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Indonesia

Ministry of Health

Asian Development Bank

Support for Health Sector Policy Reforms

TA 3579-INO, August 2004 - August 2008

Final Report

December 2008

Contents

Support for Health Sector Policy Reforms, ADB TA 3579-INO I

EPOS Health Consultants

Final Report

December 2008

Contents

1 Executive Summary....................................................................................................1 2 Activity Summary........................................................................................................3

2.1 Objectives .....................................................................................................3 2.2 Terms of Reference ......................................................................................3 2.3 Team Deployment and Activities ..................................................................4 2.4 Semester Reports .........................................................................................6 2.5 Inception Period ............................................................................................6 2.6 Activities undertaken to support the ToR ......................................................6

3 Logical Framework Review ......................................................................................17 3.1 Goal of TA-3579..........................................................................................17 3.2 Outputs of TA-3579.....................................................................................17 3.3 Issues and Uncertainties.............................................................................18

4 Policy Dialogue: Access Barriers to Health Care .....................................................20 4.1 The Primary Health Care System in Indonesia...........................................20 4.2 Health Care Providers.................................................................................22 4.3 Family Planning and Reproductive Health..................................................23 4.4 Community Health Program development ..................................................24 4.5 Budgets and Funds flow .............................................................................24 4.6 Health Service Utilization ............................................................................26 4.7 Poverty as a Barrier to Health Service Utilisation .......................................30

4.7.1 General considerations .................................................................30 4.7.2 Utilisation of outpatient services....................................................31 4.7.3 Utilisation of in-patient services.....................................................33 4.7.4 Assisted birthing rates ...................................................................34 4.7.5 Contraceptive prevalence..............................................................35 4.7.6 Immunisation and other preventative health services ...................36

5 Lessons Learned and Recommendations ................................................................42 5.1 One Size Does Not Fit All ...........................................................................42 5.2 Free Health Services Do Not Insure High Utilization ..................................44 5.3 Attitude of Health Workers towards Consumers Has an Impact.................44 5.4 Quality of Services make a Difference........................................................45 5.5 New Financial Regulations Every year Cause Difficulties ..........................45 5.6 Community Ownership Determines Utilization............................................46

6 Conclusions ..............................................................................................................47 6.1 General Conclusions...................................................................................47 6.2 Impact on Decentralisation and Health Sector Reform...............................47

Contents

Support for Health Sector Policy Reforms, ADB TA 3579-INO II


Final Report

December 2008

6.3 Impact on Millennium Development Goals .................................................48 6.4 Recommendations for Future TA................................................................49

7 Annexes....................................................................................................................50 7.1 TA-3579-INO Logical Framework ...............................................................50 7.2 Field Visits...................................................................................................54 7.3 Publications and Presentations...................................................................65

7.3.1 Technical Documents Produced ...................................................65 7.3.2 Meetings attended.........................................................................70

7.4 District level participation with Assisted Deliveries, 2004 ...........................80 7.5 Desa Siaga Guidelines ...............................................................................81

7.5.1 Summary .......................................................................................81 7.5.2 Model development of Desa Siaga ...............................................82 7.5.3 Elements and principles of the Desa Siaga Activity ......................83 7.5.4 Facilitators .....................................................................................85 7.5.5 Operational model in selected villages..........................................86 7.5.6 Impact Evaluation of Desa Siaga ..................................................94 7.5.7 Cost effectiveness .........................................................................97

7.6 Economic and Financial Analysis of Desa Siaga......................................101 7.6.1 Background and Objective of the Analysis..................................101 7.6.2 The Concept of Desa Siaga ........................................................101 7.6.3 Pos Kesehatan Desa (Village Health Post) and Desa Siaga ......102 7.6.4 Establishment and Operation of Desa Siaga ..............................103 7.6.5 Economic Analysis ......................................................................103 7.6.6 Sustainability ...............................................................................110 7.6.7 Cost Effectiveness.......................................................................111

7.7 DHS-2 District Level Health System Performance Data 2007 ..................112

Abbreviations and Acronyms

Support for Health Sector Policy Reforms, ADB TA 3579-INO IV


Final Report

December 2008


ADB Asian Development Bank

ANC Ante-natal Care

AusAID Australian Agency for International Development

BAPPEDA Badan Perencanaan Pembangunan Daerah (Provincial Planning Agency)

BAPPENAS Badan Perencanaan Pembangunan Nasional National Development Planning Agency

BCC Behavior Change Communication

BEONC Basic Emergency Obstetric Neonatal Care (PONED)

BKKBN Badan Koordinasi Keluarga Berencana Nasional (National Family Planning Coordinating Board)

BUPATI Government officer in charge of a regency

CEONC Comprehensive Emergency Obstetric Neonatal Care (PONEK)

CPCU Central Project Coordinating Unit

DEKON Dana Dekonistrasi (Funds to support decentralization)

Desa Siaga “Aware Village” (Desa Siap Antar Jaga)

DHA District Health Account

DHC District Health Committee

DHO District Health Office

DHS 1 DHS 2

First Decentralized Health Services Project Second Decentralized Health Services Project

DIPA Daftar Isian Pelaksanaan Anggaran (New Annual Operational Budget format)

DIU District Implementation Unit

DPRD Province or District Parliament

DTPS District Team Problem Solving

FP Family Planning

GIS Geographical Information System

GOI Government of Indonesia

GTZ Deutsche Gesellschaft für Technische Zusammenarbeit (German Agency for Technical Cooperation)

HIS Health Information System

HNSDP Health and Nutrition Sector Development Program

HSP Health Sector Program (USAID)

HSR Health Sector Reform

IBI Ikatan Bidan Indonesia (Indonesian Midwives Association)

IEE Initial Environmental Examination


Support for Health Sector Policy Reforms, ADB TA 3579-INO V


Final Report

December 2008

IHPB Integrated Health Planning and Budgeting

IMCI Integrated Management of Childhood Infections

IT Information Technology

JBIC Japanese Bank for International Cooperation

JKJ Jaminan Kesehatan Jembrana (Jembrana Health Network)

JPS-BK Jaring Pengaman Sosial – Bidang Kesehatan (Social Safety Net Program for Health)

KAP Knowledge, Attitudes, and Practices

KIA Kesehatan Ibu & Anak (Maternal and Child Health)

KPPN Kantor Pelayanan Perbendaharaan Negara (Government Treasury Office)

MDG Millennium Development Goals

MIS Management Information System

MMR Maternal Mortality Rate

MNCH Maternal, Neonatal, and Child Health

MOF Ministry of Finance

MOH Ministry of Health

MOHA Ministry of Home Affairs

MOHSW Ministry of Health and Social Welfare

MTR Mid-Term Review

NGO Non-Governmental Organization

NTB Nusa Tenggara Barat (West Nusa Tenggara)

NTT Nusa Tenggara Timur (East Nusa Tenggara)

PAM Project Administratin Manual

PCIU Provincial Coordination Implementation Unit

PDK Pusat Desentralisasi Kesehatan Decentralization Unit

Pemda Pemerintah Daerah (local government)

PHP Provincial Health Project

PLKB Petugas Lapangan Keluarga Berencana Family Planning Field Worker

PMS Performance Monitoring System

Polindes Pondok Persalinan Desa (Village Birthing Post)

PPM Provincial Project Manager

Puskesmas Pusat Kesehatan Masyarakat (Community Health Center)

Pustu Puskesmas Pembantu (Auxiliary Community Health Center)

QA Quality Assurance

QC Quality Control


Support for Health Sector Policy Reforms, ADB TA 3579-INO VI


Final Report

December 2008

QI Quality Improvement

RRP Report and Recommendations to the President (ADB)

S1 Bachelor level degree

S2 Master level degree

S3 Doctoral level degree

SAF Special Allocation Fund

SIKDA Sistem Informasi Kesehatan Daerah District Health Information System

SKN Sistem Kesehatan Nasional (National Health System)

SPM Surat Perintah Membayar (Payment Order)

SPSDP Social Protection Sector Development Program

SSN Social Safety Network

SUSENAS Survei Sosio-Ekonomi Nasional National Socio-Economic Survey

SWIM Sector Wide Implementation Management

TA Technical Assistance

TRT Technical Review Team

UCI Universal Coverage of Immunization

UNDP United Nations Development Programme

UNICEF United Nations Children’s Fund

USAID United States Agency for International Development

VCDC Village Community Development Cadres

WHO World Health Organization

Executive Summary

Support for Health Sector Policy Reforms, ADB TA 3579-INO 1


Final Report

December 2008

1 Executive Summary

TA-3579-INO has successfully com-

pleted four years of Technical Assis-

tance to the Ministry of Health to sup-

port health sector reform.

TA-3579-INO telah berhasil menyelesaikan

empat tahun sebagai Technical Assistance

untuk Depkes dalam mendukung reformasi

sektor kesehatan.

The final report reviews the terms of

reference from the original request for

proposal, through loan negotiation,

and project inception, and then dis-

cusses the activities undertaken as

parts of the terms of reference.

Laporan akhir meninjau kerangka acuan dari

permintaan awal untuk proposal, melalui

negosiasi pinjaman, dan proyek

pendahuluan, dan kemudian mendiskusikan

kegiatan yang diambil sebagai bagian dari

kerangka acuan.

The team composition varied during

this project, and a discussion of the

team composition, and the responsi-

bilities of the various team members

are a prelude to the review of travel

during the TA.

Susunan tim berubah selama proyek ini, dan

suatu diskusi tentang susunan tim, dan

tanggung jawab dari berbagai anggota tim

adalah suatu pendahuluan bagi tinjauan

perjalanan selama TA.

Various issues in the execution the TA

are discussed, and the report con-

cludes with some suggestion for im-

proving the quality of technical assis-

tance during the final three years of

DHS-2.

Berbagai masalah dalam menjalankan TA

dibahas, dan laporan ditutup dengan

beberapa saran untuk meningkatkan mutu

technical assistance selama tiga tahun

terakhir bagi DHS-2.

The TA has documented many of the

health sector reforms initiate by the

project in various locations. We in-

cluded these case studies to docu-

ment some of the innovations under-

taken by the DHS-1 project.

TA telah mendukumentasikan banyak hal

mengenai reformasi kesehatan yang

diperlukan oleh proyek di berbagai lokasi

Kami memasukkan pembelajaran masalah

ini untuk mencatat beberapa inovasi yang

dilaksanakan oleh Proyek DHS-1

The primary objective of the DHS

loans was to improve health status of

mothers, and children by improving

access to basic primary health care

activities.

Tujuan utama dari pendanan DHS adalah

untuk meningkatkan status kesehatan ibu

dan anak dengan meningkatakan akses

pada kegiatan kesehatan dasar.

Executive Summary



Final Report

December 2008

While the project was successful in

utilization of health care in some prov-

inces and districts, there are still many

barriers to health care and health

status with the project areas. We re-

view these barriers in order to help

future support for decentralization fo-

cus on issues that might help improve

health status and utilization of primary

health care services.

Meski proyek telah berhasil dalam

peningkatanan kesehatan di beberapa

provinsi dan kabupaten; masih banyak

kendala dalam masalah kesehatan dan

status kesehatan di daerah proyek. Kami

meninjau kendala-kendala ini untuk

kepentingan dukungan masalah

desentralisasi dimasa depan yang

diharapkan dapat meningkatakan status

kesehatan dan pelaksanaan pelayanan

kesehatan

Activity Summary



Final Report

December 2008

2 Activity Summary

2.1 Objectives

The Support for Health Sector Policy Reforms Project (TA 3579-INO) team was authorized

on 19 July 2004 at negotiations in Manila to collaborate with the Decentralized Health Sys-

tem Project (DHS-1).

The objective and scope of contract for TA-3579-INO was to assist the Ministry of Health

(MOH) and selected local governments1 in identifying, implementing and evaluating appro-

priate health sector reforms in the context of decentralization. TA resources were to be used

to support reforms at the central level and in districts and the provinces. The TA focused on

DHS-1 and DHS-2 project areas and TA resources were several times used in non-project

areas on MOH’s request and ADB’s approval.

2.2 Terms of Reference

The Objectives and terms of reference for the TA in the contract2 are as follows:

The main thrust of the TA was to suspect health system development in three main areas;

1. Access

2. Quality and

3. Efficiency

The precise terms of reference were as follows:

i) Play an active role in local capacity building to improve planning management

skills and practices in the DHS provinces.

ii) Assist with the training of core set of trainers to help provinces and districts and

develop strategic and operation plans.

iii) Play a liaison/facilitation role with MOH counterparts at national, provincial and lo-

cal levels officials.

iv) Play a proactive role through advice to MOH and provinces on emerging health

needs, health planning policy issues.

1 The original project was to include all the districts of Aceh, Riau, Bengkulu, Bali, North Su-lawesi, Central Sulawesi, and Southeast Sulawesi. When the Islands of Riau because a separate province (previously part of Riau), it was included. Tsunami affected districts in Aceh were excluded form the project in 2007.

2 Terms of reference from “Request for Proposal” TA-3579-INO, ADB August 2002

Activity Summary



Final Report

December 2008

v) Maintain and foster effective linkages with other donor projects in health and re-

lated sectors.

vi) The TA will assist the local project implementation units when possible.

During negotiations3 the terms of reference were modified and reformulated as:

1. Assessment,

2. Development of a plan of action,

3. Development and implementation of health sector reforms,

4. Development and implementation of provincial and district health sector develop-

ment programs,

5. Investment in human resources, and

6. Facilitation of Networking and Communications.

The major difference between the two sets of Terms of References are that those within the

RFP are more oriented toward a strategy of increasing capacity of local government in plan-

ning to support decentralization of health services, and the terms of reference from the nego-

tiations are more oriented toward being advocates for health sector reforms. The TA has

tried to take both into consideration in developing work plans supporting the loans.

The TA within the last four years, has helped the two Decentralized Health Service loans

integrate Health Sector reform into its program as well humans resource development poli-

cies, helped in the development and discussion of significant policy issues, has assisted with

strategic planning at all levels of the government based on assessment, health status, and

capacity of the community to support health sector reform, as well as help facilitate lessons

learned in one district to other districts and provinces. The TA also supported various ADB

supervision and special missions during this time period.

2.3 Team Deployment and Activities

Membership in the TA team remained essentially stable during this work period. However,

only the team leader (Robert Tilden) and one domestic consultant (Prof Nur Nasri Noor)

worked full time for the entire contract. Other members worked periodically, or for full time

for specified periods of time.

The original design was to have international field assistance in two provinces. This concept

had worked well in the CHIPS4 project that USAID had fielded in the 1980’s.

3 16-17 June 2004, Quality and Cost Based Selection. In attendance for ADB was Yang Dan, Yuki Shiroishi; for the consultant Robert Gaertner, and R. Nunez, and for the Government of Indonesia, Isti Ratnaningsih

Activity Summary



Final Report

December 2008

However in this case the provincial level experts were not well utilised, so that the TA recen-

tralized and worked from the centre, where demand for technical assistance was high, and

travelled to the various provinces and districts as requested. This increased the efficacy of

the technical input to the projects, but also increased the travel. Moreover health sector re-

form needed to be implemented at all levels of the government, and coordination in a decen-

tralized system takes greater effort, and a more participatory approach.

Tale 1: TA Team Deployment

Team-leader MM Team-leader MM

1 David Kelaher (DK) 04 2 Robert Tilden (RT) 44

International Consultants Domestic Consultants

1 James Sonnemann (JS) 14 1 Noor Nasry Noor (NN) 47

2 Ascobat Gani (AG) 15 2 James Darmawan5 (JD) 18

3 Don Hindle (DH) 04 3 RM Widjajanto (RW) 14

Table 2 summarizes the travel undertaken to support the DHS loans, and the purpose of the

various types of missions. As can be seen over half the travel was for technical support to

planning which was one of the major concerns within the terms of reference.

Table 2: TA travel by year and type of mission

Inception Supervision fact finding Advocacy Planning Support ADB

missions Total visits

2004 27 0 0 0 0 27

2005 0 13 27 36 11 87

2006 0 18 36 89 8 151

2007 0 12 9 59 0 80

2008 0 8 6 1 8 23

TOTAL 27 51 78 185 27 368

Travel was undertaken by invitation of the Government (National, Province and District), to

attend a meeting, or to assist with proposal development or advocacy.

4 CHIPS, (USAID): Comprehensive Health Improvement Province Specific, 1984-1989 in three provinces, Aceh, West Sumatera, and NTT. Expatriate staff were stationed full time at the provincial level, for on-site training, and facilitation. This program was considered a ground breaking project in the support of decentralization, and local empowerment.

5 Salary and contract for this consultant was directly with ADB.

Activity Summary



Final Report

December 2008

2.4 Semester Reports

The activities of the TA are summarized in progress reports. All semester reports contain an

evaluation of the previous six months against plans, presentations and publications, field ac-

tivities, etc., and working plans for all team members for the following semester.

