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Pungkas Bahjuri Ali, S.TP, MS, Ph.D Direktur Kesehatan dan Gizi Masyarakat Ir. Adhi Lukman Ketua Umum Gabungan Produsen Makanan Minuman Indonesia (GAPMMI)
It has been formulated that Development in Indonesia is human-centered to improve the quality of life and well-being, enabling human (human capabilities) to improve dignity by fulfilling all basic needs, and using a life cycle approach. The three foundations of development established are population growth and development, gender mainstreaming and social inclusion, and the life cycle approach. These foundations are elaborated in detail, namely
- Basic Services which include health services, nutrition insurance, holistic integrative early childhood education (PAUD-HI), primary and secondary education, social protection, and protection from mistreatment;
- Human Capital consists of vocational and higher education, science and technology (science and technology) and innovation, vocational training and entrepreneurship, literacy and life skills, and sports culture and achievement;
- Socio-cultural capital, namely religion, culture, character education, civic education, and family and care. All of them are aimed at building a prosperous, adaptive, noble, culturally advanced, superior and competitive human being.
Development policy has outlined that future health for all is aimed at:
- All people are able to live a healthy life, throughout the life cycle, in all regions, in all groups of society, both men and women;
- all services provided to every resident are guaranteed affordable and quality health services;
- carried out by all stakeholders including central and local governments, non-governmental organizations, business actors and communities, taking into account social, cultural, political, economic, educational, trade, food industry and environmental dynamics.
In the initial draft of the National Long-Term Development Plan 2025-2045, health and nutrition policies will be implemented in the direction of
- Social transformation includes
- Overcoming macronutrient and micronutrient problems, accelerating the resolution of stunting and overnutrition through improving diverse food consumption patterns, nutritional enrichment and nutritional security in the first 1000 days of life,
- strengthening the drug and food surveillance system with product coverage including cyber surveillance and pharmacovigilance,
- strengthening research, data and information in evidence-based policies, and the application of technology and innovation in the health sector;
- socio-cultural and ecological resilience, namely
- fulfillment of food and nutrition needs that are sufficient, diverse, nutritionally balanced and safe,
- Increased intake of essential micronutrients for quality and productive human resources through the development of biofortification and large-scale food fortification (LSFF);
- Ensuring access and affordability of food and nutrition, especially for children in the first 1000 days of life (HPK).
Strategies for handling micronutrient problems are
- research related to the magnitude of nutrition problems, food consumption patterns, efficacy studies, program effectiveness studies, cost benefit analysis (CBA), cost-effectiveness analysis (CEA), and impact evaluation,
- Additional influences from consumption patterns, supplementation and fortification;
- central and local level implementation capacity related to program planning, financing, and monitoring and evaluation, delivery and compliance targets; delivery dan compliance sasaran;
- Social and commercial determinants include food and supplement industry trends and behavior change communication (acceptance and health literacy).
In efforts to strengthen food fortification, it is necessary to consider the impact on health and nutrition related to efficacy (mean of verification), effectiveness (compliance=compliance), and complementary with other interventions. This is inseparable from:
- analysis support:
- identification of deficiency types and target groups,
- intervention models related to the market (market), social assistance and product reformulation;market), bantuan sosial dan reformulasi produk;
- accessibility variables in terms of availability and affordability;
- The processes that need to be considered are blending technology, fortificants, organoleptic and product acceptance, compliance (from providers and targets), impact;
- monitoring and evaluation at every stage from input to output. This is all necessary to develop the best policy options as well as coordination among stakeholders. stakeholders.
The food fortification program always faces various challenges that need to be resolved so that this program can successfully improve the micro-nutrition status of all levels of society, especially the poor. Problems and challenges faced in the rice fortification program, among others
- fortification is relatively expensive, costing Rp1000-1500 per kg,
- The local 'rice fortified kernel' industry has not yet developed,
- Most rice milling industries are small in capacity and present constraints in quality assurance.
The salt fortification program faces the following problems
- the quality of people's salt does not meet SNI requirements,
- the quality of iodized salt production still varies (especially content and homogeneity),
- the sustainability of KIO3 availability is still a big question,
- supervision of circulation and quality has not been effective,
- The 2013 Riskesdas results show that around 77% of households consume iodized salt that meets the standard (>30 ppm).
The implementation of the palm cooking oil fortification program (MGS) is still not running as expected because
- The fortification of MGS with vitamin A only applies to packaged cooking oil, while most consumers (70%) consume unfortified bulk MGS, hence the need for efforts to accelerate the conversion of bulk cooking oil to packaged cooking oil,
- there are still some MGS industries that have not been able to accept fortified cooking oil.
Until now, the wheat flour fortification program with iron and folic acid is running well due to limited industry players, but several things need attention for the sustainability of the program, among others
- raw materials are still 100% imported,
- fortification is often considered a trade barrier,
- Iron replacement used in fortification programs still requires scientific evidence in Indonesia.
