Hardinsyah Dan Suroso

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DRAFT - February 2002

MICRONUTRIENT PROGRAMS IN INDONESIA

Authors.

Har!"syah a" Suroso

Nat!o"a# Foo Fort!$!%at!o" Co&&!ss!o"D!re%torate o$ Co&&u"!ty Nutr!t!o"' MOH

Ce"ter $or Foo a" Nutr!t!o" Po#!%y Stu!es

(o)or A)r!%u#tura# U"!*ers!ty

Context



Indonesia is the fourth most populous country (205 million) in the world after China, India and the Unitedstates. Situated in Southeast sia, Indonesia is an archipela!o comprised of a"out #$.000 islands, located "etween the Indian and %acific &cean. "out $0 ' of the population resides in rural areas, mostly in aaIsland. aa is the home of *0 ' of the population, thou!h it represents only $' of the land area of thecountry.

+emo!raphic health indicators hae improed oer the last three decades. Indonesia has seen a rapiddecrease in population !rowth and an increase in maternal and child surial. +ue lar!ely to the success of the national family pro!ram, the population !rowth in Indonesia has decreased from a"out .0' to #.*' inthe last twenty years. -he num"er of children underfie years is 22 million or a"out #0 ' of the population, and the num"er of women of reproductie a!e is 5/ million or a"out 2 ' of the population.-he child mortality rate has improed su"stantially from #/$# to #///, reported as #15 and 1* per #000lie "irths, respectiely. n indirect estimate of maternal mortality rate (3) in #//5 was reported as$ per #00.000 lie "irths. 4oweer, the fi!ures reported are still hi!her than that of nei!h"orin!countries (alaysia, %hilippine, -hailand and Sin!apore).

Indonesia has enoyed political sta"ility and economic deelopment from #/*/ to #//$. Since the middle

#//$, Indonesia was sufferin! from economic and multidimensional crises. -he new !oernment ustesta"lished last month under %resident e!awati, and people expected that the economic and politicalsta"ility are !ettin! "etter. -he 3upiah exchan!e rate, as a simple indicator of the macro economic, is!ettin! stron!er, it reduce from a"out 3p ##.000 to a"out 3p .000 for one dollar (US) durin! one monthof the new !oernment.

-he economic !rowth of the country is still low "ut !ettin! "etter ("etween 2 '). Current 6+%consists of a!riculture (2#'), Industry (5'), and Serices (11'). Seeral a!ricultural commodities hassi!nificant contri"ution into Indonesia economic such as rice, cassaa (tapioca), peanuts, ru""er, cocoa,coffee, palm oil, fish, poultry, e!!s7 while the nona!ricultural commodities are petroleum and natural !as,textiles, apparel, and footwear, minin!, cement, chemical fertili8ers, plywood, and tourism.

-he prealence of poor families si!nificantly decreased "efore the economic crises. -he prealence of the poor in #/$0 and #//* was *0.0 ' and #.5 ' respectiely. -he prealence of the poor after one year fthe crises (in #//) was 21.2 ', a fi!ure from the Central Statistics !ency (calculated "ased onexpenditure for calorie ade9uacy), and a"out 10.0', a fi!ure from :ational ;amily %lannin! Coordination!ency ("ased on a simple assessment on the fie "asic need components). ost f the poor reside in su"ur"an and remote rural areas. -he prealence of poor families in <astern Indonesia is hi!her compared to=estern Indonesia.

acro policies to promote recoery, 9uality, !rowth and poerty alleiation has "een formulated and donesince early $0s. Since the crises, the !oernment introduced a Social Safety :et (SS:) pro!rams

particularly for poor (funded from I; loan, and other sources of loan and !rant). -hese SS: includesnutrition and "asic health serices, food security, social and education su"sidies, credit schemes etc.3ecoery from the crisis depends on "an> and corporate restructurin!, achiein! fiscal sustaina"ility andmaintainin! appropriate monetary and exchan!e rate policies. In the past, certain trade, industry and credit policies faored inefficient inestment and selected forms, includin! the creation and protected monopoliesthat resulted in hi!h costs to other sectors and economic players.

Indonesia has enoyed political sta"ility and economic deelopment from #/*/ to #//$. Since the middle



#//$, Indonesia was sufferin! from economic and multidimensional crises. -he new !oernment ustesta"lished last month under %resident e!awati, and people expected that the economic and politicalsta"ility are !ettin! "etter. -he 3upiah exchan!e rate, as a simple indicator of the macro economic, is!ettin! stron!er, it reduce from a"out 3p ##.000 to a"out 3p .000 for one dollar (US) durin! one monthof the new !oernment.

