EVALUATION OF VITAMIN A SUPPLEMENTATION

PROGRAM
IN THREE PROVINCES IN INDONESIA

Vitamin A Deficiency (VAD) continues to be a major public health concern in Indonesia.

In 1992, 50 percent of underfive children showed sub-clinical VAD as their serum retinol
were less than 20 microgram/deciliter. The primary intervention for VAD control in
Indonesia is biannual distribution of Vitamin A Capsules (VAC) to underfive children
through the national network of integrated health post (Posyandu). Although the Vitamin
A Supplementation (VAS) program has been conducted for three decades, the result, in
term of coverage, is still low. Low coverage indicates that management of the VAS
program may not properly function. Therefore, UNICEF and the Micronutrient Initiative
collaborated with SEAMEO TROPMED RCCN University of Indonesia conducted a
comprehensive survey in selected areas in three provinces to collect data on Vitamin A
coverage and other critical information, particularly that related to VAS programs
management, which is required to identify barriers of programs implementation. The
information is then used to define critical actions to improve the program coverage.
The survey was designed as a cross sectional rapid survey, and was conducted from the
forth week of February until mid of March 2007. It was conducted in West Kalimantan,
Lampung, and Southeast Sulawesi, which were purposively selected based on the
Ministry of Healths latest VAS coverage data in August 2006. Two types of survey
were done in order to collect data from community (i.e household survey to mothers of
children aged 6-59 months) and programs provider (i.e health system assessment to
health staffs at provincial, district, and Puskesmas/ Posyandu level). The household
survey was conducted in 5 districts in each province, which were purposively selected
based on its coverage (2 districts had high coverage and 3 districts had low coverage). In
each province, health system assessment was done in 3 out of 5 districts, i.e 1 district
with high coverage and 2 districts with low coverage. By having 50 percent of Vitamin
A coverage (in 2005), 10 percent difference from the true proportion in population, 95
percent of confidence level, and design effect of 2, as many as 200 children aged 6-59
months per district were included in the household survey. Thus, a total of 3000 children
aged 6-59 months were needed from 3 provinces. Household survey was done through
interview using structured questionnaire, while health system assessment was applied
through in-depth interview, focus group discussion, secondary data review, and
observation.

A total of 3466 children were included in the survey. Overall, VAS coverage in February
2007 was 56.7, 80.9 and 63.1 percent in West Kalimantan, Lampung and Southeast
Sulawesi, respectively. The coverage was lower than minimum services standard set by
ministry of health in 2003 (SPM 2003), i.e 90 percent. Kota Pontianak and Bandar
Lampung, as the capital city of West Kalimantan and Lampung Provinces, had the lowest
coverage compared to other districts in respective province. Among those who received
VAC, about 70.2 percent infants received incorrect dose (red capsule) and 13.9 percent
children aged 12-59 months received incorrect dose (blue capsule).
Health system assessment results show that no special policy was made, both in
Provincial and District level, to increase VAS coverage in February 2007, especially in
the budget allocation and socialization. Budget was mostly allocated for VAC
procurement and very limited for distribution activities. No specific budget was allocated
for program socialization and sweeping activity, which are very crucial for the program,
especially the program coverage. West Kalimantan, on the other hand, had started to
allocate budget for VAC distribution to underfive children. They provided 200 rupiah
per child to person who distributed VAC to underfive children. Sanggau District Health
Office in West Kalimantan also allocated budget for Puskesmas staff who distributed
VAC as much as 100 thousand rupiah per village per VAS period.
No specific activities were done to socialize VAS for February 2007. The information
was mostly spread orally, by cadres, midwives or mothers. In most cases, schedule of
VAC distribution was informed by cadres or midwives to mothers during Posyandu day
in January 2007. The mothers were then requested to inform the schedule to other
mothers of underfive children in their neighborhood. Cadres and midwives also reinformed underfive mothers as the distribution day became closer. Mostly, the cadres or
midwives met the mothers by chance. Socialization materials such as banners, posters, or
leaflets, were available in a very limited number at District until Posyandu levels. Such
traditional message delivery in communities was found to be a very effective method in
building awareness of the event (the distribution day), but ineffective in giving education
about the importance of Vitamin A. The reason of conducting no specific activities to
socialize VAS program may relate to the perception of almost all health workers
interviewed (from District until Posyandu level) that VAS was a routine program which
had been conducted for years, and mothers had been familiar with the program. Thus, no
specific and intensive program socialization was needed. The result from household
survey, however, shows that mothers who did not bring their children to receive VAC
were mostly because they received no information regarding VAC distribution (32.8
percent). West Kalimantan, which had the lowest VAS coverage, had the highest
proportion of mothers (41.9 percent) who received no information regarding the VAC
distribution. When mothers were asked to mention the distribution period of VAS, only
20 percent mothers gave the correct answer (i.e February and August). West Kalimantan
and Southeast Sulawesi had almost similar proportion of mothers who did not know the
distribution period (46.7 and 48.7 percent, respectively). When the mothers were further
asked about how frequent of underfive children should receive VAC per year, only 57.9
percent mothers could give the correct answer. Only 34.8 percent mothers were able to
give correct answer about the age of a child when he/she should receive VAC for the first