To enable the success of the fortification program, it is necessary to consider several cross cutting issues as follows:
- Regulatory, policy and institutional aspects require the acceleration of the establishment of working groups or institutions such as LSFF (Large-Scale Food Fortification) to coordinate food fortification made at the central and followed at the regional level,
- research and standardization aspects to promote the independence of fortifier production and build domestic fortifier production capabilities,
- aspects of supervision, including
- preparation of joint audit mechanism for synergy of food fortification supervision and guidance,
- submission of joint audit findings for synergy,
- strengthening of proficiency testing of testing laboratories,
- development of a collaborative test plan between government laboratories.
Following Government Regulation No. 17/2015 on food security and nutrition, Fortified food can be released after the following review:
- effectiveness in the prevention & management of community nutrition problems,
- availability of enrichment technologies;
- quality assurance & supervision and food safety,
- eligibility meets the required halal rules for food,
- impact of rising costs on consumers & industry.
Therefore, the involvement of various Ministries and Institutions is required in accordance with their respective main tasks and functions. The Ministry of Health sets nutrition fortification standards, IEC and regulatory support; Food and Drug Monitoring Agency is in charge of enforcing regulations and monitoring fortified food that will be produced and has been in circulation; the Ministry of Industry sets regulations for industry and business actors of food products that will be fortified; Food Security Agency and National Standardization Agency will be heavily involved in research and regulation of standard formulation and implementation mechanism; The Ministry of Trade functions in the supervision of fortified food in circulation; The Ministry of Maritime Affairs and Fisheries provides support for fortification supervision to salt farmers as marine products; The Ministry of Home Affairs will support local governments in the implementation of SNI and its regulations; The National Research and Innovation Agency together with development partners assist in research and social control.
Institutionalization or fortification forum is needed in LSFF development, especially for:
- strengthening coordination to strengthen the effectiveness of program implementation and policy improvement;
- strengthening fortification studies and its utilization by industry,
- identification of policy options and strengthening commitment to regulatory implementation,
- development of the LSFF 'roadmap' , strengthening standardization, pengembangan LSFF,
- strengthening standardization,
- translation into program implementation at various levels of government and society,
- strengthening monitoring and evaluation.
In order for the implementation activities to be effective and achieve the objectives, the fortification forum needs to involve various elements, including
- national policy makers,
- owner of good coordination in implementing fortification,
- technical implementation for food fortification development,
- involved in the planning, implementation and evaluation monitoring processes,
- experts who master the substance,
- researchers who are able to conduct studies on the impact of fortification on health and nutrition.
With the implementation of the fortification program and the impact of health and nutrition improvement in the near future, it is necessary to establish a fortification forum involving multisectoral government and non-government that is structured, has a detailed work plan, and products that must be produced for each stage of activity.
Indonesia is an archipelago with a relatively large potential market with an inflation rate of 5.51% and Gross Domestic Product (GDP) growth of 5.31%. The food expenditure of the Indonesian population is around 50.14% (2022), with 5% consumption growth. The food industry plays an important role in food availability, security, and economic growth.
Currently, the nation faces undernutrition, overnutrition, and hidden hunger (hidden hunger), namely micronutrient deficiencies. It is known that three micronutrient deficiencies are iodine, iron, and vitamin A deficiency. Efforts that have been implemented include supplementation and fortification. The experience of the iodine salt fortification program shows that coverage only reached 62.3% in 2007 and 77.15% in 2013, which is still below the 90% coverage target.
Prior to independence, the salt iodization program did not face significant problems because it was implemented under a government monopoly. However, in 1957, the salt monopoly was abolished, which led to uncontrolled quality and iodine content of consumable salt circulating in the market. In 1974, Presidential Instruction 14 instructed 10 Ministers to 'organize efforts to improve the people's diet nationally and comprehensively, both within their respective duties and in cooperation between government departments/agencies'. As a follow-up, Minister of Health Regulation 110/Menkes/XI/1975 was issued, stating that iodized salt for public consumption is salt containing Potassium Iodate 40 ppm with a tolerance of 25% in watertight packaging and quality that meets the requirements.
In 2018, the Minister of Home Affairs revoked 50 Permendagri, including Permendagri number 63 of 2010, which was the basis for local governments to make local regulations related to salt iodization. Furthermore, in 2016, SNI 3556 was issued regarding iodized salt consumption.
Global efforts to eliminate IDD (Iodine Deficiency Disorder) through Universal Salt Iodization (USI) by iodine fortification of table salt, in 2007 WHO and UNICEF recommended ten steps as follows:
- The existence of an IDD task force characterizes institutional development,
- political commitment to USI,
- There is a strong implementing organization at every level,
- legislation and regulation on USI at all levels,
- monitoring and evaluation, with accurate data,
- IEC and social mobilization to consume iodized salt,
- regular iodized salt data at producer, market, and consumer levels,
- the presence of regular EYU (Excretion of Iodine in Urine) data of school children in severely endemic areas,
- Cooperation with salt producers for quality control of iodized salt,
- monitoring and dissemination of data, including salt and EYU data.