Opportunities for Accelerating Undernutrition Reduction in Indonesia

Lawrence Haddad Institute of Development Studies, UK

AusAID August 2012
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Outline
Malnutrition rates in Indonesia and Timor Leste - stuck Consequences of malnutrition Role of income growth Opportunities in other sectors
Social protection, agriculture, womens empowerment, watsan

Conclusions
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Underweight trends in Indonesia recently stalling

SCN 6th World Nutrition Report

Indonesia has a >0.5 probability of meeting MDG 1 target (underweight)

Trends in mild, moderate, and severe stunting and underweight, and progress towards MDG 1 in 141 developing countries: a systematic analysis of population representative data. Gretchen A Stevens, Mariel M Finucane, Christopher J Paciorek, Seth R Flaxman, Richard A White, Abigail J Donner, Majid Ezzati, on behalf of Nutrition Impact Model Study Group (Child Growth). Lancet July 5,2012
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But in Indonesia underweight rates are clouded by increasing levels of overweight and obesity, even in the presence of stunting
(adults)

Roemling and Qaim 2012. Obesity Trends, Determinants and Policy Implications in Indonesia. International Agricultural Economics Association.
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Indonesia: undernutrition rates of under fives (%) Progress on stunting=MDG1 (stunting) by 2052
HKI Surveys
42.4 41.6 About 10 million under 5s are stunted

BHS Survey
40.1

NHHS Survey
28.6

24.8

23.4

19.7 14.4

19.6 14.8

5.5

5.4

2000

2001

2002 stunting

2003

2004

2005 wasting

2006

2007

underweight

If MDG1 was based on stunting instead of underweight, MDG1 target (say target of 25% stunting, based on generous assumption of 50% stunting in 1990) would be achieved by 2052 (2007+45 years)
WHO Global Database of Child Development and Growth
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Timor Leste: undernutrition rates of under fives (%)

Possibly the highest stunting rates in the world, Wasting rates also extremely high
MICS Survey
55.7 40.6

MoH Survey
54.8 41.5

DHS Survey
57.7 45.3

13.7

14.3

18.9

2002

2003

2004

2005

2006

2007

2008

2009

stunting

underweight

wasting
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WHO Global Database of Child Development and Growth

Number of countries where stunting rates are going up, down or are unchanged (latest survey minus the previous one)
Region Total number of countries Improving No change Deteriorating

Africa
Asia S. & Central America and Caribbean Total

29
20 14 63

12
13 6 31

6
6 7 19

11
1 1 13

SCN 6th World Nutrition Report. 2011

Impact of stunting at 36 months on multiple outcomes over the life course of an individual up to middle adulthood
Individuals surveyed 1969 - 1977 in rural Guatemala, re-interviewed 2002 2004 The absence of growth failure at 36 months is causally linked to: Leaving school at an older age and higher grade attainment. Someone not stunted scores > a standard deviation higher on the Successful Intelligence Assessment test After school, individuals form partnerships with individuals with higher schooling attainments. Women have 1.86 fewer pregnancies & less likely to have stillbirths or miscarriages For men, a one-standard deviation increase in height- for-age at 36 months raises hourly earnings by 20 percent. For women, similar increase raises the likelihood they derive independent income by more than 10 percentage points. Individuals who were not stunted are 33.9 percentage points less likely to live in poor households as adults. A one-standard-deviation increase in height-for-age raises the per capita consumption level of the household that they live in by nearly 20 percent.
The Consequences of Early Childhood Growth Failure over the Life Course. John Hoddinott John Maluccio Jere R. Behrman Reynaldo Martorell Paul Melgar Agnes R. Quisumbing Manuel Ramirez-Zea Aryeh D. Stein Kathryn M. Yount. IFPRI Discussion Paper 01073 March 2011

Impact of Infant Undernutrition on Indonesian Children

In the absence of any catch-up, by adolescence, a malnourished child will grow to be 4.15 cm shorter than a well-nourished child. However, there is some catch up and by adolescence, a malnourished child will grow to be only 0.95 cm shorter than a well-nourished child. A decline in stature by 0.95 cm lowers schooling attainments by 0.6 grades of schooling.

