Document of The World Bank

FOR OFFICIAL USE ONLY Public Disclosure Authorized

Report No. 4131-IN,

STAFF APPRAISAL REPORT Public Disclosure Authorized INDONESIA

PROVINCIAL HEALTH PROJECT Public Disclosure Authorized

January 12, 1983 Public Disclosure Authorized

Population, Health and Nutrition Department

This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS

US$1.00 = Rupiahs (Rp) 660 Rp 100 US$0.151 Rp 1 million = US$1,515

WEIGHTS AND 'MEASURES- METRIC SYSTEM

1 millimeter (mm) = 0.039 inches 1 meter (m) = 39.37 inches 1 ki].ometer (kn) = 0.62 miles 1 square kilometer (sq km) = 0.386 square miles 1 hectare (ha) = 2.47 acres

GOVERNMENTOF INDONESIA FISCAL YEAR

April 1 - March 31

ABBREVIATIONS

ASKES = Health Insurance Scheme For Government Employees BAPPENAS = National Development Planning Board CIDA = Canadian International Development Agency GOI = Government of Indonesia INPRES = National Subsidy for Local Governments MCH = Maternal and Child Health MHA = Ministry of Home Affairs MOH = Ministry of Health NFPCB = National FamnilyPlanning Coordinating Board PKMD = Village Comnunity Health Development Program PTC = Provincial Training Center PUSDIKLAT MOH Center for Education and Training REPELITA Five-Year Development Plan UNICEF = United Nations Children's Fund USAID = United States Agency for International Development INDONESIA FOR OFFICIAL USE ONLY PROVINCIAL HEALTH PROJECT STAFF APPRAISAL REPORT

Table of Contents

Page No.

Basic Data ...... i

Definitions...... ii

I. INTRODUCTION ...... 1

II. THE HEALTH SECTOR ...... 3

A. Health Status...... 3 B. The Health Service System...... 5 C. Health Expenditure and its Financing ...... 8

III. HEALTH SECTOR POLICIES AND PERFORMANCE ...... 10

A. Health Policies...... 10 B. Sector Performance ...... 11 C. Health Sector Issues .. .12 D. The Bank Role...... 15

IV. THE PROJECT AREA ...... 16

V. THE PROJECT...... 19

A. Project Objectives ...... 19 B. Project Composition...... 20 C. Detailed Features...... 21

VI. PROJECT COSTS AND FINANCING...... 27

A. Cost Estimates .. .27 B. Project Financing...... 29 C. Procurement...... 29 D. Disbursements...... 29 E. Accounts and Audit ...... 30

VII. PROJECT IMPLEMENTATION, MONITORING AND EVALUATION. . . . 30

A. Project Management ...... 30 B. Project Implementation ...... 31 C. Monitoring and Evaluation...... 32

VIII. JUSTIFICATION AND RISKS ...... 33

IX. AGREEMENTS REACHED AND RECOMMENDATIONS ...... 34

This report is based on the findings of an appraisal mission to Indonesia in May 1982. Mission members included Bernhard Liese (Mission Leader), Lina Domingo (Bank), and David Mills (Consultant).

This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. Table of Contents (continued)

ANNEXES

Annex 1 Tables Page No.

T-1 Population by Province: Size, Density and Growth...... 36 T-2 Socio-economic Indicators in Selected Countries, 1979 ...... 37 T-3 Principal Causes of Death in Indonesia, 1972 and 1980 .. 38 T-4 Infant Mortality and Life Expectancy, by Region, 1969 and 1978 ...... 39 T-5 Disease Patterns, 1972 and 1980 ...... 40 T-6 Central Ministry of Health Budgets, 1979/80-1981/82, by Programs ...... 41 T-7 Development, INPRES and Routine Budgets for MOH, 1974/75-1981/82 .. 42 T-8 Analysis of Household Surveys 1972 and 1980 . .43 T-9 Malariometric Indices .. 44 T-10 Location of Project Facilities...... 45 T-11 Standard Hospital Staffing Patterns ...... 46 T-12 Expected Training Loads at Provincial In-Service Training Centers...... 47 T-13 List of Studies and Technical Assistance...... 48 T-14 Detailed Cost Estimates by Component...... 49 T-15 Annual Expenditures by Component...... 56 T-16 Estimated Schedule of Disbursements ...... 57 T-17 Responsibilities for Project Implementation Activities ...... 58 T-18 Implementation Schedule.. 61 T-19 Key Project Indicators...... 64

Annex 2 Selected Documents and Data Available in the Project File...... 65

Charts

C-1 Structure of the Ministry of Health ...... 66 C-2 Organization of the Provincial Health Offices . . . . 67 C-3 Organization of the DiistrictHealth Offices . . . . . 68 C-4 Health and Family Planning Systems...... 69

MAP

M-1 Sulawesi: Location of Project Facilities and Activities INDONESIA

PROVINCIAL HEALTH PROJECT

Definitions

Crude Birth Rate: Number of live births per year per 1,000 people.

Crude Death Rate: Number of deaths per year per 1,000 people.

Rate of Natural Difference between crude birth and crude death Increase: rate; usually expressed as a percentage.

Rate of Population Rate of natural increase adjusted for (net) Growth: migration expressed as a percentage of the total population in a given year.

Infant Mortality Annual number of deaths of infants under 1 year per Rate: 1,000 live births during the same year.

Life Expectancy: Average number of years children born in the same year can expect to live if mortality rates-for each age/sex group remain the same in the future.

Annual Malaria Number of people with positive blood slides Incidence: collected over a one-year period per 1,000 population.

Slide Positivity Number of positive blood slides per 100 slides Rate: collected.

Active Case Surveillance activities in which malaria services Detection: actively search for new malaria cases through the collection of blood slides and epidemiological investigations.

Passive Case The surveillance activities in which the public Detection: health and medical services, other than the regularly constituted malaria service, assist the latter by searching for malaria cases by the collection of blood slides and epidemiological investigations.

Falciparum Malaria: A severe type of malaria caused by Plasmodium falciparum, a species of malaria parasite. I INDONESIA

PROVINCIAL HEALTH PROJECT

I. INTRODUCTION

1.01 The Indonesian economy has performed remarkably well during the past decade. Gross national product (GNP) grew at 8% per year on average and GNP per capita reached US$520 in 1981, placing Indonesia in the ranks of middle-income countries for the first time. The benefits of economic growth have been widely spread reaching all segments of the population, including the lowest income groups. The achievements in raising the well-being of Indonesians can be attributed in part to concerted Government efforts in several related and inter-dependent areas: basic education, population control, nutrition and health.

1.02 Access to primary education has increased dramatically and uni- versal enrollment has now virtually been realized. The adult literacy rate rose from 39% in 1960 to 62% in 1976. The national family planning program was vigorously pursued and has contributed to a rapid decline in fertility. The birth rate fell at an average annual rate of 1.4% during the 1970s, a rate more rapid than the average for developing countries. Agriculture and nutrition programs and policies have been successful in increasing the levels of food output and consumption and in facilitating access to a broad range of nutrition services. Significant progress has also been made in improving the health status of the population. Between 1969 and 1980 life expectancy rose from 47 years to 53 years, and the infant mortality rate declined from about 140/1000 live births to about 93/1000, an improvement that is 50% greater than the average for all low-income countries.

1.03 This progress notwithstanding, life expectancy is still low and mortality rates are still high in comparison with those in countries with similar income levels. Some diseases have been eradicated or reduced, yet many others of an infectious or parasitic nature remain. Morbidity patterns in the rural areas have not changed significantly over the past decade. Protein-calorie malnutrition is still widespread, affecting an estimated 30% of children under 5 years of age. Furthermore, while the GOI has now largely succeeded in its objective of establishing the infrastructure of a system capable of delivering basic health services nationwide, the system's effectiveness remains limited by a low level of public confidence in the services provided. This lack of confidence is attributed to a poor quality of health care at the primary level and a failure to develop an effective referral system that permits the rural hospitals to support and lend professional credibility to the primary network. 1.04 To redress this situation, the GOI has embarked upon a massive expansion in its social development programs. Its commitment to reducing the present high rate of population growth (2.3% in 1980) and to improving the health and nutritional status of the population is strong. An ambitious target has been set to reduce the 1971 fertility level by 50% by 1990. Achievement of this target will be supported by health and nutrition pro- grams focussed on maternal and child care. The GOI objectives for the year 2000 also include raising life expectancy to at least 60 years and to reducing the infant mortality rate to 45/1000, and reducing the protein- calorie malnutrition in the under-five age group to 10%. To achieve these targets, the GOI has shifted the focus of its health policies and programs from further expansion of the health network to improving service utiliza- tion and effectiveness. To facilitate implementation of such policies, responsibility for planning and implementing health programs is progressive- ly being shifted to the provinces. To this end, GOI is building up planning and technical capacity at the provincial and district levels.

1.05 The international donor community has responded favorably to these policies. The USAID, for instance, is assisting the GOI with the develop- ment of a comprehensive health improvement program in three provinces: Aceh, Nusa Tenggara and West Sumatra. The proposed Bank project will cover three other provinces: Central, Southeast and South Sulawesi which, as primary receiving areas for transmigration and because of their potential for agri- culture, are being given high priority for development. The proposed project will focus on four main areas: (i) development of an effective referral system to support outreach activities; (ii) health manpower development; (iii) malaria control; and (iv) strengthening the institutional capacity of the provincial and district health administrations. The project was identified, prepared and will be implemented by the respective Provincial Health Administrations, with policy guidance from the central Ministry of Health (MOH). - 3 -

II. THE HEALTH SECTOR a/

A. Health Status

2.01 Demographic Profile. Indonesia is the fifth most populous country in the world, after China, India, the USSR and the USA. Preliminary analysis of the 1980 census put the total population at 147 million, up by about 28 million since 1971. The rate of population growth for the whole country between 1971 and 1980 was 2.3%. The rates of population growth, however, vary among regions (Annex 1, T-1). For example, Java has a lower growth rate (2.0%) than Sulawesi and Kalimantan (2.2% and 3.0%, respectively), while Sumatra has the highest rate (3.3%). If the present growth differentials are maintained, the population of the Other Islands will surpass that of Java- Bali within a few decades.

2.02 There is conclusive evidence that there has been a decline in the overall fertility rates in Indonesia, primarily in Java-Bali and in the urban areas. Recent estimates show a change in the birth rate from 43/1000 population in 1970 to 35/1000 in 1980. This decline is the combined result of a highly successful family planning program and socio-economic development.

2.03 Despite these encouraging developments, the present national crude birth rate of 35/1000 population is still high. The death rate is likely to decline sharply in the near future, with the possible consequence of a further increase in the present high rate of population growth if fertility reduction is not accelerated. This will have important implications for economic and social development programs. Recognizing these, the GOI has intensified efforts to accelerate the decline of fertility already achieved, particularly in the Other Islands where the fertility level is higher and where the prevalence of contraceptive use is lower than in Java-Bali. Family planning program targets aim at reducing the fertility rate by 50% from the 1971 level by 1990.

2.04 Although Indonesia as a whole is not densely populated, its popu- lation is very unevenly distributed among the different islands. In 1980, nearly two-thirds of the population was concentrated in Java-Bali (which has only 7% of the total land area), 19% in Sumatra, 8% in Sulawesi, 5% in Kalimantan, and 6% on the Other Islands of Eastern indonesia. According to the 1980 census, about 18% live in urban areas.

a/ Basic information on health conditions, programs and policies in Indonesia is provided by the Indonesia Health Sector Overview (2379-IND). The 1982 Country Economic Memorandum (3795-IND) also focusses on the health sector and stresses the importance of human resources development in the country. A draft report on the health manpower situation on Indonesia reviews the training and deployment of health personnel and identifies issues important for future planning. These documents are available in the Project File. - 4 -

2.05 Mortality and Morbidity. Available data, although incomplete, indicate that over the last decade, life expectancy has increased signifi- cantly and infant mortality has declined rapidly throughout Indonesia. Nevertheless, Indonesia still lags behind comparable countries. In 1980, life expectancy was 53 years compared to an average of 57 and 61 years in low and middle income countries, respectively.

2.06 The crude death rate (1980) is 12/1000 population, of which 39% is accounted for by children under five years. Maternal mortality, due principally to post partum hemorrhage, infection and toxemia, is also high at 3/1000 deliveries. (Since this figure is derived from data confined to mothers who deliver in hospitals, the actual rate may be higher.) Only 10% of pregnant mothers receive pre-natal care, and only 15% of deliveries are attended to by medical or paramedical personnel, or trained traditional birth attendants. Children are at a high risk of mortality from acute respiratory infections and gastroenteritis. Tetanus, pertussis, diphtheria, measles and polio, although preventable diseases, are also important causes of deaths of infants and small children. The four chief causes of death for all ages are acute lower respiratory infections, diarrheal diseases, cardiovascular diseases, and tuberculosis. Injuries and traffic accidents, are becoming major causes of death at all ages (Annex 1, T-3).

2.07 Significant rural, urban and inter-regional differentials exist in the levels of mortality. Nationwide, the expected life span at birth for urban residents is more than 10% greater than those for rural dwellers. Inter-regional variations in infant mortality rates are also great. For example, the infant mortality rate in the Eastern Islands in 1978 was 133/1000 live births compared to Jogjakarta (63/1000) and Jakarta (80/1000), where access to health services is better and where disease control programs such as malaria and other endemic diseases have been successful (Annex 1, T-4).

2.08 The disease pattern in the country has not changed significantly over the past decade (Annex 1, T-5). The most common diseases are infec- tions of the respiratory system, including tuberculosis. They are followed by skin infections, diarrhea and. childhood diseases against which immuniza- tion is available. In the Other Islands malaria remains the most serious disease. Dengue haemorrhagic fever is increasing.

2.09 Over the coming decade it will be necessary for the health sector to adapt to changing disease patterns associated with economic growth and improved social conditions. While childhood diseases of the infectious type will continue to prevail, there is clearly a tendency for diseases of aging, trauma and other non-communicable diseases to increase, with the changing age structure of the population., For example, the percentage of the popu- lation in the 0-4 years age group fell from 16% in 1971 to 14% in 1980. The number in the 5-9 age group exceeded the 0-4 group for the first time and the proportion in the 55 years and older age group increased to 8.2% from 6.2% during the same period. New health problems associated with urban living are beginning to appear; the emergence of cardiovascular and cerebro- vascular diseases has recently 'been noted. Its importance should not be underestimated, since the costs of treating chronic diseases and acute trauma are high and usually require hospital care. - 5 -

B. The Health Service System

2.10 In Indonesia, rural health services are provided through a network of health sub-centers, health centers and district hospitals. In addition, attempts have been made by the GOI to develop community-based services which use village health volunteers to provide elementary health care and nutrition services. Patients requiring more specialized care such as major operations, long-term care and rehabilitation, are referred to provincial and specialized hospitals, which are usually located in larger cities. The health services provided by these facilities are technically supported by a number of separately-financed national programs, such as the national programs for expanded immunization, control of diarrhea, malaria, leprosy and tuberculo- sis, and for nutrition education and most importantly, for family planning. All these programs are functionally integrated at the health center level. However, the administration of family planning activities is completely separated from the health service system. The functional relationship of the two systems is shown in Chart C-4 which indicates that while the health network extends to the sub-district level, the family planning system reaches the village level in Java and Bali and in pilot areas in the Other Islands. In addition, it has better logistic support, has an extensive network of field workers, and is well-organized and effective.l/

2.11 As of 1982 more than 10,000 primary health facilities are function- ing as health sub-centers including MCH clinics and polyclinics. A health sub-center is generally staffed by a full-time nurse auxiliary, and provides simple medical care, basic maternal-child health (MCH) care, routine vaccinations, nutrition and community health education. The GOI is providing for an additional 4,000 health sub-centers or about 4-5 health sub-centers per health center to be completed by 1984 under the INPRES Program (National Subsidy for Local Governments).

2.12 The principal source of comprehensive health services in rural areas are the health centers. Health centers provide basic medical care, maternal and child health services, family planning services, communicable disease control, hygiene and sanitation, nutrition, community health educa- tion and dental treatment, and are also responsible for disease reporting and surveillance. Health centers generally are not equipped for in-patient care. The MOH has initiated the provision of 10-bed wards for selected health centers located in isolated areas where there are no hospital facilities nearby. A full complement of staff for a health center consists of one physician, one nurse, one midwife, three auxiliary nurse/midwives, one sanitary inspector, one dental nurse (shared by three health centers), and one clerk. This level of staffing has not yet been attained in all the health centers. At least one health center has been established in each sub-district. They serve an average of 40,000 persons in Java, Madura and Bali, and 15,000-25,000 in the Other Islands, where population is more widely dispersed. The GOI target is one center per 30,000 population.

1/ A detailed description of the family planning program structure is discussed in the Staff Appraisal Reports for the three population projects (Reports Nos. PP8a-IND, 2323-IND, 2912-IND). - 6 -

2.13 Government and private hospitals function at the central, provin- cial and district levels. The district hospital serves as the main referral point for health centers and sub-centers. In addition, it is the primary source of care for those who live in the immediate vicinity, providing both in-patient and out-patient care. These front-line hospitals fall into two main categories: facilities with 30-50 beds (Class D), and facilities with 50-100 beds (Class C). Class D hospitals are staffed by one or two physicians. Class C hospitals are staffed by three to four physicians and generally serve large catchment areas.

2.14 District hospitals play an important role in supporting the primary health care system since they shape the public and professional image of the health system and largely determine the credibility of the primary care providers. They provide continuing care to patients whom health centers and sub-centers are not equipped or not capable of treating, including compli- cated deliveries, accidents, pediatric emergencies, and general surgery.

2.15 In response to a growing awareness that clinic-based services need to be supplemented by outreach programs in order to meet basic health needs, particularly in rural areas, the GOI is presently focussing attention on more community-based programs. This emphasis has resulted in the formulation of the Village Community Health Development Program (PKMD), in which volunteer village primary health care workers are trained to respond to the basic health needs of the villages under the technical supervision of a primary health care nurse based at the health center. Primary emphasis of PKMD activities is placed on motivation and education on health of the community and of the local community leaders.

2.16 After completion of some limited training, the village health volunteer is expected to perform, on a part-time basis, simple preventive and curative tasks to improve standards of health at the village level and organize a most basic village health insurance scheme. The health volunteers are involved in this scheme through collection and management of contribu- tions (in cash or kind) from families for the purchase of drugs. The health volunteers provide early therapy for diarrhea, cough, fever, ear and skin infections, family planning and nutrition education and referral of the more severely sick to the health centers for proper diagnosis and care.