-he economic !rowth of the country is still low "ut !ettin! "etter ("etween 2 '). Current 6+%consists of a!riculture (2#'), Industry (5'), and Serices (11'). Seeral a!ricultural commodities hassi!nificant contri"ution into Indonesia economic such as rice, cassaa (tapioca), peanuts, ru""er, cocoa,coffee, palm oil, fish, poultry, e!!s7 while the nona!ricultural commodities are petroleum and natural !as,textiles, apparel, and footwear, minin!, cement, chemical fertili8ers, plywood, and tourism.

-he prealence of poor families si!nificantly decreased "efore the economic crises. -he prealence of the poor in #/$0 and #//* was *0.0 ' and #.5 ' respectiely. -he prealence of the poor after one year ofthe crises (in #//) was 21.2 ', a fi!ure from the Central Statistics !ency (calculated "ased onexpenditure for calorie ade9uacy), and a"out 10.0', a fi!ure from :ational ;amily %lannin! Coordination!ency ("ased on a simple assessment on the fie "asic need components). ost of the poor reside in su"ur"an and remote rural areas. -he prealence of poor families in <astern Indonesia is hi!her compared to=estern Indonesia.

acro policies to promote recoery, 9uality, !rowth and poerty alleiation has "een formulated and donesince early $0s. Since the crises, the !oernment introduced a Social Safety :et (SS:) pro!rams particularly for poor (funded from I; loan, and other sources of loan and !rant). -hese SS: includesnutrition and "asic health serices, food security, social and education su"sidies, credit schemes etc.3ecoery from the crisis depends on "an> and corporate restructurin!, achiein! fiscal sustaina"ility andmaintainin! appropriate monetary and exchan!e rate policies. In the past, certain trade, industry and credit policies faored inefficient inestment and selected forms, includin! the creation and protected monopoliesthat resulted in hi!h costs to other sectors and economic players.

HEA+TH AND NUTRITION PO+IC,

lthou!h part of nutrition pro!rams hae "een implemented since the +utch colonial, the welldocumented national policy of the !oernment of Indonesia was started since #/*/, when the first sta!e ofthe ;ie ?ear +eelopment %lan (;?+%) was formulated. In the first ;?+% there was no particularchapter on food and nutrition policy. t that time the policy on nutrition is ery limited and formulated inhealth policy chapter (for therapeutic@clinical nutrition policy), and in a!riculture policy chapter (forcommunity nutrition). eanwhile since the second ;?+% the food and nutrition policy was exclusielyformulated into one policy chapter. -his chapter always exists up till now in the national policy documentcalled %3&%<:S (:ational +eelopment %ro!rams).

-he policy stated that the important of nutrition in the human and economic deelopment. -he policy places hi!her prioritise on nutrition and health of pre!nant and lactatin! mothers, and children form middleand lower income families. -he Indonesian !oernment adopted a nation wide policy and pro!rams onnutrition such as food security, promotion of dietary !uidelines, food supplementation, nutritionsupplementation, food fortification and nutrition sureillance. %olicy and pro!rams on controllin!micronutrients pro"lems has "een done since #/0s, startin! with iron ta"lets and itamin capsulesdistri"ution, then iodised salt. In the nutrition health related policy also includes immuni8ation and



sanitation pro!rams, antenatal and pre natal care.

-he first Indonesians dietary !uidelines, called a !uide to hae a "alance diet, was formulated and pu"lished in #//1. 3e!ardin! itamin supplementation, twice a year infants "etween * to #2 months ofa!e should receie itamin supplementation in the amount of #00.000 IU and children "etween # to 5years receie 200.000 IU. ass campai!ns for itamin capsules are held eery ;e"ruary and u!ust.Ailla!e midwies or health center personnel should proide itamin supplements of 200.000 IU to eerywoman within the first 0 days after !iin! "irth.

Since #//, the Indonesian !oernment adopted the formulation of :utrition %lan of ction and called;ood and :utrition %lan of ction (;:%). -he food and nutrition policy chapter of %&3%<:S wasthen interpreted and formulated in more detail and measura"le into ;:%. ;:% identify prioriti8ed tar!et!roups, indicators of the pro!ram and tar!ets to "e achieed for the next fie years, as shown in -a"le #.-he ;:% was ointly formulated "y three most related +epartments (+epartment of !riculture,+epartment of 4ealth, and +epartment of Industry and -rade), set seeral tar!et indicators on nutrition for "etter human deelopment.

