Stakeholder Mapping Analysis on the Scaling-Up Nutrition Movement during the 1000 Days of Life between the Urban and Rural Government Areas

The Scaling-Up Nutrition (SUN) Movement was an intervention to overcome chronic malnutrition through integrated stakeholder collaboration. Furthermore, the roles of stakeholders' in the SUN-Movement were not optimal and their characteristics were not yet known based on the groups and government areas (cities and regency). This study aims to map the SUN-Movement stakeholders' roles in different groups and government areas based on their attitudes, powers, and interests. This is an observational descriptive research with a qualitative approach. Totally of 30 institutions as stakeholders were involved in this study and divided into 3 different groups, namely Decision Maker (DM), Provider (P), and Clients & Representatives (CR). The DM group have the power to influence programs. Also, the P group was better at handling technical issues, however, it cannot build collaboration with other stakeholders. The CR tend to build this collaboration passively, nevertheless, it does not consider the SUN-Movement to be important. Consequently, each stakeholder views their roles differently. Different perceptions about stakeholders' roles in various indicators and government areas reveals an implementation gap in the SUN-Movement. Therefore, in conclusion, strengthening advocacy, coordination, routine socialization, and communication between stakeholders could bridge the needs, constraints and challenges that cause malnutrition and stunting. pISSN 2252-6781 eISSN 2548-7604 Article Info Article History: Submitted March 2020 Accepted November 2020 Published January 2021


INTRODUCTION
Malnutrition was still a serious public health problem in Indonesia, including in Central Java Province. Health Basic Survey in 2018 showed that 30.8% of children under five years old suffering from malnutrition so they could not growth perfectly. Although lower than the survey in 2013 which was 37.2%, it was still above WHO recommendation of 20%. This condition was considered as a growth faltering of infants and toddlers due to chronic malnutrition, especially in the first 1000 days of life (Bloem et al., 2013;Latif & Istiqomah, 2017). The case of stunting in children under five years old had several factors consequence and often associated with poverty including nutrition, health, sanitation, and the environment. There are five main factors that cause stunting, namely poverty, social and culture, increased exposure to infectious diseases, food insecurity and public access to health services (Aridiyah et al., 2015). Some risk factors for stunting in developing countries such as a baby not given exclusive breastfeeding, socioeconomic factors, low birth weight (LBW), length of birth, low maternal education, infectious diseases (Budiastutik and Rahfiludin, 2019), and hereditary factors (Latif & Istiqomah, 2017).
Interventions in the first 1000 days of life could reducing risks of stunting for children and toddlers (Bloem et al., 2013). This time was critical period that determines quality of life, as well as sensitive period because of its consequen-ces for infants were permanently and cannot be corrected, including mental development and intelligence (Kemenko-Kesra, 2013). At those time began for occurring various disruption to child development process which in the long run would have an impact on health status and also not optimal productivity.
The Scaling-Up Nutrition (SUN) Movement for improvement of acceleration nutrition in the first 1000 days of life was an intervention overcoming problems of malnutrition and was implemented by health sectors and non-health sectors. SUN-Movement was an effort to overcome all forms of malnutrition with principles that every people had a right for obtaining good material of food and nutrition through a good roles, cooperation and integrated manner between government, institutions and community organizations (Giriwono & Indrayana, 2015). The main purpose of SUN Movement was increasing coordination and commitment of stakeholders in technical support, advocacy, innovative partnerships, and participation to improving nutritional and health status of community. The involvement of all parties and stakeholders was a key factor to successful of the SUN-Movement.
Through Presidential Decree Number 42 of 2013 was expected that all parties and stakeholders increasing their commitment for giving protection and fulfillment of community nutrition through best program management and coordination between multisector. Strong national and regional leadership support was needed to increase the participation of all stakeholders, not only the government but also the involvement of the business communities, professional organizations and other social institutions (Kemenko-Kesra, 2013).
