Collaborative Governance in an Effort to Reduce Stunting Rate in TTS District, NTT Province

Jacoba Daud Niga

Universitas Nusa Cendana, Indonesia

Email: [email protected]

Article Information	ABSTRACT
Received: 29 March 2023 Revised: April 12, 2023 Approved: April 25, 2023 Online: April 27, 2023	· In NTT Province, the number of stunting cases reached 42.62% or very high prevalence of stunting so that there is a need for a collaborative governance process between institutions in the process of handling stunting, especially in TTS District, NTT Province, so the author uses the theoretical model of collaboration processes: inside the black box from Thomson and Perry (2006) as a theoretical study that is able to answer the problem of high stunting prevalence in NTT Province. The method used in this study is a descriptive method with a qualitative approach with a total of 76 people determined purposively then the primary data and secondary data collected were analyzed using data analysis techniques from Creswell (2016). The results of the study found that collaborative governance in an effort to reduce stunting rates in TTS District, NTT Province, was analyzed using the opinions of Thomson and Perry (2006: 24-28) with the following findings; (1) in the governance dimension, it was found that joint decision making to reduce stunting rates had not been carried out, (2) in the administrative dimension it was still limited to the problem of database integration of each indicator in each goal that was not complete, valid, and reliable, (3) in the autonomy dimension, it was found that there was no comprehensive understanding of stunting rate indicators by collaborating parties, (4) the mutuality dimension was not effective due to the lack of mutual  dependence between actors institutionally and (5) the process of building social norms found that there is no trust and reciprocity in coordinating the reduction of stunting rates in TSS District, NTT Province.
Keywords
Effort, Collaboration, Reduction, Stunting

INTRODUCTION

The current world situation is that around 162 million children under the age of five are stunted. If this trend continues, it is projected that by 2025 127 million children under the age of five will be stunted. According to the United Nations Children's Emergency Fund (UNICEF), more than half of stunted children, 56%, live in Asia, and more than a third or 37% live in Africa. Malnutrition affects 20% of children under five in developing countries. Stunting is a form of malnutrition when children have a low height for their age. The global prevalence of stunting in 2019 was 21.4% (Grantina et al, 2020).

One of the various developing countries in the world that is facing stunting nutrition problems (short toddlers) is Indonesia. It is known that the double triple of nutritional problems in Indonesia is stunting, wasting and overveight (Ministry of National Development Planning / BAPPENAS, 2019). The results of Bappenas research in 2019 also found that Indonesia is the country with the highest stunting rank number 5 in the world. Meanwhile, at the Southeast Asian level, the Asian Development Bank (ADB) reported that the prevalence of stunted children under the age of five years (toddlers) in Indonesia is the second highest in Southeast Asia.

Handling stunting needs to be a concern considering that it can have an impact on the level of intelligence, vulnerability to disease, reduce productivity, and hamper the economy of families and countries such as economic growth, increasing poverty, and inequality. The Ministry of Finance said World Bank Investing noted that stunting can eliminate 11 percent of gross domestic product (GDP) and reduce the income of adult workers by up to 20 percent. In addition, it can reduce 10 percent of a family's total lifetime income and lead to intergenerational poverty (katadata.co.id, 2020).

Data from the Ministry of Health of the Republic of Indonesia states that in Indonesia the prevalence of stunting toddlers in 2019 decreased compared to 2018, from 30.8 percent to 27.7 percent, but this figure is high, while based on the results of the 2021 Indonesian Nutritional Status Survey (SSGI) conducted by the Ministry of Health, the stunting prevalence rate in Indonesia in 2021 was 24.4%, or decreased by 6.4% from 30.8% in 2018.

Of the 260 districts/cities designated as districts/cities in 2020 with a focus on stunting reduction interventions, it is known that there are several districts/cities in NTT Province. This is considered logical because in the Basic Health Research Report of the Ministry of Health puts NTT Province as the province that has the highest stunting prevalence rate in Indonesia, even the stunting prevalence rate in NTT Province is higher, Papua and West Papua Provinces as the poorest provinces in Indonesia. 

The 2020 Riskesdas report has placed NTT Province as the defending champion by being the province with the highest stunting cases in Indonesia with a result of 43.82%, this figure is much higher than in 2018 of 42.6% (kemkes.go.id, 2020). In the 2007-2013 period, it decreased in the 2014-2016 period, and increased again in the 2017-2018 period, then in the SSGBI report in 2019 it decreased again at 27.7% (Ministry of Health, 2020). However, wide disparities between provinces and relatively slow average declines are challenges in the framework of accelerating stunting reduction to 14% by 2024. In 2019, there are 17 (seventeen) provinces in the high category (20-<30%), 4 (four) provinces in the medium category (10-<20%) and 13 (thirteen) provinces in the very high category (=30%), one of which is NTT Province which occupies the top position.

