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Abstract
Objectives The research aims to understand the challenges and opportunities in policy and programme convergence to accelerate interventions for reducing stunting at the district, subdistrict and the 10 focused villages.
Design Data were collected through qualitative methods (in-depth interviews and document reviews), and then analysed using thematic processes with NVivo V.11 software, by QSR International The process included coding, categorising and linking to the eight implementation outcome variables (as determined themes), namely acceptability, adoption, appropriateness, feasibility, compliance, implementation cost, coverage and sustainability. The variables of convergence action policies were implemented differently by stakeholders at different layers of governance.
Setting Pidie district, Aceh province, Indonesia.
Participants 106 respondents from provincial to village levels were selected and interviewed, including leaders and policymakers (n=10); and convergence action implementers from the province to the villages (n=96).
Results Stunting reduction policies were generally acceptable to local leaders and policymakers as a policy imperative. Implementation costs were considered sufficient by stakeholders, although focusing only on nutrition-specific interventions. However, in terms of adoption, feasibility, compliance, nutrition-sensitive intervention coverage and sustainability aspects were insufficiently implemented in all the focused villages due to inadequate collaboration between health and non-health sectors and limited experts.
Conclusions This study offers key recommendations for policy and practice changes and considerations. The utilisation of methods and findings from this study in other areas in Indonesia or other low- and middle-income countries is important to explore more about the applicability, benefits and weaknesses of this study.
- public health
- nutrition & dietetics
- health policy
Data availability statement
Data are available on reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
The procedure used to select respondents in this study enhanced the representativeness of the sample size, which can improve the generalisability of the results across Pidie district and Aceh province.
The triangulation technique through direct in-depth interviews and document reviews in this study improved the quality of data collected.
Because the data analysis was conducted using translated data, some specific contexts of language and culture may have been ignored; however, this study involved many Acehnese authors who are familiar with the local language (Acehnese and Indonesian), culture and study sites, hence, misinterpretations of collected data were resolved.
Some information gathered from in-depth interviews could be verified through written or printed documents, as it is not sufficiently documented in official government records; however, the inclusion of interviewees from different agencies across multiple government levels (provincial, Pidie district, four subdistricts and 10 focused villages) enriched the quality of the research findings.
Introduction
Stunting, which refers to a child being shorter than average for their age, is a significant obstacle to the growth and development of children under the age of 5. This condition can have immediate and long-term consequences such as increased infections in early life, reduced physical and cognitive development and a higher risk of degenerative diseases later in life.1–3 Globally, stunting in children has the highest prevalence among the various forms of malnutrition.4–7 In 2020, there were 144 million stunted children under the age of 5, 47 million wasted children and 38 million overweight children.4 The Southeast Asia region alone accounted for 24.7% of the total global stunted children,6 placing them in the high category. Therefore, eradicating stunting has become the top priority of the Global Nutrition Targets 2025 and the second Sustainable Development Goal for Zero Hunger by 2030.1 8
Among the Southeast Asian nations, Indonesia has the second highest number of child stunting cases after Cambodia.9 While Indonesia has managed to reduce the national child stunting prevalence from 30.8% in 2018 to 24.4% in 2021,10 the rate still falls within the high prevalence category (20% to <30%) according to WHO standards.7 The 2022 Indonesia Nutritional Status Study revealed that >7 million children under the age of 5 (22.6%) in the country were stunted.10 This number exceeds the WHO standards (under 20%).11 12
The central government has adopted various policies and programmes aimed at reducing the number of children suffering from stunted growth. One of the nationally introduced policies is the convergence action to accelerate the reduction and prevention of stunting. This involves various actors, including government entities, private organisations, academic institutions and communities at all levels from the central down to the village level.13 Importantly, this national policy is based on vertical programmes that must be adopted and implemented by districts/cities.14
The policies and strategies of the convergence action are related to intervention programmes in the ‘nutrition-specific’ areas (mainly in the health sector) and ‘nutrition-sensitive’ areas (non-health sectors). These programmes are conducted in an integrated and comprehensive manner by all actors.13 14 We argue that convergence can reduce intervention costs in resource-constrained regions. Research also indicates that convergence interventions combining nutrition-specific and nutrition-sensitive aspects can reduce stunting prevalence by 0.7% to 2% annually.15 For instance, a multisectoral approach involving all stakeholders in the public and private sectors has successfully reduced child stunting prevalence by 2.20% each year in Senegal, Peru and Nepal.16 Additionally, the implementation of integrated management of childhood illnesses, exclusive breastfeeding, clean water and sanitation and cash assistance to the poor in rural areas of Bangladesh reduced stunting prevalence for children aged 24–59 months from 63.1% in 2000 to 50.4% in 2007.17 In Brazil, convergence actions to reduce stunting rates by increasing income among rural poor communities and improving better access to schools, basic health services and water quality decreased stunting rates from 27% in 1988 to 16% in 2006.15 A study in the Banggai district of central Sulawesi, Indonesia found that convergence interventions have reduced child stunting prevalence by 2.18% per year.18
