Milwan
| Amud Sunarya*
© 2023 IIETA. This article is published by IIETA and is licensed under the CC BY 4.0 license (http://creativecommons.org/licenses/by/4.0/).
OPEN ACCESS
This review examines the implementation of stunting reduction policies in Indonesia, focusing on the Edward III policy implementation model. We analyze secondary data using qualitative methods to understand the effectiveness of various programs such as the 2018-2024 National Strategy to Accelerate Stunting Prevention, the 1000 Nutrition Week Program, and the Supplemental Feeding Program. However, we find that these efforts have not yet achieved their targets due to four key factors: 1) inadequate communication and coordination, 2) insufficient resources, both human and financial, 3) lack of support from local governments, and 4) absence of regional Standard Operational Procedures for policy implementation. We recommend enhancing the National Strategy for the Acceleration of Stunting Prevention 2018-2024, boosting promotion and training on breastfeeding, and addressing delays in disbursing Health Operational Assistance funds. Moreover, improving human resource management and program effectiveness measurement are crucial. Increased supervision of existing programs will also accelerate stunting reduction.
policy implementation, stunting reduction, nutrition
Since Indonesia became independent 77 years ago from colonialism, but in this nation in 2021 there are still 24.4% of children who are stunted [1]. According to the World Health Organization (WHO), stunting is a developmental disorder in children caused by malnutrition, repeated infections, and inadequate psychosocial stimulation. A child is defined as stunted if his height for his age is more than two standard deviations, under the WHO Child Growth Standards [2]. Meanwhile, stunting prevention policies in Indonesia have been stipulated in several regulations, such as Law Number 36 of 2009 [3] which has been amended by Law Number 11 of 2020 [4] concerning Health which contains articles 141, 142, and 143. The law states that improving nutrition is directed at consuming balanced nutrition, increasing awareness of nutritional behavior, physical activity, and health, increasing access to nutrition and quality services, improving the food and nutrition control system, as well as cooperation between the government and the community to ensure food availability. Presidential Regulation Number 72 of 2021 [5] on the Acceleration of Stunting Reduction, where through this Presidential Regulation stunting is defined as delays in growth and development that occur in children due to chronic malnutrition and frequent infections. This is indicated by the height or length of the body which is lower than the standard set by the minister responsible for the health sector. Stunting is a growing condition that is not optimal for toddlers. Malnutrition during the First 1000 Days of Life (HPK) is one of the contributing factors in linking local institution for sustainability policy [6].
According to data from the 2021 Indonesian Nutritional Status Study, there are still 24.4% of Indonesian children suffer from stunting. This means that one in every four children is stunted [7]. There are 7 provinces with the highest stunting rates, including NTT, West Sulawesi, Southeast Sulawesi, West Kalimantan, South Kalimantan, NTB, and Aceh [8]. West Java, East Java, Central Java, North Sumatra, and Banten are the five provinces where the greatest proportion of children are stunted [9]. In addition, according to Aryastami and Tarigan [10], stunting is a persistent nutritional issue that affects the following generation and is brought on by a variety of reasons. In Indonesia, there is a wrong assumption that short growth is a hereditary factor [11]. While the study shows that heredity contributes only 15%, while the main elements are inadequate nutritional intake, growth hormones, and frequent infections [12]. The results of this study are in line with the opinion of the Indonesian Pediatrician Association (IDAI) which states that there are two causes of stunting in Indonesia, namely environmental and genetic factors. The environment is an important aspect that can still be intervened so that short stature or stunting can be overcome. Environmental factors that play a role in causing short stature include the nutritional status of the mother, feeding patterns for children, environmental hygiene, and the incidence of infection in children. Besides being caused by the environment, stunting can be caused by genetic and hormonal factors. However, most stunting is caused by malnutrition [1]. Previous studies related to the implementation of policies to accelerate the reduction of stunting in Indonesia. The resulting findings have different views, some of the differences or gaps in the intended research results can be shown in Table 1 below:
Table 1. Research gap on policy implementation to accelerate stunting reduction in Indonesia
|
Researcher |
Findings |
Research Gap |
|
The successful implementation of policies to accelerate the reduction of stunting in Indonesia. |
There are differences in the results of research on the implementation of policies to accelerate the reduction of stunting in Indonesia. |
|
The implementation of policies to accelerate the reduction of stunting in Indonesia has not been successful. |
Table 1 shows the findings that differ from one researcher to another. Prahastuti [13] Shows that public-private partnership initiatives include cooperation between the government and the private sector to overcome stunting, where companies can contribute through financial assistance, products, or goods, as well as services or services that are appropriate to their business sector. Then Arhatiani and Zulham [14] shows that overall, the participation rate for fish consumption in the Special Capital Region (DKI) Jakarta reaches 76.69%, while fish consumption per person is around 29.37 kg per year. The Thousand Islands recorded the highest percentage of participation in fish consumption, namely 98.73%, while the lowest participation rate was recorded in the Central Jakarta area, namely 58.29%. Meanwhile, the research by Khoeroh et al. [15] shows that to achieve a reduction in stunting rates in children, the implementation of the Pregnant Women's Health Program needs to be closely monitored. Signs of the program's success include the high percentage of pregnant women visiting for Atenatal Care (ANC) examinations in the first quarter 95%, and visits in the fourth quarter reaching 83.5%. In addition, exclusive breastfeeding (ASI) programs in 2015 reached 86.8%, while supplementary feeding programs related to reducing stunting rates reached 76.8% and receiving supplementary feeding (PMT). The distribution of vitamin A in infants also reached high figures, namely 98.77% in February and 100% in August. These results confirm that the level of engagement and oversight of the implementation of programs to reduce stunting cases are important and helpful factors in doing so when the public and private sectors work together.
