Stunting policy convergence model in South Buton Regency Model

Stunting is not only related to health problems, but it is related to various other conditions that do not directly affect health, such as low productivity of human resources. The right policy implementation model will greatly assist in preventing stunting in society. This study aimed to model the convergence of local government policies in stunting prevention efforts by paying attention to organizational and inter-organizational behavior, lower control behavior, and target group behaviour. The study used a qualitative design with a phenomenological approach. The data were collected through in-depth interviews with 14 informants, while the secondary data came from the relevant regional apparatus organizations data. Then it was analyzed in several stages, namely the stage of data collection, data reduction, data presentation and drawing conclusions. The results of this study were that behaviour and between organizations form a commitment to contribute to stunting prevention, then at the behavioural level the organization really understood the role and function in carrying out stunting prevention and control programs, and the behaviour of the target group showed different responses positively and negatively. So that, it could be concluded consistency of policy implementers must determine shared commitments and common goals in stunting prevention.


Introduction
Stunting or chronic malnutrition is another form of growth failure.The World Health Organization (WHO) defines stunting as a state of very short stature that exceeds a deficit of -2 SD below the median length or population height, which is the international reference (Trihono et al., 2015).Stunting has an impact on children starting from the beginning of their lives and will continue in the human life cycle (Ariyanti et al., 2022).
The Vice President of the Republic of Indonesia led the National Team for the Acceleration of Poverty Reduction (NTAPR, in Indonesian called Tim Nasional Percepatan Penanggulangan Kemiskinan/TNP2K) to launch the Stunting Reduction Program (Azhari & Mashur, 2022).The focus location of the stunting reduction intervention Since it was first implemented in 2018, the location has continued to grow, from 100 districts or cities in 2018 to 160 districts or cities in 2019, then increasing to 260 districts or cities in 2020.In 2021, this number has expanded to 360 regions or cities.Coverage will continue to increase until 2023 and will spread across 514 regions or cities.It is hoped that by 2024, all districts and cities will implement integrated stunting reduction interventions to support the achievement of the 2020-2024RPJMN target (Cegahstunting.id, 2023).
The Ministry of Health released the results of the Indonesian Nutritional Status Survey (INSS, in Indonesian called Studi Status Gizi Indonesia/SSGI), in which the prevalence of stunting in Indonesia decreased from 24,4% in 2021 to 21,6% in 2022.Presidential Regulation Number 72 of 2021 Concerning the Acceleration of Stunting Reduction with Five Pillars The first pillar is commitment; the second pillar is stunting prevention; the third pillar must be able to converge; the fourth pillar provides good food; and the fifth pillar makes breakthrough innovations and good data (Tarmizi, 2023).Therefore, stunting prevention is carried out with coordination and care towards prioritizing georgarfis and family achievements (TNP2K, 2018).

