Document of The World Bank FOR OFFICIAL USE ONLY INDONESIA FIFTH POPULATION PROJECT (FAMILY PLANNING AND SAFE MOTHERHOOD) LOAN 3298-IND.

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1 Public Disclosure Authorized Document of The World Bank FOR OFFICIAL USE ONLY Report No Public Disclosure Authorized IMPLEMENTATION COMPLETION REPORT INDONESIA Public Disclosure Authorized FIFTH POPULATION PROJECT (FAMILY PLANNING AND SAFE MOTHERHOOD) LOAN 3298-IND June 26, 1997 Public Disclosure Authorized Population and Human Resources Division East Asia and Pacific Department East Asia Region 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.

2 CURRENCY EQUIVALENT Currency Unit = Rupiah At Appraisal in 1990 US$1.00 = RP 1,901 Rp 1 million = US$ 526 Annual Average ,950 2,030 2,080 2,160 2,237 2,372 FISCAL YEAR OF BORROWER April 1 - March 31 ABBREVIATIONS BDDs BKKBN DHS GOI ICR IEC LSS MIS MOH NGOs NOLs NPV TFR Village Midwives Family Planning Coordinating Board Demographic and Health Survey Government of Indonesia Implementation Completion Report Information, Education and Communication Life Saving Skills Management Information System Ministry of Health Non-Government Organizations No Objection Letters Net Present Value Total Fertility Rate Vice President Director Division Chief Task Manager Jean-Michel Severino, EAP Marianne Haug, EA3DR Samuel Lieberman, EA3PH Fadia Saadah, EA3PH

3 FOR OFFICIAL USE ONLY TABLE OF CONTENTS Preface... Evaluation Summary...ii i PART I: PROJECT EVALUATION ASSESSMENT A. Statement of Objectives.I B. Achievement of Objectives.2 C. Major Factors Affecting the Project.7 D. Project Sustainability.8 E. Bank Performance.9 F. Borrower Performance G. Assessment of Outcome.10 H. Future Operations.10 I. Key Lessons Learned.11 PART II: STATISTICAL TABLES Table 1: Summary of Assessment Table 2: Related Bank Loans Table 3: Project Timetable.16 Table 4: Loan Disbursements: Cumulative Estimated and Actual.16 Table 5: Table 6: Studies Included in Project.19 Table 7A: Project Costs.22 Table 7B: Project Financing.22 Key Indicators for Project Implementation.17 Table 8: Status of Legal Covenants.23 Table 9: Bank Resources: Staff Inputs Table 10: Bank Resources: Missions.25 PART III: BORROWER'S ASSESSMENT 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.

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5 IMPLEMENTATION COMPLETION REPORT INDONESIA FIFTH POPULATION PROJECT (Family Planning and Safe Motherhood) LOAN 3298-IND Preface This is the Implementation Completion Report (ICR) for the Fifth Population Project (Family Planning and Safe Motherhood), for which Loan 3298-IND in the amount of US$ 104 million equivalent was approved on March 5, 1991 and made effective on June 20, The loan was closed on schedule on September 30, 1996, with an informal extension through January 31, 1997 to allow for payment of eligible expenditures incurred on or before the closing date. The final disbursement took place on January 28, 1997, at which time a balance of US$ 3.9 million was canceled. (There was a previous cancellation of US$0.2 million in November 1995). No cofinancing for the project was provided. The ICR was prepared by Eduard Bos, Population Specialist in HDDHE and Fadia Saadah, Population and Health Specialist, EA3PH. The report was reviewed by Samuel Lieberman, Chief, Human Resources Operations Division, EA3PH, and Oscar de Bruyn Kops, Acting Project Advisor, EA3DR. Preparation of this ICR was based on a mission carried out during November 1996, on materials in the project file, and on data and reports provided by the implementing agencies. The Borrower contributed to the ICR by preparing an evaluation of the project and by commenting on the draft ICR.

6 ii IMPLEMENTATION COMPLETION REPORT INDONESIA FIFTH POPULATION PROJECT (Family Planning and Safe Motherhood) LOAN 3298-IND Evaluation Summary Introduction i. By the late 1980s, Indonesia was well advanced in its fertility transition with the total fertility rate (TFR) having fallen from 5.6 to 2.9 (Demographic and Health Survey; 1994) in the previous two decades. This fertility decline was due in no small measure to the activities of the country's family planning program which the Bank had supported through four earlier loans. Under the leadership of the Family Planning Coordinating Board (BKKBN), family planning became sanctioned and accepted normatively, widely practiced, and institutionalized, the hallmarks of an advanced program. Accordingly, a key aspect of the context when this operation was designed was the need to refocus the agenda of an agency -- BKKBN -- (which became a ministry with a wider mandate early in project implementation) and to pursue goals and initiatives in keeping with the requirements of a maturing program. ii. A second important feature of the context when the project was designed was Indonesia's more limited achievements as regards morbidity and mortality due to reproductive causes. The project was prepared when the government's initial policies as regards safe motherhood were being formulated and comprised a first step towards improving reproductive health services. These initiatives preceded by several years the 1994 International Conference on Population and Development in Cairo. However, the Cairo meeting and its aftermath encouraged Indonesian policy makers to press ahead with reproductive health interventions, a decision which became part of the background for this project. Project Objectives iii. Of the project's two broad objectives, the first was to assist BKKBN in carrying out its tasks and responsibilities in a setting defined by a maturing family planning movement. These included improving access to contraceptive services for remaining difficult-to-reach groups, improving the clinical quality of services, and responding through alternative approaches to service delivery and communications campaigns to the diversity of clients' needs and to the growing number of contraceptive delivery channels. The second objective was to help the Government of Indonesia (GOI) expand access to maternal health services by training and deploying village midwives. This was a crucial part of the government's overall approach to making motherhood safer.

7 iii iv. Corresponding to these objectives, the project had the following components: PartA (BKKBN) * Targetedfamily planning and safe motherhoodpromotion activities intended to improve service accessibility and utilization among the urban poor and populations in coastal and transmigration areas; promote family planning services in the organized sector; improve quality of family planning services; and to publicize safe motherhood interventions. * Information, education and communication (IEC) and community outreach designed to support improvements in BKKBN's IEC strategy and system capacity, promote participation of youth in family planning and develop community institutions in specific areas. + Institutional development that provided for staff development training activities, reform of BKKBN's management information system (MIS), evaluation and research capacity and strengthening of the field operations through the provision of vehicles, equipment, contraceptives and other materials. Part B (Ministry of Health) * Strengthening ofpolicyframework on the objectives and related training and planning principles that would govern the deployment of village midwives (BDDs). * Strengthening training capacity through training of trainers and improving teaching materials and equipment. * Training and improving the effectiveness of about 16,000 BDDs, including establishing accreditation standards for midwifery training schools and certifications procedures for BDDs. v. The objectives were carefully formulated, drawing on the findings of a major sector study completed in The project's family planning components responded to the needs of a maturing family planning program, while the operation's support for midwife training and policy research was in keeping with GOI's decision to improve maternal health. The Bank's involvement was consistent with its country assistance strategy and its approach to human resource development in Indonesia. Implementation Experience and Results vi. The loan was approved by the Board in May 1991, became effective on June 20, 1991, and was closed on schedule on September 30, Total project costs were US $104.0 million, of which US$ 4.1 million was canceled. The project achieved its objectives and all of the major components in Part A and Part B were implemented in a satisfactory manner.

8 iv vii. The project recorded a number of achievements. Components dealing with targeted family planning services were implemented and provided valuable insights on how to improve services in these hard-to-reach areas. The importance of quality in family planning services was documented through project-funded research. Quality improvements in contraceptive services were brought about through expanded method choice (via procurement of contraceptives), and by upgrading through training the clinical and counseling skills of providers. The challenge of removal needs for implants was addressed after project-supported research revealed the magnitude of the issue. Capacity in IEC development and delivery was strengthened through equipment purchase and audience research. Institutional development was accomplished by updating and streamlining the MIS, in-country and overseas training for BKKBN staff, and operations research on various topics, including those just cited. viii. Part B attained the policy objectives concerned with clarifying the roles of midwives and setting up an accreditation mechanism for midwife schools and a ministerial decree defining the role of midwives was issued. Training capacity was enhanced through training of trainers and procurement of teaching equipment and materials and about 16,000 village midwives were trained and deployed. ix. In terms of broad outcomes, the project's design as a de facto program loan to support BKKBN's entire effort militates against measuring project specific impacts on fertility and maternal mortality and morbidity. However, it is reassuring that key fertility and mortality indicators moved in the desired direction during implementation. The project also yielded interesting results on the institutional front. This operation was one of the first for the Bank in Indonesia to concentrate on support for software, i.e., training, studies, and so forth, and provided useful lessons in this regard (see para. xiii below). The flexibility built into the project allowed for key activities to be revised several times to reflect changing needs and priorities, e.g., expanding efforts related to improving clinical skills of health providers and enhancing the quality of midwifery training. However, this flexibility was not always used optimally. This was due partly to continuing rigidities in GOI's planning and budgeting procedures, also because of the absence of clearly defined goals and targets for some interventions, and because managers within BKKBN and MOH gave higher priority to implementing long planned activities than to developing and pursuing alternative strategies. Summary of Findings, Future Operations, and Key Lessons Learned x. The project achieved its objectives. Overall performance by both the Borrower and the Bank were rated satisfactory. The Borrower's implementation performance was rated highly satisfactory. xi. The investment appears, on balance, to be sustainable. Key components and activities relating to service and information provision and quality improvements have been absorbed into BKKBN's ongoing program. As for Part B activities (MOH), follow up activities and projects have been designed to address factors bearing on the professional and economic viability of village midwives.