Meanwhile, research from Sari and Yusran [16] shows that the implementation of stunting prevention interventions in Nagari Pulakek Kota Baru Solok is not by government programs stipulated in Permenkes RI No.14 of 2019. This can be seen from the lack of optimal nutrition surveillance programs, lack of community participation, mothers' knowledge is still low, and the lack of support from the local government. Even though 163 children under five were found in August 2019, of which 13 of them were stunted with a stunting percentage of 8.0% based on the Height Based Age (TB/A) index, no significant impact was found. In the period from January to December 2020, 129 children under five were found, of which 37 were stunted with a stunting percentage of 28.7%. Then research from Febrian and Yusran [17] shows that the implementation of the stunting prevention program in the city of Padang currently only includes the general information and coordination stage. There is no cross-sectoral coordination that focuses more on stunting issues and only involves the puskesmas team, urban village officials, and nutrition officers in the program. This is due to the absence of clear regulations. In addition, research from Hermina [18] shows that out of a total of 830 toddlers studied in the implementation of PMT in 11 provinces, 28 districts/cities, and 56 health centers in Indonesia, 33.2% of these toddlers managed to spend PMT given to them, while the rest is not eaten. In terms of PMT for pregnant women, out of 468 pregnant women studied, 48.1% managed to finish the PMT they had been given, while the rest did not finish eating it. Meanwhile, research from Rahmawati et al. [19] showed that the descriptive statistical data in the study indicated that the prevalence of nutritional problems in pregnant, lactating women, infants, and toddlers was included in the high category. These findings confirm that there is a need for improvement in terms of the nutrition surveillance program, the level of community participation, mothers' knowledge that is still low, support from the local government, cross-sectoral coordination, and monitoring the implementation of the PMT. To build a powerful synergy for stunting prevention in the community, it may be inferred that cross-sectoral cooperation between the government, the business sector, and the community needs to be enhanced. To ensure that the stunting reduction program operates as expected, oversight of its implementation needs to be increased. So that there are no stunting prevention programs that are not running well anymore [20]. Thus, cases of stunting can be minimized and prevented as expected. To minimize stunting instances in Indonesia, it is also required to carry out proper monitoring, assessment, and action. This will help to remove barriers to the stunting program and boost its effectiveness. From the legal regulations, presidential policies, and the opinions of the experts above, it can be seen that there is a focus on preventing stunting in Indonesia, but the implementation is still not effective.
