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