Stunting
reduction policies are implemented not only under the responsibility of the Ministry of Health but also require the involvement of not only the provincial government and village governments but also non-government institutions, related Regional Organizations such as Regional Population and Family Planning Board (in Indonesian named Badan Kependudukan dan Keluarga Berencana Daerah/BKKBD), Regional Development Planning Agency (Badan Perencanaan Pembangunan Daerah/Bappeda), food security, community groups, and the private sector.This was the focus of preventing stunting in terms of policy convergence (TNP2K, 2018).
Stunting adversely affects brain development in children early in life, leading to a slowdown and reduction in the number and development of brain cells and other organs (Alfarisi et al. 2019).At school age, stunting can cause cognitive weakness and lower physical and mental intelligence (Yadika et al. 2019).The effects obtained interfere not only with linear growth, but also with the development of the child's brain (Patimah, 2021).The serious problem of stunting in children involves the risk of greater morbidity and mortality, obesity, and noncommunicable diseases.As an adult, he experiences poor cognitive development, a short body, and low productivity and income (Khotimah, 2022).
Adverse effects caused by nutritional problems (stunting) in the short term include disruption of brain development, impaired intelligence, impaired physical growth, and metabolic disorders in the body.In the long run, the adverse consequences include decreased cognitive abilities, learning achievement, and uncompetitive work quality, which results in low economic productivity (Ekayanthi & Suryani, 2019).
The occurrence of stunting can be triggered by several non-medical factors such as the socioeconomic level of the community.Children born to highly educated parents are less likely to be stunted than children born to parents with low education (Akombi et al., 2017).Economic conditions also had a significant effect on the incidence of stunting in children aged 0-59 months.Children from families with low economic status tend to have less nutritional intake (Chirande et al., 2015).In the results of their research, Akombi et al. (2017) showed that family economic status greatly affects the level of children's health.Economic status is closely related to the ability of families to meet nutritional intake and health services (Sari, 2019).
To overcome nutritional problems, the government established Presidential Regulation Number 42 of 2013, which regulates the implementation of the National Movement for the Acceleration of Nutrition Improvement.Both direct (specific) and indirect (sensitive) nutritional interventions need to be carried out jointly by ministries, institutions, and other stakeholders (Haryanti & Hayati, 2019).Stunting prevention efforts must be carried out in an integrated and convergent manner with multisector involvement (Hermawati & Sastrawan, 2020).
Convergence refers to the coordination and integration of multiple sectors, including health, education, agriculture, and social services, to reduce the incidence of stunting.Lenschow et al. (2005) specifically mentioned that the cause of convergence is most likely caused not only by voluntary interaction from state actors in the international arena but also by a tendency for domestic regions to act focused on one desire rather than another.Gani (2021) defined convergence as an intervention approach that is implemented in an integrated, joint, and coordinated manner on target targets in priority geographical areas and families to overcome stunting.Convergent interventions are implemented by combining or integrating diverse resources to achieve common goals.
In an effort to overcome the incidence of stunting in its jurisdiction, the South Buton Regency Government issued South Buton Regent Regulation Number 14 of 2020 concerning Integrated Stunting Prevention, where the purpose is set to provide references that have legal certainty that can be used to plan and implement activities to support stunting reduction efforts (Busel, 2020).
However, the efforts made by the South Buton Regency government have not had a positive impact on reducing stunting; it has been proven that the stunting prevalence rate in 2020 of 27% actually increased to 28,32% in 2021, so a policy convergence model is needed that can be used as a reference to be implemented so that stunting reduction can be achieved.
The purpose of this study is to find the right convergence model for stunting reduction in the South Buton Regency that can be used as a reference.

Methods
This study used qualitative methods with a phenomenological approach.This research was conducted in the South Buton Regency from February to November 2022.Data were collected through in-depth interviews with 14 informants, while secondary data came from related Regional Organizations.The data is then analyzed in several stages: data collection, data reduction, data presentation, and conclusions.
Data were obtained from document sources, interviews, and direct observations of actors who participated in stunting prevention and control efforts in the South Buton district.All evidence and the source of the findings are determined by purposive sampling techniques, and data sources are determined only from data sources that can explain the research focus, namely, the convergence of stunting reduction policies in the South Buton District.
The validity of the data can be obtained by conducting a triangulation process consisting of (1) source triangulation, namely, by checking data that has been found from various sources such as interviews, archives, and other sources; (2) Triangulation Technique, namely, by checking data with the same source but with different techniques, such as interview results checked again with observations; and (3) time triangulation, namely, by checking back on the data obtained at different times and situations until obtaining valid data.

Result and Discussion
Efforts made in the convergence of stunting reduction policies in the South Buton Regency are carried out jointly by involving all related Regional Organizations, where the Health Office is in charge of implementing specific nutrition interventions and Regional Organizations other than the Health Office are in charge of being involved in sensitive nutrition interventions (Iqbal & Yusran, 2021).