This affects the stunting rate which is not stable from year to year. To strengthen efforts to prevent stunting in Indonesia, a national plan for the acceleration of Stunting was released by the government in 2018. One of the focuses of this strategy is coordinating the participation of various sectors to accelerate the reduction of stunting [21]. The main reason for the delay in implementing stunting prevention in Indonesia is the lack of optimal coordination between government agencies [22]. Coordination between government agencies is an important strategy for achieving goals because stunting is influenced by several factors. Participation from various sectors, such as health, food, education, clean water, and sanitation, as well as social security, is urgently needed [21]. According to the results of the Ministry of Health's Indonesian Nutritional Status Study (SSGI), as many as 24.4% of toddlers in Indonesia will experience stunting in 2021. Therefore, almost half of the toddlers in the country were stunted last year. Nonetheless, this figure was lower than the previous year [7]. In 2020, the number of toddlers experiencing stunting is 26.92%. The trend is that the prevalence of stunting reached 37.2% in 2013 and 30.8% in 2018, but has tended to decrease in recent years. The government aims to reduce the prevalence of stunting below 14% in 2024, with a target of reducing 2.7% annually [23]. This is a problem that needs to be solved urgently. From the results of the evaluation carried out at this meeting, there were five problems or obstacles that all Nutrition Officers (TPG) felt about the nutrition program they were running in their respective work areas, namely: 1) Lack of public awareness of posyandu visits, so the D/S of each village is very low; 2) Lack of enthusiasm from the Village Head, as the regional person in charge of the community nutrition development program; 3) The lack of nutritionist staff (TPG) in the field, while the work load is very heavy;4) Lack of cross-sectoral coordination of nutrition programs being implemented; 5) Lack of Honor for Posyandu Cadres who assist Nutrition Officers (TPG), so that cadres complain a lot and are not optimal at work [24]. In contrast to the problems described above, a study on the implementation of a stunting policy is necessary.
From the description above, the researchers see that there are still problems related to the successful implementation of the stunting policy in Indonesia. Therefore, the formulation of the problem that the researchers propose is how to implement Presidential Regulation Number 72 of 2021 concerning accelerating the reduction of stunting and what factors influence the implementation of stunting policies in Indonesia.
2.1 Policy implementation
Policy implementation is a delicate and complex process. However, despite the complexity and complexity, policy implementation plays a vital role in the policy process [25]. In other words, policy implementation is a very important aspect of the entire policy process, because without a policy implementation stage, the policy programs that have been compiled will only become official notes on the desks of policy makers, dreams or good plans that are neatly stored. in archive. This is in accordance with Udoji's statement [26] which states that: "the execution of policies is as important if not more important then policy making. Policies will remain dreams or print in jacket files unless they are implemented”. So according to Udoji the implementation of policies is something important, maybe even far more important than policy making. Policies will be in the form of dreams or good plans that are stored neatly in the archives if they are not implemented. Therefore, a policy program must be implemented in order to have the desired impact and objectives. Grindle [27] states, implementation is a general process of administrative action that can be examined at a certain program level. Grindle [27] adds that the implementation process will only begin if the goals and objectives have been set, the program of activities has been structured and the funds are ready and have been distributed to achieve the goals. In line with Grindle's view above, Mazmanian and Sabatier [28] explain the meaning of policy implementation, namely: understanding what actually happens after a program is declared valid or formulated is the focus of attention on policy implementation, namely events and activities that arise after the adoption of guidelines. Public policy guidelines covering both efforts to administer them as well as to create real effects/impacts on society or events.
According to Van Meter and Van Horn [29], the policy implementation process as "those actions by public or private individuals (or groups) that are directed at the achievement of objective set fort in prior policy decisions". Meanwhile, Islamy's [30] view of policy implementation is somewhat different from the views of the experts above. According to Islamy [30]: “Policy implementation is not solely about implementing policies that have been accepted, because in the implementation process new demands may arise which must also be transformed back into the policy formulation mechanism. So as a consequence, the initial (original) policy must be revised or replaced. Therefore, the policy formulation process cannot be separated from the implementation process. Policy evaluation (policy review) can be carried out at any stage, both implementation and formulation, if it is deemed necessary”.
From the various opinions above, it can be concluded that policy implementation is actions carried out by actors implementing policies that actually occur after a program is declared valid to achieve the goals outlined in the relevant policy decision and the policy can be revised, at the implementation stage if indeed it is deemed necessary.
2.2 Policy implementation model
The policy implementation model was coined by many previous experts, such as the model from Edward III [31] stated that the study of policy implementation is crucial for public administration and public policy. Policy implementation is one of the stages of public policy, between the formation of policies and the consequences of policies for the people they influence. A policy that has been planned very well, may also fail if the policy is not implemented properly by the implementers of the policy. In reviewing policy implementation, Edwards III begins by asking two important questions, namely: "What are the preconditions for successful policy implementation? What are the primary obstacles to successful policy implementation?” To attempt to answer these two questions, Edwards III discussed: "...four critical factors or variables in implementing public policy: communication, resources, dispositions or attitudes, and bureaucratic structure".