Aceh province, one of the most disaster-prone regions in Indonesia, has the highest number of stunted children under 2 years of age compared with all other provinces.19 As of January 2021, 40% of all children in Aceh were stunted, making it the province with the highest number of child stunting cases under 2 years of age and the third-highest number of child stunting cases under 5 years of age out of the 34 provinces in the nation.20 Furthermore, by the end of December 2022, Aceh was recorded as having the third highest stunting rate at 33.2%, following East Nusa Tenggara and West Sumatra provinces with rates of 37.8% and 33.8%, respectively.21 The Aceh government has formulated Governor Regulation No. 14/2019 on convergence actions for stunting reduction and management to decrease the prevalence of stunting throughout the province. This regulation is part of the local government’s commitment to supporting the central government’s convergence policy.19
One of the implementation activities is the performance assessment of district authorities based on convergence actions.22 Pidie district is one of the districts in Aceh province with a high prevalence of child stunting (33.3% of total children as of November 2023).23 Therefore, this paper adopts an implementation research framework to examine stunting eradication policy implementations by considering all implementation variables, including factors that affect implementation, intervention processes, implementation results/findings and potential recommendations for the health system,24 enhancing stakeholders capacity to achieve sustainable results.25 The implementation research uses outcome variables to assess policy implementation and provides insights that can contribute to improved health outcomes. These variables include acceptability, adoption, appropriateness, feasibility, compliance (sometimes referred to as fidelity), implementation cost, coverage and sustainability.24
Nonetheless, there are no studies found on the implementation of convergence actions for stunting reduction acceleration policies after 5 years of the formulation of the Aceh Government Legislation No. 14/2019. Hence, barriers and opportunities for adoption can be investigated and identified. Also, limited research has examined the implementation of convergence actions for stunting reduction policies, particularly in Aceh, using eight outcome variables for analysis. This study aims to examine policy convergence at the local level by reviewing the acceleration of stunting prevention and reduction policy in Pidie, Aceh, Indonesia. Policy convergence is reviewed in the following domains: (1) assessing situations, (2) designing action plans, (3) organising consensus meetings, (4) establishing district and village decrees on stunting reduction, (5) enhancing human development cadre capacity, (6) improving data management systems, (7) updating stunting prevalence data and (8) evaluating annual performance.13
To achieve the aim of this study, the research answered the following questions: (1) What are the possible factors influencing the implementation of convergence actions in stunting prevention and reduction? (2) Who are the responsible actors for implementing the convergence action policy in the district? (3) How can strategies be implemented to improve the implementation of convergence policy in accelerating stunting prevention and reduction in the district?
Nutrition eradication measures
Child stunting is caused by specific and sensitive factors. Specific factors that directly lead to stunting include iron deficiency, lack of nutrition and healthcare services during the first 1000 days of life, inadequate exclusive breastfeeding practices and insufficient complementary foods for children.26 Various sensitive factors indirectly contribute to stunting,7 27 such as food insecurity, inadequate clean water and personal hygiene, poverty, poor family planning services, child protection and low education levels. Recent research also suggests that disasters can either directly impact food intake or exacerbate existing vulnerabilities and residual risks, leading to stunting among children.28–30
Thus, as stunting is caused by multiple factors, it is necessary to involve various relevant agencies in a coordinated manner from central to local (village) levels to enhance child stunting reduction interventions.13 As mentioned previously, the central government, through the Ministry of National Development Planning (BAPPENAS), established the implementation guidelines for stunting reduction in 2018 to support the third pillar of the National Convergence Actions of Stunting Reduction Framework.13 14
In addition, to complement efforts to reduce stunting, the central government established Presidential Regulation No. 72/2021 on Stunting Reduction Acceleration in 2021. Launched in the midst of the COVID-19 pandemic, the regulation aims to formulate national strategies to accelerate stunting reduction, implement accelerated stunting reduction programmes, coordinate programme activities from central to village levels, monitor, evaluate and report progress and provide funding.31 Based on this regulation, the implementation of the eight convergence actions is technically coordinated by the National Population and Family Planning Agency (BKKBN), which was previously overseen by the National/Regional Planning Agency (BAPPENAS/BAPPEDA).31
In response to the central government initiative mentioned previously, the Aceh governor issued Regulation No. 14/2019 as a new strategy to reduce and prevent stunting in Aceh province. This strategy aims to address specific and sensitive factors through multi-agency intervention and collaboration to achieve ‘Aceh Free of Stunting in 2022’.20 This new approach aligns with the 2015 Lancet research results on Maternal and Child Nutrition, which emphasise the need for extensive nutrition-sensitive interventions.32 The combination of nutrition-sensitive and nutrition-specific programmes has been shown to reduce stunting by up to 20%.32 33 Following in the footsteps of the Aceh government, Lao PDR has also taken similar actions by establishing a multisectoral committee and institutional framework to reduce child stunting prevalence. They have increased the budget for nutrition and have worked on enhancing food safety and security measures.32
Posyandu programe
Posyandu (Integrated Health Programme) is one of the central government programmes led by Community Health Centres (Puskesmas) under the supervision of a district health office (DHO), and is carried out at the village level on a monthly basis throughout the Aceh province.34 The programme has been in operation since 1985, providing five main services.35 Desk 1 handles registration, desk 2 monitors the nutritional status of children and pregnant women by measuring weight, height, arm and head circumferences, desk 3 fills out child growth and development cards, desk 4 provides counselling for children and mothers based on growth and development cards and desk 5 provides health services such as immunisations, vitamin A delivery, complementary and supplementary foods for children and pregnant women and family planning consultations.