9 v xii. Key lessons learned: Substantive issues * Local specificity of family planning interventions -- Addressing needs of specific population groups as well as increasing the effectiveness of existing programs requires plans that better reflect local needs and conditions. This was clearly illustrated in the component dealing with targeted family planning. * Quality of family planning and maternal health services. Although the initial project design included interventions to improve quality of family planning and maternal health services, the mid-term review of the project as well as other sector studies indicated that the unfinished agenda was significant. In addition, improving quality of services is essential for addressing the unfinished agenda in family planning and maternal health services. In response, project resources were reprogrammed to place more emphasis on improving quality of services. Additional programs for improving quality of care have been launched in follow-up initiatives. * Effectiveness and sustainability of BDDs. As efforts to train and deploy BDDs were underway, it became apparent that the completion of the BDD program (as initially designed) will not be adequate to address maternal health needs. The BDDs were not adequately trained and many had difficulties in gaining credibility as health providers and integrating into the village community. Moreover, it was not clear if these BDDs would be sustained in the villages after the completion of their three (or six) year contracts. GOI needs to address this important policy issue in the near future. * Linkages between supply- and demand- side interventions. The project financed pilots to address demand and supply side interventions related to safe motherhood. These pilots were effective in demonstrating the need for intensifying such efforts and for enhancing the coordination of demand and supply side activities -- a lesson that has been incorporated in follow-up operations. Implementation/process issues * Investment projects as tools for addressing policy reforms. Projects can be useful in addressing some policy issues if (a) they have very clearly defined objectives and linkages to the program; (b) there is strong ownership by the government; and (c) they are very closely supervised. This was illustrated in the component dealing with midwifery policy issues. * Annual Planning and flexibility in project design. The project adopted an annual planning process that allowed for flexibility in project implementation and strengthened the ability of the project to respond to sector issues that emerged during execution. However, the lack of flexibility in some government procedures (especially the DIP process) and the lack of well identified monitoring indicators limited the optimal use of this feature. Although the lack of felxibility in the planning and budgeting process is a systemic issue that affects most sectors in Indonesia, future operations and discussions with GOI should continue to address this constraint.

10 vi * Performance-based-contracts for research. The completion and/or quality of some studies did not always meet the expected standards. Future projects may wish to consider performance-based contracts that ensure the quality and timeliness of the delivery of the studies. * Ownership/leadership. The project enjoyed the support of strong leadership at BKKBN and high degree of ownership among its implementing agencies. These were key elements in its success and timely completion.

11 IMPLEMENTATION COMPLETION REPORT INDONESIA FIFTH POPULATION PROJECT (Family Planning and Safe Motherhood) LOAN 3298-IND Part I: PROJECT EVALUATION ASSESSMENT A. Statement and Evaluation of Objectives 1. The project's objectives were to support the strategies of the Government of Indonesia (GOI) in family planning and maternal health. Project activities were intended to increase access to family planning methods, to improve the quality of family planning services, and to improve maternal health through expanded community health services. The Bank's involvement was consistent with its strategy for assistance in human resource development in Indonesia, which emphasized a focus on less developed areas and on the poor. 2. Project objectives were developed in a context of successful realization of GOI's longstanding family planning goals. Thus project design focused on the need to refocus the agenda of an agency and to pursue goals and initiatives driven by the requirements of a maturing program. A second important feature of the context when this operation was designed was Indonesia's more limited achievements as regards morbidity and mortality due to reproductive causes. Moreover, the project was prepared when the government's initial policies as regards safe motherhood were being formulated and comprised the first step towards improving reproductive health services. 3. The specific objectives of the project were first to assist BKKBN in carrying out its tasks and responsibilities in a setting defined by a maturing family planning movement. These included improving access to contraceptive services for remaining difficult to reach groups, upgrading the clinical quality of services, and responding through alternative approaches to service delivery and communications campaigns to the diversity of clients' needs and to the growing number of contraceptive delivery channels. The second objective was to help GOI expand access to maternal health services and training and deploying village midwives. This was a crucial part of the government's overall approach to making motherhood safer. 4. Corresponding to these objectives, the project had the following components: Part A (BKKBN) * Targetedfamily planning and safe motherhood promotion activities intended to improve service accessibility and utilization among the urban poor and populations in coastal and transmigration areas; promote family planning services in the organized sector; improve quality of family planning services; and to publicize safe motherhood interventions.

12 Part B (MOH) 2 * Information, education and communication (IEC) and community outreach designed to support improvements in BKKBN's IEC strategy and system capacity, promote participation of youth in family planning and development of community institutions in specific areas. * Institutional development that provided for staff development, reform of BKKBN's management information system (MIS), evaluation and research capacity and strengthening of the field operations through the provision of vehicles, equipment, contraceptives and other materials. + Strengthening ofpolicy framework on the objectives and related training and planning principles that would govern the deployment of village midwives (BDDs). * Strengthening training capacity through training of trainers and improving teaching materials and equipment. * Training and improving the effectiveness of about 16,000 BDDs, including establishing accreditation standards for midwifery training schools and certifications procedures for BDDs. 5. The objectives were carefully formulated, drawing on the findings of a major sector study completed in The project's family planning components responded to the needs of a maturing family planning program, while the operation's support for midwife training and policy research was in keeping with GOI's decision to improve maternal health. The Bank's involvement was consistent with its country assistance strategy and its approach to human resource development in Indonesia. B. Achievement of Objectives 6. The project substantially achieved its major objectives for both Parts A and B. An assessment of the contribution of the project towards the objectives is provided below for each component. Part A: Family Planning Program (BKKBN) 7. Expansion of family planning services in hard-to-reach areas: This component included: targeted services to the coastal areas, transmigration areas, the organized sector, and the urban poor. The exact impact of these services cannot be measured for the specific areas. However, the results of the Demographic and Health Survey' results indicate that, overall, the achievements of the family planning program are consistent with the project objectives. For instance, the contraceptive Indonesia Demographic and Health Survey Central Bureau of Statistics; State Ministry of Population/National Fanily Planning Coordinating Board; Ministry of Health; and Demographic and Health Institute- Macro International Inc. October, 1995.

13 3 prevalence for modern methods increased from about 47 percent in 1991 to about 52 percent in 1994; unmet need for family planning services dropped from 12.7 percent in 1991 to 10.6 percent in 1994 among married women and from 13.9 percent in 1991 to 11.7 percent in 1994 among married women with no education. 8. Implementation of planned activities for the coastal and transmigration areas was completed. As these activities occurred in small areas in districts scattered across Indonesia, an accurate estimate of the increase in contraceptive use is unknown. However, these relatively small scale efforts provided important lessons for improving the effectiveness of family planning services that benefited the general programs dealing with these issues. For instance, the project demonstrated that the effectiveness of the interventions is greater if local conditions and needs were better reflected in the project annual plans -- a finding that guided the project implementation after its mid-term review. 9. The third component dealing with targeted service delivery focused on family planning services for the organized sector. The implementation targets for this component exceed the appraisal estimates. The project supported provision of family planning services and IEC to employees of more than 7,000 businesses. This model has worked better in larger firms with existing company clinics. Moreover, as the activities of this component were completed, a health insurance scheme for organized sector workers expanded its coverage to include family planning, ensuring sustainability of this approach. 10. The achievements of the pilots for delivery of family planning services to poor urban areas were more limited. Delays in implementation resulted from the difficulties encountered in defining the urban poor communities. While implementation of this components was achieved, the effectiveness of the activities could have been enhanced if (a) contractual arrangements with NGOs to deliver services for the urban poor were conducted in a more competitive manner and were completed more efficiently; and (b) more clearly defined outputs and indicators were defined at appraisal. 11. Safe motherhood promotion. Activities to publicize safe motherhood interventions were carried out by BKKBN. The original plan was that such demand-side interventions will support and supplement the activities supported under Part B of the project -- i.e., supply-side interventions. However, the demand- and supply-side interventions were not fully coordinated. 12. Improving the quality of family planning services. The project made important contributions towards improving the quality of family planning services through improving the method mix by procurement of long-term contraceptive methods, training providers in service delivery, and improving counseling skills of providers. These activities were completed and about 15,000 doctors, midwives, and family planning field workers were trained in clinical skills and counseling 13. After the start of the project, it became clear that not enough providers were available for skilled removal of implants, which had become a popular contraceptive method in Indonesia, after the end of its effective period. Furthermore, recording and tracking of acceptors of implants was

14 4 inadequate. These issues were exacerbated by the rapid expansion in implant use during the first two years of the project. Several initiatives were undertaken to address these issues. Studies financed by the project were carried out on the magnitude of the implant use, resulting in projections of the expected number of removals needed in the future. Training materials were produced and training of doctors and midwives in removal of implants was carried out. The addition of midwives trained in removal of implants may be expected to alleviate the backlog of women who did not have the removal done after five years (estimated at 10 percent of the 1990 cohort of acceptors). Future efforts need to continue efforts to improve tracking of implant acceptors and developing the implant strategy. 14. The importance of quality for a successful family planning program cannot be overstated. Research conducted as part of the project indicated that health concerns and side effects were the main reasons for discontinuation of a method or for not using one at all. Counseling and follow-up could in many cases address such concerns by directing couples to the most appropriate contraceptive method. One of the Norplant studies supported by the project found that women who had access to removal on demand were more likely to continue practicing family planning than those who did not. And while proximity to a service provider was the most important reason for choosing a source of contraceptive supplies, the competence of staff and the quality of the facility were also found to be important reasons. The documentation of the importance of quality and the project's efforts to improve quality must be seen as among the most important contributions of the project. 15. Improving LEC and youth outreach. Dissemination of information is an appropriate area for a mature program to be active in, and the subcomponent on youth outreach were particularly relevant. This component was designed to pilot and develop new approaches, strengthen IEC message design capabilities, and carry out audience research. The equipment was procured as planned and most activities were undertaken. However, the province specific audience research and market segmentation were only completed in the second half of the project. Thus, the expected changes in the content of the IEC messages did not materialize during implementation. Nevertheless, the investments made in this project are likely to be useful for future program development, especially as the country implements its decentralized strategy. 16. Institutional development. The training subcomponent was designed to strengthen skills at all levels of the family planning program to meet the needs of a mature program and to allow the program to change strategically. Staff development was seen as an important organizational tool when technological changes and external developments imposed new requirements. In-country training and refresher courses appeared to have been particularly successful for upgrading skills of BKKBN staff. The project supported about 132 Master degree and 11 Ph.D. students overseas. In addition, 3290 candidates received D3 degrees, 406 received masters degrees and 124 candidates received post-graduate degrees in country. Moreover, a large number of staff received in-service technical training in family planning related fields. Although several of these training activities were completed and the educational level of the staff was upgraded, BKKBN did not develop a clear manpower strategy to guide the staff development program. As a result, BKKBN did not train adequate numbers of staff in areas like reproductive and maternal health or adolescent reproductive