-a"le # :utrition Indicators and -ar!ets to Be chieed in ?ear 2005

Indicators -ar!et !roups ?ear 2000(')

?ear 2005(')

%rotein calorie malnutritionUnderwei!htSeere malnutrition

Children underfie 25.0$.0

20.05.0

:utritional nemia %re!nant D lactatin!mothers

Children underfie

=omen productie a!e

50./

10.5

/.5

10

0

0

Clinical Aitamin deficiency %re!nant D lactatin!mothers

Children underfie 50.2 0



I++-otal 6oitre 3ate

Coera!e of families use iodised salt

School children /.

*5.0

5.0

/0.0

s a reflection the ma!nitude of the pu"lic health pro"lems

In terms of food security, the ;:% also directed actions on food security at "oth the micro and macroleels is a complicated tas>. ;ood policy analysis lin>s the macro economy with the rural economy and thentraces the impact of chan!es in "oth sectors on the poor, mediated throu!h chan!es in food production andconsumption. concern for IndonesiaEs food security, whether at the household leel or in national foodmar>ets, must incorporate this macro perspectie on the food economy in order to achiee !ood policydesi!n and effectie implementation.

icronutrient %ro"lems

icronutrient deficiencies, such as iron, iodine, and certain itamins deficiencies, are a still serious pu"lichealth pro"lem in sian deelopin! countries, includin! Indonesia. -hese pro"lems hae increasin!ly!ained attention from the experts and policy ma>ers since they are aderse detrimental effects on human!rowth and deelopment, increased ris> of mor"idity and mortality

-he international commitment for reduction of micronutrient deficiencies was first adocated at the =orldSummit for Children in #//0. Since that time, micronutrient deficiencies hae "een the scope of seeralinternational and re!ional conferences, includin! the Conference for <ndin! 4idden 4un!er in #//# andthe ;&@=4& International Conference on :utrition (IC:) in #//2. <i!ht years after the IC:, on;e"ruary 2000, the sian deelopment Ban> (+B) in association with the icronutrient Initiatie (I)and the Fife Sciences Institute (IFSI) held a re!ional meetin! called -he anila ;orum 2000G Strate!ies to;ortify <ssential ;oods in sia and the %acific. -he anila ;orum 2000 was participated "y seeral sia%acific countries representaties consist of policy ma>ers, pro!ram coordinators and planners, priatesectors and researchers.

Up till now, there were no current national data on the prealence of micronutrients pro"lems, except forcoera!e of iodised salt inta>e. -his is one of the wea>nesses of the micronutrients deficiencyinformation system in Indonesia. Some national data on micronutrients deficiencies were already * to years old. +ata from small scattered studies showed that the pro"lems of micronutrients deficienciesincreased after two or three years of the economic crises.

-he prealence of iron deficiency anemia (I+) was still prealent, namely 50./ ' amon! pre!nantwomen, 10.5 ' amon! children underfie, /.5 ' amon! women in reproductie a!e, and 5$./ ' amon!

elderly. +urin! #/$5 to #//5 the prealence of I+ amon! pre!nant women only decreased a"out #5 '.Clinical itamin deficiency (A+) was 50.0 ' on children amon! underfie in #//. Clinical iodinedeficiency disorders (I++) in school children was 2$.$ ' and /. ' in #/ and #/// respectiely.



-he prealence of clinical iodine deficiency disorders (I++) in school children was 2$.$ ' and /. ' in#/ and #/// respectiely. -he iodised salt inta>e was sta!nant around *1 ', namely *5.2 ' and *1.5 'in #// and 2000 respectiely. 4istorically, the first lar!escale surey of iodine deficiency disorders (I++)after the independence was conducted amon! 1* elementary schools in four proinces (:orth Sumatra,=est Sumatra, <ast aa and Bali) in #/$. -he results showed that *0 to /0 ' of the children sufferedfrom !oitre (-63). -he second lar!escale surey of I++ was done in 2* proinces in #/0#/2. -heresults showed that *.0 ' of the selected su" districts were cate!ori8ed as !oitre endemic areas, in which/.5 ' was seere endemic. -he ma!nitude of the pro"lems in terms of num"er of people is presented in-a"le 2.

-a"le 2 <stimated a!nitude of the :utrition %ro"lems in Indonesia

%ro"lems D t ris> !roup :um"er of %eople suffered (million)

nemia

Children Under fieSchool Children-eena!e !irls=omen in productie a!e

?oun! couple marria!e women%re!nant =omen<lderly

.##$.0*.5#.