2.17 During Repelita III (1979-1984), MOH aims to train approximately 100,000 village health volunteers from 5,000 villages covering all provinces. It was estimated that this program would reach a total of about 6% of the population by 1984. By the end of 1982, about 30,600 volunteers are reported by MOH to have been trained. However, the drop-out rate of volunteers is high (about 60 - 80%).

2.18 Health Manpower. Public sector health workers are classified as follows: (a) physicians, dentists and pharmacists; (b) paramedical staff, including community health nurses, specialized nurses, assistant pharmacists, X-ray, laboratory and other technical personnel; and (c) auxiliary person- nel. Estimates of the number of public sector health workers range from 92,000 to 116,000. In addition, there are an estimated 30,000 auxiliary workers paid on an honorarium basis and about 20,000 health workers in the private sector. In 1977, 24 categories of nursing training were consolidated into two categories: community health nurse and graduate nurse. About 47,000 of the 79,000 registered traditional birth attendants were trained by - 7 -

the end of Repelita II, and approximately 5,000 of them are currently being trained each year. In addition, medical graduates were compulsorily assigned to rural areas.

2.19 Although the GOI almost doubled its health personnel during Repelita II (1974-79), the ratio of health manpower tQ population is low. For example, recent estimates put the number of Indonesian doctors at one per 13,670 population. By contrast, Philippines has one doctor per 2,800; India, one per 3,630; and Thailand, one per 8,220. Medical personnel are also unevenLy distributed, being excessively concentrated in large urban centers. There is an acute shortage of technical personnel, particularly laboratory and X-ray technicians and specialized nurses. There are still too few community health nurses beirg trained. With the increasing awareness of the need for health care, there will be an increased demand for more and improved health service. These foreseeable requirements make it imperative to intensify the training or retraining of health staff.l/

2.20 Because of its previous emphasis on increasing the number of health workers to staff an increasing number of health centers and sub-centers, and because of financial constraints, it was only recently that the MOH focussed on the upgrading of staff skills through in-service training. To date, the MOH has established three in-service training centers for the whole country. Since these centers were insufficient to meet in-service training require- ments, various MOH directorates have introduced brief, ad hoc courses given without the benefit of appropriate training facilities or staff.

2.21 In order to address these manpower problems, at the end of Repelita II, MOH embarked upon a number of operational activities including: (i) the preparation of short and long-term plans for recruiting and training primary care nurses and technical staff; (ii) the establishment of provincial centers for in-service training; and (iii) the improvement of the management of health manpower. At the same time, it intensified ongoing training activities for physicians and nurses in specialized fields such as obstetrics and gynecology, surgery, pediatrics and internal medicine.

2.22 Health Administration. At the central level is MOH which sets national policies, priorities and programs in the health sector. It is headed by a Minister responsible to the President. As can be seen from Chart C-1,the heads of division of the MOH and the chief health officer in each province are directly responsible to the Minister. The chief offices of MOH are: (a) the Secretary General, who is responsible for planning, personnel, finance, supply, health legislation, public relations and general affairs; (b) the Director General for Community Health, who is responsible for health education, MCH, family planning, nutrition and health centers; (c) the Director General for Medical Care, who is responsible for hospitals, health laboratories, dental and mental health; and (d) the Director General for Communicable Disease Control, who is responsible for epidemiological surveillance and quarantine, the control of communicable and vector borne diseases and hygiene and sanitation, including rural water supply. In

1/ The Bank is presently considering a GOI request for assistance in developing a health manpower project focussing on formal training of selected health personnel. - 8 -

addition, there is a Director General for Food and Drug Control, and two associated institutes: the Center for Education and Training, which is responsible for all non-degree health training, and the Institute of Health Research and Development.

2.23 At the provincial level, the MOH shares responsibility with the provincial government (which is answerable to the Ministry of Home Affairs (MHA)) for administering public health services. Coordination is secured by the appointment of a Provincial Health Officer with dual functions. He reports to the Minister of Health on technical matters and issues relating to national health policies, and to the Governor on the administration of the health services. The provincial health administration is responsible for the technical supervision of provincial and district hospitals, health centers and sub-centers, the in-service training of health personnel, and the execu- tion of endemic/epidemic disease control and sanitation programs.

2.24 The health administration in each district is headed by a district medical officer who also has dual functions. He reports to the Provincial Health Officer on technical matters and to the head of the district on admin- istrative matters. The district health administration plays an important role in primary health care, since it supervises the district health network and organizes distribution of drug supplies. It is also responsible for the execution of malaria and other disease control programs, sanitation, and community health education.

C. Health Expenditure and Its Financing

2.25 Health Expenditures. Total expenditures for the health sector in 1981 were estimated at about Rp. 1,306 billion (US$1.98 billion), of which about 60% was in the private sector and 40% in the public sector. There has been a shift in recent years in health expenditure patterns, with the private sector accounting for an increasing proportion of total expenditures. (In 1976, they accounted for only 45% of total expenditures.) This shift is partly due to the fact that the quality of care in the public health sector is considered inadequate, leading patients to have increasing recourse to the private sector. It is also partly, due to the rising cost of private sector health care. For instance, the average estimated cost of a private hospital bed rose from Rp. 1,000 per day in 1976 to Rp. 10,000 in 1980. The continua- tion of this trend will place the cost of private health care beyond the reach of an increasing number of Indonesians.

2.26 The 1981 MOH budget shows the following breakdown by category of expenditure: construction, 25% of the total; materials and drugs, 25%; personnel, 20%; equipment, 17%; a,nd others, including maintenance and super- vision, 13%. By type of program, about 66% of the total budget was allocated for health services, mostly to rural areas; 10% for communicable disease control; 6% for health manpower development; and the remainder for other pro- gram activities such as control of foods and drugs, research, water supply, and environmental sanitation (Annex 1, T-6). This allocation reflects GOT policies and priorities within the sector. -9-

2.27 In 1976, public expenditures on health were equivalent to about 0.7% of gross domestic product (GDP). Since that time, the percentage has risen to almost 1%. Despite this increase, the budgetary priority given to health remains inadequate; the sector receives approximately 3% of total Government expenditure, which is low. On a per capita basis, this amounts to $4.0, well below the requirements.

2.28 Sources of Financing. Public health sector financing is provided by three major sources: (i) public funds; (ii) health insurance; and (iii) patient fees. Public funds provide about 90% of total financing. Of these, 93% are channelled through the central government budgets of various minis- tries and INPRES while the remainder comes from the provincial and district governments. Out of the central government budgets, the central MOH budget accounted for 37%; the remainder comes from the budgets of the Ministries of Education, Home Affairs, Defense and the National Family Planning Coordinating Board (NFPCB). Since Repelita II, INPRES funds have increasing- ly become a major source of funding, accounting, on an average, for 54% of investment resources in health. The combined total allocation of the central MOH budget and INPRES has increased ten-fold in current price terms (from Rp. 25 billion in 1974/75 to Rp. 249 billion in 1981/82) representing a real increase of over 200%, or an average annual real growth rate of about 16%. This substantial increase reflects the low allocation to health at the begin- ning of Repelita II (Annex 1, T-7). Foreign assistance in 1980 amounted to about 20% of the central MOH development budget.

2.29 The government employees health insurance scheme (ASKES) is the second largest source of financing. Its budget for 1980/81 was Rp. 26 billion; the bulk of its funds were allocated for health services. ASKES is financed by an automatic 5% deduction from civil service salaries and a matching payment by the GOI. Current membership is about 2 million, and the population covered is about 12 million. ASKES pays for the costs of all out-patient and in-patient health care service provided by the private and public systems.

2.30 The government receives fees for most services provided by health facilities. The exceptions are free treatment of certain communicable diseases and free vaccination against childhood diseases. Otherwise, patients pay according to a scale of charges, which is, in principle, stand- ardized for all medical units (with variation by classes of accommodation for in-patient treatment). Generally, fees are low. Out-patient fees of Rp. 150 (US$0.23) ensures treatment and drugs for three days, with a smaller fee charged for additional follow-up treatment. Hospital accommodation costs range from Rp. 200 per day to Rp. 1,200 depending upon the type of accommoda- tion. The reported income from health facilities in 1980/81 was estimated at only Rp. 5.2 billion. This income was derived from MOH central hospitals (96%), health centers (2%), and drugs (2%). Fees constitute an important contribution to the district revenues, and their channelling back into the health system remains an important issue. - 10 -

2.31 Budgetary System. The present system of financing health is complex, stemming from the three-tier administration in Indonesia, i.e. the central, provincial and district governments, each budgetting for health. Each entity has its own budget for recurrent expenses (referred to as routine budget) and for capital investments (referred to as development budget). However, a clear distinction between investment and operating expenses is not possible since the development budgets and the INPRES funds include major recurrent expenditure items. At each level there is funding from more than one source. For instance, in a health center, ancillary staff are paid by the district budget while most nursing staff are paid by MOH. In addition, nearly all workers receive incentives from either the central development budget of MOH, NFPCP, or the provincial development budget. Some health center staff receive no salaries, but only incentives and honoraria from the district budgets and other sources. The district medical officers receive salaries from MOH and incentives from various other sources including ASKES. Basic drugs are provided by the District Health Office out of INPRES funds. In addition, the district administration also purchases drugs for local health facilities and rehydration drugs for cholera are funded by central MOH. The complexity of the funding process is further compounded by lack of data at the provincial and the local levels and results in inadequate control. Under these circumstances, wastage and inefficiencies in operations can be expected.

III. HEALTH SECTOR POLICIES AND PERFORMANCE

A. Health Policies

3.01 MOH has identified long-term objectives for the health system which sets specific quality of life targets for the year 2000. These targets include: (a) the increase of average life expectancy to at least 60 years; and'(b) the reduction of (i) infant mortality to 45 per 1,000 live births; (ii) the proportion of underweight babies from 14% to 7%; (iii) annual inci- dence of diarrheal morbidity from 400 to 200 per 1,000; (iv) malaria incidence in areas with a high prevalence to 25% of the 1980 level; (v) the prevalence of tuberculosis from 4 to 2 per 1,000; (vi) mortality from neonatal tetanus from 11 to 1 per 1,000 births; and (vii) protein calorie malnutrition in the under-five age group from 30% to 10%. To achieve these goals MOH has set a few specific operational targets, including: (i) increasing the proportion of fully immunized children under 14 from 40% to 80%; and (ii) increasing the proportion of supervised deliveries from 40% to 80%.

3.02 The major health strategies being adopted by the GOI under Repelita III include: (i) improvement in the coverage, quality and utilization in health services; (ii) strengthening of the referral system through improvement of the functions of health centers and rehabilitation of district hospitals; (iii) manpower development, particularly the retraining and upgrading of existing health manpower; (iv) development of village primary health care as a way to increase community participation; and (v) expansion of communicable disease control programs to the Other Islands. These strate- gies are accompanied by efforts lto improve education, nutrition, population control, hygiene, and safe water supply as these interventions have synergis- tic effects on health status. - 11 -

3.03 The MOH has identified programs under Repelita III to achieve the health sector objectives, the planning and implementation of which will be decentralized to take into account the variety of conditions and needs from one region to another. The two major programs identified are health services development (for which about 65% of program budget is allocated) and communi- cable disease control (12%). The other program areas include: improvement of nutrition status; provision of safe water supply; health manpower develop- ment; food and drug control; improvement of physical health facilities, such as office buildings, and staff housing; improvement of the efficiency of public administration; and development of appropriate technologies for health. In family planning, the program will be extended to all regions wit' increased community participation. Information and education activities on population problems will be increased and will be addressed particularly to the younger generation.

3.04 Under health service development, the coverage and quality of health services available from health centers, sub-centers, hospitals and other facilities will be improved. Emphasis will be placed on developing a functional and efficient system for storing, distributing and controlling basic drugs for use in health clinics. The referral system will be strengthened through upgrading of hospital equipment, facilities, management and administration. Retraining and upgrading of existing health manpower will be pursued through expanded in-service training. Community participation in health activities will be promoted and systematic measures will be taken to control non-communicable diseases. The communicable disease control program (particularly for malaria) will be expanded to the Other Islands.

B. Sector Performance

3.05 During Repelita I (1969-1974), the GOI assigned relatively low priority to health and the other social sectors. The MOH focussed its limited resources (about 2% of the total national budget) on health education and the prevention of epidemics. The construction and renovation of hospitals was kept to a minimum and limited to the provincial level. A shortage of trained health manpower prevented the rapid establishment of rural health services. Little progress was made in improving rural water supplies and sanitation.

3.06 During Repelita II (1974-79), remarkable progress was made in the expansion of primary health care infrastructure and manpower. The total number of health centers rose from 1,058 at the beginning of Repelita I to 5,150 at the end of 1981 and every sub-district was assured of having at least one health center. Financial barriers to health service utilization were effectively removed in 1979 by lowering the health center consultation fee from Rp. 450 to Rp. 150 (or from $0.68 to $0.23). The efforts required to develop the health center infrastructure constrained the financial and manpower resources available to expand and strengthen the disease control and immunization programs in the Other Islands. - 12 -

3.07 The development of health manpower has parallelled the pace and direction of infrastructure growth. The period 1974-79 witnessed a doubling of health personnel and substantial progress in training of medical and para- medical personnel, including tradiLtional birth attendants. The expansion of the primary health care network during this period resulted in a sharp increase in the demand for nurses which was largely met by an increase of 109% in the output of nurses. Emphasis has also been given to improving the quality of training and rationalizing the numerous categories of paramedical workers. Initiatives were also made during Repelita II and continued under the present plan to decentralize M4OH administration to develop its capacity for providing technical advice and supervision.

C. Health Sector Issues

3.08 The basic question concerning the future directions for the health sector is also faced in other soclal sectors, such as education -- whether priority should be given to further service expansion at the primary level or to improvements in quality of care and utilization of existing facilities to increase their effectiveness. The GOI decision is to accord a higher priority to the latter since the basic health infrastructure is already in place. The major issues facing the GOI in increasing the effectiveness of health services include: low utiLization of health services; ineffectiveness of the referral system; inadequacies in health service management; lack of outreach activities; inadequate financing; and complexity of the financial system. These issues have important implications for future investments in the sector and the GOI is addressing them presently.

3.09 Utilization of Health Services. While basic health infrastructure is now in place throughout the country, its effectiveness in delivering health care services remains limited. The health centers do not always provide the intended services and they are generally under-utilized. The out-patient load generally ranges from 14 to 63 persons per day. Apparently about 26% of the population who are ill do not seek assistance at all and, of those who do, only about 50% use health centers and hospitals, while the rest use traditional methods or private care (Annex 1, T-8). Maternal and child health services provided by the health center reach less than 42% of babies born, and less than 11% of under-fives. The results of the 1980 Household Survey and the 1976 Health Center Utilization Study revealed that the low quality of health care is the single most important reason cited for non- utilization of services. The under-utilization is due in large part to a low confidence in the public health services, which in turn, is attributed to the poor quality of health care provided at the health centers and sub-centers; popular preference, particularly among the rural population, for traditional healing methods; and the failure of the rural hospitals to support the primary level by providing adequate care to referred patients. The latter problem results from the GOI's former policy, imposed by financial constraints of building up the primary level without parallel improvements at the support and referral levels. In addition, inadequate management and supervision and the absence of an effective monitoring and evaluation system contribute to the problem of underutilization.

3.10 Referral System. In improving the utilization of services, it is essential to set up means of referring and channeling to the most appropriate level of care complex cases or problems that are identified but not treated - 13 -

at the primary level. Such referrals lead to continuity in care that guaran- tees the effectiveness of the overall health system. However, because of the deterioration in the physical condition and effectiveness of the district hospitals, patients are bypassing the understaffed, under-equipped, dilapi- dated district hospitals for provincial or private hospitals and are not seeking medical care until conditions warrant hospitalization. The situation is worse in the Other Islands, where the population is more dispersed, the private hospital network less dense and therefore, less accessible and where lower income levels mean that poor households cannot afford private care.

3.11 Many of the district hospitals were constructed in the 1920's. Most suffer from poor maintenance and many of them have become dilapidated, particularly in the Other Islands. Despite efforts in Repelita II, many dis- trict hospitals still do not meet minimal standards for a referral center. The hospital facilities are often in such poor condition that, in practice, they can only function as a large health center. Consequently, referrals between the health centers and district hospitals are rare. Many of them face structural deficiencies, lacking the most elementary surgical and mater- nity services and laboratory and X-ray units. In addition many suffer from functional deficiencies, including: inadequate supplies of drugs, less than the required specialist manpower, obsolete equipment, and inefficient manage- ment. Most hospitals are run by personnel without any administrative train- ing.

3.12 The GOI, recognizing the urgency of remedying these deficiencies, has recently embarked on a hospital rehabilitation program. To deal with the most urgent needs, a Rp. 50 billion crash program was initiated for equipping hospitals during the three-year period (1981/82-1983/84) with new X-ray, laboratory and surgical equipment. Arrangements have also been made for medical specialists from provincial hospitals to make regular visits to district hospitals. The GOI realizes, however, that a more comprehensive approach including not only improvements in physical infrastructure and equipment but also the upgrading of the skills of health staff, improved drug supply and better management and maintenance, is required if the district hospitals are to perform the referral role expected of them.

3.13 Health Service Management. Over the last years inadequacies in the management of the health sector have become a major concern to the GOI. The rapid pace of service expansion in general and the introduction of lower level auxilliary-based health care (which tends to be administration- intensive) in particular, has placed severe strains on the management of the system to the extent that it has now become a major constraint to future pro- gress. Three principal problems can be identified. First, the key managers of the primary health care system, the district medical officers, are often not prepared for management or administration, including the inttoduction of new health programs. Second, the management of activities to support the primary health care system such as in-service training, management and information system, and technical and administrative supervision, is very weak, particularly at the district level. The rapid growth in health man- power has resulted in some sacrifice in quality. Training facilities are - 14 -

still inadequate to cope with an increasing demand and need for in-service training, particularly for management. Third, partly due to these weaknesses in provincial management, decision-making and control tends to be highly centralized in Jakarta, leading to delays and other inefficiencies.

3.14 Notwithstanding its important role in primary health care, the district health administration has been neglected in the overall development of the health sector. It has received inadequate support in terms of train- ing and administrative guidance and, consequently, its capability for health care planning, management, supervision, information gathering, monitoring and evaluation is limited. In addition, the physical facilities assigned to them are inadequate: their present offices, usually located in hospitals, are in many cases small, overcrowded, and often dispersed in several buildings, with a consequent serious loss of administrative efficiency. Furthermore, their supervision of health center and sub-centers staff is constrained by lack of transport.