15 issues. Moreover, the mangers of the staff development program were generally more concerned with completion of the implementation as opposed to the effectiveness of the program. 17. Program monitoring and research. The research subcomponent was intended to build up research capacity in BKKBN, while simultaneously providing useful information for program implementation. A total of 44 research activities was carried out under Part A, most of which were directly linked to program issues. The 1994 DHS funded by the project has become a valuable reference for health and mortality information for many other purposes, especially service delivery related issues. Studies carried out on implants also provided useful information for program delivery, leading to additional efforts to improve program quality 2. Although research topics and terms of reference were generally good, the final quality and/or the completion of the relatively small scale studies and operational research did not meet expected standards The process for developing and seeking approval for a large number of research proposals proved to be burdensome for the Borrower, and the process of reviewing the proposals was timeconsuming for the Bank. As a result, obtaining the required approvals from the Bank for each proposal often resulted in delays in conducting the research. This was at times due to the inappropriateness or other deficiencies of the proposed studies, at other times this was due to administrative delays. Providing technical assistance at the design and/or report writing stages of research projects as well as performance-based-contracts for such projects could be useful tools that may be adopted by future projects to enhance the quality of Bank funded research. 19. The revision in the MIS to improve monitoring was successfully implemented through simplified reporting requirements and upgraded computer hardware. As a result, the number of data items in the recording and reporting system decreased from 367 to 240. Future challenges for the MIS system involve the growing role of the private sector in service delivery and identifying needed information from the private sector for program planning purposes. Part B: Midwives Development (MOH) 20. Strengthening the Policy Framework. One of the most important successes of Part B was the institutionalization of Ministerial Decree 572 that defines the role of the midwife, thereby legitimizing her role as a (private) health provider. The Decree also requires that the licenses for midwives be renewed every five years -- a measure that can be used to ensure quality control of midwifery practice. A working group has been established to operationalize the Decree and address issues related to its implementation. However, the establishment and implementation of midwifery standards are still in the early stages of development with assistance from WHO. Moreover, the establishment of a Midwifery Board, another objective of this subcomponent, did not materialize 2 This study represents an important contribution to the literature in its approach and methodology. It utilizes data that is not available in most other countries and provides important insights to the introduction and implementation of Norplant contraceptives.

16 despite several efforts and activities to create such an entity. It is likely that future projects dealing with health professionals will deal with the issue of Boards for health professionals including midwives. 21. The project also provided support for study tours related to midwifery training and deployment and a series of evaluation studies of the different midwifery training programs. These evaluative efforts provided useful information for guiding the next steps needed for improving the quality of midwifery services. Many of the recommendations put forward by these evaluation studies have already resulted in important follow-up action by MOH including a revised in-service training strategy for village midwives Strengthening the training capacity. The project was successful in developing an accreditation system for midwifery schools. By the time the project closed, this was under implementation, with 10 percent of the schools already receiving an accreditation rating. However, the implementation of the accreditation system remains a reactive process that is dependent upon individual initiative from the schools to complete the self-assessment. Accreditation needs to be more proactive for it to be effective in standardizing quality. 23. As part of the support for strengthening the training capacity, the project funded curriculum revisions. Two sets of curriculum changes were introduced in 1991 and The major difference was omitting the two-year work experience requirement before acceptance into the midwifery program. Although the 1994 curriculum is more systematic and process oriented than the 1991 program, further revisions may be needed in the future to further enhance the quality of midwifery training. 24. Another constraint affecting training quality and capacity related to the quality of trainers and teaching materials. The project responded by supporting several training programs to enhance the capacity of teachers, especially following the decree that accelerated the training and deployment of community midwives and created an immediate need to train more teachers. Forty two midwifery teachers were sent overseas for a course in education techniques and advanced midwifery, and another 20 teachers were sent for short-courses in problem-based learning in midwifery education. In-country training was also provided for midwifery teachers and clinical instructors. Although these efforts were critical to strengthening the quality of the clinical training, they could not compensate for the low exposure of the midwifery students to clinical cases -- a consequence of GOI's acceleration of the training of village midwives. 25. Training and improving effectiveness of community midwives. The planned target of training about 16,000 community midwives was achieved. In addition, the project supported efforts to develop in-service training on life savings skills (LSS) to improve the skills of village midwives. Assessment of the LSS training pointed to the need to develop an in-service training strategy for these midwives -- an effort that has already started as part of the preparation of the upcoming Safe Motherhood Project.

17 7 26. As for the deployment of community midwives, a position for a Midwife Coordinator, located at the district and sub-district level, was created to assist with management of the community midwives after deployment. However, the role and effectiveness of these Coordinators still would require future evaluation, especially since many community midwives still receive little supervision and support. 27. In addition, the project supported the establishment of a Midwife Baseline Data registration that allows for tracking midwives after their deployment. Minimal information is recorded such as: name, age, date graduated, and employment location. Computers were sent to 26 provinces but apparently the system is currently underutilized. 28. Project management. At BKKBN, a Project Secretariat was established during the first year of the project, and the Deputy for Program Planning and Analysis was the Project Director. During year 3 of the project, the Secretariat was dismantled, and project activities were institutionalized within the BKKBN organizational structure and handled by a small team. One consequence was that project financial reports were sometimes incomplete or late. In addition, and given that not all of BKKBN's Bureaus were familiar with the Bank's procedures, procurement of certain activities took longer than needed. 29. As for Part B, after initial delays in the first 18 months of implementation, project management improved significantly. This was party due to the change in the Project Secretariat. Project activities progressed smoothly thereafter due to diligent management efforts. The Secretariat efficiently executed project activities through their consistent follow-up. 30. A steering committee was established to carry out joint assessments and policy review, and to coordinate the work of the separate project secretariats that had responsibilities for implementing Part A and Part B. However, Part A and Part B were essentially implemented as two parallel projects. Factors generally outside Government control C. Major Factors Affecting the Project 31. One of the key external factors that positively affected the project was the 1994 International Conference on Population and Development. This Conference and its agenda for follow-up action represented a strategic shift in the prevailing approach as regards family planning and reproductive health issues. The Conference called for more emphasis on reproductive health concerns and stressed the importance of the quality of family planning services. Indonesia, which was an important participant and supporter of the Conference, embraced its recommendations -- a decision that supported the project and its objectives.

18 Factors generally subject to Government control 32. A number of factors affected the project's implementation and ability to achieve its objectives. These include: 8 * Expansion of BKKBN's mandate. During the third year of project implementation, BKKBN's mandate was expanded to include family welfare in addition to family planning. Although the family welfare activities are complementary to those of family planning, adjustment to the new organizational structure was time consuming and affected the implementation of various project activities at the time. However, when some of these issues were identified at the mid-term review, BKKBN's management took corrective steps and gave more attention to the project. It is not possible to assess the impact of the reorganization on service delivery and/or field activities. * Acceleration of the village midwife program. A Presidential decree issued in January 1993 accelerated the training and deployment of midwives, with the placement of a midwife in every village to be achieved by This led to the need for expedited training to meet the numerical targets, which offset efforts to improve the practical training offered to midwives. * Political support for safe motherhood. The last five years have witnessed increased political commitment and support for safe motherhood initiatives. This support enhanced the project's ability to achieve its objectives and strengthened the already strong ownership of Government to the project and its objectives. Factors generally subject to implementation agency control 33. Among the key factors that affected the project and that were under the control of the implementing agency were: * Coordination between the two parts of the project. The two agencies could have collaborated more -- this would have benefited both components. * Project management. In general, the project's managers performed well and as a result many of the project findings were institutionalized or followed-up. When the performance of Part B was unsatisfactory in the first 18 months of the project, GOI took action and appointed a new team at the project secretariat, resulting in significant improvements in implementation. In Part A, BKKBN provided strong support and leadership for the project. The Minister himself chaired most of the wrap-up meetings and followed-up on project performance and activities. However, the dismantling of the secretariat for Part A in the last 2 years of the project resulted in few delays that could have been avoided. D. Project Sustainability 34. Overall, The investment appears, on balance, to be sustainable. Key components and activities relating to service and information provision and quality improvements have been absorbed into BKKBN's ongoing program. Follow-up projects have been designed and will be used

19 to carry forward GOI's strong commitment to safe motherhood, specifically by addressing the factors bearing on the professional and economic viability of village midwives Part A. Many of the interventions in Part A of the project are already institutionalized or have been added to regular program activities. For instance, services for coastal areas are now part of the regular program activities and will continue beyond the life of the project. Efforts to improve quality of services have led to the establishment of quality assurance groups for family planning services at the district and province levels -- an activity that will also be supported in the follow-up investment to this project. On the other hand, efforts to revise the MIS are already in place. The results of the research studies have been incorporated into program activities and other investment plans. In addition, the project's investments in changing norms and behaviors will enhance the sustainability of its results and efforts to improve quality of services will increase the long term sustainability of the program. 36. Part B. Sustainability of Part B's achievements is likely, but will face important challenges in the next few years. Contracts of private community midwives expire after three years, with the first batch expected to "graduate" during Midwives who have completed their contracts may be attracted to private sector hospitals or private practices in cities. If these midwives are the linchpin of the safe motherhood strategy, then efforts to improve their effectiveness and sustainability are needed. In response to this urgent need, a number of policy options have been developed with GOI and will be implemented in the follow-up safe motherhood project. E. Bank Performance 37. Overall Bank performance was satisfactory. During project preparation and appraisal, appropriate skills mix during missions had a positive influence on the preparation of individual components for Part A. In terms of technical assessments, the project was well prepared. However, the monitoring of project impact should have received more attention. 38. Supervision occurred biannually during each of the project years, and was generally found to be useful by the Borrower. Missions were generally staffed with population/health specialists and supported with operational staff from the resident mission. The review missions drew upon other expertise as needed for project implementation. In addition, staff involved in project preparation were also involved in its supervision and there were only two changes in the task management of the project -- features that provided the project with the continuity needed for good implementation. On the other hand, the suggestion made in the SAR for the placement of a long term expert in family planning administration in the Bank's office in Jakarta did not materialize. This resulted in a higher supervision load for Bank staff than was anticipated at appraisal, especially for activities like research that require significant resources (in terms of time and skills) to review.

