indonesia: decentralized health services project

8/10/2019 Indonesia: Decentralized Health Services Project

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EvaluationIndependent

Indonesia: Decentralized

Health Services Project

PerformanceEvaluation Report


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Reference Number: PPE: INO 2013-21Loan Number: 1810-INOIndependent Evaluation: PE-!"

Performance Evaluation ReportPerformance Evaluation ReportPerformance Evaluation ReportPerformance Evaluation Report#ecember 2013#ecember 2013#ecember 2013#ecember 2013

#ecentrali$ed %ealt& 'ervice( Pro)ect in#ecentrali$ed %ealt& 'ervice( Pro)ect in#ecentrali$ed %ealt& 'ervice( Pro)ect in#ecentrali$ed %ealt& 'ervice( Pro)ect in

Indone(iaIndone(iaIndone(iaIndone(ia


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NoteNoteNoteNote

*i+ ,&e fi(cal ear *./+ of t&e overnment of Indone(ia end( on

31 #ecember

*ii+ In t&i( report 45 refer( to 6' dollar(

#ire#ire#ire#irector eneralctor eneralctor eneralctor eneral 7 ,&oma( Independent Evaluation #epartment *IE#+

#irector#irector#irector#irector 9olma Independent Evaluation #ivi(ion 1 IE#,eam leader,eam leader,eam leader,eam leader Rauniar Principal Evaluation 'peciali(t IE#,eam member(,eam member(,eam member(,eam member( P Lim Evaluation Officer IE#

7 ;elo-((i(tant IE#

,&e =uideline( formall adopted b t&e Independent Evaluation #epartment *IE#+ on

avoidin= conflict of intere(t in it( independent evaluation( ?ere ob(erved in t&epreparation of t&i( report ,o t&e no?led=e of IE# t&ere ?ere no conflict( of intere(t

of t&e per(on( preparin= revie?in= or approvin= t&i( report

In preparin= an evaluation report or b main= an de(i=nation of or reference to a

particular territor or =eo=rap&ic area in t&i( document IE# doe( not intend to mae

an )ud=ment( a( to t&e le=al or ot&er (tatu( of an territor or area

9e ord(9e ord(9e ord(9e ord(

advocac a(ian development ban capacit buildin= decentrali$ed &ealt& (ervice(pro)ect demo=rap&ic and &ealt& (urve famil plannin= (ervice( &ealt& in(urance&ealt& (ector reform( &ealt& (ervice utili$ation financin= pro=ram &ealt& ((temmana=ement independent evaluation department indone(ia infant and maternalmortalit rate performance evaluation report pro)ect mana=ement (upport under-@mortalit rate


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>bbreviation(>bbreviation(>bbreviation(>bbreviation(

>#A B >(ian #evelopment Aan

A>PPEN>' B Aadan Perencanaan dan Pemban=unan Na(ional *National#evelopment Plannin= >=enc+

A99AN B National Population and .amil Plannin= Aoard *Aadan 9oordina(i9eluar=a Aerencana Na(ional+

#%' B #ecentrali$ed %ealt& 'ervice( Pro)ect#%'2 'econd #ecentrali$ed %ealt& 'ervice( Pro)ectI#%' B Indone(ia #emo=rap&ic and %ealt& 'urveIE#I;R

BB

Independent Evaluation #epartmentinfant mortalit rate

;CE B monitorin= and evaluation;# B ;illennium #evelopment oal;;R B maternal mortalit ratio;O% B ;ini(tr of %ealt&;N B tec&nical a((i(tance6@;R B under-@ mortalit rate

t >pprai(al>t >pprai(al >t Pro)ect t Pro)ect t Pro)ect t Pro)ect t>t>t>t EvaluationEvaluationEvaluationEvaluation1 #ecember 2000 30 Fune 200" 30 November 2013

Rp100 G 4000011 400000" 4000008@4100 G Rp"31@ Rp102@ Rp11@@

lo((arlo((arlo((arlo((ar

>(e(in B &ealt& in(urance for t&e poorFame(ma( B &ealt& (ervice utili$ation financin= pro=ramFamper(al B maternal &ealt& financin= pro=ramFP'-A9 B 'ocial 'afet Net Pro=ram for %ealt&polinde( B villa=e deliver centerpo(andu( B villa=e &ealt& po(t(pu(e(ma( B &ealt& center(


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cno?led=ment(no?led=ment(no?led=ment(no?led=ment( iiii

Aa(ic #ataAa(ic #ataAa(ic #ataAa(ic #ata iiiiiiiiiiiiEHecutive 'ummarEHecutive 'ummarEHecutive 'ummarEHecutive 'ummar vvvv Impact( 28

A Performance of >#A Aorro?er and #evelopment Partner( 32

((i(tance 3@

ction( 3333> I((ue( 3

A Le((on( 38

ction( 1

>ppendiHe(>ppendiHe(>ppendiHe(>ppendiHe(1 #e(i=n and ;onitorin= .rame?or

2 Ratin= ;atriH for


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>cno?led=ment(>cno?led=ment(>cno?led=ment(>cno?led=ment(

,&i( report i( a product of t&e Independent Evaluation #epartment *IE#+ of t&e >(ian

#evelopment Aan *>#A+ ane(& Rauniar Principal Evaluation 'peciali(t led t&eevaluation ?it& t&e (upport from ;a Patricia Lim and 7alerie >nne ;elo-(ia #epartment of >#A

,&e report ?a( prepared under t&e overall =uidance of 7inod ,&oma( #irector eneraland alter 9olma #irector *#ivi(ion 1+ IE# IE# retain( full re(pon(ibilit for t&ereport


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Aa(ic #ata

Loan 1810Loan 1810Loan 1810Loan 1810----INO #ecentrali$ed %ealt& 'ervice(INO #ecentrali$ed %ealt& 'ervice(INO #ecentrali$ed %ealt& 'ervice(INO #ecentrali$ed %ealt& 'ervice(

Pro)ect Preparator and In(titution Auildin= ,ec&nical >((i(tancePro)ect Preparator and In(titution Auildin= ,ec&nical >((i(tancePro)ect Preparator and In(titution Auildin= ,ec&nical >((i(tancePro)ect Preparator and In(titution Auildin= ,ec&nical >((i(tance

,>,>,>,>NoNoNoNo ,> Name,> Name,> Name,> Name ,pe,pe,pe,pe

>mount>mount>mount>mount*4K000+ >pproval #ate>pproval #ate>pproval #ate>pproval #ate

383@"

#ecentrali$ed %ealt& 'ervice('upport for %ealt& 'ector Polic

Reform

PP>#

18000100000

2! ;a 20001 #ec 2000

9e Pro)ect #ata9e Pro)ect #ata9e Pro)ect #ata9e Pro)ect #ata *4 million+Per >#A LoanPer >#A LoanPer >#A LoanPer >#A Loan#ocument(#ocument(#ocument(#ocument(

>ctual>ctual>ctual>ctual

,otal pro)ect co(t 800 "1@>#A loan amountutili$ation !@00 @"31>#A loan amountcancellation 1@88

9e #ate(9e #ate(9e #ate(9e #ate( EHpectedEHpectedEHpectedEHpected >ctual>ctual>ctual>ctual

>pprai(al mi((ion 2@ 'epB23 Oct 2000Inception mi((ion 3B12 >pr 2001Loan ne=otiation( 1!B1 Nov 2000Aoard approval 1 #ec 2000Loan a=reement 2 ;ar 2001Loan effectivene(( 2@ Fun 2001Loan clo(in= 30 'ep 200! 30 Fun 200";ont&( *effectivene(( to completion+ "!

Aorro?erAorro?erAorro?erAorro?er Republic of Indone(iaEHecutin= >=encEHecutin= >=encEHecutin= >=encEHecutin= >=enc ;ini(tr of %ealt&

,pe of ;i((ion,pe of ;i((ion,pe of ;i((ion,pe of ;i((ion No of ;i((ion(No of ;i((ion(No of ;i((ion(No of ;i((ion( No of Per(onNo of Per(onNo of Per(onNo of Per(on----#a(#a(#a(#a(>pprai(al 1 "Inception 1 0Revie? 13 1@@;idterm revie? @Pro)ect completion revie? 20Independent evaluation mi((ion 1 1># G advi(or >#A G >(ian #evelopment Aan PP G pro)ect preparator ,> G tec&nical a((i(tance


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EHecutive 'ummarEHecutive 'ummarEHecutive 'ummarEHecutive 'ummar

,&e pro)ect performance evaluation report of t&e #ecentrali$ed %ealt& 'ervice(Pro)ect in Indone(ia provide( a (et of le((on( from a (ector-?ide reform-ba(ed &ealt&pro=ram in a countr =oin= t&rou=& a proce(( of decentrali$in= =overnment (ervice((ince 1""" ,&e findin=( from t&e evaluation ?ill feed into &i=&er-level evaluation(includin= validation of t&e countr partner(&ip (trate= final revie? planned for 201

,&e >(ian #evelopment Aan *>#A+ approved a loan of 4!@ million and pro)ectpreparator tec&nical a((i(tance *,>+ of 4800000 on 1 #ecember 2000 ,&e loanclo(ed on 30 Fune 200" after t?o eHten(ion( >n advi(or ,> of 41 million financin=3! per(on-mont&( of t&e ?or of an individual con(ultant ?a( attac&ed to t&e loan?it& t&e ob)ective of (tren=t&enin= local &ealt& (ector reform ,&e pro)ect ?a(ori=inall de(i=ned to cover @0 di(trict( and 12 citie( in (even province( buta( decentrali$ation evolved t&e covera=e eHpanded to 3 di(trict( in ei=&t province(

,&e pro)ect aimed to improve t&e &ealt& (tatu( of t&e population in t&e pro)ectarea( It &ad t?in ob)ective( of *i+ improvin= &ealt& and famil plannin= (ervice( and*ii+ =uaranteein= acce(( of t&e poor to e((ential &ealt& and famil plannin= (ervice(Pro)ect component( compri(ed *i+ advocac and capacit buildin=M *ii+ adaptation of&ealt& (ervice( to local need( t&rou=& appropriate &ealt& (ector reform(M*iii+ inve(tment( in &ealt& and famil plannin=M and *iv+ pro)ect mana=ement (upport*e= implementation and monitorin= and evaluation+ Lie?i(e t&e advi(or ,>envi(a=ed (iH output(: *i+ &ealt& (ector reform( identified *ii+ capacit for &ealt& ((temmana=ement and &ealt& (ervice deliver built *iii+ &ealt& plan( developed*iv+ a?arene(( of &ealt& prioritie( created amon= deci(ion maer( *v+ operation(re(earc& capacit developed and *vi+ pro)ect mana=ement (upported

,&e evaluation conclude( t&at pro)ect performance ?a( (ucce((ful overall?&ic& ?a( al(o t&e pro)ect completion reportJ( a((e((ment Primar di(trict andprovincial &ealt& (ervice( &ave developed to improve acce(( for a =reater number ofpeople includin= t&o(e in remote and rural area( becau(e of pro)ect (upport