Some important actors are directly involved in conducting monthly Posyandu activities, including (1) village cadres, who play a central role in the five-desk services and are responsible for conducting activities in desks 1–4; (2) health personnel, such as a village midwife and medical doctor, who provide health services at desk 5 and (3) the village head, who is responsible for organising activities at the village level.34 Hence, improving the capacity (knowledge and skills) of the Posyandu actors is essential (especially for cadres) to enhance maternal and child health programmes related to nutrition-specific factors. This, in turn, can help to reduce the prevalence of child stunting in Aceh province.
Methods
Study setting
The study was conducted in Aceh province, which consists of 23 districts and 6493 villages, with a total population of 5.371 million.36 The study focused on the Pidie district based on the following considerations. First, the district has a high prevalence of child stunting, with 33.3% of children reported as stunted as of July 2023.23 Second, the district has implemented the convergence actions for the stunting reduction programme in 10 focused villages,37 38 providing a chance to explore barriers and opportunities for improving policy implementation in those village areas. Finally, the accessibility of data in the district is high, as one of the coauthors has established contacts with key agencies and local government leaders (eg, the DHO, District Planning Agency and Secretariat and Pidie Regent offices) through involvement in various stunting reduction activities in the district.
Demographic conditions
The Pidie district has a population of 439 398, with females outnumbering males (217 964 females and 221 434 males, respectively). The primary occupation of the people is farming in the rice fields.37 Although the poverty rate in the district decreased from 21.43% in 2017 to 19.59% in 2021, the decrease is considered insignificant.
Also, the district reported that 6.7% of women are married under the age of 16.37 According to the Pidie DHO, as of July 2022, 1336 of 36 963 children under the age of 5 were stunted, spread across 730 villages, with the majority in 10 hotspot villages.39 These 10 villages, located within four subdistricts, were selected to assess stunting reduction interventions in the Pidie district in 2021.40 A detailed distribution of stunting prevalence within these 10 target villages is provided in table 1.
Selected hotspot villages for stunting reduction
Study design, population and recruitment
The study adopted a qualitative approach employing different data collection techniques, including semi-structured interviews, in-depth interviews and document reviews, to examine the implementation of convergence policies for stunting reduction interventions.
One hundred and six respondents/agencies from provincial to village levels were interviewed. These agencies or respondents were recruited based on convenient selection (purposefully determined) and snowball sampling.
The criteria include the responsibilities of implementing convergence policies for reducing stunting, considering both nutrition-specific and nutrition-sensitive factors. The selected agencies or persons were categorised into some groups including: (1) participants involved in assessing existing stunting prevalence, identifying current stunting reduction programmes and their issues/challenges in target areas/villages; (2) persons/agencies responsible for designing action plans based on identified issues and integrating them into the work plans of involved stunting reduction agencies; (3) officers/agencies in charge of organising stunting consultations and meetings with relevant agencies at the district level to define roles, responsibilities and commitments for nutrition-specific and nutrition-sensitive interventions in a coordinated manner to reduce child stunting prevalence; (4) stakeholders/agencies responsible for defining and supporting village roles and local organisations in conducting integrated stunting reduction programme activities based on district regulations; (5) persons/agencies tasked with enhancing the capacity of village-human-development cadres; (6) agencies/persons responsible for managing stunting prevalence data; (7) officers/agencies responsible for measuring child growth and development in villages; (8) institutions/persons responsible for evaluating annual integrated stunting reduction interventions. Other potential respondents related to the study topic were recruited through snowballing techniques. Details on respondent categories and the number of interviewees in each category are described in online supplemental table 1.
Supplemental material
Semi-structured question guides for the interviews were developed in the Indonesian language. These questions covered various topics related to implementation outcome variables (acceptability, adoption, appropriateness, feasibility, compliance, implementation cost, coverage and sustainability). The questions were designed to align with the eight convergence actions of stunting reduction interventions. The question guides developed for the interviews can be found in online supplemental table 2.
Supplemental material
Data collection
Data were collected from June to September 2023. The interviews began with a key official from Provincial Health Office (PHO) (one of the work partners of the first author’s office). The official then facilitated the lead researcher to interview the Provincial Sekda. A permission letter from the Sekda was obtained to facilitate interviews with all listed organisations and persons. The interview process mainly took about 20–30 min and was digitally recorded.
Following in-depth interviews, various documents related to child stunting reduction programmes were reviewed. These included Governor Regulation No. 14/2019 on Convergence Actions for Stunting Reduction and Management in Aceh, Aceh Governor Decision No. 050/1525/2020 on the Evaluation of Convergence Actions for Stunting Reduction Implementations in 2020, Presidential Regulation No. 72/2021 on Stunting Reduction Acceleration, Pidie District Regulation No. 31/2021 on Convergent Actions for Stunting Reduction Interventions, Pidie Regent Decision No. 440/220 on the Formation of the Stunting Reduction Acceleration Team and Pidie Regent Decision No. 440/425 on the Determination of Target Villages for Convergence Actions for Stunting Reduction Interventions in Pidie District from 2020 to 2021.