To further clarify the problem of stunting in NTT Province, stunting cases will be described per district in NTT Province in table 1 as follows:

Table 1

Number of Stunting Toddlers Per District in NTT Province Until February 2022

No	District/City	Number of Target Toddlers (S) (Projection)	Number of Toddlers Weighed (D)	% Toddlers Weighed (D/S)	% Stunting Feb 2022	% Stunting 2021	Trends 2021 - Feb 2022	STUNTING FEB 2022
								Very Short	Short	Usual	Tall	Measured	Number of Stunting
1.	WEST SUMBA	13,107	10,158	77.5	22.7	23.6	DOWN	635	1671	7806	46	10,158	2,306
2.	EAST SUMBA	25,892	22,428	86.6	20.9	19.1	UP	1130	3566	17691	41	22,428	4,696
3.	KAB KUPANG	39,480	29,856	75.6	24.1	22.3	UP	1856	5351	22519	130	29,856	7,207
4.	SOUTH CENTRAL TIMOR	45,859	41,707	90.9	29.8	32.1	DOWN	3697	8742	29211	57	41,707	12,439
5.	NORTH CENTRAL TIMOR	25,204	20,358	80.8	31.6	25.3	UP	1545	4883	13926	4	20,358	6,428
6.	BELU	22,243	18,058	81.2	16.2	17.9	DOWN	906	2014	15116	22	18,058	2,920
7.	ALOR	20,249	16,332	80.7	15.6	18.9	DOWN	559	1996	13723	54	16,332	2,555
8.	LEMBATA	14,663	8,364	57.0	22.7	22.2	UP	381	1514	6404	65	8,364	1,895
9.	EAST FLORES	25,328	17,809	70.3	20.4	20.9	DOWN	549	3087	14164	9	17,809	3,636
10.	SIKKA	31,394	23,204	73.9	17.2	18.2	DOWN	742	3242	19176	44	23,204	3,984
11.	ENDE	26,694	19,526	73.1	12.7	14.3	DOWN	454	2030	17020	22	19,526	2,484
12.	NGADA	16,385	10,918	66.6	10.6	11.7	DOWN	206	953	9744	15	10,918	1,159
13.	MANGGARAI	34,113	26,524	77.8	20.1	18.9	UP	1393	3927	21143	61	26,524	5,320
14.	ROTE NDAO	18,661	13,485	72.3	26.1	23.5	UP	981	2532	9955	17	13,485	3,513
15.	WEST MANGGARAI	28,332	23,208	81.9	16.2	15.1	UP	808	2961	19399	40	23,208	3,769
16.	CENTRAL SUMBA	7,316	7,635	104.4	8.8	8.1	UP	146	525	6941	23	7,635	671
17.	SOUTHWEST SUMBA	35,266	29,700	84.2	44.3	31.2	UP	4558	8592	16386	164	29,700	13,150
18.	NAGEKEO	14,498	11,376	78.5	10.4	9.2	UP	240	940	10177	19	11,376	1,180
19.	EAST MANGGARAI	28,539	23,759	83.3	11.6	13.7	DOWN	664	2103	20781	211	23,759	2,767
20.	SABU RAIJUA	10,177	8,390	82.4	24.4	25.5	DOWN	514	1534	6340	2	8,390	2,048
21.	MALACCA	19,405	16,318	84.1	18.9	21.5	DOWN	2269	807	13178	64	16,318	3,076
22.	KUPANG CITY	45,476	15,249	33.5	25.1	26.1	DOWN	1029	2800	11366	54	15,249	3,829
N T T		548,249	414,362	75.6	22.0	20.9	UP	25,262	65,770	322,166	1,164	414,362	91,032

Source: NTT Provincial Health Office, 2022

In the table above, it is known that from 22 districts/cities in NTT Province, there are 11 districts with fluctuating stunting prevalence rates, one of which is South Central Timor Regency whose stunting prevalence has dropped from 32.1% in 2021 to 29.8% in February 2022, but this figure is still high compared to other districts in NTT with a total stunting prevalence rate of 12,439 children and in an effort to accelerate stunting reduction  Therefore, a holistic, integrative, and quality movement is needed through coordination, synergy, and synchronization among ministries/agencies, provincial governments, district/city governments, village governments, and stakeholders so that a collaborative governance process between institutions is needed in the process of handling stunting in TTS District, NTT Province because in handling stunting every ministry, institution,  Non-governmental organizations (NGOs) and communities cannot run independently.