Locall &o?ever &ealt& (ervice deliver &a( been con(trained b limitedfundin= t&at focu(e( on admini(trative eHpenditure and involve( (i=nificant tran(actionco(t( In(ufficient recurrent eHpenditure limited &o(pital bed( and (peciali(t( and &i=&(taff turnover are often inadeDuatel dealt ?it& Nevert&ele(( t&e central =overnmenti( re(pondin= to (ome of t&e(e concern( ?it& t&e introduction and (ub(eDuent (calin=up of &ealt& in(urance (c&eme( (uc& a( t&o(e initiated under t&e pro)ect

,&e pro)ect i( rated relevant at t&e time of de(i=n durin= implementationat completion and at evaluation It ?a( al(o relevant in t&e conteHt of Indone(iaJ(development prioritie( >#A( countr (trate= and t&e ;illennium #evelopment oal(a((ociated ?it& c&ild and maternal &ealt& ,&e pro)ect de(i=n ?ould &ave benefitedfrom (maller covera=e *fe?er province(+ and a more ri=orou( proce(( in tar=etin=di(advanta=ed population( to furt&er en&ance pro)ect relevance reater con(iderationof pro)ect ri(( particularl related to in(titutional capacit and political econom anddevelopment of ri( miti=ation (trate=ie( ?ould &ave added ri=or to t&e pro)ect de(i=n,&e evaluation team note( t&at t&e midterm revie? of t&e pro)ect led to =reater focu(


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vi Decentralized Health Services Project in Indonesia

on maternal and c&ild &ealt& ,&i( re(ulted in le(( emp&a(i( on famil plannin= andnutrition

,&e pro)ect( performance i( rated effectivein ac&ievin= t&e (tated output( andoutcome( ,&e &ealt& (ervice infra(tructure built or renovated ?it& pro)ect (upport ?a(found to be in =ood condition and ?ell maintained 'imilarl &ealt& facilitie( are u(in=

t&e pro)ect-(upported eDuipment ?ell > lar=e number of &ealt& (ervice (taff receivedmana=ement and tec&nical trainin= and fello?(&ip( for &i=&er (tudie( 'ome of t&emno? occup e po(ition( in t&e &ealt& ((tem > revie? of &ealt& facilit utili$ation(u==e(t( t&at poor &ou(e&old( ?&o ot&er?i(e could not afford &ealt& (ervice( &avebenefited t&e mo(t %ealt& in(urance covera=e for t&e poor &a( al(o been a ma)orcatal(t for =reater u(e of &ealt& facilitie( 'ome of t&e reform mea(ure( introduced bt&e pro)ect particularl (ub(id to trained birt& attendant( and &ealt& in(urance for t&epoor &ave been (caled up and are liel to benefit di(advanta=ed =roup(

Overall t&e &ealt& outcome indicator( (&o? improvement( acro(( Indone(iaalt&ou=& no (i=nificant difference( are ob(erved bet?een pro)ect-(upported and non-pro)ect-(upported di(trict( or province( ,&i( applie( to bot& t&e infant mortalit rateand maternal mortalit ratio >( (u==e(ted earlier t&e pro)ect (et ambitiou( tar=et( and

=eo=rap&ical covera=e ?&ic& re(ulted in re(ource( bein= (pread t&inl 'ome of t&etar=et( proved unreali(tic .or eHample t&e pro)ect aimed to &ave at lea(t "0 ofdeliverie( a((i(ted b trained birt& attendant( ,&i( &a( been ac&ieved onl in AaliIn


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Executive Summary vii

,&e evaluation concur( ?it& t&e pro)ect completion report( a((e((ment t&at>#A( performance ?a( (ati(factor >#A fielded mi((ion( on time and accommodated=overnment reDuirement( includin= t?o eHten(ion( of t&e loan clo(in= dateovernment performance on t&e ot&er &and i( rated le(( t&an (ati(factor #elaedrelea(e of counterpart fund( of up to ! mont&( in a =iven ear limited pro)ect activitie(t&at could onl be taen up once fund( ?ere relea(ed Pro)ect fund( could &ave been

u(ed in fe?er province( ?it& &i=&er povert incidence and la==in= &ealt& indicator(Local area inve(tment plannin= al(o (&ould &ave been more pro-poor in it( re(ourceallocation > more eHplicit =uideline (&ould &ave been i((ued on plannin= pro)ectallocation( for different tier( of t&e &ealt& ((tem and tar=etin= lo?er-income di(trict(Effort( to encoura=e local =overnment( to increa(e recurrent &ealt& eHpenditure (&ould&ave been more emp&atic

Indone(ia continue( to face &urdle( in t&e &ealt& (ector 9e c&allen=e( are:*i+ Need( are =reate(t in remote and rural area( In man area( outreac& i(

limited due to =eo=rap&ical i(olation*ii+ ide di(paritie( in tec&nical and mana=erial capabilitie( a( ?ell a( in

monitorin= ((tem( remain acro(( &ealt& (ervice center( at all level(

*iii+ ,&e local &ealt& ((tem put( too muc& emp&a(i( on admini(trative(upport

,&e evaluation recommend( four mea(ure(:*i+ >#A (&ould remain en=a=ed ?it& t&e overnment of Indone(ia in t&e

&ealt& (ector becau(e a lar=e (e=ment of t&e population i( (till in direneed of mode(t &ealt& (ervice( ,&i( i( con(i(tent ?it& >#AJ( inclu(ive-=ro?t& approac&

*ii+ >#A (&ould promote t&at local di(trict provincial and central=overnment( ?or on and ad&ere to a clear fundin= frame?or for(tron=er &ealt& and famil plannin= (ervice( at all level( %ealt& (ervicefacilitie( need reliabilit and le(( compleHit in fundin= forinfra(tructure development procurement of eDuipment and dru=( and

retention of Dualified &ealt& ?orer(*iii+ >#A (&ould &elp t&e provincial =overnment( ?it& (upport from t&e

central =overnment to promote t?innin= arran=ement( ?it& &ealt&facilitie( in ot&er province( and citie( ,&i( can (erve a( a (u(tainablemodel for increa(in= outreac& of &ealt& (ervice( a( ?ell a( (ill(development of &ealt& ?orer(

(iv) >#A (&ould &ave polic dialo=ue ?it& t&e central =overnmentre=ardin= t&e need for a lead role of t&e National #evelopmentPlannin= >=enc ;ini(tr of %ealt& National .amil Plannin=


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P,ERP,ERP,ERP,ER 1111

IntroductionIntroductionIntroductionIntroduction

1 ,&i( c&apter de(cribe( purpo(e and proce(( adopted for t&e pro)ectperformance evaluation It (tate( eHpected re(ult( and outline( pro)ect ob)ective( and&i=&li=&t( e a((e((ment( provided in t&e pro)ect completion report

>>>> Evaluation Purpo(e and Proce((Evaluation Purpo(e and Proce((Evaluation Purpo(e and Proce((Evaluation Purpo(e and Proce((

2 ,&e #ecentrali$ed %ealt& 'ervice( Pro)ect *#%'+ in Indone(ia ?a( (elected forevaluation to determine le((on( from a (ector-?ide reform-ba(ed pro=ram in a countreHperiencin= decentrali$ation It al(o aimed to fill t&e no?led=e =ap in t&eperformance of &ealt& pro)ect( (upported b t&e >(ian #evelopment Aan *>#A+,&e evaluation findin=( ?ill feed into ot&er t&ematic and countr evaluation( b t&e

Independent Evaluation #epartment *IE#+ in t&e near future IE# did not validate t&efindin=( of t&e pro)ect completion report *P#A prepared t&e P#A 2000 Report and Recommendation of t&e Pre(ident to t&e Aoard of #irector(: Propo(edLoan and ,ec&nical >((i(tance rant *financed from t&e Fapan 'pecial .und+ to Indone(ia fort&e #ecentrali$ed %ealt& 'ervice( Pro)ect ;anila para( 11B11@

P


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2 Decentralized Health Services Project in Indonesia

evaluation of t&e efficienc and (u(tainabilit of t&e variou( local &ealt& initiative( ?a(needed before replicatin= t&e initiative( It i( not no?n if (uc& an evaluation ?a(made and if (ome or all innovation( ?ere replicated

! ,&e evaluation i( ba(ed on a revie? of pro=ram document( variou( countr(tudie( and t&e findin=( of an independent evaluation mi((ion to Indone(ia

,&e evaluation team undertoo additional anal(i( to (upplement data collected durin=t&e mi((ion and data provided b t&e #irectorate of Nutrition and ;aternal


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Introduction 3


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#e(i=n and Implementation#e(i=n and Implementation#e(i=n and Implementation#e(i=n and Implementation

1 ,&e c&apter dra?( on revie? of relevant document( di(cu((ion( ?it& einformant( and data provided b t&e pro)ect It di(cu((e( pro)ect formulation andrationale be&ind t&e pro)ect and (ummari$e( co(t financin= and implementationarran=ement(M procurement con(truction and (c&edulin=M and de(i=n c&an=e( It al(o&i=&li=&t( four e output( ac&ieved under t&e pro)ect and revie?( con(ultantperformance and loan covenant( a((ociated ?it& t&e pro)ect

>>>> .ormulation.ormulation.ormulation.ormulation

1@ Overall t&e evaluation noted t&at pro)ect preparation laced detail Local=overnment( developed preliminar inve(tment pro=ram( to meet local &ealt& i((ue(

and c&allen=e( #ue to t&e brevit of plannin= it ?a( a=reed t&at t&e pro)ect ?ould berevi(ed after di(trict and provincial (taff &ad received furt&er trainin= in &ealt& plannin=and mana=ement #Afollo?in= certain criteria defined in t&e loan document( ,&e plan( ?ere implementedin t&e (econd p&a(e of t&e pro)ect

1! iven t&e limited time for pro)ect preparation t&ere ?ere no detailed report( onpublic &ealt& medical eDuipment and procurement need( in eac& provinceM anda((e((ment( of trainin= need( a((e((ment( for operational and mana=ement (taff>ccordin= to t&e P produced a number of document( on local &ealt& (ectorreform( and trainin= module( for &ealt& plannin= and bud=etin= but t&i( input ?a(provided onl mid?a t&rou=& implementation

AAAA RationaleRationaleRationaleRationale

1 >t t&e time of pro)ect formulation &ealt& (ervice deliver in Indone(ia ?a(&i=&l centrali$ed ?it& limited mana=ement capacit at t&e di(trict and local level(>( a re(ult &ealt& (ervice( ?ere perceived to lac re(pon(ivene(( to local i((ue(,&e central =overnment devolved (ome of it( &ealt&-related re(pon(ibilitie( in 2001in line ?it& la?( =overnin= re=ional autonom and pa((ed in 1""" >t t&e time ofpro)ect de(i=n it ?a( deemed important t&at acce(( to e((ential &ealt& (ervice( for t&epoor vulnerable =roup( and ?omen be (u(tained durin= t&e tran(ition becau(e t&e

countr ?a( (till recoverin= from t&e >(ian financial cri(i( 1""B1""8 ,&e 'ocial 'afetNet Pro=ram for %ealt& *FP'-A9+8 ?&ic& &ad been e(tabli(&ed ?it& >#A (upport to

La? on Re=ional >utonom *La? No 22""+ and La? on .i(cal Aalance *La? No 2@""+8 >#A 1""8 Report and Recommendation of t&e Pre(ident to t&e Aoard of #irector(: Propo(ed