These four factors or variables are symptoms of why a policy that has been formulated is not achieved the objectives in its implementation. The factors or variables referred to can be explained as follows: (1) the first factor is communications (communication). In general, Edwards III discusses three important things in the policy communication process, namely transmission, consistency, and clarity; (2) the second factor is resources (availability of sources). Implementation instructions may be passed on carefully, clearly, and consistently, but if the implementers lack the necessary resources to carry out the policies, then even this implementation tends to be ineffective; (3) the third factor, namely dispositions (tendencies). The tendency of implementers is a third factor that has important consequences for effective policy implementation; (4) the fourth factor is the bureaucratic structure. According to Edwards III, there are two main characteristics of bureaucracy, namely work procedures, basic measures often referred to as SOPs, and fragmentation.
Next is the model from Grindle [32] who stated that the success of public policy implementation is influenced by the content of the policy and the implementation context. This model provides important insights into the factors that influence policy implementation and helps understand how the policy implementation process takes place. The model from Van Horn and Van Meter [33] says that policy performance is strongly influenced by several interrelated factors, including policy standards and objectives, resources, characteristics of implementing organizations, attitudes of implementers, inter-organizational communication, and the social, economic, and social environment, and politics. This model emphasizes that policy implementation is not only influenced by internal factors of implementing organizations but also influenced by external factors of the social, economic, and political environment. This model helps understand how various factors influence each other and affect policy performance.
The policy implementation model from Mazmanian and Sabatier [34] states that policy implementation is influenced by three groups of variables, namely problem characteristics, policy/law characteristics, and environmental variables. This model emphasizes that the performance of policy implementation will depend on how problems can be handled, how policies/laws can shape implementation, and how environmental variables affect implementation. This model helps understand how various factors influence policy implementation and provides important insights on how to ensure successful policy implementation. The model from William [35] says that the implementation of public policies is influenced by various factors, from the creation to the implementation. This process consists of 4 main stages, namely: (1) Agenda preparation, which is a very important phase and process in public policy making; (2) Policy Formulation, namely the process of making policies that are appropriate to the existing problems; (3) Policy Adoption/Legitimacy, namely the process of obtaining support and approval from stakeholders; and (4) Policy Assessment/Evaluation, which is a process to evaluate the effectiveness of implemented policies.
From the several models of policy implementation stated above, according to the researcher, the model that is suitable for analyzing cases of implementing policies to accelerate the reduction of stunting in Indonesia is the Edwards III model, with the reason that the nature of the Edwards III model is a top-down model and is suitable for implementation at a structured bureaucratic level. A government institution, where each hierarchical level has a role by the function in the elaboration of policies to be implemented and facilitates the implementation of a policy at each level of the bureaucracy starting from the departmental level (central government), provincial government, district/city government, to the level executor in the field.
2.3 Stunting and sustainable development goals
Stunting is a nutritional problem that is of global concern. This is also part of the Sustainable Development Goals (SDGs) to achieve sustainable development. Stunting is still a serious problem for the community, especially rural communities, because of the lack of knowledge about stunting by members of the public, early marriage, and lack of nutrition in children [36]. According to Kusuma and Nuryanto, stunting is malnutrition can cause growth retardation in children, as shown by body length that does not match their age. Malnutrition can result in a lack of intake of essential nutrients needed for healthy growth and development. Therefore, it is important to ensure that children receive balanced and nutritious nutrition to help them grow [37]. In contrast to this, Saputri & Tumangger [38] explained that stunting is one of the SDGs which is included in the second sustainable development goal, namely ending hunger and all forms of malnutrition by 2030 and achieving food security. The target set is to reduce the stunting rate by 40% by 2025. Efforts to reduce stunting both globally and nationally are not without reason. This is because the problem of stunting is closely related to the quality of human resources in the future. Stunting is a problem of chronic malnutrition which is still a big problem in Indonesia. Insufficient nutritional intake in the first 1000 days of life or long-term malnutrition is the main cause of stunting. Indonesia is a developing country with more than half of its children suffering from stunting. The prevalence of stunting in Indonesia ranks 115th out of 151 countries in the world [39].
In addition, according to Zurhayati and Hidayah [40], stunting is a nutritional problem that refers to the quality of life of a child, seen from its growth and development which is not by its genetic potential. Stunting hinders the growth and development of early childhood and is caused by malnutrition. Childhood stunting, or short stature in children, is the result of past malnutrition or failure to thrive and is used to assess long-term undernutrition in children. In this regard, according to Misrina and Salmiati [41], stunting is a very serious public health problem, especially in developing countries. According to the World Health Organization (WHO) in 2018, 171 million children suffer from stunting, with most of them in Africa and Asia. Predictions say that if the stunting trend continues, 56% of children in Asia will suffer from stunting by 2025. Therefore, efforts must be made to reduce stunting rates and ensure that every child has adequate access to good nutrition and health services.