The data were collected in alignment with provincial and district-support activities. Our focus was specifically on collecting data relevant to the variables that impact the implementation outcomes of each of the eight convergence actions from the provincial to village levels, including 10 focused villages.
Data analysis and reporting
A voice recorder was used to record the interview process. The data were transcribed in Indonesian in a Word document file and then translated into English as appropriate. All transcripts, including field notes and important documents (eg, policies, regulations and reports on implementing convergence policies for stunting reduction interventions), were managed and analysed using NVivo V.11 software, by QSR International.
This study used a thematic process to analyse data from interviews and document reviews.41 Nodes were created in NVivo and then organised into initial codes, which represented text quotes from participants.42 The codes representing the convergence actions of stunting reduction interventions were refined repeatedly, compared and connected to eight categories to identify similarities and differences. They were then linked and matched to the determined themes, as detailed in the introduction.43 Finally, the reporting of this study followed the Consolidated criteria for Reporting Qualitative research guidelines.43
Data protection
The participants were guaranteed that only those directly engaged in the study would have access to the information provided during the interviews. All data from transcripts and recordings were anonymised and securely stored. Participants were given a small gift (valued at approximately US$3–4) as a token of appreciation for their time and participation.
Patient and public involvement
Patients or the public were not involved in the development of research questions, design, recruitment, conduct, reports or dissemination plans for this study.
Results
This section presents the results of the study, which are based on the assessment and analysis of the implementation outcome variables of the current convergence actions for stunting reduction and prevention in Aceh province.
Acceptability
Interviews with various key stakeholders revealed that local government authorities, especially at the provincial and Pidie district levels, accept the stunting reduction policy regulations and convergence actions from the central authority. They feel obligated to implement these regulations within their jurisdictions. The district has also issued several local stunting reduction regulations. Furthermore, Pidie district has formed the District Stunting Reduction Acceleration Team (DSRAT), which is an essential team for convergence actions.44
However, not all actors in the Pidie district accept the convergence policy for reducing stunting, especially non-health officers and communities at the grassroots level. This lack of acceptance is due to a lack of awareness regarding the urgency of stunting eradication, its impact on children’s future health and the importance of convergence policies. A senior health officer explained that some community members, especially in target villages, do not see stunting as a health problem because they believe it is inherited from parents who are short in height. Nevertheless, acceptance of the convergence policy is primarily among policymakers and health agencies, who focus only on specific factors of stunting reduction interventions such as maternal and child health (KIA) and nutrition counselling programmes. The responses from participants regarding the acceptability of the convergence action for stunting reduction policies in Aceh are presented in figure 1.
Respondent responses to acceptability of convergence actions of stunting reduction policies in Aceh. Source: NVivo V.11 software, by QSR International.
Appropriateness
Many stakeholders from the DHO and BAPPEDA in the Pidie district acknowledged that the convergence actions of stunting reduction through integrated nutrition-specific and nutrition-sensitive interventions are incredibly appropriate for accelerating stunting reduction activities in the Pidie district. This is due to the fact that the underlying causes of stunting prevalence in the district are related to nutrition-specific and nutrition-sensitive factors, including inadequate nutritious food intake during pregnancy, the presence of infectious diseases in early childhood, low rates of exclusive breastfeeding, high rates of open daefecation (OD) practices and the smoking habits of family members. A key officer from the Pidie DHO further explained: “Low rates of exclusive breastfeeding practice among mothers is a key issue among other nutrition-specific factors leading to stunting in Pidie district. The exclusive breastfeeding rate decreased from 30.2% in 2022 to 29.2% in 2023”. Concerning OD practice, a senior leader at the PUPR elaborated:
Nearly 90% of people in rural areas in Pidie still practice open defecation (OD) and 33.92% of family members are cigarette smokers. Both unhealthy behaviors can also contribute to child stunting in the district.
Moreover, of the 71 respondents interviewed from four subdistricts and 10 villages, 65% reported that many rural areas in Pidie district, including the research-focused villages, lack access to clean water for drinking and other daily needs. The condition worsens during the dry season due to water scarcity.45 Furthermore, the other sensitive factor contributing to child stunting in the district is the absence of early childhood education for children in the four focused subdistricts (covering 10 focused villages) (R72, subdistrict). Similarly, a key figure from the district Education Agency testified, ‘The number of Early Childhood Education Institutions (PAUD) in Pidie is limited. Normally, only two PAUDs are available within each subdistrict and they are typically located in urban subdistricts’. Therefore, the nutrition observer concluded that reducing child stunting cannot be achieved solely by the health sector through nutrition-specific interventions. Instead, these interventions need to be integrated with nutrition-sensitive approaches within the responsibilities of non-health sectors. The interviewees’ responses regarding the appropriateness of the convergence action for reducing stunting regulations in Aceh are shown in figure 2.
Respondent responses to appropriateness of convergence actions of stunting reduction policies in Aceh. Source: NVivo V.11 software, by QSR International.
Feasibility
The implementation of the convergence policy for reducing stunting in the Pidie district is feasible because the district head (the Regent) has shown high commitment, as evidenced by issuing relevant local regulations and establishing the DSRAT. However, the policy has not been accepted and adopted by all government levels, especially non-health actors and stakeholders at the village level (as mentioned previously).