Is there Complete, Partial, or No Recovery from Childhood Malnutrition? Empirical Evidence from Indonesia. Subha Mani. October 8, 2008

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Undernutrition and Overnutrition are physiologically linked

We now know that poor fetal growth and small size at birth are followed by increased risk of coronary heart disease, stroke, hypertension, type 2 diabetes and osteoporosis. This has led to the hypothesis that these disorders originate through unbalanced nutrition in utero and during infancy
(Developmental Origins of Health and Disease Society website, 2010)

Indonesia is a stunting underperformer relative to GDP

Save the Children UK. 2012. A Life Free from Hunger.

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Income growth is not large enough to drive down nutrition status on its own

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Poverty Declines are Slowing

INDONESIA ECONOMIC QUARTERLY, Rising to present and future challenges. July 2012. World Bank.

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Inequality is relatively high and not declining

Economic Importance of Agriculture for Sustainable Development and Poverty Reduction: Findings from a Case Study of Indonesia. Dalila Cervantes-Godoy, Joe Dewbre, OECD Secretariat. 2010.

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Cause for Optimism that something can be done

Great variation in underweight rates at similar poverty levels, by district

Health Sector Decentralization And Indonesias Nutrition Programs: Opportunities And Challenges Jed Friedman, Fadia Saadah, Yoonjoung Choi. January 20, 2006. World Bank

Effective nutrition action requires coherence and critical mass from all sectors
Education Keep girls in secondary school to delay age at first pregnancy

Agriculture Focus on poverty reduction, Gender

Social Protection Focus on health conditionalities

Direct Nutrition Interventions

Health systems View nutrition as lower in hierarchyembed direct nutrition programmes

Womens empowerment Balance of upstream and downstream Water andempowerment Sanitation Focus on nutrition status outcomes

Driven by: Leadership, Ideas, Institutions, Incentives

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Country Groupings to Guide Nutrition Strategy

Gillespie and Haddad 2001 Attacking the Double Burden of Malnutrition in Asia and the Pacific. ADB/UNICEF
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For Direct Interventions We Need to Know About Coverage

Timor Leste

DHS Report 2010-11

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Indirect Interventions: Relative contribution (%) to the decline in child stunting between 1996 and 2007 in Brazil
What would this look like for Indonesia?

Other Factors 36,7%

Income 22,5%

Maternal Schooling 24,6% Health Care 10,4%

Source: Monteiro et al (2009). Causes for the decline in child undernutrition in Brazil, 1996-2007. Revi Sade Pb, 43 (1): 35-43.

Protecting Poor and Vulnerable Households in Indonesia. World Bank. 2011.

Indirect Interventions: Spending on Health, Social Assistance and Agriculture sum to <10% of public expenditures

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Latin America = 1.3 % of GDP, East Asia average = 1% of GDP Indonesia = 0.5%

Spending on Household Social Assistance is Relatively Low

Protecting Poor and Vulnerable Households in Indonesia. World Bank. 2011.
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Latin America = 1.3 % of GDP, East Asia average = 1% of GDP Indonesia = 0.5%

Spending on Household Social Assistance is Relatively Low

Protecting Poor and Vulnerable Households in Indonesia. World Bank. 2011.
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Potential Impact of PKH on Nutrition is High, but

Protecting Poor and Vulnerable Households in Indonesia. World Bank. 2011.
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No evidence to date of impact on nutrition status

Phk Cct: Social Assistance Program And Public Expenditure Review 6. World Bank 2012

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Indonesia: Relatively High Levels of UNDPs Gender Inequality Index (GII)

GII Rank 2011
96

13% improvement
100

99

19% improvement
0.352 0.305 0.286

0.581 0.549 0.505

43

48

Malaysia 1995 2005

Indonesia 2011

UNDP Human Development Report 2011

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Effect of womens decision making power on underweight rates, Sub Saharan African countries

What is this effect for Indonesia?