Loan( and ,ec&nical >((i(tance rant( *financed from t&e Fapan 'pecial .und+ to Indone(ia fort&e 'ocial Protection 'ector #evelopment Pro=ram ;anila *Loan( 1!22-INO and 1!23-INO+approved on " Ful 1""8 for 4300 million *?it& @08 of t&e loan amount for t&e &ealt&(ector+M and >#A 1""" Report and Recommendation of t&e Pre(ident to t&e Aoard of#irector(: Propo(ed Loan( and ,ec&nical >((i(tance rant( *financed from t&e >(ian


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Design and Implementation 5

protect vulnerable population( from t&e adver(e impact of t&e cri(i( al(o neededfinancial repleni(&ment

18 ,&e pro)ect de(i=n team noted t&at a reformulation of t&e FP'-A9 ?a( reDuiredcon(iderin= t&e c&allen=e of decentrali$ation ?it& better tar=etin= and co(t-effectivedeliver of &ealt& (ervice( Nutrition reproductive &ealt& and communicable di(ea(e

control remained e i((ue( for t&e &ealt& (ector alon= ?it& t&e introduction ofcapacit to reform &ealt&-care financin= and &uman re(ource developmentIn addre((in= t&e(e i((ue( t&e =overnment faced a con(iderable re(ource( =ap (incet&e FP'-A9 ?a( lar=el eHternall financed In re(pon(e to t&i( need t&e =overnmentreDue(ted >#A( (upport in earl 2000 to &elp implement decentrali$ation in t&e &ealt&(ector #%' ?a( approved on 1 #ecember 2000 and became effective on 2@ Fune2001

1" >t apprai(al t&e =overnment &ad =iven &i=& priorit to (u(tainin= &ealt&(ervice deliver at a time of ma)or up&eaval in t&e arc&itecture of t&e public (ector&ealt& ((tem ,&e pro)ect ?a( undertaen at a time ?&en central =overnment (ervice(?ere bein= devolved and limited capacit for implementation ?a( apparent at lo?er=overnment level( >t t&e midterm of implementation t&e =overnment accorded &i=&

priorit to improvin= ?omenJ( &ealt& and pro)ect activitie( ?ere reor=ani$ed to meett&i( demand ,&e pro)ect provided (upport for implementin= =overnmentJ( priorit>#A &ad al(o accorded &i=& priorit to improvin= ?omenJ( &ealt& in it( 1""" %ealt&Polic and (o t&i( pro)ect ?a( in line ?it& t&e prioritie( of bot& t&e =overnment and>#A Indone(iaJ( &ealt& polic %ealt& Indone(ia 20105 &i=&li=&t( t&e need to(upport primar &ealt& care and boo(t eHpenditure( for &ealt&"

20 In t&e ;illennium #evelopment oal *;#+ pro=re(( report t&e ;# tar=et(a((ociated ?it& maternal &ealt& in Indone(ia reDuired (pecial attention particularl inrelation to (illed attendance at c&ild birt&10 Leadin= cau(e( of maternal mortalitincluded &i=&-ri( pre=nancie( and un(afe abortion


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*>daptin= %ealt& 'ervice( to Local Need(+ incurred 1 le(( eHpenditure t&anplanned *4@3!" rat&er t&an 4!@01 million+

22 #i(bur(ement b co(t cate=or reflect( difference( in output (pecificimplementation Output 3 *Inve(tment( in %ealt& and .amil Plannin= 'ervice(+ ?a(lar=el implemented a( planned (o planned and actual di(bur(ement( for civil ?or(

and eDuipment are (imilar .or eHample 412!2" million ?a( t&e planned eHpenditurefor civil ?or( and 4120 ?a( di(bur(ed %o?ever onl 23 of t&e plannedeHpenditure on dome(tic and international con(ultant( *40833 of 43!30+ ?a( utili$ed,&e implication of t&e (&ortfall i( (ummari$ed in (ection of t&i( c&apter

23 ,&e Pt apprai(al t&e orld Aan *footnote "+ noted an intermediate role for t&eprovince( in tec&nical (upport di(ea(e (urveillance &ealt& promotion procurementand per(onnel mana=ement12 >t t&at time &o?ever it ?a( unclear &o? function(?ould be di(tributed bet?een central provincial and di(trict aut&oritie( even t&ou=&t&e La? on Re=ional >utonom &ad decentrali$ed mo(t &ealt&-related re(pon(ibilitie(

#A adopted a (ome?&at centrali$ed pro)ect mana=ement (tructure forit( follo?-on pro)ect t&e 'econd #ecentrali$ed %ealt& 'ervice( Pro)ect *#%'2+13 (incere=ional lac of profe((ional and mana=ement (ill( ?a( found to be t&e =reate(tcon(traint on implementation

2! ,&e famil plannin= component ?a( implemented b t&e National Populationand .amil Plannin= Aoard *A99AN+ It e(tabli(&ed a central mana=ement unit and(ecretariat( in eac& of t&e pro)ect province( In(titutional i((ue((uc& a( familplannin= bein= inte=rated into local =overnment office( re(ultin= in t&e lo(( of (taffand t&e ab(ence of a )oint tec&nical committee *?it& repre(entative( from ;O% andA99AN+&indered pro)ect plannin= and implementation

11,&e de(i=n of t&e follo?-on pro)ect #%'2 *footnote 13+ t&ou=&t to reflect t&e le((on of not&avin= t&i( focu( and e(tabli(&ed =reater di(trict mana=ement control over implementation

12orld Aan 2008 Provincial %ealt& Pro)ect in Indone(ia a(&in=ton #vailable: &ttp:document( ?orldbanor=curateden20080!"3!2@indone(ia-provincial-&ealt&-pro)ect

13>#A 2003 Report and Recommendation of t&e Pre(ident to t&e Aoard of #irector(: Propo(edLoan( to Indone(ia for t&e 'econd #ecentrali$ed %ealt& 'ervice( Pro)ect ;anila

,&e,&e,&e,&e provincialprovincialprovincialprovincialfocu( of t&efocu( of t&efocu( of t&efocu( of t&ede(i=n ?a(de(i=n ?a(de(i=n ?a(de(i=n ?a(

inappropriateinappropriateinappropriateinappropriate


17/67


#### Procurement


18/67


32 I((ue( a((ociated ?it& dela( in counterpart fundin= and len=t& procurementproce((e( ?ere compounded b t&e lac of capacit to develop di(trict implementationplan( durin= t&e (tartup p&a(e of t&e pro)ect ,&e lac of capacit and con(eDuent timetaen to formulate local inve(tment plan( ?a( &i=&li=&ted durin= t&e evaluation teamJ(field vi(it( and (u==e(t( t&at t&e p&a(in= and (cope of t&e pro)ect ?a( too optimi(tic=iven t&e uncertaint (urroundin= decentrali$ation in Indone(ia ,&e dela in mobili$in=

,> to &elp develop local plannin= capacit al(o undermined implementation efficiencand =iven t&e (i$e and =eo=rap&ic (cope of t&e pro)ect t&e ori=inal ,> value ?a(in(ufficient

EEEE #e(i=n at t&e reDue(t of t&e pro)ect mana=er t&e con(ultin= team formulated acompre&en(ive =rand (trate=5 to refocu( on maternal and ne?born c&ild &ealt&*;Nt t&e time of t&e midterm revie? in 200@ t&e pro)ect ?a( under t&e #irectorate eneral of


19/67


a((i(t implementation and involved 31000 participant( *@23 male and female+ ,&e pro)ect developed collaboration ?it& local univer(itie( and teac&in=in(titution( ?it& eHperti(e in public &ealt& durin= t&i( p&a(e >dvocac ?a( u(ed b t&edi(trict &ealt& office( to receive (upport from local =overnment and politicalcommitment from local parliament and from variou( local communit leader(

3 7ariou( cour(e( ?ere offered includin= (&ort one( *le(( t&an 1 ?ee+ #iplomacour(e( included mid?ifer nur(in= and nutrition ?&ile under=raduate cour(e(covered &ealt& mana=ement &ealt& promotion (tati(tic( and nur(in= ;a(ter cour(e(?ere provided bot& in Indone(ia and abroad in field epidemiolo= reproductive &ealt&&ealt& promotion public &ealt& and &ealt& economic( P cour(e( on &ealt&mana=ement and polic and nutrition and (peciali$ed trainin= for cardiolo=i(t( andpediatrician( ?ere al(o (upported In all 3032 (taff benefited from fello?(&ip(*,able 1+ and nearl @! of t&e participant( ?ere ?omen ,&e proportion of ?omenparticipatin= in bac&elor( de=ree ma(ter( de=ree and (peciali(t cour(e( ?a(unfavorable &o?evert&e (&are of female (taff trained i( ?ell belo? @0

,able,able,able,able 1: Number of .ello?(&ip( under t&e Pro)ect b 'taff Level1: Number of .ello?(&ip( under t&e Pro)ect b 'taff Level1: Number of .ello?(&ip( under t&e Pro)ect b 'taff Level1: Number of .ello?(&ip( under t&e Pro)ect b 'taff Level

/ear/ear/ear/ear'taff Level'taff Level'taff Level'taff Level

,otal,otal,otal,otal####----IIIIIIIIIIII ####----I7I7I7I7 '1'1'1'1 '2'2'2'2 'pec'pec'pec'pec '3'3'3'3 '2 *o(+'2 *o(+'2 *o(+'2 *o(+ 'fter fini(&in= #-I7 or'1 a (tudent can move to '2 *ma=i(ter+ or (peciali(t *'pec+ education *to become a doctor forin(tance+ #iploma level( are: diploma 1 *2 (eme(ter(+ diploma 2 * (eme(ter(+ diploma 3*! (eme(ter(+ diploma *8 (eme(ter(+

'ource: Independent Evaluation #epartmentdata collected b t&e evaluation team durin= field vi(it(

38 > con(ortium ?a( e(tabli(&ed to coordinate t&e trainin= pro=ram It( member(included A99AN and t&e ;ini(tr of %ealt& and 'ocial elfare univer(it (taff*national re=ional and local univer(itie(+ and repre(entative( of profe((ional bodie(*doctor( and nur(e(+ and NO( ,&e main role( covered provi(ion of tec&nical (upportto formulate and implement &uman re(ource development activitie( and actionpro=ram(M mobili$ation of nece((ar re(ource( for trainin= unit(M and evaluation of t&eimpact of &uman re(ource development ,&e con(ortium e(tabli(&ed a li(t of trainin=need( t&en (tarted developin= corre(pondin= module( for bot& t&e trainer( and t&etrainee( ,o date ei=&t module( &ave been developed

3" ;ana=ement trainin= involved 21000 participant( *@ female and

3 male+ It aimed to improve t&e capabilit of &ealt& (taff in t&e mana=ement ofdecentrali$ed &ealt& (ervice( decentrali$ed &ealt& facilitie( and priorit &ealt&pro=ram( ,&e e informant( cited capacit development a( one of t&e ma)or benefit(of t&e pro)ect ;an re(pondent( reported t&at local &ealt& re(ource( could not(upport (uc& trainin= alt&ou=& it &ad been in(trumental in t&e career development ofman current (enior &ealt& official( 9e benefit( li(ted b intervie?ee( ?ere: *i+ betterplannin= *ii+ module development for local =overnment trainin= *iii+ betteror=ani$ational plannin= *iv+ abilit to bud=et *v+ capacit to mobili$e t&e communit