3.15 Drug Supply and Distribution. The supply of drugs has improved markedly since Repelita II. (About 90% of the basic drugs are now being produced in the country). While the production of drugs is not a major prob- lem, the distribution and storage procedures in the public sector are inadequate. In some districts, existing facilities for storing drugs are deficient leading to premature deterioration due to heat and moisture. In many districts, there are neither drug storage facilities nor an inventory system to guarantee a regular supply of essential drugs. In these cases, the drug supply for the whole year is delivered directly to the district hospi- tals and health centers where the conditions for drug storage are even worse leading to even greater waste and deterioration in the quality of drugs.

3.16 Outreach. The evolution of the outreach program (PKMD) in Indonesia showed mixed results. The program was found to have had positive results in some of the pilot villages; a study conducted by UNICEF in 1980 suggested, for example, that some villages with PKMD show a decreasing number of severe cases of gastroenteritis. However, the evaluation of PKMD also suggested that its successful replication will be dependent upon a degree of community involvement, political commitment and intersectoral coordination which may not be found or feasible. The likelihood of success of the volunteer-based system is further complicated by their need to work alongside paid family planning, nutrition and community development workers. The sup- ply of support materials has been erratic and a very high drop-out rate among the health volunteers has been observed. The PKMD effort has also suffered greatly from lack of support from the highest levels of government. The speed of its further expansion will consequently depend upon the resolution of these issues. GOI is aware of this and, with the assistance of UNICEF, is presently addressing them.

3.17 In view of its potential in improving access to and utilization of health services, there is a need not only to plan for the systematic improve- ment of the program, but to develop program alternatives as well. For example, the utilization of family planning fieldworkers for the delivery of selected health services at the village level appears to be potentially a fruitful area for further examination. In addition, GOI should review the need for integrating health activities into the program of motivators in - 15 -

other development sectors (for example, nutrition workers and women's groups) as part of an overall program emphasis on decentralizing responsibilities to the community.

3.18 Financial System. The present complex system of finance places an unnecessary burden on health care administrators, and this is likely to increase as the health system utilization increases. In view of the weak financial basis of regional and local authorities, it has been necessary for the Central Government to provide funds for recurrent as well as capital expenditures. A multiplicity of budgets exists at all levels of central and local Government and any particular item of expenditure may be financed from several sources; indeed, it is seldom that a program or activity is financed entirely from one source or even from one level of Government. Such a system tends to have three disadvantages: it strains the administrative capacity at the local level; it encourages waste by reducing accountability; and it hinders effective management. The lack of correspondence between specific functions and specific budgets makes it very difficult for managers to reallocate funds when needed. This is because each manager controls only part of the resources required for each activity. Nobody, therefore, has the authority to plan or manage the system as a whole. The GOI is aware of these problems and is exploring ways for improving the linkage between managerial and financial responsibilities. Specifically, it is planned that, as the provincial and district revenue bases are strengthened, and as the quality of financial management at the local level is gradually improved, the local governments will take over increasing responsibility for financing basic recurrent expenditures. The Bank is pursuing studies on these matters in the context of its sector work.

D. The Bank Role

3.19 The Bank Group's direct lending for health in Indonesia has hither- to been confined to health components in agriculture, nutrition, population, rural development and urban projects. These components include the construction of health centers and the training of nurses, midwives and traditional birth attendants. The total amount of Bank financing committed to these components is $26.0 million.

3.20 The Bank has also helped finance three population projects, starting with an IDA credit of $13.2 million in 1972 for the first population project and loans of $24.5 million in 1975 and $35 million in 1980 for the second and third population projects, respectively. The third population project includes a health component (US$13.1 million, or 18% of total project cost) which aims to strengthen maternal and child health services through the upgrading of health centers, and training of health center doctors, nurses, midwives, and traditional birth attendants. In addition, support of a nutrition project was provided in 1977 through a loan of US$13 million.

3.21 The first population project has now been completed and implementa- tion of the second population and nutrition projects is nearing completion. The problems encountered in these projects appear to relate to two major factors: (a) GOIT'scumbersome budgetary and administrative procedures, - 16 -

delays in acquisition of sites, issue of tender documents and appointment of key staff and consultants; and (b) inadequate local participation in planning the projects.

3.22 Experience gained from these projects was taken into account in designing the proposed provincial health project. Firstly, the project has modest but achievable objectives involving a single implementing agency. Second, unlike other projects which were designed and implemented at the central level, the project has been prepared and will be implemented at the provincial level ensuring it of a strong local constituency. Third, separate project budgets for each province will be provided which will facilitate the allocation and the flow of funds ior project activities. Fourth, key project staff have already been appointed and funds for the first year activities have already been included in the FY83 budget to facilitate a timely start to project implementation. Fifth, implementation arrangements have been agreed upon at all levels of the Government -- a meeting to discuss project implementation has already taken place at which representatives from central MOH, Provincial Health Administraltions,the Provincial Planning Boards (BAPPEDA), and Provincial Public W4orks Departments were represented; and sites for civil works have been identified and their acquisition is underway.

IV. THE PROJECT AREA 1/

4.01 Sulawesi, which forms part of Eastern Indonesia, is one of the four largest islands of the country. It is predominantly agricultural and had a total population of 10.4 million in 1980, about 80% of whom live in rural areas. Like the rest of the country, it has a comparatively high rate of population growth, estimated at 2.2% per year (ranging from 1.7% in South Sulawesi to 3.9% in Central Sulawesi) during the 1971-80 period. The Island consists of four provinces: Central, North, South and Southeast Sulawesi, of which North Sulawesi is the most developed. The project area, which consists of Central, Southeast and South Sulawesi, comprises the three less developed provinces that are also the primary receiving transmigration areas in Eastern Indonesia. It covers about 80% (or 8.3 million) of Sulawesi's total population.

4.02 Of the three provinces, South Sulawesi has the highest income per capita (but only 70% of the national average) and the best roads and communi- cations. Its capital, Ujung Pandang, is the major growth center in Eastern Indonesia. In contrast, Central and Southeast Sulawesi are two of the least developed provinces in the country; people live mostly in scattered villages; the road network is limited; electricity is available only in the larger towns; and public transportation, although improving, is still inadequate. However, because these two provinces have considerable untapped land and water resources and other factors favorable to large scale settlement and agricultural development, they have been selected as primary transmigration receiving areas.

1/ The characteristics of the project area are treated in more detail in a separate Health Sector background paper for Sulawesi available in the Project File. - 17 -

4.03 Disease Pattern. The disease pattern in the project area is similar to that in the country as a whole (para. 2.08) except for malaria which is the most important single disease. The annual incidence of malaria reaches 300-400 per 1000 population in specific areas in Central and South Sulawesi (compared with 1.4/1000 in Java-Bali). In 1980, Central Sulawesi had the highest slide positivity rate: 25% in contrast to 11.4% and 1.9% for the Other Islands as a whole and for Java-Bali, respectively (Annex 1, T-9). It is estimated that 6.6 million, or 80% of the project area's population reside in malarial areas, and approximately 2.7 million of them in high risk or hyper-endemic areas. The disease is especially devastating in transmigra- tion areas, as new migrants, particularly from Java-Bali, have no immunity to the disease. Morbidity due to malaria among transmigrants, for instance, has ranged as high as 750/1000 and epidemic case fatality up to 150/1000. The most recent epidemic (1981) in Toili, Central Sulawesi, claimed about 160 lives. South Sulawesi, Timur-Timur, and the transmigration areas of Central and Southeast Sulawesi, are the target areas for expansion of the national malaria program.

4.04 Malaria infections are caused by Plasmodium vivax, P. falciparum, and P. malariae. P. falciparum has the most severe clinical effects and the greatest potential for fatalities. There are indications that strains of P. falciparum have developed resistance to chloroquine. Although this drug resistance problem appears to be confined to a limited area, it will never- theless require continuous surveillance. The fight against malaria in the Other Islands requires long-term and continuous commitment, in view of the difficulties posed by the variety of geographic conditions, the size and mobility of the population, the difficulty of access to villages, and the tropical climate that fosters parasites.

4.05 Health Care Services. As in the rest of the country, rural health services in the project area are provided through a network of health sub- centers, health centers and district hospitals. In 1981, the project area had over 760 health sub-centers, about 390 health centers and 65 hospitals with a total bed capacity of about 4,800. The health center and sub-centers have actual coverage ratios of about 12,000 population per health center and about 3,700 population per sub-center, which compare favorably with the national norms of 15,000 and 4,000, respectively. Because of the dispersed pattern of villages, however, particularly in Central and Southeast Sulawesi, services have not reached all areas. Consequently, GOI is presently constructing an additional 250 sub-centers in remote areas. The ratio of population per hospital bed (1:1,744) is high when compared to the other well-served regions in the country (e.g. Java, 1:943; Kalimantan, 1:1,140, and Maluku, 1:1,308). Furthermore, the distribution of the hospitals within the provinces is uneven. In South Sulawesi, for instance, 40% of the hospitals are located in Ujung Pandang while the rest are distributed among the other 20 districts. There are over 600 physicians in the project area (or approximately 4 physicians per 10,000 population). About one-third of these, however, work in the medical school in Ujung Pandang. Over 3,000 nursing personnel (nurses, auxiliaries and midwives) are employed in the project area; most of them, however, need additional training in compre- hensive health care delivery. - 18 -

4.06 Family Planning. The national family planning program operates in the project area and the health center network serves as the basic outlet for these services. The family planning program in the project area is better supplied with physical infrastructure, vehicles, materials and funds for operating costs than the health care system and there are 600 village contra- ceptive distribution centers in the project area. Services are provided in rural areas as part of general MCH services in the health centers and sub- centers. Family planning services are also provided in the hospitals through their post-partum program. Community leaders and village officials are responsible for recruitment of acceptors and distribution of contraceptives at the village level. Targets for acceptors have been consistently sur- passed; South Sulawesi, where the program was introduced in 1975, has the highest proportion of current users in the Other Islands (35% of eligible couples compared to 19.6% average in the Other Islands and to the national average of 36%). However, further expansion requires an effective health center system. To date, only about 8% and 10% of the eligible couples in Central and Southeast Sulawesi, respectively, are practicing family planning; this proportion is expected to increase with the expansion of the program in these provinces.

4.07 Health Related Programs. There are other ongoing and planned acti- vities in the health and other related sectors in the project area which aim to improve the health status of the population. Several of these activities are supported by multilateral and bilateral donor agencies, including the Asian Development Bank, the Canadian International Development Assistance (CIDA), UNDP, UNICEF, USAID, WHO, and the World Bank Group. They include improvements in the water supply and sanitation facilities in the provinces; provision of MCH/family planning services; improvements in the nutritional status of mothers and children; expansion of immunization and communicable disease control programs; and the training of health personnel, village-level health and nutrition workers. In addition, the GOI has rapidly increased funding of social services in rural areas through the INPRES program. This support has helped to raise the proportion of rural population with access to safe water to from 8 to 15%. It is the GOI's plan to significantly accelerate water supply development with a target of supplying 35% of the rural population with safe water by 1984.

4.08 Key Constraints. The problems relating to the health sector in the project area reflect the nationa:Lproblems (paras. 3.08-3.18) -- underutili- zation of facilities, inadequate referrals, poor management and lack of outreach. These problems are accentuated by features of the project area, particularly the dispersed settlements pattern and many remote and isolated islands.

4.09 The utilization of hea:Lthcenters and sub-centers in the project area varies between 10-60 patients a day, thus differing little from national patterns. However, in certain areas of Central and South Sulawesi, particu- larly the island districts, Muna, Buton and Banggai, cultural practices and beliefs constitute a considerable barrier to utilization. However, popular perceptions are gradually changing as a study on the marketing and consump- tion of traditional drugs in 1978 showed. Primary health facilities are now generally within reach of the population. The 1980 household survey indicated that distance was no longer reported as a problem. - 19 -

4.10 The development of outreach in the project area shows mixed results. Central Sulawesi has operated a PKMD program since 1975 and has so far trained about 980 volunteers. This program was assisted by CIDA and a recent evaluation showed that of the volunteers trained, only 60 remain active. The national PKMD program has been expanded to South and Central Sulawesi, but information on the number of villages covered and manpower trained is not available. The outreach programs suffer from a lack of continuous support, transport and supervision. Furthermore, the relationship of the new NFPCB village contraceptive distribution workers to the other village health workers raises issues which need to be resolved.

4.11 While health center personnel are in place throughout the area, the staff need in-service training to maintain and upgrade their skills. Many nurses were trained 5-10 years ago with a clinical orientation and few have since received training due to lack of facilities and funds. NFPCB has well functioning provincial in-service training facilities and programs in two of the provinces, but the provincial health administrations have no comparable faciliLies. Recognizing the urgent need for training, the provinces have recently organized short ad hoc in-service courses in various borrowed premises. These courses, however, are too few and fall short of technical requirements.

4.12 The district referral system of about 30 hospitals supports the network of about 1,000 primary health facilities. The hospitals, however, are in very poor condition and often cannot provide even minimal in-patient services. The operating standards of many hospitals are well below those in Java and Bali. This is reflected in wide variations in bed occupancy rate ranging from 15% to 70%. Hospitals which provide effective services, even if located in remote areas, are heavily utilized (i.e. Luwuk, with a bed occupancy rate of 70%). On the other hand, hospitals providing poor services are by-passed, negating the intentions of the referral process on which the credibility of the primary health care concept is based.

4.13 As elsewhere in Indonesia, poor district level management contributes to ineffective service delivery. In Sulawesi, district level health managers have not been trained and furthermore, 60% of the district health officers lack any office accommodation. There are no drug storage facilities and health center drugs are often stored in the district hospitals where they are used for hospital patients rather than being distributed to health centers.

V. THE PROJECT

A. Project Objectives

5.01 The project aims to assist GOI in its effort to improve the health status of the population by increasing the effectiveness of health care, particularly in the rural areas, and by reducing the incidence of the major endemic disease, malaria. To achieve this, the project will help: - 20 -

(a) improve the quality and increase the utilization of health services through improvements in the health center, referral and outreach system, health manpower development, and strengthening of district level management; and

(b) extend and intensify malaria control.

The project also aims to strength!en the institutional capacity of the provin- cial and district health administrations in order to support GOI's policy of decentralizing health care planning and administration. The project was identified, prepared and will be implemented by the respective provincial health administrations with technical guidance and administrative support from the central MOH.

B. Project Composition

5.02 The project will provide for:

(a) Strengthening of the Referral System:

(i) The improvement of services in ten district hospitals in development and/or transmigration settlements with large service areas, through the replacement of existing physical facilities, the provision of equipment and vehicles, technical assistance and fellowships for hospital administration and maintenance.

(ii) The expansion in the scope and improvement in the quality of services in 15 health centers in isolated districts through the provision of in-patient facilities and additional medical equipment.

(b) Staff Training:

The establishment of a provincial training center for in-service training in each of the three provinces; each to be provided with equipment, materials, vehicles, and support for training expenses.

(c) Management and Administration:

(i) The strengthening of the administration of district health services by constructing, equipping and furnishing a health office in each of the 19 districts, each with drug storage facilities and vehicles; the setting up of a drug management system; the organization of management training courses for district medical officers; and the provision of consulting services for strengthening the existing health information system and for the study of health care finance. - 21 -

(ii) The provision of vehicles, office equipment, fellowships, and support for incremental operating costs for project implementation, including consulting services for monitoring and evaluation, and the preparation of a second Bank-assisted health project.

(d) Malaria Control:

The extension and strengthening of malaria control in South Sulawesi and in transmigration and other high priority areas in Central and Southeast Sulawesi by providing equipment, vehicles, insecticides and drugs, technical assistance and support for incremental operating costs.

(e) Technical Assistance and Studies:

The provision of about 228 man-months of consultant services to carry out studies and individual project components.

C. Detailed Features

5.03 Strengthening of the Referral System. A viable primary health care system with community health activities at the village level is not likely to be effective without strong referral and support systems. GOI has, therefore, emphasized the development of infrastructure and effective services as a precondition for the expansion of outreach activities. In line with these policies, GOI is starting to improve the quality and expand the scope of health services in the rural areas by developing a referral system to support the primary health care network. Selected health centers and district hospitals are being upgraded through the provision of equipment, facilities, trained manpower and strengthening of management and administration (para. 3.04). The Bank, under the Third Population Project (L1869-IND) is supporting these efforts by providing for the construction of in-patient facilities for about 50 health centers in the country (13 of which are in South Sulawesi) and for the training of primary health nurses, midwives and health center staff. Additional support to this program will be provided by the proposed project focussing on the upgrading of health centers, rural hospital rehabilitation, staff training, management and maintenance.

5.04 At the district level, the project will provide for the construc- tion and equipment of six Class D and four Class C hospitals to replace the existing dilapidated buildings, which are over 60 years old, and which would be uneconomical to renovate. The hospitals will conform to existing GOI design standards and equipment lists, which were reviewed by Bank staff and found adequate. The district hospitals to be replaced under the project have been selected, in agreement with the local and central governments, according to the following criteria: (i) poor physical condition; (ii) large service areas; (iii) proximity to transmigration areas; and (iv) location in priority development areas. The location of these hospitals is shown in Map 16439 and in Annex 1, T-10. - 22 -

5.05 Each Class C hospital will consist of about 5,000 m2 of floor space comprising of medical, surgical, obstetric and gynecological and pediatric wards, X-ray and laboratory facilities, and residential quarters for medical and nursing staff. Each hospital will have not more than 100 beds. The present staffing pattern, which is adequate, consists of three to four physicians and about 150-170 support staff who are in place. The professional qualifications of the general practitioners are considered acceptable. In addition, the GOl has a training program for medical specialists, and no difficulties are expected in recruiting them. Each hospital will also be provided with service vehicles.

5.06 Each Class D hospital will have a total floor area of about 3,500 m2 and will provide the same basic curative and preventive services as Class C hospitals, but will not provide specialist services. Each will have not more than 50 beds. Each hospital is staffed in accordance with current staffing patterns consisting of one or two general practitioners and about 80 support staff. The staffing patterns for these hospitals are shown in Annex 1, T-11. Operating costs for these hospitals are provided by GOI under its regular budgets.

5.07 The construction of these hospitals will be accompanied by improve- ments in two other critical areas -- management and equipment maintenance. The project will provide assistance in the design and conduct of a training course in hospital administration for hospital directors. The training course will be implemented with the assistance of consultants whose major tasks will be the following: (a) review present procedures for hospital administration; (b) design and conduct a training course for hospital administration, including the production of training materials; and (c) evaluate the course for nationaL replication. The consultants will work closely with a counterpart committee which the GOI has already established for this purpose. This activity is estimated to require 48 man-months of consultant services. In addition, ten fellowships to train district hospital administrators in modern hospital administration techniques will be provided.