Collaboration is used to evoke elements of commitment or relational quality (Ariño &; De la Torre, 1998) and fair behavior within alliances (Ariño &; Ring, 2010; Luo, 2008), in the measure of collaboration as well as in the buyer-supplier relationship. Hoegl and Wagner (2005) include whether each side equally contributes to a common goal, thus indicating expectations about equality towards contribution. Because such equality can pose fairness problems where one party's contribution is not equal to another's (Doz, 1996; Ring & Van de Ven, 1994).

METHODS

The research method used in this study is a descriptive research method with a qualitative approach while the data sources in this study were obtained through primary sources and secondary sources collected using observation, interview and document tracing techniques through 76 informants related to research problems. Furthermore, the collected data will be analyzed using data analysis techniques from Creswell (2016: 264-268).

RESULTS

Stunting is a syndrome in which linear growth failure serves as a marker of various pathological disorders associated with increased morbidity and mortality, loss of physical growth potential, decreased neurodevelopmental and cognitive function, and increased risk of chronic disease in adulthood (Prendergast A.J. &; Humphrey J.H. 2014: 250). The current world situation is that there are around 162 million children under five years old who are stunted and the global prevalence of stunting in 2019 is 21.4% (Grantina et al, 2020) where one of the countries in the world that is facing stunting nutrition problems (short toddlers) is Indonesia (Margaretha et al, 2017).

Of the 514 districts/cities in Indonesia that in 2022 are designated as districts/cities with a focus on stunting reduction interventions, it is known that there are several districts/cities in NTT Province. This is considered logical because in the Basic Health Research Report of the Ministry of Health puts NTT Province as the province that has the highest stunting prevalence rate in Indonesia, even the stunting prevalence rate in NTT Province is higher, Papua and West Papua Provinces as the poorest provinces in Indonesia. 

The prevalence of stunting toddlers in three years in East Nusa Tenggara (NTT) Province continues to fluctuate. However, the figure is still high at 27.5 percent with 57 deaths. Data on the number of stunting in 2018 was 30.1%, then in 2019 it decreased to 27.9%. Meanwhile, until the August 2020 period, it was 27.5 percent and in 2021 it rose to 42.62% and was the highest in Indonesia (NTT Provincial Health Office, 2020). The results of the 2015 Inter-Census Population Survey (SUPAS) stated that the maternal mortality rate was 305/100,000 live births while data from the NTT Provincial Health, Population and Civil Registration Office stated an increase in the number of maternal deaths in 2021 to 181, and the number of infant deaths to 995 cases.

The category of stunting prevalence that has been determined by WHO 1995 is categorized into 4 parts, namely low, medium, high and very high prevalence. The following are the percent prevalence categories of stunting (World Health Organization, 2014):

<20% Low prevalence

20-29% Medium prevalence

30-39% High prevalence

>40% Very high prevalence

From the stunting prevalence category based on World Health Organization standards, NTT Province is at very high prevalence of stunting with the number of stunting cases reaching 42.62% and South Central Timor Regency whose stunting prevalence has dropped from 32.1% in 2021 to 29.8% in February 2022 tends to be still high compared to other districts in NTT with a total stunting prevalence rate of 12,439 children

These findings indicate the need for a collaborative governance process between institutions in the stunting eradication process in NTT Province because in handling stunting every ministry, institution, non-government organization (NGO) and community cannot run alone.

Referring to these findings, the author recommends the theoretical model of collaborative governance from Thomson and Perry (2006) as a theoretical study that can answer the problem of high stunting prevalence in TTS District, NTT Province, which according to Thompson and Perry (2006: 24-28), a collaboration model is composed of various basic elements of collaboration that form a certain series The stakeholder collaboration model is a description of the stakeholders involved  In collaboration, the roles, duties and responsibilities of each stakeholder as well as the characteristics of relationships between stakeholders are explained through causal relationships of collaboration elements that occur repeatedly form a framework to describe a collaboration.

Thomson and Perry (2006: 24-28) who conducted a collaboration study Processes: Inside The Black Box that the dimensions of collaboration in stunting prevention in TTS Regency are as follows:

1. The Process of Collaborative Governing: The Governance Dimension

The governance dimension is related to joint decision making, power-sharing arrangements, and problem solving. In the dimension of government, there are things that must be considered, namely as follows: (1) Hierarchical structure and authority do not dominate; (2) Awareness that collaborating parties are not only directly responsible for reaching agreement but must also impose decisions on themselves; (3) Availability to accept that all collaborating parties have legitimate interests so that the outcome reflects group consensus, not coalition forces or political forces.

