ASIAN DEVELOPMENT BANK Operations Evaluation Department

PROGRAM PERFORMANCE EVALUATION REPORT

FOR THE

HEALTH AND NUTRITION SECTOR DEVELOPMENT PROGRAM IN INDONESIA

In this electronic file, the report is followed by Managements response.

Performance Evaluation Report

Project Number: 32516 Loan Numbers: 1675 and 1676 August 2006

Indonesia: Health and Nutrition Sector Development Program

Operations Evaluation Department

CURRENCY EQUIVALENTS (as of June 2006) Currency Unit Rp1.00 $1.00 = = rupiah (Rp) $0.000107 Rp9,366.0

ABBREVIATIONS ADB BAPPENAS BKKBN EA FP HNSDP JFPR MOF MOH MONE MOSA NGO NTT OED OEM PCR PHC PIMU PIU PPER SPSDP TA Asian Development Bank Badan Perencanaan Pembangunan Nasional (National Development Planning Agency) Badan Koordinasi Kiluarga Buencana Nasional (National Family Planning Coordinating Board) executing agency family planning Health and Nutrition Sector Development Program Japan Fund for Poverty Reduction Ministry of Finance Ministry of Health Ministry of National Education Ministry of Social Affairs nongovernment organization Nusa Tenggara Timur Operations Evaluation Department operations evaluation mission project completion report primary health care provincial independent monitoring unit project implementation unit project and program performance evaluation report Social Protection Sector Development Program technical assistance NOTE In this report, "$" refers to US dollars.

Director General Director Team leader Team members

B. Murray, Operations Evaluation Department (OED) R. K. Leonard, Operations Evaluation Division 1, OED K. Hardjanti, Principal Evaluation Specialist, Operations Evaluation Division 1, OED A. Anabo, Senior Evaluation Officer, Operations Evaluation Division 1, OED A. Morales, Evaluation Officer, Operations Evaluation Division 1, OED A. Alba, Operations Evaluation Assistant, Operations Evaluation Division 1, OED Operations Evaluation Department, PE-688

CONTENTS Page iii v ix 1 1 2 3 3 3 4 5 5 6 6 8 8 8 8 8 16 20 20 21 22 23 25 40 46 49 58

BASIC DATA EXECUTIVE SUMMARY MAP I. INTRODUCTION A. Evaluation Purpose and Process B. Expected Results and Program Objectives DESIGN AND IMPLEMENTATION A. Formulation B. Rationale C. Cost, Financing, and Executing Arrangements D. Application of Counterpart Funds E. Procurement, Construction, and Scheduling F. Design Changes G. Outputs H. Consultants I. Loan Covenants J. Policy Framework PERFORMANCE ASSESSMENT A. Overall Assessment B. Other Assessments ISSUES, LESSONS, AND FOLLOW-UP ACTIONS A. Issues B. Lessons C. Follow-Up Actions

II.

III.

IV.

APPENDIXES 1. Project Cost by Component 2. Update on the Policy Matrix 3. Updates on the Program Framework 4. Assessment of Overall Program Performance 5. Summary of Findings 6. Findings of the Beneficiary Survey

Attachment:

Management Response

The guidelines formally adopted by the Operations Evaluation Department (OED) on avoiding conflict of interest in its independent evaluations were observed in the preparation of this report. Eireen Banez-Villa was the international consultant. To the knowledge of the management of OED, there were no conflicts of interest of the persons preparing, reviewing, or approving this report.

BASIC DATA Health and Nutrition Sector Development Program (Loans 1675 and 1676-INO) PROGRAM PREPARATION AND INSTITUTION BUILDING TA No. TA Project Name Type PersonMonths ADTA 48 3175 Monitoring and Evaluating the Health and Nutrition Sector Development Program 3176 Capacity Building for ADTA 90 Decentralized Health Services Management Per ADB Loan Documents 100.0

Amount $1,000,000

Approval Date 25 March 1999

$1,000,000

25 March 1999

KEY PROGRAM DATA ($ million) ADB Loan Amount and Utilization ADB Loan Amount and Cancellation

Actual

100.0 0.0
Actual

KEY PROJECT DATA ($ million) Total Project Cost Foreign Currency Cost Local Currency Cost ADB Loan Amount and Utilization ADB Loan Amount and Cancellation
KEY DATES

Per ADB Loan Documents 479.05 127.08 351.97 200.00

Expected

378.76 98.97 279.79 160.21 39.79

Actual

Appraisal Loan Negotiations Board Approval Loan Agreement Loan Effectiveness First Tranche Release Second Tranche Release Completion of Project Component Loan Closing 1675-INO 1676-INO Months (Effectiveness to Completion) BORROWER EXECUTING AGENCIES Program Loan Project Loan

March 2000 31 March 2001 30 September 2000 31 December 2001 34 Government of Indonesia

219 February 1999 2223 February 1999 25 March 1999 25 March 1999 25 March 1999 25 March 1999 22 December 2000 31 December 2003 22 December 2000 28 July 2004 64

Ministry of Finance BAPPENAS

iv MISSION DATA Type of Mission Fact-Finding Appraisal Inception Project Administration Reviewa Mid-Term Special Loan Administration Project Completion Operations Evaluationb

No. of Missions 1 1 1 4 1 1 1 1

Person-Days
73 73 9 67 20 30 20 19

ADB = Asian Development Bank, ADTA = advisory technical assistance, BAPPENAS = Badan Perencanaan Pembangunan Nasional (National Development Planning Agency), OECF = Overseas Economic Cooperation Fund of Japan, TA = technical assistance. a In October 1999, the Review Mission also assessed the fulfillment of the conditions for the release of the second tranche of the Social Protection Sector Development Program. b The Operations Evaluation Mission comprised Kus Hardjanti, senior evaluation specialist (mission leader).

EXECUTIVE SUMMARY The Health and Nutrition Sector Development Program (HNSDP) was designed and implemented in response to the economic crisis that hit Indonesia in 1997. The HNSDP comprised two loans: (i) Loan 1675-INO, a policy-based program loan (the Program) for $100 million; and (ii) Loan 1676-INO, a project loan (the Project) for $200 million. The crisis undermined the social well-being of the Indonesian people, as unemployment increased, family incomes continued to decline, and purchasing power weakened due to soaring prices of basic commodities. The Governments limited budget constrained the delivery of essential and basic services, preventing peopleespecially the poorfrom accessing quality health care. Unresponsive structures, rigid organization, poor incentives, and weak management systems aggravated the poor delivery of health care. The crisis would jeopardize the countrys gains in human development, with the poor and vulnerable groups hit the hardest. The HNSDP aimed to (i) secure for the poor access to essential health, nutrition, and family planning (FP) services; (ii) ensure maintenance of nutritional status of vulnerable groups; and (iii) reduce the incidence and impacts of communicable diseases associated with poverty and malnutrition. The program loan was designed to support fundamental reforms through the development of pro-poor health policies, structures, and systems that were more responsive to local needs. The project loan was to invest in the improvement and maintenance of the health and nutrition of the population, and secure their continued access to essential health, nutrition, and FP services. Two technical assistance (TA) grants (TA 3175-INO and TA 3176-INO) supported an independent monitoring system to allow project design to be adapted during implementation, and to strengthen the district- and community-level capacity to manage the delivery of basic health services. At program formulation, 65 policy action points were identified as requirements for fund release. The Program helped the Government institute policy reforms, and supported the equitable inclusion of the poor in health services. Due to the crisis, the Government developed innovative, nontraditional schemes to facilitate the delivery of health services and protect the poors access to health, nutrition, and FP services. The Project also produced most of the expected outputs. Project interventions largely reached the intended beneficiaries. These included (i) health card distribution to the poor; (ii) revitalization of posyandus (community-based health posts that provide prevention and promotive health, nutrition, and FP services) and kaders (community volunteers); and (iii) provision of maternal care, FP, and immunization services. However, complementary and supplementary feeding for infants 011 months old, children 1223 months old, and pregnant women with high caloric deficiency, as well as assistance for schoolchildren, reached fewer than expected. This is the first combined program and project performance evaluation report (PPER) under a Social Development Program loan that was conducted using the Operation Evaluation Departments new PPER guidelines. Therefore, some adaptations in the standard evaluation methodology were required. The program and project loans were evaluated and rated separately, and these were averaged to give the HNSDP an overall rating. The PPER rates the HNSDP as successful based on an assessment of its relevance, effectiveness, efficiency, and sustainability. The HNSDP is considered highly relevant in helping to mitigate the adverse health impacts of the financial crisis, such as protecting the access of the poor to basic health, nutrition, and FP services; and ensuring the maintenance of the nutritional status of the vulnerable groups. However, the complex design also addressed the chronic structural incapacities and weaknesses of the health care delivery system, as well as

vi the systems development and capacity building in preparation for decentralization. Thus, allowing only 2 years for implementation was overly optimistic, especially given the challenges created by the major economic crisis followed by political upheavals and some social dislocation. Sufficient time should have been included in the project design at the beginning instead of extending the Project an additional 2.5 years at the end. The policy actions required by the HNSDP were effective in creating a supportive and facilitative environment in which the Project interventions could take place. Some of notable achievements were (i) the policies securing the budget allocation for health, nutrition, and FP; (ii) the inclusion of the pro-poor criteria in budget allocation; (iii) the establishment of mechanisms for identifying and locating the poor; and (iv) the development of plans with corresponding budget to intensify outreach and promotion of health services. The HNSDP ensured access of vulnerable groups to essential health, nutrition, and FP services. The HNSDP was compounded by operational issues and bottlenecks, partly related to the challenges brought about by the crisis atmosphere in which it was designed and implemented. Because of the urgent need to reach the targeted beneficiaries quickly, the design and preparation time were shortened. Intervention schemes and guidelines were not assessed thoroughly before nationwide implementation, and implementers were not fully on board before implementation. The HNSDP also suffered from delayed procurement of goods and services, particularly the purchase of imported blended food. Defining and identifying the poor also posed a big challenge to many localities. However, the HNSDP overcame these difficulties. The policy reforms and interventions supported by the HNSDP are likely sustainable. During visits to selected project sites, the Operations Evaluation Mission (OEM) confirmed the continued adoption and compliance with these policies. In addition, poor and vulnerable groups continued to have access to essential health and nutrition services. Posyandu services were revitalized, enabling the targeted beneficiaries to continue receiving maternal and child care, nutrition feeding, assistance to street children, and FP-related services. The Government authorities concerned continue to enhance the HNSDPs interventions and schemes (e.g., refinement and unification of the process and criteria for identifying the poor, expansion of health cards to social security cards, enhancement of fund transfers from central to local government units, etc.). The project completion report rates the combined Program and Project loans at the higher range of successful, while the PPERs overall rating is successful. Both TA grants (for $1 million each) attached to the HNSDP are rated successful, confirming the rating of the TA completion reports. During HNSDP implementation, the Japan Fund for Poverty Reduction (JFPR) separately provided a grant of $1 million for a project entitled Assisting Girl Street Children at Risk of Sexual Abuse (JFPR 9000-INO). The implementation completion report had not been finished at the time of the OEM. Based on interviews by the OEM, this JFPR project is likely to be successful. An evaluation of the JFPR project should be included in the assessment of the overall JFPR program. The performance of the Borrower and the Asian Development Bank (ADB) are rated satisfactory. The Government demonstrated a high level of commitment to mitigating the damage from the crisis, as demonstrated by its compliance with the loan covenants and policy actions. The approval of this Program showed ADBs commitment to helping Indonesia through the crisis, as well as an effort to reduce the impact of increased poverty. ADB exhibited flexibility, and provided ample and timely technical support at the beginning and middle of program

vii implementation. However, ADB did not provide any supervision during the last year of the Project. A financial crisis can create opportunities for success or failure. The HNSDP demonstrated that adverse impacts can be mitigated successfully if stakeholders at the national and local levels make a concerted effort. Designed and implemented in a crisis atmosphere, the HNSDP brought to the fore innovative, nontraditional mechanisms in securing access to essential services for the poor. Follow-up actions for ADB identified under two ongoing loan projectsDecentralized Health Services Project (Loan 1810-INO) and Second Decentralized Health Services Project (Loans 2074-INO and 2075-INO)include (i) developing a strategy to help the government transcend its crisis mitigation-oriented efforts, and adopt longer-term and more sustainable approaches to improving the health and nutritional status of the poor; and (ii) fast-tracking the unified definition of the poor, and issuing a single social security card to ensure more efficient targeting of the poor.

Bruce Murray Director General Operations Evaluation Department

I. A. Evaluation Purpose and Process

INTRODUCTION

1. The Health and Nutrition Sector Development Program (HNSDP) loan1 in Indonesia was selected as part of the annual random sample of completed programs and/or projects to be evaluated by the Operations Evaluation Department (OED) of the Asian Development Bank (ADB). The Operations Evaluation Mission (OEM) visited Indonesia from 13 February to 2 March 2006more than 4 years after the program loan ended on 31 December 2001, 2 years after the project loan was completed on 31 December 2003, and 1 year after the HNSDPs project completion report (PCR). This is the first combined program and project performance evaluation report (PPER) under a Social Development Program loan that was conducted using OEDs new PPER guidelines. Therefore, some adaptations in the standard evaluation methodology were required. The program and project loans were evaluated and rated separately, and these were averaged to give the HNSDP an overall rating. 2. The evaluation draws upon a mix of data collection methods, including key informant interview, focus group discussion, a survey of selected beneficiaries, and a review of project documents and other relevant studies. The OEM conducted interviews and discussions with Government officials representing the National Development Planning Agency (BAPPENAS), Ministry of Health (MOH), National Family Planning Coordinating Board (BKKBN), Ministry of Social Affairs (MOSA), Ministry of National Education (MONE), Ministry of Finance (MOF), and other development partners at the national and local levels. The OEM made field visits to four provinces 2 with varying levels of program performance, particularly in the distribution and utilization of the health cards by the poor. Field visits included meetings and interviews with provincial, district, and subdistrict health officials and staff; and focus group discussions with the heads and staff of health centers. Six puskesmas, or primary health care (PHC) centers, were visited, representing mostly catchments of the poorest and some lower middle-income populations in urban and rural areas. A beneficiary survey was undertaken at these puskesmas, covering 70 respondents. The OEM consulted with 160 persons during the visit to Indonesia. The draft PPER was shared with relevant ADB departments, as well as with the Borrower, for comments. These comments have been incorporated and acknowledged in this PPER, where relevant. 3. The PCR rated the HNSDP as successful, at the higher range of this category. The HNSDP was rated highly relevant as a short-term response to the financial crisis, as well as to the need for longer-term structural reforms. The PCR considered the HNSDP highly successful in mitigating the impact of the crisis on the most vulnerable groups, and contributing significantly to fundamental reforms in the health sector. The project loan (Loan 1675-INO) was considered largely to have achieved its targets in (i) securing access of the vulnerable groups to essential health, nutrition, and family planning (FP); (ii) ensuring maintenance of nutritional status of the vulnerable groups; and (iii) reducing the incidence and impacts of communicable diseases. Despite these achievements, the PCR rated the implementation process as less efficient for a variety of reasons, including inconsistent targeting of beneficiaries, lack of training of staff
1

ADB. 1999. Report and Recommendation of the President to the Board of Directors on Proposed Loans and Technical Assistance Grants to the Republic of Indonesia for the Health and Nutrition Sector Development Program. Manila (Loans 1675 and 1676-INO and TAs 3175 and 3176-INO, for $300 million, approved 25 March 1999), of which $100 million was allocated for Loan 1675-INO (policy-based program loan) and $200 million was for Loan 1676-INO (project loan). Puskesmas, or primary health centers (PHC) in subdistricts of Cilinciling; Koja (North Jakarta); Tanah Sareal (Bogor); Bantar Tarus and Oesao (Nusa Tenggara Timur); and PHC in Depansar Municipality, Bali.

2 responsible for implementation, and miscalculating the capacity of the district coordinating committees to perform their work. On a whole, the PCR considered the HNSDP interventions to be likely sustainable. B. Expected Results and Program Objectives

4. The HNSDP is comprised of (i) a program loan (Loan 1675-INO) to support reforms to improve basic social services, and structural changes to enhance the Programs efficiency and effectiveness; and (ii) a project loan (Loan 1676-INO) to fund interventions in health, nutrition, and FP, and to help street children in 12 cities from 11 provinces. The HNSDP was accompanied by two technical assistance (TA) grants. The first TA (TA 3175-INO)3 supported monitoring and evaluation, while the second TA (TA 3176-INO) 4 provided training on decentralized management. 5 On 24 November 2000, the Japan Fund for Poverty Reduction (JFPR) provided a grant6 for $1.0 million to build on the Social Protection Sector Development Program7 (SPSDP) and HNSDPs efforts in helping to overcome the problem of street children. The JFPR project, which was implemented and administered separately, involved an umbrella local nongovernment organization (NGO) and 11 grassroots NGOs, the local government, and academics. 5. The primary objectives of HNSDP were to (i) secure access to essential health, nutrition, and FP services for vulnerable groups; (ii) ensure maintenance of nutritional status of vulnerable groups; and (iii) reduce incidence and impacts of communicable diseases associated with poverty and malnutrition. More specifically, the HNSDP aimed to mitigate the damage from the 1997 economic crisis by (i) maintaining access of the poor to quality health services; (ii) mobilizing additional resources for health services; (iii) enhancing decentralized management, participation, and transparency; (iv) advancing organizational structure changes at the MOH; and (v) improving efficiency. The project loan aimed to (i) ensure continued operation of the health centers; (ii) improve nutrition of the poor, especially mothers, infants, and children, through complementary feeding; (iii) strengthen control of communicable diseases most associated with poverty; (iv) enforce FP and reproductive health programs; and (vi) assist street children in urban areas. 6. TA 3175-INO (footnote 3) was designed to provide information that could improve the HNSDPs impact, targeting, and delivery mechanisms. TA 3176-INO (footnote 4) aimed to strengthen the district- and community-level capacity to manage and improve the effectiveness of basic health delivery services, particularly planning, budgeting, and financial management.

ADB. 1999. Technical Assistance to the Republic of Indonesia for Monitoring and Evaluating the Health and Nutrition Sector Development Program. Manila (TA 3175-INO, for $1 million, approved 25 March 1999). ADB. 1999. Technical Assistance to the Republic of Indonesia for Capacity Building for Decentralized Health Services Management. Manila (TA 3176-INO, for $1 million, approved 25 March 1999). The Overseas Economic Cooperation Fund of the Government of Japan provided $300 million to cofinance interventions that were implemented and administered separately. ADB. 2000. Assisting Girl Street Children at Risk of Sexual Abuse. Manila (JFPR 9000-INO, for $1 million, approved on 11 August, and closed on 30 April 2006). ADB. 1998. Report and Recommendation of the President to the Board of Directors on a Proposed Loan to the Republic of Indonesia for Social Protection Sector Development Program. Manila (Loan 1622-INO, for $100 million, approved 9 July 1998).

3 II. A. Formulation DESIGN AND IMPLEMENTATION

7. In response to the Governments request for help in mitigating the damage from the 1997 socioeconomic crisis, ADB approved the HNSDP (footnote 1). The program or policybased loan was closed on 22 December 2000, 3 months beyond its expected closing date. The project loan closed on 28 July 2004, 2.5 years later than the estimated closing date. A PCR was circulated to the Board in June 2005. The accounts of the two accompanying TAs were closed on 30 June 2003. 8. The HNSDP was an integral part of a $2.8 billion assistance program that ADB provided as part of the broader international support package to help mitigate the adverse socioeconomic consequences of the Asian financial crisis. It followed the SPSDP covering broader concerns in education, health, employment, and other social needs. The economic crisis increased the proportion of the Indonesian population living in poverty from 32.7% in 1996 to 48.0% in 1999, negating the Governments human development achievements in the previous years. 9. Many years before the financial crisis, the MOH had been trying to develop a health system that could be more responsive to the varying needs of different localities spread across a wide geographical area. A few years before the crisis, MOH worked with ADB to develop decentralization concepts for the health sector. This continuous dialogue between ADB and the Government paved the way for the development of policy actions required in the HNSDP. These policies basically advocated more local ownership and decision making in the health sector. When the Indonesian Parliament passed the Decentralization Laws in 1999, these policies made MOH by far the line ministry most prepared to implement decentralization. 10. The HNSDP introduced innovative mechanisms to ameliorate the negative impacts of the crisis. These included (i) the allocation of funds from the central Government directly to the districts based on a district poverty index, rather than on total population; (ii) decentralized decision making to enhance transparency, and to foster local decision making and ownership; (iii) a block grant mechanism that channels funds to district health centers to help cover operational costs; (iv) transfer of funds through the local post offices direct to the health centers and midwives, bypassing the usual mechanism through the State Treasury of MOF; (v) independent and continuous monitoring to ensure the effectiveness of the HNSDP and accuracy of the funds transfer; and (vi) complaint resolution units to solve problems and complaints related to the implementation of the HNSDP. B. Rationale

11. The economic crisis that hit Indonesia in 1997 continued to take its toll in 1998, unemployment increased, family incomes declined, purchasing power fell, and basic commodity prices rose. Problems in the delivery of essential social services compounded the negative impacts on social welfare. The number of people living in poverty increased significantly. From 11.3% in 1996, the percentage of poor with incomes below the poverty line peaked at 27.0% in December 1998. 8 Although the need for essential services was rising, the prices of basic supplies (e.g., drugs, vaccines, and contraceptives) increased, while the supply was constrained severely by the insufficient government budget. Well-targeted assistance was needed urgently to help alleviate the plight of the poor and vulnerable groups.
8

Japan International Cooperation Agency. 2003. Country Profile Study on Poverty: Indonesia. Tokyo.