20 10 F. Borrower Performance 39. Overall Borrower performance was satisfactory. Government commitment to the project objectives and achievements was very high. Project components, especially Part A, were well prepared and both Parts of the project were well supported. Covenant compliance was satisfactory (Table 8). Implementation was especially satisfactory with effective project staff and leadership. There was good team work between the Government and Bank teams. G. Assessment of Outcome 40. The project's net present value (NPV) cannot be calculated accurately because many of the project outcomes cannot be measured quantitatively and it is difficult to assess some outcomes in monetary terms. Moreover, the project's design, as a program support loan, does not allow for the separation of influence of the project interventions, other program interventions, and other determinants of fertility and health status. 41. The project's interventions and its immediate outcomes have been achieved. However, the medium-term impact of project activities cannot be measured at this time. For instance, the impact of increased contraceptive use on fertility, the impact of IEC messages on adolescent behavior, or the effects of training on institutional development are all likely to have a medium- to long-term effects that are beyond the scope of this evaluation. It is, however, reassuring to note that sector wide indicators moved in the desired direction during implementation -- e.g., the decline in TFR (from 3.02 in 1991 to 2.85 in 1994) the increase in contraceptive prevalence rate (from 47.1% in 1991 to 52.2% in 1994), the decrease in unmet need (from 12.7% in 1991 to 10.6% in 1994) and so forth. 42. The assessment of the effectiveness of the midwifery training program and its policy is more challenging. The effectiveness of this new cadre of health providers has not been demonstrated yet. This issue will be tackled in the upcoming Safe Motherhood Project. Experience from other countries that implemented similar "village midwife" programs (e.g., Malaysia, Philippines) points to mixed findings. It is likely that this approach has its merits and can greatly increase access to services at the village level. However, efforts to improve technical competence of the midwives and sustainability need to be carefully examined in the near future. H. Future Operations 43. Most activities carried out under the project continue to be supported by GOI. Many of the interventions have been integrated into ongoing programs. In addition, GOI has followed-up on project findings and evaluations through a series of efforts that include the upcoming Safe Motherhood Project: A Partnership and Family Approach. This project responds to the lessons learned from the Population V Project, especially those related to sustainability and effectiveness of

21 11 village midwives; quality of maternal and reproductive health services (including family planning); and the linkages between supply and demand- side interventions. In addition, lessons learned from the Population V Project were incorporated in ongoing projects like the Third Community Health and Nutrition Project (Loan 3550-IND). I. Key Lessons Learned 44. The key lessons learned from the project have been grouped into two categories: those dealing with substantive issues and others dealing with implementation/process. Substantive issues * Local specificity of family planning interventions -- Addressing needs of specific population groups as well as increasing the effectiveness of existing programs requires plans that better reflect local needs and conditions. This was clearly illustrated in the component dealing with targeted family planning. * Quality of family planning and maternal health services. Although the initial project design included interventions to improve quality of family planning and maternal health services, the mid-term review of the project as well as other sector studies indicated that the unfinished agenda was significant. In addition, improving quality of services is essential for addressing the unfinished agenda in family planning and maternal health services. In response, project resources were reprogrammed to place more emphasis on improving quality of services. Additional programs for improving quality of care have been launched in follow-up initiatives. * Effectiveness and sustainability of BDDs. As efforts to train and deploy BDDs were underway, it became apparent that the completion of the BDD program (as initially designed) will not be adequate to address maternal health needs. The BDDs were not adequately trained and many had difficulties in gaining credibility as health providers and integrating into the village community. Moreover, it was not clear if these BDDs would be sustained in the villages after the completion of their three (or six) year contracts. GOI needs to address this important policy issue in the near future. * Linkages between supply- and demand- side interventions. The project financed pilots to address demand and supply side interventions related to safe motherhood. These pilots were effective in demonstrating the need for intensifying such efforts and for enhancing the coordination of demand and supply side activities -- a lesson that has been incorporated in follow-up operations. Implementation/process issues * Investment projects as tools for addressing policy reforms. Projects can be useful in addressing some policy issues if (a) they have very clearly defined objectives and linkages to

22 12 the program; (b) there is strong ownership by the government; and (c) they are very closely supervised. This was illustrated in the component dealing with midwifery policy issues. * Annual Planning and flexibility in project design. The project adopted an annual planning process that allowed for flexibility in project implementation and strengthened the ability of the project to respond to sector issues that emerged during execution. However, the lack of flexibility in some government procedures (especially the DIP process) and the lack of well identified monitoring indicators limited the optimal use of this feature. Although the lack of felxibility in the planning and budgeting process is a systemic issue that affects most sectors in Indonesia, future operations and discussions with GOI should continue to address this constraint. * Performance-based-contracts for research. The completion and/or quality of some studies did not always meet the expected standards. Future projects may wish to consider performance-based contracts that ensure the quality and timeliness of the delivery of the studies. * Ownership/leadership. The project enjoyed the support of strong leadership at BKKBN and high degree of ownership among its implementing agencies. These were key elements in its success and timely completion.

23 13 IMPLEMENTATION COMPLETION REPORT INDONESIA FIFTH POPULATION PROJECT (Family Planning and Safe Motherhood) LOAN 3298-IND PART II: STATISTICAL TABLES Table 1: Summary of Assessments A. Achievement of Objectives Substantial Partial Negligible Not applicable Macro Policies n mxi Sector Policies E n E g Financial Objectives al le lxi Institutional Development ix] i 2i [I Physical Objectives El El Poverty Reduction m Gender Issues lx E El 2I Other Social Objectives El E El Environmental Objectives [ El ] l Public Sector Management l lx a E Private Sector Development E E El Other (specify) U E L 3 (Continued) B. Project Sustainability Likely Unlikely Uncertain (i) (.1) (i) [El 1E El

24 14 Highly C. Bank Performance satisfactory Satisfactorv Deficient Identification P7 Preparation Assistance E X Appraisal 3 Supervision C Highly D. Borrower Performance satisfactorv Satisfactory Deficient (V') (/) (/) Preparation Implementation FM Covenant Compliance a Operation (if applicable) I Eli Highly Highl E. Assessment of Outcome satisfactory Satisfactorv Unsatisfactory unsatisfactory El le

25 15 Table 2: Related Bank Loans/Credits Loan/credit title Purpose Year of Status approval 1. Credit 300-IND To assist GOI in establishing clinic-based family 1972 Closed Population I planning in six provinces in Java-Bali; improve information and motivation 2. Loan 1472-IND To expand family planning program to ten 1977 Closed Population Il additional provinces; to establish contraceptive distribution centers in Java-Bali; strengthen population education and motivation 3. Loan 1869-IND To expand family planning program to remaining 1980 Closed Population III provinces; to assist GOI decentralize management of family planning program; to strengthen planning program; to strengthen maternal and child health services 4. Loan 2529-IND To expand family planning program in Outer 1985 Closed Population IV Islands; finance field operations, staff development, IEC; assist Ministry of Population and Environment to perform its policy and coordinating role 5. Loan 3042-IND Raise health status in East Kalimantan and Nusa 1989 Closed Third Health Tenggara Barat by improving delivery of health services and strengthening sector management 6. Loan 3550-IND To enhance programs for child survival, safe 1992 Ongoing Third Community motherhood and nutrition in five provinces; build Health and Nutrition provincial capacity to plan, monitor, and evaluate services; strengthen central MOH to provide technical support to provinces 7. Loan 3905-IND To increase the capacity of provincial and district 1995 Ongoing Health IV health offices; improve access and utilization of health services by the poor; improve efficiency in service delivery of basic health services 8. Loan IND Lower STD and HIV incidence in two areas: 1996 Ongoing STD/AIDS Jakarta and Riau and to operationalize GOI's national AIDS strategy 9. Loan 4125-IND To lower the prevalence of iodine deficiency 1997 Ongoing Intensified Iodine Def. through: (a) monitoring of iodine status; (b) Control Project increasing consumption of Iodized salt; (c) targeted distribution of iodine capsules; and (d) improved coordination of activities among partners.

26 16 Table 3: Project Timetable Steps in Project Cycle Date Planned Date Actual/ Latest Estimate Identification/Preparation n.a. September 1989 Preappraisal n.a. April 1990 Appraisal August 1990 August 1990 Negotiations April 1991 April 1991 Board Presentation May 1991 May 1991 Signing May 1991 May 1991 Effectiveness June 1991 June 1991 Midterm review July 1994 July 1994 Project Completion September 1996 September 1996 Loan Closing September 1996 September 1996 Table 4: Loan/Credit Disbursements: Cumulative Estimated and Actual (US$ thousands) FY91 FY92 FY93 FY94 FY95 FY96 FY97 Appraisal estimate 6,500 12,500 26,500 51,000 80,100 97, ,000 Actual 6,500 11,630 29,420 56,800 79,920 97,960 99,890 Actual as % of Estimate 100% 93% 113% 111% 100% 100% 96% a/ Date of final January 1997 disbursement a/ USD $200 thousand was canceled in November 1995 Balance of US$ 3,909, was canceled in January 1997

27 17 Table 5: Key Indicators for Project Implementation Key Implementation Indicators Appraisal Targets Actual PART A Targeted family planning Workshops and orientation sessions at Planned on annual basis Completed provincial and district levels Operational research on target group Completed needs Preparation of annual assessments of NA Completed delivery strategy Provide FP services to coastal districts Provide FP services to transmigration UPTs Provide FP services to the organized 2,250 7,503 sector Define altematives for providing Identified at mid-term review Completed services to the urban poor Contract NGOs to provide services to Partially completed the urban poor Safe motherhood promotion Training participants by level * district NA 181 * subdistrict 363. villages 716 Training of trainers -district level NA 1,144 Training of new UPPKA NA 3,416 Training of SM cadres NA 5,126 Enhancement of contraceptive mix Number of doctors, midwives, and field 15,579 15,482 workers trained in long-term methods Procurement and distribution of NA Completed Norplant, IUD kits, and laparascopes IEC strategy and youth component TV media programs AVA 1 I Audio media: Master and copy 13 master audios 13 master audios & copies & copies MIUs MPC Procurement of other equipment and 99% completed IEC materials

28 18 Key Implementation Indicators Appraisal Targets Actual Completed Audience research carried out Youth involvement: Percentage of 88% targeted villages reached BKKBN staff development Preparation of annual training plans Completed Evaluation of the training program Requested at Mid-term review Partially completed Program monitoring and research Review of research planning and Completed preparation of agreed implementation schedule Design and introduce modifications Completed of the FPMIS on the basis of an assessment Field operations Maintenance of adequate supplies Completed and equipment throughout BKKBN PART B Develop policy framework Establish Task Force on Family Completed Planning and Safe Motherhood Revise curricula, certification, and Completed examination for community midwives Develop and employ agreed Completed standards to select institutions for training midwives Establish Midwifery Board Not Done Issue Decree regarding midwifery Completed practice Strengthen training capacity Adoption of training standards Completed Overseas training of trainers NA 62 Study tour NA Completed Procurement of teaching equipment Completed and midwifery kits Train and improve effectiveness of community midwives Number of midwives trained and 16,000 16,085 deployed