5.08 In view of the critical importance of equipment maintenance, the project will also provide technical assistance for the expansion of the national hospital equipment maintenance network to Sulawesi. This study, which will require about six man-months of consultant services, will deter- mine (a) the maintenance needs based on an inventory of existing equipment; and (b) the appropriate number, location and staffing of maintenance work- shops, and prepare preliminary architectural drawings for these workshops.

5.09 It is estimated that the above facilities will provide access to improved hospital care for aboul: 3.4 million people. The facilities will also provide referral back-up support for the primary health care services delivered by about 500 health centers and sub-centers, including (a) easier access to laboratories, X-ray rooms, and other hospital-based services for patients referred by primary health workers, (b) maintenance and repair capability for primary care faciLlities,and (c) prompt response by hospital specialists and other hospital staff to the needs of primary care workers at the community level. Support would be extended to preventive and diagnostic aspects of care and would include consultation on problem cases. In addi- - 23 -

tion, since these hospitals are participating in the national hospital post- partum program, they will provide family planning services, including refer- ral support in respect of side effects and complications of pills and IUDs.

5.10 At the sub-district level, the project will include construction, furnishing and equipment of 10-bed annexes at 15 selected health centers in Central and Southeast Sulawesi. Such enlarged health centers will be able to care for high-risk pregnancies, deliveries, emergencies, and IUD insertion, in addition to the regular services provided by health centers (para. 2.12). Each of the health centers identified for upgrading is remote from a district hospital or other referral hospital, but accessible to surrounding health centers and health sub-centers for which referral and support services will be provided.

5.11 Each in-patient annex will comprise a 10-bed ward, a small operating room, a recovery room, a nurses' station, a delivery room, a storeroom, and staff housing. The equipment to be provided will include beds with accessories, and nursing and surgical equipment. Each 10-bed annex will require additional staff comprising one midwife, two primary health nurses, one clerk and one night watchman. The total staff of an enlarged health center will then comprise: one doctor, three nurses, two midwives, one sanitarian, three auxiliary nurses/midwives, a dental nurse shared among three health centers, two clerks, and one night watchman.

5.12 Since each sub-district in the project area now has a health center and the GOI is presently constructing 250 more sub-centers, no additional facilities will be constructed at the sub-district level under the project. Assurances were obtained during negotiations that by December 1984 the GOI will review trends in the utilization of health centers and make recommendations for improving them, and that it will have also reviewed the performance of PKMD, particularly its impact on utilization of services, to plan for the expansion of PKMD or an alternative program for improving outreach (para. 3.17).

5.13 Staff Training. The technical knowledge and skills of health personnel must be kept up to date if the quality of primary and secondary health care is to be improved. Many staff who were trained 10-15 years ago to provide essentially curative services must now be upgraded and reoriented towards a community-based system. The GOI relies on the provincial health services to provide in-service training of provincial and district health personnel. However, the provinces have not been equipped to handle this, and training has been conducted in borrowed or rented premises or improvised rooms and there has been no full-time training. The present in-service training is therefore ad hoc, irregular, and limited to immediate needs; it is not geared to operational requirements and the needs of an expanding community-based system.

5.14 The MOH has started to expand and improve the quality of in-service training (para. 2.21). Because of ethnic, religious and cultural diversity and problems of distance, the design and execution of training programs will be localized at the provincial level. The project includes the establishment - 24 -

of a Provincial Training Center (PTC) in each of the three provinces. Each center will include at least two classrooms, a library, administrative offices and hostels, and will be provided with vehicles and training equip- ment. The PTC in South Sulawesi will have a floor area of about 2,500m2 and those in Central and Southeast Sulawesi, about 1,480 m2 each. The sites of the three PTCs have been identified and are conveniently located in nearby medical facilities. The project will also provide funds for training expenses.

5.15 As is customary in in-service training, the trainers will largely be drawn from the experienced provincial level staff of the MOH directorates. There are ongoing programs supported by USAID to upgrade the technical skills of trainers. The staff of each PTC will consist of a director and one course coordinator (except in South Sulawesi, where there will be three because of its larger training program), and about 4-6 administrative staff. Technical guidance will be provided by MOH's Center for Education and Training (P1USDIKLAT).

5.16 The categories to be trained have been defined and their training needs assessed based on local traini-g needs (Annex 1, T-12). The various health workers who will receive in-service training will include health center doctors, community health nurses, midwives, assistant pharmacists, laboratory assistants, assistant nutritionists, health inspectors, assistant health inspectors, and other auxiliary health workers. A detailed training program will be prepared annually by the Training Coordinator in each of the provinces in consultation with PUSDIKLAT. The program will include the training schedule, the number of trainees, and course outlines for the various categories of staff, together with itemized cost estimates.

5.17 District Health Administration. As pointed out in paras. 3.13- 3.14, the present poor state of the district health system was identified as one of the major obstacles to improving the quality and utilization of health services. As an essential accompaniment to the expansion and decentraliza- tion of health care administration, the MOH is therefore strengthening and improving the efficiency of the crganization and administration of the health service delivery system at the district level. This will be achieved through: (i) upgrading the managerial skills of district health administra- tors; (ii) improving the physical infrastructure, particularly the provision of office accommodation and transport; and (iii) construction of drug storage and development of a drug management system. District-level health care finance issues and the existing health information and reporting system will also be addressed.

5.18 To upgrade the managerial skills of district health administrators, the project will provide for the training of district medical officers (one for each district) in health care planning, management and supervision. About 36 man-months of consulting services will be provided for designing and carrying out the training course and evaluating it, for possible national replication. In addition, the project will provide 38 four-wheel drive vehicles (at least one for each of the 19 districts which do not have vehicles) to enable district level staff to perform field supervision more effectively. - 25 -

5.19 The MOH has initiated a program to construct new district health offices which include drug storage facilities and residential quarters for district health officers and assistant pharmacists. To date 12 health offices have been constructed in the project area. The project will provide for the construction of similar offices in the remaining 19 districts based on standard designs which were found acceptable. Operating costs are provided by the GOI under its regular budgets.

5.20 The drug store attached to each of the district health offices will be sufficient to hold a five-month supply of drugs for hospitals and health centers, a three-month supply for routine activities, and a one-month buffer stock. It will also be used for storing small medical equipment. Consulting services (about 6 man-months) will also be provided for setting up a drug management system and training the staff on the system to ensure that stocks are adequate to permit the demands of hospitals and health centers to be properly met, but are turned over rapidly enough to minimize storage costs and deterioration. The small drug storage facility with a well managed drug and supplies inventory should go a long way towards improving availability of drugs. Drugs will be provided by the GOI through its regular budgets.

5.21 The GOI is also exploring ways for improving the linkage between ( managerial and financial responsibilities. Specifically, it is planned that, as the provincial and district revenue base is strengthened, and as the qual- ity of financial management at this local level is gradually improved, the local governments will take over responsibility for all recurrent health expenditures. A study will therefore be undertaken in 10 selected districts for which about 6 man-months of consulting services will be provided, to review ways to simplify the health finance system at the district level and examine possibilities for additional resource mobilization through appro- priate cost recovery mechanisms. This will include a review of appropriate user fees for district hospitals and ways to retain these funds to supplement operating costs. Assurances were obtained during negotiations that this study will be completed by December 31, 1984.

5.22 An efficient hospital reporting system is being implemented by the MOH in all hospitals, including army hospitals and those in the private sector. It provides for the reporting of hospital activities, performance and morbidity/mortality statistics. In 1980, a computerized health center surveillance system was designed and implemented with the objective of improving the quality of services and collecting information on the utiliza- tion of services and conditions of health facilities. The recording and reporting by the health centers and sub-centers has continued to be weak, however, and the project therefore provides for this problem to be studied. About six man-months of consultant services and short-term fellowships will be provided for this purpose. Assurances were obtained during negotiations that the study will be completed by April 1985.

5.23 Project Implementation. The project will finance five vehicles, office equipment, fellowships, and incremental operating costs of project implementation, including consulting services (12 man-months) for monitoring and evaluation, and for the preparation of a second Bank-assisted health project. The staffing requirements of the project coordinating team and the provincial offices are described in paras. 7.01 and 7.02. - 26 -

5.24 Malaria Control. The project is designed to support the GOI s long-term efforts to reduce malaria in the Other Islands to an incidence rate of about 20/1000--a level at whichi it will no longer present a public health threat. Priority will be given to areas which are foci of resettlement and where the incidence of malaria is high.

5.25 The malaria control program (which is integrated into the health services) consists of the identifiicationof malaria transmission areas, the surveillance of malaria incidence and patterns, action needed to reduce the number of infected mosquitoes substantially, and the treatment of the sick. The project will support an expansion of the program to cover the entire pro- vince of South Sulawesi and transmigration and hyper-endemic areas in Central and Southeast Sulawesi. Control activities in other areas of Central and Southeast Sulawesi are presently not feasible because of poor road access, the rugged terrain, and the widely dispersed pattern of settlements.

5.26 Specifically, the project will provide for the deployment of about 65 additional supervisors, additional malaria spraymen (paid on a piece work basis), and for the purchase of spray equipment, DDT and vehicles. About 240 additional field operation teams will be organized, each comprising a chief and six spraymen. For every three teams, one field supervisor will be employed. Altogether, the provincial malaria control staff will be increased by about 70 full-time personnel, including 5 management and 65 supervisory staff. Blood samples will be analyzed in health centers and cross checked by the district and provincial laboratories. Infected people will be treated at health facilities. The house spraying will be carried out by the use of DDT, 75% wettable dispersable powder, applied at a dosage of 1 or 2 gram/sq. meter. -Normally 2 grams are applied in one cycle in areas of seasonal transmission and 1 gram in areas of perennial transmission in two spray cycles a year. About US$5.1 million worth of insecticides will be used over the project period, and an estimated $0.1 million-worth of spraying and other equipment and $0.3 million worth of drugs will be purchased as well as 36 vehicles (one for each district and two for each province), and about 80 motorcycles (for field team supervisors).

5.27 Epidemiological assessments will be carried out and will be based on: (i) passive case detection by health facilities; (ii) active case detec- tion by limited surveillance; (iii) malariometric surveys; and (iv) special studies in focal epidemic areas. These data will provide an adequate inform- ation base for the assessment of the program. Since there are presently no qualified local specialists, technical assistance during the duration of the project will be provided; these will include an entomologist and two malariologists (a total of 108 man-months). Assurances were obtained during negotiations that a full complement of staff and consultants will have been appointed by March 1984 when the program is expected to be in full operation.

5.28 It is expected that the intensive control activities provided under the project will reduce the malaria incidence in the operational areas from the present 140/1000 population to below 50/1000 by 1987. During the project period, about 1.3 million people will be protected by house spraying and about 2 million people will have access to drug treatment. - 27 -

5.29 Technical Assistance and Studies. In total, the project will provide about 228 man-months of consultant services to carry out studies and individual project components (paras. 5.07, 5.18, 5.20, 5.21, 5.22, 5.23 and 5.27). The services required are as follows: hospital administration (48 man-months); hospital maintenance (6 man-months); management training of dis- trict medical officers (36 man-months); development of drug management system (6 man-months); study of health finance system (6 man-months); study of health information system (6 man-months); malaria control program implementation (108 man-months), monitoring and evaluation (6 man-months), and preparation of second health project (6 man-months). (See Annex 1, T-13.) It is expected that about 50% of these will be provided by local consultants. Assurances were obtained during negotiations that terms of reference of consultants will be satisfactory to the Bank, and that their selection and employment will be in accordance with Bank guidelines.

VI. PROJECT COSTS AND FINANCING

A. Cost Estimates

6.01 The total project cost is estimated at US$54.4 million equivalent, of which US$27.7 million (51%) is the foreign exchange component. Because of the tax-exempt status of the implementing agency, the project costs do not include taxes and duties. Project costs are summarized below, and details are given in Annex 1, T-14 to T-15.

6.02 Project costs are expressed in November 1982 prices. Cost esti- mates for civil works are based on current BAPPENAS guidelines, which have been reviewed by the Bank and found reasonable. Building space allowances conform to GOI requirements. Estimates for medical equipment are based on equipment lists which are reasonable in scale and cost. The average man- month cost of consultant services, including the cost of travel, subsistence and allowances, is estimated at about $3,000 equivalent for a local consul- tant and $12,500 for a foreign consultant. These estimates are based on recent contracts in Indonesia. The costs of training courses are based on prevailing GOI local travel and per diem allowances. The contingency allow- ance of $10.2 million includes: (a) physical contingencies estimated at 10% of the base cost of civil works; and (b) price contingencies averaging 17% of base cost plus physical contingencies, assuming the following annual inflation rates:

Foreign Local Year Component Component 1983 8.0% 12% 1984 7.5% 10% 1985 7.0% 10% 1986 6.0% 10% - 28 -

Table 6.1: PROJECT COST SUMMARY

% of Foreign Total Ex- Base Local Foreign Total Local Foreign Total change Costs (Rp Billion) (US$ Million) (%)

A. Strengtheningof the Referral System

District Hospital 8.5 6.5 15.0 12.8 9.9 2207 43.6 51.5 Health Center Upgrading 0.7 0).6 1.3 1.1 0.9 2.0 45.9 4.4

Sub-total 9.2 ,.1 16.3 13.9 10.8 24.7 43.8 55.9

B. Staff Training 2.2 1.0 3.2 3.4 1.6 5.0 31.9 11.3

C. Management and Administration

District Health Administration 1.7 1.3 3.0 2.6 2.0 4.6 43.6 10.4 Project Implementation 0.5 0.3 0.8 0.7 0.5 1.2 40.7 2.7

D. Malaria Control 1.1 4.6 5.7 1.7 7.0 8.7 80.4 19.6

Base Cost: 14.7 14.5 29.2 22.3 21.9 44.2 49.5 100.0

Physical Contingencies 0.9 0.6 1.5 1.3 1.0 2.3 42.3 5.1 Price Contingencies 2.0 3.2 5.2 3.1 4.8 7.9 61.2 17.8

Total Project Costs: 17.6 18.3 35.9 26.7 27.7 54.4 50.9 122.9

Front-end Fee on the Bank loan - 0.3 0.3 - 0.4 0.4

Total Financing Required 17.6 18.6 36.2 26.7 28.1 54.8 - 29 -

B. Project Financing

6.03 The proposed Bank loan of $27.0 million (including a US$0.4 million capitalized front-end fee) will finance 50% of total project cost and will cover the total foreign exchange cost except for US$1.1 million representing the foreign exchange cost of vehicles which will be financed by GOI on the basis of reserved procurement. The balance of $27.8 million equivalent will be financed out of annual GOI budget appropriations. Retroactive financing up to US$0.3 million is recommended to help cover eligible expenditures after May 31, 1982 for start-up activities, particularly the appointment of archi- tectural consultants to prepare plans and tender documents. The closing date of the loan will be June 30, 1988.

C. Procurement

6.04 Civil Works. All civil works contracts, totalling about $17.0 million, are small and widely scattered geographically and over time. The contracts will range in amount from about $30,000 to $1.5 million, but the majority will be about $100,000. Only about four will reach $1.5 million. Past experience in Indonesia indicates that international contractors are not interested in tendering for contracts of this value. Consequently, construc- tion contracts will be awarded on the basis of local competitive bidding con- ducted according to current GOI procurement procedures, which are acceptable to the Bank.

6.05 Goods and Services. Contracts for the supply of hospital equipment ($3.3 million) and DDT ($5.1 million) will be awarded through international competitive bidding in accordance with Bank Group guidelines. Locally advertised competitive bidding, following GOI procedures which are acceptable to the Bank, will be used for furniture and drug supply contracts of less than $75,000 equivalent, subject to a maximum of $1.5 million. Contracts of value less than $32,000 (e.g. for sprayers for malaria control and other small equipment) will be procured through prudent shopping based on at least three price quotations. Consultants will be employed according to the Bank's guidelines for use of consultants and their contracts (US$1.8 million) will be awarded in accordance with Bank guidelines.

6.06 Contract Review. The threshold for the Bank's prior review of civil works contract documentation and award recommendations would be set at US$500,000. All civil works contracts below this level would be subject to post award review by the Bank. Contracts for items to be procured through ICB ($8.4 million) would be subject to the Bank's prior review of documenta- tion and award recommendations; all other contracts would be subject to review by the Bank after contract award.

D. Disbursements

6.07 The Bank will disburse at the following rates:

(a) 100% of total expenditures for the civil works contracts for the 10 hospitals and 3 PTCs; - 30 -

(b) 100% of the foreign expenditures for directly imported materials and equipment; 95% of ex-factory; and 65% of the cost of locally procured imported goods;

(c) 100% of the cost of consultant services and fellowships.

The estimated schedule of disbursements is given in Annex 1, T-16.

E. Accounts and Audit

6.08 Separate accounts for all project expenditures will be maintained in each of the three provinces and in Jakarta. Assurances were obtained during negotiations that the MOH will have the project accounts for each fis- cal year audited by independent:auditors acceptable to the Bank, and furnish the Bank with copies of the audited accounts not later than six months after the end of each GOI fiscal year.

VII. PROJECT IMPLEMENTATION, MONITORING AND EVALUATION

A. Project Management

7.01 Central Level. The Secretary-General of the MOH will be the Project Director and will be responsible for the execution of the project. He will be assisted by a Project Coordinator in Jakarta with two full-time and three part-time staff. This team, which has now been appointed, will assist the provincial project officers in the preparation of annual work programs and budgets, the procurement of goods under ICB, the recruitment of consultants and the processing of reimbursement applications. The team will also consolidate project progress reports; implement, with the assistance of consultants, the various studies; and coordinate monitoring activities and evaluation of project impact (Aknnex 1, T-17).

7.02 Provincial Level. The Provincial Health Officers who will act as the Sub-Project Directors will be responsible for the execution of all proj- ect components except those mentioned in para. 7.01 above. Each Sub-Project Director will appoint a Project:Officer. In addition to the technical staff referred to in para. 7.07, the Project Officer will be provided with support staff for local procurement, the preparation of annual work programs and budgets, and monitoring and reporting on the progress of the project.

7.03 Present practice of GOI in Bank-financed projects is that project funds are centrally-controlled and managed by the implementing ministries in Jakarta. This practice has resulted in delays in release of funds to the local implementing agencies and consequent delays in project implementation. To avoid similar problems, a separate project budget will be provided directly to each of the provincial Sub-Directors and, for activities to be implemented in Jakarta, to the Project Director. The existing budgetary system allows this without any modification in its procedures. - 31 -

B. Project Implementation

7.04 Civil Works. The civil works element consists of in-patient facil- ities for 15 health centers, four Class C and six Class D hospitals, three Provincial Training Centers, and 19 District Health Offices with drug stores and staff houses. The locations of these facilities are shown in Annex 1, T-10.