#.02.55.0

I++

%eople in endemic areas6oitreCretin

12.0#0.00./

%C amon! children under fie

Underwei!htSeere underwei!htarasmic>washior>or

5.2#.$0.2

Since #/0s the 6oernment and priate sectors hae receied much fund for reducin! pro"lem of iodinedeficiency disorder (I++) throu!h salt iodi8ation pro!rams. lthou!h the pro"lems of I++ still exists, the prealence of the I++ is decreased ery si!nificantly durin! the last 20 years mainly "ecause of saltiodi8ation. 4oweer, the prealence of iron deficiency (anemia) is still a ery serious pro"lem.

Scattered data on other micronutrient pro"lems were now aaila"le. Hinc deficiency amon! pre!nantwomen was a"out 20 to *5 '. Aitamin B* deficiency amon! school children a"out 25 '7 and folic aciddeficiency amon! pre!nant women a"out #0 to 25 '. Inta>e of itamin B#2 and folic acid are seems to "e lower since Indonesians diets is !enerally lac> of meats and fruits. Seeral dietary studies showed thatcalcium inta>es of children and pre!nant women were less then twothird of their calcium 3+s.

INITIATION AND IMP+EMENTATION FOOD FORTIFICATION



;ood fortification pro!rams, particularly wheat flour fortification was chosen for the case study in this paper. -he reason is that this pro!ram is relatiely new and limited pu"lication aaila"le on this pro!ram.

-he case study from Indonesia is case study Current opportunities of food fortification are stron!ly relatedto the pro"lems of micronutrients deficiencies faced "y Indonesians7 and related policy has "een made.&ne of the strate!ies proposed for eliminatin! the pro"lem is multinutrients food fortification, which is prioritised on wheat flour and complementary foods.

In #//, a national food and nutrition wor>shop attended "y the policy ma>ers, experts and related foodindustry leaders of Indonesia come out with the conclusion that the wheat flour was potential to "efortified with iron seeral other micronutrients (8inc, itamin B#, B2 and folic acid) for "etter nutritionalstatus of the community. -he maor considerations for that areG #) wheat flour !ettin! play an importantrole in Indonesian diet, 2) centrali8ed wheat flour industries (fie flour mills) in Indonesia, ) wheat flourfortification has "een practiced world wide, 1) aaila"ility of sophisticated fortification technolo!y, 5) lowcost of wheat flour fortification, and *) serious pro"lem of iron deficiency, =hile the special tar!et!roups strate!ies for eliminatin! of anemia, such as iron ta"let for pre!nant women are still exist.

In the #//, the inistry of 4ealthEs +ecree :um"er *2@#// issued the mandatory fortification of wheatflour. -he wheat flour produced and distri"uted in Indonesia must "e fortified with iron, 8inc, thiamine,ri"oflain and folic acid. =ith support from U:IC<; and USI+ wheat fortification with iron wasinitiated in Indonesia. ;rom anuary #/// to anuary 2000, a !rant of US 50.000 from USI+ throu!hU:IC<; was !ien to the Indonesian 6oernment to purchase 10 metric tons of iron premix, and has "een distri"uted for wheat flour fortification (*0 ppm of iron) to Bo!asari, Berdi>ari Sari Utama, Citra, SriBo!a 3atu 3aya ;lour ills. -his year (200#) wheat flour industries receied 210 metric tons of premixfrom CI+.

In addition to the a"oe decree, in ay 200#, inistry of Industry and -rade issued +ecree :um"er#5@200# on the andatory pplication of the :ational Standard of Indonesia (S:I) for ;ortified =heat

;lour. Both imported wheat flour or domestically produced wheat flour must follow this S:I. ccordin!to the S:I, the wheat flour must "e fortified with 50 ppm iron, 0 ppm 8inc, 2.5 ppm thiamin, 1 ppmri"olain, and 2 ppm folic acid.



-he a"oe current policy@re!ulation proide opportunities for all related institutions such as related sectorsof the !oernment, related industries and serices, research centers, "oth local and international :6&s for "uildin! a "etter partnership for "etter nutrition and health status of the community.

lthou!h the pro"lem of clinical itamin still exists, the ma!nitude of the pro"lems is less serious thanthe pro"lems of anemia. &pportunities also open for fortification of selected appropriate foods withitamin . Currently seeral foods such as instants noodle and mar!arine are already fortified with itamin oluntarily. %reious studies hae "een done on fortification of S6 with itamin , howeer noappropriate and feasi"le technolo!y aaila"le currently. -his is also an opportunities and challen!es forfuture research actiities.

"i! opportunity on food fortification is also !rowin! up for the commercial complementary foods. llcommercial complementary foods for children *2 years old in Indonesia hae "een fortified withmicronutrients followed its standard. Besides, durin! the crises, this year, the !oernment allocated +Bloan for producin! /.$5 tonne of fortified complementary foods for children *## years old amon! 10districts. -hose complementary foods are "ein! produced "y food industries.