29 19 Table 6: Studies Included in Project STUDY PURPOSE STATUS RESULTS/IMPACT PART A Development of Quality To identify and develop indicators for Completed Provided monitoring indicators Indicators for family the quality of family planning suitable for inclusion in the MIS planning (3 studies) services Survey of family Planning To observe the implementation of Completed Identified which factors are Services for Factory family planning program in the associated with successful Workers organized sector organized sector family planning, Results were used in the monitoring and evaluation of the component dealing with organized sector Provincial studies on Small To institutionalize research on the Completed Studied the effectiveness of Family Transition small family transition integrated programs on family welfare in 10 provinces Norplant tracking study To assess ability to track Norplant Completed Estimated the removal needs for acceptors in need of removals Norplants in the early cohorts of Norplant users. Assessment of Norplant Follow-up five cohorts of Norplant Completed Identified the needs for removals of removal needs acceptors to determine the needs of Norplant contraceptives. Results removals are being utilized for the implant strategy. This was the first study of this magnitude to be carried out. Postpartum Family To increase the participation in post- Completed Comparison of contraceptive Planning as Community partum family planning prevalence showed increase Based Services following community based postpartum family planning activities Assessment of the role of To initially assess the role of the Completed Found potential for using midwifes community midwives community midwives and their for family planning promotion acceptance at the community level I Assessment of the To assess acceptance of sterilization Completed Found level of sterilization acceptance of sterilization as a family planning method acceptance to be lower than other long-term methods Quality of Care of Non- To obtain information on quality of Completed Provided characteristics of scalpel Vasectomy in West care and acceptance of non-scalpel acceptors and information on the Java, Central Java, and vasectomy efficacy of the method South Sumatra Removal of Implant by To evaluate the ability of different Completed Identified the needs for training in Doctors & Paramedics provides to provide insertions and implant removal removals for Norplants Development of Norplant To develop Norplant IEC materials Completed Proposed and tested IEC materials IEC Materials for providers, field workers, & clients for Norplant counseling

30 20 STUDY PURPOSE STATUS RESULTS/IMPACT The Study of Performance of To assess the role of midwives as Completed Provided information on No. of Community Midwives family planning providers acceptors served, supervision, & relations with other providers Needs for Norplant Implant To assist BKKBN in developing Completed Provided information on Norplant Removal strategy for removal services of continuation and projected need for Norplant removals based on year of insertion Program Analysis for To analyze program related youth Completed Tabulations of age at marriage, National Survey Data indicators contraceptive use, and birth intervals for under-30 group. Provided useful information for further development of the youth program. Operational research (OR) To assess slum area needs for Completed Focus group analysis for slum area on service delivery in the family planning and IEC strategy development. Inputs were slum areas needed for the evaluation and design of services for the urban poor. Operation research on FP To develop the transmigration area Completed Focus group analysis for service delivery in the family planning program transmigration area strategy transmigration areas development OR on FP service delivery in To assess user preferences for Completed Focus group analysis for new new settlement areas family planning provision settlement area strategy development OR on FP service delivery in To assess knowledge and attitude Completed Focus group analysis for coastal the coastal areas regarding BKKBN activities areas strategy development through focus groups Study on Audience To analyze IEC-family planning Completed Identified most effective Characteristics in Central strategies communication channels for IEC Java and South Sumatra strategy IDHS 1994 To provide policy makers and Completed Provided province-level fertility, program managers with mortality, and contraceptive information on fertility, family information. The survey also planning, infant, child, and included a module on services and maternal mortality another on household expenditures. Study of BKKBN Provincial To explore the interaction between Completed Defined major organizational and District levels on the central unit and the field challenges at provincial level. Results Organization and Operation can be used for future institutional development of BKKBN. Part B Identification of Midwives Prioritize village ranking Completed Identified variables concerning to Placement in the Village according to need for BDD geographic, environmental, SES, health and nutrition, and health status.

31 21 STUDY PURPOSE STATUS RESULTS/IMPACT Time and Motion Study of Examine BDD time utilization, Completed BDD have insufficient training in BDD (Parts 1 and 2) adaptation to community, and communication skills; 8% of BDD community acceptance did not stay in villages; BDD capacity to provide other medical services important factor in community acceptance; BDD utility is diminished in areas already serves by other midwives Costing Study of Safe Develop costing models for MCH Completed the study provided detailed Motherhood in East Java activities at district level information on the cost structure for safe motherhood interventions. It compared unit costs of different interventions and thus provided useful data for policy making and economic analysis. BDD Training Needs Training needs assessment and Completed BDD have wide variety of skills; less Assessment study of BDD competency; than 50% of BDD can provide the deternine equipment needs services expected of them; 40% of polindes are incompletely equipped. Role of Birthing Homes in Study polindes functions and Completed Polindes concept often not accepted West Java sustainability by community; found expensive to pay both TBA and BDD Mother-Baby Package Field To implement mother-baby Completed Ineffective training methods; Trial in West Java and South package providers need on-going EOC Sumatra training Operation research on the Reason for acceptance/refusal; Completed Accepted because of similarity to feasibility of the Kangaroo length of time use; changes in local traditions; used up to 28 days; Method in rural areas temperature and weight normal weight achieved in 8 days Management of the Sick Feasibility study of applicability of Completed Main diseases were jaundice, Neonate sick newborn guidelines for dermatitis, and intrapartum infection doctors and BDD Integrated Management of Study feasibility of essential On-going Kangaroo method works well; good the Newborn Outside the neonatal care at primary level reporting of neonatal conditions by Hospital providers using modules

32 22 Table 7A: Project Costs Item Appraisal Estimate (US$M) Actual(US$M) Local Foreign Total Civil works Equipment, vehicles & IEC materials Contraceptives Local training Overseas fellowships, technical assistance and research Project development and deployment TOTAL PROJECT COSTS Table 7b: Project Financing Source Appraisal Estimate (US$M Actual/latest Estimate (US$M) GOI IBRD Total GOI IBRD Total Civil works Equipment, vehicles, instructional materials Contraceptives Local training Overseas fellowships, technical assistance, and research and evaluation Project development and deployment Unallocated TOTAL l

33 23 Table 8: Status of Legal Covenants Agreement Section Covenant Original Revised Status Description Comments type (I) fulfillment fulfillment (2) date date Loan Sch.1.3(A) 3 C No withdrawals for category Study was completed and la until the first phase of FP reviewed by Bank; MIS information system is procurement was authorized completed Loan Sch 13(B) 3 C No withdrawals for category Recommendations were 3a until recommendations for submitted to Bank; training midwifery training are activities were started submitted Loan Sch Jul 91 C Appoint project secretaries Project secretariat has been by 31 Jul 91 (BKKBN and functional since project MOH implementation Loan Sch C Submit annual project Annual reports were reports to Bank (BKKBN submitted on a regular basis and MOH) Loan Sch C Submit annual Annual implementation implementation plans to were submitted on a regular Bank (BKKBN and MOH) basis Loan Sch Jul 91 CD Appoint MIS consultants MIS consultant was (BKKBN) appointed after delay in finalizing contract Loan Sch Sep 91 CD Contract monitoring of Four firms were selected for overseas fellows the management of overseas fellows, after delays in selection and contractual arrangements Loan Sch May 94 C Submit to Bank mid-term Mid-term review review of service conducted and submitted, components (BKKBN) after slight delay Loan Sch 5 8(A) 10 C Ensure that midwives trained The agreement on the through project work only in provincial selection has agreed provinces and that been maintained training emphasizes practical teaching (MOH) Loan Sch 5.8(B) 5 C Maintaining steering Steering committee committee for project established. Coordination coordination and have efforts not very good committee meet twice a year Loan Sch Dec 92 CD Implement improved Implemented following licensing of midwives and delay school accreditation systems (MOH) (1) 3 = Flow and utilization of project funds, 5 = Management aspects; 9 = Monitoring, review and reporting; 10 = Implementation (2) C = Complied with; CD = Compliance after delay

34 24 Table 9: Bank Resources: Staff Inputs Stage of Planned Actual project cycle Weeks US$(000s) Weeks US$(000s) Preparation to Appraisal n.a. n.a Appraisal n.a. n.a Negotiations through Board n.a n.a Approval Supervision n.a. n.a Completion TOTAL l

35 25 Table 10: Bank Resources: Missions Stage of Month/ Number Days in Specialized Performance rating Types of Issues project cycle year of field staff skills persons represented Implementation status Development objectives Identification/ 9/ (2) P,H,T - preparation Pre-appraisal 4/90 6 P,E,A,F,I Appraisal 9/90 7 P,H,E,A,F,I Supervision 1 8/ P,H,N I Supervision 2 5/ P,O I I Supervision 3 11/ P,O,N I I Supervision 4 6/93 3 P,O I Supervision 5 11/ P,H,O 1 2 Components related to service delivery to the hard to reach not all successful Supervision 6 7/ P,H HS S Same as above Supervision 7 2/ H,O HS S Same as above Supervision 8 11/ H,P,O HS S Same as above Supervision 9 6/ H,O HS S Same as above Supervision 10 8/96 2 H,O HS S Same as above Completion 11/ P,O,N (1) H=Health; P-Population; T=Training, E=Economics, A=Architecture; F=Family Planning; I=IEC; N=Nursing/midwifery, O=Operations (2) Includes other projects

36 26 IMPLEMENTATION COMPLETION REPORT INDONESIA FIFTH POPULATION PROJECT (Family Planning and Safe Motherhood) LOAN 3298-IND PART IH: BORROWER'S EVALUATION OF THE FIFTH POPULATION PROJECT Project Objectives and Strategy PART A The Government of Indonesia (GOI) has given a priority to the population policy in the national development. The objectives are to reduce fertility and mortality, to increase life expectancy, and to reduce imbalance in the population's distribution. The key component to achieve this is through family planning program and related health nutrition program. In line of this priority, the National Family Planning Coordination Board (BKKBN) implemented the Fifth Population Project (Family Planning and Safe Motherhood) during The overall objectives of the project are to help the government intensify its efforts to lower fertility and maternal mortality during the 1990's by strengthening the national family planning and maternal health programs. The project consisted of two major parts. Part A: Targeted Family Planning and Safe Motherhood Promotion (BKKBN) and Part B: Midwives Development (MOH). BKKBN was responsible for the Part A which consisted of several project components including: Family planning services and safe motherhood promotion, IEC strategy and establishment for community groups, Institutional development, and project management. The targeted family planning services included at the coastal areas, transmigration areas, poor urban areas, organized sector, safe motherhood promotion, and enhancement of method mix. The IEC strategy and establishment of community groups consisted of IEC strategy, youth participation, and community groups. The institutional development consisted of staff development, monitoring and research, and field operation. The project management included project implementation, monitoring, evaluation and administration. The family planning services at the coastal areas served a total of 125 districts in 21 provinces; the urban poor areas served a total of 11 municipalities in 7 provinces; the transmigration areas served more than 740 UPTs in 13 provinces; the organized sector covered 2,250 companies in 14 provinces; the safe motherhood promotion served 181 districts in 14 provinces; and the enhancement method mix covered all provinces. The very large coverage, broad scope, and varies target groups, and centrally management made the project implementation very difficult. A similar design of the project component included an assessment of need and demand of family planning at each targeted areas, development a strategy and operational plan through workshops and meetings, and provision of limed family planning services. However, this planning effort did not provide a specific family planning and health services. Lack of local community participation including at the district, subdistrict, and village levels made the project did not provide a specific of local services. More effective and efficient project implementation is required to address the existing problem mainly to continue declining TFR, increasing CPR mainly LTM