Organizational and Interorganizational Behavior
One of the factors for the success of the implementation of local government policies in stunting reduction in the South Buton Regency is organizational and inter-organizational behavior, which includes commitment and coordination.
The form of commitment of the Regional Head and stakeholders or related agencies, as well as the commitment statement signed by the Regent of South Buton, is carried out in the program to accelerate stunting prevention and handling in the South Buton Regency, especially in stunting locus villages.Policy implementation has been realized with evidence of budget allocation for stunting prevention and control programs and activities through the regional budget contained in the Budget Implementation Document of each relevant Regional Organizations, and then implemented with a commitment to be implemented based on its functions and roles.Although budget allocation has not been able to accommodate all existing needs, some Regional Organizations have not maximized their functions and roles.
Therefore, strong commitment and sufficient budget allocation support for every stunting prevention and control program and activity in the South Buton Regency must be fulfilled.Because sufficient budget allocation is an important factor in supporting the success of a program or activity carried out by the government, coordination in the implementation of stunting prevention and control policies is carried out by cross-sectoral organizations that are policy implementers (Suhroh & Pradana 2021).
Coordination is very influential in networks between organizations when determining regional economic strategies (Rahmawati et al., 2020).In carrying out existing policies, coordination is carried out by stakeholders, both in terms of program formulation and activities to be carried out, the implementation of activities in the field, and even in terms of decision-making.
According to Malon et al. ( 2020), coordination is an interdependent action for managing activities.This understanding shows that for organizational activities to produce output as expected, especially in activities that are complex and involve many elements, coordination is needed to achieve maximum output (Borgatti & Everett, 2000).Complicated organizations as a cause of coordination do not work as expected.
The results of the researcher's interviews with the informants revealed the following: "Coordination is carried out in the form of compiling reports on the results of activities, both examinations of pregnant women and Integrated Healthcare Center toddlers and nutrition counseling in the field." "The report is then submitted to the Health Office, which will then be a reference in the process of formulating further activities."This is in line with Van Meter's view, and as Van Horn explained in various facts, the implementation of a program sometimes requires support and coordination with other institutions to achieve the desired goals (Van Meter & Van Horn, 1975).
The informants also said that "Coordination of the implementation of stunting reduction activity programs is carried out through meetings facilitated by Regional Development Planning Agency, including stunting workshops." "Coordination meetings are held before and after each action, from Action 1 to Action 8." "Meetings held before the implementation of the action to record and collect what is needed, collect the data needed in the implementation of the action, and meetings held after the action are intended to report the results of the implementation of the action." The form of coordination is carried out in actions I to 8, involving all relevant stakeholder teams, including the Ministry of Agriculture.
"We formulate which villages are the locus, where the prevalence is the highest, and coordination is carried out through meetings facilitated by Regional Development Planning Agency, including stunting workshops." The eight convergence actions in question are situation analysis, activity plans, stunting workshops, regulations on the role of villages, human development cadres, data management, measurement and publication, and annual performance reviews (Yuliana et al., 2022).
The stunting workshop that was held also presented elements outside the South Buton Regency Government, namely academics, who provided input and responses to stunting prevention and handling programs in the South Buton Regency.
The informants added: "Even though the ultimate goals and objectives of this form of coordination were achieved, in its implementation, it still encountered obstacles.""One of the obstacles that occurs is the inconsistency of stakeholders in presenting representatives at every coordination meeting." "For example, the first meeting presented is A, but the next meeting that is present is B, so this will certainly cause misunderstanding for those who attend the next meeting.Those who attend every meeting should be consistent with the same people so that the understanding of the sustainability of the implementation of programs and activities will be the same." In addition, another obstacle to coordination is the unavailability of a data management system, so sometimes the data presented is also different.For example, family data, which are the locus of stunting, must receive sensitive intervention from the Public Works and Spatial Planning Office (PWSPO, in Indonesian named Pekerjaan Umum dan Penataan Ruang/PUPR).In this case, there are no names or addresses for the construction of clean water facilities.To ensure that the beneficiaries are on the target, officers from the PUPR Office must go to the field accompanied by the local village head to rerecord which families are entitled to assistance in handling stunting.If the data management system is integrated, officers from the relevant agencies do not have to go to the field again to re-record.

