Gender, Poverty, and Disability in the National Action Plan for Food and Nutrition 2017-2019 of Indonesia and Ways Forward

INTRODUCTION Over the past two decades Indonesia has undergone a major economic transformation including reducing the poverty rate by more than half to a current level of about 10% and becoming the 10th largest economy in the world. However, as the fourth most populous nation, this means that about 25 million Indonesians are living below the poverty line and even more are at-risk of falling into poverty (1). Although Indonesia’s economic growth has been impressive, indices related to human development and inclusion indicate that there is room for improvement. Across several indices, Indonesia is ranked in the bottom third to the bottom half of all countries (Figure 1).


INTRODUCTION
Over the past two decades Indonesia has undergone a major economic transformation including reducing the poverty rate by more than half to a current level of about 10% and becoming the 10th largest economy in the world. However, as the fourth most populous nation, this means that about 25 million Indonesians are living below the poverty line and even more are at-risk of falling into poverty (1). Although Indonesia's economic growth has been impressive, indices related to human development and inclusion indicate that there is room for improvement. Across several indices, Indonesia is ranked in the bottom third to the bottom half of all countries (Figure 1).

Figure 1. Indonesia's percentile rank (compared to other countries worldwide) across several development indices
Furthermore, Indonesia's inequality-adjusted human development index (IHDI) score, which reflects actual development considering disparities in achievements across health, education, and income within the population, continues to track far below the HDI score, which is a measure of "potential" development ( Figure 2). In Indonesia, the loss in HDI due to inequality is 17.4% which is worse than in Australia (8.1%) and Singapore (13.3%), similar to that of the Philippines (18.2%) and Cambodia (20.1%), and better than in Laos (24.9%) and Timor-Leste (28.0%) (Figure 3). Within Indonesia, the loss in HDI due to inequality is similar across the dimensions of life expectancy, education, and income indicating inequalities across all of these dimensions (Figure 3).  As Indonesia's economy continues to grow, it is essential that policy makers and program implementers understand the differential impacts of this growth across population groups and the inequalities that can occur. To address this, it is important to consider whether changes in policies or programs are needed to ensure equitable growth and reduce inequalities for affected groups such as women, people living in poverty, and persons with disabilities. This is especially important to consider in nutrition-related policies and programs for several reasons. First, socially excluded groups are often the most at risk for health and nutrition problems. Second, these groups generally face greater challenges to accessing adequate goods and services such as healthy diets and high-quality health services. Third, addressing issues related to gender inequality and poverty can improve nutrition outcomes through different pathways, some of which can lead to long-term and intergenerational benefits.

Figure 2. Human development index (HDI) and inequality-adjusted HDI (IHDI) for Indonesia
This brief offers a concise overview of how, and to what extent, social inclusion, related to gender, poverty, and disability, was clearly specified in the National Action Plan for Food and Nutrition of Indonesia for 2017-2019 ("Action Plan"). It also provides a set of recommendations of how these social inclusion dimensions could be considered in future iterations of the Action Plan and/or associated policies and programs in Indonesia based on examples from other countries in the region.

METHODS
We reviewed the Action Plan through the lens of social inclusion as it relates to gender, poverty, and disability. We considered whether issues related to gender, poverty or disability were mentioned in the Action Plan in general, within each of the five pillars and if relevant indicators were listed as being tracked. In addition, to help identify opportunities for greater consideration of gender equity and social inclusion in the Action Plan in Indonesia, we also conducted a select review of programs from other Southeast Asian countries (and elsewhere when evidence from Southeast Asia was limited) in which gender, poverty, and/or disability have been meaningfully considered in nutrition-related policies.

NATIONAL ACTION PLAN FOR FOOD AND NUTRITION 2017-2019
The Action Plan is a guide for the implementation of food and nutrition policies at the central level with an aim to increase food security and improve nutrition outcomes, especially among women and children. Although the importance of considering gender, poverty, and disability in program design and targeting is mentioned throughout the Action Plan, there is limited evidence to suggest that the programs implemented are specifically designed to address or asses these issues. Across the five pillars that underpin the Action Plan, poverty was the most often considered, specifically being highlighted in three of the five pillars (Table 1). Whereas, gender and disability, were only considered in the first pillar. Within this pillar, gender was only specifically mentioned in two of the fifteen programs, and disability in one (Table 1).

SUMMARY | APRIL 2010
In addition to the limited evidence of specific consideration of gender, poverty, and disability within the five pillars, we found a few overarching gaps that limit the potential of the Action Plan to be inclusive of gender, poverty, and disability. These relate to program targeting, monitoring and evaluation, and to a clear understanding of the overall policy landscape and coordination across programs and policies. Most programs listed in the Action Plan do not provide adequate information on who the intended beneficiaries are with very few specifically mentioning targeting women, people living in poverty, or with disabilities. In addition, very few programs clearly articulated that gender, poverty or disability-related indicators would be collected. Tracking these types of indicators would enable analysis of the population groups being reached, how inclusive programs are, and if impacts differ across population groups. Conducting qualitative research related to the implementation of these programs may also help understand what is working well and what could be improved.
Lastly, the Action Plan does not include a description of the overall policy landscape and how this policy relates to or is expected to complement other policies, or how policies and programs are coordinated across relevant sectors. The apparent lack of specification in program design, coordination, and monitoring and evaluation in the Action Plan may not reflect the reality in program implementation. However, it does indicate a need to more clearly articulate how policies and programs should be designed, implemented, coordinated, monitored and evaluated to ensure inclusive programs and policies. Applying a social inclusion lens for all aspects of the policy including the design and implementation of the different actions, activities, and programs implemented under the policy could greatly contribute to creating a more inclusive policy framework and ultimately reducing inequalities from the level of implementation down to the impacts of the program. Key to this would be to ensure that people representing typically excluded groups be included from the beginning of the design process and throughout.

