Analysis of Government Policy in Reducing Stunting Rate at Aceh Jaya, Indonesia

: Today, the issue of nutrition has become the primary challenge faced by many countries due to the increase in individuals experiencing malnutrition (undernourished) in the past three years, including Indonesia. In Indonesia, one district, namely Aceh Jaya, has a high stunting percentage of 35.7 percent. The importance of political commitment and policies that support stunting alleviation underlies this research. The general objective of the current study is to analyse government policies' suitability for stunting reduction and prevention in Aceh Jaya District. The research uses a qualitative descriptive method through content analysis of information contained in national and regional policy documents related to stunting reduction and prevention efforts. Quantitative analysis was conducted to determine the relationship between program coverage and stunting prevalence in Aceh Jaya District. Aceh Jaya District's policies follow national policies; however, several improvements are needed, including a) determination of strategic issues, policy directions, and strategies in development planning; b) setting program targets, and c) implementation of several sensitive and specific nutrition interventions that have not yet been implemented. This study concludes that the government's commitment to stunting reduction efforts has increased after declaring its participation in The SUN Movement. Stunting policy shows the coherence between policies to increase access to cross-sectoral coordination as indicated by efforts to deal with stunting. Acceleration of stunting reduction to converge programs consisting of specific and sensitive nutrition interventions. Aceh Jaya Regency's commitment to reducing stunting has increased and it already has programs and activities related to sensitive and specific nutrition interventions. It has formed a stunting consultation task force.


Introduction
Reducing nutritional problems is still a challenge faced by all countries worldwide. Data from FAO, IFAD, UNICEF, WFP and WHO (2018) shows an increase in individuals experiencing malnutrition (undernourished) problems in the past three years, from 784.4 million people in 2015 to 820.8 million people in 2017 (World Health Organization, 2018, 2019. Data from World Bank (2019) also shows data worldwide in 2018 of 21.9% or ±149 million children aged 0-59 months classified as stunting, 7.3% or 49 million children aged 0-59 months classified as underweight, and 5.9% or around 40 million children aged 0-59 months are classified as overweight (Park, 2019;World Health Organization, 2021). The Development Initiative (2018) estimates that around 88% of countries in the world face nutritional problems such as stunting, anaemia in women of childbearing age, and obesity or overweight in adults) (Li et al., 2020;Poverty & Initiative, 2018). Indonesia is one of 26 countries in the world, or six in Southeast Asia (Cambodia, Laos, Myanmar, Vietnam, and Timor-Leste), that face two major nutritional problems (Fanzo et al., 2019;Rachmi et al., 2016;Titaley et al., 2019). Nutritional problems will negatively impact the health status and quality of life of millions of Indonesians because not achieving good nutritional status will impact poor health quality. The stunting rate in children under the age of 5 years in Indonesia is 27.7%. The prevalence of stunting has decreased from the previous year. The National Medium-Term Development Plan (RPJMN) 2020-2024 aims to reduce the prevalence of stunting to 14% (Labolo, 2021;Listyaningsih et al., 2021;Siscawati et al., 2020).
On the basis of the report of the Indonesian Nutrition Status Study (SSGI), in 2021, in Aceh Province, on average there were 33.2% of children under five years old (toddlers) experience stunting. It means that approximately 1 in 3 children under five in Aceh Province has a height below the average child of his age. Aceh Jaya district is one of 100 priority districts/cities for stunting interventions with 10 villages (locus). The results of the 2017 PSG show the prevalence of stunting in Aceh Jaya is 33.7%. This figure is higher than the prevalence of stunting in Aceh (33.2%) and the national prevalence (29%) (Nasir & Jasmi, 2022). Meanwhile, policies and programs should help make nutrition a priority (Bryce et al., 2008). Stunting prevention and control are a mandatory basic service affair. Article 16 stipulates that the formulation of regional policies by regional governments must be guided by the norms, standards, procedures, and standards set by the central government. Supporting stunting prevention policy commitments underlies this research, which aims to analyse government policies related to stunting reduction in the Aceh Jaya region.