4 12. Healthy and well-nourished individuals are more likely to be productive, have higher learning capacities, better school performance, and lower child mortality. The economic crisis had short- and long-term implications on the well-being of the people in terms of their productivity, capacity, and welfare. The intergenerational effects of malnutritionfrom undernourished mothers to low-birth weight infants, stunted children, malnourished adolescents, and high-risk mothersare difficult to address. These concerns underscored the need for the HNSDPs focused intervention on the health, nutrition, and welfare of the poor and vulnerable groups. In addition, chronic structural weaknesses, organizational rigidity, and poor incentives have limited the performance of the health sector, preventing it from responding effectively to the deteriorating health conditions in the country. Fundamental and structural reforms in the health care delivery system were also needed. The HNSDP was designed to complement the efforts of the Government of Indonesia and its development partners to address key policy reform issues in the social sector in a broader and unified manner. C. Cost, Financing, and Executing Arrangements

13. The details of the appraisal and actual costs are in Appendix 1. At appraisal, project costs were estimated at $479.05 million, of which ADB was to finance $200.00 million (42%) through a project loan. The Government was expected to contribute the equivalent of $279.05 million, representing 58% of project costs. The actual project cost totaled $378.76 million, of which ADB financed $160.22 million (42%), while the Government contributed $218.54 million (58%). 14. During implementation, ADB approved the Governments requests to (i) increase the ceiling of the initial deposit of $20.0 million to $50.0 million, (ii) reallocate the loan proceeds to cover higher expenditures expected in the final year of implementation, and (iii) reallocate and partially cancel loan proceeds for the remaining activities before program completion. 15. Appendix 1 shows that actual funds spent on provincial and/or district monitoring and supervision, program management operations, and research and evaluation almost doubled to $17.03 million from the appraised allocation of $9.01 million. This was due to the expanded coverage of monitoring activities. The actual cost for contraceptive supplies increased from $16.02 million to $26.14 million, because of the second round of procurement towards the end of the project. On the other hand, the allocation for MOH systems development was substantially below the appraisal estimate due to difficulties during the rapid decentralization, as well as the decision not to pursue the development of an integrated management information system. The amount spent for essential health and safe motherhood services, including communicable disease control, nutrition feeding, and support to street children, was lower than the appraisal estimate. 16. The program (policy-based) loan provided quick-disbursing assistance to support the Governments policy reforms. The first tranche of the program loan was released at loan effectiveness. However, the second tranche was delayed by 9 months due to the Governments focus on administrative restructuring, bureaucratic reform, and staff changes introduced following the presidential elections in October 1999, as well as the accelerated implementation of the decentralization. 17. MOF was the Executing Agency (EA) for the policy loan. As such, it was responsible for initiating withdrawals under the loan, and allocating and monitoring the use of counterpart funds. As EA for the project loan, BAPPENAS was in charge of coordinating implementation. The HNSDP implementation structure duplicated that of SPSDP, including the use of the same

5 management and coordination mechanisms. An advisory steering committee, chaired by BAPPENAS, was established. Comprising directors from different ministries BKKBN, MOH Ministry of Home Affairs, MONE and MOSAthe committee supported program implementation of technical matters and the allocation of resources to districts. A secretariat was formed within BAPPENAS to coordinate all program-related activities, while project implementation units (PIU) were established in MOH, BKKBN, and MOSA. 18. The secretariat in BAPPENAS focused on coordinating, monitoring, and reporting on the programs status, while the PIUs took charge of coordinating the implementation and administration of the day-to-day operations at the national level. Coordinating committees were set up at the provincial, district and subdistrict levels. The district coordinating committee was responsible mainly for the allocation of resources and monitoring. At the subdistrict levels, the coordinating committees were to (i) oversee the implementation of planned activities, (ii) withdraw and properly use the program funds, (iii) procure the necessary goods, and (iv) report on the use of funds. D. Application of Counterpart Funds

19. The Government complied with the loan covenant by making available, as promptly as needed, the funds, facilities, services, land, and other resources required, in addition to the proceeds of the loan, for carrying out the Project and for the operation and maintenance of the project facilities. In particular, each of the implementing agencies (MOH, BKKBN, and MOSA) established their PIUs with regular staff. The Government also provided its own funds to finance the traveling expenses of staff assigned to monitoring the progress of program implementation. Government counterpart inputs also came in the form of venues for meetings, supplies, other logistics needed, maintenance of project offices, and other operating expenses. E. Procurement, Construction, and Scheduling

20. Procurement followed ADB procedures, as stipulated in the project administration memorandum and ADBs Procurement Guidelines. However, the procurement of blended food required a second round that entailed 15 months, which significantly delayed the distribution from the district warehouses to the posyandus.9 Procurement of the computer package was rebid, while the bid period for the communicable disease control reagents was extended from 90 to 150 working days. The Government and ADB took longer than expected to reach an agreement on consulting services in support of the health management information system, health official information system, and health financial information system. This limited the time for implementation. 21. Approval and effectiveness of the program loan began on 25 March 1999. It closed on 22 December 2000, 2 months later than the original date of 20 September 2000. After two extensions, the project loan closed on 28 July 2004, 2.5 years beyond the original date of 31 December 2001. The first extension (from 31 December 2001 to 31 December 2002) was required to allow the proper transfers of grant funds, and to complete the procurement of blended food, contraceptives, communicable disease control reagents, and computers and software development. The second extension (from 31 December 2002 to 31 December 2003) was required to allow the completion of activities that were postponed due to the delayed procurement, such as nutrition feeding (mainly the blended food).
9

Posyandus are community-based health posts that provide preventive and promotive health, nutrition, and FP services.

6 F. Design Changes

22. The HNSDP was patterned after the SPSDP, and used the same implementation arrangements and financing mechanisms. This was an appropriate decision, and no major changes in the design were needed during implementation. However, the devaluation of the rupiah against the dollar because of the financial crisis led to the partial cancellation of the $27.0 million project loan. The project budget was also reallocated twice to accommodate the changing requirements of the different components. Procurement of blended food was conducted through international competitive bidding. The order for contraceptives was repeated, while the number of posyandus to be revitalized was increased from 65,000 to 120,000 during implementation. An integrated management information system was not developed due to the difficulty of coming up with a single system at the peak of the nationwide decentralization process. The rest of the components were implemented as designed. G. Outputs 1. Program Loan

23. ADB required 65 policy actions as conditions for the release of the loan. Of these, 29 were completed and complied with before the release of the first tranche, while another 36 conditions were fulfilled before the release of the second tranche. Appendix 2 summarizes the status of compliance with these conditions, with the program and project evaluation report confirmation of the continued application of the policy actions. 24. The program loan supported the Governments efforts in instituting policy reforms nationwide, and ensuring the equitable inclusion of the poor in health services. Specifically, the policy support helped to reform the routine budgetary allocation system based on population size by factoring the percentage of poor into the allocation formula. It also helped the national and local levels in developing the criteria to define the poor. Further, the program loan was instrumental in instituting the system for transferring funds directly from the central level to health centers and midwives at district and subdistrict levels, which greatly facilitated the access of the poor to essential health and nutrition services. With the rapid implementation of decentralization, the program loan catalyzed the strengthening of the local-level capacity in health service delivery and management of health programs, covering planning and budgeting, financial management, and institutional development. 25. One of the notable policy conditions was maintaining the allocation for health in the national budget at the same level as before the 1997 crisis. Though this was not complied with completely after 2003, the decline was addressed partially by additional resources from the provincial, city and municipal governments after decentralization. The MOH share of the national budget increased from 1.2% in 2001 to 2.6% in 2006 (Appendix 5, Table A5.3). Health allocation of subsidies for the poor increased from $119.3 million in 2004, to $304.5 million in 2005, and $402.2 million in 2006. Field visits to several districts and puskesmas confirmed that local, provincial, and central governments are providing more funds for health. 26. The formulation of guidelines regarding the establishment of complaint resolution units at the district level helped improve the transparency and accountability of the use of resources. In 2005, the MOH issued a revised version of these guidelines. In field validations, the OEM found the local level uses different mechanisms to ensure transparency and accountability of the use of resources. These include mobilizing a council within the district and subdistrict level to handle complaints by (i) including representatives from NGOs, academia, or leaders from the

7 community; (ii) making the lists of poor individuals open to the public; (iii) presenting the report on allocation and utilization of funds available to a wider audience, even those outside the health department; and (iv) encouraging others to approach the media with complaints or suspected anomalies. 2. Project Loan

27. As reported in the PCR, the project loan largely succeeded in meeting the expected outputs. The OEM validated the PCR assessment of the achievements indicated in the program framework (Appendix 3). (i) About 11.0 million of the 15.3 million targeted households (72%) had access to health services. The poor were provided with basic health services and nutrition feeding, particularly for infants 611 months old, children 1259 months old, and pregnant women with high caloric deficiency. Health cards were distributed to 92% of identified poor individuals nationwide, ranging from 79.9% in the Jakarta Capital City Special Municipality to 98% in East Java. Among health card holders, utilization by the poor to access health services ranged from 11% in Bali to 65% in Nusa Tenggara Timur (NTT). The utilization rate of poor on average increased to 17%19% in 2001 and 30% in 2003, slightly higher than the national average.10 More than three fourths (77%) of the targeted pregnant women received antenatal care in 2003, while more than two thirds (68%) of targeted post partum women received post-natal care. About 1.6 million of the 1.9 million targeted high-risk pregnant mothers received safe motherhood services, which included four prenatal visits, birth attended by a health professional, three post-natal visits, first-line obstetric care, and referral. Complementary and supplementary feeding coverage was slightly below 100%. In 2003, 65% of entitled infants 611 months old received complimentary food, and 68% of children 1223 months old received supplementary food. About 72% of mothers with chronic energy deficiency received supplementary food. The original target of revitalizing 65,000 posyandus nearly was doubled to 120,000 at the end of the Project, a remarkable achievement. Recognizing that more areas needed to be reached, the Government decided to expand the number of posyandus targeted for revitalization after the first year of implementation. The nutrition surveillance system also was revitalized and applied to all provinces nationwide. More than 90% of the health centers had supplies of all required vaccines. Distribution included 58.0 million oral contraceptives, 3.3 million vials of injectables, and 187,000 sets of implants. Funding was allocated to 201 open houses (shelters for street children)107 in 2000 and 94 in 2003. Over 2 years, about 9,200 scholarships were sponsored for primary, junior, and senior secondary education to street children, while 7,500 scholarships were sponsored for vocational and technical education. More than 6,000 street children received supplementary food.

(ii)

(iii)

(iv)

(v)

(vi) (vii)

(viii)

10

British Council. 2002. National Survey Final Report, Independent Monitoring and Evaluation of the Health and Nutrition Sector Development Project.

8 H. Consultants

28. The estimated consulting services requirement under the report and recommendation of the President consists of 5 international and 7 domestic consultants. The Program actually engaged 4 international and 7 domestic consultants. The international consultants covered strategic planning and development, health and nutrition policy analysis and review, and nutrition and project management. Domestic consultants were hired for (i) nutrition surveillance, monitoring, and evaluation; (ii) project coordination; (iii) project management and implementation; (iv) project policy analysis and review; (v) training coordination and evaluation; and (vi) public awareness and social campaign. A domestic or international consultant for cultural anthropologist or sociologist was not hired. I. Loan Covenants

29. The Loan Agreement included covenants on (i) the utilization of the loan proceeds, (ii) implementation arrangements, (iii) reporting mechanisms and requirements, (iv) monitoring and evaluation, and (v) procurement. The Government complied with all of them. Some of these covenants also were requirements for the release of the policy loan. None of the covenants was modified, waived, or suspended. J. Policy Framework

30. In 2001, implementation of the Laws on Decentralization 11 started, which created substantial changes in the health care delivery system. The time and effort of national and local agencies were reallocated to meet the new demands of the Governments rapid decentralization program. During implementation, the political leadership of the Government also changed, which led to the designation and appointment of new officials at the helm of some ministries, as well as the reassignment of some key health officials. This round of political instability took its toll on the economy, and added to the deteriorating economic condition. III. A. Overall Assessment PERFORMANCE ASSESSMENT

31. Overall, the HNSDP is rated successful. It is assessed as relevant, effective, less efficient, and likely sustainable. The HNSDP helped prevent the health and nutritional status of the Indonesian people from worsening during the crisis. Further, it was instrumental in maintaining access, especially for the poor, to basic health, nutrition, and FP services. The associated policy reforms paved the way for health service delivery that is more locally managed and poor-oriented. Innovative approaches adopted by the HNSDP effectively facilitated the delivery of the Government support, and ensured that resources reach the targets as early as possible and in the intended amounts. The mix of interventions, tailored to the lifecycle approach, was responsive to the health and nutrition requirements of infants, children, and women, thereby helping them cope with the impact of the crisis. 32. The HNSDP, as designed, faced a number of challenges during implementation. With its nationwide scope and comprehensive coverage, the HNSDP was too ambitious to be completed within 2 years. The short implementation period became more challenging given the toll of the
11

The Law of the Republic of Indonesia Regarding Regional Governance (Law 22/99); and the Law of the Republic of Indonesia Regarding the Fiscal Balance Between the Central Government and the Regions (Law 25/99).

9 crisis and the rapid implementation of the decentralization process. Little time was afforded to detailed preparation before implementation. As a result, some interventions were carried out without the necessary information and skilled implementers. The arrival of some health and nutritional supplies also was delayed, undermining the timely delivery of the benefits of the interventions. 33. Specifically, the PCR rates the combined program and project loans at the higher range of successful, while the PPER separately rates the program and project loans as successful. The two accompanying TAs are rated successful, thereby confirming the rating of the TA completion reports. 1. Relevance

34. Overall, the HNSDP is rated relevant. It was designed and implemented in response to the Governments urgent need to mitigate the impact of the 1997 financial crisis. Recognizing that the health and nutrition of the poor was at the greatest risk, the HNSDP provided timely and much-needed assistance. Its focus on the vulnerable groupsinfants, children, and women was strategically important, as the health and nutrition of those groups were highly susceptible to the worsening conditions generated by the crisis. This was reflected in the decreasing food intake, and limited health and nutrition care. The objectives of the HNSDP were consistent with the overall thrust of the Government to protect and sustain the human development gains made during the previous 15 years of rapid economic growth. The concern for the poor was reflected in the approaches and mix of its interventions. The HNSDP is also consistent with ADBs health policy, particularly in prioritizing assistance to the poor and vulnerable groups, and focusing on PHC interventions. Finally, it is aligned with ADBs emphasis on community-oriented approaches, public-private sector cooperation, and multisector coordination. During the OEM, the program was still relevant. For these reasons, HNSDP is rated highly relevant. 35. However, the project design is overstretched and overly complex to be achieved within the allotted 2 years, especially in a country in the midst of an economic crisis. During a discussion on 25 March 1999, the Board raised the complexity as an issue as members envisaged the Project taking longer than planned. Close monitoring and supervision, including the active participation of the Indonesia Resident Mission, were seen as prerequisites for effective project implementation. 36. The policy actions required on the part of the Government helped to achieve (i) a more equitable allocation of resources for the poor, (ii) better targeting of the resources, (iii) sustained pre-crisis funding level for health and nutrition services, and (iv) the fast-tracking of the delivery of services through innovative approaches. These requirements were highly relevant in securing access for the poor to health care, especially with the Governments declining revenues during the crisis. Without the HNSDP, the Governments increasingly difficult fiscal position likely would have resulted in lower public spending for social services. The mix of intervention packages was highly appropriate, as they covered (i) basic health services; (ii) nutrition feeding for infants, children, and pregnant women with high caloric deficiency; (iii) continued supply of contraceptives; and (iv) logistics support for communicable disease control. The revitalization of posyandus, as well as the mobilization of the village midwives and other community workers, helped to bring health care to the doorstep of the poor. 37. The OEM found that the policies supported by the program loan and the interventions financed by the project loan remained relevant. The Government continues to give focus and priority to ensuring that the poor have access to health services (Appendix 3). The passage of

10 the Social Security Safety Net Law in 200412 attests to the continued relevance of the policies and interventions that HNSDP supported. In Medium Term National Development Plan for 20062009, BAPPENAS ranked health and education as the top priority for external financing, followed by infrastructure, agriculture, and poverty reduction. MOH affirms its pro-poor bias in its 20062009 Health Action Plan, which aims to improve access, networking, and quality of health services. The Government is undertaking several efforts to strengthen local capacities to manage health service delivery under the devolved system. 2. Effectiveness

38. Overall, the HNSDP is rated effective. The policy actions are considered highly effective in creating a supportive and facilitative environment for the project interventions, including (i) securing a budget allocation for health, nutrition, and FP at the same level as before the 1997 crisis; (ii) issuing decrees on budget allocations, giving a greater share to areas with a higher proportion of poor, and establishing an objective system for defining and identifying the poor; (iii) developing plans with corresponding funds to intensify outreach activities targeting the poor; and (iv) formulating plans and strategies to improve the quality of health, nutrition, and FP services. Complementary to these was the Programs proactive push for the establishment of complaint resolution units at the district and subdistrict levels, which helped minimize leaks and administrative bottlenecks in health care delivery. a. Policy Reforms

39. Focusing the program assistance on the poor was highly strategic. The development of a set of criteria for defining the poor, locating them, listing their names, and providing them with health cards as their passport to basic health services worked very well. The adoption of the pro-poor budget allocation system is highly effective in ensuring that the poor receive an equitable share of the Governments resources for health. The block grant mechanism for transferring funds from central Government to the local level, and releasing these block grants directly to the PHC and midwives through PT Pos Indonesia (Indonesian Post, Inc.)instead of the routine route through the State Treasury of MOFwas highly effective in bringing the assistance immediately to the poor. Further, this increased transparency and reduced fraud and corruption. The program loan instituted policy reforms that improved the access of the poor and vulnerable groups to quality health services. b. Securing Access of Vulnerable Groups to Health, Nutrition, and FP Services

40. As the first anticipated outcome, the HNSDP was to secure the access of vulnerable groups to health, nutrition, and FP services. This was achieved by identifying the poor and giving them health cards that enable them to access health care at PHC centers, hospitals, and other public service outlets for free. Reports show that, on average, nine of 10 identified poor individuals received their health cards. In parallel, the HNSDP supported the network of health providers as a ready source of health care by revitalizing 120,000 posyandus nationwide. The HNSDP provided a block grant to every midwife and a separate block grant to all health centers throughout the country, with accompanying training and provision of necessary equipment, drugs or medicines, and other supplies (e.g., contraceptives, reagents for communicable disease control, blended food, etc.). The results of the beneficiary survey confirmed that the card holders received health care and nutrition feeding during the Program (Appendix 6).
12

Law No. 40 of 2004, Social Security Safety System Law, Republic of Indonesia.