7.05 With the exception of three PTCs, standard designs, which have been used satisfactorily by GOI for many years and found satisfactory by the Bank, exist for all facilities and will be used for construction of buildings under the project. Designs for the PTCs will be prepared at provincial level by consultants according to schedules of accommodation which have been agreed with the Bank and using as guidelines the successful PTCs built by NFPCB under the Second Population Project. Consultants at each province will adapt the standard designs for the other facilities to suit individual sites and local planning conditions.

7.06 The Provincial Project Officers will be responsible for initiating construction in accordance with normal GOI procedures and they will appoint one or more consultants to prepare plans, tender documents, contracts, and to supervise construction and advise on technical matters.

7.07 To assist the project officer in implementing the civil works component, the GOI has agreed to appoint additional full-time technical staff to each province for the duration of the planning and construction period. Three such staff members will be appointed to South Sulawesi and one each to Central and Southeast Sulawesi. Additional technical advice and control will be obtained from the PWD whose provincial representative will be a member of the tender and implementation committees required under GOI regulations. Contracts for construction will be awarded at provincial level through tender committees convened by the Provincial Health Officer in accordance with normal GOI procedures.

7.08 Control of documentation and construction will thus be located at each province under the Provincial Project Officer. It is expected that this arrangement will have the advantage of decentralizing decision-making and speeding up implementation.

7.09 Sites. About 32 new sites will be required for project buildings, six of them during the first year of the project period. Most of the project sites have been selected and found to have adequate water, road and elec- trical services, and in most cases the sites will shortly be acquired by the MOH. All the six sites for the first year construction program have been acquired. During negotiations, assurances were obtained that the remaining sites will be acquired according to a timetable satisfactory to the Bank and that evidence satisfactory to the Bank will be furnished after acquisition.

7.10 Implementation Schedule. The project is scheduled for completion within four years. The implementation schedule is given in Annex 1, T-18. - 32 -

C. Monitoring and Evaluation

7.11 The efficiency with which project components are being carried out will be monitored against agreed indicators (Annex 1, T-19). Input indica- tors will include: the number of project facilities constructed, staffed, equipped, and in operation, and the number of staff trained. Indicators of coverage and utilization of services as a measure of the provision of health care would include: the number of children immunized; the number of pregnant women who received ante-natal care or have their deliveries supervised by a trained attendant; number of first and repeated consultations per health unit and by type of illness; number of referrals, and number of family planning users by type of contraceptive use. Periodic visits to health centers and sub-centers will be made as part of- the routine supervisory function of the district health administration to ensure that this information is being collected accurately by the health units and promptly submitted to the district offices for submission to MOH in Jakarta through the provincial health administration.

7.12 Hospital utilization data in respect of in-patient and out-patient care will be analyzed through existing routine reporting. The indicators would include, among others: number of admissions per month; average length of stay; bed occupancy rates; number of deliveries; number of operations; number of referrals from health centers; and disease specific mortality rates.

7.13 Information on trends and current levels of utilization, and reasons for non-use of health faciLities, are available from the 1976 and 1980 household surveys. Another household survey is planned in 1987. By comparing the results of two recenit surveys, the change toward attaining the project objectives will be measured.

7.14 The performance of the malaria control component will be monitored against agreed indicators. The process indicators will include the number of dwellings treated with chemicals, the number of blood samples collected and analyzed (slide positivity rate), and the number of patients treated. The outcome indicator will be the annual malaria incidence.

7.15 An evaluation of the direct impact of the project on mortality and morbidity is not possible due to t'hevariety of external factors influencing health status. However, the project will attempt to document changes in health status in the project area. The health status indicators will include: nutritional status; infant mortality rate; child mortality rate; life expectancy at birth; maternal mortality rate; disease specific mortal- ity; and incidence of major diseases. The data from the 1980 Household Survey, 1980 Census and National Public Expenditure Survey for the project area will be used as baseline data. Data from the planned 1987 household survey will provide an opportunity for monitoring changes in the health status.

7.16 The Project Coordination Team in Jakarta assisted by MOH's Division for Data Collection and Analysis (which has computerized facilities and access to provincial data) will have overall responsibility for monitoring and evaluation. - 33 -

VIII. JUSTIFICATION AND RISKS

8.01 Justification. The project will accelerate the improvement of the health status of the population in the three provinces by (i) improving the effectiveness of the primary health care system, and (ii) reducing the incidence of the major endemic disease, malaria.

8.02 It is expected that the expansion in the scope and improvements in the quality of health care provided at the health centers and district hospitals through the upgrading of facilities, staff training, management and other outreach efforts will lead to an increase in utilization of health services. In addition, the expected increase in the effectiveness of the health center system is also a precondition for the further development of the outreach program. While it is difficult to quantify the impact of the project on health status, both the increased utilization and improved quality of care are expected to lead to a substantial reduction in morbidity and mortality.

8.03 The project beneficiaries will be mainly mothers and children who constitute about 80% of those presently seeking primary care in health cen- ters and sub-centers and as out-patients in district hospitals. The improve- ments in district hospitals and health centers will directly benefit the rural poor who cannot afford to go to private hospitals and doctors, which are, in any case, mostly located in urban areas. Assuming that utilization will increase by about 50% of present level, it is estimated that by 1987 about 3 million mothers and children will be reached. Since deaths of children below 5 years of age accounts for about 40% of all deaths, project impact on infant and child mortality is expected to be substantial. Such reduction in mortality may be expected to increase motivation to accept family planning.

8.04 The project will also reduce mortality and morbidity by providing hospital care for which there is considerable unmet demand. The expected utilization of the facilities after they are completed and in full operation is estimated at about 250,000 out-patient consultations per year, and about 38,000 in-patient admissions per year (or an increase of about 144,000 and 10,000, respectively). Additionally, they will greatly enhance the much- needed credibility of the primary health care network by providing referral back-up support to about 500 health centers and health sub-centers.

8.05 The intensified and expanded spraying operations under the project will make possible the drastic reduction of malaria incidence from 140/1000 to about 50/1000 by 1987. In addition, the proper treatment of malaria will reduce morbidity considerably. By maintaining these efforts over a period of 5 to 7 years, it will be possible to gradually control malaria in the areas now seriously affected.

8.06 The institution-building effect of the project will be at least as important as the direct service benefits. The assignment of responsibility for planning and implementing the project to the provincial authorities will support GOI efforts to decentralize health administration. This new approach will facilitate execution of health programs adopted to local needs. - 34 -

Furthermore, the project will directly strengthen the district health administration through staff training, provision of transport and office accommodations.

8.07 Fiscal Impact. It is estimated that incremental annual recurrrent costs generated by the project when it is fully operational in 1987 will amount to about US$3.1 million, or about 15% of the health budget of the three provinces, which is considered well within the fiscal capability of GOI. On a per capita basis, the operating cost for the comprehensive and sustained large-scale attack on malaria represents about US$1.40 per person protected, per year. It is expected that these costs will decline as the intensity of malaria control operations diminishes. Project-generated incremental costs for improving the services of the 10 hospitals are low principally because these would replace or upgrade existing facilities. The project will not require new personnel to be posted nor provide additional hospital beds.

8.08 Environmental Impact. The use of DDT for malaria control has a much smaller environmental impact than when it is used for agriculture, since it is used selectively inside houses. There are in any case, no cost- effective alternative pesticides.

8.09 Risk. Implementation capacity is a concern. A great deal will depend on the ability of the provincial health services to execute the proj- ect. However, experience under the MOH's hospital rehabilitation and INPRES health center construction programs indicates that the provinces have already considerably increased their capacity to carry out development projects. Furthermore, the appointment of additional staff and architectural consultants to supervise the civil works component will minimize the risks.

8.10 The technical feasibility of the malaria control program has already been successfully proven in Java-Bali. Nevertheless, the probability that in due course mosquitoes will become resistant to DDT and parasites to chloroquine will make malaria control more difficult. The development of alternative pesticides and anti-malaria drugs, however, is a priority research area of the Tropical Disease Research Program jointly sponsored by the WHO, UNDP and the Bank.

IX. AGREEMENTS REACHED AND RECOMMENDATIONS

Agreements Reached

9.01 Assurances were obtained from the GOI during negotiations that:

(a) by December 31, 1984, the MOH will have reviewed trends in the utilization of health centers and make recommendations for improving them and will have also reviewed the performance of PKMD, particularly its impact on utilization of services to plan for the expansion of PKMD or alternative programs for improving outreach (para. 5.12); - 35 -

(b) by December 31, 1984, the MOH will have undertaken a study on simplifying the health finance system at the district level and on possibilities for additional resource mobilization through appropriate cost recovery mechanism (para. 5.21);

(c) by April 1985, the MOH will have undertaken a study on the existing recording and reporting activities at the health centers and sub-centers and make recommendations for strengthening the existing health information system (para. 5.22);

(d) the full complement of staff and consultants for the malaria component will be appointed by March 1984 when the program is expected to be in full operation (para. 5.27);

(e) terms of reference for consultants and the contracts entered into with them will be satisfactory to the Bank, and the selection and employment of the consultants will be in accordance with Bank policies and procedures (para. 5.29);

(f) the implementing units will maintain separate accounts for all project expenditures and retain these accounts until at least one year after the closing date; these accounts will be audited by independent auditors acceptable to the Bank; and audit reports will be submitted to the Bank not later than six months after the end of each GOI fiscal year (para. 6.08);

(g) the GOI will appoint additional full-time technical staff (three in South Sulawesi and one each in Central and Southeast Sulawesi) throughout the planning and construction period to assist in implementing the civil works (para. 7.07); and

(h) sites for the project facilities will be acquired according to a timetable satisfactory to the Bank and evidence satisfactory to the Bank will be furnished after acquisition (para. 7.09).

Recommendation

9.02 With the above assurances, the project would be suitable for a Bank loan of $27 million, with a 20-year maturity, including a grace period of five years. The Borrower would be the Republic of Indonesia. - 36 - ANnEX 1 T-1 INDONESIA

PROVINCIAL HEALTH PROJECT

POPULATION BY PROVINCE: SIZE, DENSITY AND GROWTH

Population Population Popnlation Percent of Growth Rate Size 1980 Density, 1980 Total (% p.a.) (million) (persons/sq.km.) Populatlon 1961-71. 1971-80

D.K.I. Jakarta 6.5 11,028 4.4 4.6 4.0 West Java 27.5 594 18.6 2.1 2.7 Central Java 25.4 742 17.2 1.7 1.7 D.I. Jogjakarta 2.7 866 1.9 1.1 1.1 East Java 29.2 609 19.8 1.6 1.5

Java: Total 91.3 691 .61.9 1.9 2.0

D.I. Aceh 2.6 47 1.8 2.1 2.9 North Sumatra 8.4 118 5.7 2.9 2.6 West Sumatra 3.4 68 2.3 1.9 2.2 Riau 2.2 23 1.5 2.9 3.1 Jambi 1.4 32 1.0 3.1 4.1 South Sumatra 4.6 45 3.1 2.2 3.3 Bengkulu 0.8 36 0.5 2.5 4.4 Lampung 4.6 139 3.1 5.2 5.8

Sumatra: Total 28.2 59 19.0 2.8 3.3

West Kalimantan 2.5 17 1.7 2.5 2.3 Central Kalimantan 0.9 6 0.7 3.5 3.5 South Kalimantan 2.1 55 1.4 1.4 2.2 East Kalimantan 1.2 6 0.8 2.9 5.8

Kalimantan: Total 6.7 12 4.6 2.3 3.0

North Sulawesi 2.1 110 1.4 2.4 2.2 Central Sulawesi 1.3 18 0.9 3.4 3.9 South Sulawesi 6.1 83 4.1 1.4 1.7 South East Sulawesi 0.9 34 0.6 2.5 3.1

Sulawesi: Total 10.4 55 7.0 1.9 2.2

Bali 2.5 444 1.7 1.8 1.7 West Nusa TengFara 2.7 135 1.9 2.0 2.4 East Nusa Tenggara 2.7 57 1.8 1.6 1.9 Maluku 1.4 19 0.9 3.3 2.9 Irian Jaya 1.1 3 0.8 2.0 2.4 East Timor 0.6 37 0.4 n.a. n.a.

Others: Total 11.0 16 7.5 n.a. n.a.

INDONESIA: TOTAL 147.4 77 100.0 2.1 2.3 -37 - ANNEX 1 T-2

INDONESIA

PROVINCIAL HEALTH PROJECT

SOCIOECONOMIC INDICATORS IN SELECTED COUNTRIES: 1979 /1

Indonesia /2 Korea Malaysia Philippines Singapore

Total Population (mlns.) 147 37.8 13.1 46.7 2.4

Urban Population (%) /2 18 55 29 36 100

Crude Birth Rate (per 1000) 35 25 28 34 18

Crude Death Rate (per 1000) 12 8 6 8 5

Rate of Natural Increase (%) 2.3 1.7 2.2 2.6 1.3

Infant Mortality Rate /2 93 37 32 65 13 (per 1000 live birthsY

Life Expectancy at Birth 53 63 68 62 71

Adult Literacy Rate (%) /3 62 93 60 33 87

Per Capita Income (US$) 520 /4 1480 1370 600 3830

Annual Per Capita Health Budget (US$; 1978) 4 2 15 3 52

Health Budget as % of Total National Budget (1978) 2 n.a. 5.2 3.6 4.8

/1 Source: IBRD, World Development Report, 1981; Data are for 1979 unless noted otherwise.

/2 1980

/3 1976

/4 1981 - 38 - ANNEX 1 T-3

INDONESIA

PROVINCIAL HEALTH PROJECT

PRINCIPAL CAUSES OF DEATH IN INDONESIA, 1972 AND 1980

1972 1980 Causes of Death Numbe.r Z Number %

Acute lower respiratory tract infection 70 12.0 180 19.9 Diarrheal diseases 99 16..9 170 18.8 Cardiovascular diseases 30 5.1 90 9.9 Tuberculosis 35 6.0 76 8.4 Tetanus 27 4.6 59 6.5 Diseases of the nervous system 30 -5.1 45 5.0 Liver diseases - - 37 4.2 Injuries and accidents 12 2.1 32 3.5 Neoplasm - - 31 3.4 Typhoid fever 12 2.1 30 3.3 Other infectious diseases 27 3.0 Ccmplication of pregnancy 13 2.2 23 2.5 childbirth 14 2.4 - - Neonatal condition 241 /a 41.3 /a 62 6.8 Other - - 43 4.8

TOTAL 583 100.0 905 100.0

Source: MOH, Household Survey, 1972 and 1980

/a Includes causes of death listed above, ANNEX 1 - 39 - T-4

INDONESIA

PROVINCIAL HEALTH PROJECT

INFANT MORTALITY AND LIFE EXPECTANCY, BY REGION, 1969 AND 1978

Life ExDectancy b/ Province/ Infant Mortality,?a/ Years Island 1969 1978 X decline 1969 1978 Increase

Java-Madura 137.6 104.0 24 47.1 53.1 6.0 West Java 159.4 132.2 17 43.5 48.0 4.5 Central Java 135.8 98.2 28 47.4 54.2 6.8 East Java 114.0 95.4 16 51.3 54.8 3.5 Jakarta 119.4 80.1 33 50.2 57.9 7.5 Yogjakarta 93.1 62.5 33 55.3 .61.8 6.5

Sumatra 138.5 92.6 33 47.0 55.4 8.4

Kalimantan 139.3 106.1 34 46.8 53.8 7.0

Sulawesi 149.0 108.2 27 45.2 52.3 7.1

Eastern Islands 164.4 133.4 19 42.7 47.8 5.1

Indonesia 140.0 105.2 25 46.7 52.9 6.2

a/ Per 1,000 live births. b/ In years, at birth. ANNEX 1 -- 40 - T-5

INDONESIA

PROVINCIAL HEALTH PROJECT

DISEASE PATTERNS, 1972 AND 1980

1972 1980 Per 1000 Diseases Number of Per 1000 Popu- Cases Population Cases lation

Upper respiratory tract infection 980 0.9 3.796 3.1 Skin diseases 721 0.6 1.013 0.8 Lower respiratory tract infection 422 0.4 1.041 0.9 Diarrheal diseases 297 0.3 947 0.8 Tuberculosis 577 0.5 732 0.6 Cardiovascular diseases 120 0.1 717 0.6 Eye infections 224 0.2 451 0.4 Diseases of musculo skeletal and ___ connective tissues 26 0.0 442 0.4 Malaria 279 0.2 219 0.2 Diseases of the nervous system 74 0.1 254 0.2 Aniemia 182 0.2 250 0.2 Arthro-skeletal diseases 94 0.1 321 0.3 Dental d.iseases 70 0.1 293 0.2 Other infectious diseases 107 0.1 268 0.2 Accidents 55 0.1 248 0.2 Others 1,319 1.2 2,937 2.4

TOTAL 5,547 13,929

Source: Ministry of Health, Household Survey, 1972 and 1980 - 41 -

ANNEX 1 T-6 INDONESIA PROVINCIAL HEALTH PROJECT

CENTRAL MINISTRY OF HEALTH BUDGETS 1979/80-1981/82, BY PROGRAMS

(in millions Rupiahs) 1979/80 1980/81 1981/82

A. DeveloDment Budget Education and Training ror health social welfare, women's role, family planning 2,050 6,000 6,600 Health Education 750 1,200 1,250 Health Services Development 30,650 42,300 56,500 Control of Co=unicable Diseases 10,700 16,500 19,500 Improvement of Nutrition Status in the Community 1,odo 3,000 3,325 Control of Food and Drugs *1,250 2,100 2,400 Research and Development 750 850 1,000 Efficiency of Public Administration 475 625 900 Improve Physical Facilities 975 2,925 3,800 Women's Role 300 400 425 Water Supply 800 1,500 2,100 Environmental Sanitation 200 300 350 Younger Generation 200 300 350

Total: Development Budget 50,100 78,200 106,750

B. Special Pr-esidential Funds (INPRES) Health Servizes Development 24,465 43,468 56,520 Environmental Sanitation 5,535 6,523 13,471

Total: INPRES 30,000 49,991 69,991

C. Routine Central Ministrv of Health Administration 5,276 10,742 18,112 Education and Training for Upgrading, Technical and Professional Staff 2,717 4,101 5,395 Education and Training for Administrative Staff 321 446 590 Health Services Development 21,079 30,909 45,015 Control of Comunicable Diseases 1,140 1,567 2,173 Production and Distribution of Drugs 914 972 1,121

Total: Routine 31,447 48,737 72,406

Total Budget for Health 111,547 176,928 249,147

NOTE: This does not include the budget for health of the provinces, districts and other ministries. INDONESIA