Furthermore, a lack of coordination and collaboration among agencies involved in the first/initial action (as an example) of convergence in the Pidie district was identified. As a consequence, the actions for nutrition-specific and nutrition-sensitive interventions do not align. One senior officer from the Education Agency in Pidie district mentioned that ‘each agency still works in isolation in stunting reduction actions and follows its own central regulations set by each line Ministry at the national level’. For instance, the District Social Agency provides social protection for poor villagers through programmes like PKH (Programme Keluarga Harapan/Hope Family Programme) and Direct Cash Assistant Scheme (BLT) with their own internal criteria/categories specified by the Ministry of Social, regardless of whether the selected family has members with children, pregnant women, lactating mothers or children with stunting. Similarly, a senior stakeholder from Pidie district stated that the Agriculture Agency distributes vegetable and fruit plants and other seeds based on the category of farmer groups in target villages as stipulated by the Agriculture Ministry, without considering whether the group has family members who are pregnant, in the first 1000 days of life, or have stunted children (R38, district; R65, district). Thus, since the delivery of the aforementioned social protection and social assistance programmes was not focused on the 10 designated villages due to discrepancies in stunting data recorded/collected by different involved actors, some villages did not even receive the programmes.
Another issue related to inadequate coordination was the lack of synchronicity in presenting work by each key stakeholder during coordination meetings (in the third action, particularly in the stunting consultation/discussion). This was due to the unavailability of updates and accurate data on stunting and beneficiaries in Pidie district and villages. Nevertheless, all stakeholders recognise that integrated actions take time and effort to overcome sectoral egos and improve coordination among relevant actors. The interviewee responses regarding the feasibility of the convergence action of stunting reduction regulations in Aceh are shown in figure 3.
Respondent responses to feasibility of convergence actions of stunting reduction policies in Aceh. Source: NVivo V.11 software, by QSR International.
Adoption and compliance
So far, the convergence policy for reducing stunting in the Pidie district has not been implemented as planned or designed. The adoption of convergence actions in the Pidie district is influenced by the commitment of the district chief (Regent). Despite the Regent’s commitment to implementing the eight convergence actions through establishing the DSRAT, some key respondents in the Pidie district mentioned that the convergence actions had not been successfully adopted due to various barriers. These barriers include a lack of understanding of child stunting concepts, inadequate integration between nutrition-specific and nutrition-sensitive interventions and inadequate coordination between stakeholders (R37, district; R42, district; R52, subdistrict).
Information gathered from in-depth interviews with key respondents in the Pidie district explained that the district had identified focused villages for convergence actions in stages. Initially, 10 villages within five subdistricts were targeted from 2018 to 2019, followed by an additional 20 villages in 2020. In 2021, the convergence actions were focused on 10 villages within four subdistricts. However, some senior officers from the Pidie district noted, ‘Most target villages did not have the Village Stunting Reduction Acceleration Team (VSRAT), which is a crucial committee in the convergence actions for stunting reduction as outlined in President Regulation No. 72/2021 on Stunting Reduction Acceleration’. Likewise, key respondents from focused villages further complained:
We do not clearly understand the stunting and convergence actions policy, and how to implement it within our village. We have not yet established a VSRAT because we are unsure of how creating the team can reduce child stunting in our villages.
A senior officer from the PHO clarified that no VSRAT was formed at the village level in 2021, shortly after the establishment of Regulation No. 72/2021. Yet, since 2022, most villages within the 23 districts have successfully established VSRATs in their localities. This is part of the effort to achieve the national target of a 14% reduction in stunting by 2024, as required by Regulation No. 72/2021.
Nonetheless, a health observer argued that although the VSRAT has been formulated in many villages, many village heads and their teams do not have sufficient capacity (skills and knowledge related to child stunting) to design action plans for the convergence actions of the stunting reduction programme activities within their villages. They also lack the ability to coordinate, collaborate, synergise and evaluate the activities, as mandated by Article 22 of President Regulation No. 72/2021. The responses of interviewed stakeholders regarding the adoption and compliance of the convergence actions of stunting reduction regulations in Aceh are provided in figure 4.
Respondent responses to adoption and compliance of convergence actions of stunting reduction policies in Aceh. Source: NVivo V.11 software, by QSR Internationald.
Implementation cost
The implementation of convergence actions for reducing stunting at the local level is funded by various financial sources, including the National and Provincial Revenue and Expenditure Budgets, as well as the General Allocation Fund (GAF), which is directly transferred to local governments.31 46 Recently, the central government (via GAF) transferred over US$16 million in stunting reduction funds to Aceh province.
According to Hadi,47 there are significant stunting reduction funds available at the central government (line ministries) and village levels. For example, >US$2.1 million in stunting reduction funds were used by 20 relevant ministries at the central level, each with different programmes. Additionally, a considerable amount of funds is provided to regional governments down to villages through special allocation funds and village funds for stunting reduction, each with also different programmes at the provincial and village levels. However, key officials from provincial and district BAPPEDAs stated that the funds are not converged or integrated with specific focused stunting reduction programmes from central, provincial, district and subdistrict to village levels within certain local areas.
As a result, many village heads (eight out of 10 focused villages) do not understand how and from which financial sources to finance the convergence programmes. Other village heads are hesitant to allocate village funds for the convergence actions of stunting reduction within their localities. A senior staff member from the Community-Village Empowerment Agency testified that many village heads are reluctant to use the stunting funds as they believe that the fund utilisation must be regulated by a specific local regulation. The respondents’ views on the implementation costs of the convergence actions of stunting reduction policies in Aceh are illustrated in figure 5.