Report Reporting Period

Inception Report September 2004 December 2004

1st Progress Report October 2004 March 2005

2nd Progress Report April 2005 September 2005

3rd Progress Report October 2005 March 2006

4th Progress Report April 2006 September 2006

5th Progress Report October 2006 March 2007

6th Progress Report April 2007 September 2007

1st Extension Phase Report October 2007 December 2007

2nd Extension Phase Report January 2008 June 2008

3rd Extension Phase Report July 2008 August 2008

2.5 Inception Period

The initial inception report development and its review by the technical team lead to a

change in personnel of the TA, including the team leader. A modified team was mobilized in

December of 2004, and ADB project managers worked closely with the TA unit to help it de-

velop a sense of teamwork and encouraged the MOH to efficiently utilize the TA for program

support and policy development. There have been additional staff added, but the core team

has been supporting the project since December 2005. The inception report did develop a

logical framework for TA-3579-INO which is included as Appendix A. The Outputs and Ac-

tivities described in the logical framework will be discussed.

2.6 Activities undertaken to support the ToR

TA activities to full-fill the ToR have been many and varied. It has involved attendance and

presentations at meetings, capacity building of provincial and district staff, advocacy, data

analysis, writing and dissemination of information, but it has also required a great deal of

travel. Many of the districts participating in the DHS project are underdeveloped economi-

cally, and in terms in infrastructure. There are many isolated areas covered by the DHS pro-

jects, and travel was often difficult, and long.

Activity Summary



Final Report

December 2008

The activities the TA has been involved across the span of the Indonesian archipelago, and

has involved different themes at many venues. Rather than chronologically recreate the ac-

tivities of the TA, this report will organize them around the various terms of reference which

are the primary responsibility of the TA, and give short examples of how the TA supported

local, national and provincial health sector reform and decentralization.

1) Local capacity building to improve planning and management skills and prac-tices in the DHS provinces.

1-a) MNCH Grand Design: During an ADB Special Mission in April 2005, the DHS 1 loan

programme was offered the possibility of extension through the end of 2008 if it could be re-

focused on its original goals, particularly the reduction of maternal, infant, and under five’s

mortality. To help focusing DHO activities on sustainable cost effective interventions to re-

duce risk to mothers and children, the TA developed a “Grand Design” for MNCH, including

investments in supply of services, community demand for quality MNCH services, coopera-

tion between government agencies, and cooperation with private sector and NGO, develop-

ing the capacity of local health offices, and advocacy to local parliaments. After developing

this strategy, much consultation was held with the Maternal Health Directorate, and the tech-

nical review team. The effect of the development of the grand design, its structure, and so-

cialization are discussed in case study annex section 8.

1-b) Prioritization of districts by risks to maternal health: In the absence of recent and

specific data on maternal mortality, the TA suggested using the percentage of assisted deliv-

eries (by trained health personnel) as a legitimate proxy indicator of maternal mortality risk.

This data is available on an annual basis from the Central Bureau of Statistics, and moreover

can be linked to household expenditure and has a large enough sample to be statistically

representative at the district level. Moreover, the literature suggests that maternal mortality

is strongly (inversely) associated with assisted delivery. In discussions with the Project

Manager (Head of Planning), the TA was requested to review time series of material mortal-

ity based on assisted delivery and total number of births at district level. The results of this

analysis were used to focus MOH resource allocation to priority districts. The USAID HSP

project also used this information to select districts to assist with MNCH programs. A map

showing the distribution of district level assisted deliveries in 2004 is included as annex 8.4

1-c) Revised logical framework of DHS-2: The acceptance of results and recommenda-

tions of the Mid-term Review (MTR) within the MoH was not automatic, and required a series

of meetings and discussions, particularly within the Directorate General of Community Health

(DGCH). The MoH eventually accepted the results of the MTR. Discussion continued with

BAPPENAS, and the Ministry of Finance (MoF), and after six months the results of the MTR

were officially accepted by the MoF, and a loan amendment requested. The logical frame-

work for DHS-2 was based on the logical framework from DHS-1, but contained more goals

in health status improvement, and more objectives in health program performance. As a re-

Activity Summary



Final Report

December 2008

sults of the mid term review of DHS-2, its logical framework was brought into line with the

mid-term review findings, this in terms was discussed on modified in various stakeholder fo-

rums, until a agreement was reached. The Ministry of finance submitted this to ADB as part

of the loan amendment in June 2008.

1-d) Desa Siaga Guidelines: During the MTR, component 1 of the new design for DHS-2

was to support the Desa Siaga Programme through the development and evaluation of

model Desa Siaga in all DHS-2 districts. Guidelines and strategies especially for disease

surveillance and project monitoring for the Desa Siaga Programme were drafted by the TA,

and reviewed and revised by the TRT, the community health section of the MoH, and the

steering committee. The Desa Siaga guidelines are included as annex 8.5.

1-e) Analysis and evaluation of district performance: Working with two loans widely

spread throughout the Indonesian archipelago gave an opportunity to explore the perform-

ance of the various provinces and districts with regard to outpatient, in-patient, and immuni-

zation services. The Indonesian Central Bureau of Statistics routinely collects information on

participation in public health programs from a sample of individuals and households that can

be analyzed down to the district level (SUSENAS). Through the analysis of the SUSENAS

data, access barriers were identified, and pro-active intervention was made to improve the

capacity of the district to meet the health challenges. This was initially undertaken for the

DHS-1 districts but also eventually included all DHS-2 projects, and was using 2000 as a

benchmark year, and comparing 2004, 2005, 2006, and 2007. This health system perform-

ance data for DHS-2 districts from the 2007 SUSENAS data set is included as Annex 7.6

2) Training of a core set of trainers to help provinces and districts developing stra-tegic and operational plans.

2-a) Planning for greater focus in DHS-1: Participatory planning by district health offices

for the remaining final two years of DHS-1 was completed in a timely fashion during 2005

2006. These plans were reviewed by the TRT and the TA and suggestions were made for

strengthening and improvements. Then the plans were resubmitted and evaluated. Be-

cause of the TA support, DHS-1 was the first of the multi- or bilateral projects to focus on

MNCH when the Minister of Health requested that all loans focus on supporting the reduction

of maternal mortality. However it should be noted that promotion of maternal health was al-

ways central to the objectives of DHS-1.

2-b) Utilization of DEKON Funds for MNCH improvement: One of the unexpected out-

growths that reflects the synergy between team members was the translation of the concept

of district team problem solving (DTPS) into an operational reality, with districts meeting at

provinces to develop strong proposals for the DEKON grants from the national MOH. With

assistance from TA staff, members of the MOH Maternal Health Unit worked with all districts

Activity Summary



Final Report

December 2008

in several provinces to develop district level proposals for use of the general funds made

available by the national government in DHS-1 areas.

2-c) Integrated Health Planning and Budgeting: Supporting integrated health planning

and budgeting is a specific ToR for the TA. Almost all districts in DHS-1 have participated in

various training exercises concerning integrated planning and budgeting. In addition, many

of the staff of the bureau of planning, and the Secretary General’s office have also partici-

pated in this exercise, which includes the review of nine different manuals. The impact of

this training is reviewed as a case study in the book annex, section 12.

2-d) Development and review of DHS-2 strategic plans: Participation of the TA in the

DHS-2 planning process was different from the assistance provided to the DHS-1 loan pro-

gramme during its refocusing exercise. The planning process for DHS-2 was carried out by

the Decentralization Unit of the MOH which was also the office of the DHS-2 Project Man-

ager, and also under the office of the Executive Director of DHS-2, the special advisor to the

Minister for Decentralization. The TA was involved in the technical review of the proposed

strategic plans developed by the various districts in the project. However, at the same time

the TA was involved in technical planning meetings as resource people in various DHS-2

districts around the country.

2-e) Field Visits to DHS districts: Many of the DHS-1 districts requested visits during the

socialization of the new MNCH orientation, and the TA responded at the request of the ex-

ecutive secretary. Based on the TA’s evaluation of health services data, many of the districts

in DHS-2 were visited to help strengthening the plans developed, and to help in local advo-

cacy to address structural issues and manpower needs. These visits also allowed for some

assessments into the various barriers to care seen through out the DHS-1 and DHS-2 areas,

and helped identify health sector reforms initiated by local governments. The field visits and

dates which they occurred are listed in annex 8.2.

2-f) Maternal Mortality Ratio (MMR) estimation and evaluation: As the Indonesian

government experiments with various approaches to develop valid vital registration systems,

the issue of MMR remains illusive. The international community tends to use rather higher

estimates (300-400 deaths per 100,000 live-births), than local health records collected na-

tionally estimate (130). The Central Bureau of Statistics estimates that in 2007, the MMR

was around 246. The MoH Community Health Division has developed a birth and maternal

death registration system, which estimates the maternal mortality ratio to be 130. Mean

while the demographic health survey of 2007 suggest it is still above 300. As reduction of

maternal mortality is one of the key elements of the logical framework, the TA has been very

involved in various research forums reviewing maternal mortality, and has developed several

methodologies for developing district level elements from data collected on assisted birthing.

One methodology developed by the TA is be investigated and enhanced by the University of

Indonesia, School of Public Health, with financial support from AusAID.

Activity Summary



Final Report

December 2008

2-g) Guidelines for using data in planning and decision making: One of the compo-

nents of the MTR for DHS-2 was developing a training program for district health officers to

work with local staff from the statistics bureau along with district BAPPEDA in analyzing

health status, and health utilization data. This activity is proposed for 2009-2010 in DHS-2.

The description of this activity can be found in the second extension progress report.

2-h) Guidelines for District Health Accounts: In the socialization for the new post MTR

DHS-2 management structure, districts were given time to discuss some of the various activi-

ties within the new structure they preferred. Over 30 districts said they wanted to develop

District Health Accounts, and by December of 2008, an instrument developed with support

by AusAid will be available to collect cost data from the private and public sector and the

consumers. This will help BAPPENAS and the MoH better understand health expenditure

patterns at the district level, and improve the national health accounts. This document is

found in the second extension progress report.

2-i) Guidelines for Desa Siaga Impact Evaluation: There is a need to demonstrate the

impact of the Desa Siaga program on the health status and community capacity for manag-

ing illness within communities. To date, the evaluation of various Desa Siaga initiatives have

been few in number and limited in scope. Brining researchers from local universities in-

volved in the evaluation of Desa Siaga, with technical support from larger Indonesian schools

of public health, offers the opportunity to identify attributes of successful programs, and those

that limit the impact, and thus will improve the quality of the program over time, as well as

decision making, that will be based on evidence for the cost-effectiveness of this approach.

This document can be found in the second extension progress report.

2-j) Operational research priorities in the area of nutrition: Many of the districts with

the highest levels of malnutrition are in the DHS-2 project area. While nutrition was an indi-

cator in the initial logical framework for DHS-2, it has not been included in the post MTR logi-

cal framework except for malnutrition in mothers as a component of Desa Siaga. The TA

helped developing some suggestions for operations research for districts with high rates of

malnutrition and has worked on nutritional issues related to growth faltering, and breast feed-

ing. This document can be found in the second extension progress report.

3) Liaison with MOH counterparts at national, provincial and local levels

3-a) Short “Project Preparation Technical Assistance” (PPTA) for DHS-1 refocus: As

a part of the loan extension process and approval from the ADB board for this extension and

focus, the TA was requested to go through a short PPTA, and revise the “Report and Rec-

ommendations to the President” (RRP) for DHS-1 to highlight the focus on MNCH. This was

done, commented by ADB staff, revised by DHS-1 management, however ADB made no

official change to the scope of the DHS-1 project.

Activity Summary



Final Report

December 2008

3-b) BKKBN data analysis: BKKBN has on a number of occasions asked support from

the TA. Data analysis on the SUSENAS data on district and provincial contraceptive preva-

lence rates was undertaken. This includes time series analysis, and poverty level analysis.

BKKBN has been very successful in achieving equality in access for contraceptives across

all levels of household expenditure. Susenas data gives lower estimation of contraceptive

prevalence rates, and does not have information on “un-met” family planning needs, that the

demographic health survey has, and so it is not officially recognized as the “preferred” data

source on contraceptive prevalence usage. However it is valid down to the district level, and

many low performance areas for contraceptive usage have been identified.

3-c) BKKBN annual planning meetings: Using data analysis undertaken for BKKBN, the

TA supported the 2006 and 20008 annual planning meetings for BKKBN at the national, pro-

vincial, and district level. In addition, the TA has worked with the executive secretary of

BKKBN DHS-2 to help develop a proposal on demand creation, and help in the formulation

and evaluation of annual plans. However, the Demographic Health Survey (DHS) remains

the official data source on contraceptive prevalence rates.

3-d) District level advocacy with focus on MDGs: The information generated by the

time series analysis of SUSENAS data was used as national and district level attainment

material for advocacy of MDGs at various district and provincial meetings to which the TA

was invited to participate. These meetings included governors, bupatis, and heads of BAP-

PEDA at the provincial level, and district health staff, various NGO’s, private health care pro-

viders, and intersecting social programs at district level.

3-e) Evaluation of DHS-2 management structure: By late 2007, DHS-2 had been red-

flagged by MoF, BAPPENAS, and the MoH as being “at risk” because of management is-

sues. DHS-2 management units, including the steering committee, the TRT, the project

manager, reviewed various issues with the TA, and discussed potential corrective actions.

3-f) DHS-2 Mid-Term Review (MTR): The TA was an active participant in the MTR, in

terms of assisting with meetings, provision of district level data, in field visits, in inception and

wrap up meetings, and review and revision of the MTR document.

3-g) Review of project priorities and plans: Directorates within the DG of Community

Health (where DHS-2 now resides) submitted requests to DHS-2 to support their programs

where there are over-laps between DHS-2 and program activities. The TA worked with the

TRT to help develop networks with the directorates and prioritizing requests for support.

3-h) DHS-2 involvement with the community health program: Prior to 2008, the linkage

between DHS-2 and the directorates within community health was limited. The TA has facili-

tated communication between the project management and the directorates by working with

the members of the TRT, coming from the various units of the directorate general, and get-

ting them involved in reviewing and discussing policy options for DHS-2.

Activity Summary



Final Report

December 2008

3-i) Plans for DHS-2 for 2009-2010. With the new post MTR DHS-2 structure, the issue

of centralization of funds flow changed both the nature of the strategic planning and the ac-

tivities that would be undertaken. The TA reviewed capital absorption in 2006 and 2007 at

the district and provincial level, and how the districts were utilizing the funds. The TA worked

with the CPCU and the districts at the national planning meetings and helped developing the

plans for 2009 - 2010 which were included as a part of the loan amendment.

4) Emerging health needs and health policy issues

4-a) Response to the Aceh Tsunami: The first month of the TA after the inception period

was dominated by the Aceh Tsunami and sorting through a possible role for the DHS-1 loan

of which Aceh is one of the participating provinces. Eventually a proposal for reconstruction

of health centres and a draft MOU was developed; the responsibility for reconstruction for

health centres was given to IOM of the United Nations system.

4-b) MNCH Component Strengthening: Even though MNCH was not part of its initial

ToR, MOH and ADB requested the TA to modify the team composition in order to have

stronger MNCH capacity. A specialist in Gynaecology & Obstetrics was added to the team,

with the mandate of developing guidelines on strengthening MNCH services in remote areas.

Team members and DHS-1 and 2 staff accompanied him on various trips to remote areas,

resulting in a great deal of cross fertilization, and a very useful guideline report. His report on

strategies to improve the maternal health services in remote and isolated areas is included in

the book annex as section 11.

4-c) Targeting the project to the poor and underserved: Systematically, the TA ad-

dressed issues of social responsibility, good governance, gender, and the pro-poor orienta-

tion suggested by the RRP. An “equity index” was developed to demonstrate the differences

in health service utilization between the top and bottom quintile of household expenditure.

Gender specific analysis was undertaken where appropriate.

4-d) Minimum Services Standards: While not a direct item of the ToR, Minimum Service

Standards became a subject of discussion. The ES of DHS-2 requested that members of

the TA participate in the discussion and review of Minimum Services Standards that he was

responsible to develop and submit to the Ministry of Home Affairs. The standards developed

by MOH had 64 programs included. The proposal developed by the special advisor to the

Minister on decentralization had 14 items, and was later reduced to 9. The finalization of the

Minimum Services Standards is now in the hands of the Ministry of Home Affairs.

4-f) Guidelines for Health Sector Reform and Operational Research: The executive

secretary of DHS-1 requested that the TA develop a series of guidelines, in Indonesian,

which it will publish it as a part of the intellectual legacy of the DHS project. These include:

a. Guidelines for Health Sector Reform;

Activity Summary



Final Report

December 2008

b. Guidelines for operational research, and

c. Guidelines for strengthening MNCH in remote and isolated areas.