;an;an;an;an

re(pondent(re(pondent(re(pondent(re(pondent(reported t&atreported t&atreported t&atreported t&atlocal &ealt&local &ealt&local &ealt&local &ealt&re(ource( couldre(ource( couldre(ource( couldre(ource( couldnot (upportnot (upportnot (upportnot (upport(uc& trainin=(uc& trainin=(uc& trainin=(uc& trainin=


20/67


*vi+ en&anced mana=ement of public &ealt& center facilitie( *vii+ problem (olvin= and*viii+ net?orin=

0 ,ec&nical need(-ba(ed trainin= covered life(avin= (ill( for mid?ive( ba(icemer=enc ob(tetric or neonatal care normal deliver care and compre&en(iveemer=enc ob(tetric and neonatal care ,rainin= focu(ed on developin= t&e (ill( of

mid?ive( at &ealt& center( and villa=e deliver center( *polinde(+ t&at provide ante- andpo(tnatal care and a((i(t ?it& deliverie(

1 ,&e P#A revie?( noted t&at t&e ,> &elped&i=&li=&t e i((ue( for local &ealt& (ector reform and documented variou( ca(e (tudie(?&ile t&e P


21/67


,able 2: %ealt& 'ector Reform( Introduced and ,&eir 'tatu(,able 2: %ealt& 'ector Reform( Introduced and ,&eir 'tatu(,able 2: %ealt& 'ector Reform( Introduced and ,&eir 'tatu(,able 2: %ealt& 'ector Reform( Introduced and ,&eir 'tatu(

1111 Aae(ra *Aalaie(e&atanraat+ 'out&ea(t 'ula?e(i Rural and Remote %ealt& Po(tAae(ra *Aalaie(e&atanraat+ 'out&ea(t 'ula?e(i Rural and Remote %ealt& Po(tAae(ra *Aalaie(e&atanraat+ 'out&ea(t 'ula?e(i Rural and Remote %ealt& Po(tAae(ra *Aalaie(e&atanraat+ 'out&ea(t 'ula?e(i Rural and Remote %ealt& Po(t

,&e initiative aimed to improve acce(( to &ealt& (ervice( and communit empo?erment particularl for rural and remote area(It ?a( piloted in 9olaa #i(trict of 'out&ea(t 'ula?e(i coverin= 18 (ubdi(trict( and 30 villa=e( It led to increa(ed covera=e ofantenatal care immuni$ation better nutrition and &ealt& promotion in t&e intervention area( .indin=( indicated t&at a &ealt&

life(tle i( a =ood approac& to communit empo?erment and Aae(ra &a( t&e potential to develop into an in(urance pro=ram lie>e(ra ,&e initiative in(pired t&e development of national #e(a 'ia=a %o?ever Aae(ra ?a( di(continued due to t&e (&ift inattention to Fame(ma(Fame(da Famper(al and AO9

2222 Faminan 9e(e&atan Fembrana 2003Faminan 9e(e&atan Fembrana 2003Faminan 9e(e&atan Fembrana 2003Faminan 9e(e&atan Fembrana 2003----200200200200

,&e initiative ?a( piloted in Fembrana #i(trict Aali to inve(ti=ate t&e potential of univer(al &ealt& in(urance ?it& an aim toimprove eDuit and Dualit of &ealt& (ervice( It covered ! (ubdi(trict( and @1 villa=e( It a((i(ted renovation of buildin=(provi(ion of medical and nonmedical eDuipment a( ?ell a( fello?(&ip( for (taff (upported b A&upati ,&e re(ult( &ave beenencoura=in= >bout 8 of t&e di(trictJ( population i( covered under t&e (c&eme and re(ident( &ave &ealt& card( t&at entitlet&em to =et free primar and (econdar *&o(pital+ &ealt& care ,&e pilot &a( introduced inte=rated &ealt& (ervice( offered bprivate provider( It &a( been (ucce((ful in unifin= &ealt& bud=et( and providin= &ealt& (ervice( do?n to t&e villa=e levelRe=ulation( on tariff( (tandard operatin= procedure( for (ervice( poolin= of re(ource( and promotion of public-privatepartner(&ip( in &ealt& (ervice deliver ?ere developed a( part of t&e pilot ,&e pro=ram i( no? adopted acro(( all di(trict( of AaliProvince

3333

Provide .amil #octor In Riau I(land( ProvinceProvide .amil #octor In Riau I(land( ProvinceProvide .amil #octor In Riau I(land( ProvinceProvide .amil #octor In Riau I(land( Province

Riau I(land( Province i( a =eo=rap&icall difficult area to (erve becau(e t&e population i( (pread over man i(land( ,&i( initiative?a( launc&ed to overcome (&orta=e of &ealt& facilitie( and (taff includin= doctor( and nur(e( in t&e arc&ipela=o ?it& an aim toimprove eDuit in acce(( to Dualit &ealt& (ervice( It ?a( piloted in ,an)un= Aalai 9arimun #i(trict coverin= ! (ubdi(trict( and!@ villa=e( ,&e initiative (tarted in 200! ?it& onl t?o medical doctor( and &ad eHpanded to 3@ doctor( b 2008 ,&e pro=ramallo?( &ome vi(it( b contracted doctor( and nur(e( to familie( in remote area( and on avera=e one doctor i( a((i=ned to118 familie( in a mont& ,&e eHperience &a( been promi(in= >( a re(ult of t&i( initiative *i+ familie( &ave acce(( to compre&en(ive&ealt& (ervice( *ii+ local people &ave demon(trated c&an=e in t&eir be&avior and &ave adopted &ealt& life(tle( *iii+ (c&ool &ealt&pro=ram( are runnin= effectivel and *iv+ deliver of (ervice( &a( been more co(t-effective t&an u(in= motorboat( a( mobile&ealt& center( ,&e pro=ram &a( been (caled up and adopted in all di(trict( of t&e province ?it& remote communitie( >t t&e timeof t&e evaluation teamJ( field vi(it( 11@ contracted doctor( ?ere (ervin= remote area( #i(trict &ealt& office( provide buildin=(and medicine( ,&e (ucce(( of t&e initiative ?a( noted a( bein= driven b t&e =overnorJ( (tron= commitment

;id?ive(;id?ive(;id?ive(;id?ive( ---- ,rained Airt& >ttendant Partner(&ip,rained Airt& >ttendant Partner(&ip,rained Airt& >ttendant Partner(&ip,rained Airt& >ttendant Partner(&ip

,&e pilot pro=ram ?a( launc&ed in t&ree (ubdi(trict( of 'ia #i(trict *Riau Province+ in 200 ?it& an aim to en&ance communitempo?erment and focu(ed particularl on improvin= &ealt& (ervice( and reformin= t&e referral ((tem 6nder t&i( initiative t&elocal =overnment provided Rp100000 per mont& a( an incentive for trained birt& attendant( *,A>(+ to brin= pre=nant ?omen tomid?ive( It offered better acce(( to c&ild deliver ?it& t&e (upport of trained &ealt& ?orer( particularl for ?omen fromeconomicall di(advanta=ed =roup( ?&ic& al(o &elped reduce maternal and neonatal mortalit rate( Aetter recordin= andreportin= of ;N( &ave been di(continued o?in= to lac of fund( ,&e impact of t&i( &a( not et been a((e((ed

> (imilar pilot ?a( launc&ed in ;ina&a(a #i(trict Nort& 'ula?e(i ?it& t&e (ame ob)ective coverin= all villa=e( and all (ubdi(trict(,&e pro=ram &a( &elped improve antenatal care deliver b trained &ealt& ?orer( and an inte=rated local bud=et for ;N


22/67


23/67


con(truction undertaen under t&e pro)ect1" ;edical and nonmedical eDuipment*includin= ve&icle(+ accounted for 4208 million *23 of total pro)ect co(t+,&e provi(ion of motorccle( to t&e mid?ife coordinator( (tren=t&ened outreac&activitie( #evelopin= t&e(e facilitie( &elped promote utili$ation of &ealt& in(uranceA99AN inve(tment( included *i+ civil ?or( (uc& a( renovation of (c&ool room( foradole(cent reproductive &ealt& information and coun(elin= center( and contraceptive

(tora=e room at a co(t of 411 million and for villa=e famil plannin= clinic(M and*ii+ information education and communication eDuipment and ve&icle( at a co(t of4 2 million

! It (&ould be noted &o?ever t&at t&e Pudit>ut&orit accordin= to ?&ic& t&e provi(ion of eDuipment under t&e #%' ?a( =enerallnot (ati(factor becau(e t&e deliver of =ood( *e= ambulance boat( and mid?ifereDuipment it(+ ?a( incomplete delaed andor not in compliance ?it& (pecification(,&e audit al(o found t&at civil ?or( did not conform to t&e ori=inal de(i=n and (ome?ere left incomplete ,&e evaluation team did not &ave enou=& time to verif t&e(eaudit findin=( but ;O% did not conte(t t&em

Output : Pro)ect ;ana=ementOutput : Pro)ect ;ana=ementOutput : Pro)ect ;ana=ementOutput : Pro)ect ;ana=ement

6nder t&e output 2@80 (taff received trainin= in pro)ect mana=ement andimplementation ,&e actual eHpenditure eHceeded apprai(al e(timate( becau(e of t&eeHtended implementation period and t&e need to (upport central provincial anddi(trict implementation committee( for lon=er t&an eHpected >ll planned activitie(appear to &ave been implemented alt&ou=& monitorin= and evaluation *;CE+ ?a( le((t&an (ati(factor ,&i( i((ue i( eHamined in t&e a((e((ment of overall performance*c&apter 3+


24/67


recruitment of individual con(ultant( introduced fleHibilit it made it &arder for pro)ectmana=ement to coordinate t&eir input( and output(

@1 ,&e planned en=a=ement of local con(ultin= firm( or NO( to conduct (ocialand environmental impact a((e((ment( did not receive adeDuate attention;CE (uffered from t&e ab(ence of ba(eline information a=ain(t ?&ic& pro=re(( could

be mea(ured .urt&ermore t&e &ealt& mana=ement information ((tem introducedunder t&e pro)ect i( deemed inadeDuate

%%%% Loan


25/67


Performance >((e((mentPerformance >((e((mentPerformance >((e((mentPerformance >((e((ment

@3 ,&e c&apter provide( an overall a((e((ment of t&e pro)ect performance anddi(cu((e( eac& of t&e four e performance a((e((ment parameter( ,&e(e includerelevance effectivene(( efficienc and (u(tainabilit

>>>> OverallOverallOverallOverall >((e((ment>((e((ment>((e((ment>((e((ment

@ ,&e evaluation rate( t&e overall pro)ect performance (ucce((ful ?&ic& i(con(i(tent ?it& t&e PppendiH 1 outline( t&e ac&ievement( a=ain(t t&e tar=et( (et in t&e de(i=nand monitorin= frame?or

,able 3: >((e((ment of Overall Performance,able 3: >((e((ment of Overall Performance,able 3: >((e((ment of Overall Performance,able 3: >((e((ment of Overall Performance

(((((e((me((me((me((meeeentntntntRatiRatiRatiRatinnnn====7alue7alue7alue7alue

ei=ei=ei=ei=&&&&tedtedtedtedRatiRatiRatiRatinnnn====

Relevance 2@ Relevant 2 0@0

Effectivene(( 2@ Effective 2 0@0

Efficienc 2@ Le(( t&an Efficient 1 02@

'u(tainabilit 2@ Liel 'u(tainable 2 0@0

OveralOveralOveralOveralllll ratin=ratin=ratin=ratin= 'ucce((ful'ucce((ful'ucce((ful'ucce((ful 1@1@1@1@'ource: Independent Evaluation #epartmentevaluation team a((e((ment ba(ed on >ppendiH 2