Lower-level Bureauctratic Behavior
In addition to organizational and interorganizational behavior, one of the important factors in the implementation of local government policies for stunting reduction in the South Buton Regency is the behavior of lower-level bureaucracy.
Lower-level bureaucracy is one of the key actors in the implementation of public policy, and its work is consistently guided by program standards related to its activities.The results of the interviews with health worker informants stated the following: "Our role and function in preventing and handling stunting as health workers in the field is to change the behavior of the community, especially mothers and mothers-to-be.""The behaviors referred to here are diet and parenting." "Diet is food availability and knowledge about food content, while parenting is how food availability and knowledge about food content are implemented." Furthermore, researchers conducted interviews with policy implementers, obtaining information that informants, as implementors, had carried out their respective roles and functions.
"One of the roles we do is entrust stunting prevention messages to "Bisa" marriage and childbirth.""...Although we have been given socialization about stunting prevention through the Health Office, "Bisa" has actually run this stunting prevention program through local wisdom long before stunting was known to the community and became a government program." Local wisdom that is closely related to handling stunting is the "Posuo" procession, which is a traditional ceremony held when a woman has changed her status from kabuabua, or teenage girl, to kalambe, or adult girl (Muslim et al., 2021).

Hisanuddin et al.
In this posuo procession, young women are given knowledge about how they behave when entering the household ark because the role of women in a family is very important and influential, both for their husbands and offspring (Andriani, 2019).The role and behavior in question are how a woman prepares herself as a wife and even more so as a mother later.
In addition to the Posuo ritual, after a woman marries and then conceives, there is another thing called the Posipo ritual, which is a traditional seven-month pregnancy ritual to welcome the birth of a baby.In this posipo ritual, pregnant women are fed a number of foods that are considered to bring blessings to the mother and prospective baby in the third trimester (Andriani & Mufida, 2021).Although, according to the informant of the health officer, "the nutritional content in posipo food is not perfect to meet the needs of pregnant women, it is necessary to combine it with other types of healthy foods so that the nutritional needs of pregnant women can be fully met."Human Development Cadres and Integrated Healthcare Center Cadres, each of whom has carried out its functions and roles well, where the Human Development Cadre conducts detailed data collection on how many pregnant women are in the village and how many children in the village are aged 0-4 months.While carrying out their duties, Human Development Cadres sometimes go directly to the village without first reporting to the village government.This is because if they have to report to the village first, there will be a waste of time, and the process will be quite timeconsuming, which will hamper the data collection process in the field.
While the Integrated Healthcare Center Cadres perform their roles and functions to determine who the pregnant women are, ensure that pregnant mothers check their health at the public health center, and ensure that mothers who have toddlers around their homes routinely bring their toddlers to the Integrated Healthcare Center, and during the implementation of Integrated Healthcare Center activities, Kepo Cadres are given the responsibility to help health workers measure and record the weight and height of toddlers.
Another study found that Empowering Family Welfare (EFW, in Indonesian named Pemberdayaan Kesejahteraan Keluarga/PKK) of South Buton Regency has also carried out stunting prevention and handling activity programs by routinely socializing activities and providing supplementary feeding to children in stunting locus areas.However, this activity is only carried out once a year because of the limited budget allocation.
Based on the descriptions of the interview results and observations in the field, it was concluded that the lower-level implementors, namely health workers, "Bhisa," cadres, Human Development Cadres (in Indonesian called Kader Pemberdayaan Masyarakat/KPM), and EFW administrators, already understand their roles and functions in carrying out stunting prevention and control activity programs in South Buton Regency.The role of Bhisa is to support efforts to improve maternal and child health (Andriani et al. 2021).However, some implementors, especially cadres recruited from the community, still need regular training and coaching (Andriani & Mufida, 2021).Therefore, in carrying out its roles and functions, it is consistently guided by rules that have been set.In addition, the professionalism of the officers must be supported by maximum budget allocation so that the activities they carry out are fast and on target in preventing and overcoming stunting in the South Buton Regency.
Organizational control functions carry out control over all activities carried out by employees both inside and outside the work environment, so that employees can carry out duties properly based on their main duties and functions (Zainal, 2014).
The results of interviews with informants revealed that the one who controls all the implementation of tasks and functions of the regional apparatus related to stunting handling is the Regional Development Planning Agency as the leading sector.Organizational control is carried out not only through the monitoring and evaluation of reports carried out at coordination meetings but also by going directly to the field to check the extent of the truth of the reports received from each RDOs concerned.
Interviews with several informants stated that, in order to know the extent of the progress of the programs and activities carried out by their RDOs, reports on the results of implementation became mandatory in every coordination meeting.Meanwhile, based on the results of interviews with other informants, they compiled periodic reports to be submitted to relevant agencies as evaluation materials.
Based on the descriptions of the interview results above, the researcher concluded that organizational control was carried out by the regional apparatus, which is the leading sector, as input material for conducting policy evaluations.