37 27 users and declining MMR. Centrally planned and supervised vertical grams were less effective. The effectiveness and efficiency of the project could only be increased by decentralizing management of family planning and health program. Key Achievements of the Project During the , the Government of Indonesia has successfully declined TFR, increased CPR, increased new acceptors, current users, long term contraceptive method users. and current users who received from private sectors. The average of TFR declined from 3.3 children per woman in 1990 to 2.7 children per woman in 1996; the CPR increased from 49.7% in 1991 to 66.6% in The new acceptors increased from 4,284,336 in 1990 to 5,544,226 in The current users increased from 18,525,304 in 1990 to 24,203,265 in The long term contraceptives method users slightly increased from 6,583,570 in 1990 to 8,804,849 in The current users receiving family planning services from private sectors increased from 11.7% in 1990 to 27.9% in The National Family Planning Program was financed by various sources of inputs including 79.6% GOI budget, 11.3% IBRD, 1.6% USAID, 4.5% Pathfinder, and 2.5% UNFPA, ADB 0.5%, and UNICEF 0.004%. GOI contributed the largest part of budget inputs to the national family planning program. Since the Bank has the largest donor contribution, it may be concluded that the project has substantially contributed in declining TFR and increasing various demographic indicators including CPR and new acceptors..the performance of each project component was good since most of the outputs indicators, % were achieved, even several sub-project components reached more than 100%. In addition, the results of each project component is described as follows At the coastal areas, the project was to improve accessibility of family planning services to 2,000 villages in 125 districts. At the end of the project, a total of 3,608 villages in 935 sub-districts of 161 districts in 21 provinces were improved. BKKBN had achieved more than 100% of districts targeted by the project At the transmigration areas, the project was to institutionalize family planning services for the transmigration communities at the UPTs. A total of 740 UPTs covering 1.8 million people in 13 provinces were targeted by the project. At the end of the project more than 800 UPTs at the transmigration areas received family planning services. Of these, more than 50% UPTs were transferred to the local government responsibility and receiving family planning and health services from the existing facilities such as local health center and sub-health centers. As of March 31, 1996 the project served a total of 393 UPTs in 13 provinces covering 127,760 families, 74,920 Elcos, and 52,778 active users. At the urban areas, the project was to help BKKBN improving family planning services for poor urban communities at 11 municipalities in 7 provinces. During the project period, a total of 330 persons were trained as trainers, 181 persons trained in family planning services and 3,300 community leaders attended orientation meetings. BKKBN sought co-operation from NGOs and local authorities to extend outreach services. The organized sector subcomponent was to increase the commitment and participation of 2,250 small and medium companies in family planning program in 14 provinces. BKKBN in collaboration with the company and Association Company Owners developed family planning services program involving insurance company. This effort reached a total of 7,503 firms consisting of 2,298 firms with employees, 1,688 firms with employees, and 303 firms with more than 500 employees.

38 28 In addition, training of 150 midwives and 215 paramedics in clinical skills, 681 field workers and motivators in counseling, conducting family planning contest, and providing IEC materials. The safe motherhood campaign at the villages was well accepted. However, there is difference from posyandu supported by MOH. The campaign has a few messages about maternal and child health and similar across the country. In the safe motherhood provinces, the increase of all contraceptive methods is 4.2 times; LTM users is 2.9 times; and STM users is 4.8 times. In other provinces the increase of all contraceptive methods 0.3 times and STM 0.6%; however the LTM users decreased 0.2%. The increase of all contraceptive methods, LTM users, and STM users in the safe motherhood provinces is larger than those of the non safe motherhood provinces. It indicates that the safe motherhood services in the 14 provinces may affect the increase of the LTM users even there are many other variables determnining the use of LTMs. The enhancement of contraceptive method mix subcomponent was to increase accessibility and quality of LTM services. The target was to train 3,000 doctors, 3,000 midwives, and 6,000 field workers in clinical skills. After the project end, a total of 3,709 doctors and 4,531 midwives were trained in IUD and norplant insertion and removal and sterilization, 6,242 fieldworkers in counseling. In addition, the project procured 500,000 norplant sets, 200 laparoscopes and 4,000 IUD kits which were distributed to services delivery points. Although most activities were not directly addressed to the recruitment of the family planning acceptors, BKKBN reported an increase of the LTM users after the project. Of the total new acceptors, norplant users increased from 8.3% in 1990 to 10.3% in 1996 and injectable users increased from 33.5% in 1990 to 47% in On the other hand, VSC users declined from 3.4% in 1990 to 1.8% in 1996; IUD users declined from 3.4% in 1990 to 1.8% in 1996; Pills users declined from 30.5% in 1990 to 25.4% in 1996; and condom users declined from 2.4% to 1.4%. There is a contribution of the project in increasing the use on norplant. The IEC sub- component focused on helping provinces to develop messages for the local needs, and on enhancing collaboration with the operational bureau for the development of messages for special population groups. The project provided and distributed equipment to BKKBN Provinces and Districts including 187 Mobile Information Units, 7 units Media Production Centers, 1 AVA for East Kalimantan, 332 units public address, 301 units video monitor and recorders, 1,505 copies film master and copies, 50 copies/episode serial TV, 9 master and copies of audio, 4 master and copies of video, and provision of 450,000 IEC kits for use in communication by fieldworkers. The Central and Provincial BKKBN have increased their capacity in developing and distributing IEC local materials. The youth subcomponent developed youth participation program covering a total of 281 districts, 1,546 subdistricts, 13,087 villages. A total of 11,259 trainers and cadres were trained in 22 provinces; 5,630 training packages and 468,925 materials for cadres were produced; training curriculum and operational guidelines for youth involvement in family planning program were completed and used. The family planning activities reached to 88% of total villages targeted during the project implementation. The results of BKKBN evaluation indicated that in 5 provinces the knowledge of youth on family planning were good, and they responded and participated positively in the family planning program. The development of community institutions recorded remarkable increase in the number of PPKBD and similar increase in the sub PPKBD. BKKBN provided orientation to Chief of Operational Program from 11 provinces to increase their technical skills in the implementation of the family planning program. Orientations were also provided to 2,000 fieldworkers, 13,501 women organization at district, subdistrict, and village levels; 5,222 PPKBDs and sub PPKBDs, and 10,996 cadres; 3,559 head

39 29 of subdistricts and midwives; and 8,725 community leaders. A total of 121,950 training orientation materials and guidebooks were produced and distributed to support its implementation of the program. The project provided various training staff including a specialized training, in country training and overseas training. The participants of the specialized training included 2,231 staff in program management, 3,771 field workers in undergraduate training, and another 14,022 field workers for refresher courses. BKKBN Provinces provided training to total of 3,741 doctors and 4,619 in effective contraceptive methods, and 6,367 in LTM counseling in 17 provinces. The overseas training program covered a total of 143 persons consisting of 133 persons in master degree (57 in USA, 35 in UK, and 41 in Australia), and 10 persons in doctoral degree program. In addition, 50 participants involved in the short-term program in several universities in USA, United Kingdom, and Australia. The International Training Program with the assistance of foreign consultant improved the curriculum and teaching materials for courses that offers to participants from other countries. At least 2 workshops about curriculum development, video program development, and computer skills training were completed. A training consultant was conducted to select BKKBN staff in Management consultant skills. In collaboration with several research institutes of Universities conducted a total of 44 research activities during 5 year period. Most of the results have provided input for improving policy, strategy, and operation of family planning and population programs both in the central and provincial levels. In addition, the project improved MIS, provided computers and its software, and trained provincial staff, and applied the new MIS. BKKBN has improved the existing family planning information system to support the new redefined goal by UU no ; the dual role of the Chairperson of BKKBN as the Ministry of Population as well as other key staff; and the modification of the organizational structure of BKKBN. The field operation subcomponent was to provide office equipment, vehicles, medical and non medical equipment to expand the family planning field operation. The project purchased equipment and vehicles including 4,219 typewriters, 359 units mimeograph, 31 units laminating equipment, 1,068 units SSB radio communication, 187 MIUs, 450 four-wheel vehicle, 1,836 motorcycles, 365 computers. The medical equipment includes 235 vasectomy kits, 23,071 IUD kits, 70 norplant kits, 200 units laparoscopes, 6,276 OB/Gyn beds. Of the targeted procurement, 90.5% were completed and distributed to BKKBN central, district, and subdistrict levels. BKKBN performance. BKKBN was responsible for the project implementation both at the central and provincial levels. Of the total 1,874 project activities consisting 685 at the central level and 1,189 at the province level, 94.6% were completed. The other 5.4% activities were canceled due to procurement of boats, overseas training, local training, some research activities, workshops and seminars. Of the total project cost of Part A US$ 77,559,600.00, 94.3% were disbursed by the end of the project end, 2.3% are being process, and 3.4% were undisbursed. The high results of programmatic and financial project accomplishment show a good project performance. Bank performance. In the appraisal report, the Bank has identified various indicators for project monitoring and evaluation. On the other hand, BKKBN has discussed with each project component to select the realistic and most feasible indicators for monitor and submitted to the Bank. Both BKKBN and Bank did not utilize such indicators for project monitoring and evaluation. The Bank did not have any simple instrument for project monitoring and evaluation, even though qualitative results of each monitoring are reported on the Aide Memoire. In addition, the complicated process of issuing NOLs (No Objection Letter) for each procurement should be reviewed, and less involvement in the process of procurement should be considered.