4-g) Case Studies on Health Sector Reform and Decentralization: The TA identified

various case studies and did in depth studies on districts and specific themes, including:

a) Introduction to the Indonesian Community Health System.

b) Changes in Utilization of Indonesian Health Care System 2000 to 2007

c) JKJ Insurance Scheme in Jembrana District: Does it promote Equity?

d) Improving Utilization of Outpatient Services by improving Quality of Care

e) The Tabanan Initiative: A Case Study of Decentralization improving the Quality

and Utilization of a District Hospital in Bali.

f) Managing Insurance Funds in the Puskesmas: A Case Study in Bali.

g) Community Based Health Services

h) Partnership between Traditional Birth Attendants and Midwives in Siak District,

Riau Province

i) Sharpening the Focus of the DHS-1 Project on Decentralized MNCH Services

j) Private Public Partnerships in North Sulawesi

k) Operational Research supporting Health Sector Reform and Decentralization

l) The “Cluster-Islands” Approach for Archipelago Areas to reduce Maternal Death

m) Integrated Health Planning at District Level: It’s impact on Health Sector Planning

4-h) Policy Dialogue: Issue papers related to surveillance, community empowerment,

improving quality of medical services, and health care financing were developed and dis-

cussed with senior health managers, on different occasions between 2006- 2008. In addition

a great deal of policy dialogue also went into the development of the post MTR logical

framework for DHS-2 that accompanied the loan amendment.

4-i) Initial Costing and Review of Desa Siaga: The TA, in response to a request from

the ADB supervision mission of June 2007, undertook a costing exercise for the proposed

Desa Siaga initiative, and analyzed several approaches to mobilize this program. This is

included as annex 8.7

4-j) Collection and Analysis of RisKesDes Data: The TA has been involved in the de-

velopment of variables and the collection of data for the new baseline survey undertaken by

the MoH research section. This data set includes information on nutritional status, infectious

and chronic diseases, accidents, quality of life, dental and visual health, blood chemistry,

health care utilization, participation in public health programs, and household health expendi-

Activity Summary



Final Report

December 2008

tures. The data set covers all the districts of Indonesia and will be Officially launched on De-

cember 1, 2008. This data will allow for districts to begin to explore various aspects of their

health system performance over time.

5) Linkages with other Projects and Programs in Health and related Sectors

5-a) Interaction with various bi- and multi-lateral donors: This was not a primary re-

sponsibility of the TA, as communication with bi- and multi-lateral agencies is channelled

through the Indonesian Resident Mission. However the TA has interacted directly with do-

nors when approached, and at the request of the government.

5-b) AusAid: They worked closely with the TA to review progress after the inception pe-

riod. During this time, the AusAid health representative met monthly with the TA and the Ex-

ecutive Director of DHS-1 to review issues, and plans for activities. During the development

of the AusAid long term programme, one TA member was seconded for a month to work with

the team and help in the development of a Health Service Strengthening project. The TA

has also worked closely with the national AusAid health consultant on the identification of

policy initiatives, and review of program performance.

5-c) USAID: The TA has collaborated with the USAID Health Sector Project, both in terms

of policy dialogue, as well as training for advocators for MNCH in West Java, and developed

a series of structured data analysis to help identify areas of high risk considering MMR and

the absolute number of maternal deaths. Socialization of the MNCH Grand Design was held

early on in the HSP project. Recently the TA has been working with USAID in supporting the

GAVI-HSS proposal development.

5-d) GTZ: GTZ has one of the strongest bilateral presences within the MoH, but also focus

on two provinces which are part of DHS-2. Various meetings have been attended to coordi-

nate activities. GTZ supported the development of annual and strategic plans for NTB and

NTT provinces, and was involved in the review of these plans.

5-e) World Bank: The World Bank also has several decentralized health loans, and the

TA shared lessons learned, and discussed various issues arising with the support and im-

plementation of decentralized health sector reform with the health advisor. Now, the Bank is

taking a new direction focusing on policy development, and specific technical issues.

5-f) UNICEF: UNICEF is very active in the eastern part of Indonesia, and Sulawesi. The

TA has worked with UNICEF both at the national level, and in the province of West Sulawesi.

The TA has given several presentations at UNICEF meetings.

5-g) Global Alliance Vaccine Imitative: GAVI has been developing a proposal for a grant

on strengthening health service delivery systems. They have used some of the work of the

TA in the conceptual framework, and have asked the TA to participate in review meetings.

Activity Summary



Final Report

December 2008

5-h) Quintile Analysis: The TA developed in 2005 an analysis of the frequency of assisted

birthing in relation to household expenditure quintiles, which was immediately picked up by

other bilateral and multilateral agencies. In 2006 this analysis was expanded to include utili-

zation of out-, and inpatient services, measles immunization, contraceptive prevalence rates

in fertile married women, as well as the nutritional status of preschool children. In 2007, an

equity index was developed, which looked at the difference in health service utilization be-

tween the top and bottom quintile of income. In 2008, most social policy analysis undertaken

reviewed differences between levels of household expenditures.

5-i) NGO workshop: The TA organized a workshop, to inform NGO’s of the project’s pur-

pose and structure, and to identify areas for collaboration, and requested the NGO’s to re-

view ways in which they might contribute and support DHS-2, particularly the Desa Siaga

component. This activity is described in more detail in the second extension report.

5-j) Sector Wide Management (SWiM) in NTB: The TA reviewed the organization of the

many donors working in NTB and has made some observations on how the inputs from the

various agencies can be better coordinated.

6) Local Project Implementation Units

6-a) Grand Design on MNCH: Socialisation to district governments and the development

of specific plans was done in series of meetings organized to train and standardize the ap-

proach and to develop consensus among provincial and district level staff. This was followed

by provincial meetings attended by district health officers to discuss the utilization of project

resources to strengthen MNCH programs (through investments from the DHS-1 loan).

6-b) SUSENAS Data Analysis: In anticipation of the project completion report, the TA has

been involved in reviewing program impact in terms of utilization of outpatient and inpatient

services, trends in contraceptive prevalence, assisted delivery, and measles vaccination

coverage in districts supported by various programs.

6-c) Health Sector Reform Bulletin: DHS-1 published a semi-annual bulletin, which con-

tains short articles on various project components, health sector reform research, and since

2005 all issues contained one or more articles provided by various TA members.

6-d) ADB missions: The TA supported and accompanied all ADB missions related to the

DHS loans since its inception. This has helped make the TA more effective and efficient.

6-e) Socialization of Technical Review Team (TRT) of DHS-2: The former DHS-2 man-

agement did not utilize TA for the directorates working in community health, and for the first

two years, no meeting was called for the TRT. Only after BAPPENAS combined TRT func-

tions of DHS 1 and 2, some technical involvement of the community health program was

achieved. In 12/2007, DHS-1 had a meeting for the TRT and MOF, in which the TA re-

viewed both loans and presented approaches to improve loan impact.

Activity Summary



Final Report

December 2008

6-f) Development of training plans: The TA worked with the DHS-2 secretariat on de-

veloping training plans for degree and non-degree training. The degree fellowships included

both domestic and international degree training, and the non-degree included both flagship,

and on the job training. These plans have been amended by several sections of BAP-

PENAS, and revised according to their suggestions.

6-g) Cost tables for reformulated DHS-2 project: New plans have been developed by all

DHS-2 provinces using the post MTR logical frame work; all budgets have been compiled,

and new cost tables were developed for submission with the DHS-2 loan amendment.

6-h) Training of facilitators for DHS-2 Desa Siaga component: The TA was involved in

the development of a module for training facilitators for the post Desa Siaga component.

The facilitators will work with village health committee’s and local mid-wives to develop vil-

lage action plans for the implementation of the “Desa Siaga” block grants.

6-i) Development of ToR for meetings, contracts, and study tours: At the request of

the project’s executive secretary, manager, and director, and the head of the steering com-

mittee, the TA has facilitated the drafting of terms of reference for activities, meetings, con-

tracts, research, and study tours.

6-j) New DHS-2 management structure post MTR. The TA reviewed and participated in

the development of the new management structure for DHS-2, as the loan management from

DHS-1 and DHS-2 was streamlined and integrated.

6-K) Socialization of the new DHS-2 management structure: The TA worked with the

new management for DHS-2 in socializing the revised logical framework to DHS-2 provinces

and districts. It helped provinces and districts in adapting their strategic plans, and how best

to implement them considering the new management structure and funds flow environment.

6-l) Implementation of the MTR: Because of the involvement of the TA in the mid term

review, it was in a good position to help reviewing the new management structure within

MoH. After the MTR report was finalized, the TA worked under the guidance of the execu-

tive secretary on setting up a number of steps that would get the BAPPENAS and the Minis-

try of Finance to agree to the changes suggested in the Mid-term review.

Logical Framework Review



Final Report

December 2008

3 Logical Framework Review

The Logical Framework for the TA remained unchanged for the duration of the project, the

logical framework for DHS-1 was modified as a result of the gap analysis and refocusing of

DHS-1 and submitted to ADB, but no formal modification of the logical framework was under-

taken. DHS-2 went through a substantial modification after the Mid-Term review when the

Ministry of Finance requested a loan amendment.

3.1 Goal of TA-3579

The Goals of TA3579 are essentially the goals of DHS-1 and DHS-2 which in turn are similar

except that DHS-2 also has the goal of reducing malnutrition. Specifically the health dimen-

sion goals of DHS-1&2 are on the following health parameters, their targets and impact are

however different:

i) Reduce the maternal mortality ratio to below 200 (DHS-1) / 175 (DHS -2).

ii) Reduce infant mortality to 30 (DHS-1) / 25 (DHS-2)

iii) Reduce under five year mortality rate to 40 (DHS-1) / 25-(DHS-2).

iv) Life expectancy at birth - 2 year increase (DHS-1&2)

v) Reduce Underweight children from 34% to 22% (DHS 2)

It appears that DHS-1 is well positioned to meet the goals for maternal mortality and infant

mortality for the project area by the years 2010 (as specified in its logical frame work), al-

though several provinces still remain low in terms of health status attainment (Central and

South East Sulawesi).

The 2007 Demographic Health Survey gives cause for concern with regard to the under five

(U5) mortality goal. The survey suggests that the rate has not improved since 2002 and in

two of the DHS provinces with low level of U5 mortality in 2002 (Bali and North Sulawesi) the

U5 mortality rates have actually increased. Only two districts made the goal of the logical

framework on U5 mortality, those being Riau and SE Sulawesi.

DHS-2 does not appear to be in a position to meet any of their goals for the project area with

the exception of South Sumatra. Two the project districts have some of the highest rates of

malnutrition in Indonesia, as well as the highest infant mortality and maternal mortality.

3.2 Outputs of TA-3579

The outputs for the TA within the log frame are six:

1) Health sector reform (HSR) supported at decentralized levels.

2) Human Capacity for health systems management and delivery strengthened.




Final Report

December 2008

3) Health Plans based on actual costs developed.

4) Decision maker understanding of public health priorities improved.

5) Operations research capacity strengthened.

6) Project management improved.

The TA has made contribution to all six areas outlined as outputs of the TA within the log

frame. The TA team has worked on all health sector reform areas with particular focus on

the improvement of capacities for health systems management and service delivery. Health

plans have been reviewed for cost estimates, operations research proposals have been ana-

lysed, and the TA has assisted in all aspects of project management.

3.3 Issues and Uncertainties

While DHS-1 was implemented slowly, it showed steady improvement during the years of the

TA. However DHS-2 was plagued by late release of funds and management shifts during

the period the TA was in existence. After continued years of low loan performance in terms

of budgetary achievement, and there is some question as to its continued existence, particu-

larly after 2008, which will also be a year of low budgetary achievement. While DHS-2 was

able to modify its scope, the late release of funds in 2008 will make this year a lower level of

capital absorption than previous years.

Within the TA, work has been shared, and communication between the team members has

been excellent. All members of the TA showed a high level of professional commitment in

their support provided to local, provincial and national governments. Travel schedules were

often extreme as many of the areas of the project are isolated. Moreover the environment

within the TA was frank and all members of the TA would critical review various comments

before collectively making a decision. Thus, the TA was able to provide support to health

sector reform, not only in the DHS1&DHS-2 areas, but in the country in general.

The function of the IRM in managing contacts with various donors was intermittent, so that

collaboration with agencies often depended on in-formal contacts, and government forums.

Often other donors would anticipate support from the project, however the funds within the

DHS loans belong to the local government, and while suggestions can be made, the final

decision, in what to invest, belongs to provincial and district governments. Donors would

often put themselves in a position to influence fund allocation, particularly in those provinces

where they had a mandate from BAPPENAS to focus their assistance to specific districts.

The problems encountered during the inception, partly due to a too general design of the TA

unit, were solved in coordination with the government. The various ADB task managers

have worked diligently to fill the gaps left by the original TOR, by assigning additional terms

of reference to the TA, particularly for the three contract extensions.




Final Report

December 2008

The utilization of the TA by the government has been high, both the planning unit and vari-

ous directorates within the Secretary General’s office and the DG of Community Health have

made various requests to the TA in line with DHS-1 refocus on MNCH, and to support policy

development and implementation. DHS-2 structural and financing issues have caused a

great deal of confusion, not only between the MOH and District Health Offices within the pro-

ject, but also between various Ministries in Jakarta. This particularly has been a problem in

the time since the post MTR reorganization of DHS-2.

Late release of government funds has affected not only program performance in DHS-1 and

DHS-2, but also the TA’s ability to interact with provincial and district governments. In 2008

the government development budget is programmed to be released in December and con-

tracting takes 1-2 months, so that no achievement is expected in DHS-2 this year. This fun-

damental uncertainty influences the operations of all projects within the government. This

will continue to be a problem for DHS-2 into the fiscal year 2009, which is an election year.

One of the major unresolved issues is the inclusion of nutrition in the DHS-2 log frame as an

indicator of program performance, while it remains absent in national plans. Though some

districts have identified nutrition as an issue, it is rather addressed by capacity building than

through the development of new approaches, or making existing programs more effective.

Continuation of DHS-2 after 2008 remains a question due to its low performance. However,

if it is continued, strong managerial support, along with assistance from and cooperation with

the Ministry of Finance will be required to reach a higher level of capital absorption. DHS-2

does stand to make rapid progress in the next years if these structural issues are resolved.

In addition, specific technical input continues to be required for DHS-2. The national initiative

of the Desa Siaga block grant will require continuous support though 2009 in order to ensure

that the facilitators work with villagers to develop village action plans and that these plans are

implemented efficiently. Moreover, technical input is required on the impact evaluation of

Desa Siaga, and on establishing the surveillance and monitoring functions within the Desa

Siaga initiative. Given the low utilization of consultants by the government, it should be an-

ticipated that arrangements to cover the cost of this unit be covered by ADB.

Desa Siaga is one of the post MTR DHS-2 initiatives, but component five which focuses on

using data for decision making is also an area where additional technical resources are

needed. In particular, with the number of districts and provinces working on improving In-

formation Technology at the service delivery level, national technical assistance should be

available to help support and standardize various approaches, as well as assist in the cross

fertilization to districts that have not identified this as a crucial issue. However there is a lack

time between the training of facilitators and the formation of village action communities and

the development of plans. There are considerable capital costs involved with this program

as can be seen in annex 8.7 “Cost analysis of Deas Siaga”.

Policy Dialogue: Access Barriers to Health Care



Final Report

December 2008

4 Policy Dialogue: Access Barriers to Health Care

4.1 The Primary Health Care System in Indonesia

The DHS loans while designed to promote health sector reform and decentralization, and all

the districts under DHS or other projects work within the larger framework of the Indonesian

Public Health System. The Government of Indonesia has historically considered health and

primary health care as a human right. The public health care, and especially the outpatient

system, has achieved good coverage throughout the country. However it is not performing

at its optimal level because of inadequate financial support.

Hospital based care is located in every district but has low rates of utilization, and it is as-

sumed that the poorer the family, the less likely they are to utilize these health care services.

While every district has a hospital, many of these hospitals do not offer the complete set of

specialist services, and often have insufficient equipment.

Training for nurses, midwives, and other public health staff is done by both the government

and by private schools. The quality of this training is often limited because of lack of training

materials, equipment and libraries.

Despite universal access to outpatient medical services, people, when they are sick, usually

treat themselves, and are often more inclined to visit health care providers during their pri-

vate practice time, than visiting the same provider at the public clinic, where the cost for ser-

vices are reduced or non-existent.

The developers of the Indonesian Health Care System were trained in cost effectiveness,

and the development and expansion of the system was based on the evaluation of program

impact and efficiency. This approach has helped the health care system develop low cost

activities with high levels of coverage and Indonesia has reached a threshold of life expec-

tancy on a very low level of resource input from Government and consumers. The money

spent on health care in Indonesia is 1/8 of the amount spent in the Philippines, yet they have

almost equivalent life expectancies.