11 41. The PCR reported that the poor increased their utilization of health care from less than 10% before the Program to 17%19% in 2001 and to 30% in 2003slightly higher than the national average. The National Survey Final Report (footnote 3) under the TA on Independent Monitoring and Evaluation showed that the major success of the HNSDP was the delivery care provided by health professionals to more than 83% of poor mothers. The Project also appeared to have improved the equity of access by poor mothers to antenatal care. Though the distribution of health cards was very high (92%), the utilization of health services is still low, mainly because most poor come only when they are sick, and some have difficulty getting to the service outlets due to distance and transportation cost (Appendix 6). Field validation confirms that the list of the poor is updated continuously, with health cards provided accordingly. If some poor individuals were missed in an earlier round of identification, a letter from the village head endorsing an individual as poor serves as a backup document. Poor individuals who needed emergency care at the hospital were given immediate treatment, as they were allowed to present their health cards or endorsement letter the next day. c. Maintaining Nutritional Status of Vulnerable Groups

42. As the second anticipated output, the HNSDP was to ensure the maintenance of nutritional status of vulnerable groups. Data from 1998 to 2003 show that the prevalence of underweight and severely underweight children fluctuated during the crisis, but remains slightly lower than the 1998 levels. 43. The nutrition component of the Program is rated less effective. Only 65% of the targeted infants 611 months old, 68% of the targeted children 1223 months old, and 72% of the targeted pregnant women received feeding. These feedings were characterized by long delays in the arrival of funds, and intermittent breaks in the program. The distribution of the imported blended food was completed only during the last quarter of 2002. 44. Field validation shows that the feedback from service providers and reactions of beneficiaries regarding the blended food varied. People with a relatively better economic status are more experienced with the taste and texture of preprocessed food supplements. Hence, they complained less compared with those in poorer, more remote communities, who were more emphatic about the unacceptability of the blended food. At the start of the HNSDP, the use of blended food had sparked debate. Because it is formulated correctly to meet the calorie and micronutrient requirements of children, and was considered more expedient in improving their nutritional status during the crisis, the HNSDP proceeded with its procurement. However, the effectiveness of the blended food is reduced when children refuse to eat it in correct amounts and frequency. According to some anecdotal accounts, blended food ended up being eaten by other members of the household. 45. Data on the proportion of chronically energy deficient pregnant mothers showed a decrease from 20.1% in 2000 to 17.6% in 2003. However, data on this indicator was not available before the crisis. Thus, an assessment of HNSDPs contribution is difficult. Project monitoring reports showed the weights of pregnant mothers who were given feeding increased. d. Reducing Incidence and Impact of Communicable Diseases

46. As the third anticipated output, the HNSDP was to reduce the incidence and impact of communicable diseases associated with poverty and malnutrition. The HNSDPs support was mainly in the procurement of supplies and reagents for malaria, tuberculosis, and immunization. Other requirements for communicable diseases control were provided under a separate ADB

12 loan (Intensified Communicable Diseases Control),13 which was implemented in parallel with the HNSDP. The contribution of the HNSDP to controlling these diseases is rated less effective, because the inputs were procured and delivered only during the second and third quarters of 2004the last year of implementation. Further, the National Survey Final Report (footnote 3) noted that the performance level of this subcomponent was mediocre considering that several facilities did not have adequate functioning diagnostic apparatus for malaria and tuberculosis. It also remarked that the resources could have been used to treat other infectious diseases prevalent in localities where malaria is not present. e. Support for the Street Children

47. The program support for neglected and street children is rated less effective. While some children were provided with scholarships, training, feeding, and care, their number kept increasing. The PCR found that the loan assistance financed care for the street children, and some returned to their families. However, the number of street children increased since many other poor children, although not really street children, wanted to receive the same benefits. The Governments PCR also noted the limited capacity and lack of experience of some NGOs that participated in the program for the neglected and street children. 48. A social mapping survey in 1999 showed that 20% of the projected street children were girls, though the existing programs for street children were designed for boys. Hence, the existing street children programs were not addressing some vulnerabilities of girl street children. The JFPR project (footnote 6) enabled piloting interventions for girl street children. An implementation completion memorandum of this JFPR project was being prepared at the time of the OEM. Based on the OEMs interviews and the findings of a special evaluation study, entitled the Involvement of Civil Society Organizations in ADB Operations,14 this JFPR project appears to have demonstrated good results. It has been able to establish and sustain the network of grassroots and umbrella NGOs, academia, and the local government units in support of female street children. An evaluation of this JFPR project should be included in the assessment of the JFPR Program. 3. Efficiency

49. Overall, the HNSDP is rated less efficient. The program loan, which nearly was completed on time, is rated efficient. The project loan is rated less efficient for some components, and highly efficient for a few others. The project loan required 4.5 years for full implementation, instead of 2.0 years as originally planned. However, the original design schedule was too optimistic for such a highly complex project that encompassed health, nutrition, and FP service delivery; a program for street children; health systems development; and capacity building in a decentralized systemall during a crisis that created socioeconomic constraints. Moreover, Indonesias widespread geographic area, as well as its large and diverse population, made project management more complex. This required sophisticated coordination at various levels of operations, and intensive monitoring. An extension of 2.5 years was inevitable. The procurement of goods, especially the blended food (which delayed the implementation of the nutrition feeding program) and the drugs for communicable diseases, and the procurement of consultancy services were considered less efficient. However, the
13

ADB. 2005. Report and Recommendation of the President to the Board of Directors on a Proposed Loan to the Republic of Indonesia for the Intensified Communicable Diseases Control. Manila (Loan 1523-INO, for $87,400, approved 19 June 1997 and closed 2 May 2005). 14 ADB. 2006. Special Evaluation Study on the Involvement of Civil Society Organizations in Asian Development Bank Operations. Manila.

13 procurement of contraceptives and the revitalization of posyandus, two very important subcomponents, were rated highly efficient. They were well-coordinated and exceeded expectations, which helped to prevent the crisis from disrupting the FP and mother and child health programs. 50. The HNSDPs intervention for the street children is rated less efficient. A uniform budget was allocated to each open house for 160 targeted children, regardless of the number of street children in the area. As a result, extra slots were filled with other poor children who were not really neglected or on the streets. Not all NGOs selected to operate the program for street children were skilled and equipped. Thus, the quality of services they provided generally was not at par with the established NGOs for children. Better screening of the NGOs was needed. The JFPR project, on the other hand, consulted effectively with all stakeholdersincluding grassroots NGOs dealing with street childrenstarting from the design stage, which strengthened local ownership and commitment of the stakeholders. 51. Estimating the proportion of poor people at the national level has always been a challenge to the stakeholders, especially with the varying sets of criteria from different sources. Identifying and targeting the poor is continuing at the local level. While the identification and listing of the poor was relatively easier in the rural areas, the process was difficult in highly urbanized villages where the population is mobile. Unforeseen circumstances or calamities also affected previous listings of the poor. Complaints were received regarding the inclusion of nonpoor on the list and the exclusion of the real poor. The identification of the poor required regular updating and validation. Further, health staff needed to be equipped to explain the criteria to those who were mistakenly classified or missed out. 52. The use of the PT Pos Indonesia in transferring the funds to the health facilities and midwives is rated highly efficient compared with the routine mechanism of fund transfer through the State Treasury of MOF. The routine transfer usually takes 6 months from the central Government to the local level. PT Pos Indonesia took only 2 weeks to make the transfers, although some delays were experienced at the beginning. The direct release of funds to the PHC centers and midwives facilitated the delivery of services to intended beneficiaries. This suggests that the project interventions responded to the immediate needs of the targeted beneficiaries highly efficiently. 53. In general, the funds were released and used flawlessly and without delay. The independent monitoring report (footnote 10) found several areas where the release of funds was delayed, which consequently diminished program interventions and activity. The same report also pointed out that many heads of the health centers operated in secrecy, failing to show the allocation decree to their staff and to the requisitioning midwives. Consequently, these village midwives and other health facility employees were unaware of the entitlement of the health unit, or the amount allocated for services. The survey noted that, although 88% of the heads of facilities claimed to have allocated a budget to the village midwives, only 63% of the village midwives acknowledged receipt of such. This finding highlights the need for transparency by the health facility management and staff to ensure appropriate use of funds. The same report recommended that the guidelines regarding the receipt of funds be changed from the head of the facility (during the HNSDP) to the treasurer of the unit (after the HNSDP) to ensure better accounting of resources.

14 4. Sustainability

54. The program and project loans are assessed as likely sustainable. Government policies formulated and issued in compliance with the program loan still were in effect, if not further refined or strengthened, at the time of the OEM. Likewise, most of the interventions supported by the project loan continue to be undertaken, and health, nutrition, and FP services remain accessible to the poor and nonpoor. 55. The pro-poor focus has been ingrained deeply in the Governments health policy formulation, development and strategic planning, resource allocation, and budgeting at the central, provincial, city and municipal levels. After the project loan ended in December 2003, the national Government continued to provide increasing subsidies to the poor drawn from the savings in oil subsidies. Interviews with heads of puskesmas confirmed their regular receipt of much larger funding from the central Government than they received in the past to assist the poor. The most recent releases were received during the last quarter of 2005. Health cards continue to serve as the passports of the poor to access basic health services. The direct transfer mechanism outside the State Treasury of MOF is still being used. However, the central Government has contracted different entitiesPT Post Indonesia, Health Insurance or Asuransi Kesehatan (ASKES), and Bank Rakyat Indonesiato transfer the funds after the Project ended. Funds now flow directly to the district, which is responsible for allocating the amounts to the account of the puskesmas. The central Government is contemplating releasing financial assistance to the puskesmas through capitation, while continuing with the reimbursement mode for the hospitals. Local health managers, however, complained of the frequent changes in the guidelines, which created confusion at the local level. 56. With the implementation of the Social Security Safety Net Law (footnote 12), the Government plans to unify and harmonize the criteria for defining the poor based on the existing criteria of the Central Board of Statistics, MOSA, and BKKBN. In addition, a plan is in place to turn the health card into a social insurance card that would entitle the poor access to basic health services as well as other social assistance (e.g., education). The Action Plan for 2006 2009 and the 20052009 National Medium Term Development Plan of BAPPENAS continue to treat the welfare of the poor as a top priority. 57. The MOH budget has increased significantly over the yearsfrom $437.4 million in 2001 to $1.68 billion in 2006. MOHs share of the Government budget doubled from 1.20% in 2001 to 2.55% in 2006 (Appendix 5, Table A5.3). Under the devolved setup, local governments are expected to be responsible for financing the delivery of basic health, nutrition, and FP services. Field validation shows that local governments do provide for the delivery of health care. In areas with higher fiscal revenues, such as Jakarta and Bali, health staff reported that their local governments contributed sufficient funding for health. Those in poorer areas, such as NTT, encounter difficulty in providing health services and need larger subsidies from the national Government. 58. The Government continues to mobilize its own local funds for financing health needs of its people. The contribution of foreign assistance to the countrys overall budget for health and FP is minimal, and has diminished in recent years. External loans and grants as a proportion of Government funds for health fell from 31.3% in 2001 to 9.8% in 2006 (Appendix 5, Table A5.5). The share of foreign assistance for FP also decreased by half from 13.2% in 1999 to 6.1% in 2005 (Appendix 5, Table A5.6). This indicates that MOH and BKKBN have mobilized more local funds to support the delivery of health and FP services, which is more sustainable over the long run than dependence on foreign funds.

15 Table 1: Contribution of Foreign Assistance to the Governments Budget for Health and Family Planning, 19962006a 1999
MOH Budget (Rp) Foreign Assistance Grants and Loans (Rp) % Foreign Assistance BKKBN Budget (Rp) Foreign Assistance Grants and Loans (Rp) % Foreign Assistance 866.4 114.2 13.2

2000
823.7 130.1 15.8

2001
4,150.0 1,300.0 31.3 899.4 39.0 4.3

2002
4,249.0 787.0 18.5 1,046.7 57.5 5.5

2003
6,635.0 883.7 13.3 1,411.2 65.2 4.6

2004
7,185.2 1,174.6 16.3 615.8 45.4 7.4

2005
11,651.9 1,361.7 11.7 705.2 42.7 6.1

2006
15,930.3 1,563.3 9.8

= not available, BKKBN = Badan Koordinasi Kiluarga Buencana Nasional (National Family Planning Coordinating Board), FP = family planning, MOH = Ministry of Health. a See Appendix 5, Tables A5.5 and A5.6. Sources: MOH Budget and BKKBN Budget Report, 19992006.

59. The Government continues to support strengthening the local level to operate and function under the decentralized setup with assistance from ADB through the Decentralized Health Services Project15 and the Second Decentralized Health Services Project,16 as well as other development partner agencies (e.g., European Union, Gesellschaft fur Technische Zusammenarbeit [GTZ] and World Bank). The health management information system under the decentralized system has been developed and is being pilot-tested in several districts. The integrated health planning and budgeting is being refined to rationalize the share of central and local government resources. However, local health managers and staff have had mixed reactions to decentralization. Those in more economically developed local governments prefer decentralization, because of the increased autonomy in decision making and management, as well as the flexibility in adapting interventions most appropriate to their local needs. In the poorer areas, decentralization has made health service delivery more difficult due to the limited resources of the local government. Decentralization also has curtailed the career paths of health staff, as their promotions are limited to positions available within their local governments. Before decentralization, public servants commonly were promoted to positions available in other districts and provinces across the country. Other challenges include the weak management capability of staff, and the unclear delineation of roles and functions of the national, provincial, and district levels. 60. The results of the beneficiary survey (Appendix 6) confirmed the continued access of the poor to basic health, nutrition, and FP services. Further, posyandus revitalized by the Project are still operating. Nutrition feeding continues to be supported for children who are poor and severely malnourished. However, the feeding is expanded to those who are not malnourished if sufficient funds are available. The nutrition feeding for high-risk pregnant women no longer is provided, because of limited funds. Although blended food continued to be distributed, the central Government planned to provide cash assistance beginning in 2006 to give the local health managers leeway to plan and procure the most appropriate food items or supplements for the children in their areas. BKKBN continues to provide contraceptives for free to the poor.

15

ADB. 2000. Report and Recommendation of the President to the Board of Directors on a Proposed Loan to the Republic of Indonesia for the Decentralized Health Services Project. Manila (Loan 1810-INO, for $65.0 million, approved 14 December 2000). 16 ADB. 2003. Report and Recommendation of the President on Proposed Loans to the Republic of Indonesia for the Second Decentralized Health Services Project. Manila (Loans 2074/2075-INO, for $64.8 million and $35.2 million, respectively, approved 19 December 2003).

16 61. Training of health staff has continued after the HNSDP ended. The human resource development of MOH incorporates a budget for training health staff, while the local government is another source for training assistance. The kader (health volunteers) continue to receive regular orientation and updates. B. Other Assessments 1. Impacts a. Impact on Health and Nutrition Status Including FP Practice

62. Overall, the OEM concludes that the HNSDP helped mitigate the adverse impact of the financial crisis on the health and nutrition of the Indonesian people. Key health indicators suggest that the general health and nutrition status of the population, including their FP practice, did not deteriorateand even improved after the crisis (Table 2). Table 2: Health, Nutrition, and Family Planning Indicators Pre- and Post-Program
Indicators Infant Mortality Rate (per 1,000 live births) Under 5 Mortality Rate (per 1,000 live births) Maternal Mortality Rate (per 100,000 live births) Contraceptive Prevalence Rate Prevalence of Malnutrition (severe and lack malnutrition) Pre-Program Year Rate 1997 52.0 1998 1997 1997 1998 64.0a 334.0 57.4 40.0 Post-Program Year Rate 20022003 35.0 20022003 20022003 20022003 2003 46.0 307.0 60.3 35.8 Source of Data IDHS IDHS IDHS IDRHS BKKBN Report

SUSENAS, Nutrition Component BKKBN = Badan Koordinasi Kiluarga Buencana Nasional (National Family Planning Coordinating Board), IDHS = Indonesian demographic and health survey, IDRHS = Indonesian demographic and reproductive health survey, SUSENAS = National Socioeconomic Survey. a National Socioeconomic Survey Estimation. Sources: IDHS, BKKBN, and SUSENAS.

63. The HNSDP seems to have contributed to containing maternal deaths by (i) increasing coverage of pregnant mothers with adequate prenatal care, (ii) increasing the number of deliveries attended by professionals, and (iii) improving the referral system for high-risk women to appropriate hospitals for better management and care. Further, it helped sustain the health of infants and children by revitalizing posyandus; intensifying outreach by the kader and midwives, particularly village midwives; and ensuring continued logistical support for immunization and other communicable disease programs. The HNSDP helped prevent large dropout rates of FP users during the crisis, and sustained their FP practice afterwards because of the continued availability of contraceptive supplies and improved mobility of FP village workers. Maintaining the health and nutritional status of the country during and after the crisis is expected to propel human development and support more productive citizens in the long run. 64. The HNSDP contributed to securing an equitable share of health resources for the poor by establishing the pro-poor-based planning and resource-allocation system, and identifying and targeting the real poor in the population. While this might be an indirect intervention in reducing

17 poverty, the HNSDP was instrumental in pursuing a clearer definition of the poor and establishing a more systematic process of identifying them as the priority beneficiaries of health, nutrition and FP services. b. Impact on Institutions

65. The HNSDP is likely to contribute to increasingly equitable use of the Governments financial resources for health. With the adoption of a faster, less cumbersome fund transfer scheme that has helped to reduce leaks, the HNSDP also is likely to make the management of funds more efficient. Further, the HNSDP will enhance funds management by providing local health managers with the necessary knowledge and skills for integrated health planning and budgeting, as well as financial management. During the OEM, the Government was streamlining the guidelines and mechanisms for a single social insurance card based on the experiences during the HNSDP (e.g., use of single card for all social services) and the use of capitation funds to support the PHC centers. However, the frequent changes in guidelines have created some confusion among local health managers, who are unsure which ones to follow and implement. 66. Some HNSDP initiatives, such as the establishment of complaint resolution units, the social marketing of project resources to the general public, and the participation of the private sector in monitoring these resources, are leading to greater transparency and accountability, as well as better governance of public resources. Several efforts were made to ensure that the HNSDP resources were allocated appropriately and utilized for the purposes they were intended. At program design, mechanisms were put in place to minimize the misuse of resources, including (i) direct transfer of funds from the central Government to the intended users (i.e., midwives and health centers), (ii) formation of the independent monitoring network to monitor continuously the effectiveness of the HNSDP and accuracy of the funds transfers, and (iii) establishment of complaint resolution units to solve problems and complaints related to the implementation of the HNSDP. Transparency and accountability were enhanced by (i) mobilizing existing councils within the district or subdistrict level to handle complaints; (ii) encouraging representatives from NGOs and academia, as well as community leaders, to become members of the complaint resolution committees; (iii) opening the lists of poor individuals to the public; (iv) presenting the report on the allocation and utilization of funds available to wider audience, even those outside the health department; and (v) encouraging others to approach the media with complaints or suspected anomalies. 67. Within the decentralized system, the HNSDP has helped to maintain the coordination links between the central and local government health offices. Further, it has fostered and strengthened partnerships among the national Government agencies, particularly MOH, MOSA, BAPPENAS, MONE, BKKBN, and other institutions involved in the implementation. Field visits confirmed that the provincial health office consults regularly with the district health offices, as does the district or subdistrict level with the PHC centers. 68. The HNSDP has introduced innovative measures that continue to benefit the poor. MOSA acknowledged that HNSDP was instrumental in developing the agencys model for assisting neglected and street children, which did not exist before the Program. BKKBN reported that the HNSDP experience helped evolve the institutions strategic approach to sustaining FP practice among current acceptors, especially the poor. Integrating a pro-poor focus and prioritization into national agencies vision, mission, and strategic plans elevates the poor on the development agenda. As a result, poor and vulnerable groups are now priority targets for health and other social interventions.

18 c. Socioeconomic Impact

69. The central Governments increased regular subsidy of the poor, and the implementation of the Social Security System Law (footnote 12), strengthened the intended objective of HNSDP by improving the access of poor and vulnerable groups to essential health and nutrition services. Given its nationwide coverage, the Program is believed to have reached indigenous peoples in Indonesia as well. With the high distribution percentage for health cards, the HNSDP probably helped improve the access of indigenous peoples to basic health, nutrition, and FP services. However, this type of all-out support for the poor could have a potential negative impact by creating a dependence on Government support. It might reduce the incentives for the poor to become fully responsible for their health and nutrition. d. Environmental Impact

70. As reported in the PCR, the HNSDP did not have any environmental and land acquisition or involuntary resettlement impacts. The OEM confirmed this assessment. None of the HNSDP interventions directly affected the environment. No health facilities were constructed or renovated that might have harmed the environment. 2. Asian Development Bank Performance

71. ADBs performance is rated satisfactory. The $2.8 billion program assistance provided to help mitigate the damage from the 1997 crisis, which included the HNSDP loans, reflected ADBs desire to assist member countries in a manner that prioritized poverty reduction. ADB provided ample assistance to the EAs and implementing agencies at program design and implementation. The Inception Mission was instrumental in helping the Government establish adequate coordination and management structures. The Midterm Review Mission acted decisively on several pending issues that required ADBs review and approval. ADB also increased the initial deposit in the imprest account from $20 million to $50 million, and showed sound judgment by approving two extensions for the project loan to accommodate the full procurement of basic health commodities and to complete other delayed interventions. Though ADB fielded seven review missions, it did not undertake any during the last year of implementation. This was a critical period in ensuring technology transfer and institutionalization of effective processes and innovations. Based on interviews during the OEM, ADB appears to have maintained good coordination with other development partners in implementing the HNSDP. 72. Given the urgent need for the loan during the crisis, ADB did not have sufficient time to prepare thoroughly the scope and coverage of the loan, or to assess the complexity of its design. ADB did not factor into the implementation schedule potential disruptions to health care delivery from (i) the impending implementation of the decentralization program, and (ii) the changes in the national health leadership and management under the new administration. The 24-month extension of the Project suggests that a more reasonable set of targeted outputs and activities should have been prepared. 73. Furthermore, the late consensus on the terms and conditions for the procurement of consultants for the development of health management information systems, as well as the delayed international procurement of blended food, suggests some gaps in the coordination between ADB and the Government. ADB and the Government should have explored the possibility of modifying the independent monitoring scheme to a form that can be institutionalized, such as joint monitoring by public and private groups.