In terms of coordinatin! institutions, the :ational Commission on ;ood ;ortification (:C;;) has "eenreor!anised. Since the inistry of ;ood and 4orticulture in which the preious Commission attached, wasno lon!er existed, the new home for the :C;; was proposed and accepted, namely, at the +eputyCoordinatin! inistry for finance and Industry, under Coordinatin! inistry of <conomic ffairs. -henew position of the :C;; and its consolidation would hae "etter opportunities to play a "etter role oncoordination of the food fortification pro!rams in Indonesia.

&ne of the results of the preious anila ;orum, proide an opportunity for :C;; and its colla"orationresearch centers for conductin! a preliminary reiew on the possi"le areas of the country inestment plan(CI%) for Indonesia. -he preliminary reiew has "een done in 2000 "y the :C;; in colla"oration withCenter for ;ood and :utrition %olicy Studies (C;:%S) of I%B and funded "y U:IC<; f Indonesia. -he

results proposed six areas of the future CI% of Indonesia, as followsG #) Stren!thenin! related re!ulationand policy of food fortification, 2) Stren!thenin! capa"ility of related food industries and sectors (capacity "uildin!) of food fortification, ) Improin! related monitorin! and controllin! actiities of foodfortification, 1) Stren!thenin! adocacy, promotion and social mar>etin! of food fortification, 5)Conductin! operational and ealuation studies and deelopin! innoation technolo!y actiities for "etterfood fortification pro!rams, and *) Stren!thenin! related or!anisation and mana!ement pro!rams for "etter food fortification pro!rams.

decreasin! trend in the prealence of clinical itamin deficiency is eident, "ut, for lac> of data, trendscould not "e assessed for su"clinical itamin deficiency. Besides, it may also caused "y lac> of capacityof human resource and institution deelopment for mana!ement and ealuation of the selected pro!ram atthe lower leel. It seems that the rapid adoption and expansion of micronutrient deficiency control pro!rams was not followed "y well desi!n, monitorin! and ealuation of the pro!rams, and ade9uatecapacity "uildin!. Fac> of current data is also "ecause of that. Up till now there is no national data oncurrent maor micronutrient pro"lems, and new emer!in! micronutrients deficiencies, such as 8inc, itaminB#, itamin 2 and folic acid. -herefore, future well monitorin! and control, ealuation studies andade9uate capacity"uildin! pro!rams on food fortification system are ur!ently re9uired.

-he inistry of Industry and -rade +ecree :um"er #5@200# on andatory pplication of the :ationalStandard of Indonesia (S:I) for ;ortified =heat ;lour, will soon "e mandatory enforced (since &cto"er 2nd



200#). Before the +ecree will "e mandatory enforced, some related policies hae to "e formulated andissued "y the !oernment. ;or instance, #) =hat >ind of policy should "e made imported wheat flour ornonfortified wheat flour7 2) 4ow to control the distri"ution of the nonfortified wheat flour7 ) 4ow toincrease the capacity of the local food control la"oratories on this issue7 1) 4ow is the implications on foodla"ellin! of its deried products, what sorts of policies should "e made. -hese all "e challen!es for theIndonesian !oernment in the near future.

Challen!es are also faced on additional cost of food fortification for food industries, and lac> of >nowled!eof the people on the health "enefits of the food fortification. 4oweer, a feasi"le and suita"le CI% and "ecomplemented with an initial !rant and facilities for the industries, to!ether with a "etter promotion offood fortification will minimi8ed the challen!es.

3e!ardin! the complementary foods, many research studies showed that nutrition interention "y proidin!hi!h calorie protein density as well as micronutrients to underwei!ht children could proide improementin term of their normal !rowth. eanwhile, the prealence of underwei!ht amon! children undertwoyears is approximately 25' and remains steady until 5 years of a!e. -he most pro"a"le causes of hi!hinfant mortality rate in Indonesia are inade9uacy food inta>e and hi!h fre9uency of infection disease due to

poor sanitation and hy!iene "eside poor health care.

Some challen!es are also faced "y the complementary food industries, as hi!hli!hted in the preious paperof the anila ;orum 2000, presented "y an IndonesiaEs food industry, such asG #) -he current nationalcapacity aaila"le could not fullfill total re9uirement (J 25 0'), 2) -he reality of short duration incomplementary food usa!e compare to mil> usa!e, ) -he perceie ima!e of complementary food still lowamon! mothers, 1) -he re!ulation especially standard and other rule need to "e reised and esta"lished, 5)Fac> of lon! term nutrition strate!ic plan and pro!ram at re!ional leel.

Hardinsyah Dan Suroso

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