Country

Health Expdenditure

US$ 2002 %GDP

Government Health Ex-pend. Per capita US

% of Total Govern

expend on health

Life Ex-pect at birth

Indonesia 20 2.8% 5 3.5% 68

Malaysia 294 3.3% 156 6.1% 72

Myanmar 28 2.2% 4 1.2% 59

Philippines 169 3.4% 80 7.0% 69

Singapore 993 3.6% 329 6.7% 80

Thailand 237 3.6% 138 11.8% 70




Final Report

December 2008

Country

Health Expdenditure

US$ 2002 %GDP

Government Health Ex-pend. Per capita US

% of Total Govern

expend on health

Life Ex-pect at birth

Canada 2,541 9.9% 1,452 15.2% 80

France 2,416 9.3% 2,061 13.4% 80

Japan 2,827 7.6% 2,298 16.1% 82

United Kingdom 1,859 7.3% 1,442 14.6% 78

United States 4,539 13.1% 2,017 18.2% 77

The public health and medical system was developed during a period of time that all admin-

istrative and management functions were centralized. So the health system is rather stan-

dardized across the country. But since 2001 the government has decentralized, and control

of the provincial health system is the responsibility of the governor, and the health system at

the district and sub district level is the domain of the district government. Most of the districts

and cities of Indonesia, however, have not yet fully utilized the opportunity that decentraliza-

tion has brought them, to make their health system appropriate to the demands of local con-

sumer expectations, and develop health care as part of their regional economies.

According to law, money to support community health activities is the responsibility of the

district government, but in reality almost 70% of the government health budget is still allo-

cated through the national government. And the government health budget is only about

35% of the total health expenditure budget in Indonesia.

Several other units of the Government work with the Ministry of Health in the delivery of

health services to the poor, this would include the National Development Planning Agency

(Bappenas), the family planning board (BKKBN), Ministry of Home Affairs, Ministry of Fi-

nance, the Ministry of Agriculture, the Ministry of Food and Drugs, and the Ministry of Educa-

tion. But within this network of Government support to community health, the Ministry of

Health plays a cutting edge role.

The Alma Ata Declaration on Primary Health Care for All occurred in 1978, at the same

time that the Government of Indonesia was attempting to develop a nation wide primary

health care and public health system. The key to this program was a community health care

centre (Puskesmas), which was staffed with a physician, but also contained public health

nurses, midwives, sanitarians, infectious disease control staff, and nutritionists. The WHO

motto of health for all by the year 2000 became one of the cornerstones of the Indonesian

public health program. The core 14 elements of primary health care as laid out by the Alma

Ata declaration became the basic elements of health care development in Indonesia.

On the forefront of this primary health care revolution was the Posyandu, where mothers

bring their children once a month for growth monitoring, nutritional first aid, immunization,

basic treatment, and access to basic maternal health. The Posyandu was adopted as a na-




Final Report

December 2008

tional program in 1982, and covers all villages in Indonesia with basic health services. In

areas where community ownership was developed, Posyandu has been a strong promoter of

good community health, and community “self-help”.

4.2 Health Care Providers

Physicians are not the only medical care providers in Indonesia. Reproductive health is the

domain of midwives (many with only one year of training past high school). And even though

many physicians work for the health system, they will still have private practices that they run

in the afternoon and evening. Midwives, while recruited and trained by the government, also

run a semi-private practice, and while they get money from local government for assisting

with delivery of poor mothers, they provide care to better off community members on a fee

for service basis. Many nurses also hold afternoon private practice. Although service during

private practice hours might be 3 to 4 times more expensive than registration fee’s during the

hours of public practice hours, almost half of the outpatient care in Indonesia is given within

the “private” setting. Although better off families tend to utilize private services more than

poorer families, the utilization of public outpatient care services remain constant across in-

come, with the higher income families making more visits to private providers.

Figure 1:

The role of traditional health care gives has decreased dramatically over the last 20 years as

educational levels have increased, although in rural areas Traditional Birth Attendants do




Final Report

December 2008

about 40% of the delivers because of limited availability of qualified midwives. So while the

use of traditional medicine and “magical” cures are still occurring traditional medicine is no

longer as prevalent as it was after independence. More often this approach is used with

chronic diseases that do not respond to traditional therapy. Herbal therapy and the con-

sumption of herbals teas called “Jamu”, to treat disease and promote health is also wide

spread. In addition for some conditions, massage is considered the appropriate therapy.

4.3 Family Planning and Reproductive Health

During the 50’s and early 60’s Indonesia had a pro-population growth policy, but during the

early 70’s the multilateral and bilateral health development policy was dominated by a wide-

spread concern about population growth. Keeping the world’s population within reasonable

bounds became a major priority for bilateral and multi-lateral agencies.

After the establishment of the “new order” in the late 1960’s, the policy of the government

changed, and unlimited population growth was viewed as a threat to “development”, which

was the major priority of the new government.

The development of a national population planning board independent of the Ministry of

Health, was supported by a number of multilateral and bilateral development assistance poli-

cies, and in Indonesia, the National Family Planning Board (BKKBN) was established.

USAID and the United Nations Family Planning Agency invested heavily in BKKBN’s devel-

opment, its procurement of contraceptives, and for its research and development activities.

The R&D initiative of family planning helped develop the posyandu program as well the mid-

wife in the village (BDD) strategy.

The family planning movement in Indonesia became one of the world’s success stories in

family planning with significant coverage of the poor with contraception, and significant re-

duction in overall fertility and population growth in Indonesia. Their success was based on

their ability to make communities feel they owned the program, of keeping families small and

prosperous. However during the decentralization period, the family planning unit maintained

a belief in a vertical program delivery, remained centralized, and lost its operation units at the

District level. Contraceptive prevalence rate though have continued high with Susenas re-

porting over 54% of married women between the age of 15 and 45 reporting using some type

of contraception within the last month.

The need to establish a central unit in the government to promote contraceptive usage,

demonstrates how important limiting population growth is as a basic element of Indonesia’s

development strategy, despite some opposition from conservative religious elements. At the

same time, the historical major support for family planning (USAID) is no longer supporting

BKKBN in Indonesia.




Final Report

December 2008

4.4 Community Health Program development

Because of limited budget very few initiatives (with the exception of the Puskesmas program)

were implemented nationally. Moreover an approach of program development, evaluation,

further expansion, further evaluation, and eventually bringing the program up to scale if the

program had proved effective was the way in which most program in community health pro-

grams (such as the growth monitoring, IDD, and Vitamin A program, had been developed).

One of the large scales health programs implemented with a crash program, was the Village

Midwife (Bidan di desa), program in which every village (approximately 72,000) received a

midwife for several years supported by central funds. This program was initiated in the early

90’s and continued on thru the mid 90’s. However isolated villages with small populations

had a hard time keeping midwives, as their volume of work is limited, as was the financial

support by the local population. After finishing their contract if unmarried they would often

move to urban areas where they could do enough deliveries to make adequate living. The

midwife remains the primary health care worker in most rural areas, not only providing repro-

ductive health services, but also basic medical care, and other public health services.

4.5 Budgets and Funds flow

Before decentralization, five year plans were developed with objects, goals, targets and

budget estimates. Various units of the government were evaluated on how many of their

targets were achieved, and budgets for future activities depended on previous performance.

There have been traditionally two budgets, an operational budget, and a development

budget.

The operational budget is released every month, so that salaries can be paid, and utilities

supplied to the offices. But the development budget is often not released until later in the

year. This has become consistently problematic since decentralization, with development

budgets not being released until there is only 5-6 months to utilize the funds. According to

the decentralization laws, the districts are not only responsible for the implementation of the

health program, but also for funding the health program.

The district government budget (APBD) consists of funds allocated from the central level

(balancing fund), and funds generated from the local tax (PAD). The balancing funds further

consist of (a) revenue sharing funds (DBH), (b) general allocation funds (DAU), and (c) spe-

cific allocation funds (DAK) that are used for financing physical infrastructure. In addition,

districts also receive funding from the central level for rendering health services for the poor.

This has been started since the economic crisis hit the country in 1998 and initially seen as a

social safety net program, and currently seen as the implementation of the constitution

clause on the government’s responsibility to protect the welfare of the poor.




Final Report

December 2008

APBD (District Budget):

• a. Balancing Fund

- Revenue Sharing Fund (DBH)

- General Allocation Fund (DAU)

- Specified Allocation Fund (DAK)

• b. Local Tax Revenue (PAD)

Indirectly, districts also receive support from the central Government through two additional

funding mechanisms. The first is the “Deconcentration” budget, allocated by the central level

to the province. This is actually the provincial budget used among other things to support

districts in areas such as capacity building (training), technical assistance, coordination, etc.

The second one is the “Co-administered Task Fund” (Tugas Perbantuan or TP), allocated by

the central level to the district that has been assigned to perform a specific task related to

certain central (MoH) policies.

The analysis of district health accounts under the fiscal decentralization as described above

revealed evidence for performance constraints:

• DAU in many district was spent mostly for salary

• The remaining DAU is used to share 10% of the DAK (this is regulated in Law #

33/2004 on fiscal decentralization)

• DAK is mostly used for physical infrastructure, civil works, and equipment

• Revenue Sharing Funds (DBH) are only available if the district has revenues from

mining, forestry and agro farming

• Local tax revenue (PAD) is relatively small especially in districts/municipalities

with little industrial activity

With these conditions, health programs have been suffering from insufficient operating and

maintenance budgets that in turn affected the performance of health services, facilities, and

public health programs.

DHS-1 and its TA has been proposing and advocating a major reform in the fiscal de-centralization as to assure the availability of sufficient funds to cover operating and maintenance costs for service delivery. The proposed reform is to eliminate restriction

that DAK can only be used for physical infrastructure so that DAK can also be used for pro-

gram operating costs. Another major reform proposed is to shift the “deconcentration fund” to

become a “specified block grant” to the district level, earmarked only for program operating

costs. This reform will assure improved availability of funds to cover operating costs at the

district level which is essential for improving health program performance.




Final Report

December 2008

4.6 Health Service Utilization

Major constraints to improved utilization of medical care lie in poor quality of service supply,

and in weak community demand for these services, which often were developed and imple-

mented without community assistance. In terms of access to and utilisation of services, ba-

sic primary health care including maternal and child health, outpatient services for moderate

illness, inpatient services for severe illness, and prevention and public health programs (vac-

cination and family planning programs) will be discussed.

Level Public Services Management of Public Services Private Services

Neighborhoods Posyandu Midwife, Women’s Group(PKK), health cen-ter staff

Traditional Birth At-tendants, Shaman, "Healers"

Village

Midwives (Birthing Huts), family planning coordinators Sub health centers

Health Center Staff, Vil-lage Head man

Religious boarding schools, private physi-cians

Sub District

Health Center (outpa-tient care, in some places delivery referral, delivery management

District Health Office which is under the control of "Bupati", and local par-liament

Private physicians, Public physicians after hours treatment, mid-wives, nurses, mid-wife,

District District Hospital

District Hospital office not linked with public health office, but also under the control of Bupati and local parliament.

Private physicians, Private Hospitals (profit, and non-profit facilities)

Province

Provencal Hospital Training of public health staff Coordination of district efforts

Governor, provincial fam-ily planning offices

Private physicians, Private Hospitals (profit, and non-profit facilities)

National

Teaching hospitals, Public health programs Community Health Ser-vices Communicable Disease control, Standards, Licensing Food Safety Nutrition

Ministry of Education, Ministry of Health, family planning National Development Planning agency, Parliament Ministry of Finance Ministry of home affairs Food and Drug Admini-stration Agriculture

Private physicians, private Hospitals, poly clinics, family planning services. Food manufactures




Final Report

December 2008

The structure of the health system from the village to the national level, and the responsibili-

ties of the various elements of the system are described above. This system works covers

the larger population centers, but there are many isolated, remote, and poor population in

Indonesia that are not covered by this system.

Local Government & Parliament

Placing MNCH high on district policy agendas

MIS

QA/QI/QC

Capacity to supervise

Planning & Budgeting

Advocacy

Community participation

Transportation

Health promotion

BCC

Incentive system

SSN for the poor

Cost effective interventions

Incentive system

HRH

Infrastructure & equipment

Hospital,Puskesmas,Polindes,

Midwives,Private

providers

Mother,Family,Local

community

Menu for capacity building

IT/GIS, Surveillance, IHPB, DHA, Prospect, Supervision, DTPS, etc

DHO

DemandSupply

MCH, FP, Immunization, Delivery by Health Staff, Maternal Nutrition,

Breastfeeding Nutrient, Under-5 Nutrient, Infant Nutrition, IMCI, Environment Hygiene,

Household Sanitation, etc

Partnership with NGOs & other sectors

DHS supports

Regulation

The grand design developed by TA-2579-INO6 illustrates the roles that various projects can

take, and a menu of interventions, and community mobilization (demand side) activities for

increased utilization of health services (supply side) that might influence how the health, pub-

lic health and family planning services are perceived and utilized by various communities.

Self reliance is also an important attribute of the Indonesian culture. Families and communi-

ties both will do their best to take care of problems within the family, not realizing that the

pooling of efforts between families, communities and market segments is usually a more effi-

cient way of dealing with health care needs, and health promotion. So while supply of medi-

cal care is available in Indonesia, and geographical access is usually not a major barrier, it is

of low quality (both in terms of health care facilities, and also level of training of the provider).

6 Sharpening the Focus of the DHS-1 Project on Decentralized Maternal Neonatal Child Health Services and the Impact on Capital Absorption: Bringing Project and Program into Alignment




Final Report

December 2008

Therefore in most areas of Indonesia (with the exception of urban areas and several smaller

provinces) the demand for Government health services is low. However throughout the coun-

try there are facilities that are highly utilised and several district/city governments have made

significant improvement in out patient services using DHS funds.

The role of the district health office in organizing and managing health services can also be

an obstacle to health care utilization. How well the district health is staffed and organized,

and how it is funded (which depends on how well it does advocacy with local district parlia-

ments and government), will also affect the quality of the services, and the community de-

mand for those services. Equally important is the ability of the district health office in forming

partnerships with other government offices (Bappeda, Ministry of Health, Ministry of Social

Welfare, Hospital services, Police) and local NGO’s and local businesses and industry.

This health system was developed when 85% of the health market was rural, and there was

a large population of landless agricultural workers. This rural based health model is still the

standard for health care, despite the growing number of new health consumer segments,

and a 45% urban population. The rich of the large cities go to Singapore or Malaysia for in-

patient health care for many chronic and high risk diseases. Limited access to appropriate

health care in Indonesian is a phenomenon across all health product consumer segments.

There are two major issues in terms of access to care.

• The first is that not all medical products demanded by various consumers of

medical services in Indonesia are available. Yet some hospitals in the city of

Batam primarily deliver services to customers looking at bargains from Singapore;

• The second is that government services are not as widely utilized, with consum-

ers of all levels of income preferring to deal with government medical officers dur-

ing their “private” afternoon clinics, than go to the government facilities.

In order to review barriers to care several levels shall be looked at: The first is utilization of

health services and public health programs between the rich and the poor. Much research

has gone into the area of disparities of health status and health care utilization by level of

economic attainment. It has been demonstrated to be true in developed as well as in under-

developed countries, countries with “free market” health care.

We will start our investigation into barriers to utilization of public health and primary health

care with the hypothesis that socio economic attainment and disparity is the primary determinant of utilization of health services.

This implies that cost (direct and indirect cost) of health care is the primary obstacle to utili-

zation of health services. Figure 3 below shows how socio-economic attainment influences

birthing and delivery by type of maternal health care provider across the five quintiles of per

capita daily expenditure in Indonesian in 2007.




Final Report

December 2008

Figure 3:

If one considers midwife, doctor, or nurse to be appropriate delivery assistance, and delivery

by a traditional birth attendant (Dukun) or family member to be inappropriate, then the role of

household socio-economic status in determining birthing patterns is obvious. Richer families

use doctors and midwives almost exclusively, while only slightly over 50% of the mothers

giving birth in the last year reported using a midwife or doctor.

If this hypothesis is correct, as the health system improves its program for medical assis-

tance to the poor, the access for the poor will improve, and this should be the primary policy

tool for improved service utilization (and also for increased consumer expenditure for health).

But since “reformasi” in the late 1990’s, the Government of Indonesia has tried to be more

responsive to the needs of its vast population, by decentralizing functional and financial re-

sponsibly to the district. Almost 25% of Indonesia’s districts are now experimenting with

some type of “free” outpatient care for certain population segments, and in some districts the

entire population can utilize the outpatient health services at no direct cost.