Part of governance that has the capacity and responsibility to design and control systems that produce goods or services for the procurement of inputs and make outputs in reducing stunting rates in TTS Districts by:

Allocate personnel to each unit and function

Based on this explanation, the personnel for each unit and function with the aim of reducing stunting in TTS District are as follows:

At the TTS District level with personnel consisting of the Head of the TTS District Health Office, the Head of the TTS Regency BKKBN, the TTS Regency Women and Children Empowerment Integrated Service Center (P2TP2A) in charge:

Ensure planning and budgeting of programs/activities for priority interventions, especially in locations with high stunting rates and/or high service coverage gaps.

Improve service management for priority nutrition interventions and ensure that priority targets obtain and utilize the intervention packages provided.

Coordinate sub-districts and village governments in implementing priority interventions, including optimizing resources, funding sources, and updating data.

At the sub-district level with sub-district heads as personnel perform:

Coordination of stunting prevention interventions is led by the sub-district head as the sub-district coordinator.

The sub-district head meets regularly with subdistrict, village-level, and community officials to discuss planning and progress on interventions to reduce stunting.

Provide support in carrying out data monitoring and verification and assisting the implementation of activities at the village level.

At the village level in TTS Regency with personnel, namely village officials, Human Development Cadres (KPM), Family Hope Program (PKH) assistants, Puskesmas officers and village midwives, and Family Planning (KB) officers with the following duties:

Village governments synchronize the planning and budgeting of village development programs and activities to support the reduction of stunting rates.

Village governments ensure that each priority target receives and utilizes priority nutrition intervention service packages. The implementation of activities is carried out in collaboration with Human Development Cadres (KPM), Family Hope Program (PKH) assistants, Puskesmas officers and village midwives, and Family Planning (KB) officers.

The village government strengthens monitoring and evaluation of service implementation to all priority targets and coordinates target data collection and regular data updates.

In the dimension of government there are things that must be considered, namely as follows:

The author's findings are known that in terms of (1) The hierarchical structure and authority in stunting prevention in NTT Province are uneven and mutually dominating where there is no synchronization of personnel allocation for each unit and function in implementing the goal of reducing stunting rates in each organization in TTS District makes implementation in TTS District hampered, (2) Awareness that parties who collaborate in stunting prevention in NTT Province are not only  directly responsible for reaching agreement but also having to impose decisions on themselves does not yet exist and (3) Availability to accept that all parties collaborating in stunting prevention in NTT Province have legitimate interests so that the results reflect group consensus, not coalition forces or political forces still not felt by the community.

It should be very important to organize integrated stunting reduction interventions at the TTS district level to ensure:

Each institution understands its role and contribution in reducing maternal and infant mortality

Know the targets and locations of interventions to reduce maternal and infant mortality

Develop ways or methodologies to ensure that each target group receives the required interventions

Build a coordination mechanism between institutions that can be used to ensure program integration from planning, implementation, and monitoring.

Mapping and integrating national SDGs targets and indicators into the RPJMD

2. The Process of Collaborative: The Administration Dimension

The administrative dimension in collaboration is very important in the continuity of the relationship between collaborating parties in stunting prevention in NTT Province and the findings of the researcher are known that the administrative structure in stunting prevention collaboration in NTT Province has a central position for coordination of communication, organization and dissemination of information but has not been able to strive for collaborating parties to jointly manage their relationships in collaboration  The reduction in stunting rates is good in terms of clarity of roles and responsibilities of each actor, effective cooperation meetings, clarity of goals, well-coordinated tasks.

3. The Process of Reconciling Individual and Collective Interest: The Autonomy Dimension

The autonomy dimension has a contrasting relationship between shared control and individual control (Wood and Gray, 1991) in stunting prevention in NTT Province. In a collaboration, the actors involved protect their identity by maintaining individual control. On the other hand, joint control involves the availability of partners to share information, not only about their own organization's operations, but also about what they can and cannot collaborate on stunting prevention in NTT Province. The autonomy dimension tries to capture the implicit tension between the interests of actors and shared interests in stunting prevention efforts in NTT Province. This autonomy dimension indicator relates to the extent to which actors see stunting prevention collaboration in NTT Province as a barrier to the organization's mission, the belief that their profits are influenced by collaboration, and the awareness of actors to strive to meet organizational expectations and the expectations of other actors in collaboration.

