharmacy has since been introduced to all health centres in the district, ensuring no shortages of stocks of micronutrient supplements in 35 puskesmas in the district.

A bright future ahead

Sumedang district has an official catchphrase: “Insun Medal Insun Madangan.” This translates to “born to light up the world.” Due to the collective and interconnected actions through the BISA project, the district is a shining example of stunting reduction. In addition to strengthening the health system and supply chain, Sumedang has made significant legislative progress. The district passed a decree, aligned with the Presidential Regulation, to enable the convergence of all stunting reduction efforts by different stakeholders.

Facing nausea and vomiting in her early trimesters, Sinta consulted with puskesmas staff and began diligently consuming her recommended antenatal supplements every night after eating. As a result, by her third trimester, Sinta’s hemoglobin levels improved and her symptoms gradually subsided. She’s eagerly anticipating the arrival of her newborn and is hopeful for a bright future for her children. “My wish for my children — I hope that they can be successful, healthy and useful for the nation.”

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