PROVINCIAL HEALTH PROJECT

DEVELOPMENT, INPRES, AND ROUTINE BUDGETS FOR MOH, 1974/75-1981/82

1974/75 1975/76 1976/77 1977/78 1978/79 1979/80 1980/81 1981/82 B U D G E T. Millions Millions Millions Millions Millions Millions Millions Millions Rp. % Rp. % Rp. % Rp. % Rp. % Rp. % Rp. % Rp. %

National Ministry of Health - Development 8,615 34 13,010 27 15,742 29 20,970 30 23,842 31 50,100 78,200 106,750 t Budget

Special Presidential 5,291 21 15,220 32 20,929 39 26,292 38 26,900 30,000 49,991 69,991 Funds

National Ministry of .Health - Routine 11,285 45 19,190 41 17,379 32 21,646 31 25,979 34 31,447 48,737 72,406 Budget

TOTALS 25,191 100 47,421 54,051 100 68,907 100 76,720 111,547 176,928 249,147

01 >c I- - 43 - ANNEX 1 T-8

INDONESIA

PROVINCIAL HEALTH PROJECT

ANALYSIS OF HOUSEHOLD SURVEY, 1972 AND 1980

A. NUMBER AND PERCENTAGE OF POPULATION REPORTED ILL/SICK BY TYPE OF TREATMENT, 1972 AND 1980

Population Condition P o p u 1 a t i o n

Effort of Treatment 1972 1980 Number 7 Number %

Population surveyed 111,689 100.0 121,129 100.0

Population without complaint 106,142 95.0 107,288 88.6

Population with complaint 5,547 4.9 13,841 11.4

a. Not receiving treatment 2,442 44.1 3,630 26.2

b. Receiving treatment: 3,105 55.9 10,221 73.8

- Medical treatment 2,122 38.3 6,021 43.5 - Non-medical treatment 252 4.5 613 4.4 - Self treatment 705 12.7 3,551 25.7 - Others 26 0.5 26 0.2

B. NUMBER AND PERCENTAGE OF PATIENTS NOT TREATED BY REASON GIVEN, 1972 AND 1980

Population Condition P o p u 1 a t i o n

Effort of Treatment 1972 1980 Number % Number

Cost 315 26.8 1,547 42.6 Distance 289 24.8 185 5.1 Not needed 385 33.1 1,304 35.9 Others 178 15.3 594 16.4

T 0 T A L 1,164 100.0 3,630 100.0

Source: M0H Household Survey, 1972 and 1980 INDONESIA

PROCU5J1IALHEALTH PRO=EC'

MAIARIMGMEMICINDICES

Central Sulawesi South East Sulawesi South Sulawesi Other Islands Java I ~~~~~~A.P.I. YEAR lPer.Ex.IS.P.R.%l% F Per.Ex. S.P.R.% % F Per.Ex. S.P.R.% % F Per.Ex. S.P.R.% % F j Per.Ex. S.P.R.% % F [(0/00)

1978 20,000 35 (a) 20 (b) 13,000 11.0 (a) 85 (b) 23,000 14.8 18 423,000 14.0 34 8,174,000 1.5 35 1.4

1979 15,000 16 (a) 64 (b) 3,000 12.6 (a) 18 (b) 18,000 13.0 23 514,000 18.0 32 8,042,000 0.9 47 0.8

1980 17,000 25 (a) 17 (b) 8,000 10.4 (a) 17 (b) 18,000 13.4 17 503,000 11.4 30 9,089,000 1.9 47 1.8

S.P.R.: Slidepositivity rate.

% F: Percentof plasmodiumfalciparum.

A.P.I.: Annualparasite incidence.

Per.Ex.: Persons examined by blood slide. (Represents on average about one-third of clinically reported cases.)

(a) Data observed through nmlariometric survey. tE (b) Data reflects local conditions in survey areas, not provincial averages. - 45 -

Annex 1 T-10

INDONESIA

PROVINCIAL HEALTH PROJECT

LOCATION OF PROJECT FACILITIES

Facilities Central Sulawesi Southeast Sulawesi South Sulawesi

Class D Hospitals Toli-Toli Kendari Majene Ampana Bulukumba Selayar

Class C Hospitals Luwuk Pare-Pare Bone Palopo

Provincial Training Center Palu Kendari Ujung Pandang

District Health Offices Donggala Kendari Maros Pankep Barru Pare-Pare Pinrang Polmas Majene Enrekang Sidrap Waj'o Bone Gowa Takalar Jeneponto Bantaeng Bulukumba Sinjai

Health Center Upgrading Banggai Rumbia Leok Kabaena Bungku Mawasangka Dondo Lasolo Pendolo Lasusua Banawa Kalisusu Tomini Tiworo-Kepulaun Tombu - 46 - ANNEX 1 T-l1l

INDONESIA

PROVINCIAL HEALTH PROJECT

STANDARD HOSPITAL STAFFING PATTERNS

Staff Class C Class D

General Practitioner 1 2 Dentist 1 1 Pediatrician 1 - Surgeon 1 - Obstetrician & Gynecologist 1 - Internist 1 - Pharmacist 1 - Nurse 5 2 Assistant Nurse 30 12 Auxilliary Nurse 90 43 Midwife 6 3 X-Ray Technician 2 1 Nutritionist 1 Assistant Nutritionist 1 1 Anesthesist 1 Analyst 2 1 Physiotherapist 1 - Dental Nurse 1 1 Trained Statistician 2 1 Technican 2 1 Housekeeper 2 1 Sanitarian 1 1 Driver 4 3 Supervisor 1 - Finance/Accountant 5 4 Administrator 5 2

TOTAL: 173 81

Source: Directorate General of Medical Care, MOH, Indonesia ANNEX 1 T-12

ININESIA

PRDVT2IALHEAUS PRalECT

MINIM1 EXPECI TRAINDCILDAIS AT POVINIAL IN-SEVICETRAINI CENIES

No. to be Course Title Trained Course Participants Course Typical Istructional Province & Audience per yr Duration per Course per Year Ccurse Content Staff /a

SS Hospital and 125 6 days 20 6 Medical and MbnagementTopics: Hospital and Health Center - mmnagementof primary care problems Health Center Doctors - appropriate referral doctors plus - -w diagnostic techiique District CS 50 16 3 - useful drug therapy Administ - supervision of persornel SE 60 20 3 - drg logistics - insuization programs

SS Health Nnrses 300 6 days 25 12 NHrsing and Mnagement Topics: NHrsing School anxdAadliary - nutritional assessment of infants staff plus Nurses and children hospital and - identifying the higr-risk health oenter pregnancy doctors.

CS 125 25 5 - magement of diarrteal disease in children - organizing the nursing team SE 150 25 6 - imainization programs

Ss Assistant 32 6 days 16 2 Pharmcy and Drug Tventory 1harcy Schmol Pharmacists Management: Faculty plus - mnaging dnrg inventory Practicing CS 12 12 1 - expiration of drugs Pharnacists aid - the cold chain for vaccines District SE 12 12 1 - drug control including Administration security

SS Health Center 50 6 days 16 3 laboratory Procedures: Medical and Hospital - blood examLnations Analysts, Lni- CS laboratory 30 15 2 - stool exaninations versity IPG - urine examinations SE 30 15 2

Hospital YonageMent 12 days 25 2 Hospital Mangement Procedures Hospital Course for South,SE and Problems: Manag-ent and Central - persornel management Consultants & Silasesi Hospital - equipment maintenne counterparts Directors - supply irventory procedures frao Jakarta

Others: Health In- To be determined. pectors, Dental Nurses, leprosy Inspectors, Mlaria Supervisors, Assistant Nutritionists, etc.

/a There is an ongoing program to train trainers for the categories listed.

SS - South Sulaoesi CS - Central Sulawesi CE - South East ANNEX 1 - 48 - T-13

INDONESIA

PREOVINCIALEEALTR PROJECT

LIST OP STUDIES AND TECfNICAL ASSISTANCE

C-naItisg Servicen Pro- Inplementig vided under the Project Starting Corplation Pt-pose- (in 550-macthe) Date Date

A. Studies health Fi-atce To re-iew says to saiplify health MOH/PCJ 6 mae-mtha of Jaly 1984 Decenber 1984 finance system at the district leve consultants sad etane pos.hbilitias fot sddi- tional resoocoe mobili-ation through appropriate cost recovery =echanis-. Mao, to stody appropri- ate nser fees for district hospitals cad =ays to cetain these fsnds to suppleteot operating casts.

Health Infot=ation To review the e.istiog syste f-or MOH/ 6 -as-noths of Asgust 1984 April 1985 Systen reporting cod recording activities Directocate consultant of health centeve and the dintrtit Genera: C- offices sad thereafter make reco- unity Health =endatis_ for atreogtheaing the system to effecti-ely support plao- viog activities.

Utilizatics of Health To review preseot trends of tilica- MOH/Ilotitote None; iscluded as Jlly 1984 Desb- 1984 S-rvices tics of health center aod tv make of Health a c tvece=t recotodario-s for i=proving them. Besearch

Ostreach Activities To st-dy the porfarmcoce of PYMD, MOH/ NSon; incloded an a July 1984 April 1985 portic-larly its irpact oe otilisa- Directorate -coenat tion of health seevices in order to Gecral establish optimal conditioss for Mrectirate program taintenance cod to plan for Gene-al far its expansion or alterective pro- Cordity gra=s fot iprevig outreach. health

B. TechnicaL Assistanne

Hospital Addiailtration To review present procedorer for PCU/lro-ctcr- 46 mae-mortho August 1984 May 1984 district hospital ad=inistvation, ate Gen.-ral design sad condoct tra-iaig coot-e for HeaLth fa- hospital ad=linLtratora sad Sereices/PHA eyalucte the cose far ntional replication.

Hespital Eqip-nt To determine: (i) saistecanoe needs PCU/Driectot- 6 mano- tha of Juns 1984 Decehbe- 1984 Maintenance of district hospitals baaed on as ate Genral cone-ltants isnyetary of redical cqfip-not, f-r MedIcal cad (ii) the approprlcte nu=ber, Care locstion ssd staffig for maintenance workshops, and prepare preliriasry architectt-al drawings for these etk-hahpo.

Hespital Equiprnst To assist MOHto prepare specifica- PCU/Dir!cto.r- 2 -a-onths April 1983 May 1983 tices of hospital eqsip-ent ate Gea!rcl of casltr for Medical Care

Msnagesent Traning of Ta design sod carry act a managerent PNa/PUSIIVViT 36 man-mantho of Septe=e- 1984 Hsy 1985 District IsdAl ttaining toarae fo- dIstrict tedical consultntsr Officer officer..

Drug Managemnt System To estahblih a drag inventory system PbA 6 man-mtho of at the district level. co-naLtantr DSeneser 1983 May 1985

Entamologist and Ta assist in malaria srueilLance PNW 108 a-nths of Decehr 1983 Decehe 1986 HsLariologist cad epidemiclogicaL aDsecsremt. irectorate consoltants Generl far Casicshle Diseases

Monitoring and To masEat MOHiv -ealnatiag project MOH1/Planniag 6 -an-nths of Febhuary 1987 May 1987 EyaLuation Iqiract. Bureau c-nsalta-es

Project Preparation TI sasist MOHin preparing a second MOI/Planaing 6 -ahnantho of Sapteaetr 1983 February 1984 health proJect for bank fi-ancing. Ba- co-otants

PCI - Project Coordinating Unit PdA - Prviacial HeaLth Adinoatration - 49 -

ANNEX 1 INDONESIA T-14 PROVINCIAL HEALTH PROJECT Page 1 of 11 Table A. DISTRICT HOSPITALS Detailed Cost Table (Rp. '000)

Quaritits BaseCobts

Urlit 1 2 3 4 Total Unit Cost 1 2 3 4 Total

! .lQE>ltlENTr 0'15

h. CENTkAl iUIAWE5I

Cl, i C 50,000m: - - - I R,. 7,500/m2 392,599.9 - - - 392,5S9.9 CIASS D 25,000m2 - I 1 - 2 Rp.7,500/m2 - 196,333.4 196,333.4 - 392,666.9

Sub-Tutal LA'ND 392,599.9 196?333.4 196,333.4 - 785,266.8 CIVIL UDRN.S

COINSTRUICTION NO. 1 1 1 - 3 1,066t616.5 632,680.3 632,680.3 - 2,331,977.1 FUFNITURE Amount - - - - 213,185.8 126,536.1 126,536.1 - 466?257.9

Si lut l CiVIlU0ohNS 1,279,802.3 759,216.4 759,216.4 - 20798235.0 3. HDSFPITALE0UIPMENT

t(IASiC /a No, - 1 - - 1 307,071.6 - 307.071.6 - - 307,071.6 ClASSI' No. - - I 1 2 307,071.6 - - 307,071.6 307,071.6 614,143.2

Sub-Tutal H0SFITALEQUIPMENT - 307,071.6 307,071.6 307,071.6 921,214.8 4. VEHICLES

CEE'ANFOR CLASS C NO. - 2 - 2 8,463,744 - 16,927.5 - - 16,927.5 SEDANFOR CLASS D NO. - - 1 1 2 8,463.744 - - 8,463.7 B,463.7 16,927.5

Sub-Total VEHICLES - 16,927.5 8,463.7 8,463.7 33t855.0

Sub-Total CENTRALSULAWESI 1,672,402.11,279,548.9 1,271,085.2 315,535.3 4,538,571.6 B. FELLOVSHIFS

CLAS'C ADMINISTRATORS ND, 1 - - - 1 17,853 17Y853.0 - - - 179853.0 CLASSD HOSPITALADMINISTRATORS NO. - 2 - 2 1,071.1B - 2.142.4 - - 2o142.4

Sub-Total FELLOWSHIPS 17,853.0 29142.4 - - 19P995.4 C. SOUTHSULAWESI

1. LAND

CLASSC 50,000m2 1 2 - - 3 Rp. 7,500/02 392.599,9 785,199.7 - - 1,177,799.6 CLASSD 25,000 m2 1 1 - 1 3 RP, 7,500/m2 196s333.4 196,333.4 - 196,333.4 589,000.3

Sub-Total LAND 588,933.3 981.533.2 - 196,333.4 1,766,799.9 2. CIVII WORNS

CONSTRUCTION- CLASS C NO. 1 2 - - 3 1,066,616.52,133,233.0 - - 3,199,849.5 FUF:NITURE- CLASS C Amount - - - - - 213,185.8 426,371.5 - - 639,557.3 CONSTRUCTION- CLASS D NO. 1 1 - 1 3 632,680.3 632,680.3 - 632,680.3 1898,041.0 FURNITURE- CLASS D Amourit - - - - - 126,536.1 126,536.1 - 126,536.1 379,608,2

Si,b-Tot2l CIVIL WORNS 2,039,018.6 3,318,820.9 - 759,216.4 6,117,055.9 - 50 ANNEX 1 Table A. (Continued) T-14 Page 2 of 11

3. HOSFITALEQUIPMENT

CLASSC lb No. ------CLASSD No, - I I 1 3 307,071.6 - 307.071.6 307,071.6 3079071.6 921.214.8

Sib-Total HOSPITALEOUIPMENT - 307,071.6 307,071,6 307.071.6 921,214.8

4. VEHICLES

SEDANFOR CLASS C No. 2 4 - - 6 RF, 7.5. 16,927.5 33,855.0 - - 50,782.5 SEDANFOR CLASS D No. I I 1 - 3 RF. 7.5sm 8,463.7 8.463.7 8.463.7 - 25.391.2

Sub-Total VEHICLES 25.391.2 42.318,7 8.463.7 - 76.073.7 5. FELLOWSHIP

CLASSC HOSPITALADMINISTRATORS Ac,our,t - 1 2 - 3 17,853 - 17,853.0 350706.0 - 53,559.0 CLASSD HOSPITALADMINISTRATORS Amount - 3 - - 3 1,071.18 - 3213.5 - - 3,213,5

Sub-Total FELLOWSHIP - 21.066.5 35,706.0 - 56,772.5

Sub-Total SOUTHSULAWESI 2,653,343,24,670,B10,9 3519241,31,262,621.4 8,938,016.9 D, SOUTHEASTSULAWESI

1. LAND

CLASSDi 25,000m2 - - I - 1 RP. 7,500/n2 - - 1969333.4 - 196,333,4 2 CIVILWORKS

CONSTRUCTION Anour,t - - 1 - I - - 632.680,3 - 632P680.3 FURNITURE Amount ------126.536,1 - 126,536,1

Sib-Total CIVILWORKS - - 759,216,4 - 759,716.4 3. HOSFITALEQUIPMENT No. - - I - 1 307,071.6 - - 307,071.6 - 307,071.6 4. VEHICLES

SElIANFOR CLASS D No. - - I - 1 8.463.744 - - 8,463.7 - 8P463,7

Sb-Total VEHICLES 8.463.7 - B,463.7 S. FELLOWSHIP

CLASSD HOSPITALAPIMINISTRATOR Amount - I - - 1 1,071.18 - 1,071.2 - - 1,071,2

Sub-Total SOUTHEASTSULAWESI - 1,071.2 1,271,085.2 - 1.272,156.3 E. JAKARTA

1. CONSULTANTS

HOSPITALADMINISTRATION 10REILiNCONSIILTANTS sm 10 6 - - 16 $12.500/mm 89,265.0 53t559.0 - - 142,824.0 HOSPITALADMINISTRATION LOCALCONSULTANTS MO 10 10 5 5 30 $3,000/mm 20,102.4 20,102.4 10,051.2 10,051.2 60,307.2 HOSPITALMAINTENANCE FuREIGNCONSULTANTS M5 6 - - - 6 $12,500/MM 53,559.0 - - - 53t559.0 HOSPITALEOUIPMENT SPECIFICATIONS mm 2 - - - 2 $12,500/MM 17,853.0 - - - 17,853.0

SJb-Total CONSULTANTS 180,779.4 73,661.4 10,051.2 10,051.2 274,543.2

Sub-TotalJAKARTA 180,779.4 73,6b1.4 10,051.2 10.051.2 274,543.2

Total INVESTMENTCOSTS 4,524,377.76,027,234.8 2,903,462.9 1,588.20B.015,043,283.4

Total BASELINECOSTS 4,524,377.76,027t234.8 2,903,462.9 1,588,208.015.043,283.4

la Partial eouipmer,tFrovided through Dutch aid. /b Hospital eauiF*ent for Palopo,8one,aad Pare-Pareprovided ba Japaneseaid. - 51 -

ANNEX 1 INDONESIA T-14 PROVINCIAL HEALTH PROJECT Page 3 of 11 Table B. HEALTH CENTER UPGRADING Detailed Cost Table (Rp. '000)