AAAA RelevanceRelevanceRelevanceRelevance

@! ,&e evaluation rate( t&e pro)ect relevant at de(i=n durin= implementationat completion and at t&e time of evaluation In 1""" and compared ?it& ot&er >(iancountrie( Indone(ia &ad a &i=& ;;R of 20 maternal deat&( per 100000 live birt&(and an infant mortalit rate of 3 deat&( per 1000 live birt&( #ecentrali$ation

,&e evaluation,&e evaluation,&e evaluation,&e evaluationrate( t&e overallrate( t&e overallrate( t&e overallrate( t&e overallpro)ectpro)ectpro)ectpro)ectperformanceperformanceperformanceperformance

(ucce((ful(ucce((ful(ucce((ful(ucce((ful


26/67


t&reatened to (lo? an improvement in or even ?or(en t&e(e &ealt& indicator(becau(e at t&e time of t&i( polic c&an=e di(trict( and communitie( &ad limitedcapacit and in(titutional proce((e(

@ #evelopment of &uman re(ource( t&rou=& trainin= ?or(&op( and &i=&er(tudie( accounted for about 2" of pro)ect eHpenditure ,&e allocation i( deemed

)u(tified =iven t&e need for provincial and di(trict capacit to improve &ealt& (ervicedeliver plan infra(tructure inve(tment( and purc&a(e medical and nonmedicaleDuipment ,&e pro)ect made provi(ion( for pilotin= ne? approac&e( to &ealt&-carereform t&at ?ould improve acce(( and Dualit of &ealt& (ervice( particularl for=eo=rap&icall and economicall di(advanta=ed population (e=ment(

@8 ,&e pro)ect document( did not eHplicitl (tate a rationale for re(ource allocationamon= central provincial and di(trict level( >llocation( (&ould &ave been ba(ed ont&e eHtent to ?&ic& t&e (upported particular function( under a decentrali$ed model#i(trict( put for?ard propo(al( for fundin= of civil ?or( trainin= and eDuipment?it&in eac& pro)ect province >cce(( to e((ential &ealt& (ervice( for t&e poor vulnerable=roup( and ?omen ?a( to be t&e overarc&in= priorit in an propo(al for pro)ect(upport > povert and (ocial a((e((ment ?a( to be prepared on &o? t&e variou(

(trate=ie( and activitie( propo(ed for pro)ect (upport met t&e need( of t&e poorvulnerable =roup( and ?omen ,&i( ta( ?a( not accompli(&ed

@" ,&e pro)ect formulated =uideline( for t&e preparation of a compre&en(ive&ealt& (ector plan and for central provincial or di(trict propo(al( for pro)ect financin=>fter tran(lation into Aa&a(a Indone(ia t&e =uideline( ?ere di(tributed to all pro)ectprovince( and di(trict( One international con(ultant and t?o dome(tic con(ultant(vi(ited all pro)ect province( to a((i(t local team( in preparin= t&eir plan( Ideall&o(pital (upport (&ould &ave focu(ed on level-t&ree inpatient( to en(ure t&at poorpeople benefited from t&e pro)ect

!0 ,&e pro)ect aimed to improve locall mana=ed &ealt& care deliver (upport&ealt& (ector reform and (tren=t&en &ealt& (ervice infra(tructure in t&e di(trict( ,&einclu(ion of communit-led plannin= reflected le((on( from earlier pro)ect( >( noted int&e P


27/67

Performance Assessment 17

facilit available number of &ealt& ?orer( inventor of eDuipment and ot&er(upplie(?a( lacin= ( a re(ult pro)ect funddi(bur(ement improved

!3 ,&e pro)ect de(i=n ?a( ambitiou( in it( (cope and =eo=rap&ical covera=eIt ori=inall included all di(trict( in (even province( coverin= more t&an 1" millionpeople in @0 di(trict( and 12 citie( *in Aali Aen=ulu Riau ?a( t&e proper lendin= modalit for t&i( pro)ect >#AJ( Operation( ;anualnote( t&at implementation eHperience ?it& pa(t polic-ba(ed loan( compre&en(ive(ector anal(e( t&at identif (tructural con(traint( to (ector development and (oundpolic and in(titutional (ettin=( are prereDui(ite( for main= financin= commitment(

,&e pro)ect,&e pro)ect,&e pro)ect,&e pro)ectde(i=n ?a(de(i=n ?a(de(i=n ?a(de(i=n ?a(ambitiou( in it(ambitiou( in it(ambitiou( in it(ambitiou( in it((cope and(cope and(cope and(cope and=eo=rap&ical=eo=rap&ical=eo=rap&ical=eo=rap&icalcovera=ecovera=ecovera=ecovera=e


28/67


a((ociated ?it& pro=ram lendin=20 ,&e(e condition( or anal(e( ?ere not evident atapprai(al ;oreover t&e report and recommendation of t&e Pre(ident ?ent to (omelen=t& to detail t&e uncertaintie( (urroundin= decentrali$ation et adeDuate ,> to(upport t&e pro)ect loan alon= ?it& reali(tic =eo=rap&ic covera=e ?a( not factoredinto t&e de(i=n

! ,&e evaluation team noted durin= t&e field vi(it( t&at lo?er level( of t&e &ealt&((tem mo(t freDuentl u(ed b t&e poor ?ere (upported b t&e pro)ect and continueto operate Pro-poor fund allocation( did not (eem to follo? a =eo=rap&ic priorit;an of t&e di(trict( vi(ited b t&e evaluation team ?ere clo(e to urban center( ?&erepovert rate( are not (o pronounced

!8 Plottin= di(trict-(pecific civil ?or( eHpenditure a=ain(t povert &eadcount ineac& di(trict *or cit+ illu(trate( a pro-ric& allocation of re(ource( *.i=ure 2+ ,&e di(trict(?it& &i=&er povert &eadcount or =reater percenta=e of people livin= belo? t&epovert line received t&e lo?e(t (&are of civil ?or( fundin=21Ot&er >#A &ealt& (ector(upport pro)ect( ?&ic& include t&e %ealt& pril 201321#A 2008 Report and Recommendation of t&e Pre(ident to t&e Aoard of #irector(: Propo(ed

Loan to 7iet Nam for t&e %ealt&


29/67


!" #e(pite t&e above-mentioned (&ortcomin=( in t&e pro)ect de(i=n di(trict&ealt& (ervice( ?ere encoura=ed to identif &ealt& prioritie( and e area( of &ealt&-care reform %ealt&-care reform( ?ere piloted in man in(tance((uc& a( t&e in(urance(c&eme in Aali and (ub(idie( for traditional birt& attendant( ;uc& of t&e con(tructioncentered on lo?er-level &ealt& facilitie( t&at are primaril u(ed b t&e poor %ealt&

facilit u(e b people in lo?er ?ealt& Duintile( i( particularl lo? in Indone(ia (o t&etar=etin= of infra(tructure to improve &ealt& outcome( for t&i( =roup i( con(idered (tillrelevant at evaluation


30/67


,able : Outpatient and .amil Plannin=


31/67


pro=ram inte=rated into population office( ?it&in local =overnment( ,&e bud=etprovided to famil plannin= (ervice( decrea(ed (ub(tantiall


32/67


anal(i( per pro)ect and non-pro)ect di(trict it i( difficult to Duantif t&e ma=nitude oft&e impact t&at could be attributed to t&e pro)ect

3333 #i(trict bud=et for &ealti(trict bud=et for &ealti(trict bud=et for &ealti(trict bud=et for &ealt&

81 > tar=et in t&e report and recommendation of t&e Pre(ident ?a( t&at mo(t

di(trict =overnment( ?ould allocate at lea(t of t&eir bud=et to &ealt& It i( evidentt&at all province( ac&ieved t&i( tar=et in t&eir o?n bud=et( but t&ere ?a( no((tematic collection of data on &o? far t&e di(trict( t&em(elve( ac&ieved t&i(,&e (ame i((ue ?a( &i=&li=&ted in completion report( for t&e orld Aan( provincial&ealt& pro)ect( Lie man indicator( a((e((ed in t&i( report t&e e(timate( &ave a =reatdeal of ear-on-ear variation *,able @+ .or eHample t&e percenta=e allocation of AaliJ(bud=et to &ealt& increa(ed from 3@ in 2002 to "3 in 200@ t&en dropped to 3"in 2011 ,&e definition of t&e indicator appear( to differ on ?&et&er to include oreHclude t&e value of &ealt& in(urance 'uc& variation mae( (pecific time (erie(evaluation impractical #e(pite t&i( i((ue t&e overall up?ard trend in t&e allocation oflocal bud=et to &ealt& i( evident particularl in t&e province( ?it& a lar=erconcentration of t&e poor *N># Riau Riau I(land( Aen=ulu revie? of di(trict &ealt& eHpenditure in 200! found t&at at lea(t 0 ofpublic eHpenditure on &ealt& i( for per(onnel and di(trict( &ave limited di(cretion overt&e deploment of public eHpenditure on &ealt&28 #e(pite deci(ion main= bein=limited t&e evaluation team ob(erved t&at at t&e di(trict level appropriate plannin=and bud=etin= tool( are bein= u(ed in preparin= di(trict &ealt& plan( Lo? level( ofpublic (pendin= on &ealt& &ave been deemed to be a e rea(on for poor &ealt&indicator( (uc& a( &i=& mortalit rate( and t&e eHce((ive u(e of (elf-treatment inIndone(ia 9e informant( indicated t&at trainin= provided under t&e pro)ect &a(a((i(ted in mobili$in= local level re(ource( for t&e &ealt& (ector

83 ,&e pro)ect &a( al(o &elped promote coun(elin= (ervice( and a?arene(( of&ealt& i((ue( amon= bot& men and ?omen %o?ever t&e outreac& of famil plannin=(ervice( &a( (ta=nated in recent ear( due to t&e reduced focu( in t&e later (ta=e ofpro)ect implementation ,&e P


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of contraceptive u(e mi=&t &ave contributed to unmet need(2" for famil plannin=(ervice( ,&e decrea(e in famil plannin= indicator( mi=&t be lined to t&e decrea(e inA99AN bud=et and t&e reor=ani$ation of A99AN

8 ,&e P(ian financial cri(i( in 1"" b providin= bloc =rant( to pu(e(ma( and

mid?ive( to (upport local &ealt& (ervice( >doption of >(e(in*a &ealt& in(urance fort&e poor+ from 200! &a( enabled provi(ion of free outpatient and limited inpatient carefor t&e poor and nutritional (upplement( for pre=nant ?omen and ne?born(,&e covera=e of t&e in(urance (c&eme varie( acro(( t&e province( Nevert&ele(( t&ere i(no evidence of (i=nificant difference( in &ealt& (ervice u(e bet?een pro)ect and non-pro)ect province(