This review was carried out using a literature study method that involved collecting and evaluating previous research. The aim is to find information relating to the evaluation of stunting programs and stunting data from various reference sources such as google scholar and publish or perish. A search using google scholar resulted in 5.540 articles and publish or perish yielded 749 articles. From the two search engines, the article was then filtered again according to the theme of this article and found 7 relevant articles. There are 7 articles that are relevant to the theme of this article, among others: 1) Evaluation of Stunting Prevention Policy in Nagari Pulakek Kota Baru, Sungai Pagu District, South Solok Regency [16]; 2) Coordination in Implementation of Prevention Policy in Padang City [17]; 3) Policy Review: Public Private Partnership for Stunting Management in Indonesia within the Framework of Sustainable Development Goals [13]; 4) Consumption of Fish and Efforts to Overcome Stunting in the Province of the Special Capital Region of Jakarta [14]; 5) Research Report: Evaluation of the Implementation of the Supplementary Feeding Program (PMT) for Underweight Toddlers and Chronic Energy Lack of Pregnant Women (KEK) [18]; 6) Evaluation of Nutrition Management for Stunting Toddlers in the Working Area of the Sirampog Health Center [15]); 7) Overview of Nutritional Problems in 1000 HPK in the City and District of Malang, Indonesia [19]. To facilitate the search for references, the authors use the keywords policy implementation, stunting reduction, stunting program, nutrition, and genetic stunting. The limitations of the reviewed journal are related to the implementation and evaluation of stunting reduction policies. In addition, the publication year range is limited to 2016-2022 to obtain the latest information, especially the stunting data presented.
The qualitative data processing procedure in this study was carried out through three stages, namely 1) Data reduction: it is a process of selecting data, focusing attention on simplifying data, abstracting data, and transforming raw data that emerges from written records in the field. At the data reduction stage, the selection of data that needs to be coded, data that must be discarded, and patterns that must be summarized. In data reduction activities, data sharpening, data classification, data directing, removal of unnecessary data, and data organization are carried out to make it easier to understand; 2) Presentation of data: after the data has been reduced, the next step is to display the data. By displaying data, it will make it easier to understand what happened and plan further work based on what has been understood. The most frequent presentation of data in qualitative research is with narrative text. The presentation of data displays structured information that gives the possibility of drawing conclusions and taking action. The data that has been compiled is then presented in the form of analysis so that the problems that are the object of study will be illustrated; 3) Concluding: the technique of concluding is an essential step in the research process, concluding is based on the organization of information obtained in data analysis. Concluding this study using deductive techniques, namely drawing techniques from general data to specific conclusions.
The Indonesian government's seriousness in implementing policies to prevent and accelerate the reduction of stunting in Indonesia has been pursued since 2009. This is evidenced by the provision of a special website related to stunting prevention and the stipulation of several regulations, namely Law Number 36 of 2009 [3] concerning Health which has been amended by Law Number 11 of 2020 [4] concerning Health which is regulated in articles 141, 142 and 143. Apart from being in the form of the Act above, the central government has also provided a special website related to stunting prevention [42] and has issued many operational regulations related to prevention and acceleration reduction of stunting in Indonesia. The types of stunting operational regulations can be seen in the following Table 2.