Strategies for overcoming malnutrition could be carry out through nutritional specific and sensitives interventions in integrated and sustainable manner (Rosha et al., 2016). Specific interventions were carried out addressing the direct and indirect causes of malnutrition occurring and focus on the health sector, while sensitive interventions were directed addressing the root causes that affected direct and indirect causes and it was multisector. The intervention of health sectors contributes only 30%, while 70% of contribute comes from non-health sector. Multisector collaboration was very important to solved malnutrition and health problem occurred in community (Kemenko-Kesra, 2013;Rosha et al., 2016). The multi-stakeholder approach also raises awareness of all sectors related to their potential roles in improving public health status by reducing mal-nutrition (Sardjunani & Achadi, 2016).
Participation and involvement of stakeholders in health and nutrition so far had not been optimal because its constrained by the understanding and perception of the policy makers that health problems were problems that must be resolved by health sector only, including issues of malnutrition and stunting (Syafrina et al., 2019)), as such as malaria prevention (Manalu et al., 2014), treatment of HIV/AIDS (Purbani et al., 2019), and maternal and child health programs (Iswarno et al., 2013). The commitment of stakeholders could be identified through several aspects, especially in the process of planning and budgeting, coordination, and advocacy. The low involvement in planning and budgeting process, having minimal budget allocations (Iswarno et al., 2013), weak coordination and advocacy (Purbani et al., 2019), tend to be passive (Nursanti et al., 2017), the dis-synchronization of programs and activities, as well as health programs were not priorities as evidence of the weakness supports and the roles of stakeholders in health programs (Prabowo & Rostyaningsih, 2019). Study in India showed only 6 interventions had direct impact on the SUN Movement from 33 interventions related to maternal and child nutrition programs. There was an overlapping of roles and responsibilities of the stakeholders in their implementation and monitoring functions (Khandelwal et al., 2014).
The same condition also occurring in case of malnutrition. The study in Pasaman District showed that the absence of written regulations, lacking of commitment and multisector involvement, limited material and infrastructure and lacking of monitoring evaluation significantly affect the implementation of SUN Movement (Nefy et al., 2019). In line with research in Semarang City also showed that stakeholders have good attitudes about the SUN Movement but they tend passively (Nursanti et al., 2017). Research of Samsudrajat & Jati (2018) also showed that content of MCH Regulation in Semarang City was not focused yet on discussing sensitive interventions on tackling malnutrition and stunting because its more regulates specific interventions in maternal and child health services. The high competition between programs and activities among stakeholders was an obstacle in allocated a limited resources (Plessis et al., 2018).
The numbers of malnutrition cases among children under five years old were still high in Central Java Province with fluctuating numbers from 2014 to 2016, namely 933 cases, 922 cases and 982 cases. In 2017, the number was increased to 1,352 cases. In Strategic Plan of Central Java Health Office 2018-2023 it was seen that infant mortality rate tends to down, but relatively still below the strategic plan target of 11/1000 live births in the 2016-2017 period. Poor status of child nutrition was one of the risk factors for infant mortality. These indicates that malnutrition issues have not been handled well and its implementation still constrained, which one of the problems are lacking roles and participation of stakeholders (Holdsworth et al., 2015), especially those related to the implementation of health program and SUN Movement. The main challenges were related to how maintaining interest, build commitment, regional capacity and availability of resources (Sardjunani & Achadi, 2016).
The roles of each stakeholder group in supporting success of SUN Movement at the level of regional governments (regency or city) have never been identified before. It was not yet known whether the different characteristics of local government (regency and city) distinguished roles of each stakeholder group based on their performance indicators. The aim of study was analyzed the roles and characteristics of stakeholders in the SUN Movement based on differences of urban and rural government areas.

METHOD
This is an observational descriptive research with a qualitative approach. The qualitative design is exploratory so that it is appropriate to use because it could identify the roles of all stakeholders (institutions) and their ability to influence various policies and implementation of health programs related to the SUN Movement. Stakeholders were divided into 3 categories, namely the group of Decision Maker (DM), the Provider (P), and the Clients & Representatives (CR).
Measurement of the role and commitment of stakeholders based on 3 (three) dimensions such as: (1). The attitude of institution; (2). The ability to influence (power); and (3). The institutional importance (level of interest) for their involvement of various activities that must be carried out as an indicator of performance. Each dimension was measured using 6 (six) indicators, i.e.: (1). Participation and role of institutions; (2). Coherent policy formulation; (3). Programs were implemented; (4). Resources and financing; (5). Developing cooperation and alliances; and (6). Give the guarantee for sustainability and quality of commitments. Given sign of plus (+) if stakeholders have done well for every indicator that were directed, otherwise the sign of minus (-) if the indicator had not been implemented. The results were analyzed through a stakeholder-matrix diagram between the power of influence and the level of importance (interest) to determine the position of each category per performance indicator (The Power & Interest Matrix).
