Food Alone Will Not Address Malnutrition in Indonesia
Malnutrition in Indonesia, as in many countries, is a complex issue, with perplexing coexistence of undernourishment and obesity in populations. Three ongoing studies are revealing how to improve the situation.
Indonesia has made significant progress against malnutrition over the past twenty years. The under-five stunting rate – an indicator of impaired growth measured by height relative to age – dropped from over 40% in 2000 to under 30% today.
Over the same period, however, being overweight has emerged as a serious nutrition problem, and anemia among women has been on the rise since 2011. Recognizing the urgency of tackling these malnutrition issues, the government of Indonesia has prioritized nutrition in its development programs.
In all 34 provinces of Indonesia, under-nutrition in young children (stunting) and over-nutrition in adults (obesity, measured by body mass index) co-exist geographically – a double burden of malnutrition that exists even within families. This suggests that availability of food is not among the leading causes of the double burden. Rather, causes include limited access to healthy foods, inadequate nutrition knowledge, and poor dietary habits.
These malnutrition problems inflict a devastating economic cost. Stunted children earn 10% less over their lifetimes, while overweight individuals are at higher risk of diet-related non-communicable diseases that cost Indonesia billions of dollars in treatment and lost productivity. One estimate places the total cost of malnutrition in Indonesia at 3% of GDP.
The importance of nutrition programs has only grown due to the COVID-19 pandemic. Economic contraction has threatened progress against malnutrition across the globe, with experts projecting an additional 2.6 million stunted children in low- and middle-income countries at a cost of nearly $30 billion in future output if nutrition interventions are not scaled up immediately. This is because stunting will cause irreversible education and economic losses for years to come.
With mounting fiscal pressure and competing budgetary priorities, policy research that provides evidence-based recommendations on how to spend public health resources efficiently is more important than ever. Three studies led by Indonesian universities and government agencies were presented at the ADB Economists’ Forum 2022 that illuminate the issue of malnutrition in Indonesia and can give policymakers insights on moving forward.
The first study finds that household-level improvements in socioeconomic status, sanitation, and access to health services contributed to the 13% decline in child stunting rate achieved by Indonesia between 2007 and 2018. The underlying role of maternal health factors in reducing stunting through higher birth weight and exclusive breastfeeding practice shows that breaking the intergenerational transmission of malnutrition unleashes a virtuous cycle, with healthier mothers raising healthier children.
The second study picks up on the first study’s theme of sanitation and goes into the mechanisms of its relationship with stunting. It finds that local sanitation (measured by municipality’s fraction of individuals engaging in open defecation) is strongly associated with children’s diarrhea, which disrupts children’s retention of key nutrients, and increases likelihood of stunting.
Adjusting for household factors, child stunting is twice as prevalent in municipalities where the open defecation rate is over 75% versus below 25%. The relationship between local sanitation and stunting is much stronger than the relationship between private sanitation and stunting. This is evidence on the importance of public investments in hygienic practices and sanitation facilities to complement nutrition-specific programs.
The third study finds that while the population prevalence of anemia has been stubbornly stable over the past decade at around 30%, it is not highly persistent at the individual level over the long run: women move into and out of the state of anemia over their lifecycle.
Moreover, anemia is not strongly correlated with income. Women in poor and rich households alike suffer from anemia. Targeted interventions can be expensive and inefficient, so this is a promising sign that anemia in Indonesia can be managed through mass nutrition interventions that use broad platforms, like schools and community centers.
This includes education campaigns and micronutrient supplementation, which are already part of the national government strategy through initiatives like the Ministry of Health’s Weekly Iron and Folic Acid Supplementation program.
These studies have a common message: Malnutrition is not just a problem of poverty, and economic growth alone has not been enough to reduce stunting in Indonesia. That will hold true as the country strives for further improvements. Progress against malnutrition has been achieved over relatively short periods of time, and the levers for continued improvement will be nutrition-sensitive interventions that educate families on healthy diets, improve access to nutritious foods, and support agriculture and sanitation.
The next step is to launch local, solution-oriented research that builds on these national studies to illuminate the path to a healthier, more prosperous future for children in Indonesia.