19 3. Borrower Performance

74. The performance of the Borrower is rated satisfactory. The Government demonstrated its commitment to mitigating the effects of the crisis by complying with the required conditions on the release of the loan, and by mobilizing the necessary counterpart resources (budget and staff) during program implementation. The Governments openness to changing the traditional scheme for transferring funds to the local level reflects its unified support for the poor. The national government agencies involved in HNSDP did not want to be an impediment in the immediate flow of assistance to the poor. Each agency was open and supportive to the new mechanisms which the Project adopted. Every agency concerned cooperated and worked proactively to implement the Program. The political will of the Government to maintain pre-crisis level of funding for health, despite the Governments call for reduction in public expenditure, was an important decision that prevented the health care delivery system from deteriorating. The Government also attempted to minimize the leaks and misuse of the loan assistance by establishing complaint resolution units at the local level. However, as mentioned in para. 73, the delayed consensus between ADB and the Government with regard to the procurement of blended food and the consultancy services for the management information system resulted to delayed implementation of these components. 4. Technical Assistance

75. The HNSDP was accompanied by two TAsone focused on monitoring and evaluation; the other on capacity building for decentralized health services management (para. 4; footnotes 3 and 4). a. Technical Assistance on Monitoring and Evaluating the Health and Nutrition Sector Development Program (TA 3175-INO)

76. This TA was designed as an independent monitoring scheme to (i) keep track of the flow of block grants; (ii) deliver benefits to intended beneficiaries; and (iii) monitor and evaluate the impact of the Program on the provision of health, nutrition, and FP services to the most vulnerable groups. The TA is rated relevant, as the lack of transparency and potential leaks of assistance during the political and financial crisis were concerns. Given the large size of the assistance ($100.0 million program loan, $200.0 million project loan, and $300.0 million cofinancing), the establishment of an independent monitoring scheme during implementation is commendable. Independent monitoring is assured through the hiring of the British Council to lead the Central Independent Monitoring Unit, supported by a network of provincial independent monitoring units (PIMU) in the provinces. Two NGOs manage the PIMUs: The Indonesian Planned Parenthood Association (IPPA) was responsible for 19 PIMUs, while CARE International Indonesia was responsible for 7 PIMUs. Founded in 1957, the Indonesian Planned Parenthood Association has chapters in almost all provinces in the country. CARE has worked in many parts of Indonesia since 1967. These NGOs have established their local contacts nationwide, which afforded them familiarity with the national and local health setup and facilitated their networking throughout the country. The CIMU also involved academia: (i) the School of Public Health, University of Indonesia, Jakarta; (ii) the Institute of Demography, Gajah Mada University, Yogyakarta; and (iii) the Center for Public Health and Research, Gajah Mada University, Yogyakarta. 77. The TA was instrumental in generating an appreciation for evidenced-based reporting among stakeholders from government offices and health facilities. The monthly monitoring system maintained a high standard of coverage and data quality, and achieved a fast

20 turnaround from data collection to distribution of analyzed reports. Results of monitoring helped stakeholders at various levels of operations address critical issues that were delaying implementation. Although the implementers of HNSDP initially had reservations about independent monitoring, they began to appreciate its importance and usefulness. Interviews during the OEM also suggest that independent monitoring helped reduce the leaks of assistance. For these reasons, the TA is rated highly effective. 78. The independent monitoring was designed and structured to allow program implementation status to be established clearly, validated accurately, and reported in a timely manner. Issues affecting operations were identified and acted upon immediately by those concerned. The TA assistance money appears to have been well spent. Thus, the TA is rated efficient. 79. The independent monitoring units halted operations after the TA grant ended. The TA completion report found that the basic monitoring tools developed and used in the independent monitoring program were transferred to the government with training of selected government staff and NGOs. However, monitoring could not be sustained after the TA primarily due to high maintenance costs. Thus, the independent monitoring initiatives are rated less likely sustainable. The inability to institutionalize the monitoring system and skills developed during the Program raises the question whether the resources would have been better spent developing the capacity of government units with the participation of the private sector (as in the complaint resolution units) to undertake the monitoring. The TA is relevant, highly effective, efficient, and less likely sustainable. Overall, this TA is rated successful. b. Technical Assistance on Capacity Building for Decentralized Health Services Management (TA 3176-INO)

80. This TA was designed to assist and support the governments efforts to decentralize management of health service delivery during the financial crisis. However, the rapid implementation of decentralization, which entailed sweeping changes that impacted government structures and financial management procedures, prevented the pursuit of the TAs original intent. As a result, the scope of the TA was modified to provide additional funds to intensify the independent monitoring being supported under the accompanying TA (TA 3175-INO). The original design is rated partly relevant, while the modified version is rated relevant. Hence, the overall rating is partly relevant. 81. With its new scope, this TA essentially became an integral part of the monitoring and evaluation TA, which is rated highly effective and efficient. The modified TA completed its envisaged deliverables, and helped ensure that the HNSDP resources were utilized as intended. The national sentinel survey it supported was implemented well, providing data on management capacity and performance of health services. It also supplied critical inputs for addressing identified bottlenecks and constraints. The TA is rated less likely sustainable for the same reasons as TA 3175-INO. Overall, TA 3176-INO is rated successful. IV. A. Issues ISSUES, LESSONS, AND FOLLOW-UP ACTIONS

82. The HNSDP was implemented in a crisis situation, wherein basic health, nutrition, and FP services were provided for free, especially to the poor. While the Program helped mitigate the crisis damage to health and nutrition, it also encouraged dependency of the poor on

21 Government assistance. Before the crisis, the health care delivery system reportedly encouraged counterpart funding from clients in the form of small cash contributions or donations for the services they received at health centers. This practice was disrupted by the crisis mitigation assistance. Most national agencies and local governments apparently continue to operate as if in a crisis situation, and have not switched to a more long-term, sustainable mechanism for securing access to basic health and nutrition services for the poor. 83. The absence of a unified definition and process for identifying the poor is a related issue. A standard and collective classification of the poor is crucial in establishing a more rationalized and equitable allocation and utilization of government resources for health. National subsidies to local governments for health and other social services must be guided by the percentage of poor people in a given locality who need such a subsidy. During the OEM, the national Government expressed plans to harmonize the criteria for defining the poor. This needs to be fast-tracked to ensure better targeting of the poor, and to serve as a guide in allocating subsidies and assistance. Moreover, the scheme for transferring funds from the central to the local governments keeps changing. Most of the local health managers that were interviewed found that these frequent changes are counterproductive, and create uncertainty at the field level. After becoming familiar with funds management procedures, these officials are required to learn new guidelines and unlearn the previous ones. 84. The central Governments continued provision of support for basic health services at the local level, with some augmentation from the provinces, sends mixed signals to the local governments that are primarily responsible for delivering health services to their constituents. While support and augmentation from higher levels might benefit the local governments, especially those with limited financial resources, the availability of those funds also might prevent local officials from allocating their own resources for health service delivery. A more sensitive and rationalized budgeting system must be established at the local level that takes into account the varying capacities and behaviors of local governments. 85. The utilization of health services by the poor remains low. Health-seeking behavior of the population is weak. People have limited appreciation of preventive and promotive care. Even if quality care is provided, the population cannot achieve health and nutrition if people do not access these services. B. Lessons

86. The damage from the financial crisis was multifaceted, with some immediate impacts and some long-lasting ones. The HNSDP experience indicates that some of these were mitigated through (i) the concerted effort of the national and local governments; (ii) the participation of the community and the public, as well as the private sector; and (iii) assistance from ADB and other development partners. All the above were in response to the crisis and the peoples demand for action. The high-level support and commitment of the top government officials is vital in promoting and harnessing coordination and involvement across different sectors and levels of government. 87. The continued political and financial support of the Government to pursuing and enhancing the innovations after the loan assistance ended contributed to the sustainability of the programs outcomes. 88. The project loan under the HNSDP, which was given only 2 years for implementation, had to be extended for another 2.5 years. The Project was based on a highly complex design

22 that included immediate assistance to mitigate the negative impacts of the economic crisis on the (i) accessibility of health, nutrition, and FP delivery services; and (ii) issues faced by street children, whose numbers increased because of school dropouts. The Project also supported fundamental changes in the health care delivery system in relation to decentralization. The Project required much more implementation time to achieve these challenging objectives, especially in a country enduring a major economic crisis that was compounded by political upheavals and some social dislocation. C. 89. Follow-Up Actions Follow-up actions are recommended below. Actions Assist the Government in developing a strategy to transcend its crisis mitigationoriented efforts, and develop longer-term and more sustainable approaches to improving the health and nutritional status of the poor. Responsibility ADB, under Loan 1810-INO: Decentralized Health Services Project; and Loans 2074 and 2075INO: Second Decentralized Health Services Project. Time 2007

1.

2. Fast-track the development of a unified definition of the poor, and support the issuance of a single social security card to ensure more efficient targeting of the poor.
ADB = Asian Development Bank.

ADB, under Loan 1810-INO: Decentralized Health Services Project; and Loans 2074 and 2075INO: Second Decentralized Health Services Project

2007

PROJECT COST BY COMPONENT

Project Cost (Appraisal) Foreign Local Total Exchange Cost Appraisal ADB Financing Government Financing Foreign Local Total Foreign Local Total Exchange Cost Exchange Cost 10.73 27.59 38.32 12.50 32.14 44.64 Actual ADB Financing Government Financing Foreign Local Total Foreign Local Total Exchange Cost Exchange Cost 7.55 19.39 26.94 11.81 25.70 35.71 Project Cost (Actual) Foreign Local Total Exchange Cost

Component A. 1. Base Cost Health Services for Poor Families Safe Motherhood for Poor Families Subtotal (A1) 2. Communicable Disease Control 3. Nutrition Infant feeding Supplementary Feeding (Children Under 2) Supplementary Feeding (Pregnant Women) Revitalization of Food and Nutrition Surveillance Subtotal (A3) 4. Revitalization of Posyandu 5. Family Planning Long-Term Method Supply of Contraceptives Increasing Access of Services Maintaining Quality of Services Subtotal (A5) 6. Programs for Street Children and Neglected Children 7. Ministry of Health System Development 8.Training and Staff Development

23.23

59.74

82.97

19.36

45.09

64.45

5.96

53.62

59.58

2.96

26.81

29.79

2.98

26.81

29.79

1.95

17.57

19.52

3.05

23.29

26.34

5.00

40.86

45.86

29.19 3.50 38.12

113.36 14.04 0.00

142.55 17.54 38.12

13.71 1.60 17.61

54.40 6.44 0.00

68.11 8.04 17.61

15.48 1.90 20.51

58.95 7.60 0.00

74.43 9.51 20.51

9.50 1.15 10.70

36.96 4.86 0.00

46.46 6.01 10.70

14.86 1.80 16.74

48.99 6.44 0.00

63.85 8.24 16.74

24.36 2.95 27.44

85.95 11.30 0.00

110.31 14.25 27.44

0.00

75.05

75.05

0.00

34.66

34.66

0.00

40.38

40.38

0.00

29.93

29.93

0.00

39.67

39.67

0.00

69.60

69.60

0.00

24.12

24.12

0.00

11.14

11.14

0.00

12.98

12.98

0.00

9.40

9.40

0.00

12.46

12.46

0.00

21.86

21.86

0.41

0.21

0.62

0.41

0.21

0.62

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

38.53 6.06

99.38 27.26

137.91 33.33

18.02 1.63

46.01 7.31

64.03 8.94

20.41 4.43

53.36 19.95

73.87 24.39

10.70 2.24

39.33 10.05

50.03 12.29

16.74 3.50

68.87 16.83

68.87 16.83

27.44 5.74

91.47 23.37

118.90 29.12

2.16

3.02

5.18

1.08

1.51

2.59

1.08

1.51

2.59

0.67

0.93

1.60

1.05

2.28

2.28

1.72

2.16

3.88

14.41

1.61

16.02

10.13

1.13

11.26

4.28

0.48

4.76

9.26

1.03

10.29

14.48

15.85

15.85

23.74

2.40

26.14

0.00

1.66

1.66

0.00

1.66

1.66

0.00

0.00

0.00

0.00

2.10

2.10

0.00

2.78

2.78

0.00

4.88

4.88

0.00

4.50

4.50

0.00

4.50

4.50

0.00

0.00

0.00

0.00

1.68

1.68

0.00

2.23

2.23

0.00

3.91

3.91

16.57 1.37

10.79 25.94

27.36 27.31

11.21 0.91

8.80 17.29

20.01 18.20

5.36 0.46

1.99 8.65

7.35 9.10

9.93 0.48

5.74 9.14

15.67 9.62

15.53 0.75

23.14 12.12

23.14 12.87

25.46 1.23

13.35 21.26

38.81 22.49

Appendix 1

2.45

9.05

11.50

0.96

3.54

4.50

1.49

5.51

7.00

0.14

0.55

0.69

0.22

0.73

0.95

0.36

1.28

1.64

0.00

8.73

8.73

0.00

2.00

2.00

0.00

6.73

6.73

0.00

4.24

4.24

0.00

5.62

5.62

0.00

9.86

9.86

23

24

Component 9. Implementation Social Awareness, Health Promotion, and Health Education Provincial District Monitoring and Supervision Program Management Operations Research and Evaluation Subtotal (A9) 10. Taxes and Duties Subtotal (A) B. Contingencies Physical Contingencies Price Escalation Subtotal (B) C. Interest and Other Charges During Implementation Total

Project Cost (Appraisal) Foreign Local Total Exchange Cost 0.30 3.20 3.50

Appraisal ADB Financing Government Financing Foreign Local Total Foreign Local Total Exchange Cost Exchange Cost 0.50 0.50 0.00 3.00 2.70 0.30

Actual ADB Financing Foreign Local Exchange Cost 0.62 0.17 Total 0.79 Government Financing Foreign Local Total Exchange Cost 0.82 0.82 0.00

Project Cost (Actual) Foreign Local Total Exchange Cost 0.17 1.44 1.61

Appendix 1

0.15

8.86

9.01

0.15

1.36

1.51

0.00

7.50

7.50

1.98

6.47

8.45

0.00

8.58

8.58

1.98

15.05

17.03

1.35

1.15

2.50

0.90

0.76

1.66

0.45

0.38

0.83

3.62

2.35

5.97

5.66

3.12

8.78

9.28

5.47

14.75

1.80 0.00

13.21 3.22

15.01 3.22

1.35 0.00

4.82 0.00

6.17 0.00

0.45 0.00

8.38 3.22

8.83 3.22

5.77 0.00

9.44 0.00

15.21 0.00

5.66 0.00

12.51 0.00

18.18 0.00

11.43 0.00

21.95 0.00

33.39 0.00

99.47

324.98

424.46

49.39

150.61

200.00

50.08

174.34

224.43

39.91

120.31

160.22

59.06

159.48

218.54

98.97

279.79 378.76

3.69 11.30 14.99

13.30 13.70 27.00

16.99 25.00 41.99

0.00 0.00 0.00

0.00 0.00 0.00

0.00 0.00 0.00

3.69 11.30 14.99

13.30 13.70 27.00

16.99 25.00 41.99

0.00 0.00 0.00

0.00 0.00 0.00

0.00 0.00 0.00

0.00 0.00 0.00

0.00 0.00 0.00

0.00 0.00 0.00

0.00 0.00 0.00

0.00 0.00 0.00

0.00 0.00 0.00

12.62 127.08

0.00 351.98

12.62 479.07

0.00 49.39

0.00 150.61

0.00 200.00

12.62 77.69

0.00 201.34

12.62 279.04

0.00 39.91

0.00 120.31

0.00 160.22

0.00 59.06

0.00 159.48

0.00 218.54

0.00 98.97

0.00

0.00

279.79 378.76

ADB = Asian Development Bank. Source: ADB. 2005. Project Completion Report for the Health and Nutrition Sector Development Program. Manila.

UPDATE ON THE POLICY MATRIX

Policy Priorities Conditions Fulfilled by Loan Conditions Fulfilled by Effectiveness 25 March 1999 31 March 2000 for Second and for First Tranche Release Last Tranche Release A. Maintain Access of Vulnerable Groups to Essential Health Services 1. Facilitate MOH issued guidelines on MOH issued a ministerial access of the decree defining a package of 7 October 1998 to implement poor to an objective and transparent essential health services essential system to identify the poor (including FP and nutrition health and FP services) that must be who were eligible for free services. universally accessible. health services (including FP). MOH formulated a financing MOH issued a ministerial plan for delivery of the decree 18 February 1999 to essential package of services, including collection of user implement a mechanism to fees linked to the allocate the MOH budget to districts based on an beneficiaries ability to pay. objective assessment of the number of the poor in the MOH issued guidelines, within district. the framework of regulations on implementation of Law 22/99 and Law 25/99, to district health offices and district health committees, institutionalizing the link between the budget allocated to health centers within the district and the number of poor in the health catchment area. Status of Project Completion Review Mission (April 2005) In 2002, the Government reduced subsidies for oil. Some of the savings were used to support the safety net program, particularly in health and education. ADBs new projects (DHSI, approved in November 2000; and DHS-2, approved in March 2005) support health decentralization and require local governments to prepare local schemes to protect access to health services for the poor. The Law on National Social Security System, issued in April 2004, includes supporting access of poor to health services. Status During the PPER

2. Develop proactive activities targeting the poor.

MOH issued instructions to health centers and village midwives to develop outreach plans for the poor. The plan included (i) the list of poor families in the midwifes area,

MOH developed guidelines and introduced procedures to ensure funding for outreach activities of the village midwives quarterly activity plans. Implementation of

The program of outreach health services by the village midwives initiated under the HNDSP has been very successful.

20062009 Medium-Term National Development Plan prioritizes health and education. Central Government continues to subsidize the poor in increasing amounts: $296.2 million in 2005 and $381.0 million in 2006. Social Security Law aims for universal coverage, prioritizing the poor. Lists of identified poor individuals continue to be updated. Identified poor grew from 30.0 million to 60.0 million. Lists of poor are open to public scrutiny. Criteria used by MOH, BPS, and BKKBN in defining the poor to be harmonized. Budget allocation at the district level continues to be based on the proportion of poor. Collection of user fees continues in hospitals and health centers for nonpoor clients. Some health facilities under devolution provide basic services for free to even nonpoor clients. Vision of the 20062009 MOH Strategic Plan is a self reliant community to have healthy lives Central government subsidy for the poor includes allocation for outreach activities for the poor

Appendix 2

25

26

Policy Priorities

Conditions Fulfilled by Loan Effectiveness 25 March 1999 for First Tranche Release (ii) the number of pregnant women and young children among these families, and (iii) the number of home visits to these families planned for the 3 months of the Program. Budget allocation to MOH, verified by BAPPENAS in 31 March 2000, ensured sufficient budget allocation for village midwives outreach activities for FY2000. Budget allocation to MOH, verified by BAPPENAS 21 June 1999, ensured sufficient budget allocation for expansion of village midwives outreach activities for FY2000.

Conditions Fulfilled by 31 March 2000 for Second and Last Tranche Release these plans was coordinated and supervised by the health center concerned.

Status of Project Completion Review Mission (April 2005) Funds were guaranteed until 2005. With decentralization, local governments will have to take over financing of health, village midwives, and outreach activities. Advocacy campaigns and policy dialogue under ADBs new health sector projects are continuously lobbying local governments to continue outreach programs.

Status During the PPER Some local governments (particularly those with high income) provide additional allocation for health services. Posyandus (community-based health posts) that provide preventive and promotive health, nutrition and FP services) continue to function. Budget of MOH from 2001 to 2006 accounts for an increasingly larger share of the national Government budget. Year MOH Budget as % of National Govt. Budget 2001 1.22 2002 1.24 2003 1.76 2004 1.92 2005 2.93 2006 2.55 FNSS continues to be done at the district level. Cascading the same to subdistricts is planned. A timely warning information system is functional at the central, provincial, and district levels for the regular collection of data on people at risk to malnutrition. Not all committees are functional at the provincial and district levels. Nutrition mapping in NTT identified a resurgence of severe malnutrition (kwashiorkor), causing MOSA to release separate assistance to address malnutrition.

Appendix 2

3. Improve identification and targeting of vulnerable groups at risk from malnutrition.

MOHA issued instructions requiring the provincial and district committees of the FNSS to submit quarterly reports. Ministerial instruction issued 4 November 1998. The Government issued necessary administrative orders (ministerial decree issued by Minister of Food and Horticulture 25 June 1998) to reestablish the intersectoral committee for the FNSS, and appointed the committee members in all provinces and districts.

FNSS provided map on malnutrition using geographic information system. Applicable training completed of district personnel. Quarterly reports are being submitted regularly.

Village team established to verify and validate data on poor households. District government issued decree on poverty criteria adjusted to local conditions for better identification of vulnerable and poor households.

Policy Priorities

Conditions Fulfilled by Loan Conditions Fulfilled by Effectiveness 25 March 1999 31 March 2000 for Second and for First Tranche Release Last Tranche Release 4. Strengthen The Government and MOH MOH issued an preventive and earmarked at least 2% of the administrative order on health MOH budget (routine and 28 February 1999 to establish promotion development) in FY2000, a working group to strengthen programs. FY2001, and FY2002 for health promotion campaigns health promotion (before to address existing health March 2001). As certified by concerns and emerging BAPPENAS 31 March 2000 lifestyle issues, specifically indicated, 2.88% of MOH including programs to reduce budget used for health smoking and to promote promotion. family life education (especially adult reproductive health). MOH issued an administrative order to establish a working group in cooperation with the Ministries of Education and Culture and Religious Affairs to strengthen health education, including nutrition and reproductive health, in the formal school curriculum. B. Mobilize Additional Resources to Support Essential Health and Nutrition Services 1. Increase the In the FY1999 and FY2000 The Government allocated share of budgets, the Government $3.11 million of the FY2000 Government maintained the share of budget (routine and resources development expenditures development expenditures) for allocated to allocated to health, nutrition, health, nutrition, and FP health, FP, and and FP at the same level as programs (excluding district nutrition. in FY1997. level allocation). The Government allocated 4% of the FY2001 budget (routine and development expenditures), and annually thereafter, for health, nutrition,

Status of Project Completion Review Mission (April 2005) MOH maintained budget allocation for health promotion at least at the same level as 2001.

Status During the PPER Budget for health promotion continues to be part of the MOH budget for its different programs. Part of the subsidy for the poor released by central office to the local governments includes provision for doing outreach and health promotion activities.

The working group is still active. Health education, including nutrition and reproductive health, has been partly accommodated in school curriculum (competency based curriculum).

Coordination between MOH and MONE officials continues regarding health education and promotion targeting the school children. Reference book for school children regarding preparedness for tsunamis was developed.