Totally of 30 institutions as stakeholders were involved in this study and divided into 3 different groups according to their roles, namely: Decision Maker (DM), Provider (P), and Clients & Representatives (CR). The study was conducted at 2018 in Temanggung Regency and Semarang City that were selected and represented rural and urban government areas. The sample of study was number of selected institutional stakeholders who represented and were selected using purposive criteria based on their direct or indirect linkages in the SUN Movement. The subject of study was the person in charge of the program at the institutional level. They were chosen because they were considered having a good understanding of their institution roles , especially in the SUN Movement activities.
The data were collected with in-depth interviews and focus group discussions (FGD). To measure of stakeholder performances on each dimension use supporting instruments in the form of interview guides that have been developed previously. Data were analyzed using a stakeholder-mapping analysis method in the form matrix quadrant of Power-Interest.

RESULTS AND DISCUSSION
Through focus group discussions (FGD) and in-depth interviews, it was obtained the description and perceptions of each stakeholder group in Temanggung Regency and Semarang City related to their attitude, influence (power) and interest in the SUN Movement through 6 (six) performance indicators as shown in Table 1,  Table 2, and Table 3. Values (+) and (-) in the assessment indicate the strength or weakness of the roles of each stakeholder group. Table 1. showed the attitude of 'Decision Maker' (DM) group from two government areas were generally good or positive point (+) related to the SUN-Movement, although its look weakness (-) for indicators of developing cooperation and alliances as well as indicators of guarantee of sustainability and quality of commitment, especially in Temanggung Regency. For Semarang City, a negatively attitudes were seen also in indicators of coherent policy development and guarantee the sustainability and quality of commitments. The 'Decision Maker' group in two government areas also had very high power for most indicators, except for indicators of sustainability and the quality of commitment. There was a weak influence (-) on indicators of resource allocation and financial (funding support) in Semarang City.
The 'Decision Maker' group was high interested of SUN Movement successfully, although they unable to guarantee the sustainability and quality of its commitments. They were not able influencing external factors and guarantee their realization. They assumed that SUN Movement policies were determined by a higher structure (national government), so the sustainability of program also depends entirely on the national government. The lack of bargaining power in resources support and financing of the SUN Movement program in Semarang City implies that the SUN Movement have not yet become a priority program for the decision makers. Table 2 showed the attitudes of 'Provider' groups (P) in Temanggung Regency and Semarang City were good, especially on indicators of participation and the institutions' roles, for programs implemented and resources facilitation. The group had a high power to influence and a high level of importance to the success of this indicator. Although their attitude was positive for resource and financing indicators, but they did not have the power to determine amounts and allocation of resources needed. The 'Provider'  group also have an interest in developing coherent policy standards, cooperation, and alliances, but they tend to perceive that these two indicators as not the main ones, moreover they also did not have the power of influence over these indicators.
In the indicator of guarantee of sustainability and the quality of commitments related to the SUN Movement, although 'Provider' has a high power and influence, they tend to consider it not to be important. Whether the program and the SUN Movement be continued or stopped was not important for this group. The 'Provider' groups were only oriented to how carried out routine technical activities even though their involvement in developing coherent policies and building cooperation with other parties tends to be ignored. They depend on the national government in its decision of program priorities, including in determining its sustainability.
The attitude of the 'Clients & Representatives' (CR) group appears supporting the efforts of the SUN Movement in both government areas, although for indicators of resources and financing as well as indicators of sustainability assurance tend to be low of supports. The influence of this group tends to be lacking and only seen in indicators of participation and institution's roles as well as in conducting collaborations (alliances) in Temanggung Regency. Meanwhile in Semarang City, the group had strong influences on the participation and institutions' roles as well as on the implementation for the existing programs. This group was more interested in how the implementation and program was carried out (see Table 3).