Materials and Methods
This study uses a quantitative descriptive approach to determine the relationship between program coverage and stunting rates in the Aceh Jaya region. The unit of analysis in this study is one district, namely Aceh Jaya Regency, by analysing district-level policies and program coverage related to stunting prevention efforts in every village in Aceh Regency. The research was conducted in Aceh Jaya Regency from December 2021 to April 2022. The informants selected as resource persons in this study were chosen through purposeful sampling from agencies related to stunting prevention. Respondents interviewed included the Deputy Regent, Regional Secretary, Regional Assistant, Head of the Health Service, Head of the Regional Planning and Development Agency, Head of Public Health Centre and nutritionist at each Puskesmas in Aceh Jaya District. Data analysis was carried out qualitatively with content analysis on regional policy documents related to stunting prevention efforts. Content analysis in this study is used to identify and analyse policy suitability and compare the completeness of regional policies with policies to reduce stunting prevalence. The policy in the planning document (RPJM) analysed is strategic issues, mission, goals, objectives, targets, policy directions, and strategies.  (3) villages with the highest number of stunting sufferers in Aceh Jaya Regency, namely the Indra Jaya Puskesmas working area village, the Panga health centre area village and Darul Hikmah village in the Patek Puskesmas work area. Based on data from the Aceh Jaya Regency Health Office in 2019, the number of stunting toddlers in the Indra Jaya health centre area is 149 (23.1). The Panga health centre area is 118 toddlers (17.4), and the Patek health centre area is 70 toddlers (12.0).  (2019) Further, this study reports the result of stunting rate prevalence in 2020. The result as seen in Table 2 below: Source: Aceh Jaya Health Office in 2020 Table 2 shows three (3) villages with the highest number of stunting sufferers in Aceh Jaya Regency, namely the Pasie Raya puskesmas work area village, the Lamno puskesmas work area village and the Teunom puskesmas work area village. Based on data from the Aceh Jaya Regency Health Office in 2020, the number of stunting toddlers in the Pasie Raya health centre area is 222 (46.2). The Lamno health centre area is 211 toddlers (18.9), and the Teunom health centre area is 207 toddlers (32.8).  (3) villages with the highest number of stunting sufferers in Aceh Jaya Regency, namely the Teunom puskesmas work area village, the Pasie Raya health centre area village and the Krueng Sabee health centre area village. Based on data from the Aceh Jaya Regency Health Office in 2021, the number of stunting toddlers in the Teunom health centre area is 292 toddlers (23.2), the Pasie Raya health centre area is 217 toddlers (31.6), the Krueng Sabee health centre area is 183 toddlers (40.0).

Trend of Stunting Cases in Aceh Jaya
The stunting prevention programs carried out by the health centre include Supplementary Food Provision (PMT), Village Nutrition Center (RGG), and Infant and Child Feeding Counseling (PMBA), such as father counselling, mother counselling, toddler counselling, and breastfeeding counselling. The KruengSabee Health Center has only two stunting prevention programs: Supplementary Feeding (PMT) and Infant and Child Feeding (PMBA). Calang Health Center stunting prevention programs that are run are Infant and Child Feeding (PMBA), Village Nutrition Rumoh (RGG), and Supplementary Food Provision (PMT). Their Lageun Health Center runs a program of Supplementary Feeding (PMT) and Infant and Child Feeding (PMBA), Rumoh Gizi Gampong (RGG). The information obtained from each nutritionist showed that the Krueng Sabee Health Center experienced more stunting reductions than the Lageun Health Center and Calang Health Center.

National Policy Related to Stunting
With the end of the MDGs (Millennium Development Goals) and the replacement of the SDGs (Sustainable Development Goals), the focus of overcoming nutrition is not only hunger and malnutrition but also chronic nutrition, known as stunting. The prevalence of stunting in Indonesia was 36.  (2016-2021) is to reduce the prevalence of stunting in children under five from the previous 40% (Fracassi et al., 2020), (Lie, 2021). This figure is included in the high category (above 20%), indicating chronic nutritional problems (Nisa, 2018). The Indonesian government is committed to solving nutritional problems by joining Scaling-Up Nutrition (SUN). Indonesia's participation was followed up by the issuance of Presidential Regulation No. 42 of 2013 concerning the National Movement for the Acceleration of Nutrition Improvement in the 1000 HPK Framework after publishing the 1000 HPK Policy Framework and the 1000 HPK Movement Program Planning Guidelines in 2012. Indonesia's involvement is important to facilitate access to funding, government awareness, cooperation, and research (Kampman et al., 2017). Indonesia's development mission for the 2015-2019 period is to realize a high, advanced, and prosperous quality of life for Indonesian people." Improving the health of mothers, children, adolescents, and the elderly, as well as accelerating the improvement of community nutrition are strategic issues in the health and nutrition sector in the 2015-2019 RPJMN.