time. The figures reflect that mothers were not as familiar with VAS program as the
health workers thought, meaning that VAS socialization is indeed still needed.
To increase coverage, schedule of VAC distribution has to be informed to subjects at
least one month prior to the distribution day, and become more frequent as it is closer to
the day. Household survey resulted that in general, mothers received information more
than one week before the distribution day (23 percent), within one week before the day
(28.2 percent), on the day (26.8 percent). About 22.1 percent mothers had never been
informed about the VAC distribution schedule, with the highest percentage in West
Kalimantan (31.3 percent).
Some good points were found in relation with VAS socialization activities. In Southeast
Sulawesi, two Puskesmas together with local youth organization (Karang Taruna)
produced their own banners for VAS program. In some areas in Lampung, the schedule
of VAC distribution was also announced through loudspeakers at the mosques on the day
of distribution. In one sub-district in West Kalimantan, the Puskesmas sent a letter to the
head of village to inform the chedule of VAC distribution, especially the village that was
far from Posyandu.
Lack of coordination between Nutrition Unit of District Health Office and Pharmacy
Warehouse was found in Lampung and Southeast Sulawesi. This condition resulted in
many expired left over capsules from previous period. Poor coordination led to poor
VAC distribution to lower level. Some Puskesmas/Posyandu had more number of
capsules than needed, while other Puskesmas/Posyandu experienced lacking of stocks.
Most VAC was not stored at Pharmacy Warehouse because VAS program implementer
(Nutrition Unit) perceived that taking VAC from Pharmacy Warehouse took a long
bureaucracy. Therefore, the capsules were stored at Nutrition Unit. There was no specific
date set by the upper level as deadline for the lower level to submit the VAC request.
However, none of the District Health Offices, Puskesmas, and Posyandus received the
VAC late.
VAC was mostly distributed in Posyandu (87.1 percent) by cadres (42.7 percent) or
midwives (41.9 percent), on Posyandu day (89.7 percent). Almost all mothers (96
percent) were satisfied with the distribution. Most mothers went to Posyandu on foot
(86.2 percent), which took less than 10 minutes (70.3 percent). Some mothers (13.2
percent) in Muna District Southeast Sulawesi, had to take ojek (motorcycle taxi) to go to
Posyandu that cost more than ten thousand rupiah. Ratio numbers of cadres to underfive
children in most areas was considered sufficient. However, there was no consideration
yet on ratio number of cadres to the size of Posyandu service area which affect the
cadres ability to do socialization and conduct sweeping. In Sanggau District West
Kalimantan, there were Posyandus which had no cadres. In some areas, cadres play a
very significant role on VAS program to underfive children, since they did the
socialization, distribution, recording and reporting, as well as sweeping activity. This
significant role needs qualified and capable cadres who may be achieved by giving
training and nutrition education to the cadres. In fact, however, there was a very limited
number of cadres who ever received training for the past 2 years related to VAS program.