40 30 Partial Successes of the Project The project has successfully assisted the GOI in declining TFR and increasing various demographic indicators including CPR, new acceptors, current users, and private sectors participation in family planning and health services. However, the reduction of fertility and increase of various demographic indicators should be continued to achieve the replacement level of fertility. The fertility rate of many provinces mainly outside Java Bali are still high and special effort should be done to address these problems. In addition, more effective and efficient strategies and operational activities should be done to address the remaining high maternal mortality rate across the country. Various project activities were designed to address the project objectives. These included expanding family planning and primary health services at targeted communities, providing staff in country and overseas training, training providers in clinical and non clinical skills, developing and distributing IEC materials for providers, clients and community, conducting research activities, and improving BKKBN capability in managing family planning program. Most of these activities have successfully achieved their target and outputs. However, these have not reached to the grass root levels and need to be continued to achieve the national family movement goal and objectives. The existing family planning and health facilities have not reached to most people at the hard to reach areas including coastal areas, urban poor areas, transmigration areas, youth communities, industrial areas and have not been fully utilized by those seeking who are in need of services. GOI should continue expanding such services so as to make it available in most of the country mainly to those who do not have access. These include couples living in hard-to-reach areas, including far-away islands, distant transmigration areas, as well as the urban poor and others hard-to-reach for social and cultural reasons. Most of the available services delivery points mainly at the rural areas are not able to provide a good quality of family planning and health services. Improving the quality of family planning services should be continued by training skills of providers, providing better medical and non medical equipment, and improving information and service delivery. Careful screening of acceptors for suitability for specific methods, counseling about side-effects, making a range of short-and long-term methods available, and the accessibility of family planning service providers to address follow-up concerns, including the acceptors' desire to change methods. Clinical training such as insertion and removal norplant and IUD, sterilization, and infection prevention, and counseling skills have been provided to doctors and midwives. However, there are many doctors and midwives either at the services delivery facilities have not received a standardized clinical training. The project was not able to train all doctors and midwives in clinical skills and counseling. In addition, there are many village midwives just graduated from the Midwifery Schools and deployed at the villages. Continued a standardized clinical training skills should be carried out in the future project. The project has trained BKKBN staff at the central and province levels, and provided various equipment for developing IEC materials locally. However, such efforts are still very limited and need to be continued. Increase the capability of staff at the BKKBN province in identifying, developing, producing, and utilizing various IEC materials which are meeting the local needs should be continued. Various training skills and workshops in IEC development should be provided to those who responsible for developing and distributing IEC materials at the provincial and district levels.

41 31 The previous effort in increasing the participation of private sectors in the family planning and MCH program is very limited and need to be expanded in the future. Since the government resources in providing family planning and MCH services are limited, the availability of private sectors and community resources should be mobilized to assist the government effort in addressing the fertility and maternal mortality problems. The private sectors could involve in various activities including in providing family planning and primary health services not only at the urban areas but also at the remote rural areas, providing clinical and non clinical training under the supervision of the MOH. The project completed various research activities and some of those are utilized to improve the policy, strategy and operational program. The need of further research should be identified and completed to improve the effectiveness and efficiency of family planning and health program management. More specific and good quality research activities should be done in future project. These included operational research for developing new strategy in reducing fertility and maternal mortality and evaluation research of various project implementation. Areas for Further Support Despite many accomplishments in family planning and safe motherhood promotion the reduction of fertility should be continued to reach a replacement level. The fertility rate of many provinces are still high mainly in those provinces out of Java and Bali. In addition, the GOI should put more effort in reducing the high maternal mortality rate in the next project. Persistently high maternal risk accompanied by morbidity's and disabilities that results from poor antenatal care, managed complications of pregnancy and delivery, and post-partum cares. Prevalence of anemia in pregnancy is still high and aggravates the complications of pregnancy and delivery. These take an enormous toll on family welfare, particularly among the poor. Even with the major gains in family planning, much remains to be done. Unmet need remains high for the poorer, less educated, and geographically remote in segments of the population. Key improvements in the quality of services are yet to be fully realized, particularly in improving screening, counseling, and follow-up for side effects of longer-term clinical methods such as IUDs, injectables, and implants, for which demand is increasing. Safety and informed freedom of choice should be the hallmarks of quality. Quality is also essential for sustainability, because people will only pay for what they perceive to be beneficial, and cost-recovery is essential if resources are to be available to extend coverage to undeserved groups. Neglected adolescents and youth reproductive health problems should be addressed by both BKKBN and MOH. Indonesia's adolescents and youth remain poorly prepared for the reproductive health challenges and responsibilities they will face as they move into their reproductive years. These challenges are increasing as society urbanizes and exposure to mass media which in turn imparts attitudes and encourages behaviors that increase reproductive health risks. Reproductive morbidity before, during and after childbearing years is also need more attention. Reproductive health problems that affect women before, during and after their childbearing years, including reproductive tract infections and pregnancy-related morbidity, are the dimension of reproductive health in Indonesia which have received less attention. Other non-reproductive morbidity, such as anemia among adolescents, congenital anomalies, rheumatoid heart defect have subsequent complications during the reproductive process. Further, many of these problems are preventable if consumers are aware of the problem; when consumers do become aware of the implications, they are willing to pay for diagnosis and treatment.

42 32 To guarantee the effectiveness of the future project implementation and management, the following specific activities should be carried out either at the central or provincial levels. The family planning and primary health care project (reproductive health) at the hard to reach areas including coastal areas, transmigration areas, urban poor areas, and organized sectors should be continued to increase the accessibility and quality of services. The target groups of services also included the poor population of Pre Welfare and Welfare I (Pra S and KS 1), and should be clearly defined to provide better services. The project strategy and activities should be designed to provide more effective services and address local needs. The service strategy should be selected to increase the use of all methods particularly LTM. Various project inputs should be coordinated and integrated to provide more efficient services delivery. The project needs to maintain its focus on quality of training both pre-service and inservice especially for doctors, midwives, paramedics, and fieldworkers who work at the targeted areas. Standardized clinical and non clinical training including IUD and norplant insertion and removal, tubectomy, vasectomy, infection prevention, counseling technique, and IEC delivery should be provided to those who become trainers and providers. Guidelines, manuals, clinical and non clinical equipment should be provided to various service delivery points including health centers, sub health centers, village health posts, and clinics to increase quality of services. Monitoring and evaluation of the training activities should be conducted to improve such activities during the project period. IEC materials developed at the central level did not meet local need. Therefore, these should be developed and produced in the provincial and district levels. In addition, the IEC materials should be developed based upon P-Process to provide better and right information for the clients. The existing materials should be evaluated and redesigned to provide more effective messages. Orientation meetings with community and religious leaders should be followed up to develop their commitment and involvement in the reproductive health program. Research and development is needed to provide information for improving project strategies and implementation. The research problems should be discussed and identified by related Bureau, BKKBN Provinces and Research Centers. Research and development activities should be conducted by professional researchers and research institutes which could develop good quality of research proposals, completed research in time, and submitting report in accordance with the schedule. This mechanism will increase the use of research results by the program. The next population project (reproductive health) should not be developed only by BKKBN, but should involve representatives of other sectors including MOH, PEMDA, Department of Religion, NGOs, community leaders and other related institutions at provincial, district, and subdistrict levels. An effective and efficient planning technique such as "Objective Oriented Project Planning" (ZOPP) should be applied in developing future population project. During the project implementation, better coordination should be done by BKKBN with other related Ministries, among various Bureaus, Centers, Divisions at the Central and Provincial levels. In addition, various project inputs and activities in reproductive health services should be integrated each other to increase the effectiveness and efficiency of resources. BKKBN and the Bank need to develop more efficient mechanisms in processing NOL for procurement of good and services. Procurement of clinical and non clinical equipment and goods for

43 33 provinces such as boats, vehicles, motorcycles, SSB, and other needs should be based upon the local needs in the province. Selection of foreign and local consultants should be carefully recruited in order to meet the need of expertise in providing technical assistance. Research proposal should be carefully reviewed so as to meet the need of the program. In addition, an effective project monitoring and evaluation should be conducted to provide information for improving project management. The management of a new project should be integrated into the BKKBN management function and responsibility. Each bureau should involve in managing its related project component. In case of a large project coverage, cost and lack of the existing management capability of the borrower, it is essential that enough staff or consultants have been assigned specifically to assist the project management.

44 34 Implementation Completion Report INDONESIA Population V Project/Part B Loan IND Borrowers Evaluation of the Population V Project - Part B. Project Design 1. The broad goal of the Part B project is to ensure that the Indonesian midwifery programs have the financial human and managerial resources necessary to achieve the desired changes in the midwifery development during the five years project period. The objective of these changes are to decrease maternal mortality in accordance with targets set in Repelita V/VI. The goal and objective as stated are relevant to the government's need and consistent with the government's strategy to accelerate the reduction of Indonesia's ligh maternal mortality. 2. The three major components of Part B: 1. Strengthening policy framework on training and deployment of midwives, 2. Strengthening training capacity through training of trainers or teachers and improving teaching materials and equipment and 3. Supporting training and improvement of the effectiveness of about community midwives. The three major components have addressed issues specific to midwifery training program like the number of midwives, the quality of midwifery and the capacity of training institutions as well as contributed to strengthening effectively of midwives deployment at village level. 3. The project objective to support enhanced coordination and joint operational planning between BKKBN and MOH is appropriate, however it is well known that effective intersectoral coordination is difficult to materialized if there is lack of strong commitment among the parties concerned. 4. For a project with a five year project life the size is more or less right. If the activities are planned properly and implemented efficiently it would be feasible to accomplish the work within the defined period. The selected components are quite appropriate with a flexibility enable to include additional relevant activities. The scope of investment is sufficient to facilitate the various aspects of the development of midwives. 5. As project activities support mainly the training and deployment of midwives, the two institutions, the Directorate of Family Health and the Center for Education of Health Manpower particularly the nursing schools running midwifery training programs would be strengthened.