#### EfficiencEfficiencEfficiencEfficienc

8@ Lie t&e P#A operational procedure( >#A received t&e =overnmentJ( decree fore(tabli(&in= t&e central pro)ect mana=ement unit 30;EN9E'-9E'O''92001on 11 Fanuar 2001 but it became effective onl on 2@ Fune 2001 ,&i( ?a( lar=ela((ociated ?it& dela( in t&e i((uance of le=al opinion on pro)ect implementationbefore all nece((ar le=al document( bet?een >#A and t&e overnment of Indone(ia&ad been endor(ed

8! ,&e problem ?a( eHacerbated b t&e need to e(tabli(& a lar=e number ofimplementation unit( ?&en Indone(ia adopted decentrali$ation and devolution ofdeci(ion main= to t&e di(trict( 'ince all di(trict( in eac& pro)ect province ?ere eli=iblefor (upport more t&an @0 di(trict( &ad to prepare inve(tment plan( durin= t&e fir(tp&a(e to pro=ram civil ?or( eDuipment and muc& of t&e trainin= bud=et No ,> ?a(provided at (tartup

8 iven t&e perceived compleHit of >#A procedure( and limited pro)ectpreparation t&e omi((ion of ,> compounded t&e lac of international pro)ectmana=ement eHperience >lt&ou=& dela( ?ere inevitable =iven t&e lar=e c&an=e( inor=ani$ational (tructure( and proce((e( ?it&in t&e public &ealt& (ervice durin=decentrali$ation t&e(e could &ave been reduced to (ome de=ree ?it& appropriate ,>Pro)ect p&a(in= (&ould &ave reflected t&i( de=ree of compleHit devotin= more time tocapacit development in t&e initial 2 ear( >l(o a( alread mentioned t&e number ofpro)ect province( and di(trict( could &ave been reduced to mana=e t&e demand for&ealt& (ervice capacit development

88 ,&e P(ian financial>(ian financial>(ian financial>(ian financialcri(i( in 1"" bcri(i( in 1"" bcri(i( in 1"" bcri(i( in 1"" bprovidin= bprovidin= bprovidin= bprovidin= blocloclocloc=rant(=rant(=rant(=rant(

,&e omi((ion of,&e omi((ion of,&e omi((ion of,&e omi((ion of,>,>,>,>compoundedcompoundedcompoundedcompoundedt&e lac oft&e lac oft&e lac oft&e lac ofinternationalinternationalinternationalinternationalpro)ectpro)ectpro)ectpro)ectmana=ementmana=ementmana=ementmana=ementeHperienceeHperienceeHperienceeHperience


34/67


ab(orptive capacit of di(trict &ealt& office(M and *iii+ lon= dela( in relea(e ofcounterpart fundin= from t&e ;ini(tr of .inance30 >( a re(ult t&e pro)ect &ad to beeHtended t?ice

"0 Implementation arran=ement(Implementation arran=ement(Implementation arran=ement(Implementation arran=ement( >t t&e completion of t&e pro)ect ei=&tprovincial implementation unit( and 3 di(trict implementation unit( &ad been

e(tabli(&ed > tec&nical revie? team ?a( (et up in ever province to revie? di(trict andprovincial propo(al( and annual report( ,&e team compri(ed tec&nical eHpert( fromprovincial &ealt& (ervice( and A99AN t&e private (ector t&e communit profe((ional&ealt& or=ani$ation( local academic in(titution( and pro)ect con(ultant(>#A (upervi(ion mi((ion( noted t&at A99AN (taff periodicall participated in t&eprovincial and di(trict meetin=( but (ince t&e ?ere not involved in local (ituationanal(i( and in t&e (election of famil plannin= activitie( t&eir input at t&e meetin=(?a( limited ,&e P


35/67


vaccination covera=e u(e of &ealt& care for c&ild&ood di(ea(e(+ are not (i=nificantppendiH 3 contain( detailed anal(i( u(in= atime frame of 20 ear( ?&ic& more clo(el reflect( t&e economic life of t&einfra(tructure developed under t&e pro)ect

" It i( e(timated t&at t&e pro)ect reDuire( a reduction in burden of di(ea(e inpro)ect province( of 2 ,&e breaeven burden-of-di(ea(e reduction i( le(( t&an e(timated at apprai(al >lt&ou=& compari(on of &ealt& indicator( in pro)ect and non-pro)ect province( found no evidence of burden of di(ea(e decrea(e t&e evaluationteam in di(cu((ion( ?it& e informant( noted t&at pro)ect &a( &ad po(itive &ealt&benefit( iven onl mar=inal decrea(e in burden of di(ea(e i( reDuired for breaeven iti( liel t&at t&e pro)ect =enerated mar=inal net benefit(

"@ ;onitorin= and evaluation;onitorin= and evaluation;onitorin= and evaluation;onitorin= and evaluation ;O% (upported t&e compilation of benefitmonitorin= report( at t&e end of t&e pro)ect for all pro)ect province( In eac& provincet?o di(trict( *or citie(+ ?it& &i=& and lo? Indone(ian %uman #evelopment IndeH 2002ratin=( ?ere (elected to mea(ure outcome( in term( of &uman development: lon=evit*life eHpectanc+ no?led=e *education attainment+ and a decent (tandard of livin=

*ad)u(ted income+ EHit intervie?( ?ere al(o u(ed to a((e(( client(J (ati(faction in a(ample of 30 re(pondent( per &ealt& center ,&e (core( of t&e (urve ?ere provided int&e En=li(& ver(ion of t&e report %o?ever t&e in(trument and (ample( u(ed to=enerate (core( ?ere not provided ender-di(a==re=ated data ?a( collated in re=ardto pro=ram input( and a ran=e of ca(e (tudie( conducted to illu(trate (elected impact(

"! Reportin= durin= implementation ?a( not (ati(factor it&in ! mont&( ofloan effectivene(( t&e central pro)ect mana=ement unit ?a( to develop a performancemonitorin= ((tem for trainin= and capacit-buildin= activitie( and eac& province ?a(to develop an ;CE frame?or for local activitie( ,> ?a( to be provided to (upportcollection of data >t midterm >#A reDue(ted t&at ;CE mu(t be (tren=t&ened ;andi(trict( &ad not et identified indicator( related to t&eir local prioritie( trainin= Dualit?a( not ((tematicall a((e((ed and t&e &ealt& information ((tem ?a( not developed>( a re(ult Duarterl implementation report( ?ere often delaed and notcompre&en(ive ,o ((tematicall a((e(( impact( facilit-level data from pro)ect andnon-pro)ect province( need( to be anal$ed >dditionall a (urve of &ealt& outcome(u(in= a (tati(tical approac& i( reDuired to Duantif impact( Indicator( (uc& a( maternaland infant mortalit are not liel to be meanin=ful at t&i( level =iven t&e lo? number(of ca(e( relative to population (i$e Indicator( for maternal &ealt& (uc& a( ob(tetriccomplication( referral( client (ati(faction and &ealt& eHpenditure( are more liel tocapture an difference( in t&e &ealt& (tatu( and t&u( pro)ect impact

EEEE 'u(tainabilit'u(tainabilit'u(tainabilit'u(tainabilit

" ,&e pro)ect i( liel to be (u(tainable ,&e evaluation team found durin= it( (ite

vi(it( t&at buildin=( and eDuipment ?ere in =ood condition and ?ell u(ed 32 >lmo(t allprovincial and di(trict &ealt& official( intervie?ed con(idered on=oin= financial (upportfrom local =overnment re(ource( to be (ufficient for t&e current capacit and covera=eof public &ealt& facilitie(

32it& t&e eHception of t&e provincial &o(pital of


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"8 ,&e evaluation team and t&e P# 12!@ 11 222!3 " 8@0 1832Riau !@3! 3"1 2!! !88! 2!21 1"11"

Aen=ulu 8@ !8 "2 1! 3 @@2!Riau I(land( N> "0 """ na 2! !3

Nort& 'ula?e(i 30@ 1! "0! 2! 1!3 !!!#A a((i(tance in t&e (ector and =overnment commitment &elped prioriti$euniver(al covera=e in province( (uc& a( Aali ,&e pro)ect provided (ome continuit topreviou(l e(tabli(&ed pro=ram( in particular t&o(e related to t&e bloc-=rant fundin=of &ealt& center( under t&e =overnmentJ( earlier (ocial (afet-net pro=ram ;O% &a(made an effort to en(ure continuit of t&e pro)ect output( b incorporatin= t&e(eelement( into ot&er aid-a=enc-(upported activitie( on maternal &ealt& ood practice(identified durin= t&e pro)ect implementation &ave been adopted in #%'2*footnote 13+

102 .urt&ermore tec&nical and mana=erial (taff trained under t&e pro)ect are no?in influential po(ition( in t&e =overnmentJ( &ealt& ((tem and are better placed toen(ure t&at =ood practice( under t&e pro)ect are implemented effectivel and (u(tainedfor t&e benefit of people particularl t&o(e in =eo=rap&icall c&allen=in= area(

Referral( &aveReferral( &aveReferral( &aveReferral( &avemore t&anmore t&anmore t&anmore t&an

tripled intripled intripled intripled in(everal pro)ect(everal pro)ect(everal pro)ect(everal pro)ect

province(province(province(province(

oodoodoodoodpractice(practice(practice(practice(

identifiedidentifiedidentifiedidentified &&&&aveaveaveavebeen adoptedbeen adoptedbeen adoptedbeen adopted

''''taff trainedtaff trainedtaff trainedtaff trainedunder t&eunder t&eunder t&eunder t&e

pro)ect arepro)ect arepro)ect arepro)ect areno? inno? inno? inno? in

influentialinfluentialinfluentialinfluentialpo(ition(po(ition(po(ition(po(ition(


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103 >t t&e di(trict level mo(t of t&e &ealt& (ervice facilitie( (till rel &eavil onannual bud=etar allocation from t&e central =overnment ?&ile local =overnmentbud=et( are u(ed for &irin= (taff for t&e &ealt& facilitie( and purc&a(in= eDuipmentand medical (upplie( >t time( allocation from t&e central =overnment particularl for&ealt& infra(tructure improvement or eHpan(ion tend( to be inadeDuate to (ervice

demand for &ealt& (ervice(


38/67

P,ERP,ERP,ERP,ER

Ot&er >((e((ment(Ot&er >((e((ment(Ot&er >((e((ment(Ot&er >((e((ment(

10 #A and t&e borro?er role ofdevelopment partner( in Indone(iaJ( &ealt& (ector and t&e performance of tec&nicala((i(tance to t&e pro)ect

>>>> Impact(Impact(Impact(Impact(

10@ ,&i( (ection i( ba(ed on data anal(i( lar=el (ourced from I#%' publi(&ed in1"" 2003 and 200 and findin=( from t&e 2012 I#%' >lt&ou=& t&e P(ian Nation( *e= t&e P&ilippine( ,&ailand and 7iet Nam+

,&e pro)ect,&e pro)ect,&e pro)ect,&e pro)ect&a( &elped&a( &elped&a( &elped&a( &elped

Indone(ia toIndone(ia toIndone(ia toIndone(ia to(ta on trac(ta on trac(ta on trac(ta on trac

to ac&ieveto ac&ieveto ac&ieveto ac&ievereduction ofreduction ofreduction ofreduction of

c&ild mortalitc&ild mortalitc&ild mortalitc&ild mortalit


39/67


40/67


41/67

Other Assessments 31

3333


42/67


121 #A Aorro?er and #evelopment PartnerPerformance of >#A Aorro?er and #evelopment PartnerPerformance of >#A Aorro?er and #evelopment PartnerPerformance of >#A Aorro?er and #evelopment Partner((((