The lacking attitude and support (-) was showed by the CR group in the SUN Movement. The low level of participation and involvement was due to the lack of socialization and information related to the SUN Movement. The group did not yet to knowing and understanding the concept of SUN Movement in the first 1000 days of life and its socialization have not been effective yet. The influence and power of these group was so weak on the institution aspects, but their ability of internal resources becomes an extraordinary force when these group was involved in the implementation of the SUN Movement. The group indirectly had a high interest in these acti- Resources Based on the Power-Interest Matrix diagram for stakeholder mapping in Temanggung Regency, it appears that the 'Decision Makers' (DM) group mostly were in the "Manage-Closely" position and had strong authority to make decisions for 5 indicators namely: (1). Developing stakeholders' participation and role of institution; (2). Developing coherent policies; (3). Determining various programs to be implemented; (4). Providing support and facilitation of resources (including human resources, material, infrastructure and financing); and (5). Developing cooperation (alliances). The 'Provider' group (P) in Temanggung Regency could developed forms of participation and identified many programs and activities to be implemented and related to the SUN Movement (see Figure 1).
Even though the majority position of 'Decision Maker' (DM) group in Semarang City was in 'Manage-Closely', the authority to allocate resources and program funding was not as strong as in Temanggung Regency. The diagram also showed that the roles of 'Provider' group and 'Clients & Representatives' group were so strong in developing forms of participation and implementation of various work programs. This condition was what distinguished it with Temanggung Regency. The 'Clients & Representatives' group in Semarang City had a strong role and participation in supporting the SUN Movement through mobilization of their respective organizations, such as the Health cadres, the driving force team of PKK, NGOs, the community organization (Fatayat NU, Aisyiyah, MUI) and the local mass media in regional areas (TV or radios).
The group which included in the 'Keep Satisfied' position (high power and low interest) in quadrant matrix of Temanggung Regency was the 'Provider' group, especially for the indicators of ensuring sustainability and quality of commitment. The same condition was occurred in the city of Semarang. Position of the 'Keep Satisfied' also exists for the 'Clients & Representatives' group in Temanggung Regency, especially in its role in developing participation and cooperation (alliances). This illustration showed that 'Clients & Representatives' group had less optimal roles, even though they had more authority to make decisions. During this time, they felt uninformed and not interested with these program and SUN Movement, so they were not actively involved. A proactive strategy was needed to build this 'CR' group involvement through socialization, communication, and persuasive approach for strengt-hening support.
The position of 'Keep Informed' illustrated high interest but low influence (power). Included in this position in Temanggung Regency was the 'Provider' group, especially in its role in developing various coherent policies and establishing cooperation. The 'Clients & Representatives' group was weak in their role to developing programs that must be implemented even though they had a high interest in the SUN Movement. Different conditions occurred in Semarang City, because the position of 'Keep Informed' was occupied by the 'Decision Maker' group (DM), which was in terms of indicators of resource allocation and financing. The 'Provider' group also was included in this position, especially for indicators that related to allocation and distribution of resources and how improving cooperation and alliances. The 'Decision Maker' group in Semarang City could not fully influence the resources and financial allocation for the SUN Movement. There was a dependency on funding sources from the national government in implementing programs and activities related to the SUN Movement. Although they had high interested, due to their weak influenced, supporting from other stakeholders were needed. They need to be given more explanations and relevant information about this program that could interested them to be actively involved.
The 'Monitor or Minimum Effort' position describe stakeholders in situations of low power and low interest which means they were not actively involved and tend to be passive. In the matrix of Temanggung Regency, it could be seen that the three stakeholder groups were in this position, namely 'Decision Maker' group in ensuring of program sustainability and commitment quality, the 'Provider' group in resources allocation, and the group of 'Clients & Representatives' in determining coherent policies, resource allocation, and in ensuring sustainability program and commitment quality. It must be recognized that the regional authorities (District or City) were still lacking. There was a tendency for regions to be passive and highly dependent on national government support, especially in program sustainability of SUN Movement, allocation of resources and funding distribution.