Table 2. Operational regulations for prevention and acceleration of stunting reduction
|
No. |
Types of Stunting Operational Regulations |
Regulation Number |
Contents of Regulations (Things that are Regulated) |
|
1. |
Regulation of the Minister of Finance (PMK) |
41 of 2014 |
Balanced Nutrition Guidelines |
|
2. |
Circular of the Directorate General of Public Health, Ministry of Health |
HK.03.03/V/0595/2016 |
Administration of Blood Supplement Tablets to Young Women and Women of Reproductive Age |
|
3. |
Letter of the Minister of National Development Planning/Head of Bappenas |
B.240/M.PPN/D.51PP.01.01 /04/2019 |
Submission of the 2020 Integrated Stunt Reduction Intervention Focus Area Expansion |
|
4. |
Decree of the Minister of National Development Planning/Head of the National Development Planning Agency |
KEP 42/M.PPN/HK/04/2020 |
Determination of District/City Expansion Focus Locations for Integrated Stunting Reduction Interventions in 2021 |
|
5. |
Presidential decree |
72 of 2021 |
Percepatan Penurunan Stunting |
|
6. |
Regulation of the Minister of Finance (PMK) |
8 of 2021 |
Operational Instructions for the Use of Special Physical Allocation Funds for the Health Sector for the 2021 Fiscal Year |
|
7. |
Regulations of the National Population and Family Planning Agency of the Republic of Indonesia |
12 of 2021 |
National Action Plan to Accelerate Reduction of Indonesia's Stunting Rate for 2021-2024 |
|
8. |
Decree of the Minister of National Development Planning/Head of the National Development Planning Agency |
KEP 124/M.PPN/HK/10/2021 |
Determination of the National Action Plan for Food and Nutrition for 2021-2024 |
|
9. |
Minister of National Development Planning/ Head of National Development Planning Agency |
4 of 2021 |
Preparation of Regional Action Plans for Food and Nutrition |
|
10. |
Decree of the Deputy for Human, Community and Cultural Development of the Ministry of National Development Planning |
KEP. 27/D.V/03/ 2021 |
Network of the National Movement for the Acceleration of Scaling-Up Nutrition (Sun) Networks Indonesia |
|
11. |
Decree of the Minister of National Development Planning/Head of the National Development Planning Agency |
KEP. 10/M.PPN/HK/02/2021 |
Determination of District/City Expansion Focus Locations for Integrated Stunting Reduction Interventions in 2022 |
|
12. |
Decree of the Secretary of the Ministry of National Development Planning/ Principal Secretary of the National Development Planning Agency |
KEP. 58A/SES/05/ 2022 |
Network of the National Movement for the Acceleration of Nutrition Improvement/Scaling-Up Nutrition (Sun) Networks Indonesia |
|
13. |
Decree of the Minister of National Development Planning/Head of the National Development Planning Agency |
KEP.101/M.PPN/HK/06/2022 |
Determination of Districts/Cities Locations of Intervention Focus to Accelerate the Reduction of Integrated Stunting in 2023 |
Table 3. The target to reduce and achievements in Indonesia in the last 3 (three) years
|
Years |
Targets |
Prevalence of Stunting |
Achievements |
|
2020 2021 2022 |
24.1% 21.1% 18.4% |
11.6% 24.4% 21.6% |
Success Not Success Not Success |
Based on the Table 2, the data shows that the central government through a number of related ministries has provided and established operational regulations that must be referred to or used as guidelines by the relevant ministries and all local governments in implementing policies to prevent and accelerate the reduction of stunting in Indonesia. However, until the end of 2022, the implementation of the policy to accelerate the reduction of stunting in Indonesia has not been effective. This can be seen from the achievement data on the stunting reduction target for the last 3 years (2020-2022) in the following table.
Based on Table 3, the data shows that in the last 3 years stunting reduction achievements have fluctuated, only in 2020 the stunting reduction target has been successful. Meanwhile, in the last two years (2021 and 2022) the stunting reduction target has not been achieved. Therefore, the implementation of policies to accelerate the reduction of stunting is still a serious problem faced by the Indonesian government, both central and regional governments. Referring to the theory put forward by Edward III, the implementation of policies to accelerate the reduction of stunting in Indonesia is influenced by the following factors.
The first is the communications factor. There are three important things in the policy communication process, namely transmission, consistency, and clarity. The first important thing in the policy communication process to accelerate stunting reduction is transmission. There are several obstacles that arise in transmitting implementation orders, namely: 1) disagreements between implementers and orders issued by policy makers; 2) information passes through layers of bureaucratic hierarchies; 3) ultimately the capture of communications may be hampered by selective perceptions and unwillingness of implementers to know the requirements of a policy. The second important thing, in the policy communication process, is consistency. If policy implementation is to be effective, implementation orders must be consistent and clear. The third important thing, in the policy communication process, is clarity. Often the instructions passed on to executors are vague and do not specify when and how a program is implemented. The ambiguity of the communication message conveyed regarding policy implementation will encourage wrong interpretations, perhaps even contrary to the meaning of the initial message.