Budget allocated from part of the reduction of oil subsidy is being used for ensuring access of poor households to basic health services and nutrition. The new health sector projects supporting decentralization (funded by ADB, World Bank, and other development partners) prioritize

The Government allocated the following amounts for routine and development budgets of MOH from 2001 to 2006: Total Amounts Budgeted For Routine and Development $277.8 million $371.8 million $670.5 million $621.3 million $996.4 million $1,265.8 million

Year 2001 2002 2003 2004 2005 2006

Appendix 2

27

28

Policy Priorities

Conditions Fulfilled by Loan Effectiveness 25 March 1999 for First Tranche Release

Conditions Fulfilled by 31 March 2000 for Second and Last Tranche Release and FP programs (health sector routine and developmental expenditures, excluding transfers to provinces and districts). In the central Government budget allocation for FY2000, the proportion of the budget for health sector declined from 3.70% in FY1997 to 3.11% in FY2000. However, this was offset by provincial and district allocation to basic health services from budget transfers.

Status of Project Completion Review Mission (April 2005) financing primary health care and those services most used by the poor. Based on the Law on National Social Security System, a new health insurance system managed by PT ASKES was introduced in 2005 with the premium for the poor being paid by the Government. The proportion of the budget for health, nutrition, and FP in 2001, 2002, 2003, and 2004 was 2.01%, 2.53%, 3.23%, and 3.36%, respectively. (This does not include national budget allocated to districts; starting 2001, when fiscal decentralization was implemented, budgets for social sectors were allocated directly to district governments in form of General Allocation Fund and Special Allocation Fund).

Status During the PPER The Government budget for MOH and BKKBN from 2001 to 2005 are as follows:

Appendix 2

MOH BKKKBN Total Routine and ($million) Development Special 2001 277.8 83.8 361.6 2002 371.8 106.2 478.0 2003 670.5 156.9 827.4 2004 672.4 63.8 736.2 2005 1,060.3 68.3 1128.6

Policy Priorities 2. Maintain priority allocation of public resources to basic health services.

Conditions Fulfilled by Loan Effectiveness 25 March 1999 for First Tranche Release

Conditions Fulfilled by 31 March 2000 for Second and Last Tranche Release The Government ensured that the proportion of the budget (routine and development expenditures, for the health sector, including transfers form the Government to provinces and districts) allocated to basic health services in the FY2000 budget and thereafter was at least the same as FY1997.

3. Increase resource allocation to poor communities.

The MOH issued an administrative order to develop a funding mechanism to allocate a greater share of public health resources to poor communities based on objective measures of poverty and population.

The Government issued administrative orders to introduce a resources allocation mechanism, employing objective property and population criteria, to allocate a larger share of the Government resources to poorer districts.

4. Encourage greater private sector spending on health care (prevention and promotion).

MOF issued an administrative order to establish a working group, with participation from other concerned agencies. The working group was established 19 November 2000. The working group reviewed relevant provisions of

Status of Project Completion Review Mission (April 2005) MOH set national standards ands guidelines on nutrition, food, and medicine quality and distribution. MOH uses the standards to monitor the performance of districts and provinces on critical indicators. Districts and provinces will receive block grants from the central Government, and will be responsible for managing their own health planning and budgeting to reflect local needs and priorities, and to provide community-oriented health services. The Government set up regulations describing in detail the criteria and formulas for allocating funds from the central Government to local governments, consistent with Law25/99. Through the Equalization Fund, poor districts will receive larger budget allocations, in addition to locally generated revenues. DHS-2 advocates spending of 5% of the regional annual budget for the health sector by the end of DHS-2; and will promote an integrated approach to health financing, cross-cultural coordination, public-private partnerships,

Status During the PPER The central office continues to release funds to local governments for the delivery of basic health and nutrition services, referral services, support services (e.g., revitalization of posyandus), essential drugs and medicines for pharmacies, funds for island provinces, etc. See Appendix 5 for the 2005 Budget Subsidy for the Poor.

The national and local governments continue to allocate funds based on the proportion of poor.

Work on the income tax laws and regulations is continuing. The DHS Projects 1 and 2 continue to develop capacities of national and local stakeholders to mobilize the participation of the private sector.

Appendix 2

29

30

Policy Priorities

Conditions Fulfilled by Loan Effectiveness 25 March 1999 for First Tranche Release

Conditions Fulfilled by Status of Project 31 March 2000 for Second and Completion Review Mission Last Tranche Release (April 2005) monitoring of health service the income tax laws and performance and health regulations to assess the status indicators, feasibility of deducting from dissemination of information, pre-tax income (i) corporate and increased transparency expenditures on employee and accountability. health care and qualifying expenditures on health The Government issued Law promotion and preventive on National Social Security health care (including health System in April 2004, which insurance premiums and the encourages greater private investment and recurrent sector contribution to health costs for improving care using the health occupation health and safety insurance system. of employees); and The steering committee (ii) individual expenditures on convened a national health insurance premiums. workshop, with participation The Government made of the private sector sufficient allocation in the (including employers, FY2000 budget to maintain insurance providers, and supervision activities by health others), professional centers (over midwives and associations (medical, subhealth centers), and by financial, accounting), and district health office over the other interested parties, to health centers, at least at the review and strengthen the same level as in FY1997. recommendations and make specific proposals to MOF for consideration during the next review of the income tax law. On 31 March 2002, the MOF incorporated such recommendations in appropriate administrative orders, ministerial decrees, draft legislation to amend laws, and regulations on income tax.

Status During the PPER Aiming for universal coverage of the National Social Security Law is strategic in ensuring the equitable sharing by the poor and nonpoor of the health expenditures, as well as those in the public and private sector.

Appendix 2

Policy Priorities

Conditions Fulfilled by Loan Effectiveness 25 March 1999 for First Tranche Release

Conditions Fulfilled by 31 March 2000 for Second and Last Tranche Release

Status of Project Completion Review Mission (April 2005) DHS-1 and DHS-2 projects strengthen public-private partnerships in health care delivery and financing. In the context of decentralization, MOH helps strengthen local capacity in health services delivery, including planning and management, and improve quality, cost efficiency, and sustainability of health and FP services (implemented in DHS-1 and continued and extended in DHS-2).

Status During the PPER

C. Maintain Quality of Essential Health and Nutrition Services 1. Maintain The Government made The Government made supervision sufficient allocation in the sufficient allocation in the and FY1999 and FY2000 budget FY2000 budget to maintain monitoring MOH training activities in to maintain supervision activities for the districts and provinces at activities by health centers basic health (over village midwives and least at the same level as in services. FY1997. subhealth centers), and by the district health office over health centers, at least at the same level as in FY1997. 2. Maintain MOH submitted to ADB a The Government made training consolidated training sufficient allocation in programs for program to strengthen the FY1999 and FY2000 budget basic health effective delivery of health to maintain MOH training personnel. services, particularly activities in the districts and provinces at least at the through enhanced outreach same level as in FY1997. activities and the rational use of drugs, including appropriate training modules, materials, identifications of trainers, and schedule for implementation for all districts beginning in FY1999 and FY2000.

Budget for supervision and monitoring are integral to the budget allocated by MOH to its different health programs. Central office releases funds to the provincial level for monitoring and supervision at the district level.

Training program is being implemented and continued.

3. Maintain FP programs for the poor.

Each health center submitted to the district coordinating committee a plan and schedule for delivery of refresher training

The mechanisms used under JPSBK Program (SPSDP and HNSDP, and later funded by oil subsidy compensation) has been continued at the district level.

Staff development continues to be undertaken. Budget for MOH for training is part of the budget allocated for its Human Resource and Development Bureau. Central office continues to release funds to the provinces for the technical training of health staff at the local level. Some local governments also provide funds for the training of their health staff. Kader (volunteer workers) continues to receive orientation and updates. Beneficiary survey confirms the continuous availability of FP contraceptives at the health center level.

Appendix 2

31

32

Policy Priorities

Conditions Fulfilled by Loan Effectiveness 25 March 1999 for First Tranche Release

Conditions Fulfilled by 31 March 2000 for Second and Last Tranche Release to all kaders it supervises using standardized training modules as a condition of replenishing its block grant The Government submitted to ADB a medium-term strategy to maintain access to FP services for the poor, including measures to provide methods of contraception appropriate to the individual needs of the acceptor (cafeteria system), and counseling to acceptors if switching methods becomes necessary due to inadequate supplies or irregular distribution.

Status of Project Completion Review Mission (April 2005) BKKBNs 5-year development plan was updated for 19992004. The National Medium-Term Planning has been issued. Starting on 1 January 2004, BKKBN decentralized its FP services, and regional governments became responsible for ensuring access to FP and reproductive health programs. BKKBNs vision is to help Indonesian families become prosperous, healthy, and independent, with only two children; and to provide access to Family Planning services for the poor. One policy of BKKBN is to ensure continuous availability of free or subsidized contraceptives for the poor. JPS-BK (SPSDP and HNSDP) developed implementation and utilization of IHPB in all districts. The IHPB has been implemented. Because the potential problems of decentralization of health services are of major concern, all aid agencies involved in the health sector are participating in efforts to strengthen local capacity and assist local governments in identifying needs, developing and implementing appropriate reforms, and making adequate and cost-efficient investments.

Status During the PPER BKKBN Development Plan continues to support the promotion and advocacy on FP, and to generate demand for FP services at the community level. BKKBN continues to implement its development plan, and to provide focus to the poor.

Appendix 2

D. Enhancing Decentralization, Participation, and Transparency 1. Delegate MOH submitted to ADB MOH submitted to ADB a further proposed revisions to the plan to extend and authority to IHPB system and accelerate the effective local levels for procedures. implementation of IHPB for planning and all districts. MOH submitted Human resource Resources Development The Government issued allocation in instructions establishing a Plan for staff training to the health legal and administrative support implementation of sector to the streamlined IHPB framework for the block grant improve system at the district level; mechanisms as the principal targeting of and for training of health means of financing essential resources to health services at the district center staff in integrated the poor to level, including health budget, planning, and enable flexible centers and village midwives. management, including and timely training needs assessment, response to training modules and

Local health officials interviewed confirmed their attendance at training on integrated health planning and budgeting. Annual planning and budgeting are being undertaken at the health center, subdistrict, district, and provincial levels. Not all health units receive the amount proposed.

Policy Priorities emerging health issues. Develop local management capacity.

Conditions Fulfilled by Loan Effectiveness 25 March 1999 for First Tranche Release MOF issued an administrative order to adopt specific block grants as the principal mechanism to channel operations and maintenance funds directly to the operational level (e.g., health centers) in all districts. MOH issued an administrative order delegating responsibility and authority to the district level for identifying the poor and vulnerable, allocating resources, and providing basic health services to manage services and improve quality and efficiency.

Conditions Fulfilled by 31 March 2000 for Second and Last Tranche Release materials, identification of trainers, timetables, and indicative budgets. MOH submitted to ADB on 17 March 2000 a report on the implementation of the monitoring system to determine whether resources are reaching health centers on a timely basis, and whether these resources are used effectively to enhance quality of services.

Status of Project Completion Review Mission (April 2005) The Government issued necessary instructions and/or regulations to make block grants the principal means of providing central Government funds to the district. MOH set national standards and guidelines on nutrition, food, and medicine quality and distribution. MOH uses the standards to monitor the performance of districts and provinces on critical indicators. Districts and provinces will receive block grants from the central Government, and will be responsible for managing their own health planning and budgeting to reflect local needs and priorities, and to provide community-oriented health services.

Status During the PPER A continuing area of concern is the development of more rationalized planning and budgeting in the context of the decentralized system to factor in all possible contributions from various levels. This will enable the local level to manage and allocate appropriately all these resources from the central office, their own local governments, and external sources. In September 2005, MOH issued the guidelines on Budget Allocation and the Use of Block Grants. Block grants continue to be the mechanism for transferring central funds direct to the district health offices, which in turn reallocates these to the health centers. District Health Offices continue to allocate resources based on the proportion of the poor population. The list of poor is prepared and submitted to the district by the health facilities, and are updated from time to time.

Appendix 2

33

34

Conditions Fulfilled by Loan Conditions Fulfilled by Effectiveness 25 March 1999 31 March 2000 for Second and for First Tranche Release Last Tranche Release 2. Strengthen MOH issued an administrative MOH submitted to ADB community public awareness training order establishing a working oversight of programs for health group to review the roles of basic health communities at the district community organizations and nutrition level and their village-level involved in health services at services. counterparts to clarify the district and subdistrict functions and level, and to recommend ways responsibilities; and to to strengthen the role of the enhance effective community in oversight and community participation in, management, especially and transparency of, financial management of resource allocation. health sector resources. MOH issued an administrative order establishing a high-level working group to undertake a comprehensive strategic review of structure and staffing of MOH, including redefinition of roles and responsibilities of central, provincial, and district levels to accommodate and support decentralization. E. MOH Organizational Change and Development 1. Strategic MOH issued an administrative MOH submitted a mediumdevelopment order establishing an term (57 years) strategy for plan for MOH. executive steering committee, decentralization of human with participation of all major resources management, MOH operating units to including an assessment of coordinate programs, needed capacity building, integrate policy development, systems development, and and manage the structuring of staff training and MOH. redeployment.

Policy Priorities

Status of Project Completion Review Mission (April 2005) Working group established. Community organization incorporated in MOH monitoring and complaints resolution structures.

Status During the PPER The MOH issued in 2005 the updated guidelines on the establishment of the complaints resolution units, which defined the role of the community in monitoring the proper allocation and utilization of resources. Several mechanisms are established by the different localities to ensure the proper allocation and utilization of resources (e.g., presentation of budget allocation per program government departments; harnessing the involvement of media; making public the list of poor).

Appendix 2

Healthy Indonesia 2010, developed in 1999, describes MOHs vision, strategy, and policy. The vision is to ensure that the Indonesian people live in a healthy environment with healthy living behavior, and obtain qualified health services that are effective, efficient, and evenly distributed. MOH developed strategic planning to promote Healthy Indonesia based on preventive and promotion approaches.

The draft 20062009 Strategic Plan of MOH indicates a vision for healthy Indonesians who are empowered and self-reliant. The plan specified four major strategies: (i) empower the community; (ii) improve access to quality health services; (iii) strengthen monitoring, surveillance, and management information system; and (iv) improve

Policy Priorities

Conditions Fulfilled by Loan Effectiveness 25 March 1999 for First Tranche Release

Conditions Fulfilled by 31 March 2000 for Second and Last Tranche Release

Status of Project Completion Review Mission (April 2005) MOH issued National Health System using the preventive approach of Health Paradigm 2010. DHS-2 will help strengthen coordination and cooperation among districts and provinces, in particular for (i) epidemiological surveillance and control of communicable diseases, (ii) developing an effective referral system, and (iii) developing capacity in the provincial hospitals to train qualified professionals that will work in the region. Dialogue with regional governments will emphasize the benefits of involving professional associations, local universities, the private sector, and local NGOs in managing local health services. MOH, with Parliament, is preparing laws and regulations to ensure peoples access to essential health services.

Status During the PPER advocacy. MOH continues to make structural changes, particularly in the reassignments of senior health officials occupying key positions.

2. Legislative and regulatory framework.

MOH, in consultation with MOHA and other ministries, identified legislative and regulatory instruments (MOH, MOHA, MOF, etc.) that require updating or revision to support greater decentralization of health services delivery.

MOH prepared, in consultation with all ministries concerned, an integrated proposal to update and rationalize the legal and regulatory framework for decentralized health care delivery and management; and (i) issued appropriate ministerial

The government continues to fulfill the requirements of the decentralization law

Appendix 2

35

36

Policy Priorities

Conditions Fulfilled by Loan Effectiveness 25 March 1999 for First Tranche Release

3. Information systems development.

MOH issued administrative orders establishing a highlevel working group to coordinate preparation and implementation of a program to improve accuracy, reliability, and timeliness of the collection, validation, and analysis of data to support operational and strategic decision making.

Conditions Fulfilled by 31 March 2000 for Second and Last Tranche Release instructions (MOH, MOHA, etc.) to address issues within the ministerial competence, and (ii) prepared and submitted draft bills for legislative action. MOH submitted to ADB a strategy and timetable (including indicative resources) to develop and implement a single integrated information system to meet health data requirements of all MOH vertical programs and operational units, and to eliminate parallel and redundant data collection and processing systems. MOH has included accuracy, timeliness, and comprehensiveness of reporting as factors in the performance evaluation for operational unit managers to ensure continuity, quality, and consistency of routine facility-based reports. Government devised a policy matrix and guide for reducing subsidies to selffinancing swadana hospitals, linking future subsidy to the services provided to the poor.

Status of Project Completion Review Mission (April 2005)

Status During the PPER

Appendix 2

District health information systems have been developed and pilot-tested with ADB and World Bank assistance. FNSS has been developed at central, provincial, and district levels. It provides a map on malnutrition using a geographic information system. Quarterly reports are being submitted regularly. However, the system is not functioning properly in some districts. In addition, the Government issued a decree on the establishment of a food (and nutrition) security body at central and provincial levels.

Pilot areas continue to implement the new health management information system. FNSS is functional at the central, provincial, and district levels. FNSS consists of (i) monitoring nutritional status at the national level through the regular Food and Nutrition Survey with anthropometric measurements, and (ii) a timely warning information system at the national, provincial, and district levels. MOH also has established a nutrition information network (e.g., Web site).

4. Improve efficiency of resource use a. Strengthen MOHA issued a decree responsibility confirming that swadana and hospitals (hospitals that accountability of have been granted partial local managers. financial autonomy with the objective of becoming selfsufficient) are exempted from transferring their revenues to local

Swadana management was implemented in provincial and district hospitals. The system was extended to some big puskesmas (primary health centers), particularly in urban (city) areas.

Provincial and district hospitals continue to exercise financial autonomy. Puskesmas visited in Jakarta reported retaining a portion of the collected fees for their annual operations.

Policy Priorities

Conditions Fulfilled by Loan Effectiveness 25 March 1999 for First Tranche Release government; and issued instructions to local governments to permit all district hospitals to retain their revenues and to use such revenues for hospital operational costs. MOH and MOHA issued a joint decree providing that the minimum qualification for candidates for the head of a health center will be public health training. If the selected candidate does not have prior management experience, appropriate management training will be provided within 6 months of appointment. MOH will submit to ADB a plan to test and evaluate, on a trial basis, the appointment of trained personnel resident in the community as health center head.

Conditions Fulfilled by 31 March 2000 for Second and Last Tranche Release MOH submitted an evaluation of the feasibility of applying the swadana (self-supporting) management concept at the health center level.

Status of Project Completion Review Mission (April 2005)

Status During the PPER Other health centers continue to collect user fees from the nonpoor. Health centers still return back to the local government treasury their collections, and these are returned through the annual allocation of their budget.

b. Strengthen management and responsiveness of health centers.

MOH submitted a proposal to pilot test the provision of block grants to districts and to health centers to cover personnel costs (salaries and allowances); and to permit more flexible staff recruitment, deployment, and management, as well as incentives to provide services more efficiently. MOH established a working group to test and evaluate, on a trial basis, the delegation of authority and flexibility to designated districts to modify staffing patterns of health centers to meet local requirements better, including possible contracting of doctors to provide services to groups of health centers. The MOH reviewed regulations and procedures on recruitment, assignment, and release of staff; and, where possible, devised approaches to

Appendix 2

37

38

Policy Priorities

Conditions Fulfilled by Loan Effectiveness 25 March 1999 for First Tranche Release

c. Improve the cost efficiency of pharmaceutical use.

MOH issued an administrative order establishing working groups to review the existing national drugs list to ensure only those drugs needed for the delivery of essential health services are procured for health centers and district hospitals. MOH reviewed adherence to guidelines on the rationale use of drugs, and devised a training program for all primary health care providers, incorporating a system for monitoring compliance with treatment protocols. MOH issued guidelines governing the supplementary purchase of pharmaceuticals by health centers from block grants.

Conditions Fulfilled by 31 March 2000 for Second and Last Tranche Release enable districts to balance skill requirements and distribution of staff more effectively. MOH revised the National Essential Drugs List and ensured the supply of the reduced list of essential pharmaceuticals to all public health facilities. MOH issued instructions governing the transparent and cost-effective procurement of supplementary drug needs by districts to target local needs effectively. MOH submitted a plan covering delivery of inservice training on the rational use of drugs to health care providers in all public health facilities (including training needs assessment, proposed training modules and materials, identification of trainers, schedule, and indicative budget). MOH submitted a proposal on collaboration with professional associations to provide training on the rationale use of drugs to private health care providers. MOH submitted a strategy and program for public information campaigns

Status of Project Completion Review Mission (April 2005)

Status During the PPER

Appendix 2

Badan Pengawasan Obat dan Makanan (Food and Drugs Control Agency) has been established as a separate institution (previously under MOH). Proposals have been developed with the Indonesian Medical Association.

The National Agency of Drug and Food Control, now a separate entity from MOH, identified its major functions as in charge of (i) legislation, regulation and standardization; (ii) licensing and certification of pharmaceutical industries based on good manufacturing practices; (iii) pre-market evaluation of products; and (iv) preaudit and post-audit of product advertisement, among others. For balance and control, MOH retains the registration of drugs and medicines and the preparation of the listing of essential drugs Interviews of staff in selected health centers and district health offices confirmed their training on rational drug use.