Three stakeholder groups in Semarang were in 'Monitor or Minimum Efforts' position too, namely 'Decision-Maker' group in ensuring program sustainability and commitment quality, the 'Providers' group in developing coherent policies, and group of 'Client & Representatives' in developing a coherent policy, facilitating resour-ces and financing, building cooperation among stakeholders, or making alliances, and in ensuring program sustainability and quality of organizational commitment. Although the involvement and participation level of 'Client & Representatives' groups was high in SUN Movement implementation, they did not have the ability to facilitate all of resources be needed. Its means that their involvement in the SUN Movement depend on the availability of resources and funding from other institution (see Figure 1).
Based on characteristics it was known that 'Decision Maker' group in Temanggung Regency and Semarang City had very strong roles in success of SUN Movement in their respective regions, although it was different role of allocating resources and financing which proved to be strongly influential in Temanggung Regency, while in Semarang City it was rather weak. On the other hand, the 'Decision Maker' group in two regions apparently did not have the ability to guarantee programs sustainability and stakeholder commitments. The role of group was limited to program execution and implementation of SUN Movement at the regional level, through regulatory arrangements, reinforcing stakeholder participation, building cooperation and partnerships, formulating the types of activities carried out and allocating the budget and costs needed.
The 'Provider' group as a technical implementor of the SUN Movement had bigger control over these issues and they had known the strategy to ensure successfully of SUN Movement in both regions, including the forms of participation and types of activities that must be carried out. However, this group had less powerful roles in building cooperation with other sectors or stakeholders, in the sense of not being able to be forced other parties to be actively involved in the SUN Movement, so it needs the help from other stakeholders with higher authority. On the other hand, this group had strong influence in ensuring the continuity of SUN Movement. Whether the program be continued or not, it was entirely determined by this group as the results of their monitoring and evaluation. A limited budget and resources make the 'Provider' group in Temanggung Regency tend to be passive, whereas in Semarang City because of their development budget was quite large, they could allocate the budget needed even though it has to get approval from other parties (for example: Bappeda). They also tend to be passive in formulating coherent policies because it was fully under the control of the Semarang City government.
The results also showed that the 'Client & Representatives' group in Temanggung Regency tended to be passive even though they could deploy their structure in participation and cooperation (alliances) between internal and external stakeholders in the program implementation. This weakness was due to assumption and understanding that SUN Movements were less important. In contrast, in Semarang City, this group has high power and ability in mobilizing the participation and involvement of groups and other stakeholders in carrying out various activities related to the SUN Movement, even though they could not provide and facilitate their resources and funding. Stakeholders were groups of individuals or institutions that influence decision making process (as well as being influenced) for the achievement of objectives, and could be carried out by community, government, and private groups according to their interests. This research proved that each stakeholder groups perceived differently their respective roles in health programs, especially in overcoming the problem of malnutrition through the SUN Movement. An understanding of the roles of different stakeholder groups with their indicators and different government areas indicated a gap in their perception of SUN Movement. Not all stakeholders understand their roles in effort of the first 1000 days of life and understand the SUN Movement as an intervention to solve problems of malnutrition and stunting.
This study was in line with study of Bold et al. (2015) that malnutrition and nutrition issues were not a priority for across sectors, including the agriculture sectors in India, Bangladesh, and Pakistan. This situation created inequalities in leadership and ineffective coordination between sectors. The lacking knowledge of policy maker about nutrition (especially nutrition for infants and children) and ineffective knowledge transfer created a gap between policy maker and the implementor, both at the national and regional government level. Stakeholders did not focus to solve health problems and malnutrition because they prioritized technical services in their respective sectors (Bold et al., 2015). It was not same as study about stakeholder network analysis of maternal and child nutrition programs in five countries (Sri Lanka, India, Nepal, Bangladesh, and Pakistan) which showed that government stakeholders had greater roles in supporting technical programs than their involvement in funding because they had more relied on program funding from international stakeholders (Uddin et al., 2017).
Although stakeholder groups (Decision Makers, Providers and Client-Representatives) had significant influence on the success of the SUN Movement, all of them were unable to guarantee the sustainability of the SUN Movement because it was entirely dependent on the national government. As representation of regional level stakeholders, they only became an executor of all national programs. The 'Provider' group could indirectly influence sustainability of the program because this group was technically understanding the context and content of malnutrition and stunting issues, so it knows very well what to do, how to do and how measuring performance, as well as the mechanism of monitoring and evaluation that must doing.