Target Group Behavior
In addition to organizational and interorganizational behavior and target group behavior, there is one more factor that influences the success of stunting prevention and handling policies in the South Buton Regency, namely target group behavior, whose dimensions are positive and negative responses.
The behavior of the target group not only has an influence on the policies made, but also has an impact on the performance of lower-level agencies.If the resulting effect is good, then the performance is good and vice versa.Target group behavior includes positive and negative responses from the community in supporting or not supporting a policy, as well as feedback in the form of target group responses to policies.Public support for a policy If it is not supported by the target group, the policy will not be maximally implemented (Sabatier & Mazmanian 1980).
The results showed that the community received positive support for the implemented policies.This is based on the results of the researcher's interviews with informants 13 and 14, who said that.
"They feel very helped by the government's program in preventing and dealing with stunting because they are assisted not only in terms of health, but also in the construction of clean water and sanitation facilities from related agencies.
Interviews with informants 1 and 8 revealed that, based on the results of field visits by the Regional Development Planning Agency and the health office, it can be concluded that the community's response was very good.In addition to learning about the importance of stunting prevention for the golden generation, especially in South Buton District, it is hoped that the youth will be productive and competitive.
Based on the descriptions of the interview results and observations in the field, it was concluded that the lower-level implementors, namely health workers, "Bhisa," cadres, Human Development Cadres (in Indonesian called Kader Pemberdayaan Masyarakat/KPM), and EFW administrators, already understand their roles and functions in carrying out stunting prevention and control activity programs in South Buton Regency.The role of Bhisa is to support efforts to improve maternal and child health (Andriani et al. 2021).However, some implementors, especially cadres recruited from the community, still need regular training and coaching (Andriani & Mufida, 2021).Therefore, in carrying out its roles and functions, it is consistently guided by rules that have been set.In addition, the professionalism of the officers must be supported by maximum budget allocation so that the activities they carry out are fast and on target in preventing and overcoming stunting in the South Buton Regency.
Organizational control functions carry out control over all activities carried out by employees both inside and outside the work environment, so that employees can carry out duties properly based on their main duties and functions (Zainal, 2014).
The results of interviews with informants revealed that the one who controls all the implementation of tasks and functions of the regional apparatus related to stunting handling is the Regional Development Planning Agency as the leading sector.Organizational control is carried out not only through the monitoring and evaluation of reports carried out at coordination meetings but also by going directly to the field to check the truth of the reports received from each Regional Organization concerned.
Interviews with several informants stated that, in order to know the extent of the progress of the programs and activities carried out by their Regional Organization, reports on the results of implementation became mandatory in every coordination meeting.Meanwhile, based on the results of interviews with other informants, they compiled periodic reports to be submitted to relevant agencies as evaluation materials.Based on the descriptions of the interview results above, the researcher concluded that organizational control was carried out by the regional apparatus, which is the leading sector, as input material for conducting policy evaluations.