However, the findings of researchers in the field are known that the Regional Apparatus Organization (OPD) in TTS District does not yet have a comprehensive understanding of stunting rate indicators where technical discussions are still limited to the issue of database integration of each indicator in each objective that is not complete, valid, and reliable so that the availability of partners to share information about their own organization's operations and about what they can and cannot in  collaborate for stunting prevention in TTS District, NTT Province

The available stunting rate data is also still very common, meaning that calculations still need to be made so that data is obtained in accordance with the indicators. Some of the data that are not available in BPS Kabupaten TTS is because some indicators are included in national-global indicators and OPD feels that it is not the obligation of regional apparatus organizations to achieve them.

4. The Process of Forging Mutually Benefical Relationship: The Mutuality Dimension

The dimension of mutualism is rooted in the interdependence between actors in stunting prevention in TTS District, NTT Province. Organizations involved in stunting prevention in NTT Province must experience interdependence both in common interests and differences in interests, which Powell (1990) later referred to as "complementarities". Complementarity describes a situation in which an organization sacrifices its right to gain power from other organizations in order to achieve their own interests. In the collaboration of stunting prevention in TTS District, NTT Province, interdependence is an important key so that relations between actors continue to be well established.

The author's findings show that interdependence between actors institutionally has not been effective where the availability of data in BPS TTS Regency is not used as a reference by OPD which spearheads the reduction in stunting rates. Each OPD conducts its own data collection through a data system by name by address while if examined carefully, organizational capacity development is a unity between organizations as in the context of the system (Brown, 2001), Morison, 2001, Araya-Quesada et al. (2010), community (Banyan, 2007), environment (OECD, 2008), institutions (Grindle, 1997; Horton et al., 2003) have the same orientation, namely how individual and organizational dimensions can interact with the environment in developing their capacity, and systems and communities are the environment of organizations and individuals within the organization.

But what happens to the regional apparatus organization in TTS Regency, each agency also has a different calculation method from each other. This condition causes the absence of valid and reliable data integration to be used as a reference in harmonizing regional programs and work plans. In addition, the current data does not represent the calculation method set by Bappenas in the integration of reducing stunting rates in the regions while data integration is needed to design policies and regulations that are really on target to achieve the goals that have been set (Gandara, 2008: 9) or to be achieved (Rainer Rohdewohld, 2005: 11).

5. The Process of Building Social Capital Norms: The Trust and Reciprocity Dimension

In the stunting prevention collaboration in TTS District, NTT Province, individual actors will show willingness to interact in collaboration if other actors also show the same willingness. The reciprocal relationship will form trust between collaborating parties if done repeatedly. The existence of trust between collaborating parties in stunting prevention in TTS District, NTT Province, provides benefits for the continuity of collaboration, namely; (1) in good faith, the collaborating parties will behave in accordance with explicit and implicit commitments;  (2) be honest in any negotiations; (3) Collaborating parties will not take advantage of more despite the opportunity (Cummings and Bromiley, 1996: 303).

The author's findings are known that one of the institutions that handles stunting is BKKBN, but stunting handling at BKKBN is not too focused and BKKBN argues that the task is the domain of the Health Office, even BKKBN does not have stunting rate data, even in some agencies there is no program that includes stunting reduction as the main indicator. Bappeda itself does not coordinate stunting reduction programs with related agencies so that the process of building social norms: trust and reciprocal dimensions has not been effectively implemented because each OPD still works individually

A willingness to interact in collaboration through organizing stunting reduction interventions at the TTS District level should be essential to ensure each institution understands its role and contribution, knows the goals and locations of stunting reduction interventions, develops ways or methodologies to ensure that each target group receives the required interventions, establishes coordination mechanisms between institutions that can be used to ensure  implementation of program integration from planning, implementation, and monitoring as well as mapping and integrating national stunting targets and indicators into the RPJMD.

CONCLUSION

Collaborative governance in efforts to reduce stunting rates in TTS District, NTT Province, was analyzed using the opinions of Thomson and Perry (2006: 24-28) with the following findings; (1) in the governance dimension, it was found that joint decision making to reduce stunting rates had not been carried out, (2) in the administrative dimension it was still limited to the problem of database integration of each indicator in each goal that was not complete, valid, and reliable, (3) in the autonomy dimension, it was found that there was no comprehensive understanding of stunting rate indicators by collaborating parties, (4) the mutuality dimension was not effective due to the lack of mutual  dependence between actors institutionally and (5) the process of building social norms found that there is no trust and reciprocity in coordinating the reduction of stunting rates in TSS District, NTT Province.

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