This study consistent with research of Nursanti et al. (2017) that the 'Provider' sector was in a 'Savior' position because it was considered as the most prepared party in the SUN Movement. The technical readiness of 'Provider' group was often not followed by the readiness of budgeting resources, materials, and infrastructure, even though their human resources were more flexible. Budgetary issues were main reason for lacking cross-sectoral support (Uddin et al., 2017). Research of Syafrina et al. (2019) showed that budgeting had significant effect on program implementation and local government performance . Therefore, advocacy to the Regional Legislative Council (DPRD) and Regional Government and strengthening multi-stakeholder coordination in integrating various activities through partnership principals could reducing weaknesses and disintegration of existing programs (Manalu et al., 2014;Purbani et al., 2019). The weak ability and advocacy of Health Management Office as a leading sector was thought to be one of the influencing factors (Iswarno et al., 2013).
Clarity of regulation was important in successes of SUN Movement. Through regulation, the roles of each stakeholder were accommodated in an integrated and continuous manner. Impact of unclear roles of each stakeholder was duplication of activities, targets, and inefficiency. Like a case in Ethiopia, potential duplication were identified when more than one partner supported the same interventions in the same district (WHO, 2014). Giriwono & Indrayana's study showed that regulation support that adopted partnerships pattern and oversight mechanisms could ensure compliance in overcoming challenges and problems of malnutrition in Indonesia (Giriwono & Indrayana, 2015). The stakeholder's involvement in formulating policies and regulation according to their authority will strengthen understanding as well as a foundation for decisions.
The unclear regulations and not understan-ding by stakeholders would have implications for not optimal program performance. The result was in line with study of Oktaviani et al. (2018) on the implementation of Regional Rules of Semarang City Number: 2 of 2015 (Perda) concerning Maternal and Child Safety which turned out to be ineffective because all stakeholders involved in the content of these rules have not understood it due to weak socialization and communication between and between institutions. Lacking of communication functions made the programs not integrated and ran separately (Purbani et al., 2019). Study of Rahmawati et al. (2016) conclude that communication and socialization gaps regarding the reference rules (Regional Rule of Semarang City Number 5 of 2010) have resulted in the control program of Dengue Fever (DBD) not running optimal. The main challenges identified including the lack of specific roles of institutions in program implementation, mechanisms that have not been effective in linking national with regional institution, and lacking awareness to develop specific plans and budgets allocated by each institution (Kennedy et al., 2016). In addition to communication factor, the absence of written regulations governing such roles, forms and responsibilities made difficulties for stakeholders making decisions because basis of commitment was not strong enough and less binding. This conditions directly impacted weak multi-sector involvement, including in support and facilitation of human resources, costs, material and infrastructure, as well as monitoring support for evaluations (Nefy et al., 2019). Socialization of stunting prevention and SUN Movement as strategic intervention overcoming problems of malnutrition have not been sufficient providing information clarity for stakeholders. Therefore, through activities and strengthening of advocacy, routine coordination, clarity of socialization and communication between stakeholders were the keys and success factors of the SUN Movement on 1000 days of life. The limitations of this study could not identify and explain how the mechanism of coordination and communication between the stakeholders in each group. The implementation of the six dimensions of indicators also could not be explained in detail so further research be needed.

CONCLUSION
Each stakeholder groups (the Decision Maker, Provider, and Clients & Representatives) had different roles, attitudes, strengths and interests in carrying out various activities that were indicators, both in the participation and role of insti-tutions, building coherent policies, implementing various programs, allocating resources and financing, building cooperation and alliances, and ensuring the sustainability of programs and quality of its commitment. The dependence on national government, especially in facilitating resources, made districts tend to be passive in adopting various practices, regulations and policies related to the SUN Movement. Existing stakeholder groups acted as regional implementers only. Differences in characteristics of government areas (regency and city) also distinguished the strength of influence and interest level of each stakeholders involved in SUN Movement. Differences ability of regional development resources, perceptions and understanding of importance SUN Movement for their institutions were factors influencing their roles gap too. Through strengthening of routine and structured advocacy, coordination, sosialization and communication between stakeholders and Health Management Office as leading sector and Bappeda as a coordination function could bridging the needs, constraints and challenges in overcoming problems of malnutrition and stunting through intervention of SUN Movements.