A review of the national health care utilization statistics of selected districts throughout the

DHS provinces, some with high utilization and high poverty, some with low poverty levels

and low utilization rates, has led to some conclusions. The highest performing districts were

analysed with regard to the various indicators of utilization. The following paragraphs will

start analysing national data and discuss information gathered through personal observation

and interviews with various health care providers and consumers across Indonesia.




Final Report

December 2008

4.7 Poverty as a Barrier to Health Service Utilisation

Several indicators of health care utilization, including outpatient visits, inpatient visits, as-

sisted delivery, measles immunization, and contraceptive prevalence rates will be used as

the primary indicators of health service utilisation.

4.7.1 General considerations

What can be said about Indonesia is that it is a vast country and the barriers to care vary

among regions, and among consumer segments within the regions. Indonesia is a wealthy

country with many natural resources, however much of the population lives below the 1$ per

person per day cut off that the Millennium Development Goals set as a threshold for accept-

able income for living adequately.

The household expenditure pattern in Indonesia in 2007 is illustrated below. In breaking it

into five quintiles we can see that for unadjusted income about 50% of the population lives in

households spending less than 1$ per person / day. If that is adjusted for purchasing parity

(price differentials throughout the country), than about 20% of the country lives in households

spending less than $1 per person per year.

Figure 4: Per-capita daily expenditure quintiles Susenas 2007

In this analysis, the proportion of the population in the bottom two quintiles within the various

districts was used as a proxy measure for poverty. The national average in the two bottom

quintiles should be 40%, but some rich districts have 80% of their population in the top quin-

tile, while some very poor ones have 80% of its population in the bottom two quintiles.




Final Report

December 2008

4.7.2 Utilisation of outpatient services

Utilization of outpatient health services implies a disease state. In 20077 approximately 25%

of the entire population reported being “sick” in the preceding month. The majority of those ill

(80%), reported self treating their illness. Only 44% of those ill went to a provider of health

services (private or public). Almost 50% of the richest families in Indonesia reported seek-

ing outpatient care when ill, while only 38.1% of the poorest families sought care when ill.

This gives a ratio or “equity index” suggesting that the rich utilize the outpatient health care

system 30% more than the poor in 2007.

Figure 5: Equity Index for outpatient care Susenas 2007

However, about 50% of outpatient care services used by people from the lowest expenditure

quintiles are private services for which the patient must pay 3-5 times more than with public

health services; and most bottom quintile households spend more for Tobacco than for

health care services. This suggests that direct “costs” for health services are not a primary

factor influencing utilization of health services. It is also interesting to note that the use of

traditional practitioners has nearly died off in Indonesia, and, while still seen, has almost

been replaced by self treatment as the population has become more educated and affluent.

Outpatient and inpatient utilization vary a great deal across the provinces in Indonesia, and

Bali which has the highest utilization is also a relatively prosperous location within Indonesia.

However, NTB and NTT which are both areas with a vast amount of poverty also have high

levels of outpatient utilization, while Central Kalimantan, and the Islands of Riau, which are

both relatively prosperous have low levels of outpatient utilization.

7 2007 Susenas Core Data Individual data set




Final Report

December 2008

Not only does household income have low impact on utilization of outpatient services, but

community wealth also does not appear to be a good predictor of outpatient utilization.

Figure 5 a + b: Outpatient and inpatient utilization by province, Susenas 2007




Final Report

December 2008

Figure 6: Equity ratio between provinces for outpatient services 2007

We compared the ratio (equity index) of utilization between the rich and poor across the vari-

ous income segments in the province, and found a great deal of regional variation. In Yogja-

karta, and North Maluku the equity index is close to one which means equal access and utili-

zation of outpatient services between the rich and the poor.

However, in some provinces there is an extreme difference. Perhaps “The islands of Riau”

province represents the most extreme example. The province is relatively prosperous, and

has only a small proportion of its population in the bottom quintile living in isolated fishing

communities, far from the urban areas, south of Singapore, where over 70% of the popula-

tion live in two large cities. It is also a DHS-1 area, and they are now aware of the problem,

and have had several policy meetings (funded by DHS-1) to review various strategies to ad-

dress the issue of outpatient care, and improve the access for poor remote areas. They

have also undertaken a study tour to other provinces that are developing plans for this issue.

4.7.3 Utilisation of in-patient services

Differences in inpatient utilisation rates between the rich and the poor is much greater than

the difference in outpatient utilisation. In 2007, at the national level, the rich were over two

times as likely to utilise in-hospital care, than the poor. This is illustrated below. The prov-

inces with the biggest difference for in-hospital service utilisation rates between the rich and

the poor are in areas with very small “poor” populations, that being Riau, and Jakarta. Prov-

inces with the lowest levels of inequity have a great deal of poor people, such as NTB,

Papua, North Sumatera, and Central Sulawesi.




Final Report

December 2008

It is interesting to note the “Islands of Riau” has one of the best equity index on inpatient care

(close to one), which suggests that all consumer income segments have equal access to

inpatient care, but not outpatient care.

Figure 7: Inpatient Equity Index 2007 Susenas

Quality inpatient services to the poor remain a challenge to the development of the health

care system in Indonesia. This is partly due to financial challenges, partly due to cultural

issues, and the need for the entire family to participate in an “in-patient” medical treatment.

Very few hospitals in Indonesia have been designed to accommodate an entire family, but

among the rural poor, a visit to a hospital is not made alone. Moreover the need to staff

hospitals in small and remote districts with adequate number of specialist remains a chal-

lenge because of the income differentials between urban and rural specialty practices.

4.7.4 Assisted birthing rates

The equity index for assisted delivery also has a great deal of variation across the regions as

can be seen in figure 8 below. The five best provinces in terms of equity of access and utili-

zation of birthing services between the rich and the poor are Jakarta, Yogjakarta, Bali, Riau,

and North Sulawesi. The six provinces with the highest levels in equity between economic

strata for assisted delivery are North Maluku, Papua, Banten, West Java, NTT, and Ambon.

Not all of these areas are necessarily poor, but access to trained health personnel to assist

in delivery is problematic in the Eastern Islands of Indonesia. West Java and Banten con-




Final Report

December 2008

tinue having low utilization of obstetric services among the poor too, but access is less an

issue, and the effect of belief on preferences for delivery services is also strong in these ar-

eas.

Figure 8, Equity Index for assisted Delivery – Susenas 2007

4.7.5 Contraceptive prevalence

Figure 8A, Equity Index for Contraceptive Prevalence Rate – Susenas 2007




Final Report

December 2008

As mentioned earlier, besides the Ministry of Health, the Family Planning Board also has a

significant role in targeting reproductive health services. In particular, the mission of BKKBN

is to target contraceptive access to the poor across Indonesia. As can be seen in figure 8A

contraceptive prevalence nationally indicates that poor mothers use contraceptives more

than the households of higher income, except for four provinces that do not take part in the

DHS programme.

The national average is below one which suggests that at country level, BKKBN is meeting

its mission of getting contraceptives to the poor. However in several provinces with high

number of poor people such as NTT and Maluku, the inequity of utilization of contraception

between the poor and the rich is also troublesome.

4.7.6 Immunisation and other preventative health services

Immunization is a service managed by the health centers, Posyandu, and the village mid-

wives. When vaccines are available, they do a reasonably good job of immunizing most of

the children. Less than 18 percent of the children report not receiving a measles vaccination

before their first birthday. The community demand for immunization insures a relative good

distribution. In all of the areas with strong community developed health programs, it has

been observed that all children are immunized completely.

Figure 9 Children 12-24 months reporting no immunization by quintile

The limitations of the immunization service system do not affect the contact with the various

consumer segments by the health center immunization team, but the adequacy of the immu-

nization. Most immunization (other than BCG and measles) require multiple doses but not all

children are getting adequate dosage.




Final Report

December 2008

Moreover RiskesDas demonstrates that certain areas while having high levels of measles

vaccination, they also have very high levels of reported measles, suggesting that cold chain

failure might be influencing the efficacy of the vaccines administered.

Figure 10: Number of doses of vaccine reported by children aged 12-24 months

As demonstrated earlier, the rich tends to utilize obstetric services more than the poor; it is

therefore logical to assume that levels of assisted birthing could be explained by poverty.

Figure 11 Poverty and levels of assisted birthing




Final Report

December 2008

As can be seen in these figures for DHS-2 districts, poverty is a reasonable predictor for lev-

els of assisted birthing coverage. However there are some other trends that are more under

the influence of the provincial policies. South Sumatra has many districts at high level of

coverage despite high levels of poverty, suggesting that government policy can promote high

levels of birthing in areas of high poverty.

Measles vaccine coverage in children between 12-24 months seems to have no relation to

poverty, as seen in figure 12. In fact some of the poorest districts have very good coverage,

or utilization of outpatient service as seen in figure 13.

NTT with the lowest levels of assisted birthing has the highest coverage in immunisation

against measles, as well as outpatient utilization. Most of the DHS-2 districts have low levels

of assisted delivery, but they are above the national average with regard to anti-measles im-

munisation. Not all elements of the health system have the same capacity in the same re-

gion. Consequently it is not possible to judge the performance of regions based on one utili-

sation indicator, as every region seems to have one area where it excels over the others.

Figure 12 Poverty and measles immunization

It is also interesting to note in figure 13 below, that NTT has very high levels of outpatient

utilization, some of the highest within Indonesia. So while NTT has high levels of immunisa-

tion coverage, and the poor and rich are alike in utilising outpatient health services, they are

not likely to utilize health staff for assisted birthing. They are however likely to utilize outpa-

tient services.




Final Report

December 2008

Figure 13 Poverty and outpatient utilization

Concerning the impact of “poverty” on health service utilization, one can say that poverty ap-

pears to influence a family’s choice for delivery assistance; it does not however appear to

influence immunization coverage and the utilization of outpatient services (only a little).

There are other obstacles, some of them related to accessibility, some to the lack of effi-

ciency of public services; but a great deal of low utilization rates have to do with community

demand, and its ability to attract and maintain adequately trained health personnel. Projects

need to work on demand creation as well as infrastructure and systems development.

Table 1 below summarizes the trends in utilization rates as seen in various SUSENAS sur-

veys undertaken between 2000 and 07. Rates of self treatment tend to fluctuate over time,

hovering around 70%, but self treatment is similar across the household expenditure quin-

tiles with the poor opting for self treatment slightly more often than the highest quintile. Out-

patient utilisation was steady from 2000 to 06 but jumped almost 25% from 2006 to 07, and

equity of access improved. This was also true for inpatient utilization, with a 60% increase in

2007. Contraceptive prevalence rates did not increase but the equity index improved. As-

sisted delivery from 2006 to 2007 increased slightly, but equity of access did not.

The utilization of out- and inpatient services took a major jump between 2006 and 2007.

This is partly due to funds made available to pay for health services to the poor, but this must

also be supported by increased demand. It is unclear how the increase in demand was

achieved. Assisted birthing has increased over the last seven years and become more equi-

table. However the jump seen in inpatient and outpatient services between 2006 and 2007

was not seen in assisted birthing or contraceptive prevalence rates, suggesting that increase

seen in outpatient and inpatient utilization was not a system wide improvement in outreach.




Final Report

December 2008

Table 1: Utilization of basic health services 2000 – 2007

2000 2004 2005 2006 2007

Self treatment 62.90% 72.60% 69.90% 71.40% 65.00%

Equity index self treatment 0.93 0.96 0.97 0.93

Outpatient care (contact rate) 35.80% 38.10% 34.40% 34.10% 44.10%

Equity index contact rate 1.35 1.43 1.38 1.3

Inpatient care 1.10% 1.00% 1.20% 1.20% 2.00%

Equity index inpatient 4.68 3.94 3.61 3.23

Assisted delivery 63.50% 72.90% 73.40% 75.10% 75.40%

Equity index assisted delivery 1.78 1.72 1.64 1.69

Contraceptive prevalence rate (cpr) 54.30% 56.70% 57.80% 57.90% 57.40%

Equity index (cpr) 0.93 0.92 0.91 0.88

The poor can access outpatient services. The rich however tends to utilize health services

more frequently than the poor. At district level, poverty does not always predict inpatient

utilization, even with the large difference that exists between the rich and the poor house-

holds in the utilization of these services.

While direct costs of services influence utilization, the indirect costs for transportation and the

time lost (for the patient and family members) also have an impact on the utilization of outpa-

tient services, especially among the poor who are predominately rural landless agricultural

labourers.

Table 2 Rural urban population of Indonesia by household expenditure quintile 2007

household expenditure

quintile Total

HouseholdsTotal Popu-

lation

% Rural Population

living in rural areas

Mean Per-capita Daily Expenditure

household size

1 11,231,106 52,659,892 79.6% 4,704 4.69

2 11,553,773 47,987,296 69.6% 6,732 4.15

3 11,214,530 43,804,886 58.3% 8,755 3.91

4 10,809,705 40,064,730 43.8% 11,769 3.71

5 12,069,399 40,660,606 20.4% 22,570 3.37

Total 56,878,513 225,177,410 56.3% 11,048 3.96

Indonesia is in the midst of a demographic transition. Both in terms of its age structure as

well as its urbanisation: In 1980, the 85% of the population was residing in rural areas, in

1995 it was 65%, and in 2007 56.3%. Moreover, table 2 illustrates, that most of the popula-

tion of household quintile one is living in rural areas whereas only 20% of quintile 5 do live in

a rural environment.




Final Report

December 2008

It is assumed, considering the higher potential for income, that the younger population will

continue migrating to urban areas, and that many rural areas will be transformed into urban

zones as their labor markets are transformed by the expansion of industrial production.

Although women in the bottom quintile report higher levels of contraception usage, the family

size in the bottom quintile is larger than the national average (4.69 vs. 3.96), and almost 1.3

heads larger than the average family of the top quintile (3.37). This suggests that more ef-

forts are needed in family planning in order to promote sustained and equitable economic

growth for all economic strata of the population.

Table 3: Midwives Practice by Village Size

VILLAGESIZE

Nb. of Midwives < 500 500 to 1500 1500 to 2500 2500 to 5000 5000 to 10000 > 10000 Total

0 9,198 92.7% 14,703 77.8% 6,871 56.9% 6,541 37.8% 1,917 22.2% 425 14.1% 39,655

1 710 3.1% 4,015 17.3% 4,690 20.3% 8,826 38.1% 4,216 18.2% 701 3.0% 23,158

2 10 0.3% 151 3.9% 380 9.8% 1,313 33.9% 1,395 36.0% 626 16.2% 3,875

3 3 0.2% 26 1.6% 94 6.0% 412 26.1% 617 39.1% 424 26.9% 1,576

4 1 0.1% 9 1.2% 33 4.4% 148 19.6% 271 35.8% 295 39.0% 757

6+ 0 0.0% 3 0.4% 13 1.5% 74 8.7% 213 25.2% 543 64.2% 846

Total 9,922 18,907 12,081 17,314 8,629 3,016 69,869

In table 3 above we have the number of birthing facilities by the size of the village. In vil-

lages less that 500 people 92.7% do not have trained midwives, while in villages with over

10,000 only 14.1% do not have midwives. This suggests that still there are not enough mid-

wives to meet all needs. As a matter of fact, isolated rural areas are less likely to attract a

midwife. And, in small villages there are normally less than 6 births a year to attend, cer-

tainly not enough to maintain a practice, unless the midwife is a resident of that village. To

insure adequate coverage of delivery assistance in small villages, mobile midwife services

are needed, and incentives (such as reimbursement of travel costs and per diem) to initiate

midwives to travel periodically to the more remote and isolated areas.

If the government chooses to place health personnel in a remote and isolated area, they

have to provide some type of subsidy to help them maintaining their practice. If possible,

candidates from rural areas should be trained to increase the probability that they will stay in

post, once deployed to the rural facility. Moreover, career development needs should be

considered, and refresher courses offered; a wider scope of work opportunities may help

maintaining the professional spirit and involvement with the community.

Lessons Learned and Recommendations



Final Report

December 2008

5 Lessons Learned and Recommendations

Reflecting on the various lessons learned in the various field trips, the TA team has identified

six major issues that appear to be affecting utilization with the DHS supported health system.

The following chapter summarizes the team’s findings, discussions with health care provid-

ers, consumers, planners and mangers of the health care system.

Health centres are built on a standard plan, but their utilization varies greatly. The average

Health Centre sees about 25 outpatients a day (with a staff of 20-30), although there are a

few high performers seeing more than 200 patients per day. These health centers are usu-

ally located in urban, or on the edge of urban areas. The most highly utilized health facilities

are surrounded by vendors, transport for hire, and have patients waiting for services.

The DHS1 and DHS2 loans were designed under the premise that under-utilization of these

health centres was one of the major obstacles to improving the health status of the popula-

tion, and that giving them a fresh coat of paint, and some minor repairs along with some ad-

ditional equipment would increase the contact rate, and improve the health status. As a mat-

ter of fact, the utilization of outpatient and inpatient contacts did jump last year, but it was a

system wide increase, not limited to provinces with decentralization projects.

