Indonesia and Timor Leste Final

7/31/2019 Indonesia and Timor Leste Final

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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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SCN 6th World Nutrition Report

Underweight trends in Indonesia recently stalling

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4

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

Indonesia has a >0.5 probability

of meeting MDG 1 target

(underweight)


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5

Roemling and Qaim 2012. Obesity Trends, Determinants and Policy

Implications in Indonesia. International Agricultural Economics Association.

But in Indonesia underweight rates are clouded by increasing levels

of overweight and obesity, even in the presence of stunting

(adults)


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Indonesia: undernutrition rates of under fives (%)

Progress on stunting=MDG1 (stunting) by 2052

42.4 41.6

28.6

40.1

24.8 23.4

19.7 19.6

5.5 5.4

14.4 14.8

2000 2001 2002 2003 2004 2005 2006 2007

stunting underweight wasting

6

HKI Surveys

NHHS Survey

BHS Survey

WHO Global Database of Child Development and Growth

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)

About 10

million

under 5s

are

stunted


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Timor Leste: undernutrition rates of under fives (%)Possibly the highest stunting rates in the world,

Wasting rates also extremely high

55.7 54.857.7

40.641.5

45.3

13.7 14.318.9

2002 2003 2004 2005 2006 2007 2008 2009

stunting underweight wasting

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MICS Survey MoH SurveyDHS Survey

WHO Global Database of Child Development and Growth


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Number of countries where stunting rates are going up, down or

are unchanged (latest survey minus the previous one)

Region Totalnumber of

countries

Improving Nochange

Deteriorating

Africa 29 12 6 11

Asia 20 13 6 1

S. & Central America

and Caribbean

14 6 7 1

Total 63 31 19 13

SCN 6th World Nutrition Report. 2011 8


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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 9

Impact of stunting at 36 months on multiple outcomes over the

life course of an individual up to middle adulthood


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Is there Complete, Partial, or No Recovery from Childhood Malnutrition?

Empirical Evidence from Indonesia. Subha Mani. October 8, 2008

In the absence of any catch-up, by adolescence, amalnourished 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.

Impact of Infant Undernutrition

on Indonesian Children


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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 diabetesand 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)

Undernutrition and Overnutrition

are physiologically linked


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12Save the Children UK. 2012. A Life Free from Hunger.

Indonesia is a stunting

underperformer relative

to GDP


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Income growth is not large enough to drive

down nutrition status on its own


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

World Bank.

Poverty Declines are Slowing


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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.

Inequality is relatively high and not declining


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Health Sector Decentralization And Indonesias Nutrition Programs: Opportunities And

Challenges Jed Friedman, Fadia Saadah, Yoonjoung Choi. January 20, 2006. World Bank

Cause for

Optimism that

something can

be done

Great variation

in underweight

rates at similarpoverty levels,

by district


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DirectNutrition

Interventions

Agriculture

Focus onpoverty

reduction,

Gender

Social

Protection

Focus on

health

conditionalities

Womens

empowermentBalance of

upstream and

downstream

empowermentWater and

Sanitation

Focus on

nutrition status

outcomes

Health systems

View nutrition as

lower in

hierarchyembeddirect nutrition

programmes

Education

Keep girls in

secondary

school to delay

age at firstpregnancy

Driven by:Leadership,

Ideas,

Institutions,

Incentives

Effective nutrition

action requires

coherence and critical

massfrom all sectors


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18

Gillespie and Haddad 2001 Attacking the Double Burden of

Malnutrition in Asia and the Pacific. ADB/UNICEF

Country

Groupings to

Guide NutritionStrategy


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Timor Leste

For Direct Interventions We Need to Know About Coverage

DHS Report 2010-11


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Indirect Interventions: Relative contribution (%) to the

decline in child stunting between 1996 and 2007 in Brazil

Income

22,5%

Maternal

Schooling 24,6%

Health

Care

10,4%

Other Factors

36,7%

Source: Monteiro et al (2009). Causes for the decline in child

undernutrition in Brazil, 1996-2007. Revi Sade Pb, 43 (1): 35-43.

What would

this look like

for

Indonesia?