Based on these strategic issues, the government has set a development target in the nutrition sector to improve the nutritional status of the community. One of the indicators of success is the stunting prevalence, which is targeted to decrease to 28% by 2019. Since 2015, the central government has established a Strategic Policy, especially the Food Security Council. Food and Nutrition (KSPG) 2015-2019. Government Regulation Number 83 of 2017 concerning Strategic Food and Nutrition Policy is a strategic policy of the government in food and nutrition development to improve the quality and power of human resources. The strategic policy covers five areas: food availability, affordability, utilisation, community nutrition, and strengthening of food and nutrition institutions. The government focuses on changing consumption patterns to be nutritious, balanced and safe. Nutrition improvement is prioritized for the target of 1000 HPK, young women, and other nutritionally vulnerable groups. In addition, strategic policies are also directed at strengthening food and nutrition institutions at both the national and regional levels.
Regulation of the Minister of National Development Planning/Head of Bappenas RI Number 1 of 2018 concerning the Food and Nutrition Action Plan confirms that the Food and Nutrition Action Plan is a guideline for coordinating and working together to achieve the interests of both government and non-government. It is in line with Presidential Regulation 42 of 2013 concerning the National Movement for the Acceleration of Nutrition Improvement, which focuses on the 1000 HPK target and involves multi-sectors. A multi-sectoral approach is very important in stunting because specific nutrition interventions (health sector interventions) contribute only 30%. The other 70% are supported by sectors outside the health sector or sensitive nutrition interventions that target the underlying causes of stunting. Increased access to nutritious • underprivileged access to non-cash food assistance (BPNT) for families • Access fortification of main food ingredients (salt, wheat flour, oil) fried) Table 4 represents the sensitive nutrition interventions that the Indonesian government has launched. The Indonesian government has made many changes to improve nutrition, especially stunting. In addition, the government has developed and established an intervention strategy and a special team to tackle stunting. The 2018 Riskesdas results show that the prevalence of stunting decreased by 6.4% to 30.8% in 2018, according to 2018 Riskesdas data (Balitbangkes Kemenkes Republik Indonesia, 2018). It reflects the government's commitment, a supportive policy environment, and cross-sectoral coordination, which is important to prevent and control nutritional problems, particularly stunts.

The Aceh Jaya District Government's Policy Regarding Stunting
The COVID-19 pandemic has impacted human development in Aceh Jaya District. It can be seen from the slowdown in the Human Development Index (HDI) growth in 2020 compared to previous years. Aceh Jaya's HDI in 2020 was 69.75, or it grew 0.01 percent (an increase of 0.01 points) compared to the previous year's achievement. The decline strongly influenced the slowdown in Aceh Jaya's HDI growth in 2020 in the adjusted average per capita expenditure. Aceh Jaya District already has several policies, programs and activities to alleviate health and nutrition problems.  Table 5 describes the policies and programs/activities in the health and nutrition sector already in the RPJMD. The specific nutrition intervention program already owned by Aceh Jaya district is still focused on the Maternal Mortality Rate, Under-five Mortality Rate, and handling of malnutrition. Local governments have also launched programs related to sensitive nutrition interventions in outline consisting of 1) the provision of clean water, drinking water, and sanitation facilities; 2) Program for family control, family planning, and empowerment of women and children; 3) environmental sanitation; 4) promotion of healthy and clean lifestyle; 5) fostering PKH beneficiary families (KPM); 6) provision of health insurance for the community, and 7) increasing food security and diversity. The Aceh Jaya regional government made various efforts to improve policies, programs and activities. The local government's awareness has begun to be shown by holding a Stunting Conference and is committed to forming a Food and Nutrition Awareness Task Force Team, which the Deputy Regent of Aceh Jaya chairs with Bappeda and the Health Service as the leading sector. The main function of the Food and Nutrition Awareness Team in Handling Stunting is to coordinate activities and various programs related to stunting alleviation by various sectors.
Coordination in stunting reduction and prevention efforts is very important to converge programs between sectors so that the interventions can be effective and on target. The local government also included stunting as a strategic issue in the 3rd quarter by stipulating the 2018 RKPD Amendment. The innovation of local government policies in stunting prevention is to focus on sensitive interventions, particularly the provision of clean water, drinking water, and sanitation improvements (providing latrines) in villages that become the locus of stunting as determined by the central government.