The TA tem identified seven crucial issues influencing health care utilization, which are:

1. One size does not fit all

2. Free health services do not insure high utilization

3. Attitude of health workers towards consumers has an impact and (financial and

non-financial) incentives for health staff are important

4. Quality services make a difference

5. New financial regulations every year make project implementation difficult

6. Community ownership determines utilization

5.1 One Size Does Not Fit All

Indonesia is going through an epidemiological transition with coronary vascular diseases,

and in some areas surprising infectious diseases, becoming a major burden. It is also going

through a demographic transition with a much older median age than 30 years ago, marked

by accelerating rates of urbanization. The population is becoming better educated, older,

consuming more, and is less isolated from world trends. Yet, despite decentralization, giving

the opportunity to districts to develop a health system based on the needs of their population,

most districts have generally continued to look to the center (Ministry of Health) for financial

support and direction for program development and expansion.




Final Report

December 2008

The vision and enthusiasm of the local government, and its ability to work with other units of

the government, and enlist the assistance of NGO’s and other social organizations to im-

prove health care delivery is one of the attributes to differentiate the district’s ability to mobi-

lize a strong community health program, well utilized by the consumers. Several of these

districts are in DHS1 and DHS2 project areas, but the PHP districts of the World Bank de-

centralization program has also produced several very good practice examples.

The future of health development in Indonesia depends on the capacity of the district health

office to meet the needs of the various consumer segments in their area, using resources

locally available. The contributions of the center e.g. through the construction of clinics and

hospitals and the supply of equipment, are probably of less importance, than the investments

in human resource development, and the development of local systems for managing impor-

tant health issues. If the system is improved and more community involvement generated,

than the system will be more responsive to the needs of that population.

In both DHS-1 and DHS-2 there were funds for operational research on local health issues.

DHS-1 appeared to utilize the funds in terms of situational analysis, however, there was very

little follow-up research done to look at the impact of various initiatives undertaken during the

loan periods. The importance of data and monitoring of program development needs to be

promoted with local governments in a way that will insure appropriate evaluation.

Subsidized programs need to be developed to support medical care in remote and isolated

populations, but the local government needs to take the initiative in coming up with ways to

get the local community to participate in and pay for many of these services, particularly for

services and products that are in high demand.

In urban areas there is a different demand for health services, and consumers’ needs should

be considered. Loosing market share of certain health services to nearby countries is also

not appropriate, and ways to capture these consumer segments with more cost-effective

high quality local service providers need to be developed.

For those services that are considered “Public Goods” by the government (Immunization,

MCH services, Primary Health Care), the programs need some support and direction from

the central government. But consumers, particularly in urban areas should help define the

nature of the health services, and programs in their area, and help develop health care as

part of the local economy. Health care has the capacity to contribute to the economic devel-

opment of Indonesia, not only as something that makes Indonesian healthier and economi-

cally more productive, but also as a contributor to the gross domestic product.




Final Report

December 2008

5.2 Free Health Services Do Not Insure High Utilization

There are a number of districts experimenting with free access to outpatient services, and

the country as a whole is dealing with the issue of free inpatient medical care for the poor.

This is an evolving process, and much adjustment will be needed before the goal of a sus-

tainable system of supporting the poor to get adequate health care is achieved.

Districts have had different results with their experiments. The TA team visited one district

where the remission of charges had no significant impact on health care utilization. Asking

the consumers the TA found out that most of the health centers did not offer the complete

range of services for which the family was looking for. This district has one of the lowest

outpatient utilization rates in Indonesia, although it does not have high levels of poverty.

To confirm this result of the analysis, the TA visited a health centre within an area of endemic

poverty. The TA found that outpatient services were usually well utilised by the population,

when all types of services were delivered, even though the population had to travel to get

there, and pay a registration fee to utilize the service.

In another district we asked to see the “worst” and the “best” health centre. The “worst” cen-

tre, although run down, was staffed, busy with treatment of locals, and active with many

community outreach activities. The “best” health center, with new facilities and new equip-

ment located in a market area, had seen only two patients that day, and the health center

staff did not show much initiative in community outreach, partly because they did not have

support for this kind of activity.

In the City of Batam, in the “Islands of Riau” Province, free health care has almost ruptured

the City’s annual budget because of increased demand, and has had a negative impact on

public health services, because of the high number of people requesting care.

Obviously, direct costs of health services are not the major obstacle to access. As long as

the population in the catchment area feels the health center is “theirs”, they utilize it quite

heavily. If it is viewed as belonging to the government, and the staff is not viewed as “mem-

bers of the community”, than the services of the health centre will be less utilized.

5.3 Attitude of Health Workers towards Consumers Has an Impact

While most health centre staff are helpful and respectful to the clients who seek care at the

clinic, there are other indicators that community members will take as a sign of how the

community health workers feel toward them.

If the health centre is closed and locked up by 11:00 AM, that is an indication that being

available for medical needs is not as important to the health worker than other activities that

they are involved in e.g. for family or financial reasons. If the health center staff only comes

one every three months to the posyandu (e.g. because of limited transportation allowance),




Final Report

December 2008

not only will the posyandu attendance go down, but the rural population will perceive it as a

sign that they are not important to the health workers. Health workers need incentives (in-

cluding institutional recognition) to perform at high standards.

However, though underpaid and operating for much of the year without adequate fi-

nancial support for community outreach, public health staff in Indonesia does a re-markable job in maintaining the health of the various communities.

During the TQM exercise in Central Sulawesi, health care provider sessions were held to

help them understand the relationship with clients, and how to encourage them by openness,

respect, and understanding. The transformation of government officials to civil servants

needs to be addressed and managed by the national government, e.g. through local gov-

ernment initiatives to work with communities to implement health policies and programs that

local villages want and that are in line with local, and national priorities.

One important domain of health sector reform is to make health workers more satisfied with

their jobs, this can be attained by better remuneration, and better management practices.

Local governments should be encouraged to experiment with new and innovative ap-

proaches to provide incentives to their staff.

5.4 Quality of Services make a Difference

One of the DHS loan goals was to improve the quality of health services through civil works

and the provision of new equipment. In some places, the local government contributed

funds, and completely rebuilt the health centre, making it larger, improving the quality of wait-

ing rooms and registration, and the layout of the building. Repainting and repair alone did

not seem to have much of an effect on utilization, truly improving the quality of facilities did, if

there was an associated attempt to improve the way in which services were delivered.

High quality services are less an issue of facility repair, than of concern and commitment to

the clients and the wellbeing of the patients. Moreover, health care workers need support

from local governments to meet the needs of their clients for both community and primary

health care services. The issue of ownership by the community is central, and the highest

quality services are provided by health care workers that are truly integrated into their com-

munities, regardless of the state of repair of their treatment center.

5.5 New Financial Regulations Every year Cause Difficulties

Decentralization has lead to new fund channelling mechanisms, and the establishment of

new provinces and districts has changed the boundaries of responsibility. One thing that has

consistently impacted on the implementation of the DHS projects is that development budg-

ets have been released late on every year, making it difficult to accomplish plans and pro-

curements in a timely fashion.




Final Report

December 2008

Not only are projects negatively impacted by this issue, but the implementation of activities

supported by local funds is also limited by this problem. In addition, new programs imple-

mented in a hurry (during the remainder of the year), are not implemented as well as if they

were done in a more systematic way from the very beginning of the financial year. Trying to

muddle through year after year makes solutions for immediate problems becoming more im-

portant than systematic health sector reform.

In addition to the delayed release of funds, the government has been changing regulations

concerning decentralization every year. One good example is the development of the KMK

35 regulation concerning cost sharing at the district level between loan and counterpart funds

(depending on the fiscal capacity) in the DHS-2. After a lot of efforts, the regulation was re-

scinded because it became “unworkable”, and fund allocation and management were again

centralized, despite the fact that provincial and district offices did a very good job in utilizing

their budgets: all provinces but three in DHS-2 exceeded 75% capital absorption, and dis-

tricts hit close to 70% capital absorption. However, the budget from the centre had been de-

layed, and only a small portion of the budget was utilized. It is uncertain, even after the loan

has been centralized, whether it will be able to achieve again the rates of capital absorption

reached in 2007 when the funds were executed primarily by the districts.

5.6 Community Ownership Determines Utilization

One of the over-riding factors in utilization is when the community sees the health program

as being theirs. This is the case in most of Bali, where the banjar system works with the

midwives and has village health committees. Similar effects were observed when exploring

various examples of early implementation of the Desa Siaga Program.

Community ownership is promoted by inspired leadership. The synergy between a strong

leader and a willing community is not something that can be easily developed, but takes con-

tinuous effort and work over time.

One district has experimented with community empowerment and community financing. In

Kolaka of Southeast Sulawesi, a program was developed that put nurses in villages to deal

with outpatient services and referrals as this area has a shortage of midwives and physi-

cians. The nurses receive some basic government financial support, equipment and drugs,

and then they receive “fees for services” for basic treatment. Some of the communities have

developed “risk pooling” mechanisms to pay the nurse a standard salary, and insure local

community members have 24 hour access to basic outpatient services. It turns out that this

resource pooling generates more revenues than expenses and has become a source of in-

come for the village.

Health services do have value, and particularly if people are paying for them, they feel a

sense of ownership. However entitlements for the poor could play an important role in im-

proving the medical care services in rural and poor areas of Indonesia.

Conclusions



Final Report

December 2008

6 Conclusions

6.1 General Conclusions

The major constraint to the development of well utilised health services within the Indonesian

Health Care System can not be found in a lack of commitment of the local or national Gov-

ernment. Far from it, the continuous efforts of the Government to implement a centrally de-

fined program based on the principle of health being a human right, rather than seeing health

care as an emerging market that is an element of the overall socio-economic development,

and that on its own turn contributes to the economic welfare of the community both by pro-

ducing healthier people and by generating jobs and secondary markets for health system

components and services, is an obstacle.

Health care needs to be delivered as a system, and the consumers, who already cover the

majority of health care expenditures in Indonesia, have the capacity to carry even a larger

part of the cost, particularly if the risk is pooled among the community members.

The issue of quality remains problematic throughout the health system, and limits the value

that consumers attach to this “commodity”. However, in some parts of the country such as

Bali, models of quality care are well accepted by the population and have reached high lev-

els of service provision to the community.

The major issue across the country is the lack of a sense of ownership by the local communi-

ties to the program promoted and developed. There are exceptions to this such as the Po-

syandu program, and the Family Planning Program of the “new order” government. These

programs were based on community participation and local ownership, but supervision, and

continuous quality improvement is needed in all these programs.

Decentralization offers an opportunity for district health programs to “take off”, in setting up

activities to accelerate the improvement of health status. A few districts under the dynamic

guidance of visionary leaders have made major improvements in their health system. Many

districts supported by ADB, the World Bank, and EU have pursued health sector reform

agendas in specific areas that they found important. As a result, the packages of services

available at health centres are remarkably similar across the country, but there is a shortage

of adequately trained health personnel throughout the country, but particularly in smaller

more remote districts.

6.2 Impact on Decentralisation and Health Sector Reform

Health Sector Reform continues to be an area of major concern in Indonesia. Decentraliza-

tion as a process is adapting to the variations in capacity that exist throughout the country.

While many districts have the capacity to use the potential of the decentralization laws to

Conclusions



Final Report

December 2008

develop new and more effective approaches towards health care, many still look to provincial

and national government for policy and strategy direction and financial support.

ADB has fielded two types of loans to support the social sector during social unrest, decen-

tralization and health sector reform in the last decade. The first was the social safety net

loans which were crucial in maintaining social services. It was during this period that DHS-1

was designed. The design of DHS-1 was based on lessons learned with the social safety

net, but did not anticipate all the changes that would come with decentralization, and it took a

while to develop bridging mechanisms that would allow the project to be implemented effec-

tively. DHS-2 was designed while DHS-1 was still figuring out how to make things work.

DHS-2 was more ambitious than DHS-1 in terms of health indicators to be improved, and the

number of managers involved within the system: Every district has an executive secretary,

and its own strategic plan. On top of this, the executive management changed every year

bringing in slightly different perceptions on what the loan should support.

The TA came at the time to be a catalyst in the performance of DHS-1, and has been a buff-

ering force between the national and the district governments during the inception of the

DHS-2 loan. With regard to the project’s substance, the TA’s important contribution for DHS-

1 was helping the project to focus on MNCH as directed by the Ministry of Health, followed

by various health reform initiatives in this specific area. As for the DHS-2, the TA helped

bringing back the project focus on MDG related issues as also emphasized in the MTR.

Another significant contribution of the TA to both DHS-1 and DHS-2 is promoting better use

of data for the planning at the central, provincial, and district level. Furthermore, TA visits to

districts, and especially to remote ones, helped the project being more responsive to local

needs and characteristics and more relevant to the local situation. It is also important to note

that the TA has played the role of bridging the projects reform to the national policy. A num-

ber of policy dialogues at the central Ministry of Health and BAPPENAS were the forums

where the TA helped transfer the project success into the policy reform.

While DHS-2 remains at risk because of the late release of funds, the district health offices

are moving ahead with plans for health sector reform and how to utilise the loan in 2009-

2010. It is hoped that the new MTR focus will help linking the districts, which are moving

forward, with the national office in a way that will encourage cooperation and support for

technically strong local initiatives.

6.3 Impact on Millennium Development Goals

District health offices need to face the next five year development period with a commitment

to insure that all districts in Indonesia meet the five health related Millennium Developments

Goals.

Conclusions



Final Report

December 2008

• MDG 1 on adequacy of dietary intake can be reached, but certain districts need to

be target for intense intervention.

• MDG-4 on child mortality is a reachable target, but the results of the 2007 demo-

graphic health survey suggest that little progress has been made over the last 5

years in achieving the goal.

• Achieving MDG-5 on maternal health will take an extra effort, particularly in DHS-

2 areas.

• MDG-6 on infectious diseases can be reached, but it will take extra effort, and

• MDG-7 on sanitation can also be reached, but many districts will have to work

very hard in order to achieve it.

The key to continued progress on the MDG’s is to work with the communities on how they

plan to achieve these goals. Strengthening the health component of village based develop-

ment programs hold great promise. These programs also have access to funds much larger

than available to the Ministry of Health. The TA suggests that DHS-2 experiment with ways

to increase community communication with District Health Offices, and that local communi-

ties be mobilized in community based development efforts to meet these goals.

6.4 Recommendations for Future TA

In order to determine whether the health sector reforms initiated under this loan are effective

and sustainable, more evaluation needs to be done. Future technical assistance should take

a more proactive approach towards program evaluation. Local governments, provincial gov-

ernments, and the national secretariat should work together to identify operations research

topics for implementation and review. This means that program evaluation, and information

management will be two areas that need additional technical support.

Annexes



Final Report

December 2008

7 Annexes

7.1 TA-3579-INO Logical Framework

Ann

exes

Supp

ort f

or H

ealth

Sec

tor P

olic

y R

efor

ms,

AD

B T

A 3

579-

INO

51

EPO

S H

ealth

C

onsu

ltant

s

Fina

l Rep

ort

Dec

embe

r 200

8

TA 3

579-

INO

LO

GIC

AL

FRA

MEW

OR

K

Nar

rativ

e Su

mm

ary

of

Proj

ect S

trat

egie

s Pe

rfor

man

ce T

arge

ts

(Ver

ifiab

le In

dica

tors

) M

onito

ring

Mec

hani

sms

(Sou

rces

of I

nfor

mat

ion)

A

ssum

ptio

ns

A. G

OA

L: T

A 3

579-

INO

sha

res

the

goa

ls o

f the

DH

S Pr

ojec

ts:

GO

AL

of D

HS-

1:

Im

prov

ed h

ealth

sta

tus

of th

e

p

opul

atio

n in

all

Proj

ect d

istr

icts

G

oal o

f DH

S-2:

Impr

oved

hea

lth s

tatu

s of

the

pop

ulat

ion,

esp

ecia

lly th

e po

or

a

nd v

ulne

rabl

e gr

oups

DH

S-1

Goa

l Tar

gets

: by

201

0, in

DH

S-1

proj

ect d

istri

cts:

•

Mat

erna

l mor

talit

y ra

tio (M

MR

)1 200

/ 10

0,00

0 liv

e bi

rths

or a

t lea

st 3

0% lo

wer

than

ben

chm

ark

data

•

Infa

nt m

orta

lity

rate

(IM

R)2 :

30 /

1000

live

birt

hs, o

r at

leas

t 30%

low

er th

an lo

cal b

ench

mar

k da

ta

• U

nder

-5 m

orta

lity

rate

(U5M

R)3 :

40 /

1000

chi

ldre

n un

der 5

yea

rs, o

r at l

east

30%

low

er th

an lo

cal

benc

hmar

k da

ta

• Li

fe e

xpec

tanc

y at

birt

h (L

EB)

4 : 70

yea

rs, o

r at l

east

2

year

s m

ore

than

loca

l ben

chm

ark

D

HS-

2 G

oal T

arge

ts:

by 2

010

in th

e pr

ojec

t are

a:

• M

DG

: red

uce

child

mal

nut.

from

34%

(199

5) to

22%

•

MD

G: r

educ

e U

5MR

from

51

(200

0) to

35/

1000

birt

hs

• M

DG

: red

uce

IMR

from

41

(200

0) to

25

live

birth

s •

MD

G: r

educ

e M

MR

from

470

(199

5) to

175

/100

,000

•

LEB

incr

ease

d >2

yea

rs fr

om lo

cal b

ench

mar

k da

ta.