Policy Priorities

Conditions Fulfilled by Loan Effectiveness 25 March 1999 for First Tranche Release

d. Maintain private sector involvement.

MOH issued an administrative order establishing a working group to monitor and assess the impact of the crisis on the utilization, performance, and finances of private health providers (including private hospitals and clinics); and to ensure that private sector providers are not discriminated against in implementation of the HNSDP.

Conditions Fulfilled by 31 March 2000 for Second and Last Tranche Release targeting users of health centers to provide information on generic drugs and rationale use of drugs. MOH provided a policy statement supporting equitable treatment of private practitioners in provision of health services to the poor, and initiated a study of options to facilitate the involvement of the private sector and private health providers in the implementation of managed health care.

Status of Project Completion Review Mission (April 2005)

Status During the PPER

Measures to ensure equitable treatment of private providers incorporated into MOHs Business Plan for a Sustainable Social Safety Net Under Decentralization. Business plan will be finalized within evolving framework of regulations on implementation of Law 22/99 and Law 25/99. Dialogue with regional governments will emphasize the benefits of involving professional associations, local universities, the private sector, and local NGOs in managing local health services (DHS-2)

DHS-1 and DHS-2 continue to support the mobilization of the private sector in health development. Selected district and subdistrict health offices, including puskesmas confirmed the participation of NGOs and private sector in different health-related programs and activities.

ADB = Asian Development Bank, BAPPENAS = Badan Perencanaan Pembangunan Nasional (National Development Planning Agency), BKKBN = Badan Koordinasi Kiluarga Buencana Nasional (National Family Planning Coordinating Board), BPS = Central Board of Statistics, DHS = Decentralized Health Services, FNSS = Food and Nutrition Surveillance System, FP = family planning, HNSDP = Health and Nutrition Sector Development Program, IHPB = integrated health planning and budgeting, JPS-BK = Social Safety Net in Health Sector, MOF = Ministry of Finance, MOH = Ministry of Health, MOHA = Ministry of Home Affairs, MONE = Ministry of National Education, MOSA = Ministry of Social Affairs, NGO = nongovernment organization, NTT = Nusa Tenggara Timur. Sources: ADB. 2005. Project Completion Report for the Health and Nutrition Sector Development Program. Manila; interviews with stakeholders; MOH and BKKBN budget allocation.

Appendix 2

39

40

UPDATES ON THE PROGRAM FRAMEWORK

Design Performance Monitoring Mechanisms Summary Indicators and Targets Goal: Mitigate the Impact of the Financial and Economic Crisis on the Poor 1.1 Facilitate access to Purpose Block grants to health centers. essential health and 1. Access by Public awareness campaigns. family planning for the vulnerable Revitalize national nutrition poor. groups to surveillance system. essential health Establish partnership between services public health network and maintained for NGOs. 15.3 million Consultant inputs and training households. for identifying needs of culturally distinct communities. Outcomes and Achievements as of the PCR Some 11 million households gained access to essential primary health care (70% of the coverage target). Health cards were distributed to 92% of the identified poor households. Public awareness campaigns were undertaken in 2001. Status as of PPER

Appendix 3

Confirmed.

Results of beneficiary survey confirmed most respondents received health cards during program implementation; and are knowledgeable about the use and importance, as well as the basis for entitlement. Program developed capacity of provincial and district level staff on nutrition surveillance.

1.2 Develop proactive strategies targeting the poor.

Provision of block grants for intensified outreach activities. Training for midwives in targeted villages. Revitalization of posyandus (outreach activities organized in community by volunteers with support of health center staff).

National nutrition surveillance system was reactivated, including a sentinel surveillance system in vulnerable provinces for food shortages and high prevalence of child malnutrition. NGOs were involved in the complaints resolution units, and managed and monitored open houses for neglected and street children. A specific training module was not designed for culturally distinct communities. Midwives received block grants. Midwives trained. 208 mini-laparatomy kits provided to midwives. 94% of the targeted posyandus received revitalization package.

Confirmed.

Confirmed.

Confirmed based on interviews with health center and village midwives. Confirmed, including procurement of eight laparoscope units. Beneficiary survey confirmed presence and functionality of posyandus.

Design Summary

Performance Indicators/Targets 1.3 Improve identification of and assist to vulnerable groups at risk from malnutrition.

Monitoring Mechanisms Complementary feeding program for infants 611 months old, children 1259 months old, and women at risk. Reactivating FNSS.

1.4 Strengthen preventive and health promotion activities.

Health and nutrition programs for street and neglected children. Social marketing and health promotion campaigns. Inputs for monitoring diagnosis, and treatment for communicable diseases. Immunization programs for childhood illnesses. Health education programs in school. Provide block grants to health centers. Provide block grants to midwives for outreach services. Develop formula for allocating resources to districts based on an objective measure of poverty. Develop nutrition surveillance systems for better needs assessment. Training activities for PLKB. Review income tax act to provide incentives for greater investment in employee health care.

Outcomes/Achievements as of PCR 65% of target coverage achieved for infant 611 months old. 68% of target coverage achieved for children 1259 months old. 72% of target coverage achieved for women at risk. FNSS revitalized to provide nutrition mapping for all provinces. 6,000 street and neglected children received food supplements. Socialization and health promotion campaigns conducted in 400 districts. Laparoscopes (instruments used to examine visually the interior of peritoneal cavity) delivered to eight provinces.

Status as of PPER Confirmed based on Governments PCR. Results of beneficiary survey showed more than half of respondents have attended nutrition feeding. Copies of nutrition mapping per province available. Confirmed based on Governments PCR, but coverage included other poor but not neglected and street children. Immunization services continue to be provided in puskesmas (primary health centers). No clear activities, but MONE developed reference book on preparing for tsunamis. Confirmed: districts continue to adopt block grants in allocating resources to the health centers. Criteria of poor adapted from one locality to another. National Government plans to unify the definition of poor and to issue single social security card.
Appendix 3

2. Mobilize additional resources of essential health and nutrition services.

2.1 Increase the share of Government resources allocated to health, family planning, and nutrition. 2.2 Maintain priority allocation of public resources to basic health services. 2.3 Increase resource allocation to poor communities. 2.4 Encourage greater private sector expenditure on health care.

Block grants allocated to health centers ($26 million). Block grants allocated to midwives ($20 million). Formulas to target poor households have been adopted, based on poverty data from BKKBN and SUSENAS, and adjusted to the local context. Surveillance system was established at national and district level. 35,000 PLKB trained. Review of income tax bill continuing.

41

42

Design Summary 3. Maintain quality of essential health services.

Performance Indicators/Targets 3.1 Maintain intensity of supervision and monitoring activities for basic health services.

Monitoring Mechanisms Train health centers to increase responsiveness to community and improve efficiency. Provide training in oversight and monitoring role of village and district heath communities. Provide training in rational use of drugs and standards protocols for diagnosis and treatment. Provide training and monitoring. Assist in developing outsourcing of training. Provide contraceptives and materials. Provide training in counseling and technical skills improvement. Build capacity in planning and management for consolidated budgeting. Evaluate capacity building program through TA. Develop training models through TA. Ensure NGO participation in beneficiary targeting and monitoring. Review health system organizations and structure. Build capacity in operational planning and management. Integrate health planning and budgeting for all districts.

Outcomes/Achievements as of PCR Training conducted for health centers on management. No new procedures have been introduced to increase responsiveness to communities and efficiency. Training conducted. Training conducted. No effective training evaluation system has been developed. No outsourcing of training Contraceptives distributed in all provinces. Sufficient supply of contraceptives. 10,800 PLKB trained in counseling. Grants to midwives provided incentives for outreach activities. TA 3176 provided essential data on management capacity and performance of health services, which provided inputs to the design of training modules on management capacity and performance of health services. NGOs participated in monitoring of support to street and neglected children. Some NGOs are preparing a proposal, including monitoring of services provided by the health centers. Strategic development adviser employed to support review of health system organization and structures.

Status as of PPER Confirmed.

Appendix 3

3.2 Maintain training programs for basic health personnel.

Confirmed.

3.3 Maintain family planning programs for the poor.

4. Enhance decentralization, participation, and transparency.

4.1 Delegate authority to local levels for planning and resource allocation to improve targeting of resources to the poor, and enable flexible and timely response to emerging heath issues. 4.2 Develop local management capacity. 4.3 Strengthen community oversight of basic health and nutrition services.

Confirmed procurement of 58 million cycles of pills, 769,657 vials of injectables, 186,149 sets of implants. Operational budget for the FP village worker improved their mobility to do outreach. Confirmed. Progress reports on the achievement of Millennium Development Goals in 2004 and 2005 noted that one of the challenges faced in the decentralized health care system is the unclear delineation of roles and authorities between the central, provincial, and district governments, as well as the management and flow of information, especially facilitybased data collection.a

Design Summary

Performance Indicators/Targets

Monitoring Mechanisms Build capacity building in planning and management for local nutrition surveillance committees. Train local committees. Develop new selection criteria for heads of health centers to increase responsiveness to community. Provide systems development assistance, training, and capacity building in planning and implementing health management information system, financial management and monitoring system, and health human resource information and mgt system. Develop information and reporting systems responsiveness to data needs at district, province, and central levels to support timely response to emerging health and nutrition concerns. Streamline data collection and reporting requirements, clarify roles and responsibilities, and allocate resources and authority consistent with responsibilities. Develop data analysis capability to support planning and policy formulation. Provide system development assistance, training, and capacity building in planning, financial management and

5. Introduce structural changes and development of MOH.

5.1 Develop strategic development plan for MOH.

Outcomes/Achievements as of PCR Training on integrated health planning and budgeting conducted for all districts. All districts have prepared action plans for integrated health planning and budgeting. Training module developed by MOH on special budget allocation for health services for the poor. New selection criteria introduced. Health management and financial management systems developed based on basic minimum standards.

Status as of PPER

Confirmed.

Districts submitted data to MOH every 6 months, which are used for planning and monitoring.

Confirmed.

Reporting on health data to MOH has been streamlined.

Confirmed.

5.2 Develop information systems.

Not implemented.

Health Management Information System, Health Official Information System, and Health Financial Information System were not developed due to delayed consensus on the terms of

Appendix 3

43

44

Design Summary

Performance Indicators/Targets

Monitoring Mechanisms monitoring system, and health resources information and management system. Improve control, deployment, and utilization of human resources. Improve performance and efficiency through rationalization and appropriate incentive structure. Clarify responsibilities and develop performance benchmarks. Pilot test utilization of block grant mechanism for flexible personnel management. Improve equity in fund allocation among health centers through targeting based on poverty. Extend block grant funding mechanism to support health centers directly. Establish mechanism to improve targeting of Government subsidies. Increase number of facilities with autonomous management and revenue collection responsibilities. Increase accountability of health facility managers. Develop financial systems and design of training modules. Provide intensified staff training based on training needs assessment to ensure effective control/utilization through improved financial management capabilities of staff, comprehensive financial audit systems, and greater community participation.

Outcomes/Achievements as of PCR

Status as of PPER procurement.

Appendix 3

6. Improve efficiency of resource use.

6.1 Strengthen responsibility and accountability of local managers. 6.2 Strengthen management and responsiveness of health centers.

Fund allocation among health centers based on poverty indicators. Block grant funding as introduced by the Project was continued until the end of 2004. New selection procedures of health facility management adopted.

Confirmed.

Design Summary

Performance Indicators/Targets 6.3 Improve the cost efficiency of pharmaceutical use. 6.4 Maintain private sector involvement.

Monitoring Mechanisms Streamline essential drugs list. Train health providers in rational drug use. Employ public-private partnerships in monitoring and service delivery.

Outcomes/Achievements as of PCR Essential drug lists have been streamlined and training in rationale use of drugs has been undertaken. NGO forum involved in monitoring and service delivery.

Status as of PPER Confirmed.

Confirmed.

BKKBN = National Family Planning Coordinating Board, FNSS = Food and Nutrition Surveillance System, FP = family planning, MOH = Ministry of Health, MONE = Ministry of National Education, NGO = nongovernment organization, PCR = project completion report, PLKB = family planning field worker, SUSENAS = National Socioeconomic Survey, TA = technical assistance. a Indonesia Progress Reports on the Millennium Development Goals, 2004 and 2005. Sources: ADB. 2005. Project Completion Report for the Health and Nutrition Sector Development Program. Manila.; Indonesian Progress Reports on the Millennium Development Goal, 2004 and 2005; interviews with key stakeholders and field visits.

Appendix 3

45

46

Appendix 4

ASSESSMENT OF OVERALL PROGRAM PERFORMANCE A. Program Loan Table A4.1: Maintain Access of Vulnerable Groups to Essential Services Criterion Relevance Effectiveness Efficiency Sustainability Overall Rating Weight 20% 30% 30% 20% Assessment Highly Relevant Highly Effective Efficient Likely Sustainable Highly Successful Rating Value 3 3 2 2 Weighted Rating 0.6 0.9 0.6 0.4 2.5

Source: Operations Evaluation Mission.

Table A4.2: Mobilize Additional Resources to Support Essential Health and Nutrition Services Criterion Relevance Effectiveness Efficiency Sustainability Overall Rating Weight 20% 30% 30% 20% Assessment Highly Relevant Highly Effective Efficient Likely Sustainable Highly Successful Rating Value 3 3 2 2 Weighted Rating 0.6 0.9 0.6 0.4 2.5

Source: Operations Evaluation Mission.

Table A4.3: Maintain Quality of Essential Health and Nutrition Services Criterion Relevance Effectiveness Efficiency Sustainability Overall Rating Weight 20% 30% 30% 20% Assessment Highly Relevant Highly Effective Efficient Likely Sustainable Successful Rating Value 3 3 2 2 Weighted Rating 0.6 0.9 0.6 0.4 2.5

Source: Operations Evaluation Mission.

Table A4.4: Enhancing Decentralization, Participation, and Transparency Criterion Relevance Effectiveness Efficiency Sustainability Overall Rating Weight 20% 30% 30% 20% Assessment Relevant Effective Efficient Likely Sustainable Successful Rating Value 2 2 2 2 Weighted Rating 0.4 0.6 0.6 0.4 2.0

Source: Operations Evaluation Mission.

Table A4.5: Ministry of Health Organizational Change and Development Criterion Relevance Effectiveness Efficiency Sustainability Overall Rating Weight 20% 30% 30% 20% Assessment Relevant Effective Less Efficient Likely Sustainable Successful Rating Value 2 2 2 1 Weighted Rating 0.4 0.6 0.6 0.2 1.8

Source: Operations Evaluation Mission.

Appendix 4

47

B.

Project Loan Table A4.6: Health Services for Poor Families

Criterion Relevance Effectiveness Efficiency Sustainability Overall Rating

Weight 20% 30% 30% 20%

Assessment Highly Relevant Effective Efficient Likely Sustainable Successful

Rating Value 3 2 2 2

Weighted Rating 0.6 0.6 0.6 0.4 2.2

Source: Operations Evaluation Mission.

Table A4.7: Communicable Disease Control Criterion Relevance Effectiveness Efficiency Sustainability Overall Rating Weight 20% 30% 30% 20% Assessment Highly Relevant Less Effective Less Efficient Likely Sustainable Successful Table A4.8: Nutrition Criterion Relevance Effectiveness Efficiency Sustainability Overall Rating Weight 20% 30% 30% 20% Assessment Highly Relevant Less Effective Less Efficient Likely Sustainable Successful Rating Value 3 1 1 2 NA Weighted Rating 0.6 0.3 0.3 0.4 1.6 Rating Value 3 1 1 2 Weighted Rating 0.6 0.3 0.3 0.4 1.6

Source: Operations Evaluation Mission.

Source: Operations Evaluation Mission.

Table A4.9: Revitalization of Posyandu Criterion Relevance Effectiveness Efficiency Sustainability Overall Rating Weight 20% 30% 30% 20% Assessment Highly Relevant Highly Effective Highly Efficient Likely Sustainable Highly Successful Rating Value 3 3 3 2 NA Weighted Rating 0.6 0.9 0.9 0.4 2.8

Source: Operations Evaluation Mission.

Table A4.10: Family Planning Criterion Relevance Effectiveness Efficiency Sustainability Overall Rating Weight 20% 30% 30% 20% Assessment Highly Relevant Highly Effective Highly Efficient Likely Sustainable Highly Successful Rating Value 3 3 3 2 Weighted Rating 0.6 0.9 0.9 0.4 2.8

Source: Operations Evaluation Mission.

48

Appendix 4

Table A4.11: Program for Street Children Criterion Relevance Effectiveness Efficiency Sustainability Overall Rating Weight 20% 30% 30% 20% Assessment Less Relevant Less Effective Less Efficient Likely Sustainable Partly Successful Rating Value 1 1 1 2 Weighted Rating 0.2 0.3 0.3 0.4 1.2

Source: Operations Evaluation Mission.

Table A4.12: Ministry of Health System Development Criterion Relevance Effectiveness Efficiency Sustainability Overall Rating Weight 20% 30% 30% 20% Assessment Relevant Less Effective Less Efficient Likely Sustainable Partly Successful Table A4.13: Training Criterion Relevance Effectiveness Efficiency Sustainability Overall Rating Weight 20% 30% 30% 20% Assessment Highly Relevant Highly Effective Efficient Likely Sustainable Successful Rating Value 3 3 2 2 Weighted Rating 0.6 0.9 0.6 0.4 2.5 Rating Value 2 1 1 2 Weighted Rating 0.4 0.3 0.3 0.4 1.4

Source: Operations Evaluation Mission.

Source: Operations Evaluation Mission.

Table A4.14: Implementation, Social Awareness, Health Promotion, and Education Criterion Relevance Effectiveness Efficiency Sustainability Overall Rating Weight 20% 30% 30% 20% Assessment Highly Relevant Less Effective Less Efficient Likely Sustainable Successful Rating Value 3 1 1 2 Weighted Rating 0.6 0.3 0.3 0.4 1.6

Source: Operations Evaluation Mission.

Table A4.15: Overall Rating of the Program and Project Loans Overall Rating - Program Loan - Project Loan
Source: Operations Evaluation Mission.

2.14 2.30 1.97

Successful Successful Successful

Appendix 5

49

SUMMARY OF FINDINGS Structured Interviews and Group Discussions with Stakeholders Including Results of Secondary Data Collection A. Introduction

1. The Health and Nutrition Sector Development Program (HNSDP) was designed and implemented covering a wide range of health, nutrition and family planning services. HNSDP had a nationwide scope that entailed multisector and multilevel coordination among government executing and implementing agencies, the private sector, funding agencies, and other contracted parties that helped to implement the Program. The National Development Planning Agency (BAPPENAS) was the Executing Agency. The Ministry of Health (MOH) coordinated the health and nutrition component, the Ministry of Social Affairs (MOSA) handled the program support to street children, and the National Family Planning Coordinating Board (BKKBN) oversaw the family planning (FP) program component. The design and implementation of the HNSDP entailed the participation of public and private sector stakeholders at the national and local levels including health service providers and community volunteer workers. B. Methodology

2. As part of its overall methodology, the Operations Evaluation Mission (OEM) conducted structured interviews and focus group discussions with representatives from the concerned agencies and institutions (para. 1). The OEM interviewed 38 national officials from BAPPENAS and the implementing agencies, including representatives from nongovernment organizations and the funding agencies. In addition, 48 local officials, including service providers, were consulted regarding the program design and implementation, as well as its outputs. The OEM held group discussions with the MOH Planning and Budget Bureau, and BKKBN officials and staff. At the local level, the OEM interviewed Provincial Health Office (PHO) officials and staff, and district and subdistrict health officials and service providers. The focus of the discussions with the stakeholders were: (i) the overall outputs or outcome of the Program; (ii) the major issues or difficulties encountered; (iii) the sustainability of the program interventions and approaches; and (d) other related concerns influencing health, nutrition, and FP development in the country. 3. Field validations were conducted in three provinces: Jakarta, Bali, and Nusa Tenggara Timur (NTT). These provinces were selected based on their varied performance levels in utilizing the health cards that were issued. NTT had high utilization of health cards, but also a high percentage of poor in the population. In Jakarta, the field validations covered the Koja and Cilincing subdistricts, representing the depressed urban areas compared with the Bogor district, where the catchment populations are better off economically. Bali, on the other hand, had the lowest utilization of health cards, but also low percentage of poor people. Table A5.1 shows the basic characteristics of these areas. Overall, the OEM visited six puskesmas (primary health centers) in four districts/sub-districts: (i) Lagoa in Subdistrict Koja, North Jakarta; (ii) Kali Baru in Cilincing, North Jakarta; (iii) Tanah Sareal in Subdistrict Bogor; (iv) Denpasar Selatan I in Bali; (v) Tarus in Kupang, NTT; and (vi) Oseao in Kupang, NTT. 4. Table A5.1 presents the basic health and nutrition profiles of these areas compared to the demographic, health, and nutrition profile at the national level.