1111

>#A Performance>#A Performance>#A Performance>#A Performance

123 Overall >#AJ( performance i( rated (ati(factor >( li(ted in t&e P#A fielded 13 pro)ect revie? mi((ion( 1 emer=enc re&abilitation mi((ion 1 midtermrevie? mi((ion 1 final revie? mi((ion and 1 P#A and t&e =overnment >#A al(o po(itivel re(ponded toevolvin= or=ani$ational c&an=e ?it&in ;O% and placement of t&e pro)ectimplementation re(pon(ibilit a( de(ired b t&e =overnment >#A al(o approved t?o

eHten(ion( of t&e pro)ect *2 mont&( and 3 mont&(+ at t&e reDue(t of t&e =overnment?&ic& &elped complete pro)ect activitie( a( muc& a( po((ible

12 ,&e evaluation team t&rou=& focu( =roup di(cu((ion( and e informantintervie?( learned t&at >#A revie? mi((ion( lar=el concentrated on Faarta and tooonl limited field vi(it( >ccordin= to t&e P#A al(o c&an=ed pro)ect officer( fourtime( and pro)ect anal(t( t?ice >#A (taff turnover (lo?ed communication bet?eenpro)ect and >#A (taff Nevert&ele(( t&e =overnment and pro)ect (taff deemed >#AJ((upport durin= implementation (ati(factor

2222 Aorro?er PerformanceAorro?er PerformanceAorro?er PerformanceAorro?er Performance

12@ ,&e evaluation rate( t&e borro?erJ( performance le(( t&an (ati(factor under

t&e decentrali$ation model adopted b Indone(ia ,&e P#Abot& from >#Abot& from >#Abot& from >#Aand t&eand t&eand t&eand t&e

=overnment=overnment=overnment=overnment


43/67


44/67


45/67

Other Assessments 35

t&e(e di(ea(e( ,&e =rant( contain fund( to (upport &ealt& ?orer trainin= communitoutreac& capacit of laboratorie( vector control te(tin= procurement of in(ecticide-treated net( and en&ancin= t&e &ealt& information ((tem

13@ ,&e lobal .und and t&e >u(tralian >=enc for International #evelopment arecurrentl t&e ma)or (upporter( of &ealt& ((tem( (tren=t&enin= ,&e lobal .und &ealt&

((tem( (tren=t&enin= pro=ram entail( a =rant of 41!@ million to develop a national&ealt& information ((tem (calin= up t&e (ample re=i(tration ((tem and promotin=&ealt& ((tem re(earc& ,&e >u(tralia Indone(ia Partner(&ip for %ealt& '(tem('tren=t&enin= *valued at 4@0 million from Ful 2011 to Fune 201!+ ?ill lin ?it& t&elobal .und pro=ram It aim( to eHpand t&e number of Dualified nur(e( and mid?ive(and (upport local =overnment( to (taff &ealt& center( >dditionall t&e >u(traliaIndone(ia Partner(&ip for ;aternal and Neonatal %ealt& *valued at 41!! million inFune 2012 aim( to increa(e t&e number of birt&( covered b (illed birt& attendant(increa(e t&e number of ?omen u(in= &ealt& facilitie( to =ive birt& and &elp reducemalaria and anemia amon= mot&er(


46/67


?a( lar=el on documentation of eHi(tin= reform( rat&er t&an launc&in= and evaluatin=ne? local initiative(5 ,&e evaluation team could acce(( onl a fe? of t&e output(produced under t&e ,> and &ence t&e Dualit of con(ultant(J output( could not bea((e((ed ;oreover (everal output( &ad no En=li(& tran(lation ,&e con(ultantrecruitment approac& provided fleHibilit in en=a=in= individual con(ultant( butcoordination of variou( output( proved c&allen=in= for pro)ect mana=ement

,&e evaluation con(ider( t&at (eDuencin= of con(ultant(J en=a=ement could &ave beenmore (trate=ic .or eHample di(trict &ealt& plannin= could &ave been follo?ed b ;CE;oreover tan=ible contribution from t&e ,> came onl after t&e midterm revie? If afirm &ad been en=a=ed from t&e be=innin= (ome pro)ect implementation dela could&ave been avoided In vie? of t&e broad =eo=rap&ic (cope of t&e pro)ect and t&etec&nical nature of decentrali$ation-related c&allen=e( t&e ,> ?a( ori=inall under-re(ourced


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P,ERP,ERP,ERP,ER @@@@

I((ue( Le((on( and .ollo?I((ue( Le((on( and .ollo?I((ue( Le((on( and .ollo?I((ue( Le((on( and .ollo?----

6p >ction(6p >ction(6p >ction(6p >ction(10 ,&i( c&apter dra?( on evaluation findin=( di(cu((ed in precedin= c&apter(It identifie( e i((ue( facin= Indone(iaJ( &ealt& (ector le((on( derived from t&e pro)ectde(i=n implementation and completionM and recommend( follo?-up action( b >#Aand t&e =overnment

>>>> I((ue(I((ue(I((ue(I((ue(

1111 eo=rap&ic ,ar=etin=eo=rap&ic ,ar=etin=eo=rap&ic ,ar=etin=eo=rap&ic ,ar=etin=

11 >ccordin= to (enior (taff at ;O% t&e ori=inal (election of (even province(acro(( Indone(ia intended to avoid duplication of re(ource( bet?een >#A and t&eorld Aan ,&e rationale for t&i( (election a( provided to t&e evaluation team?a( ?ea ,&e(e province( did not &ave proportionatel lar=er poor population(particularl adver(e &ealt& indicator( or (everal di(trict( ?it&out doctor( nor ?ere t&eeHperiencin= i((ue( ?it& overall economic development In(tead t&e (election=enerated a ver broad and (cattered footprint for implementation 'ome of t&eprovince( (uc& a( Aali and Nort& 'ula?e(i &ave ver favorable &ealt& indicator(,&ere ?a( (ome (u==e(tion t&at t&e(e province( could provide a model for t&e poorer-performin= province( and interaction durin= t&e pro)ect ?ould increa(e avera=eperformance of participatin= province( >part from (ome (tud tour( to in(urance-

implementin= di(trict( in Aali t&ere appeared to be limited interaction bet?eenprovince(

12 If t&e pairin= of &i=&er- and lo?er-performin= province( ?a( done ?it& t&e aimof liftin= avera=e performance a number of activitie( (uc& a( in(titutional t?innin=reciprocal ?or placement and a broader pro=ram of information and eHperienceeHc&an=e (&ould &ave been included in t&e de(i=n In addition to a va=ue rationale forprovince (election t&e allocation of fund( amon= participatin= di(trict( ?a( not ba(edon evidence of povert prevalence or &ealt& performance indicator( >nal(i( providedin t&e relevance (ection of t&i( report (u==e(t( t&at di(trict allocation ?a( not pro-poor

2222 #i(trict capacit and monitorin= ((tem(#i(trict capacit and monitorin= ((tem(#i(trict capacit and monitorin= ((tem(#i(trict capacit and monitorin= ((tem(

13 In(ufficient di(trict capacit and internal admini(tration and mana=ement((tem( con(trained t&e (ucce(( of &ealt& (ervice deliver and (till do Pro)ect dela(reflected cumber(ome procedure( in procurement contract revie? di(bur(ementliDuidation and approval proce((e( ,&e ?or of tec&nical and admini(trative unit( ?a(not adeDuatel (nc&roni$ed for efficient pro)ect implementation Aenefit monitorin=and evaluation ?a( not inte=rated ;an of t&e indicator( e(tabli(&ed to tracin(titutional development ?ere not (pecific and reDuired definition from a time-boundand Dualit-(tandard point of vie? In a decentrali$ed (ervice ((tem local &ealt&

,&e allocation,&e allocation,&e allocation,&e allocationof fund( ?of fund( ?of fund( ?of fund( ?a(a(a(a(not ba(ed onnot ba(ed onnot ba(ed onnot ba(ed onevidence ofevidence ofevidence ofevidence ofpovertpovertpovertpovertprevalence orprevalence orprevalence orprevalence or&ealt&&ealt&&ealt&&ealt&performanceperformanceperformanceperformanceindicator(indicator(indicator(indicator(

Pro)ect dela(Pro)ect dela(Pro)ect dela(Pro)ect dela(reflectedreflectedreflectedreflectedcumber(omecumber(omecumber(omecumber(omeprocedure(procedure(procedure(procedure(


48/67


department( need a functionin= ;CE ((tem to trac inve(tment activitie( and output(and &ealt& (ector performance and impact ,ec&nical monitorin= =uideline( (uc& a( t&eorld %ealt& Or=ani$ation( &andboo@&ave been developed to monitor and evaluate&ealt& ((tem performance ;ea(urable and time-dependent indicator( (uc& a( t&o(eoutlined in t&e &andboo (&ould &ave been u(ed to monitor and evaluate pro)ectperformance and con(olidate in pro)ect completion and implementation reportin=

3333 Pro)ect de(i=n and (c&edulin=Pro)ect de(i=n and (c&edulin=Pro)ect de(i=n and (c&edulin=Pro)ect de(i=n and (c&edulin=

1 Overall t&e pro)ect de(i=n ?a( under(tood and lar=e-value component( ?ere(ucce((full implemented de(pite dela( in pro=re(( ,&e u(e of a pro)ect loan coupled?it& ,> ?a( t&e proper modalit =iven t&e limited (ector a((e((ment and con(iderablepolic uncertaint at t&e time of decentrali$ation Revie?( of ot&er >#A loan( (uc& a(t&e performance evaluation report for t&e Pun)ab #evolved 'ocial 'ervice( Pro=ram !noted t&at pro)ect lendin= i( be(t (uited to demarcate (pecific capacit developmentmea(ure( needed in t&e implementation of a=reed reform( a( t&i(Q i( a le(( predictableproce(( t&at reDuire( (ome fleHibilit and re(pon(ivene(( ,&e #%' de(i=n =avefleHibilit to adapt to t&e evolvin= decentrali$ation proce(( It contributed to t&e overallcapacit buildin= of &uman re(ource( ?it& initiative( (uc& a( fello?(&ip pro=ram(

re(ultin= in t&e placement of trained (taff into &i=&er mana=ement po(ition( in pro)ectarea( #i(trict(J plannin= capacit and vi(ion of t&e propo(ed pro)ect activitie( ?a( not(ufficient durin= pro)ect (tartup and earl revie? mi((ion( noted t&i( problem

1@ ,&e implementation (c&edule did not accommodate an appropriate time frameor activitie( to fo(ter earl pro)ect o?ner(&ip ,&e de(i=n ?a( al(o overambitiou( in it(=eo=rap&ic (cope ;ore t&an 0 di(trict( ?ere involved in implementation ?it&differin= level( of capacit &i=& (taff turnover and all ?it& limited eHperience ininternational pro)ect operation( ,&e number of province( (&ould &ave been reducedand re(ource allocation (&ould &ave been ba(ed on povert and &ealt& (tatu(