DH

S-1

Goa

l Mon

itorin

g M

echs

: •

Ann

ual d

istri

ct h

ealth

pro

files

•

Uni

ted

Nat

ions

Chi

ldre

n’s

Fund

(U

NIC

EF)

and

Wor

ld H

ealth

O

rgan

izat

ion

(WH

O) d

ata

or

estim

ates

D

HS-

2 G

oal M

onito

ring

Mec

hs:

• B

PS a

nd S

US

ENS

dat

a •

BKK

BN d

ata

• U

NIC

EF a

nd W

HO

dat

a •

Dem

ogra

phic

& H

ealth

Sur

veys

•

Pov

erty

line

indi

cato

rs fr

om

SM

ERU

, SU

SEN

AS, W

orld

Ban

k,

and

BKK

BN.

DH

S-1

Goa

l Ass

umpt

ions

: •

Pol

itica

l sta

bilit

y in

DH

S-1

proj

ect

area

•

Con

tinue

d ec

onom

ic re

cove

ry

DH

S-2

Goa

l Ass

umpt

ions

:

[Non

e lis

ted]

B.

PUR

POSE

of T

A 3

579-

INO

1.

Ass

ist M

OH

and

sel

ecte

d lo

cal

g

over

nmen

ts id

entif

y, im

plem

ent

a

nd e

valu

ate

heal

th s

ecto

r ref

orm

s

i

n th

e co

ntex

t of d

ecen

tralis

atio

n.

2. S

uppo

rt D

HS

in m

eetin

g its

pur

pose

s:

a)

impr

oved

hea

lth a

nd fa

mily

pl

anni

ng s

ervi

ces

in p

roje

ct a

reas

b)

gu

aran

teed

acc

ess

of p

oor t

o es

sent

ial h

ealth

and

fam

ily

plan

ning

ser

vice

s

TA 3

579-

INO

Per

form

ance

Tar

gets

: •

Com

preh

ensi

ve lo

cal h

ealth

sec

tor d

evel

opm

ent

plan

s de

velo

ped

and

in u

se in

all

Proj

ect d

istri

cts

• In

crea

sed

publ

ic e

xpen

ditu

re b

udge

ted

for h

ealth

in

all P

roje

ct d

istri

cts

• Lo

cal h

ealth

soc

ial s

afet

y ne

t pro

gram

s fu

nctio

ning

in

all d

istri

cts

• Ti

mel

y pr

ovis

ion

of te

chni

cal a

ssis

tanc

e to

impr

ove

DH

S P

roje

ct im

plem

enta

tion

at C

ente

r, pr

ovin

ces,

an

d di

stric

ts

TA 3

579-

INO

Mon

itorin

g M

echs

: •

Per

iodi

c re

ports

of T

A t

eam

m

embe

rs a

nd D

HS-

1 st

aff

• D

HS

eva

luat

ion

of b

udge

ts a

nd

expe

nditu

res

of s

elec

ted

site

s •

Loca

l gov

ernm

ent b

udge

t rev

iew

an

d as

sess

men

t by

expe

rts

• D

HS

mon

itorin

g m

echa

nism

s

TA

357

9-IN

O A

ssum

ptio

ns:

• D

efin

ition

of h

ealth

sec

tor

deve

lopm

ent p

lans

unc

hang

ed

• N

o un

expe

cted

cris

is in

oth

er

sect

ors

limiti

ng b

udge

t ava

ilabl

e •

No

maj

or in

fluxe

s of

poo

r int

o pr

ojec

t dis

trict

s •

No

maj

or u

nres

t in

Proj

ect a

reas

•

DH

S as

sum

ptio

ns a

re m

et

1 N

umbe

r of m

ater

nal d

eath

s per

100

,000

live

birt

hs.

Nat

iona

l MM

R is

est

imat

ed b

etw

een

390

and

450

(199

9).

2 Num

ber o

f dea

ths o

f chi

ldre

n be

twee

n 0

and

1 ye

ar o

f age

per

1,0

00 li

ve b

irths

. N

atio

nal I

MR

is e

stim

ated

at 4

0 (1

999)

. 3 N

umbe

r of d

eath

s of c

hild

ren

less

than

5 y

ears

old

per

1.0

00 li

ve b

irths

. N

atio

nal U

5MR

is e

stim

ated

at 5

6 (1

998)

. 4 N

atio

nal L

EB is

est

imat

ed a

t 68

year

s (19

99).

Ann

exes

Supp

ort f

or H

ealth

Sec

tor P

olic

y R

efor

ms,

AD

B T

A 3

579-

INO

52

EPO

S H

ealth

C

onsu

ltant

s

Fina

l Rep

ort

Dec

embe

r 200

8

Nar

rativ

e Su

mm

ary

of

Proj

ect S

trat

egie

s Pe

rfor

man

ce T

arge

ts

(Ver

ifiab

le In

dica

tors

) M

onito

ring

Mec

hani

sms

(Sou

rces

of I

nfor

mat

ion)

A

ssum

ptio

ns

C.

TA 3

579-

INO

OU

TPU

TS:

1. H

ealth

sec

tor r

efor

m (H

RS

) at

d

ecen

tralis

ed le

vels

2.

Hum

an c

apac

ity fo

r hea

lth s

yste

ms

man

agem

ent &

del

iver

y 3.

Hea

lth p

lans

bas

ed o

n ac

tual

cos

ts

4. D

ecis

ion

mak

er u

nder

stan

ding

of

p

ublic

hea

lth p

riorit

ies

5. O

pera

tiona

l res

earc

h ca

paci

ty

6. P

roje

ct m

anag

emen

t

• H

SR

iden

tifie

d in

100

% o

f Pro

ject

dis

trict

s

• H

SR

gui

delin

es d

evel

oped

and

dis

sem

inat

ed

• Te

n pe

rcen

t inc

reas

e pe

r yea

r in

achi

evem

ent o

f m

inim

um s

ervi

ce s

tand

ards

in D

HS

dis

trict

s •

Hea

lth s

ervi

ces

unit

cost

s de

term

ined

in a

t lea

st o

ne

dist

rict o

f eve

ry P

roje

ct p

rovi

nce

• P

ropo

rtion

of l

ocal

pub

lic h

ealth

bud

gets

allo

cate

d to

pr

even

tion/

prom

otio

n/ba

sic

serv

ices

up

by >

20%

•

Mor

e th

an 8

0% o

f ope

ratio

nal r

esea

rch

carr

ied

out

judg

ed re

leva

nt to

"ope

ratio

n" o

f hea

lth s

ervi

ces

• TA

ser

vice

s ac

cess

ible

to a

ll D

HS

dist

ricts

• Ex

perts

’ ass

essm

ents

of t

he

need

and

qua

lity

of lo

cal

refo

rms

•

Perfo

rman

ce m

onito

ring

syst

em; f

ield

vis

its

• R

epor

ts a

nd e

xper

t as

sess

men

ts

• R

evie

w o

f dis

trict

bud

gets

•

Expe

rts’ a

sses

smen

t of t

he

need

and

qua

lity

of O

R

impl

emen

ted

• Ye

arly

and

6-m

o TA

repo

rts

• C

omm

itmen

t of p

erso

nnel

at a

ll le

vels

to re

view

and

refo

rm

• Fl

exib

le n

atio

nal r

egul

atio

ns

• P

erso

nnel

dep

loym

ent s

yste

m

stab

ilised

•

Loca

l gov

ernm

ents

’ com

mitm

ent t

o th

e he

alth

sec

tor

• A

cces

s to

pro

ject

are

as is

not

co

mpr

omis

ed b

y se

curit

y pr

oble

ms

D. T

A 3

579-

INO

AC

TIVI

TIES

1.

Rev

iew

and

mon

itor s

tatu

s an

d ch

ange

s in

the

follo

win

g ar

eas:

a)

H

ealth

Sec

tor R

efor

m to

impr

ove

acce

ss to

and

qua

lity

of h

ealth

se

rvic

es fr

om p

ublic

and

priv

ate

sour

ces;

b)

Pr

otec

tion

of th

e he

alth

of t

he p

oor

and

mos

t vul

nera

ble;

c)

H

uman

and

non

-hum

an h

ealth

re

sour

ces;

d)

O

pera

tions

rese

arch

in h

ealth

se

rvic

es;

e)

Man

agem

ent c

omm

unic

atio

ns

incl

udin

g he

alth

info

rmat

ion

syst

ems,

mon

itorin

g;

f) C

omm

unic

atio

ns fo

r lia

ison

and

ad

voca

cy;

g)

Eval

uatio

n 2.

Ass

ist t

he h

ealth

sec

tor t

o id

entif

y op

portu

nitie

s fo

r ref

orm

at s

ervi

ce

deliv

ery,

dis

trict

, pro

vinc

e, a

nd c

entra

l le

vels

. 3.

Ass

ist h

ealth

sec

tor p

erso

nnel

to

deve

lop,

test

, im

plem

ent,

and

eval

uate

A

ssis

tanc

e pr

ovid

ed to

revi

ew a

nd im

prov

e he

alth

se

ctor

pol

icie

s / p

ract

ices

at a

ll le

vels

;

Cle

arer

und

erst

andi

ng o

f nat

iona

l hea

lth s

ecto

r pol

icy

at

perip

hera

l lev

els;

Impr

oved

und

erst

andi

ng o

f loc

al h

ealth

sta

tus

and

heal

th s

ervi

ces

trend

s;

K

ey a

reas

of h

ealth

ser

vice

s re

form

sch

emes

eva

luat

ed

in a

t lea

st o

ne a

rea:

a)

lo

cal h

ealth

insu

ranc

e sc

hem

es,

b)

stra

tegi

c re

sour

ces

allo

catio

n,

c)

heal

th fi

nanc

ing

advo

cacy

d)

pe

rform

ance

-bas

ed p

aym

ents

, e)

he

alth

car

e ef

ficie

ncy,

f)

drug

s us

e m

anag

emen

t, g)

w

orkf

orce

man

agem

ent,

h)

loca

l hea

lth in

form

atio

n sy

stem

s,

i) he

alth

car

e qu

ality

impr

ovem

ent,

j) op

erat

iona

l res

earc

h st

udie

s,

k)

orga

niza

tiona

l cul

ture

sup

porti

ng re

form

, l)

man

agem

ent o

f cap

ital a

sset

s,

m)

man

agem

ent o

f sup

plie

s,

n)

cons

umer

par

ticip

atio

n,

o)

publ

ic-p

rivat

e pa

rtner

ship

s.

M

etho

ds in

pla

ce a

t all

leve

ls to

mon

itor a

cces

s to

he

alth

ser

vice

s;

P

artn

ersh

ip w

ith p

rivat

e se

ctor

incr

easi

ng;

M

OH

/BK

KBN

par

tner

ship

impr

ovin

g;

Si

x-m

onth

sum

mar

ies

and

repo

rts o

f the

TA

team

Trip

repo

rt of

team

mem

bers

Tech

nica

l rev

iew

s as

requ

este

d by

cou

nter

parts

Topi

cal t

echn

ical

pap

ers

prod

uced

and

dis

sem

inat

ed

rela

ting

to h

ealth

ser

vice

s re

form

that

con

tribu

te

info

rmat

ion

from

els

ewhe

re in

In

done

sia

and

the

wor

ld

Pl

ans,

met

hodo

logy

, fin

ding

s,

and

criti

cal r

evie

w o

f ope

ratio

nal

rese

arch

und

erta

ken.

Lo

cal h

ealth

sec

tor p

erso

nnel

and

de

cisi

on m

aker

s ar

e w

illin

g to

sha

re

plan

ning

and

dev

elop

men

t with

pr

ofes

sion

als

incl

udin

g TA

from

ou

tsid

e th

e lo

cal a

rea

Le

sson

s le

arne

d an

d ex

perie

nce

else

whe

re m

ay b

e re

leva

nt to

the

proj

ect a

reas

Ade

quat

e co

mpl

emen

tary

fina

ncia

l re

sour

ces

will

be p

rovi

ded

by D

HS

an

d G

OI c

ount

erpa

rt fu

ndin

g.

E

ffect

ive

com

mun

icat

ions

in

Indo

nesi

an.

Ann

exes

Supp

ort f

or H

ealth

Sec

tor P

olic

y R

efor

ms,

AD

B T

A 3

579-

INO

53

EPO

S H

ealth

C

onsu

ltant

s

Fina

l Rep

ort

Dec

embe

r 200

8

de

velo

p, te

st, i

mpl

emen

t, an

d ev

alua

te

refo

rms,

par

ticul

arly

at d

istri

ct a

nd

serv

ice

deliv

ery

leve

ls.

4. D

evel

op g

uide

lines

, tra

inin

g m

ater

ials

, an

d st

rate

gies

for d

esig

ning

, im

plem

entin

g, a

nd e

valu

atin

g re

form

s.

5. A

ssis

t in

the

eval

uatio

n,

docu

men

tatio

n, a

nd s

harin

g of

less

ons

lear

nt.

6. D

esig

n an

d co

ntra

ct o

pera

tions

re

sear

ch re

leva

nt to

nee

d of

hea

lth

sect

or re

form

pp

pg;

C

olla

bora

tion

with

oth

er s

ocia

l sec

tors

incr

easi

ng in

all

prov

ince

s an

d di

stric

ts;

M

etho

ds to

mon

itor h

ealth

ser

vice

s qu

ality

in p

lace

for

use

by a

ll pr

ovin

ces,

dis

trict

s, c

ities

;

Acc

ess

to h

ealth

ser

vice

s by

poo

r and

mos

t vul

nera

ble

impl

emen

ted

in a

ll di

stric

ts/c

ities

;

Opt

ions

for r

efor

m id

entif

ied

and

appr

aise

d in

co

nsul

tatio

n w

ith a

ll st

akeh

olde

rs;

Le

sson

s do

cum

ente

d an

d di

ssem

inat

ed w

ithin

pro

ject

ar

eas

and

mor

e br

oadl

y;

In

crea

sed

oppo

rtuni

ties

for c

omm

unity

par

ticip

atio

n w

ithin

all

dist

ricts

and

pro

vinc

es;

O

pera

tions

rese

arch

for h

ealth

ser

vice

s re

form

de

sign

ed, i

mpl

emen

ted,

ana

lyze

d.

Annexes



Final Report

December 2008

7.2 Field Visits

Table 3 - 6 summarize the field visits carried out by the TA consultants during the period Au-

gust 2004 through September 2007.