50

Table A5.1: Health and Nutrition Profile at the National, Provincial, and Health Center Levels
Provincial Profile Demographic, Health and Nutrition Indicators Nationala Jakarta Bali 3.4 m 7.34 14 19 66 2.1 90.8 90.4 16.4 94.4 69.4 69.4 84.6 16.2
b

Population 214.4 m 8.6 m % of poor people 17.4 3.4 Infant mortality rate (per 1,000 live 35 35 births) Under-5 mortality rate 46 41 (per 1,000 live births) Maternal mortality rate 307d (per 100,000 live births) Total fertility rate 2.6 2.2 Contraceptive prevalence rate (active 68.5 78.7 users) Proportion of pregnant women with at 72.6 73.7 least four prenatal visits Proportion of high-risk pregnant 16.4 5.8 women referred Proportion of deliveries attended by 73.1 70.5 health professionals Proportion of women with at least two 66.1 58.8 Tetanus Toxoid Doses Proportion of women with at least one 66.1 58.8 postpartum visit Proportion of pregnant women with 59.6 52.6 three doses of iron supplements Prevalence of malnutrition (severe 27.6 22.5 and lack malnutrition) - under 3 years old - under 5 years old 28.2 23.1 Universal immunization coverage 72.5 76.6 Incidence of malaria 63.6 Poor households covered with health98.4 98.5 managed care Proportion of poor given health cards over target Proportion utilized card No. of functioning posyandus No. of active kaders = data not available. a Ministry of Health. 2005. 2003 Indonesia Health Profile. Jakarta. b Ministry of Health. 2005. 2003 Indonesia Health Profile. Jakarta. c 2005 Accomplishment Report by Puskesmas. d 20022003 Indonesia Demographic and Health Survey. e 2005 Provincial Accomplishment Report, Nusa Tenggara Timur.

Nusa Tenggara Timur 4.1 m 28.6 59 73 484 4.1 86.4 72.0 13.8 77.6 50.3 50.3 71.2 36.6

Lagoa, Koja 57,046 67.7 48 deaths 9 deaths 2 deaths 13.3

Kali Baru, Cilincing 248,384 53.7 12 deaths 3 deaths 75.4 64.3 6.7

Health Center Profilec Tanah Seral, Depansar Bogor Selata 1 8,000 9.0 2 deaths 0 deaths 42.7 67.0 94.0 47.1 93.0 2.2 (severe) 10 57 58,936 3.8 0 deaths 9 deaths (dengue) 0 deaths 115.9 102.8 .6 92.5 95.8 100.8 0.1 (severe) 136.4 100.0 37.1

Appendix 5

Oseao, Kupang 42,670 53.4 10 deaths 62.0 8.3 70.3 7.9 (severe) 100.0 100.0 62 310

Tarus Kupang 26,881 65.4 0 death 4 deaths 62.6 6.5 65.1 80.4 82.9 10.6 (severe) 61.9 65.4 40 200

12.0 12.0 0.7 (severe) 113.2 18

66.0 105.6 7.0 (severe) 164 737

16.4 98.6 .03 40.2 89.2 16.1

38.8 81.6e 177.6 63.4 82.5 83.0

Appendix 5

51

C.

Findings 1. Major Outputs or Outcome

5. The Program helped mitigate the impact of the financial crisis. BAPPENAS and the implementing agencies believe that the overall purpose of the HNSDP was achieved, as it helped mitigate the impact of the financial crisis on the health and nutrition of the population, including their continued access to FP services. This assessment is borne out by the indicators in Table A5.2. Table A5.2: Health, Nutrition, and Family Planning Indicators Pre and Post Program Implementation
Indicators Infant Mortality Rate (per 1,000 live births) Under-5 Mortality Rate (per 1,000 live births) Maternal Mortality Rate (per 100,000 live births) Contraceptive Prevalence Rate Prevalence of Malnutrition (severe and lack malnutrition) Pre-Program Year Rate 1997 52 1998 64a 1997 1997 1998 334 57.4 40.0 Post-Program Year Rate 20022003 35 20022003 46 20022003 20022003 2003 307 60.3 35.8 Source of Data IDHS IDHS IDHS IDHS, BKKBN SUSENAS, Nutrition Component

BKKBN = Badan Koordinasi Kiluarga Buencana Nasional (National Family Planning Coordinating Board), IDHS = Indonesian demographic and health survey, SUSENAS = National Socioeconomic Survey. a National Socioeconomic Survey Estimation. Source: BKKBN, IDHS, and SUSENAS.

6. The policy actions were effective in securing the Governments budget allocation for health, nutrition, and FP services during and after the Program. MOHs share from the Government budget has been increasing, if not maintained, since the end of the Program in 2003 (Table A5.3). The proportion, however, is lower than the 1997 level before the financial crisis, because some of the funds have been reallocated to the local government as a result of decentralization that began in 2001. Table A5.3: Budget Allocation for MOH, 20012006 (in rupiah)
Budget Source National Budget MOH Budget % of the National Government Budget 2001 340,325.7 4,150.0 1.22 2002 344,008.8 4,249.0 1.24 2003 377,247.8 6,635.0 1.76 2004 374,351.3 7,185.2 1.92 2005 397,769.3 11,651.9 2.93 2006 625,237.0 15,930.3 2.55

MOH = Ministry of Health. Source: MOH Budget, 20012006.

7. The Government consistently has prioritized securing access for the poor to basic health and nutrition services, as expressed in their development and strategic plans. These include the National Medium-Term Development Plan, as well as the MOH, BKKBN, and MOSA strategic plans. This prioritization also is reflected in the allocation of resources to the poor. The budget subsidy of MOH for the poor to secure their access to basic health, referral, and support services has increased from Rp1.0 trillion in 2004, to Rp2.8 trillion in 2005, and to Rp3.6 trillion in 2006. However, some of the funds in 2005 were spent to support the operations and administration of the subsidy program. The specific allocation of the subsidy for the poor in 2005 is shown in Table A5.4.

52

Table A5.4: National Budget Allocation for the Poor, 2005 (in rupiah)
Transfer Mechanism Bank Rakyat MOF Indonesia State Treasury 395,780,000 1,323,000,000 75,000,000 18,000,000 171,000,000 108,890,000 61,000,000 135,000,000 79,530,000 1,000,000 110,000,000 40,000,000 157,000,000 100,000,000 135,000,000 79,530,000 1,000,000. Hospitals 110,000,000 40,000,000 157,000,000 100,000,000 9,000,000 66,000,000 Pharmacy Health centers 75,000,000 18,000,000 9,000,00.0 66,000,000 171,000,000 108,890,000 61,000,000

Appendix 5

Components A. Direct Services 1. Basic Health Services 2. Referral Services B. Support Services 1. Revitalization of Posyandus 2. For Remote Areas and Islands 3. Essential Drugs 4. Rehabilitation of Pharmacy 5. Vehicles and Motorcycles 6. Cars 7. Delivery of Services for Village Midwives 8. Health Center Management and Operations 9. Administration 10. Allowance for Hospital Claims 11. Hepatitis B Vaccines 12. Basic Health Equipment 13. Blood Donor Subsidy 14. Supervision, Monitoring, and Evaluation - newspaper - radio - monitoring and evaluation

Insurance (ASKES)

MOH

PHO

District

Recipient

Total

395,780,000 1,323,000,000

Health centers

395,780,000 1,323,000,000 75,000,000 18,000,000 180,000,000 66,000,000 108,890,000 61,000,000 135,000,000 79,530,000 1,000,000 110,000,000 40,000,000 157,000,000 100,000,000

495,000 495,000 5,239,435

9,753,100

Promotion Promotion Monitoring and Evaluation; Community Empowerment

495,000 495,000 14,992,535

495,000 495,000 14,992,535

- central office 9,017,465 Total 1,323,000,000 757,907,465 MOH = Ministry of Health, PHO = provincial health office. Source: MOH Budget for 2005.

24,229,435

770,063,100

904,292,535

9,017,465 1,970,907,465

9,017,465 2,875,200,000

Appendix 5

53

8. The Program supported the institutionalization of the pro-poor-based budget allocation. The central Governments subsidy for the poor was allocated to the different provinces and districts according to the proportion of poor population in these areas, rather than population size. District health offices said the lump sum budget received from the central Government is allocated to the puskesmas based on the number of poor within their catchment areas. 9. The Program developed a more expedient mechanism for transferring central funds to local governments, compared to the traditional State Treasury of the MOF. The transfer of funds directly to the health center and midwives through PT Post Indonesia or other courier remains a viable and preferred option to facilitate the release and receipt of financial assistance for the poor. While PT Post Indonesia served as the courier during the Program, the Government utilized the Health Insurance or Asuransi Kesehatan (ASKES) in 2004 to deliver the funds to health centers and hospitals. In 2005, however, the government contracted Bank Rakyat Indonesia (BRI) to courier the funds to the health centers, while ASKES continued to transfer funds for the hospitals. In 2006, the Government is contemplating bringing back all fund transfers through ASKES, though this time through a capitation scheme for health centers, while hospitals remain under the reimbursement scheme. Despite some related issues concerning these changes, the alternative fund transfer mechanism outside the State Treasury still is being used. The transfer of funds through ASKES or BRI takes at most 2 weeks, while the transfer through the State Treasury takes 46 months. 10. The Program helped refine the criteria and mechanism for identifying and classifying the poor. Prioritizing program assistance to the poor hinges on the criteria and mechanism used to identify the truly poor segments of the population. From the experience gained during the Program, the national and local governments continue to refine the criteria and the process for identifying the poor. The central Government plans to streamline the criteria used by BKKBN, Central Board of Statistics (BPS), and MOSA to arrive at a unified set of criteria for the poor. The local governments are encouraged to localize the criteria set by the central Government, and apply or modify them as appropriate to their situations and needs. Interviews with the district health officials confirmed that the criteria for identifying the poor differ from one area to another. In one of the puskesmas, only seven of the 14 criteria prescribed by the higher level were applied. The OEM saw evidence of updated lists of the poor in the puskesmas it visited. 11. The Program modeled innovative program approaches and interventions that address the plight of the poor, particularly during the crisis. For one, MOSA considered the HNSDP pioneering because it helped generate the approach and program for addressing the needs of the neglected and street children. Before the Program, MOSA did not have a designed approach and intervention for the street children. BKKBN, on the other hand, reported that the Program was instrumental in demonstrating how FP practices can be sustained, or increased, by focusing the assistance to the poor. Through the mobilization of community FP workers, the poor who really need an FP method were reached, counseled, and serviced. The Program is seen to have helped in preventing large dropout rates, because of the regular visits by FP community workers. MOH and local health officials, on the other hand, believe that the revitalization of the posyandus (community-based health posts that provide basic health, nutrition and FP services) and the provision of operating budget to the village midwives and health centers, improved the reach and coverage of the poor, especially those in remote or farflung areas. 12. The Program reactivated and strengthening health management support systems. For example, the reactivation of the Food and Nutrition Surveillance System (FNSS) provided a clearer picture of the nutritional state of the country, and helped identify the provinces or districts

54

Appendix 5

where assistance is needed most. As a result of the FNSS, NTT was able to detect in a timely manner the resurgence of severe malnutrition in the forms of marasmus and kwashiorkor.1 In response, MOSA allocated a special budget to help the province address its malnutrition problem. The requirement to prioritize access by the poor to health services through the health card system helped strengthen the referral system from the lower units of the health delivery to hospitals or other higher level of care. This ensured that the poor could access complete care as needed. On the other hand, the Program also helped established the link between program planning and budgeting, which was a precursor to the decentralized planning and budgeting system. 13. The Program helped promote good governance, transparency, and accountability of resources. The Program supported two major mechanisms to ensure that funds were allocated properly and utilized for the intended beneficiaries at the appropriate time. The independent monitoring established under the Program helped minimize leaks of project funds, while expediting fund releases and facilitating the implementation of program activities and delivery of services. In any project, an estimated 18% of funds are lost to leaks. The Program reduced this to only 5%. In addition, the Program supported the establishment of complaint resolution units at various levels of operations. These units helped resolve technical and administrative issues related to the Program, and also were useful as a watchdog for misallocation or misuse of funds. Provincial and district health officials reported that these committees comprised health officials from puskesmas, district and subdistrict levels, heads of villages, and two representative from NGOs and academia. In 2005, MOH issued a manual that provided guidelines for establishing complaint resolution units. 14. The independent monitoring and evaluation minimized leaks and administrative bottlenecks during program implementation. Further, it was effective in generating timely and accurate reports that helped address operational bottlenecks encountered in project implementation. The independent monitoring made local and national government stakeholders appreciate the status of the Program, leading to decisive actions by national and local stakeholders regarding issues affecting implementation. The downside, however, was the high cost to establish and operate the system, as well as the failure to institutionalize it after the Program. D. Issues and Concerns

15. The implementation of the HNSDP was not without operational bottlenecks and programmatic concerns. 16. Project activities started slowly, and some difficulties were encountered during implementation, including: (i) The block grants were not transferred immediately from the central office to the local government for health facilities and midwives, which in turn delayed interventions directed at the poor. The procurement of the blended food was extremely delayed, reaching the targeted beneficiaries only in the last year of implementation. The blended food received a mixed response. In more economically progressive areas, local health officials and staff reported that the blended food is acceptable to the children. In

(ii)

Marasmus is a form of severe malnutrition among children due to deficiency in calories and proteins; kwashiorkor is another form of severe malnutrition among children caused by a diet high in calories but very low in protein.

Appendix 5

55

(iii)

lower-income areas, beneficiaries apparently complained more about its taste. The centralized procurement of the blended food also created storage difficulties, as the food requires a large space, and led to high costs for freight from the central to the lower levels. The synchronization of the program interventions with health promotion activities was another issue. While the block grants have reached the health centers and midwives, local health managers have not been oriented on the use of these assistances.

17. The direct transfer of central funds to local governments using the non-traditional route is considered effective. However, local health managers found the frequent changes in couriers and mechanics after the Program to be counterproductive. After becoming familiar with funds management procedures, these officials are required to learn new guidelines and unlearn the previous ones. These changes have sowed confusion at the field level. 18. The utilization of health services by the poor remains low. Health-seeking behavior of the population is weak. People have limited appreciation of preventive and promotive care. Even if quality care is provided, the population cannot achieve health and nutrition if people do not access these services. Distance and high cost of transportation prevent the poor from accessing health care. Outreach activities must be sustained, and the continuous updates and training of health staff and community volunteers must be assured. 19. The provision of free services, on the other hand, has made the poor dependent on the government. As the OEM observed, some people seem to take these services for granted, and have come to demand treatment for even minor symptoms. Assistance for the poor results in other nonpoor becoming poor. The original estimate of 30 million poor at the start of the Program ballooned to 60 million in 2005, though the majority of these could be a result of the more systematic and sensitive criteria used in classifying people as poor. 20. While the program for neglected and street children helped address their basic and other social needs, their number continues to grow. This rendered the program inefficient and ineffective, and took its toll on the Ministry of Social Affairs budget. The Government needs to address the double-edged impact of this kind of all-out assistance to the poor. 21. Defining and identifying the poor is a continuing challenge for the national and local governments. The Government continues to grapple with a unified set of criteria for defining the poor, as various programs and surveys use different sets of indicators. At the local level, health officials must respond to queries by members of the community regarding why some were excluded or others were entitled to health cards. Local officials also mentioned difficulties in managing subsidies for the poor in cases where some of their constituents suddenly become poor as a result of natural disasters (e.g., flood) or accidents (e.g., fire). 22. The independent monitoring established under the Program was effective and beneficial during program implementation. However, the absence of technology transfer and the inability to institutionalize the system rendered it less sustainable. The recommendation for joint monitoring of any subsequent program or project by the Asian Development Bank (ADB) needs to be explored and examined further.

56 E.

Appendix 5

Sustainability of the Program Outputs and Outcomes

23. Through interviews with local officials and visits to selected health centers, the OEM confirmed the sustained provision of basic health services to the poor. Maternal and child health services, nutrition feeding, and FP services continue to be available to the poor. The health cards remain their passport to these basic health services. Poor people who missed out on a health card are still entitled to the same health care through an endorsement letter from the village head. 24. The local health staff continue to provide technical training of health staff. Kader (volunteers working in the community-based health posts) continue to be oriented and updated on health programs and interventions. Training funds are usually provided by the province (taken from assistance released by the Central Office) and the local governments. Support for health promotion, through the posyandus and other outreach activities, is made available to the health facilities and midwives. 25. Despite decentralization, regular coordination meetings between the province and the district/subdistricts continue to be convened. The OEM observed one regular meeting, attended by all district health officials and the Provincial Health Office (PHO)Planning Unit, to discuss the MOH Strategic Plan for 20062009. District health officials confirmed that they continue to submit accomplishment reports to the province and to the Central Office. 26. BKKBN has raised concerns regarding the sustained quality of FP services at the local level. BKKBN officials surmised that the interventions supported under the HNSDP are likely sustainable, though they might not be as intense as before. The comprehensive training undergone by the FP service providers during the Program was the last of its kind. Their continued training depends heavily on the available resources and prioritization of the local units. In addition, decentralization has affected the deployment of FP field workers. Data show that the number of registered FP field workers dropped from about 26,000 before devolution to 19,000 after decentralization. The national Government circular directing local government units to bring back the field workers to their original assignment helped restore the numbers to about 22,000. F. Other Relevant Factors Influencing Health and Nutrition Development in the Country

27. The decentralization process, which began in 2001, has generated mixed feelings among local stakeholders. Economically better-off cities and municipalities prefer the decentralized health care delivery system, because of the increased autonomy in decision making and management, as well as the flexibility in adapting interventions most appropriate to their local needs. However, other areas with less income reported difficulty in meeting the requirements of their constituents. Decentralization also affects the opportunities for promotion of health staff, as they now are limited to the highest position available within the local government. 28. With the change in administrations, MOH has undergone organizational changes. Key officials have been reassigned to other posts, which has required familiarizing new officials with the expected tasks and equipping them to carry out such expectations. 29. New health concerns continue to emerge in different localities that the OEM visited. For example, dengue cases have surged in Bali, while malnutrition has worsened in NTT.

Appendix 5

57

30. External assistance as a share of MOH resources declined from 31.3 % in 2001 to 9.1% in 2006. Similarly, it fell as a percentage of the BKKBN budget from 1999 to 2005. Hence, the contributions of ADB and the other funding agencies must be seen in the context of total Government resources poured into health and nutrition interventions, and FP activities. The share of external funds seems to be small relative to overall Government resources. Table A5.5: Total Budget of the Ministry of Health, 20012006
MOH Budget Item (Rp) 1. Regular Budget 2. Development Fund 2.1 Sectoral Fund 2.2 Grant and Loan 3. Special Budget Allocation Total MOH Budget Regular Budget as % of MOH Budget Sectoral Fund as % of MOH Budget Grant and Loan Funds as % of MOH Budget 2001 1,105.0 3,045.0 1,745.0 1,300.0 4,150.0 26.6 42.0 31.3 2002 994.0 3,255.0 2,468.0 787.0 4,249.0 23.4 58.1 18.5 2003 1,231.3 5,028.7 4,145.0 883.7 375.0 6,635.0 18.6 62.5 13.3 2004 1,284.5 5,444.6 4,270.0 1,174.6 456.2 7,185.2 17.9 59.4 16.3 2005 1,434.3 9,597.7 8,236.0 1,361.7 620.0 11,651.9 12.3 70.7 11.7 2006 1,956.8 11,566.7 10,003.4 1,563.3 2,406.8 15,930.3 12.3 62.8 9.8

= no data available, MOH = Ministry of Health, Rp = rupiah. Source: MOH Budget.

31. For the FP Program, the share of external funds ranged from 13.2% in 1999 to 6.1% in 2005, though it fluctuated in between. The highest share of external funds was in 2000 at 15.8%, while the lowest was in 2001 at 4.3%. Table A5.6: Total Budget of BKKBN, 19992006
Budget Source 1999 Government Amount (Rp) % Foreign Loan and Grant (Rp) % Total Budget (Rp) Sources of Foreign Funds 752,210,470 86.8 2000 693,602,428 84.2 2001 860,395,431 95.7 2002 989,241,957 94.5 2003 1,345,974,967 95.4 2004 570,424,836 92.6 2005 662,519,900 93.9

114,178,572 13.2 866,389,042 WB, ADB, AusAID, UNFPA, USAID-SDES Project

130,105,234 15.8 823,707,662 WB, ADB HNSDP, AusAID, UNFPA

39,036,551 4.3 899,431,982 WB, ADBDHS1 and HNSDP, FHN Project, AusAID, UNFPA

57,463,267 5.5 1,046,705,224 WB, ADBDHS1, HNSDP and FHN Project, AusAID

65,183,051 4.6 1,411,158,018 WB, ADBDHS1, HNSDP, AusAID, UNFPA

45,421,584 7.4 615,846,420 WB, ADBDHS1, AusAID

42,699,000 6.1 705,218,900 ADB-DHS 1, and DHS 2 AusAID

ADB = Asian Development Bank, AusAID = Australian Agency for International Development, BKKBN = Badan Koordinasi Kiluarga Buencana Nasional (National Family Planning Coordinating Board), DHS = Decentralized Health Services, FHN = Food, Health and Nutrition, HNSDP = Health and Nutrition Sector Development Program, Rp = rupiah, SDES = Service Delivery Expansion Support, UNFPA = United Nations Population Fund, WB = World Bank. Source: BKKBN Budget Report, 19992006.