Respondent responses to implementation cost of convergence actions of stunting reduction policies in Aceh. Source: NVivo V.11 software, by QSR International.
Coverage
Stakeholders in the Pidie district, subdistrict and 10 focused villages confirmed that the health sector has covered nutrition-specific interventions through Puskesmas’ programmes, namely Posyandu five-desk activities (under the DHO’s instruction) (as described previously). Information gathered via interviews in the Pidie district revealed that activities for reducing stunting are conducted in the 10 focused villages, with a focus on KIA activities. These activities include providing supplementary and complementary foods for pregnant women and children under the age of 5, distributing iron and folic acid tablets to adolescent girls and pregnant women, increasing immunisation coverage for children, delivering vitamin A to children and distributing zinc to pregnant women and children in cases of diarrhoea.
However, there is a lack of knowledge transfer to new Posyandu cadres, as newly elected village heads frequently change the cadres. This results in inadequate knowledge and skills of Posyandu cadres on the five essential services, which include recording child growth and development, and conducting family or child counselling (R10, province; R16, district; R81, subdistrict).
Regarding nutrition-sensitive interventions (eg, a clean water and sanitation (WASH) programme in Aceh province), non-governmental organisations (NGOs) like UNICEF and Yayasan Aceh Hijau typically support the programme through the PHO or DHOs.48 49 In Pidie district, the WASH programme is also supported by the local NGO BAITULMAL, which mainly focuses on constructing latrines in some villages (R49, R87, district). Also, the PUPR agency constructed habitable houses with adequate water and sanitation in the district in 2021 and 2022 (R71, district).
In terms of social protection programmes, especially in health services in Aceh, the National Health Insurance programme under the Ministry of Health covers the Acehnese people (R11, province). The programme began in 2014, with the goal of providing access to health services at affordable costs in primary and referral healthcare facilities, as well as improving the quality of services.50 The local government also offers Health Insurance for the Acehnese people to expand coverage. The responses of interviewed participants regarding the coverage of the convergence action of stunting reduction regulations in Aceh are provided in figure 6.
Respondent responses to coverage of convergence actions of stunting reduction policies in Aceh. Source: NVivo V.11 software, by QSR International.
Identifying current programme interventions and their issues is related to the first action of the eight convergence actions. This action involves assessing situations to identify existing substance reduction programmes. It is the most critical stage for convergence actions and needs to be conducted in a coordinated manner. This is because it can facilitate the development and design of appropriate programme plans in the second action.
Sustainability
Although the convergence of stunting reduction policies can be made more sustainable at the local government level, as a national policy imperative, it is highly dependent on the strong leadership of leaders and policymakers from provincial, Pidie district, subdistrict and village levels. Meanwhile, a senior media officer criticised that so far, no activities have been facilitated by the central, provincial or district/city governments to enhance the capacity of villagers in stunting reduction actions, specifically in designing plans, budgeting, implementing and monitoring and evaluating the programme. In fact, implementing convergence actions requires thorough planning and budgeting at the operational level (village), and the subdistricts (as the government layer directly above villages and under districts) should also be able to assist the villages (R9, province; R11, district). The respondents’ insights on the sustainability of the convergence action of stunting reduction policies in Aceh are described in figure 7.
Respondent responses to sustainability of convergence actions of stunting reduction policies in Aceh. Source: NVivo V.11 software, by QSR International.
Discussion
Findings have revealed that the implementation of convergence action policies to accelerate the prevention and reduction of stunting only exists at the provincial and district levels. However, it is not being appropriately implemented, especially at the district and village levels. The local government needs to conduct the convergence policy with wholehearted actions and total commitments. This means that local regulations (eg, DSRAT) on stunting should be formulated and must be properly implemented at the district level.
Hence, the political will of local leaders to enforce established local regulations is crucial for enhancing the acceleration of stunting reduction in Aceh. Research conducted in 16 low- and middle-income countries in Asia, Latin America and Africa revealed that the successful implementation of stunting reduction policies across these countries is indicated by several aspects. These include good coordination and collaboration between government and non-government agencies, as well as active community engagement with stunting reduction programmes at a local level. These aspects are highly dependent on the strong political will of central and local leaders to carry out the programme effectively.51 Hence, the strong political commitment of the Pidie Regent and its local secretariat as the top managers of the district is necessary to adopt the established convergence action policies within their location comprehensively.
Another good example of strong political will from government authorities can be seen in three states of India (Gujarat, Tamil Nadu and Chhattisgarh) during the implementation of stunting reduction programmes between 2000 and 2016.52 The leaders across the three states committed to maintaining and strengthening the child stunting eradication programme as they remained in power for three successive terms.53
In contrast, the International Food Policy Research Institute reports that inadequate or weak political commitment of government authorities to formulate and implement stunting reduction policies is one of the key barriers among others in many low-income nations, despite the global recognition of the importance of sufficient nutrition for children’s development.54 55 The other barriers include interagency coordination complexity (as each line ministry has its own priority area), inadequate public pressure and advocacy on the urgency of stunting reduction acceleration and a lack of skilled personnel to address stunting reduction programmes at the local level.55 56
Nonetheless, Scott and Tarazona57 emphasise that some conditions can compel or encourage government authorities to increase their political interest in implementing certain programmes in various settings, including accelerating the reduction of stunting. These conditions include55 57:
High pressure from the public, scientists and academic communities to prevent and reduce child stunting prevalence.