Source: Smith, Haddad et. al. 2003, IFPRI Research Report 131

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Indonesia: water and sanitation coverage to 2010 and projections to 2015

Rural Sanitation is Lagging

World Health Organization and United Nations Childrens Fund Joint Monitoring Programme (JMP) for Water Supply and Sanitation. Coverage estimates for 2010.

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Indonesia: growth (%) in Total Factor Productivity in agriculture is lagging

Economic Importance of Agriculture for Sustainable Development and Poverty Reduction: Findings from a Case Study of Indonesia. Dalila Cervantes-Godoy, Joe Dewbre, OECD Secretariat. 2010.

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MoA Budget is Increasing

Agriculture Public Spending and Growth in Indonesia Enrique Blanco Armas, Camilo Gomez Osorio, Blanca Moreno-Dodson and Dwi Endah Abriningrum. Policy Research Working Paper 5977. World Bank

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Growth in Indonesian agriculture would have the biggest impact on poverty rates (urban and rural)

Agric growth

Industrial growth

Services growth Industrial growth Services growth

Agric growth

Economic Importance of Agriculture for Sustainable Development and Poverty Reduction: Findings from a Case Study of Indonesia. Dalila Cervantes-Godoy, Joe Dewbre, OECD Secretariat. 2010.

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Opportunities for AusAID to meet strategic goals

Saving Lives Promoting opportunities for all Prevention of undernutrition.. Sustainable economic development Prevention of undernutrition.. Effective governance Humanitarian and disaster response

Prevention of undernutrition..

Because of Rapid response invisibility and required in first need to work 1000 days.. across sectors .. need to means innovate on attention to accountability prevention and and real time commitment is monitoring high

saves 30% of deaths of children under 5

increases grade attainment by one standard deviation

results in a 34% lower chance of the adult living in poverty NCD links

Which aid donors are committed to reducing hunger?

Country Government expenditure rank Policies and programmes rank Hunger Reduction Commitment Index (1 is best)

Denmark
Finland Belgium Ireland Norway France United Kingdom Australia Netherlands Spain Germany South Korea Japan Canada Greece Sweden Italy USA Austria Switzerland New Zealand

3
6 9 5 2 11 14 16 10 4 12 23 8 13 21 7 22 18 20 15 17

4
9 7 11 15 6 3 2 8 14 10 1 17 13 5 19 12 18 16 22 20

1
2 3 3 5 5 5 8 8 8 11 12 13 14 14 14 17 18 18 20 20
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Source: IDS at hrcindex.org

Changes in Donor Spending in Basic Nutrition: 2003-08

Figure 4.5: % change in basic nutrition aid over 2000-03 and 2005-08
France Canada New Zealand Spain United Kingdom Ireland Belgium EU Institutions Germany UNICEF IDA Norway Sweden Denmark Portugal Finland United States Australia Italy Netherlands Japan IFAD Austria

10 15 20 USD Millions (2008 constant prices)

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UP: France, Canada, NZ, Spain, UK, Ireland, Belgium, EU, Germany, UNICEF, IDA, Norway
-6% -31% -35% -74% -79% -81% -83% -92% -99% -100% -100%

44726% 815% 623% 462% 418% 338% 279% 135% 72% 37% 26% 17%

DOWN: Austria, IFAD, Japan, Netherlands, Italy, Australia, USA, Poland, Portugal, Denmark, Sweden
100%

-100%

-50%

0% 50% % change between 2000-03 and 2005-08

Source:

OECD-CRS online database. Accessed December 2010

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Nutrition Advocacy Landscaping in Europe: An Analysis of donor commitments. February 2011. Daniel Coppard, Asma. Devint.

Most nutrition resources are for Indirect Interventions

Aid For Nutrition: Can investments to scale up nutrition actions be accurately tracked? ACF. 2012.

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Conclusions
Stunting is stuck in Indonesia (2052 for MDG1!) Significant consequences for economy Economic growth is not fast enough or broad based enough to deal with undernutrition on its own Need direct and indirect interventions Direct: Coverage needs to improve, esp for 0-2 ages Indirect: Large scope for improvement in agriculture, social protection, sanitation, womens status Need leadership and a whole of society strategy Nutrition investment supports AusAID strategy well
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