In terms of communication regarding the implementation of policies to accelerate stunting reduction in Indonesia related to transmission, consistency, and clarity in communication between stakeholders or actors implementing stunting policies across ministries and local governments, they have not been fully implemented properly. This is supported by the results of the following relevant studies. The research results of Febrian and Yusran [17] show that the implementation of the stunting prevention program in the city of Padang currently only includes the general information and coordination stage. There is no cross-sectoral coordination that focuses more on stunting issues and only involves the puskesmas team, urban village officials and nutrition officers in the program. This is due to the absence of clear regional regulations. Furthermore, the results of the research by Sari and Yusran [16] show that the implementation of the stunting prevention policy in Nagari Pulakek Koto Baru, Sungai Pagu District, Solok Selatan Regency has not been optimally implemented because the technical implementation of nutritional surveillance at the Posyandu is not yet optimal due to the lack of awareness and understanding of mothers under five about the importance of providing good and correct parenting, the low level of community participation in participating in posyandu activities. Based on the results of research by Milwan et al. [43], the success or failure of a program is largely determined by the factor of resources, where resources greatly affect almost all variables in all sectors. Resources that will support effective policy implementation include: a) adequate staff and good skills to carry out their duties; b) information on how to implement a policy and information/data on the compliance of other personnel with government regulations; c) authority; authority will vary from program to program and take many different forms, from giving assistance to coercing behavior; d) physical facilities can also be important sources in policy implementation.
Judging from the factor resources available for implementing policies to accelerate the reduction of stunting, they are not sufficient. This is supported by the results of the following relevant studies. Based on the research results of Sari and Yusran [16] found that the implementation of stunting prevention policies in Nagari Pulakek Koto Baru, Sungai Pagu District, South Solok Regency was not optimally implemented due to budget constraints and inadequate health workers and uneven distribution of stunting prevention. Furthermore, the results of research by Sari and Yusran [16] show that the 1000 Families Hope Program is running well, although there are obstacles such as a lack of Human Resources (HR) and delays in the disbursement of Health Operational Assistance (BOK) funds so that the Puskesmas must take funds from the National Health Insurance (JKN). Furthermore, Sari and Yusran [16] found several obstacles that often occur during the implementation of programs to accelerate stunting reduction, especially the lack of Human Resources (HR) and high workload at the Health Service making Human Resources (HR) only focus on main tasks just them. Creativity and innovation in making programs related to stunting prevention are not optimally absorbed. Apart from that, campaigning, advocacy and dissemination regarding stunting prevention programs are still lacking [17]. Many plans, such as targets for access to clean water, access to sanitation coverage, and others, have not been implemented due to a lack of funds for Health Operational Assistance (BOK) which are insufficient to carry out campaigns [44]. Delays in the disbursement of Health Operational Assistance (BOK) funds are still a problem in several puskesmas. In addition, according to Fentiana et al. [45] the ability of human resources to measure program effectiveness from existing outputs is still lacking, such as whether multivitamins or additional food provided by officers are actually eaten by children or not.
The three dispositions factors. If implementers have a favorable attitude toward a particular policy, and in this case means support, they are more likely to carry out the policy as intended by the original decision makers. And vice versa, if the behavior or perspectives of implementers are different from those of decision makers, then the process of implementing a policy becomes more difficult. This is in accordance with the research of Khoeroh et al. [15] which states that to achieve a reduction in stunting rates in children, the implementation of the Pregnant Women's Health Program needs to be closely monitored. Signs of the program's success include the high percentage of pregnant women visiting for Atenatal Care (ANC) examinations in the first quarter of 95%, and visits in the fourth quarter reaching 83.5%. In addition, exclusive breastfeeding (ASI) programs in 2015 reached 86.8%, while supplementary feeding programs related to reducing stunting rates reached 76.8% and receiving supplementary feeding (PMT). The distribution of vitamin A in infants also reached high figures, namely 98.77% in February and 100% in August. These findings confirm that with the cooperation between the government and the private sector, the level of participation and supervision of the implementation of stunting reduction programs are significant and positive determinants in reducing stunting cases.
The four bureaucratic structural factors. There are two main characteristics of the bureaucracy, namely work procedures, basic measures or often referred to as SOPs and fragmentation. First, it developed as an internal response to the limited time and resources of implementers and the desire for uniformity in the workings of complex and widely dispersed organizations. Second, it stems mainly from pressures outside bureaucratic units, such as legislative committees, interest groups, executive officials, the state constitution, and the nature of policies that influence the organization of government bureaucracies. This is in accordance with research by Sari and Yusran [16] which states that the implementation of stunting prevention interventions in Nagari Pulakek Kota Baru Solok is not in accordance with government programs stipulated in Permenkes RI No.14 of 2019. This can be seen from the lack of optimal nutrition surveillance programs, lack of community participation, mothers' knowledge is still low, and the lack of support from the local government. Even though 163 children under five were found in August 2019, of which 13 of them were stunted with a stunting percentage of 8.0% based on the Height Based Age (TB/A) index, no significant impact was found. In the period from January to December 2020, 129 children under five were found, of which 37 were stunted with a stunting percentage of 28.7%. In addition, according to Prahastuti's research, the government can establish partnerships with the private sector in implementing stunting prevention programs, where the private sector can provide financial assistance or the products and services it owns [13]. So that not only the government will benefit, but the private sector can also build their reputation by helping improve people's welfare through partnerships with the government. This is in accordance with Prahastuti's research [13] which states that the public private partnership initiative includes cooperation between the government and the private sector to overcome stunting, where companies can contribute through financial assistance, products or goods, as well as services or services that are appropriate to their business sector.