Gender
The 2016 report on nutrition security in ASEAN identifies the promotion of gender equality and women's empowerment as one of the key nutrition-sensitive intervention strategies and specifically emphasizes the need to address the issues of early marriage and teenage pregnancy (2). Most countries in Southeast Asia have acknowledged women of reproductive age, especially pregnant and lactating women, as a nutritionally vulnerable group in their national nutrition strategies and action plans and have strategies designed to address relevant nutrition problems, especially anemia (3-10). Some countries, however, have applied a broader, more comprehensive gender lens to their nutrition policies. For example, Cambodia, Laos, and Timor-Leste have recognized the importance of improving women's socio-economic status (i.e., through education and income-generation) as well as agency (such as, decision-making power and control over resources) in their nutrition strategies in addition to having interventions directly targeting women's health and nutrition (3, 5,9). While the Action Plan of Indonesia lists some gender-specific nutrition interventions such as the provision of iron supplements for adolescent girls and pregnant women, it lacks more comprehensive consideration of gender norms, roles, and other opportunities to reduce gender inequality in Indonesia more broadly.

Poverty
Although poverty eradication often falls under the mandate of social protection strategies or broader economic development plans, acknowledging the linkages between poverty and malnutrition within the policy vision sets the stage for poverty inclusion in nutrition programming. Many of the Southeast Asian countries, in their national food and nutrition action plans, have discussed the ways in which poverty can contribute to poor nutrition (4,5,7-9). Myanmar has taken an extra step and assessed the urban/rural and wealth differentials in food poverty and nutritional status across the country to better understand the complex association between these socio-economic differences and nutrition outcomes (7). Similar analyses have been conducted in other countries and can be useful for understanding how to effectively design and target programs. To address multiple dimensions and various forms of malnutrition, Myanmar has also emphasized the effort in coordinating between different national policies and strategies, including the Rural Development and Poverty Reduction Strategy, to work in harmony with the nutrition plan (7). Indonesia has implemented several programs to address the needs of those living in poverty such as subsidized rice for the poor (Raskin/Rastra), health Insurance for the poor (Jamkesmas), cash transfers for poor students (BSM), conditional cash transfer program for poor families (PKH) and the child assistance program-PKH (Program Perlindungan Pekerja Anak-PKH). In addition, the government has suggested an institutional approach to addressing undernutrition that consists of participating government ministries and agencies from other sectors. However, it is unclear how the strategies to reduce poverty also consider nutrition or how the Action Plan would work with other national policies or strategies.

Disability
While some countries in Southeast Asia have recognized the links between malnutrition and disability, they have failed to articulate on how the nutrition policies and programs can be designed to address such concerns (5,10). Yet, disability tends to be more visible and recognized in social protection policies and broader development plans, through programs in employment, education, housing, and social welfare. For example, in Malaysia, several social protection programs have been designed to be more inclusive of disability, with an emphasis on improving access to economic opportunities through employment guarantee schemes and skills training (11). In Cambodia and Myanmar, disability-based cash transfer programs have been put in place to help people with disabilities meet their immediate needs (12,13). The issue of malnutrition, however, has not been considered central to the priorities in these efforts. In Indonesia, although people with disabilities have been targeted in the social rehabilitation program and disability is included as an indicator measuring performance of the program, the indicator lacks specificity and a standardized definition. Similarly, as seen in other national nutrition plans, the Indonesia Action Plan doesn't pay adequate attention to disability as an important factor that can affect nutritional outcomes.

RECOMMENDATIONS
To develop food and nutrition policy and programming in Indonesia that is inclusive of vulnerable groups of interest, this brief provides the following high-level recommendations, spanning from policy design to program implementation and evaluation.
1. Raise awareness within the leadership about social exclusion and the importance of building a socially inclusive food and nutrition strategy. Involve representatives from traditionally excluded groups in the planning of the food and nutrition strategy.
2. Harness political and financial commitment from key participating ministries/agencies and other stakeholders to embed a social inclusion strategy within the multisectoral approach.
3. Build/strengthen local partnerships and facilitate intersectoral coordination between all relevant stakeholders across all phases from design and implementation through monitoring and evaluation of the Action Plan.
4. Design new programs or improve existing programs where gaps exist. Consider integrating nutrition-sensitive measures and addressing the underlying causes of malnutrition as well as the enabling environment.
5. Provide clear definitions of all terms used in the Action Plan and cite statistics on nutritional outcomes that are disaggregated by gender, wealth levels, and disability, where appropriate. Report on best practices in implementation of programs to reach and include these vulnerable groups.
6. Provide clear guidance as to when and how socially excluded groups should be targeted through nutrition-specific and nutrition-sensitive programs.
7. Assess the reach, coverage, and impact of the programs in the Action Plan. Where possible, collect more and better-quality data, including qualitative data, to fully capture all dimensions of social inclusion/exclusion in nutrition and nutrition-related programs.