Increased public awareness and concern about child stunting prevalence.
The availability of adequate facilities and experts for policy and practice related to stunting reduction at the local government level.
The availability of sufficient funds for stunting reduction.
Nutrition management leaders ought to be held mainly by scientists and civil society organisations, rather than politicians.
The other finding revealed that only the health sector (Pidie DHO) carries out nutrition-specific interventions via Posyandu activities. Non-health sectors assume that they are not responsible for reducing and preventing stunting prevalence. This assumption aligns with findings by Gillespie et al 58 in many countries in South Asia and Africa. The interviewed stakeholders from Agriculture Offices in Ethiopia mentioned that stunting reduction is not their responsibility, as they primarily focus on ensuring food availability and diversification. They believe that reducing child stunting is primarily a health sector issue under the purview of the Ministry of Health.58
Likewise, the interview results from key stakeholders in education and agricultural agencies in Uganda and Pakistan concluded that ‘nutrition and other nutrition-related issues, including stunting reduction, are the mandate of health agencies’.59 60 A similar misconception about stunting reduction (seen as solely the health sector’s responsibility) exists in Yogyakarta city, Central Java province, Indonesia. Research by Siswati et al 61 revealed that while most local government agencies and leaders in Yogyakarta have agreed to and conducted convergence actions for stunting reduction activities, many non-health sectors assume these activities are not their responsibility. As a result, a lack of coordination among involved actors hampers the effectiveness of the convergence action in the districts.61
Furthermore, the findings also indicated that many people in villages believe that child stunting is not related to nutrition inadequacy, but rather a genetic factor. This assumption is not unique to Aceh province and is similar to perceptions in rural areas of Tanzania.62 63 The assumption is that stunted children are not related to malnutrition and cannot be prevented by good nutrition, as their heights are thought to be dependent on their parents’ physical shapes (tall or short) and or God’s creation.62 64 Thus, it is believed that a child’s height cannot be improved by adequate nutrition and medical services.62 Rural communities in the Philippines also share similar assumptions, believing that stunting is genetic and passed down from ancestors, and thus, the prevalence of child stunting cannot be reduced or prevented through health interventions.65
In response to the aforementioned issues, the Aceh government, along with health agencies at the provincial and Pidie district levels, need to conduct more socialisation or public communication of the concepts of child stunting, its underlying causes and consequences and the importance of integrated actions between health and non-health institutions. This can be achieved through regular coordination meetings to reduce and prevent stunting in Aceh. Furthermore, at the community level, information can be disseminated through intensive and extensive health and non-health combination campaigns (eg, religious teachings) throughout Aceh province. By doing so, the correct information on child stunting (which is related to health issues), can be better/effectively communicated to the grassroots level and thus, amend the community’s misunderstanding of child stunting.
Moving to the other finding, it was noted that there is a limited capacity among local villagers to develop programme plans or convergence policies at the village level. Yet, the village plays a crucial role in implementing the policy at the community level, which is the most important operational level, as mandated by Presidential Regulation No. 72/2021. As a forefront convergence action policy implementer, the village is responsible for (1) developing planning and budgeting for convergence activities, (2) improving the quality of implementation and (3) improving monitoring, evaluation and reporting of convergence activities.31 In practice, these three mandated responsibilities are challenging for village stakeholders to fulfil, especially within the 10 focused villages, without the assistance of the Pidie District Health Agency through Puskesmas programmes. These programmes, such as the district stunting reduction acceleration programme and Posyandu (as mentioned previously), need to support the village VSRATs by providing public health experts, nutritionists and other relevant practitioners to all target villages. This is effective because some activities in the Puskesmas’ stunting reduction acceleration programme involve village stakeholders. The programme aligns with the village convergence actions for reducing stunting as outlined in Presidential Regulation No. 72/2021. The Buhit Community Health Centre (Puskesmas) in the Samosir district of North Sumatera province, Indonesia serves as a good example of assisting convergence actions of stunting reduction in villages via the stunting reduction programme held by the Puskesmas.66 Human resources involved in the programme (eg, medical doctors, the Puskesmas chief and nutrition programme staff) have been trained in the programme. The training also involved village midwives, Posyandu cadres, village chiefs and respected village figures.
Another identified finding related to implementing convergence policies at the district and village levels was a lack of coordination on convergence actions. The findings revealed a lack of coordination among health and non-health sectors: the DHO only plays a singular role (working in isolation) on nutrition-specific interventions, with no integration between nutrition-specific and nutrition-sensitive interventions being recorded. These findings mirror those in Odisha, India, where the health agency is heavily dominated in nutrition-specific interventions for stunting reduction programmes.67 The convergence actions are determined beyond the health agency’s responsibility, capability and authority. The interagency approach (especially involving non-health agencies) at the operational level is restricted by departmental silos in the field, as they must adhere to their own internal line ministries’ instructions and regulations from the central government.