1! #i(trict-(pecific plan( (upported b more (ub(tantive ,> (&ould &ave beendeveloped Procurement could &ave been paca=ed into a (maller number of lar=e-value contract( reducin= t&e dela( a((ociated ?it& >#A and =overnment procurementproce((e( ( alread noted pro)ect inve(tment accounted for le(( t&an 2 of di(tricteHpenditure ?&ic& limit( t&e (cope for fundin= to &ave a (i=nificant impact on t&ere=ional &ealt& (tati(tic( *para !3+ Lar=er allocation( per di(trict ?ould not &ave &ad a(ub(tantial impact =iven t&e (mall (i$e of t&e pro)ect relative to overall di(trict &ealt&eHpenditure

AAAA Le((on(Le((on(Le((on(Le((on(

147. Proper problem anal(i( i( needed ba(ed on ri( and miti=ation anal(i( beforeProper problem anal(i( i( needed ba(ed on ri( and miti=ation anal(i( beforeProper problem anal(i( i( needed ba(ed on ri( and miti=ation anal(i( beforeProper problem anal(i( i( needed ba(ed on ri( and miti=ation anal(i( before

rollin= out a pro=ram under decentrali$ationrollin= out a pro=ram under decentrali$ationrollin= out a pro=ram under decentrali$ationrollin= out a pro=ram under decentrali$ation Problem anal(i( ?a( undertaen to(ome de=ree durin= pro)ect preparation( Ri(( ?ere outlined in t&e pro)ect frame?or*under >((umption( and Ri((+ but little detail ?a( =iven in t&e main teHt of t&e report

@orld %ealt& Or=ani$ation 2010 ;onitorin= t&e buildin= bloc( of &ealt& ((tem(: a&andboo of indicator( and t&eir mea(urement (trate=ie( eneva

!>#A 2012 Performance Evaluation Report: Pun)ab #evolved 'ocial 'ervice( Pro=ram inPai(tan ;anila

>#A 200 uideline( for Preparin= a #e(i=n and ;onitorin= .rame?or ;anila

;ea(urable;ea(urable;ea(urable;ea(urableand timeand timeand timeand time----

dependentdependentdependentdependentindicator(indicator(indicator(indicator(

(&ould &ave(&ould &ave(&ould &ave(&ould &ave

been u(edbeen u(edbeen u(edbeen u(ed

,&e de(i=n,&e de(i=n,&e de(i=n,&e de(i=n?a( al(o?a( al(o?a( al(o?a( al(o

overambitiou(overambitiou(overambitiou(overambitiou(

#i(trict#i(trict#i(trict#i(trict----

(pecific pla(pecific pla(pecific pla(pecific plan(n(n(n((upported b(upported b(upported b(upported b

moremoremoremore(ub(tantive(ub(tantive(ub(tantive(ub(tantive,> (&ould,> (&ould,> (&ould,> (&ould&ave been&ave been&ave been&ave beendevelo eddevelo eddevelo eddevelo ed


49/67

Issues !essons and "ollo#$%p Actions 39

and recommendation of t&e Pre(ident or in t&e pro)ect de(i=n reater attention(&ould &ave been placed on t&e political econom of decentrali$ation (uc& a( outlinin=e (tae&older( definin= differential impact( of reform( and identifin= ri((a((ociated ?it& po((ible future be&avior of e (tae&older(8 alon= ?it& capacita((e((ment( acro(( t&e broad =eo=rap&ic (pread of t&e pro)ect It ?ould &ave beenimportant to better a((e(( t&e factor( t&at &elp or &inder mana=erial and operational

in(titutionali$ation of local &ealt& ((tem(,&e pro)ect did not do (o >( a re(ult t&e(tandardi$ed approac& ma not &ave ?ored in all di(trict( #ecentrali$ation i( anevolvin= proce(( and reDuire( time to develop adeDuate capacit"

148. Re(ult( from (ucce((ful pilot initiative( (&ould be di((eminated in time andRe(ult( from (ucce((ful pilot initiative( (&ould be di((eminated in time andRe(ult( from (ucce((ful pilot initiative( (&ould be di((eminated in time andRe(ult( from (ucce((ful pilot initiative( (&ould be di((eminated in time andu(ed in (calin= up (uc& initiative( to maHimi$e t&e impactu(ed in (calin= up (uc& initiative( to maHimi$e t&e impactu(ed in (calin= up (uc& initiative( to maHimi$e t&e impactu(ed in (calin= up (uc& initiative( to maHimi$e t&e impact ,&e &ealt& in(urance (c&emepiloted in t&e Fembrana di(trict of Aali &a( been reco=ni$ed a( one of t&e (ucce((fulinitiative( and i( no? bein= rolled out acro(( t&e entire province > number of le((on(&ave emer=ed for >#A and t&e orld Aan from pilotin= of t&i( reform ,&i( vie? ?a((&ared b people intervie?ed durin= t&e evaluation and b t&e orld Aan ?&o (tatedt&at more le((on( could undoubtedl be dra?n b undertain= a comparative (tud ofall decentrali$ation eHperience( includin= t&o(e (upported b development partner(lie t&e orld Aan and >#A 'uc& a (tud could focu( on t&e different ?a( province(

&ave e(tabli(&ed t&e province-di(trict relation(&ip t&e relative co(t( and benefit( ofeac& and t&e variet of ?a( di(trict( and province( &ave developed to eHerci(eautonom in t&e &ealt& (ector de(pite continuin= lac of clarit in t&e policenvironment and t&eir dependenc on central =overnment fundin=5 *footnote 12+

1" ,&e (cope and implementatio,&e (cope and implementatio,&e (cope and implementatio,&e (cope and implementation covera=e of pro)ect( (&ould be mana=eablen covera=e of pro)ect( (&ould be mana=eablen covera=e of pro)ect( (&ould be mana=eablen covera=e of pro)ect( (&ould be mana=eable.or (i=nificant impact pro)ect inve(tment (&ould not be (pread too t&inl nor be (oambitiou( in (cope a( to &amper implementation ,&e pro)ect intervention( ?&ile=eneratin= (ome po(itive outcome( locall did not (&o? muc& impact at t&e provinciallevel becau(e t&e ?ere too (mall to produce a broader impact


50/67


1@1 reater (ner= i( reDuired bet?een famil plannin= and &ealt&reater (ner= i( reDuired bet?een famil plannin= and &ealt&reater (ner= i( reDuired bet?een famil plannin= and &ealt&reater (ner= i( reDuired bet?een famil plannin= and &ealt&----care (ervice(care (ervice(care (ervice(care (ervice(Inclu(ion of famil plannin= advocac in future pro=ram( could &elp reduce maternalmortalit a( &i=& fertilit and maternal mortalit are correlated #urin= e informantintervie?( man eHpre((ed an opinion t&at more (upport for famil plannin= i(needed It ?ill reDuire a coordinated and balanced )oint approac& from ;O% andA99AN (upported b appropriate re(ource(

1@2 > compre&en(ive approac& i( needed for a ?ell> compre&en(ive approac& i( needed for a ?ell> compre&en(ive approac& i( needed for a ?ell> compre&en(ive approac& i( needed for a ?ell----functionin= &ealt& ((temfunctionin= &ealt& ((temfunctionin= &ealt& ((temfunctionin= &ealt& ((temell-functionin= provincial and di(trict ((tem( &ave proven to contribute to overallcoordination and control of local &ealt& (ervice deliver #urin= evaluation &ealt&facilit (taff freDuentl cited t&e development of &uman re(ource capacit t&rou=&lon=er-term fello?(&ip( a( a e benefit of t&e pro)ect ;an of t&e pro)ect-(upportedfello?( are no? in e po(ition( ?it&in t&e di(trict and provincial &ealt& (ervice( ;anfello?( t&ou=&t t&at t&eir career( ?ould not &ave pro=re((ed (o ?ell ?it&out t&epro)ect ,&e (ill( for net?orin= problem-(olvin= and data anal(i( and pre(entationt&at t&e(e fello?(&ip( &elp develop are (till bein= u(ed

1@3 >#A &a( &elped improve infra(tructure and promote reform( in acompre&en(ive manner ,&i( ?a( (een a( a e po(itive feature of t&e pro)ect

Informant( t&ou=&t t&at b combinin= better plannin= and infra(tructure and &i=&er-Dualit &uman re(ource( acce(( to &ealt& (ervice( and t&eir Dualit &ad improved;an felt t&at ?it&out a compre&en(ive approac& t&i( mi=&t not &ave &appened

1@ > =ood ;CE ((tem can &elp develop a better under(tandin= of ?&at ?or(> =ood ;CE ((tem can &elp develop a better under(tandin= of ?&at ?or(> =ood ;CE ((tem can &elp develop a better under(tandin= of ?&at ?or(> =ood ;CE ((tem can &elp develop a better under(tandin= of ?&at ?or(and ?&at doe( notand ?&at doe( notand ?&at doe( notand ?&at doe( not &ile t&e potential benefit( of a compre&en(ive approac& ?erenoted durin= t&e evaluation teamJ( field vi(it( t&ere i( limited effort to Duantif t&e(ebenefit( ((tematicall > (urve of (tae&older( ?a( conducted at pro)ect eHit anddocumented in a benefit-monitorin= report > ran=e of cu(tomer (ati(faction Due(tion(?ere po(ed and (cored in t&e (urve 'ati(faction indicator( related to benefit(a((ociated ?it& *i+ trainin= for mid?ive( *ii+ utili$ation of (ill( b (taff after trainin=*iii+ availabilit and eDuipment to (upport ;N


51/67

Issues !essons and "ollo#$%p Actions 41

and di(trict =overnment( to determine (ill( =ap( t&at can be tar=eted over t&e neHtcouple of decade( Periodic evaluation of t&e value and impact of eHpenditure oncapacit development (&ould &ave been conducted >lt&ou=& t&e number of p&(ician(and t&e ratio of p&(ician( to population &ave increa(ed in all province( and in ruralarea( deploment practice( and ineDuitable di(tribution remain (eriou( concern( ;CEof current deploment and a (ill( audit are crucial to a(certain ?&et&er an effective

lon=-term &ealt& ?orforce (trate= i( bein= implemented *footnote "+

ction(

1@ ,&e >#A-(upported #%'2 approved in 2003 *footnote 13+ and on=oin=&a( incorporated (ome of t&e le((on( derived from t&e implementation of t&i( pro)ect,&e province( covered in t&e #%'2 are different from t&o(e in t&e #%' Nevert&ele((t&i( evaluation &a( t&at are applicable to t&e on=oin= pro)ect a( ?ell a( an futureinve(tment b >#A ot&er development partner( and t&e =overnment ,&e evaluation&a( four e recommendation(:

1@8 >#A (&ould remain en=a=ed ?it& t&e overnment of Indone(ia in t&e &ealt&>#A (&ould remain en=a=ed ?it& t&e overnment of Indone(ia in t&e &ealt&>#A (&ould remain en=a=ed ?it& t&e overnment of Indone(ia in t&e &ealt&>#A (&ould remain en=a=ed ?it& t&e overnment of Indone(ia in t&e &ealt&(ector(ector(ector(ector (ince t&ere i( tremendou( need and (cope for (upportin= &ealt& (ervice( and&ealt& polic reform( to ac&ieve better &ealt& outcome( for more people includin=(ome of t&e e ;# indicator( (uc& a( maternal mortalit and infectiou( di(ea(econtrol ,&e countr i( (till la==in= in t&e(e area( and muc& of t&e current donor(upport i( a((ocia

indonesia: decentralized health services project

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