45 35 6. No aspect would be anticipated which lead to implementation difficulties. Minor problems are expected in obtaining the necessary information on the distribution of books and equipment to the schools and midwives and in obtaining of the financial reports from the provinces. 7. The Staff Appraisal Report provided a comprehensive picture of the nature and scope of the project and guided the project management for correct implementation but some selected process indicators were less sensitive for measuring project success and impact indicators were less feasible applied to a five year project. Project Implementation 8. The project was implemented during a five-year period within the Indonesia's fiscal years 1991/1992 to 1995/1996. Part B components and activities were mainly for the development of community midwives in order to support the national safe motherhood program. The project started with budget provision of the first year period from April 1991 to March 1992 and without opportunity for project extension it was closed on September 30, 1996 as has been planned. 9. The Director General of Community Health MOH was the project manager who was responsible for overall project implementation. The Chief, Directorate of Family Health was the project director responsible for annual project planning, implementation, monitoring and supervision. A project secretariat with full-time staff was established since the start of the project. All project secretariat personnel were not recruited for five years as suggested in the staff appraisal report but assigned annually to provide more flexibility in changing of secretariat personnel if necessary. 10. An intersectoral task force chaired by the Secretary General MOH was established at central level for monitoring the production and deployment of midwives. During the last 2 years no task force meetings were held. One of the reasons might be that the target of producing midwives and posting them in the villages was already achieved. 11. Based on the nature of the project components most of the activities were budgeted and implemented by the Directorate of Family Health (Dit. Bina Kesga), the Center for Education of Health Manpower and the 13 project provinces. For a period of 2 years the Center for Training of Health Personnel (Pusdiklat) took part by conducting a pilot Life Saving Skills (LSS) training for the community of midwives through distance learning. 12. During the first year project period delays in project implementation and administration were observed. It was apparently caused by insufficient experiences of most officials and project secretariat staff involved in project management. Another constraint for fast implementation was the lack of mastering the Bank's procedures, the frequent changing of the government regulation and the amount of staff to be involved before an activity could start. Starting from the second year the secretariat tried to accelerate project implementation by intensifying communication with the people concerned, making consistent efforts to solve the problems encountered and in obtaining faster decision from the related authorities. Two other problems hampering fast implementation of the

46 36 -prject were the insufficient knowledge of some tender committee members in formulating specification of the teaching equipment for the schools and the complicated procedure to be followed for direct appointing of companies providing consultants, fellowships and conducting studies. However in general project implementation was considered successful reflected by accomplishment of most of the activities and timely disbursement. The estimated disbursement after the closing account is 96%. 13. Bank's regular supervision mission and its Aide Memories made substantial contribution to accelerate project implementation and facilitated consistent follow up. Comments given to study proposals were very helpful but the back and forth correspondence was time consuming leading to canceling some studies. 14. It was noted that capabilities of some local agencies conducting studies and evaluation were inadequate, the products therefore were less satisfying. This could be prevented by more careful selection of the agencies involved. Project Results A. Strengthening ofpolicyframework 15. One of the major achievement of this project was the Minister of Health Decree no: 572 issued on June 1996, regulating the registration and the practice of midwives. The main difference with the previous decree was the provision of more authorities to the midwives, particularly in handling abnormal deliveries. In order to maintain the quality of the midwives a recommendation from Ikatan Bidan Indonesia (IBI) was required for obtaining the license and a renewal of the license should be applied after every five years, if the midwife would continue having practice. As this decree is still in broad terms, the Director General of Community Health would provide guidelines for implementation. 16. The Establishment of a Midwifery Board suggested by the Bank was not materialized, but the idea of assuring quality and standardizing midwifery practice were embodied in the new Ministerial Decree. 17. The project provided overseas study tours to key officials related to midwifery training programs and midwives deployment; overseas fellowships training were also provided to midwifeteachers, including Ikatan Bidan Indonesia (IBI) members. Assisted by international consultants the project conducted evaluations of the various midwifery training program. All of this did contribute to increasing the awareness that a better quality of midwives were needed for speeding up the reduction of maternal and neonatal mortality. As a response the MOH started this year with running the D 3 midwifery education, supported by the project by the provision of adequate teaching equipment and teachers training abroad for the 6 planned D 3 programs. B. Strengthening Training Capacity

47 The project supported the revision of the curriculum for midwifery training program A, completed in 1994 replacing the 1991 curriculum. Then all program A training implemented the 1994 curricula. However the professional competencies gained by the graduates were still questionable as the time allocated for midwifery training remains 1 year compared to the old system of 2 to 3 years. 19. It was noted that many midwife teachers were nurses or midwives who did not receive adequate midwifery training and did not assist in the delivery in the community. It was understandable that they were not very qualified in teaching midwifery, except those who were working in the hospitals. To improve the quality of the midwife teachers the project sent 42 midwife teachers to UK to joint a short course in education technique and advanced midwifery. Two other midwife teachers who were having sufficient English language capability have successfully obtained the post graduate diploma in advanced midwifery. Twenty midwife teachers were sent to Australia to attend a short course in problem-based learning in midwifery education. In-country training were also given to midwife teachers and clinical instructors. 20. The project also improved the accreditation tools used for measuring the midwifery training programs. Accreditation forms were sent to 136 schools located in the 13 project provinces but only 102 schools or 75% returned the forms. From the returned forms conclusion was made that 22,55% of the schools obtained a score of , 57,85% the score was and the remainder or 19,60% the score was less than The project provided teaching materials, audio visual aids and teaching equipment to 121 program A training, 5 program B training and 6 D 3 midwifery training 22. In order to improve the midwifery training program a Midwife Supervisor was assigned in each province for supervising and guiding the implementation of the program. Regular meetings for the midwife supervisors were held to clarify their duties and supervision guidelines were provided. C. Training and Improving Effectiveness of Community Midwives 23. The project supported the program A training of community midwives, conducted in 97 nursing schools in the 13 project provinces. This number contributed 29,72% to the government target of community midwives to be produced up to third year of Repelita VI, 1996/1997. They were posted in the villages as civil -servants or recruited on contractual basis (PTT). The project provided all the newly posted midwives in the project villages with midwifery kits, IUD kits, books and manuals. About bidan kits, IUD kits and sets of books were provided to those midwives. 24. Noting that most of the newly graduated midwives still lack confidence and skill in handling emergency cases, the project supported the introduction of the LSS training as a pilot effort in the project. About midwives jointed the LSS training and about 700 midwives received LSS training through distance learning. However this 12 days training was regarded too short and less effective. A longer training program was introduced by American College of Nurse Midwives

48 38 (ACNM) using a strict criteria for the selection of training site, training equipment and number of trainees. 25. Because of the increasing number of community midwives working in a district, a bidan coordinator was established to assist the HC doctor in supervising and monitoring the community midwives.. The project supported the development of working guidelines for the midwife coordinators. 26. The project initiated the establishment of a database for the midwives. The intention was to enable check the midwives whether they reside in the assigned villages or whether they received the distributed kits and books. Personal data and mutation data would be recorded. Computers were sent to 26 provinces and a software for data processing was provided. Training for the application of the software were given to staff engaged in data processing but it seemed that the time for training was too short for mastering the software. D. Studies 27. Various studies and operations research were conducted during project implementation. Some studies like the identification of the potentials of villages and the time motion study of the community midwives were beneficial. The innovative interventions for reducing maternal and neonatal mortality carried out through operations research were helpful for the MCH program holders at the Directorate of Family Health but some results were not convincing due to the small samples which have been taken and the limited time available for doing the research. E. Project Sustainability 28. The new MOH Decree No. 572 issued in June 1996 which gives more authority to the midwives would be one of the sustainable product of the project. This will protect the midwives in handling complicated cases in remote areas where doctors and senior midwives are not available to supervised them as has been required in the previous Decree. For operational purposes the new Decree would be elaborated and issued as guidelines of the Director General of Community Health. 29. Another product which is regarded sustainable is the standard and protocol of midwifery practice which have been published by IBI and disseminated to all IBI members. 30. The D 3 academic midwifery program which was much supported by the project is expected to running well in the future. 31. The LSS training introduced by the project is felt as compulsory training for the midwife for improving her skills for handling emergency obstetrical and neonatal cases. The MOH and IBI have continued conducting this training to other midwives. 32. A monthly publication, called the Buletin Bidan, was issued by the Center of Education of Health Manpower, and is a forum of communication between midwives in the field. The project

49 39 provided funds for its printing and dissemination to all provinces. After the project the Center for Education of Health Manpower will continue producing the Bulletin. F. Lessons Learned 33. It was observed that at the early stage of project life delays were encountered in project implementation. This was common in many projects with foreign aids. These delays could be minimized by producing important documents and early involvement of key officials and staff for project management before the project start. The availability of the type, number of man months and TOR of the needed international and domestic consultants before project commencing would be very helpful for immediate start. If the need for studies and training could be described in more detail and TOR's could be developed in advance, it will facilitate the project a lot. Another important point is to provide the key officials and staff with sufficient knowledge of procurement and disbursement procedures and request them for mastering the loan agreement, staff appraisal report and government regulation. 34. To maintain and improve the quality of midwives the Bank recommended the establishment of a midwifery board for registration of midwives and licensing of midwifery practice. For this purpose the project organized 3 groups of study tours for 15 key officials related to education, training and deployment of midwives. The countries visited were Thailand, UK, The Netherland, The Philippines, Australia, USA, Canada and Denmark. However, this independent midwifery body was not materialized as this set up was not in line with the Indonesian system where such authority of control is still kept by the government, instead, the functions of such a board were embodied in the MOH organization structure. 35. There is a need to improve the quality of training of midwives, particularly midwife teachers and clinical instructors. To date the target of producing sufficient midwives for posting them in the villages has been achieved. Priority should be given to producing competent graduates which needs strong commitment from the GOI. Training programs for midwife teachers (program B) need to be upgraded rather than closed down. Additional training for the midwife teachers should be more in the country as their English language proficiency are limited. 36. The project supported the deployment of community midwives in the project villages. Facilities and working tools were given such as shelter, berthing homes, midwife kits, IUD kits, books and operational cost. The village head has the duty to make the midwife comfortable in the village. However, some efforts have to be made to keep the midwives in the villages after the contract is finished.

50

51 IBRD odawl, NDQT'INDONESIA South China sea ~~~~~~FIFTH POPULATION PROJECT / / ~~~~~~~~~~~~~~~~~~~BRUNFLIJFamily Planning and Safe Motherhood P A A Sol ~'od Soanr(CompoenPt oterinnlprootn Ni ~~~~~~~~SINGAPOREMoo PWIPeIM do~ ~~~imi/ A t / ~~~~~~~~~~~~~~~~~~~~ OCEAN\ [3 Ke~~~~~~-odo Ambon < - 'z j- 5- ~ ~ ~ ~~~~~~~ Semn At t. son~~~~suaaa * NtotioaooCopttot INDIAN OCEAN 23/"y n we so' mm ~~~~~~~~~~~~~~~~~~<j) (tc> AU~~~~~~~~~~~~~STRALIA er FEBRUARY 1991

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