Quantit'3 BaseCosts

Unit 1 2 3 4 TotalUnit Cost 1 2 3 4 Total

1. INVESThENTCOSTS

A. CENTiRALSULAWESI

1. LAND,

L,ANEl No. 2 2 2 2 8 8.308.992 16,616.0 16,618.0 16Y618.0 16,618.0 66,471.9 2. CItJILWORKS

CONSTRUCTION No. 2 2 2 2 8 54,671,832 109,343.7 109,343.7 109,343.7 109,343.7 437.374,7 FEES No. 2 2 2 2 8 2,814.336 5,628.7 5,628.7 5Y628.7 5,628.7 22,514.7 EQUIPMENT No. 2 2 2 2 8 14,282.4281J64.8 28,564.8 28tJ64.828,564.8 114,259.2 FURNITURE No. 2 2 2 2 8 50776.64611,553.3 11,553.3 11,553.3 11,553.3 46,213.2

Sub-TotalCIVIL WORKS 155,090.4155,090.4 155,090.4 155,090.4 620,361.7

Sub-TotalCENTRAL SULAWESI 171.708.4171,708.4 171,708.4 171,708.4 686,833.7 B. SOUTHEASTSULAWESI

1. LANI,

LANED No. 2 2 2 1 7 8,308.992 16,618.016,618,0 16,618,0 8,309.0 58,162.9 2. CIVILWORKS

CONSTRUCTION No. 2 2 2 1 7 54,671.832109,343.7 109,343.7 109,343.7 54,671.8 382,702.8 FEES No. 2 2 2 1 7 2,814,336 5,628.7 5,628.7 5,628.7 2,814.3 19,700.4 EQUIPMENT No. 2 2 2 1 7 14,282.428,564,8 28,564.8 28,564.8 14,282.4 99,976.8 FURNITURE No. 2 2 2 1 7 5,776.64611,553.3 11,553.3 11,553.3 5,776.6 40,436.5

Sub-TotalCIVIL WORKS 155,090.4155,090.4 155,090.4 77,545.2 542,816.5

Sub-TotalSOUTHEAST SULAWESI 171,708.4171,708.4 171,708.4 85,854.2 60O,979.4

TotalINVESTMENT COSTS 343t416.8343v416.8 343,416.8 257,562.6 1,287,813.1

TotalBASELINE COSTS 343,416.8343,416.8 343,416.8 257,562.6 1287,813.1

------_ ------52 - ANNEX 1 INDONESIA T-14 PROVINCIAL HEALTH PROJECT Page 4 of 11 Table C. PROVINCIAL TRAINING CENTER Detailed Cost Table (Rp. '000)

guantitv BaseCosts

Unit 1 2 3 4 TotalUnit Cost 1 2 4 Total

I. INVESTHENTCOSTS

A. SOUTHSULAWESI

1, LAND'

LA.,N D Amount - 1 - - 1 - 2099065.0 - - 209,065.0 2. CIVIL WORKS

7ONSTRUCTION Amount - l - - I - 658,812.8 - - 658,812.8 FEES Aniount ------66,018.8 - - 66,018.8 FURNITURE Amount ------120Y346.8 - 120i346.8

Sub-TotalCIVIL WORKS - 845,178.4 - - 845,178.4 3. VEHICLES No. - 4 - - 4 Rp.7.5m - 33,008.6 - - 33,008.6 4. A.V.EGUIFMENT and BOOKS Anount ------28,300.6 - - 28S300.6 5. TRAININGEXPENSES Aiouirt------149,355.42855133.0 434,488.3

Sub-TotalSOUTH SULAWESI - 1,115,552.5149,355.4 285,133.0 1,550,040.8 B. CENTRALSULAWESI

1. LAND

LAND Amount - I - - 1 - 104,532.5 - - 104,532.5 2. CIVILWORKS

CONSTRUCTION Anount - I - 1 - 378,232.8 - - 378,232.8 FEES Amount ------37,823.3 - - 37,823.3 FURNITURE Amount ------68!769.6 - - 68.769.6

Sub-TotalCIVIL WORKS - 484.825.7 - - 484,825.7 3. VEHICLES No. - 2 - - 2 RP,7.5m - 16,504.3 - - 16.504.3 4. A.V.EQUIPMENT and BOOKS Amount ------14,150.3 - - 14,150.3 5, TRAININGEXPENSES Amount ------58,255.4169.722.0 257,977.4

Sub-TotalCENTRAL SULAWESI - 620,012.788,255.4 169,722.0 877,990.2 - 53 - ANNEX 1 Table C. (Continued) T-14 Page 5 of 11

Quantity lase Costs

Unit 1 2 3 4 TotalUnit Cost 1 2 3 4 Total

C. SOUTHEASTSULAWESI ______1. LAND

LAND Amount - 1 - - 1 - 104,532.5 - - 104,532.5 2. CIVILWORKS

CONSTRUCTION Amoulnt------366,542.0 - - 366,542.0 FEES Amount ------36,447.9 - - 36,447.9 FURNITURE Amount------66,706.5 - - 66,706.5

Sub-TotalCIVIL WORKS - 469,696.4 - - 469,696.4 3. VEHICLES No. - 2 - - 2 RP.7.5s - 16,504.3 - - 16,504.3 4. A.V. EOUIPMENTandBOOKS Amount ------14,150.3 - - 149150.3 5.TRAINING EXPENSES Amount ------SBY255.4169,722.0 257,977.4

Sub-TotalSOUTHEAST SULAWESI - 604,883.498,255.4 169,722.0 862,B60.9

TotalINVESTHENT COSTS - 2,340,448.7325,866.2 624,577.0 3,290,891.9

TotalBASELINE COSTS - 2,340,448.7325,866.2 624,577.0 3,290,891.9

…------…------54 - ANNEX 1 INDONESIA T-14 PROVINCIAL HEALTH PROJECT Page 6 of 11 Table D. DISTRICT HEALTH ADMINISTRATION Detailied Cost Table (Rp. '000)

Guantitv base Costs

Unit 1 2 3 4 Total Unit Cost 1 2 3 4 Total

I. INVESTMENTCOSTS

A. SOUTHSULAWESI

1. LAND

LAND Aoount 4 7 6 - 17 15r076.8 60,307.2 105,537.6 90,460.8 - 256,305.6 2. CIVIL WORKS

CDNSTRUCTION Amount 4 7 6 - 17 108301.375 433,205.5 758,109.6 649,808.2 - 1,841,123.4 FURNITURE Amount 4 7 6 - 17 5t372,625 21P490.5 37,608.4 32,235.8 - 91,334.6

Sub-Total CIVIL WORKS 454,696.0 7950718.0 682,044.0 - 1,932,458.0 3. EQUIPMENT Amount 4 7 6 - 17 39537.57 14,150.3 24,763.0 21,225.4 - 60i138.7 4. VEHICLES No. - 10 10 14 34 8,252.15 - 82,521.5 82,521.5 115,530.1 28O0573.1 5.TRAINING EXPENSES /a Asount ------15,614,4 15,614.4 15,614.4 46P843.3

Sub-Total SOUTHSULAWESI 529,153.5 1,024i154.5 891,866.1 131P144.52,576,318.7 B. CENTRALSULAWESI

1. LAND

LAND Amount - I - - 1 15,076.8 - 15,076,8 - - 15P076.8 2. CIVIL WORKS

CONSTRUCTION Amount - I - - 1 108,301.375 - 108,301,4 - - 108,301.4 FURNITURE Amount - 1 - - 1 5,372.625 - 5t372.6 - - 5,372.6

Sub-Total CIVIL WORKS - 113,674.0 - - 113,674.0 3. EQUIfMENT Amount - 1 - - 1 3t537.57 - 3,537.6 - - 3,537.6 4. VEHICLES Amount - 2 - - 2 Bt252.15 - 16,504.3 - - 166504.3 5. TRAININGEXPENSES /b Anount ------2,036.7 2,036.7 2,715.6 6,788.9

Sub-Total CENTRALSULAWESI - 150,829.3 2,036.7 2,715.6 155,581.6 C. SOUTHEASTSULAUESI

1. LAND

LAND Amount - 1 - - 1 - 149741.8 - - 149741.8 2. CIVIL WORKS

CONSTRUCTION Aaount - I - - 1 108v301.375 - 108,301.4 - - 108301,4 FURNITURE Amount - 1 - - 1 59372.625 - 5,372.6 - - 5,372.6

Sub-Total CIVIL WORKS - 113,674.0 - - 113,674.0 3- EQUIPMENT Amount - 1 - - 1 3,537.57 - 3,537.6 - - 3,537.6 4. VEHICLES Amount - 2 - - 2 8,252.15 - 16,504.3 - - 166504.3 5. TRAININGEXPENSES /a Amount ------1,357.8 2,036.7 2,715.6 6,110.0

Sub-Total SOUTHEASTSULAWESI - 149,815.4 2,036.7 2,715.6 154,567.6 - 55 - ANNEX 1 T-14 Table D. (Continued) Page 7 of 11

Quantitv Base Costs

Unit 1 2 3 4 Total Unit Cost 1 2 3 4 Total

D. JAKARTA

1.CONSULTANTS

MANAGEMENTTRAINING Anount 12 12 6 6 36 S3,000/ma 16.081,9 16,081,9 8,041.0 B.041.0 48,245.8 DRUGMANAGEMENT STUDY Amount- 6 - - 6 $3,000/mm - 8,041.0 - - 8,041.0 FINANCESTUDY Amount- 6 - - 6 $12,500/MM - 53,559.0 - - 53,559.0 INFORMATIONSYSTEM Amount - 6 - - 6 $12,500/MM - 53t559.0 - - 53F559.0

Sub-TotalCONSULTANTS 16,081.9 131,240.9 8,041.0 B,041.0 163,404.7

Sub-TotalJAKARTA 16,081.7 131,240.9 8,041.0 8.041.0 163,404.7

TotalINVESTMENT COSTS 545F235.41,456,040.1 903,980.4 144t616.6 3,049,872.6

Total BASELINECOSTS 545,235.41,456,040.1 903,980.4 144,616.6 3,049,872.6

/a 22 DokabusY. Rp. 25,000 x 21daas x 2 sears. /b 4 tikabus x RP.25,000 x 21 davsx 2 vears.

------_ - - - _ ------56 -

ANNEX 1 INDONESIA T-14 PROVINCIAL HEALTH PROJECT Page 8 of 11 Table E. MALARIA CONTROL Detailed Cost Table (Rp. '000)

Quantity BaseCosts

Unit 1 2 3 4 Total Unit Cost 1 2 3 4 lotal

1. INVESTMENTCOSTS

A. SOUTHSULAWESI

1. ['[T Amount - - - - - 428,472.0 4289472.0 42B,472.0 4287472.01,713i888.0 2. VEHICLES

.11IFS No. 12 13 - - 25 8t463.744 101t564.9 11002877 - 211,593.6 MOTORCYCLES No. 60 - - - 60 705.312 42v316.7 - - 42318.7

Sub-Toutl VEHICLES 143,883.6 110,028.7 - - 253,912.3 3. EGlIIlMENTISPRAY CANS) No. 300 170 - - 470 83.845 25,153.4 14t253.6 - - 39s407.0 4. D'RUGS Amounrt - - - - 29,601.4 29,601.4 29t601.4 29,601.4 118,405.7 5. RECIJRENTCUSTS

SAlAhRESAND DAILY WAGES Auulint - - - 89120.6 89,120.6 89,120.6 89,120.6 356,482.6 FElOhL Arount - - - - - 24,994.2 24p994.2 24,994.2 24,994.2 99,976.8 TRAININGEXFENSES Amount - - - - - 33,944.4 33.944.4 33Y944.4 33,944.4 135,777.6

SuL-lotil RLCUIRRENTCOSTS 148,059.2 148P059.2 148,059.2 14B8059.2 592,237.0

Sub Tut31SOUTH SUIAWESI 775,169.7 730,414.9 606,132.7606,132.7 2,717F850.0 B. CENIRALSULAWESI /a

1.* lLI Amount - - - -06,59,2 206,559.2 206,5959.2206,559.2 826*236.8 2. VEHICIES

JELPS No. 6 - - 6 Bt463.744 500782,5 - - - 500782.5 MOTORCYCLES No. 10 - - - 10 705.312 7,053.1 - - - 7,053.1

Suab-TotalVEHICLES 57,835.6 - - 57,835.6 3. EQUIPMENT Amount 150 160 - - 310 83.845 12t576.7 13,415.2 - - 25P991.9 4. [liUGS Amount - - - - - 12,188.B 12,188.8 129188.8 12,188.B 48,755.3 5. RECURRENTCOSTS

SALARIESAND [1AILY WAGES Asournt - - - - - 35,514.2 35,514.2 35,514.2 35,514.2 142,057.0 FElROL Amount - - - - - 9,819.2 9,B19.2 9,B19.2 9,819,2 39,276.6 TRAININGEXPENSES Amourt - - - - - 16,972.2 16,972.2 16,972.2 16,972.2 67,888.8

Sub-Totdl RhCURRENTCOSTS 62,305.6 621305.6 62,305.6 62,305.6 249,222.4

SI,b-o0tdl CENTRAL.SULAWESI /a 351,465.9 294,468.8 281P053.6 281,053.6Ii208041.9 - 57 -

ANNEX 1 Table E. (Continued) T-14 Page 9 of 11

Quantity BaseCosts

Unit 1 2 3 4 Total Unit Cost 1 2 3 4 Total

C. SOUIHEASTSU\.AIESI

1.11T Amount - - - - - 206,559.2 206,559.2 206,559.2 206P559.2 8269236.8 27 VEHICLES

JELfS No. 6 - - - 6 8,463,744 50,782.5 - - - 50,7B2.5 MOTORCYCLES No. 10 - - - 10 705,312 7,053.1 - - - 7,053.1

Sub-Total VEHICLES 57,835.6 - - - 57,835.6 3. EQUIPMENT Amount 200 180 - - 380 a3.a4s 1676689 15s092.O - - 31w861.0 4. RfilUGS Amount - - - - - 1,218.9 1P218.9 1,218.9 1,218.9 4,875.5 5. RECURRENTCOSTS

SAIARIESAND IAILY WAGES Amolurit - - - - - 35,514.2 35,514.2 35vbI4.2 35,514.2 142,057.0 PETRhL Amour,t - - - - - 9,819.2 9,819.2 9,819.2 9,8192 39,276.6 TRAININGEXPENSES Amount - - - - - 16?972.2 16,972.2 16,972.2 16,972.2 67,888.8

Sub-TotalRECURRENT COSTS 62,305.6 62,305.6 62,305.6 62,305.6 249,222.4

Sub-lotal SOUTHEASTSULAWESI 344,688.2 285ol75.7 270,083.7 270,083.7 1,170,031.3 D. JAKARTA

1. CONSULTANTS

MM ARILiIGIST HANHON1H15 15 15 15 60 MM290oo/MH133,897.5 133t897.5 133tB97.5 133,897.5 535,590.0 ENTOMOLOGISI MANMONTH 12 12 12 12 48 3,000/MM 24,122.9 24,122.9 24,122.9 24,122.9 96,491.5

.wib-Totdl l(lNSULTANTS 158,020.4 158i020.4 15820.4 158,020.4 632,081.5

'b lutul JAlKARTA 158,020.4 158,020.4 158,020.4 158,020.4 632,081.5 lotalINVESTMENT COSIS 1,629p344.2194689079.B 1,315,290.3 1,315,290.3 5,728,004.7 lotal BASEIlNECOSTS 1,629s344.2 1,468)079.8 1,315,290.3 1.315,290.3 5,728,004.7

la About 40X of South Sulawesi - 58 -

INDONES IA ANNEX 1 PROVINCIAL HEALTH PROJECT Page 10 of 11 Table F. PROJE3CT IIIPLEMENTATION Detailedi Cost Table (Rp. '000)

Ouantit~~~~~~~~~ BaseCosts

Unit 1I 3 4 Total Unit Cost 1 2 3 4 Total

I. INYESTMENTCOSTS

A, CENTRALSULAWESI

YEHICLES No. 1 - - - 1 8,463,744 8,463.7 --- 8,463.7 OFFICEEOUIPMENT Amournt - - - - - 5o660.1 - - - 5,660.1 FELLOWSHIPS No. ------7,y141.2 7,i141.2 - 149282.4 OFFICESUPPLIES Aafourit- - - - - 1,397.4 4P890.9 4,192.2 4,p192.2414,672.8 HONORARIUM Amount - - - - - 49690.6 49690,6 4,690.6 4,690.6 16,762.2 INCREMENTALSALARIES Amouint - - - - - 24010,2 2,010.2 2,010.2 2,010.2 8?041.0 PERDIEM/TRANSPORT Amfount - - - - - 4,020.5139401.6 13,401.6 13,401.6 44,225.3

MISCELLANEOUS Amount - - - - 1,340.2 3,350.4 3,350.4 2,680,3 10,721.3

Suib-TotalCENTRAL SULAWESI 27,582.7.35,484.9 34,786.2 26,975.0 124,828.8 B. SOUTHEASTSULAWESI

YEHICLES No, 1 I 8,463.7448,463.7 --- 8,463,7

OFFICEEQUIPMENT Amoutr - - - - - 5,660.1-- - 5,660.1 FELLOWSHIPS No. - 7,141.2 7,141,2 - 14,282.4

OFFICESUPPLIES Amount - - - - - 1,397.4 4,192,2 4,192.2 4,192.213,974,1

HONORARIUM Amounjrt- - - - - 2,680.3 4,690,6 4,690.6 1,340,2 13,401,6

INCREMENTALSALARIES Amount - - - - -2,010.2 2,010.2 2,Y010.22,010.2 8,041.0

P-ERDIEM/TRANSPORT Amouint - - - - -4,020.5 13,401.613,401.6 9,381,140,204.8

MISCELLANEOUS Amfount- - - - -1Y340.2' 3,350.4 3,350.4 2,680.3 10,721.3

Sujb-TotalSOUTHEAST SULAWESI 25i572.534,786,2 34,786.2 19,604,1 114,749,0 C. SOUTHSULAWESI

VEHICLES No. 29 8,463,74416,9217.5 - - 16,927.5

OFFICEEQUIP'MENT Amfounrt- - - - - 11,320.2- - - 11,320.2 FELLOWSHIPS No. - - - - - 14,282.4 14,282,4 - 28,564.8

OFFICESUPPFLIES Amounirt - - - - -2,794.8 5,589,6 5,589.6 4,890.9 18i865,1

HONORARIUM Amount - - - - -69700.8 12,731.5 10,721.3 10,721.3 409874,9 INCREMENTALSALARIES Amounrt - - - - -6,030.7 6,030,7 6,030.7 6,030.724,122,9

PERDIEM/TRANSPORT Amouint - - - - - 10,721.316,752.0 16,752.0 13,401.6 579626.?