Handling malnutrition is part of individual health and public health programs in the 2017-2022 RPJMD and activities to reduce MMR/IMR and control under-fives with malnutrition as well as primary health services and referrals in the Renstra of the District Health Office Aceh Jaya 2017-2022. The target indicator set is the number of malnourished children under five receiving treatment, with a target of 100% in 2018. Aceh Jaya District already has programs and activities related to efforts to alleviate nutritional problems but has not specifically targeted stunting alleviation. The health development policy in Aceh Jaya Regency is still too broad, with the development target set to increase access and health services.

The direction of the Stunting Policy and Strategy
Stunting policy and strategy became a concern for the Aceh Jaya District government in the second year of RPJMD implementation after the announcement of the 100 Priority Districts/Cities for Stunting Intervention. The issue of stunting began to be included in local government policy documents in the 2018 RPKD changes. Stunting became one of the indicators of increasing the Health Index to increase HDI. Before it was announced that Aceh Jaya District was one of the priority districts, the target of aid programs was still focused on the poor registered in the UDB (Integrated Database). The database contains poor people managed by the Social Service under the Ministry of Social policy to determine the target of social assistance in poverty alleviation efforts. Program targets began to be directed at low-income families and have family members included in the 1000 HPK target, especially those registered with the UDB, to prevent and combat stunting. The results of the interviews indicate that the Aceh Jaya District government is still trying to coordinate related data slices between the poor and stunting (see Table 6). The decrease in helminthiasis Aceh Jaya Regency has not been much to have specific intervention programs and activities for priority and important targets listed in regional policy documents. Programs and activities in regional policy documents include antenatal care and management of acute malnutrition. Pregnancy check-ups in Aceh Jaya District are included in the efforts to reduce the MMR/IMR and prevent under-five malnutrition, as well as primary health services for children and referrals in the Health Office Strategic Plan 2017-2022. At the national level, antenatal care is part of developing maternal and reproductive health services. Standards for pregnancy examination activities are regulated by the Minister of Health of the Republic of Indonesia No. 97 of 2014 concerning Health Services for the Period Before Pregnancy, Pregnancy, Childbirth, and the Period After Childbirth, Implementation of Contraception, and Sexual Health Services, the second part is Health Services for Pregnancy. The provisions for prenatal care are set at least four times, namely 1 (one) time in the first trimester, 1 (one) time in the second trimester, and 2 (two) times in the third trimester.
There are several programs and activities carried out in the Aceh Jaya district. Still, they have not been included in the policy document because they are mandatory programs from the central government, so local governments only facilitate the implementation of these programs and activities. These programs and activities include providing additional food for pregnant women from the poor group, calcium supplementation for pregnant women, blood-supplementation tablet (TTD) supplementation for pregnant women and young women, vitamin A supplementation, promotion and counselling on breastfeeding, promotion and counselling on feeding. Infants and Children (IPM), growth monitoring, taburia supplementation, zinc supplementation for the treatment of diarrhea, IMCI, immunization, and decreased helminthiasis. Provision of food for pregnant women with SEZ and underweight toddlers is regulated in (Nisa, 2018) concerning Efforts to Improve Nutrition in Part Three, namely Nutritional Supplementation, and disseminated through the Circular Letter of the Director General of Public Health Number: HK.02.02/V/407/2017 concerning the Provision of Nutritional Supplementation for Pregnant Women, PMT for Toddlers, and PMT for School Children.
Supplementary food for pregnant women is given in the form of layered biscuits made with a special formula and fortified to meet the nutritional needs of pregnant women, especially mothers who experience SEZ (Renyoet et al., 2016). This intervention has been implemented by the local government of Aceh Jaya Regency and is the responsibility of the Public Health Sector of Health. Supplementary food for pregnant women is distributed through Posyandu and given to pregnant women during pregnancy check-ups. The policy of giving blood tablets is a mandatory program from the central government regulated in RPJMN 2015-2019, RAN-PG 2017-2019and (Listyaningrum, 2014 concerning Standards for Blood Added Tablets for Women of Childbearing Age and Pregnant Women. Based on the interview results, Aceh Jaya District does not yet have a special budget for young women because the existing budget is still focused on pregnant women, so it is insufficient for the target of young women. Vitamin A supplementation is regulated in (Nisa, 2018)  The implementation of immunization is regulated by the Minister of Health of the Republic of Indonesia No. 12 of 2017. Immunization is divided into three types, namely routine immunization, additional immunization, and special immunization. Immunization for toddlers is included in routine immunization, which is divided into basic immunization and advanced immunization. Basic immunization consists of hepatitis B, poliomyelitis, tuberculosis, diphtheria, pertussis, tetanus, pneumonia and meningitis, and measles. Complete Basic Immunization in Aceh Jaya District is the responsibility of the Health Office. Calcium supplementation for pregnant women is an activity listed in the Pocket Book of Maternal Health Services at Primary and Referral Health Facilities. Calcium supplementation in areas with low calcium intake, as much as 1.5-2g/day, is recommended to reduce preeclampsia for all pregnant women, especially those at high risk (Suryanegara & Reviani, 2020).