Target Group Behavior
In addition to organizational and interorganizational behavior and target group behavior, there is one more factor that influences the success of stunting prevention and handling policies in the South Buton Regency, namely target group behavior, whose dimensions are positive and negative responses.
The behavior of the target group not only has an influence on the policies made, but also has an impact on the performance of lower-level agencies.If the resulting effect is good, then the performance is good and vice versa.Target group behavior includes positive and negative responses from the community in supporting or not supporting a policy, as well as feedback in the form of target group responses to policies.Public support for a policy If it is not supported by the target group, the policy will not be maximally implemented (Sabatier & Mazmanian 1980).
The results showed that the community received positive support for the implemented policies.This is based on the results of the researcher's interviews with informants 13 and 14, who said that "They feel very helped by the government's program in preventing and dealing with stunting because they are assisted not only in terms of health, but also in the construction of clean water and sanitation facilities from related agencies.
Interviews with informants 1 and 8 revealed that, based on the results of field visits by the Regional Development Planning Agency and the health office, it can be concluded that the community's response was very good.In addition to learning impo.
In addition, the community's response is very good because, in addition to thematic poverty programs, stunting is also a national program where the community feels positive impacts directly.For example, some previous studies did not have MCK facilities, and there were no clean water and sanitation facilities.With a specific stunting prevention program, all these needs can be met by the government.
The results of the researcher's interview with informants as lower-level implementors said that to determine the community's response to the program of activities that have been carried out by health workers, the community, in this case pregnant women and breastfeeding women, will be given questions through image media, where the picture contains "the contents of my plate," which is a portion of food, with half the plate filled with vegetables and fruit, and the other half filled with protein sources (both vegetable and animal) with more proportions than carbohydrates.
Health workers will ask the public to explain what "the contents of my plate" are, the benefits of "the contents of my plate," and what people do with the contents of their plates.The questions through the images are intended as feedback on the program of activities carried out by health workers in the field and to determine whether the target community, namely pregnant and lactating women, implements all the knowledge provided by health workers.
There are negative and positive responses when implementing a policy, similar to the two sides of a coin that are not separate (Adair, 2008).Although most target groups responded well to government policies to prevent and tackle stunting in South Buton District, there were still a small number of target groups who were less receptive to these policies.
The results of the interviews with informants revealed that some adolescent girls were afraid of consuming blood-added tablets.This fear stems from information about a TTB "poisoning" case in one of the secondary schools in neighboring districts, precisely in Pasarwajo District, Buton Regency.This is also in line with the results of the researchers' interviews with informants 1 and 5, who obtained information that members of the target group who did not receive stunting prevention and control programs were adolescent girls who received blood and tablet assistance.
The "poisoning" event did not come from blood-add tablets but from a mistake in how to consume the tablets, as most of the female students who consumed blood-add tablets were on an empty stomach.Even though the tablet should be consumed shortly after meals because it contains amino acids and vitamin C, which is quite high, to anticipate the recurrence of the incident, health workers changed the pattern of consumption of blood ad tablets, which is no longer carried out in schools when distributed by health workers but at night immediately after eating.
Based on the results of the interviews and observations in the field, it can be concluded that in every policy taken by the government, although perfectly designed and intended as much as possible for the benefit of the community, there will still be a negative response or a lack of support from the policy target group.Lack of understanding and negative stigma in the community are factors inhibiting the success of a policy, so continuous communication and persuasive action are needed so that the public can understand the importance of programs and activities run by the government for the community itself.

Conclusion
Convergence Stunting prevention policies in the South Buton Regency have been implemented by the Regional Government together with relevant stakeholders, but the implementation has not gone well because the stunting prevalence rate is increasing.This is due to organizational and interorganizational behavior in the convergence of stunting mitigation in the South Buton Regency, which has not been in accordance with commitment and coordination as well as a lack of organizational contribution.
The behavior of the lower-level bureaucracy, health workers, cadres, Human Development Cadres, and Empowering Family Welfare administrators already reflects their roles and functions, although there are still positive and negative responses from target groups.
Recommendations that can be given to lower-level bureaucracy need to increase the capacity of expertise so that it can understand its role and function, and persuasive action is needed in socializing policies to target groups that still have a negative response.
The lower-level bureaucratic behavior referred to here is the ability of health workers in Puskesmas, cadres formed by the Health Office, Human Development Cadres (HDC) in