The integration of intersectoral roles and responsibilities in nutrition-specific and nutrition-sensitive interventions (based on the analysis of the situation in the first action and programme plans in the second action) at the village level, including the 10 focused villages, needs to be clearly defined and described to avoid overlapping or ineffective work on the convergence action. Many programmes, with substantial funding aimed at stunting reduction, have yet to be converged from the ministerial to village levels. In this respect, support from higher local authorities (eg, provincial and central governments) with strong leadership and expert knowledge is required. Academics can play a more impartial and proportionate role in sharing and supporting capacities in the field.22
Thus, the existence of clear responsibilities among all involved actors in coordinating and collaborating their resources, leadership and governance (from central to local levels) to support nutrition-specific and nutrition-sensitive interventions has a strong positive impact on accelerating the reduction of stunting in many low- and middle-income countries.68 The developed strategies are conducted by providing sustainable food and nutrition, health services, adequate clean water and sanitation, health safety insurance and early childhood services.
Studies conducted in three countries (Guatemala, Bangladesh and Rwanda) have shown that good coordination and collaboration across multiple sectors have improved the impact of nutrition-specific and nutrition-sensitive interventions and reduced costs.69 Lowering costs can be attributed to decreasing redundant activities, as multisectoral partners can combine strengths by accessing resources, opportunities, skills and knowledge to jointly identify and solve problems.69 70
The other example of effective coordination and collaboration in reducing stunting (that the Aceh government and Pidie district need to learn) comes from the local governments of Pandeglang district, in West Java province, Indonesia.71 Through multisectoral collaboration and coordination with provincial and district authorities, the Village Ministry, Cipto Mangunkusumo General Hospital, School of Medicine at the University of Indonesia and Danone Corporation, they were able to share human and technical resources, knowledge and funding. This collaboration has successfully reduced the stunting prevalence rate to 8% within 6 months of interventions in Bayumunda village.71
However, learning from the experiences of other countries (eg, Peru, Thailand, Vietnam, Brazil, Papua New Guinea and Afghanistan), it has taken a long time to see the positive impact of implementing convergence policies on reducing stunting.72 73 For instance, at the beginning of the implementation of convergence actions in Afghanistan, interventions addressing nutrition-specific and nutrition-sensitive factors were not consistently applied at the community level. However, over time, the government’s political will and commitment to addressing these issues gradually grew.74
This study has various strengths. It is the first study carried out in Aceh that investigates the implementation outcome variables of district convergence policies for stunting prevention and reduction at the operational level. The study focused on the Pidie district, four subdistricts and 10 specific villages. It used in-depth interviews and document reviews. The findings from this study can facilitate further research on the barriers and opportunities for implementing the eight convergence actions for accelerating stunting reduction in Aceh.
Nonetheless, several limitations were identified in this study. Information gathered via in-depth interviews cannot be confirmed through written documents as it was not sufficiently reported and documented in formal government records. However, because this study involved many respondents from various government agencies at different levels, the various collected sources improved the quality of the study’s results. Furthermore, the findings of this study might not be generalised more broadly because participant selection for the interviews could greatly influence the findings. Hence, it is possible that the synthesis of the interviewees could have affected the generalisability of the findings.
Conclusions
The convergence action policies aimed at reducing stunting at the district and village levels have not been fully implemented. Findings from this study, gathered through in-depth interviews and document reviews, revealed that the policy’s implementation is generally acceptable and appropriate, with a focus on nutrition-specific interventions and consideration of implementation costs. Nevertheless, acceptability varies at the community level in the 10 focused villages due to inadequate knowledge and misconceptions about stunting and convergence actions. Additionally, implementation is suboptimal in terms of adoption and compliance, feasibility, nutrition-sensitive intervention coverage and sustainability aspects. This is largely due to inadequate coordination and collaboration between health and non-health sectors, as well as a lack of skilled personnel at the operational level in villages.
The findings and recommendations of this study can contribute to changing the policies and practices of Aceh government actors and other relevant stakeholders/agencies (eg, the governor, provincial and Pidie district secretariats, PHO, Pidie Regent, DHO, relevant non-health agencies and other involved private/public institutions) to improve the implementation of comprehensive convergence policies. This will accelerate stunting reduction and prevention in Pidie district and in other districts across the Aceh province.
Data availability statement
Data are available on reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
This study obtained ethical approval from the Aceh Health Polytechnics Human Research Ethics Committee (no. 14/GZ/KEP-Poltekkesaceh/2022). It was conducted in accordance with the ethical standards outlined in the 1964 Declaration of Helsinki and its subsequent amendments. The primary researcher used the Indonesian language to explain the data collection process to all interviewees, who were required to sign the informed consent sheet before participating in the study.
Acknowledgments
The first author would like to express sincere gratitude to all those who contributed to and were involved in this study.
References
Supplementary materials
Supplementary Data
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Footnotes
Contributors SS and II constructed and designed the study, conducted the interviews and analysis and prepared and wrote the manuscript. NN, MJ and RR conducted the interviews and data analysis. SIN, FS and SB assisted in the study design and analysis. SS and JAL wrote the manuscript, with JAL and FS reviewing the manuscript draft. SS, as the first author acts as the guarantor and holds full responsibility for the overall content of the manuscript, including data accessibility and the decision to publish.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.