The standard for calcium supplementation is stipulated in the Indonesian Minister of Health Regulation No. 51 concerning Nutritional Supplementation Product Standards. Calcium supplementation is an effort to prevent preeclampsia for pregnant women, especially women with high risk. Aceh Jaya District does not have a specific program related to this intervention. Malaria reduction is included in disease control and environmental health programs. The target set at the national level is the number of districts/cities with malaria elimination, as many as 285 cities/districts. Aceh Jaya district does not have a specific program for malaria reduction. District BPS data. Aceh Jaya shows no malaria incidence in the Aceh Jaya district from 2012 to 2015 (Abidin et al., 2018). Aceh Jaya district 2018 figures also show the same thing. Research in Ethiopia showed that malaria is a risk factor for stunting and wasting, but not vice versa (Gari et al., 2018). Breastfeeding promotion and counselling are regulated in Government Regulation of the Republic of Indonesia No. 33 of 2012 concerning Exclusive Breastfeeding Part Four, namely information and education Article 13. Research by (Bryce et al., 2008) showed that breastfeeding promotion had little effect on stunting. Aceh Jaya District has carried out this activity in conjunction with Posyandu, but in practice, counselling and counselling are not carried out intensely.
In addition, Posyandu cadres' capacity to provide counselling is still lacking, so the midwife conveys information about exclusive breastfeeding. IDM Promotion and Counselling (Infant and Child Feeding) is a guide created by MCA-USA in collaboration with the Directorate General of Nutrition and Community Development, Ministry of Health. Aceh Jaya District has carried out outreach activities related to PMBA funded by the Health Operational Assistance and the Special Allocation Fund. Growth monitoring programs and activities have been carried out routinely at Posyandu, but there is no written specific policy related to growth monitoring. MTBS (Integrated Management of Sick Toddlers) is an infant and child health service that involves the community. The IMCI program is regulated in Permenkes No. 70 of 2013 concerning implementing Integrated Management of Sick Toddlers. IMCI started from an integrated service package developed by (United Nations International Children's Emergency Fund, 2000), Integrated Management of Childhood Illness (IMCI). Aceh Jaya District does not yet have a specific policy regarding IMCI but in practice. In addition to specific nutrition interventions, sensitive nutrition interventions are also provided by the central and local governments.

Conclusions
In conclusion, this study indicates that the government's commitment to stunting reduction efforts has increased after declaring its participation in The SUN Movement. This commitment is demonstrated by issuing Presidential Decree No. 42 of 2013, KSPG, and RANPG. The existence of stunting in policy documents shows the existence of coherence between policies to increase access to cross-sectoral coordination, as indicated by efforts to deal with stunting. Acceleration of Stunting Reduction to converge stunting reduction programs consisting of specific and sensitive nutrition interventions. Aceh Jaya Regency's commitment to reducing stunting has increased since it was declared included in the 100 Priority Districts/Cities for Stunting Interventions. Aceh Jaya District already has programs and activities related to sensitive and specific nutrition interventions and has formed a stunting consultation task force. Aceh Jaya District still does not have a Food and Nutrition Action Plan, which will begin to be made in 2019. The Aceh Jaya District policies are following national policies, but some improvements need to be made, including a) determination of strategic issues, policy directions, and strategies in planning development; b) setting program targets; and c) implementation of several sensitive and specific nutrition interventions that have not yet been implemented. Specific intervention policies/programs/activities already exist in the Aceh Jaya District policy document, including pregnancy check-ups and handling of malnutrition and undernutrition. Blood (TTD) for pregnant women and adolescent girls, vitamin A supplementation, immunization, and reduction of helminthiasis. Programs and activities already exist in Aceh Jaya District policy documents following national policies. It includes increasing access to drinking water and proper sanitation, health promotion, family planning services, JKN, PKH, PAUD, parenting counselling for parents, counselling adolescent health and reproduction, as well as women's empowerment and child protection.