MISCELLANEOUS Amouirt - - - - 3,350.4 4,690,6 4,690.6 49690.6 17,422.1

Sub-TotalSOUTH SULAWESI 57,845,7 60,076.8 'J8,066.6 39,735.1 215,724,3 - 59 - ANNEX 1 Table F. (Continued) T-14 Page 11 of 11

Quantitv BaseCosts

Unit 1 2 3 4 Total Unit Cost 1 2 3 4 Total DI. JAKARTA

VEHILlES No. 1 - - - 1 8,463.744 8,463.7 - - - 8, '3. CONSULTANT MANHONTH- 6 - 6 12 $12t500/NM - 539559.0 - 53,559.0107,118.0 FELLOWSHIPS No. ------21,423.6 28,564.8 - 49,988.4 OFFICESUPPLIES An,aur,t- - - - - 4,890,9 6,987.1 5,589.6 4,890.9 22.358.6 HONORARIUM Amount - - - - - 11,391.410,721.3 10,721.3 10,721.3 43,555.2 INCREMENTALSALARIES Amount - - - - - 4,020.5 4,020.5 4,020.5 4,020.5 16,081.9 FER DIEM/TRANSPORTAmount - - - - - 16,752.0 16,752.0 16,752.0 16,752.0 67,008.0 MISCELLANEOUS Amount - - - - - 4,690.6 4,690.6 4,020.5 4,020.5 17,422.1 OFFICE ELUIPMENT Amount - - - - - 14,150.3 - - - 14,150.3

Sib-TotalJAKARTA 64,359.4118,154.0 69,668.7 93,964.2 346,146.2

TotalINVESTMENT COSTS 175,360.3248,502.0 197,307.8 180,278.3 801,448.4

TotalBASELINE COSTS 175,360.3248,502.0 197,307,8 180,278.3 801,448.4

------_------_ ------60 -

ANNEX 1 INDONESIA T-15 PROVINCIAL HEALTH PROJECT ANNUAL EXPENDITURE BY COMPONENT (Rp. Billion)

Total Base Costs ------(USS 1 2 3 4 Rp. Million)

A. REFERRALSYSTEM DEVELOFPMENT

DISTRICTHOSPITALS 4.5 6,0 2.9 1.6 15.0 22.8 HEALTHCENTER UPGRADING 0.3 0.3 0.3 0.3 1.3 2.0

Sub-TotalREFERRAL SYSTEM DEVELOPMENT 4,9 6.4 3.2 1.8 16.3 24.7 B. STAFFDEVELOPMENT and TRAINING

PROVINCIALTRAINING CENTERS - 2.3 0.3 0.6 3.3 5.0

Suib-Total STAFFDEVELOPMENT andTRAINING - 2.3 0.3 0.6 3.3 5.0 C. MANAGEMENTand ADMINISTRATION

DISTRICTHEALTH OFFICES 0.5 1.5 0.9 0.1 3.0 4.6 PROJECTIMPLEMENTATION 0.2 0.2 0.2 0.2 0.8 1.2

Sub-Total MANAGEMENTand ADMINISTRATION 0.7 1.7 1.1 0.3 3.9 5.8 lI.HALARIA CONTROL PROGRAM 1.6 1.5 1.3 1.3 5.7 8.7

TotalBASELINE COSTS 7.2 11.9 6.0 4.1 29.2 44.2 PhvsicalContingencies 0.4 0.7 0.3 0.1 1.5 2.2 Price Contingencies 0.4 1.8 1.5 1.5 5.2 7.9

TotalPROJECT COSTS 8.0 14.4 7.8 5.7 35.9 54.4

Foreign Exchange 3.7 6.7 4.4 3.5 18.3 27.7

------__------__ - - 61 - ANNEX 1 T-16

INDONESIA

PROVINCIAL HEALTH PROJECT

ESTIMATED SCHEDULE OF DISBURSEMENTS /a

Cumulative Disbursements IBRD Fiscal Year and Semester US$ Million Percent

FY83 Second 0.4 1.0

FY84 First 0.7 3.0 Second 2.5 9.0

FY85 First 4.0 15.0 Second 5.4 20.0

FY86 First 9.4 35.0 Second 13.5 50.0

FY87 First 16.2 60.0 Second 20.2 75.0

FY88 First 23.0 85.0 Second 27.0 100.0

/a The disbursement schedule has taken into consideration the annual phasing of project expenditures and time overruns in Bank-financed projects in Indonesia. - 62 - ANNEX 1 T-17 Page 1 of 3 INDONESIA

PROVINCIAL HEALTH PROJECT

RESPONSIBILITIES FOR PROJECT IMPLEMENTATION ACTIVITIES

Activities Agency Responsible

A. Referral System Development

1. Civil Works Component

Land acquisition Provincial Health Administration (PHA) Preparation of plans and tender documents PEA Tendering PEA Award of contracts and payment PEA Supervision PEA

2. Procurement

ICB (hospital equipment) Central MOH Local procurement PRA

3. Hospital Administration and Maintenance

Selection, appointment:and payment of consultants Central MOH, in consulta- tion with PHA Supervision of consult:ants PEA Training of hospital administrators PEA

B. Staff Training

1. Civil Works Component PHA

2. Local Procurement PEA

3. In-Service Training

Preparation of annual program PEA, in consultation with central MOH Submission of program to the Bank for review MOH

Implementation ot program PHA - 63 -

ANNEX 1 T-17 Page 2 of 3

Activities Agency Respbnsible

C. Management and Administration

1. Civil Works ComDonent PEA

2. Procurement PHA

3. Management Training

Selection, recruitment and payment of consultants MOE Supervision of consuiltants PEA lmplementation of program PEA

4. Studies

Selection, recruitment and payment of consultants M.OH Supervision of consultants PEA

D. Malaria Control

1. Procurement

ICB (DDT) MOE Local procurement PEA

2. Appointment of Consultants

Selection, contracting and payment MOH, in consultation with with PEA Supervision PEA

E. Reporting, Monitorinz, Evaluation and Other Studies

1. Quarterly Proaress Renorts

Preparation of reports PEA Coasolidation and submission to the Bank MOE

2. Monitorinz and Evaluation

Monitoring of key indicators PEA Analysis of data MOH

3. Preparation; of Second Health Project MOP - 64 -

ANNEX 1 T-17 Page 3 of 3

Activities Agency Requirements

F. Budgets and Accounts

1. Preparation of annual work program and budget PEA, in consultation with MOH

2. Preparation of withdrawal applications

Supporting documents PEA Preparation and submission of with- drawaal applications to the Bank MOH - 65 - Annex I T-18 Page 1 of 3

INDONESIA

PROVINCIAL HEALTH PROJECT

IMPLEMENTATION SCHEDULE

1983 1984 1985 1986 1987 Facility No. JFMAMJJASOND JFMAMJJASOND JFMAMJJASOND JFMAMJJASOND JFMAMJJASON\

CENTRAL SULAWESI

District Hospitals Type "C" Hospitals I DD TTTTT CCC CCCCCCCC Type "D" Hospitals 2 ODDDD DDDD TTTTT TTT T CC CCCCCCCCC CCCCCCCCCCC CC

Provincial Training Centers Small P.T.C. 1 DDDDDDD TT TTT CCCCCCCCC CCCCCCC

District Health Offices with Drug Stores

(a) Health Office (1) D DD (b) Drug Store (1) I TTTTT (c) Staff Houses (2) CCCCC CCC

Health Center Annexes Ward Block Annexes 8 | DDD DDD DDD DDD DDD TTTT TTTT T TTT TTTT TTTTTT CC CCCCCC CCCCC CC CCCCCC CC CCCCC CCC CCCC

Project Pro,ect Begins Ends

LEGEND: DDD: Drawings TTT: Tenders CCC: Construction - 66 - Annex 1 T-18 Page 2 of 3

INDONESIA

PROVINCIAL HEALTH PROJECT

IMPLEMENTATION SCHEDULE

1983 1984 1985 1986 1987 Facility No. JFMAMJJASOND JFMAMJJASOND JFMAMJJASOND JFMAMJJASOND JFMAMJJASOND

SOUTH SULAWESI

District Hospitals Type "C" Hospitals 3 LDDD DDD DDD TTTT TTT TTTTT CCC CCCCCCC CCCC CCCCCCCC CC CCCCCCCCCCCC CCC

Type "D" Hospitals 3 DDD DDD DDD TTTTT TTTTT TTTTT c ccccccc CC cccCCCCCcc ccCCCccCCCcc cCc

Provincial Training Centers Large P.T.C. 1 DDDDDDDDD DDD TTTTT CCCCC CCCCCCCC

District Health Offices with Drug Stores (a) Health Office (1) DDDD DDD DDD (b) Drug Store (1) 3 TTT TTTT TTTT (c) Staff Houses (2) CCCCCCCCC CCCCC CC CCCC (At 17 locations in South Sulawesi)

DDD DDD DDD 3 TTTT TTTT TTTT CC CCCCCC CC CCCC CCCC CC DDD DD DD 3 | TTTT T TTT T TTT CCCCCCCCC CCCCCCCC CCCCCCCC DDD DD DDD DD 4 TTT TTTT TT TT TTTT CCCCC CCCCCCC CCCCC CCCCCC DDD DDD D DDD D DD 3 | TTTT TTTT TTTT TTTT CCC CCC CCCCCCC C CCCCCCC CCCCCCC C

Health Center Annexes Ward Block Annexes Nil

Project Project Begins Ends LEGEND: DDD: Drawings TTT: Tenders CCC: Construction - 67 - Annex I

Page 3 of 3

INDONESIA

PROVINCIAL HEALTH PROJECT

IMPLEMENTATION SCHEDULE

1983 1984 1985 1986 1987 Facility No. JFMAMJJASOND JFMAMJJASOND JFMAMJJASOND JFMAMJJASOND JFMAMJJASOND

SOUTH-EAST SULAWESI

District Hospitals

Type "D" Hospitals 1 D DDD TTTTT l ~~~~~~~~CCCCCCCCCCI

Provincial Training Centers Small P.T.C. 1 DDDDDDD T TTT l ~~~CCCCCCCCCCCCI

District Health Offices with Drug Stores (a) Health Office (1) | DDDD (b) Drug Store (1) 1 TT TT (c) Staff Houses (2) I CCCCCCCCCC

Health Center Annexes Ward Block Annexes 2 DDDD DDD D DD (at 7 locations) TTT TTTT TTTT CCCCC CCCC CCCCC CC CCCCCCCC CCI

DDD DDD DDD 2 TTTT TTTT TTTT C CCCCCCC C CCCCCC CC CCCCCCI

DDD DDD DDD DDD 2 TTTT TTTT TT TT TTT T CCCC CC CCCCCCC C CCCCCCCCC CCCCCCCCI

I TTT l ~~~~~~~~~~~CCCC I

Project Project Begins Ends

LEGEND: DDD: Drawings TTT: Tenders CCC: Construction ANNEX1 - 68 -ANN__ T-19

INDONESIA

PROVINCIALREALTH PROJECT

KEY PROJECT INDICATORS

Actual Targets Principal Objectives Key Indicators _ _

1982 1983 1984 1985 1986 1987

A. Referral System Development

To strengthen referral system through: - Number of hospitals constructed 3 5 2

a. Reconstructing and equipping - Number of hospitals fully staffed, 10 regency hospitals equipped and in operation 3 5 2

b. Strengthening hospital administration, - Number of out-patient consulta- maintenance and financing mechanism tiuns per month per hospital 1,100 1,200 1,200 1,500 2,100 2,400

c. upgrading 15 health centers by - Average length of stay 7 days providing in-patient facilities - Bed occupancy rate 58% 80%

- Number of deliveries/hospital/month 10-40

- Number of maternal deaths/hospital 2% 1%

- Number of hospital administrators trained

- Number of health centers with in-patient facilities staffed, equipped and in operation 5 5 5

- Mothers and children seeking care at health center/sc'bcenters 1,500,000 3,000,000

- Number of consultat.ions/day/health cester 15-40 60

B. Staff Development and Training

To improve quality of health services - Number of PTCs constructed 3 through health manpower development by: - Number of PTCs fully staffed, a. Establishing a provincial training equipped and in operation 3 center in each province - Number of staff trained by b. Empand and improve quality of in- category (To be determined annually) service training of health staff

C. Management and Administration

To strengthen the administrative capacity - Number of district health offices of district health offices to plan, imple- and drug stores constructed 6 12 19 ment and maintain health services in line with GOI's policy of decentrali-ation - Number of district health officers through: trained 20 40 60

a. Construction of district health offices

b. Construction of drug storage facilities

C. Improvement of drug management system

d. Training of district health officers

D. Malaria Control Program - Number of spraymen trained 2,000 2,000 2,000 2,000 To reduce the incidenee of malaria through: - Number malaria supervisors trained 65 a. Training of malaria workers and super- visors - Number of houses sprayed 180,000 280,000 380,000 480,000 596,000 596,000

b. House spraying - Number of cases found and treated 152,000 167,000 252,000 358,000 460,000 460,000

c. Case finding and treatment - Annual Parasite Incidence 14% (To be determined annually) 5%

d. Blood examination I I - 69 -

ANNEX 2

INDONESIA

PROVINCIAL HEALTH PROJECT

SELECTED DOCUMENTS AND DATA AVAILABLE IN PROJECT FILE

A. General Reports and Studies Relating to the Health Sector

A.1 World Bank, Indonesia Health Sector Overview, Feburary 1979, 2379-IND

A.2 World Bank, Indonesia Updated Health Sector Review (In Draft)

A.3 World Bank, Indonesia Health Manpower Review, October 1, 1982 (In Draft)

A.4 World Bank, Indonesia 1982 Country Economic Memorandum, May 3, 1982, 3795-IND

A.5 World Bank, Indonesia Growth Patterns, Social Progress and Development Prospects, February 1979; 2093-IND

A.6 CIDA, Sulawesi Regional Development Study: Final Report, May 1979

A.7 GOI, Mid-Term Review of Repelita III for Central and South Sulawesi

A.8 GOI, INPRES Program for Health, 1981-82

A.9 GOI, National Health System, March 1982

A.10 WHO, Role of Hospitals in Primary Health Care, November 1981

B. Selected Working Papers

B.1 Sector Background Paper for Sulawesi B.2 Summary Project Proposal B.3 Central Sulawesi Project Proposal B.4 Southeast Sulawesi Project Proposal B.5 South Sulawesi Project Proposal B.6 Hospital Equipment List B.7 Architect's Working Papers - 70 -

INDONESIA PROVINCIAL HEALTH PROJECT C-1: The Structure of the Ministry of Health

Minister of Health

Inspector General Secretary General

Director General Directoe General Director General Director General of of Medical Care of Community Health o Coamunscable Drug and Food Control

National Institute of National Center for Research & Development Education and Training

Head of Provincial Health Office

Head of District Health Office

Head of Health Center (PUSKESMAS)

World Bank - 21489 JOU\:S A PROVINCIAL HEALTH PROJECT C-2: OrganizationStructure of the Ministryof Health ProvincialHealth Office

Provincial Health Officer

Administration Division

Personnel Finance Logistic GeneralAffairs Sub Division Sub Division Sub Division Sub Division

Division of Directing 1 Programs Formulation Division of Directing Division of Directing and Monitoring of and Evaluation Div. and Monitoring Comm. and Monitoring of CDC Prod, and Utilization Medical Care of Food and Drugs

Data Collection and Section of Health Section of Epidomi- Section of Prod. and ProcessingSection Center Services ological Surveillance Distribution of Food of CDC and Drugs

Programs Formulation Section of Hospital Section of Surveillance Section of Food and Section Services (Transmitter-insects) Drugs Utilization

Health Manpower Secton of Nutri- Section of Environ- Section of Dangerous Formulation SectiOn tional Improvement mental Health Drugs Control

Evaluation and l Section of Lab. and | Section of Health l Section of Traditional Reporting Division Health Facilities Engineering J Drugs

World Bank-24005 - 72 -

INrDONESIA PROVINCIAL HEALTH PROJECT C-3: Organization Structure of the Ministry of Health District Health Office

Head

| _ J ~~~~Adnninistration Sub Division

Sub Section:;ofv Sub Section of of Geea Affairs Personnel ll Fiac l

Section of D irect- Section of Direct- ing and Monitoring ing and Monitoring of Community of CDC and Drugs Services and Food Control

World Bank-24006 - 73 -

INDONESIA

PROVINCIAL HEALTH PROJECT

C-4: The Indonesia Health and Family Planning Systems

Level Health Network Family Planning Network

I l | INational Family Planingi I Central Ministry of Healthi |Coordinating Board

Prvic I I

ProvinceI I| Health Office I I NEPCB Office

I i L j.I

| District I District Office I i NEPCB Office

1-__~~~~~~~~~~~~~~~~ I

I 1 5 [ | | Field Workers I ISub-Districtl I Health Center II (Java/Bali and I | pilot areas in I 5I Other Islands)

1 1 I

I _ __ _ I _ _

Village i IVillage VolunteersI IVillage Contraceptive l(in few villages) I I Distribution Center

IBRD 16439 120° 122° 124- JUNE 1982

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-2- Srnpaga INDONESIA 2 HEALTH PROJECT

Uf9kUn ProjectFacilities and Activities Morn l u' / a\w$e) X . ,> Sulawesi

; ; as ' .4 s- ' 4.FF REGENCY HEALTH OFFICE & DRUG STORAGE alopo ~~~~~~~~~~~~~REGENCYHOSPITALS: h WT I CLASS2 AXC ! ;COPOA (Sf CLASS D Moien re ,9 Las...~~ t ~'A PROVINCIAL TRAINING CENTERS MO;eneX3Enre~s, 6 \P S t L(3;6aSOlO < ®) HEALTH CENTERS WITH BEDS PinrorT PP \2V \\ w . b

nU .;U | 6 C' o POPULATION DENSITY/ SOQKM. mmas f Mawasangka - , MORE THAN 250

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WTHAILAND . = - PHILIPPINES

. _ s3RUNE5'-%B -> fE z ' Z__Rt--S fX / kMALAYS I A-' -. NEW

O 50 100 150 200 a,,ksstaffo sX,SINGAPORE 5015,0 IT 2 0 PAPANE 0 00lso20bedmesom6tersm ~ ~ ~ ~ ~ ~ ~~~,O-,AAA,,ArKal,mantan, - GUINEW j>> ,oAO4A - , } Suiowesi ~ -I

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