Improving Health Service Provision through Incentivized Block Grants to Communities:

The Experience of PNPM Generasi

February 2010

Introduction

◦ Intro: Indonesia PNPM◦ Why Community-based approach to SP?◦ How does it work?◦ What was achieved?◦ Where to go from here?

Why a Community-Based Approach?

Indonesia has made good strides in key human development indicators

However, key indicators lagging:◦ Infant mortality ◦ Child malnutrition◦ Maternal mortality

Strongly associated with ◦ Levels of poverty◦ Geographical disparities: poorer outcomes in rural and remote areas

Patterns of vulnerability: a large cluster of the near poor (40%)

Learning: How can communities and local service providers target demand and small supply side constraints to improve

access to and use of health and education services.

Why a Community-Based Approach?

State:◦ Challenge matching supply-

side and demand-side

◦ Weak institutional capacities to administer complex programs

Providers◦ Poor provision of social

services in poor regions

◦ Poor targeting in previous cash transfer and other programs

Citizens/clients◦ Challenges with elite

capture

Accountability◦ Lesson from CDD: specific

role of communities

How does it work?

PNPM Generasi is an incentivized block grant program targeting 3 Millennium Development Goals lagging in Indonesia:◦ Reducing child mortality◦ Reducing maternal mortality, and ◦ Ensuring universal coverage of basic education

Villages, with assistance from trained facilitators and service providers, use a participatory planning process and block

grant funds to reach 12 health and education indicators.

Socialization stageWhat is Community CCT?What are the 12 indicators?

Villageplanning stage

Village implementation

stage

Performancemeasurement

Social mapping;Village council

election;Women’s focus

groups;Inter-village

meetings;Workshop with

providers;Prioritization;

Decision-making

Implementation of village activities;Monitoring of 12 indicators;Village Council monthly review meetings;

Cross-village audits;External audits

PNPM-GenerasiImplementation Cycle

Fund allocation for following year

Generasi Project Cycle

How does it work?

Communities can use the funds flexibly, for example:

Improve service quality and performance directly and contract private providers if

public provision of services is considered sub-optimal.

Help mitigate against external shocks and avoid negative coping strategies such as

pulling children into the workforce

Adjust use of resources over time

Generasi Facts

Program Start: July 2007

Scope: 5 Provinces (West/East Java, Gorontalo, North Sulawesi and East Nusa Tenggara), 21 Districts, 178 sub-districts and 2144 villages.

Total Budget: USD 110 million (2007 /2008)

Community Contribution: USD 720,000 (2007/2008)

Average Block Grant Amount: USD185,000 (2009)

Total Beneficiaries: 3,100,000 villagers (2007/2008)

Implementing Agency: Ministry of Home Affairs

Source of Funds: The World Bank, The Royal Netherlands Embassy and the PSF Support Facility. 2010 will see additional grant funding from AusAID.

Generasi Facts:

12 Health & Education Indicators

Indictors for pregnant mothers Four prenatal care visits during

pregnancy Taking iron tablets during pregnancy Delivery assisted by trained professional Two postnatal care visits

Indicators for children under five Complete childhood immunization Ensuring monthly weight increases for

infants Regular weighing for under-fives Taking Vitamin A twice a year for under-

fives

Indicators for school-aged children (NB these indicators will change) Primary school enrolment (7-12 year

olds) Regular primary school attendance

(>85%) Junior secondary school enrolment (13-

15 year olds) Regular secondary school attendance

(>85%)

Evaluations Built Into Project Design

Uses a 3 Wave randomized evaluation

◦ Baseline (2007, with HH CCT)◦ One-year follow-up (2008, Generasi only)◦ Two-year follow-up (2009, with HH CCT)

Initial Design Randomized subdistricts into three groups: ◦ with performance incentives, ◦ without performance incentives*, and ◦ Controls

Subdistrict randomization addresses spillovers and crowding out

Design structure allows comparison with HH-CCT

Common survey instruments for HH-CCT and Generasi evaluation

*The 2008 evaluation showed better performance in incentivized locations. In third year of implementation all locations used performance incentives.

What was achieved?

•Impact on Indicators

•Strengthened governance and accountability through:•

Increased demand

•Improved targeting

•Improvements in quality of service delivery including coordination of

various agencies

Health Impacts in the Community Year 1

Results suggest that a major contribution of Generasi was a revitalization of the existing village health post system that

brought more mothers and children into the health care net.

The first 15-18 months of Generasi saw:

◦20% increase in children weighed

◦32% increase in children receiving supplementary feeding

◦59% increase in children receiving intensive supplementary feeding

◦27% increase in immunization rates

◦20% increase in children receiving Vitamin A tablets

◦42% increase in the number of pregnant mothers receiving antenatal care

◦48% increase in pregnant mothers receiving iron pills

Long Term Health Impacts in the Community Year

1

Large reductions in neonatal and infant mortality

◦Neonatal mortality reduced by 47% compared to

control groups

◦Infant mortality reduced by 28% compared to control

Significant reductions in malnutrition in NTT and

Sulawesi

◦Among children under-three in seasonal famine-prone NTT,

children were 17.6% less likely to be malnourished

compared to control groups.

Stimulating demand

Stimulates demand by providing the means to access basic health services

Stronger demand improved services◦ Improvements in the quality of village integrated health posts measured by the

content of services mothers received during the village health post sessions.

COMMUNITIES IN ACTION:

Short term contracts for midwives–North Sulawesi

Communities in remote villages off the coast of North Sulawesi used Generasi funds to contract midwives to provide routine health

services to women and children in the local community. In consultation with the local health clinic, midwives are funded for one year

and placed in villages that do not currently have a midwife until a permanent placement is found.

Targeting

Targeting the poor and vulnerable:

Communities identify the poor and vulnerable through social mapping.

The program requires that 10% of the total funds for each village in Java and 25% of those outside of Java specifically target those not yet

receiving the relevant health and education services, and who are performing poorly against the 12 health and education indicators e.g. out-of-

school-children and malnourished children.

Facilitators and health service providers monitor and record information about the services obtained for all villages in the target group.

Villages and local governments are now using data collected by Generasi as their official data

Improvements in quality of service delivery

Incentive for various agencies to collaborate and coordinate

Coordination Team Against Malnutrition-North Central Timor, NTT

Eleven organizations, including the Health Department, PNPM Generasi, International NGOs such as CARE, and local NGOs fighting chronic malnutrition now hold coordination meetings monthly to target activities and funds.

Combating Malnutrition with Local Harvest Menus- East Flores, NTT

In coordination with a local NGO and Generasi, health posts are teaching women in rural areas how to cook nutritious menus using food growing on their land. Local harvest menus are substantially cheaper to make, and offer a variety of well-balanced dishes so children want to eat.

Increased Outreach Services

◦Many communities used funds to provide transportation money and assistance to poor pregnant mothers. As a result, there were:

22% increases in women using trained midwives for deliveries

Midwives were significantly more active in providing maternal, neonatal and child health services; and

Midwives spent more time providing outreach services, especially in Java.

Improved Education for Health Post Volunteers-Magetan, East Java

Increased community interest and enthusiasm has spurred the Health Department to provide monthly seminars for health center

volunteers who, along with midwives, are front line service providers in monthly health post.

Improvements in quality of service delivery

Where to go from here?

Linkages with other CDD efforts◦ Consolidation of participatory process◦ Earmarking of resources?

Operationalizing integration in sectoral policy framework Strengthening linkages with District level budgeting and planning

processes

Main lesson: tapping into synergies leverages impact

What are the comparative advantages of various actors?

How can we bring these to bear?

Thank you