In 2020, Indonesia experienced the Covid-19 pandemic, which resulted in the government making Large-Scale Social Restrictions (PSBB) rules. The increasing number of victims of the Covid-19 virus has caused the public to have a negative view of health services. Therefore, during a pandemic, several activities such as monitoring and tracking toddlers were carried out through door-to-door visits to mothers and toddlers' homes by posyandu cadres [46]. The government also issued a medium-term program called the National Strategy for the Acceleration of Stunting Prevention 2018-2024. This program was created to reduce the high stunting rate in Indonesia through interventions focused on pregnant women, nursing mothers, and children aged 0-23 months. This program also targets children aged 24-59 months, women of childbearing age, and young women. For its implementation, this program was formed in priority districts and cities covering 1,000 focus villages in 100 districts/cities in 2018. According to Fentiana et al. [45] in 2019 this program was implemented again by increasing the target number of focus villages to 1,600 villages focus on 160 priority districts/cities. It is planned that this program will be implemented again in 2020 to 2024 to gradually cover all villages in the priority districts/cities. This is done to maximize the implementation of interventions so that they spread throughout Indonesian society and help reduce stunting rates. This program has the advantages of comprehensive planning, identification of the causes of stunting directly, indirectly, and the root cause of the problem and can determine targets and priority areas. This program is also a reference in making guidelines for the implementation of existing intervention programs. In carrying out the stunting prevention program, of course there are obstacles that arise.
The implementation of the stunting reduction policy in Indonesia has been carried out with various programs, such as the 2018-2024 National Strategy for the Acceleration of Stunting Prevention, the 1000 Nutrition Week Program, the Supplemental Feeding Program (PMT) and other programs. However, the implementation of policies to accelerate the reduction of stunting in Indonesia has not yet reached the set targets.
There are 4 factors that influence the implementation of policies to accelerate stunting reduction in Indonesia, namely:
The factors of communication, program socialization and coordination between actors/stakeholders implementing the policy have not been fully implemented properly;
Factor resources, the availability of human resources in terms of quantity and quality as well as sources of funds for the implementation of the stunting reduction policy in Indonesia are inadequate;
Dispositions factor, support from local governments (provinces, cities and districts) to seriously implement policies to accelerate stunting reduction is still lacking;
The bureaucratic structure factor, Standard Operational Procedure (SOP) for implementing policies to accelerate the reduction of stunting are available at the central level, but not all Standard Operational Procedure (SOP) at the regional level are available because not all regions have issued Regional Regulations regarding the acceleration of stunting reduction.
From the conclusions above, the recommendations that the researchers convey are that there is still much that needs to be addressed by the government regarding obstacles in implementing policies to accelerate stunting reduction, for example the implementation of the National Strategy for the Acceleration of Stunting Prevention 2018-2024 still requires better convergence and program elaboration, then implementation the 1000 Nutrition Week program also requires promotion of the importance of breastfeeding (ASI), as well as training and counseling for breastfeeding mothers so they can produce sufficient breast milk (ASI). Next is the implementation of the Supplemental Feeding Program (PMT), which still requires developing a variety of food at the puskesmas so that mothers and toddlers do not feel bored with the additional food provided. In addition to the several obstacles above, there are also obstacles such as delays in the disbursement of Health Operational Assistance (BOK) funds, lack of Human Resources (HR), and difficulties in measuring program effectiveness from existing outputs that need to be of concern to the government and across sectors in minimizing obstacles - existing constraints. Therefore, the Indonesian government needs to consider increasing supervision of the existing stunting program to reduce stunting cases, as well as overcome the obstacles that still occur in the field.
The authors thanked to Universitas Terbuka, Indonesia for giving support to accomplished this research.
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