Training was also highly needed to increase cadres knowledge and capability to give
nutrition education to mothers. This issue was raised by most cadres as they felt they
were not capable enough to deliver nutrition education, whereas nutrition education was
considered the best way to increase mothers awareness about the benefits of Vitamin A.
Such awareness is needed to create demand for Vitamin A and lead to action to get the
capsule, as it is shown by the result of household survey. Most mothers who received
VAC for their children said that the reason to get the capsule was because vitamin A
would increase their childs health (50.6 percent), and it also would benefit for the childs
eye (32.5 percent). The reasons reflect that mothers are already aware of the benefit of
Vitamin A. Lampung, which had the highest coverage of VAS, had the highest
proportion of mothers (37.5 percent) who received health and nutrition education during
distribution of VAC, compared to that in West Kalimantan (6.2 percent) and Southeast
Sulawesi (12.5 percent). Cadres and midwives also noticed that Posyandu attendance was
generally higher on Vitamin A months (February and August) compared to other months.
Attendance of regular Posyandu during the last three months was 53.2 percent (routine)
and 24.2 percent (not routine). Around 23 percent children never attended Posyandu for
the last three months, with the highest percentage in West Kalimantan (39.9 percent).
In general, 9.2 percent children received VAC through sweeping approach, with the
highest percentage in West Kalimantan (12.4 percent). In West Kalimantan and
Lampung, sweeping approach was mostly done by cadres. While in Southeast Sulawesi,
proportion of sweeping conducted by cadres and midwives were almost similar. In West
Kalimantan, 20.3 percent of children received VAC at home from their family or
neighbor. In West Kalimantan, some Puskesmas did sweeping for VAS program together
with other programs, such as immunization and antenatal care. The decision of
conducting integrated sweeping was based on program coverage, where the data may be
available few weeks after the distribution day. In case of VAS program, the intensive
and integrated sweeping was done when the coverage was less than 50 percent. Cadres
admitted that no transportation support was the main constraint to do sweeping,
especially in order to reach targets who lived in remote areas or lived as nomad.
Recording is very important for documenting facts. Among those who had Growth
Monitoring Card (Kartu Menuju Sehat/KMS) and received VAC, only 55.4 percent had
mark on their KMS that they received VAC, with the highest percentage in Lampung
(83.3 percent). To reach underfive children who lived far from Posyandu, cadres or
midwives sometimes entrusted the capsule to her/his neighbor. No supervision of this
mechanism was done, which may lead to underreporting or over reporting of the number
of children receiving VAC.
There was no standard format for reporting. There was inconsistency in defining the
number of targeted children as well as the number of children who received VAC, from
Posyandu until Provincial Health levels. Puskesmas mostly used the reports from
Posyandu in defining the number of targeted children, which was the actual number.
District and Provincial Health Office mostly used projection data derived from BPS data.
Puskesmas preferred to use the actual number instead of the projected one, because the
number of the targeted children based on projection data usually was higher than that

from the actual data. Thus, using projection data as denominator in calculating coverage
would result in lower coverage. Two districts in Lampung (i.e Tanggamus and Lampung
Timur) distributed VAC every month instead of February and August. Close supervision
and monitoring especially in recording are needed in this case to reduce the risk of giving
the children incorrect spaced doses of VAC (which is high dose).
In some areas, especially in Southeast Sulawesi, sweeping data was not included in the
report and coverage calculation. Reporting mechanism of VAC distributed by other
channels besides Posyandu had not yet been established. Some areas had no deadline for
report submission. No final data were available even until several months after VAC
distribution day. Delay on report submission may also relate to poor data filling in each
level.
By having all of the information regarding management of VAS program, some
recommendations are proposed to increase performance of VAS program
implementation. Socialization has to be given bigger attention regardless the fact that the
VAS program is a routine program and perception that mothers are familiar with the
program. Budget has to be allocated for socialization activities. Involving village and
religious leaders to do socialization is considered an effective way since community very
often listen more to its leader. Adequate supply of socialization materials should be
supported by Provincial and District Health Office in coordination with other parties such
as youth organizations.
Since Districts are expected to procure the needed VAC, coordination between Provincial
and District Health Office is highly needed. VAC supply from Provincial Health Office
without early information to District Health Office may ruin the Districts logistic plan.
Each level has to give information on the number of VAC stocks in the request letter.
This information will avoid the unnecessary purchase of VAC. Good recording in
inventory log books at Provincial Health Office until Puskesmas levels is needed to
provide information on the number and the distribution of VAC at different distribution
points. First In First out (FIFO) system has to be practiced to prevent expired capsules.
One example of good inventory log book is the one in Ketapang District in West
Kalimantan.
Realizing that many children live in remote areas or even live as nomad (especially in
Southeast Sulawesi), transportation support is highly needed by cadres to reach the
children. Another way is by expanding the distribution channel through community or
religious leader. To reduce operational cost, integrated sweeping like the one practiced in
West Kalimantan, is one of the solutions to increase VAS coverage. Attention has to be
put on when sweeping approach will be conducted and also its regularity.

VAS coverage calculation must include the number of children who received VAC
through sweeping and other channels besides Posyandu. Province until Puskesmas levels
have to use the same source of data in defining the number of targeted children for VAS
program. The decision has to be made by the Provincial Health Office and applied by all
levels in the respective province. Cadres have to put childrens date of birth in their
recording books. Childrens age calculation has to be based on the date of birth, to avoid
giving incorrect dosing of VAC to the child.
Nutrition education as the key factor in increasing mothers awareness has to be done
continuously, both in formal or informal setting. Since cadres are the person who will
deliver the nutrition education to mothers, cadres have to receive training on VAS
program to make them become more capable and at the same time more confident to
deliver the nutrition extension.
Survey conducted by MOH, UNICEF, and the Micronutrient Initiative collaborated with
SEAMEO TROPMED RCCN University of Indonesia, 2007