Given the pervasive and multigenerational impact of malnutrition, addressing it is central to achieving results for the GFF along the RMNCAH continuum. Undernutrition and poor health in the reproductive and early life periods worsen outcomes for mothers and children alike. Meanwhile, social protection and education play key roles in improving nutrition outcomes, and are underlying drivers across all positive outlier countries in nutrition.

Undernutrition is an underlying cause of about 45 percent of all child deaths and anemia contributes to about 20 percent of maternal deaths. Poor maternal health and nutrition at conception and during pregnancy increases children’s risk of adverse outcomes, including death, low birth weight, and stunting (when a child is too short for their age). Worldwide, 155 million children under 5 are stunted, with serious consequences for their physical and cognitive development.

• Integrating nutrition into the full continuum of maternal and child health services, by focusing on actions such as increasing exclusive breastfeeding rates, improving counseling on infant feeding and early stimulation, and the prevention and treatment of maternal anemia as part of routine provision of primary care services;
• Building capacity at the community and health-facility levels, by training health providers on peer-to-peer counseling on infant feeding and early stimulation, to improve child feeding practices; better management of moderate and severe acute malnutrition; and the scale up of Kangaroo Mother Care to assist low birthweight babies;
• Providing commodities, such as micronutrient supplements and fortificants, ready-to-use therapeutic foods, and deworming medications;
• Increasing the community-based delivery of nutrition services through community health and early childhood development workers;
• Reaching underserved areas, by setting up mobile clinics and using a rapid in-and-out approach in security-challenged settings to deliver health and nutrition services to vulnerable women and children;
• Supporting the Baby-Friendly Hospital Initiative, which encourages breastfeeding and other best practices for infant survival; and
• Working multisectorally to address the underlying determinants of undernutrition, integrating nutrition-sensitive activities into other sectors, such as social protection, agriculture, and water and sanitation.

Much is known about cost-effective interventions to improve nutrition outcomes across the RMNCAH-N continuum. The GFF works through a partnership approach to support uptake and use of data and evidence to inform decision-making on nutrition.

With a focus on linking reforms to outcomes, the GFF engagement in Indonesia has focused support upon Indonesia’s multi-sectoral program or Convergence Approach in which multisectoral interventions are coordinated to jointly target priority geographic areas and most at-risk populations.

Engagement and Support

GFF supports management capacity and accountability system across sectors and levels of government and works with government to use existing resources more effectively. Specific examples include:

• Coordination platforms: to improve management capacity and align incentives horizontally (across sectors) and vertically (between levels) across government.
• Public financial reform: to address PFM issues to improve the efficiency in the allocation and use of existing resources. 
• Data systems and utilization for decision-making: to establish and utilize data to course correct program implementation towards results. 
• Delivery of critical gaps in the package of services: the focus is on  ECD for children 0-3 yeas-old, nutrition-sensitive food assistance, locally-adapted interpersonal behavioral change communication) critical to stunting reduction.
• Citizen engagement and accountability: to generate demand and improve accountability for nutrition interventions at the community level.

Implementation Progress

• Increased public spending from USD 1.9 billion in 2018 to USD 2.7 billion in 2021 informed by budget tagging and evaluation results.
• Established an integrated monitoring dashboard at national level managed by Vice President Office.
• Established a publicly accessible dashboard to monitor convergence actions implementation at the district level.
• Utilization of monitoring dashboard data to inform coordination platforms and regional planning and budgeting.
• Publication of District Performance Assessment results to inform the fiscal transfers allocation.
• Nutrition budget note presented to parliament in 2020 and 2021.
• Established Indonesia’s first annual anthropometric surveys to regularly measure stunting outcomes up to district level.

The GFF works with Exemplars in Global Health (EGH) to support both global and country uptake and use of evidence generated through the EGH program.

Exemplars in Global Health brings together experts, funders, and partners around the world with the mission of identifying positive global health outliers, analyzing what makes countries successful, and disseminating core lessons so they can be adapted in comparable settings. The program aims to help country-level decision makers, global partners, and funders make strategic decisions, allocate resources, and craft evidence-based policies. Become a member of the EGH community and sign up for the EGH monthly newsletter to learn more.

To learn more about stunting in children under 5 years, visit the Exemplars in Global Health webpage: Stunting Overview.

Several GFF countries have made great strides in reducing childhood stunting using a multisectoral approach.

Ethiopia
Exemplars in Global Health, in collaboration with The Hospital for Sick Children (SickKids) and Addis Ababa University, developed a case study to understand the drivers of stunting reduction in Ethiopia. From 1992 to 2016, Ethiopia cut its stunting rate from 67% to 38%. To achieve this, Ethiopia made significant investments in agriculture, education, vocational training, health systems and WASH conditions through impressive community-based programming, to deliver services at a large scale. This successful implementation was driven by a unified plan with decentralized execution, pro-poor policies targeting the most vulnerable communities, training for community health workers, effective donor coordination, strong data collection and evidence-based program design. Study details and additional key learnings can be found on the Exemplars in Global Health webpage: Ethiopia Overview.

Senegal
Exemplars in Global Health, in collaboration with The Hospital for Sick Children (SickKids) and Institute for Training and Research in Population, Development and Reproductive Health (IPDSR), developed a case study to understand the drivers of stunting reduction in Senegal. From 1992 to 2017, Senegal cut its stunting rate in half, from 34% to 17%. To achieve this, Senegal established the Cellule de Lutte contre la Malnutrition (CLM), a dedicated nutrition body within the office of the Prime Minister, that provides oversight and implements nutrition programming. Additionally, Senegal expanded its community health system and saw the number of women who completed four or more antenatal care visits increase from 14% to 57%. Study details and additional key learnings can be found on the Exemplars in Global Health webpage: Senegal Overview.

Uganda
Exemplars in Global Health, in collaboration with The Hospital for Sick Children (SickKids) and Makerere University School of Public Health, developed a case study to understand the drivers of stunting reduction in Uganda. From 1988 to 2016, Uganda reduced stunting rates from 48% to 29%, through implementation of direct and indirect nutrition actions, often using community-based delivery platforms. Much of the change in under-five stunting can be attributed to the scale-up of malaria control, specifically insecticide-treated nets (ITNs), to prevent malaria in pregnancy and during childhood, along with broader improvements to the health system. Investments in expanded access to primary and secondary education, especially for girls, improved school attendance over the last several decades. This had downstream, positive effects on women’s empowerment, employment opportunities and adolescent births and reduced the intergenerational transfer of malnutrition. Study details and additional key learnings can be found on the Exemplars in Global Health webpage: Uganda Overview.