58

Appendix 6

FINDINGS OF THE BENEFICIARY SURVEY A. Introduction

1. The Health and Nutrition Sector Development Program (HNSDP) aimed to mitigate the impact of the financial crisis on the health and nutrition of the Indonesian population, and to secure their continued practice of family planning (FP). The focus was on the poor, which required (i) identifying the poor according to a set of criteria from the central Government, modified by the local government to meet the on-the-ground situation; and (ii) providing health cards to the identified poor as their passport to free basic health services. Training, logistics, and operational support were also provided to health facilities and staff to conduct outreach, and to ensure that people living in far-flung areas are reached. 2. Through the health card mechanism, the HNSDP hoped to secure the continued access of the poor to basic health services, referral services, and support interventions. These include (i) maternal care during prenatal, natal, and post-natal period; (ii) child health services upon birth, and through their immunization period; (iii) general consultations and check-ups, drugs, and medicines, as needed; and (iv) higher level or specialized health care upon referral. The HNSDP supported nutrition feeding for infants 611 months old, children 1223 months old, and pregnant mothers with high caloric deficiency. Free contraceptives were also provided to women of reproductive age. B. Methodology

3. The Operations Evaluation Mission (OEM) methodology included a survey of program beneficiaries in selected health centers. The overall purpose of the survey was to determine their awareness of, access to, and participation in health programs and services supported by the Program. The survey also wanted to validate if these services continue to be available, and to determine difficulties encountered by the beneficiaries in accessing these services. 4. The survey included 70 beneficiaries from health centers in the subdistricts of Cilinciling and Koja in North Jakarta, and Tarus and Oesao in Nusa Tenggara Timur. Although the OEM tried to survey beneficiaries from the health centers in Tanah Sareal, Bogor, and Denpasar Municipality, no health card holders were found during the visit. As these areas are economically better-off than the other survey sites, most of the clients in the health centers did not have health cards. 5. Questionnaires in Bahasa were distributed to beneficiaries, who were supposed to fill them out on their own. Respondents were advised to leave items blank if they were not certain of the answers. Table A6.1 shows the number of respondents surveyed per health center. Table A6.1: Distribution of Sample Beneficiaries by Puskesmas
Area Lagoa, Koja, Jakarta Cilincing, Jakarta Tarus, NTT Oseao, NTT Total Respondents 33 22 9 6 70

NTT = Nusa Tenggara Timur. Source: Operations Evaluation Mission beneficiary survey.

Appendix 6

59

C.

Findings

6. The analysis of findings was focused on three main concerns: (i) the availability of basic health services, (ii) the distribution and utilization of health cards, and (iii) participation of respondents in selected health and nutrition interventions. 1. Availability of Basic Health Services

7. Most respondents confirmed the availability of basic health services in their area: child health services (95.5%), maternal care (82.9%), FP (71.4%), and nutrition feeding (62.9%). 8. Most respondents noted the availability of immunizations, as well as check-ups or consultations for cough, fever, or colds for child health services. About two thirds of the respondents confirmed the availability of prenatal care, while a lower percentage mentioned delivery services and post-natal care for maternal services. 9. FP contraceptives are also available. Three fourths of the respondents identified the injectables, and more than half identified the pills. The least mentioned were implants. For nutrition feeding, slightly more than half of the respondents reported feeding for infants 6 11 months and for children 1223 months old. Less than half cited feeding for the pregnant women. 10. The puskesmas (primary health centers) were the main source of the basic health services, while a significant number also mentioned the kader (volunteer workers) especially for child care. Only a few mentioned nongovernment organizations as a source of these services. 11. Almost two thirds (62.9%) rated the child health services as always available when needed. However, only about a third considered maternal health services (32.9%) and FP services (35.7%) always available. Most rated nutrition feeding as sometimes available. Only one rated the child health services as seldom available. Table A6.2: Services Available, Provider, and Rating on Continued Availability (%)
Provider of Services Rating on Availability Kader Health NGO Always Sometimes Seldom Center available Available Available Child Health Servicesa 95.7 41.4 70.0 4.3 62.9 10.0 1.4 Maternal Health Servicesb 82.9 12.9 58.6 2.9 32.9 10.0 Nutrition Feedingc 62.9 15.0 65.0 13.0 36.0 Family Planning Servicesd 71.4 4.3 62.9 1.4 35.7 4.3 = not available, NGO = nongovernment organization. a Includes immunization services (86.9%) and consultations for common illnesses (e.g., fever, cough, colds) (58%). b Includes prenatal care (62.9%), delivery services (51.4%), and post-natal care (58.6%). c Includes feeding for 611 months old (58.6%), 1223 months old (51.4%), and pregnant women (44.3%). d Includes pills (51.4%), injectables (71.4%), and implants (27.1%). Source: Operations Evaluation Mission beneficiary survey. Basic Health Services Available Services

2.

Distribution and Utilization of Health Cards

12. Year Respondents Given the Health Cards. Nearly two thirds (65.8%) were provided with health cards during the Program (19992003), which confirms the HNSDPs strategic role in helping to focus the delivery of basic health and nutrition services on the poor. However, about a third (32.9%) received their health cards in 2003the last year of program

60

Appendix 6

implementation. This could mean that the mechanism for identifying the poor took some time to be implemented, or that the criteria used in defining the poor got more refined and became more sensitive in locating the poor. A few (2.8%) received health cards in 2004 or 2005, indicating the sustained pro-poor focus of the Government in health service delivery. This also suggests that the list of poor is never static, because external factors (e.g., fires, flash floods, and other calamities) easily could affect the peoples economic status. Thus, the list needs to be updated regularly. Before the HNSDP, some respondents were already health card holders the output of the earlier Social Protection Sector Development Program, which also aimed to improve the health of the poor. Table A6.3: Year Respondents Received Health Cards
Year Respondent Received Health Card Pre-Program (1998) During Program (19992003) 1999 2000 2001 2002 2003 Post-Program (20042005) 2004 2005 No Response/Cant Remember Total
Source: Operations Evaluation Mission beneficiary survey.

No. 4 46 9 5 2 7 23 2 1 1 18 70

% 5.7 65.8 12.9 7.1 2.9 10.0 32.9 2.8 1.4 1.4 25.7 100.0

13. Provider of Health Card. More than half (57.1%) identified the health center staff as the provider of health cards, while one third (32.9%) specified the kader. Only 10% mentioned that they received health cards from local officials. Although the classification of the poor was the task of the local government, the health cards were handed over through different providers. As a result, the health center staff received most queries and complaints, as they were identified by most respondents as the source of health cards. Table A6.4: Providers of Health Cards
Providers of Health Cards Kader (volunteer) Health Center Staff Local Officials Total
Source: Operations Evaluation Mission beneficiary survey.

No. 23 40 7 70

% 32.9 57.1 10.0 100.0

14. Orientation on the Health Card. Cardholders seem to have received adequate orientation about the use of health cards when they were issued. Most remembered that health cards can be used for free basic health services (85.7%) whenever a family member needed the services (67.1%) at any given time (64.3%). A few (4.3%) mentioned that it also can be used for free services from the hospitals. This confirms that the health cards also entitled the poor to higher level or specialized care from the hospitals or other service outlets for free upon referral by the lower level. On the other hand, only three of 10 (29.9%) were able to cite the basis of their entitlement as being poor, having no permanent job, with low family income, limited funds, or needing alleviation of family burden.

Appendix 6

61

Table A6.5: Information Given About Health Cards

Information About Health Card can be used to avail of free health services can be used by every member of the family can be used anytime can be used to avail of hospital services Basis in Selecting Cardholders Poor No permanent job Reduce families burden House income low Limited fund Sickly members No. 60 47 45 3 22 15 1 2 1 1 1 % 85.7 67.1 64.3 4.3 29.9 21.4 1.4 2.9 1.4 1.4 1.4

Source: Operations Evaluation Mission beneficiary survey.

15. Utilization of Health Cards. Most continue to utilize their health cards, as confirmed by three fourths (72.9%) who reported using them before the survey. Many recently used their cards in 2006, a few in 2005, and only one in 2000. More than one fourth (27.1%), however, were unable to specify the year they last used it. Table A6.6: Last Time Beneficiary Used the Health Card Prior to the Survey
Utilization of Health Cards Yes 2000 2005 2006 No Response/Cant Remember No. 51 1 9 41 19 % 72.9 1.4 12.9 58.6 27.1

Source: Operations Evaluation Mission beneficiary survey.

16. Reasons for Non-Utilization of Health Services. The main reason cited for not utilizing the health services was that the cardholder did not get sick (38.6%). The distance from the respondents residence to the health facility, and the corresponding high cost of transportation, were other significant factors (24.3%). This is consistent with the findings of the special evaluation study sponsored by the Government in 2004, which identified high transportation cost as the major reason for low level of health service utilization. Local health officials expressed similar views during the interview. Other reasons cited by the respondents were the absence of a surrogate caretaker for their children, and being too busy with household chores. A few do not see any need for the services (4.3%). These responses suggest that further promotion is needed to make people seek health services, especially preventive and promotive care. The distance and high cost of transportation are realities that challenge the kader, village midwives, and other health facility staff to bring health services closer to those who cannot afford to come to the center. The mobilization of workers for outreach services remains a relevant strategy for increasing the utilization of health services by the poor.

62

Appendix 6

Table A6.7: Reasons for Not Using the Health Card

Reasons Cardholder did not get sick Got sick but high cost of transportation Got sick but center is far Sought help from someone else Didnt see the need to get service No time to go to the center Got sick but nobody to take care of home Services offered not good Others (specify)
Source: Operations Evaluation Mission beneficiary survey.

No. 27 9 7 4 3 2 1 1 1

% 38.6 12.9 10.0 5.7 4.3 2.9 1.4 1.4 1.4

17. Measures to Improve Utilization of Health Cards. Measures recommended to improve the utilization of health services include expanding the service covered by the health card and upgrading the quality of services provided by the health facilities. More promotion and explanation of the health card are needed, while the Government should explore and pursue bringing health services nearer to the residences of the poor or health card beneficiaries. Table A6.8: Measures to Improve Health Service Utilization
Measures for Strengthening Use of Health Card Expand coverage Better service in the facility Nearer point of service More explanation about its importance and use
Source: Operations Evaluation Mission beneficiary survey.

No. 33 33 23 29

% 47.1 47.1 32.9 41.4

3.

Participation in Posyandu and Nutrition Interventions

18. Interventions supported by the Program included the revitalization of the posyandus and nutrition feeding for infants 011 month old infants, children 1223 month old, and pregnant women who are high-caloric deficient. Tables A6.9 and A6.14 show that these interventions were carried out during the Program, and were still being undertaken during the OEM. Respondents have attended or participated in these interventions to varying degrees, and continue to do so in 2006. a. Participation in Posyandus

19. Attendance to Posyandus. More than half (58.6%) have attended posyandus, particularly after the Program ended in 2003. Many continued to attend in 2006, which confirms that posyandus revitalized during the Program still were operating as of the OEM. Table A6.9: Attendance to Posyandus
Attendance to Posyandus Attended Posyandu Pre-Program : 1998 During Program : 19992003 Post-Program : 20042006 Not Attended Posyandus No Response/Cant Remember
Source: Operations Evaluation Mission beneficiary survey.

No. 41 1 3 37 24 5

% 58.6 1.4 4.3 52.9 34.3 7.1

Appendix 6

63

20. Benefits of Posyandus. Most consider the posyandu beneficial, because it provides appropriate health information, the right advice, health services. Respondents also are reminded of the schedule when services are available. Table A6.10: Benefits from Attending the Posyandus
Benefits Give health information Provide services Reminder to avail services Food supplement
Source: Operations Evaluation Mission beneficiary survey.

No. 57 36 27 1

% 81.4 51.4 38.6 1.4

21. Topics Discussed in Posyandu. Several health concerns are discussed in the posyandu. Three-fourths of the respondents (74.5%) mentioned the health and nutrition of children, about two-thirds (64.3%) cited health and nutrition care for women, and more than half (54.3%) noted FP services. Other health topics (e.g., sanitation, healthy lifestyle, etc.) also were mentioned. Table A6.11: Topics Covered in the Posyandu
Topics Discussed Child health and nutrition Maternal health and nutrition Family planning Other health concerns
Source: Operations Evaluation Mission beneficiary survey.

No. 52 45 38 32

% 74.3 64.3 54.3 45.7

22. Reasons for Non-Attendance. Of the 24 respondents who were unable to attend the posyandus said they were too busy, too far from the venue, or lacked an alternative caretaker to watch their children at home. One mentioned that she did not need to attend posyandu, because she did not have a child. One was not interested in attending the activity. Table A6.12: Reasons for Not Attending Posyandu
Reasons No time or too busy Far from place No one to take care of child or household chores Time not conducive Not interested No child
Source: Operations Evaluation Mission beneficiary survey.

No. 10 5 3 4 1 1

% 41.7 20.8 12.5 16.7 4.2 4.2

23. Ways to Improve Posyandu. Measures recommended to improve posyandus include employing a more dynamic approach, having workers make more frequent visits, and making more services available. A few suggested moving the venue nearer to their residence, while others wanted to change the time the posyandus are held.

64

Appendix 6

Table A6.13: Ways to Enhance the Posyandus

Recommendations More dynamic approach More frequent visit by worker More services to offer Change venue nearer home More conducive time
Source: Operations Evaluation Mission beneficiary survey.

No. 38 32 27 10 8

% 54.3 45.7 38.6 14.3 11.4

b.

Nutrition Feeding

24. Three groups were targeted for complementary feeding by the Program: (i) infants 611 months old for 180 days using the blended food; (ii) children 1223 months old for 90 days using local food; and (iii) pregnant women with high caloric deficiency for 90 days using local food. 25. Attendance to Nutrition Feeding. About two thirds (62.9%) had a family member who attended a nutrition feeding in the past. These were mainly children 1223 months old. Less than one fifth (18.6%) had their infants 611 months old participate, while only a few pregnant women (14.3%) attended the feeding program. Table A6.14: Family Members Who Attended Nutrition Feeding
Family Member With at least 1 family member attended feeding 611 month old children 1223 month old children pregnant mothers No response or cant remember
Source: Operations Evaluation Mission beneficiary survey.

No. 44 13 21 10 26

% 62.9 18.6 30.0 14.3 37.1

26. Year Last Attended Nutrition Feeding. Of those who reported attending a feeding in the past, more than half participated from 20042006. This confirms that the Government sustained nutrition feeding after the Program. Table A6.15: Last Time Family Member Attended Feeding
Year Last Attended Feeding Pre-Program (1998) During Program (19992003) Post-Program (20042006) No response or cant remember Total
Source: Operations Evaluation Mission beneficiary survey.

No. 1 5 23 15 44

% 2.2 11.4 52.3 34.1 100.0

27. Mechanics in Nutrition Feeding. Different mechanics were employed in the feeding program. A majority of respondents mentioned that feeding was conducted in one place, while a few cited food rationing to the entitled family members. A combination of these also was carried out. The food served or rationed also varied. Some mentioned the use of blended food, others the use only of local foods or a combination of both.

Appendix 6

65

Table A6.16: Type of Feeding Providing

Feeding Mechanism Feeding in one place Food ration Mixed combination No response Total No. 30 4 6 4 44 % 68.2 9.1 13.6 9.1 100.0

Source: Operations Evaluation Mission beneficiary survey.

Table A6.17: Type of Food Provided

Type of Food Blended food Local food Mixed blended and local food No response Total No. 6 9 8 21 44 % 13.6 20.5 18.2 47.7 100.0

Source: Operations Evaluation Mission beneficiary survey.

28. Acceptability and Completeness of Feeding. The questionnaire was unable to distinguish between the acceptability of blended and the local food items that were served. In general, though, the foods served or rationed were acceptable to the participating family members (95.5%). On the other hand, more than a third (36.6%) reported not completing the feeding program as prescribed. Non-completion of the feeding program was due to distance, the monotony of the food served, the lack of time to bring the child to the feeding, and the noncontinuous supply of the food supplements. Table A6.18: Reasons for Not Completing the Feeding Program
Reasons Feeding area far from home Got tired of the taste of food No time to bring child Food supply not continuous Total
Source: Operations Evaluation Mission beneficiary survey.

No. 2 2 2 10 16

% 12.5 12.5 12.5 62.5 100.0

D.

Conclusions and Recommendations

29. The survey showed encouraging results. It confirmed the participation of the poor in the interventions supported by the Program, and validated the sustained provision of basic health services after the end of the Program. The survey also identified some difficulties and bottlenecks in implementing health and nutrition programs. Finally, respondents recommended ways to enhance health services. 30. The majority of the beneficiaries (poor or cardholders) confirmed the continued availability of basic health services and their ready access as needed. Basic services include maternal and child health care, nutrition feeding, and FP, including referral services to hospitals. 31. Welfare of the poor remains the top priority and focus of the national and local governments, as evidenced by the continuous provision of health cards to the poor.

66

Appendix 6

32. The cardholders generally are well-informed about the importance of health cards. Further measures are needed to improve their health-seeking behavior to utilize the card not only when they are sick, but also to prevent illness and promote health. 33. Low utilization of health cards was noted in the results. Similar factors prevent the poor from accessing basic health services, attending the posyandus, and completing their nutrition feeding program. Distance, high cost of transportation, lack of time to attend, and an apparent lack of interest prevent the poor from utilizing the services and completing the program. These pose a continuous challenge to kader, village midwives, and other health center staff to bring the services closer to the poor. Further, these reinforce the need to continue the operational budget provided to the midwives, community FP workers, and kader for outreach services. 34. Posyandus continue to operate, while health centers pursue nutrition feeding continually. A majority still participate in these programs. Respondents recommended ways to improve the posyandus, such as (i) using a more dynamic approach, (ii) holding sessions at a more convenient time for the attendees, and (iii) widening the scope of topics and services provided. 35. The quality of services could be enhanced, including making posyandus more effective and maximizing use of the health card.

MANAGEMENT RESPONSE TO THE PROGRAM PERFORMANCE EVALUATION REPORT FOR THE HEALTH AND NUTRITION SECTOR DEVELOPMENT PROGRAM IN INDONESIA (Loans 1675/1676-INO)

On 2 October 2006, the Director General, Operations Evaluation Department, received the following response from the Managing Director General on behalf of Management:

1. Management finds OEDs Project Performance Evaluation Report (PPER) of the Health and Nutrition Sector Development Program (HNSDP) well prepared with a commendable effort to evaluate the performance of this national sector development program. The overall assessment and rating (satisfactory) of the HNSDP is similar to the rating in the Project Completion Report (successful, at the higher range of this category) (para. 3). Management response focuses on some issues, lessons learned and, OED recommendations. A. Overall Assessment

2. Design and Formulation. We appreciate the comments on the formulation process of the HNSDP, referring to the relationship ADB had built up with the Ministry of Health through earlier support that facilitated a constructive planning process, and thereby demonstrated the importance of continuity of engagement in a particular sector (para. 9). We appreciate the recognition that the HNSDP, with a pro-poor targeted approach, experimented with innovative methods to channel funds in a transparent manner, developed mechanisms to ensure results-based independent monitoring focus, and introduced early implementation responsiveness through the complaint resolution units. (paras. 10 and 41). 3. Performance. We note the overall positive assessment of the HNSDP performance, despite the challenges of implementing this highly complex project across Indonesia (para. 49). We agree with the identified efficiency recommendations on the timing of procurement for drugs, and the selected method of procurement for the blended food. 4. Other Assessments. The constructive comments on the institutional impact of the HNSDP are appreciated (paras. 6568). B. Issues and Lessons Learned

5. The country still faces high out-of-pocket contributions, and ADB along with other development partners are in dialogue with the Government in this area. ADB is encouraging Government to consider demand-side financing, and mechanisms to protect households against health care costs. (para. 82). 6. Management agrees that identifying and tracking the poor is complex and costly, and that a standard classification for the poor could substantially reduce overheads of programs targeting the poor. However, this was beyond the scope of the HNSDP. We are in close communication with the Government to encourage improved mechanisms on targeting of the poor. (para. 83).

7. We agree that the HNSDP, given its focus to address the post-crisis situation, may have led many public sector facilities to be dependent on central government contribution for operation of their facilities, thus crowding-out local government contributions. We agree that the supplementary funding of basic health services from central and provincial levels is sending mixed signals under the decentralization laws and is encouraging Government to consider targeted health financing for the poor and to address this challenge through the various projects (para. 84). C. Follow-up Actions

8. Regarding the recommendation to assist the Government in developing a strategy to transcend its crisis mitigation-oriented efforts, and develop longerterm and more sustainable approaches to improving the health and nutritional status of the poor (para. 89), Management has the following: (i) Since the tsunami of December 2004, crisis mitigation has received substantial attention by the Government. ADB and other development partners have been critical in this response. ADB is examining its future role in risk-mitigation oriented efforts in the social sector in this regard, and will report this back to Management. Several development agencies including ADB (under the current Loan 1810-INO: Decentralized Health Services Project, and Loans 2074 and 2075-INO: Second Decentralized Health Services Project) are assisting in the development of more sustainable approaches to improving health and nutrition of the poor. This will be further supported through the forthcoming Nutrition Improvement through Community Empowerment (NICE) Project and the Poverty Reduction and Millennium Development Goals Acceleration Program (PRMAP), both scheduled for 2007.

(ii)

9. Regarding the recommendation to fast-track the development of a unified definition of the poor, and support the issuance of a single social security card to ensure more efficient targeting of the poor (para. 89). (i) The development of a unified definition of the poor is currently being examined by the Government. The issuance of a single social security card is currently being examined by the Government.

(ii)

D.

Conclusions

10. Management agrees with the reports overall assessment and rating and appreciates the many positive aspects of the HNSDP as recorded in the PPER, which, as noted, reflect a combination of strong Government commitment, innovative design, control mechanisms, and flexibility, while working on a large scale in a complex environment.