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Indirect Interventions:

Spending on Health, Social Assistance and

Agriculture sum to


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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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Spending on Household Social

Assistance is Relatively Low

Latin America = 1.3

% of GDP,

East Asia average =

1% of GDP

Indonesia = 0.5%Protecting Poor and Vulnerable Households in



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Potential Impact of PKH on Nutrition is

High, but

Protecting Poor and Vulnerable Households in



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Phk Cct: Social Assistance Program And Public Expenditure

Review 6. World Bank 2012

No evidence to

date of impact

on nutrition

status


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Indonesia: Relatively High Levels of

UNDPs Gender Inequality Index (GII)

4348

96 99100

GII Rank 2011

26UNDP Human Development Report 2011

0.352

0.581

0.305

0.549

0.286

0.505

Malaysia Indonesia

1995 2005 2011

19%

improvement

13%

improvement


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27Source: Smith, Haddad et. al. 2003, IFPRI Research Report 131

What is

this effect

for

Indonesia?

Effect of womens decision making power on underweight rates,

Sub Saharan African countries


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World Health Organization and United Nations Childrens Fund Joint Monitoring Programme

(JMP) for Water Supply and Sanitation. Coverage estimates for 2010.

Rural

Sanitation

is Lagging

Indonesia: water and sanitation coverage to 2010 and

projections to 2015

( )


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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.

Indonesia: growth (%) in Total Factor Productivity in

agriculture is lagging


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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

MoA Budgetis Increasing


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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.

Agric

growth

Industrial

growth

Services

growth

Services

growth

Industrial

growthAgric

growth

Growth in Indonesian agriculture would have the

biggest impact on poverty rates (urban and rural)


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Opportunities for AusAID to meet strategic goals

Saving Lives Promoting

opportunities

for all

Sustainable

economic

development

Effective

governance

Humanitarian

and disaster

response

Prevention of

under-

nutrition..

saves 30% of

deaths of

childrenunder 5

Prevention of

under-

nutrition..

increases

grade

attainment byone standard

deviation

Prevention of

under-

nutrition..

results in

a 34% lower

chance of theadult living in

poverty

NCD links

Because of

invisibility and

need to work

across sectors ..

need to

innovate on

accountabilityand

commitment is

high

Rapid response

required in first

1000 days..

means

attention to

prevention andreal time

monitoring

Which aid donors are committed to reducing hunger?


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Which aid donors are committed to reducing hunger?Country Government

expenditure rankPolicies and

programmes rankHunger ReductionCommitment Index

(1 is best)

Denmark 3 4 1

Finland 6 9 2Belgium 9 7 3Ireland 5 11 3Norway 2 15 5France 11 6 5United Kingdom 14 3 5Australia 16 2 8Netherlands 10 8 8Spain 4 14 8Germany 12 10 11South Korea 23 1 12Japan 8 17 13Canada 13 13 14

Greece 21 5 14Sweden 7 19 14Italy 22 12 17USA 18 18 18

Austria 20 16 18Switzerland 15 22 20New Zealand 17 20 20

Source: IDS at hrcindex.org33

Ch i D S di i B i N i i 2003 08


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Source: OECD-CRS online database.Accessed December 2010

-100%-100%

-99%

-92%

-83%

-81%

-79%

-74%

-35%

-31%-6%

17%

26%

37%

72%

135%

279%

338%

418%462%

623%

815%

44726%

-100% -50% 0% 50% 100%

AustriaIFAD

Japan

Netherlands

Italy

Australia

United States

Finland

Portugal

DenmarkSweden

Norway

IDA

UNICEF

Germany

EU Institutions

Belgium

Ireland

United KingdomSpain

New Zealand

Canada

France

% change between 2000-03 and 2005-08

Figure 4.5: % change in basic nutrition aid over 2000-03 and 2005-08

Nutrition Advocacy Landscaping in Europe: An Analysis of donor

commitments. February 2011. Daniel Coppard, Asma. Devint.

Changes in Donor Spending in Basic Nutrition: 2003-08

UP: France, Canada, NZ,Spain, UK, Ireland,

Belgium, EU, Germany,

UNICEF, IDA, Norway

DOWN: Austria, IFAD,

Japan, Netherlands, Italy,

Australia, USA, Poland,

Portugal, Denmark,

Sweden

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

Most nutritionresources are for

Indirect Interventions

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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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Documents

Indonesia and Timor Leste Final