Table 3 - Field Visits by TA Team Members, 2004, Inception Phase

When Province Who Purpose Nr of Visits

August

9 – 11 Bengkulu JD Learning current condition of health sector in Bengkulu and meeting with PHO 1

11 – 13 Pekanbaru (Riau) JD, JS Province Visit ; Meeting with PHO and stake holder 2

18 – 20

South east Su-lawesi (Kendari) JS Meeting with PHO and stake holder of Southeas Su-

lawesi 1

18 – 20

Manado (North Sulawes DH Meeting with PHO and stake holders 1

23 – 24 Denpasar (Bali) JD, DH Visit Puskesmas model and Pustu 2

October

4 – 6 Pekanbaru (Riau) JS, NN Riau Province Visit to find current conditions, status plan and progress of Health sector Reform in the area. 2

7 – 8 Batam JS, NN Kepulauan Riau Province Visit to find current condition of the area. 2

25 – 27

Puncak (Jawa Barat)

JS, NN, DH Seminar on OR program and HSR Implementation 4

November

2 – 3 Pekanbaru DK, NN Riau Province Visit 2

9 – 10 Banda Aceh NN Banda Aceh Province Visit 1

16 – 19

Southeast Su-lawesi (Kendari) NN Visit South East Sulawesi 1

21 – 24 Denpasar (Bali) JS, NN,

DK TA meeting on IR revision 3

27 – 30

Palu (Central Su-lawesi) NN Visit Central Sulawesi 1

December

1 – 4 Pekanbaru (Riau) NN Attend seminar on HSR implementation, develop of OR proposal and Unit cost for Puskesmas 1

9 – 10 Banda Aceh NN Banda Aceh Province Visit 1

16 – 17

Southeast Su-lawesi (Kendari) NN Field Visit in Puskesmas and PHO 1

27 – 29

Palu (Central Su-lawesi) NN Visit Central Sulawesi 1

Total 2004: 27

Annexes



Final Report

December 2008

Table 4 - Field Visits by TA Team Members, 2005

When Province Who Purpose Supervision Advo-cacy

Plan-ning

ADB mission

February

13 – 17 Banda Aceh RT Visit Banda Aceh Tsunami disaster 1

March

13 – 16 Pekanbaru (Riau) RT,

NN Field Visit 2

25 – 27 Jogyakarta RT Meeting at UGM 1

April

10 – 12

Southeast Su-lawesi (Kendari)

RT, NN

Field Visit to Kendari and Kolaka District 2

13 – 16

Manado (North Sulawesi)

RT, NN

Field Visit to Manado and Bitung City 2

27 – 29 Denpasar (Bali) JD, JS

Field Visit to with P. Fedon (ADB) to Tabanan District Hospital, Indera Hospital, Puskesmas Den-pasar Barat 3, Puskesmas Mengui

3

26 – 29

Banda Aceh (NAD)

RT, NN Field Visit 2

May

18 – 22 Denpasar (Bali) RT, JS Field Visit to Tabanan District,

Klungkung, Bangli 2

26 – 28 Bengkulu RT,

NN Field Visit to Bengkulu Selatan, Suka Makmur District, and Beng-kulu City

2

June

2 – 4 Cisarua (West Java) All Workshop Preparation to Increase

Health Effort DHS (ADB)

11 – 12

Southeast Su-lawesi (Kendari) NN Field visit with Karima Saleh

22 – 24

Cisarua (West Java) All Lokakarya Evaluasi pelaksanaan

HSR

4 4 1

July

25 – 27

Cipayung (West Java) All Workshop Finalizing Proposal for

Loan Extension 4

August

1 – 5 Palu (Central Sulawesi) All Field Visit with EPOS (M. Niech-

zial) 4

22 – 25

Palu (Central Sulawesi)

RT, NN Field Visit To Palu 2

September

Annexes



Final Report

December 2008


Plan-ning

ADB mission

4 – 6 Bandung (West Java)

RT, NN, AG, JS

Workshop on Socialization, Pres-entation material for Socialization, Prepare time schedule for visit

4

8 -10 Palu (Central Sulawesi)

RT, NN 2

8 -9 Manado (North Sulawesi)

AG, JS 2

12 – 14


RT, NN 2

13 – 14 Pekanbaru (Riau) AG,

JS 2

18 – 19 Bengkulu

RT, NN, AG

3

21 – 23 Denpasar (Bali) NN,

JS 2

22 – 23

Banda Aceh (NAD)

RT, AG

Field Visit (Socialization Grand Design to Provinces)

2

24 – 26 Sanur (Bali) All TA strategic Retreat to review TOR 4

29 – 30

Cisarua (West Java)

RT, NN, AG

Grand Design Finalization Plan-ning 2006 3

October

1 Cisarua (West Java) All Review Meeting plan 2006 by

provinces 4

17 – 19

Cisarua (West Java) All Workshop sharing experiences

DHS-1 4

November

23 – 25

Palu (Central Sulawesi) NN Seminar on exit strategy 1

15 – 16

Manado (North Sulawesi) AG Analysis health North Sulawesi

(Province & District) 1

29 – 30

Bengkulu (Beng-kulu) NN Workshop on DTPS 1

December

2 – 3 Cisarua (West Java) All Workshop on project achievement

review & planning for year 2006 4

7 – 10 Manado (North Sulawesi), Palu (Central Sulawesi)

AG Advocacy to Province DHS-1 2

8 – 9 West Sulawesi (Mamuju) NN

Visit West Sulawesi for DHS2, district Polewali and District Ma-jene

1

Annexes



Final Report

December 2008


Plan-ning

ADB mission

9 – 11 Palu (Central Sulawesi)

RT, AG Advocacy to Province DHS-1 2

11 – 12

Bengkulu (Beng-kulu) NN District Training for Health Plan-

ning 1

17 Makassar (Ujung Pandang) NN

Meeting Advocation & Socialization of Project DHS-2 in South Su-lawesi

2

18 – 19 Bali (Denpasar) AG Advocacy 1

20 – 21

Banda Aceh (NAD) AG TA for NAD strategic planning 1

TOTAL 2005: 87 13 27 36 11


When Province Who Purpose Supervision Advo-cacy Planning ADB

mission

January

19 – 20

Riau (Pekan Baru) RT Strategic planning to district 1

21 – 23

Kepulauan Riau (Batam) RT Strategic planning to district 1

23 – 24

Banda Aceh (NAD) AG TA for strategic planning review

(NAD) 1

22 – 24

Kendari (South-east Sulawesi) NN Workshop on District proposals 1

26 – 28

Cisarua (West Java) All District strategic plan evaluation 4

February

Manado (North Sulawesi) NN Field Visit to Bolaang Man-

gando District,

8 – 10 Gorontalo (Goron-talo) RT

Visit PHO & DHO, meeting Bappeda (Regional Develop-ment Board) & Governor of Gorontalo

2

18 – 22

Banda Aceh (NAD) NN

Visit provincial hospital, PHO, and health centres, pustu & polindes; meeting with ADB Mission (K. Saleh);

2

March

16 – 18

Riau (Pekan Baru)

NN JS

Workshop on Strategic plan-ning, Riau 2

20 – 22

Cisarua (West Java) All Evaluation of strategic plan 4

27 – 29

Bengkulu (Beng-kulu) NN Workshop on strategic plan-

ning, Bengkulu 1

Annexes



Final Report

December 2008


mission

April

12 – 14

Cisarua, West Java

RT, AG, NN, JS

HSR workshop, report presen-tation on HSR Guideline DHS-1 4

25 – 28 Bali (Denpasar) RT Socialization 1

May

1 Bali (Buleleng District) JS, AG District plans review 2

08 – 11

South Sulawesi (Makassar) NN Review Strategic Planning 1

10 – 11 Aceh AG Assisting strategic planning 1

15 – 16

Central Sulawesi (Palu) AG Advocacy 1

16 Riau (Pekanbaru) NN Strat.plan workshop 1

17 – 19

Kepri (Tanjung Pinang)

RT, NN Strat.plan workshop 2

29 – 31


RT, NN Strat.plan workshop 2

June

05 – 08

West Java (Bandung)

RT, NN, AG

National meeting on decentrali-zation 3

19 South Sulawesi (Makassar)

NN, RT, RW

Field visit ADB mission & DHS-2 3

15 – 17

West Nusa Teng-gara (Mataram) All

Meeting coordination develop-ment health plan 2007 for DHS-2

5

23 – 24 West Sulawesi NN Filed visit to Polewali and Ma-

jene 1

23 – 24

North Sulawesi (Manado, To-mohon)

RT Socialization data Susenas maternal & neonatal death rate 1

July

03 – 05 Bali (Denpasar) JS WHO meeting, edit issue paper,

& review Bali districts plan 1

04 – 05

Bengkulu (Beng-kulu)

AG, NN

MNCH planning seminar, advo-cacy & strategic planning 2

06 – 08

West Nusa Teng-gara (Mataram) All

Discussion DHS-2 future pro-grams, training technical review team NTB-NTT with ADB mis-sion (K. Saleh)

3

11 – 13 Riau (Pekanbaru) RT,

NN Strategic plan province DHS-1 2

Annexes



Final Report

December 2008


mission

11 – 15 Bali (Denpasar) JS Review Bali strategic Plan 1

21 – 24

Southeast Su-lawesi (Kendari) NN Meeting ES Southeast Su-

lawesi & Head of Dinkes 1

26 – 28

Kepulauan Riau (Natuna)

RT, RW Final review strategic plan 2

26 – 28

South Sulawesi (Makassar) NN Review strategic plan South-

east & Central Sulawesi 1

21 – 24

Southeast Su-lawesi (Kendari) NN

Collect material strategic plan all districts & HSR Kolaka dis-trict

2

August

02 – 04

West Java (Cisa-rua) All

Planning workshop DHS-1 with all provinces, technical review 2007

4

08 – 09

South Sulawesi (Makassar) NN Seminar at Wahidin Hospital 1

10 West Java (Cisa-rua) All 3 yrs planning 4

15 – 16

West Nusa Teng-gara (Mataram) RT Evaluation project DHS-2 1

22 – 25

West Java (Cisa-rua) AG Revise IHPB module 2

23 South Sulawesi (Makassar) NN Meeting with DHS-2 staff 1

22 – 26

Central Sulawesi (Palu)

RT, RW

Visit Dinkes Poso District & puskesmas, visit puskesmas Ampana Tete

2

29 Bali (Denpasar) AG Advocacy 1

30.-1.9. Jogjakarta (DIY)

RT, AG, NN, RW

Annual Opr. Budget DHS-2, Exit Strategy Workshop 4

September

09 – 14

Southeast Su-lawesi (Kendari) NN Advocacy at Konawe District,

Kendari City, & Kolaka District 3

10 – 12

Bali (Nusa Penida)

RT, RW

Evaluation Poned & Ponek at Nusa Penida District 2

13 – 15 Bali (Denpasar)

RT, AG, RW

Workshop monitoring & evalua-tion DHS-1, DIP (part of Annual Opr. Budget) DHS-2

3

17 – 21

North Sumatera (Medan)

NN, RW Training DTPS for NAD 2

18 – 19

East Java (Sura-baya) RT Workshop Synchronizing DHS-

2 Activities 1

Annexes



Final Report

December 2008


mission

18 – 19

Southeast Su-lawesi (Kendari) AG Advocacy MNCH 1

20 – 22

East Java (Sura-baya)

RT, NN

Workshop Synchronizing DHS-2 Activities 2

21 - 22

South Sumatera (Palembang)

RM, RW Planning workshop DHS-2 1

21 – 22 Kepulauan Riau AG Strategic planning & advocacy 1

October

2 – 4 South East Su-lawesi (Kendari) RW Socialization DTPS 1

5 – 6 West Java (Bandung)

RW, NN, RT

BKKBN West Regional Work-shop on Family Planning 3

9 – 11 North Sulawesi (Manado)

RT, NN, RW, AG

Workshop on exit strategy DHS1 4

12 South Kalimantan (Banjarmasin) AG DHS2 Planning Meeting 1

12 – 13

West Nusa Teng-gara (Mataram)

NN, RT

BKKBN East Regional Work-shop on Family Planning 2

12 – 14

South Sumatera (Palembang) RW Strategic Planning 1

18 – 19

West Java (Bandung)

RW, RT, AG

Meeting MNCH advocacy 3

30 – 1.11.

South Sulawesi (Makassar) NN DHS2 District Officer Training 1

November

6 – 7 West Nusa Teng-gara (Mataram) RT 1

7 – 8 West Nusa Teng-gara (Mataram) RW

MNCH Assessment at remote area

1

7 – 9 West Nusa Teng-gara (Mataram) NN Strategic planning to district 1

8 – 10 North Nusa Tenggara (Ku-pang)

RT, AG

Workshop arrange proposal & Master Plan 2007-2010 Project DHS2

2

9 – 12 Bengkulu (Beng-kulu) RW Training for based line study 1

13 South Sulawesi (Selayar)

NN, RT

Workshop on DHS2 District Planning 2

14 South Sulawesi (Selayar) NN Visit Health Center and Sub

Health Center

Annexes



Final Report

December 2008


mission

15 South Sulawesi (Pare-pare)

NN, RT

Workshop on preparation dis-trict health system 2

17 – 18

Central Sulawesi (Palu) NN Research proposal of DHS1

local program 1

19 – 20

South East Su-lawesi (Kendari)

NN, RW, RT

Advocacy Grand Design & Socialization DTPS in South Konawe District

3

21 – 22

South East Su-lawesi (Raha)

NN, RW, RT

Advocacy Grand Design & Socialization DTPS in Muna District

3

23 – 24

South East Su-lawesi (Bau-bau)

NN, RW, RT

Advocacy Grand Design & Socialization DTPS in Bau-bau City

3

28 – 29

South Sulawesi (Ujung Pandang) RT Visit to Bappeda (Local Plan-

ning & Development Agency) 1

27 – 30

Kepulauan Riau (Batam)

NN RW

Workshop on DTPS action plan 3

30 – 1.12.

Banjarmasin (South Kaliman-tan)

RT Workshop arrange proposal & master plan 2007-2010 project DHS2

1

December

1 West Java (Bo-gor) AG MNCH advocacy DHS1 1

5 – 7 Kepulauan Riau (Batam) AG Integrated Health Planning and

Budgeting (IHPB) Training 1

8 – 9 West Java (Bandung)

RW, RT, NN

Workshop on Lesson Learned & Shared Experience 3

11 – 13

West Java (Bo-gor)

AG, RT HSR TOT 1

13 – 14

West Java (Bo-gor) NN Meeting finalization master plan

DHS2 1

19 East Java (Sura-baya) RW MNCH Guideline clinics 1

20 West Java (Bo-gor) RT Meeting TRT work plan DHS2 1

18 – 20 Bali (Denpasar) NN WHO SEARO Meeting for ADB 1

20 - 23

Kepulauan Riau (Tanjung Pinang) RW Socialization for District Team

Problem Solving (DTPS) 1

26 – 27

South Sulawesi (Jeneponto) NN Visit for advocacy DHS2 1

Total 2006:151 18 36 89 8

Annexes



Final Report

December 2008


When Province Who Purpose Supervi-sion

Advo-cacy Planning

January

7 – 8 Central Kaliman-tan (Palangkaraya)

RT, NN, RW

Meet with Head Health Office, Field Visit Poned & Ponek District Project DHS2

2

9 – 11 Central Kaliman-tan (Kasongan District)

RT, NN Visit Kasongan District & Tumbang Habangoi Village 2

15 – 16 East Java (Sura-baya) RW Preparation for workshop comple-

tion of MNCH guideline 1

DHS1 workshop Monev Analysis RT, NN

DHS1 planning activities 2007 2

16 – 21 Bali (Denpasar)

All TA Meeting for book writing

26 – 27 East Java (Sura-baya) RW Preparation workshop for IPHB

Improvement 1

February

8 Bali (Denpasar) RT Socialization DHS-1 1

Visit Riau Province

Visit Siak District 13 – 15 Riau (Pekanbaru) RT, NN, RW

Partnership TBA with midwives

3

21 – 24 South East Su-lawesi (Kendari) RT, NN

Visit villages with Bakesra (com-munity health hall) in Kolaka Dis-trict

2

25 – 27 West Nusa Teng-gara (Mataram) RT, AG

Workshop IHPB improvement of the district health system in East Nusa Tenggara & West Nusa Tenggara

2

26 – 27 South Sulawesi (Ujung Pandang)

RW, NN

Workshop monev management DHS 2

March

12 – 15 Central Sulawesi (Palu) RT, NN Work on Palu Total Quality Man-

agement (TQM )chapter 2

21 – 22 Bali (Denpasar) RT, AG Socialization DHS1 & visit to Jim-brana District 2

27 – 28 West Java (Bogor) All Compiling work plan TRT DHS1 4

28 – 29 South East Su-lawesi (Kendari) NN Socialization DHS1 1

April

2 – 4 Bandung (Jawa Barat) RT, NN Workshop DHS2 on Program Co-

ordination 2

2 – 6 North Sumatera (Medan)

RW, AG Workshop DTPS 1

Annexes



Final Report

December 2008


Advo-cacy Planning

10 Banda Aceh (NAD) NN Socialization DHS1

17 Bogor (West Java) RT, NN, RW

Present at workshop on advocacy for mother & child with HSP (USAID)

3

18 – 21 Ujung Pandang (South Sulawesi) RT, NN Visit Mamuju District and working

on master plan West Sulawesi 2

24 – 26 Bandung (West Java)

RT, NN, AG

Workshop Analysis monev & per-siapan project completion report (PCR) & Benefit Monitoring Evaluation (BME) & Field visit SUbang District

3

May

8 – 11 Batam (Kepri) RT, AG Workshop exit strategy DHS1 2

22 – 24 Surabaya (East Java)

NN, AG

Meeting Work Plan Years Project DHS1 2

June

4 – 8 Palu (Central Su-lawesi) RT, NN

Participate in DTPS for maternal health, develop annual MNCH work-plan

2

7 - 10 Bandung (West Java)

RT, NN, AG

Demand Creation Technical sup-port for DHS-1, and prepartion for mission

3

19 – 20 Bengkulu (Beng-kulu) RT, NN DTPS, DHS impact survey, 3

July

3 – 6 Polewali Mandar (West Sulawesi) RT, NN Visit Polewali District : two Pusk-

esmas at two Subdistricts 3

08 – 09 Gorontalo (Goron-talo) RT, NN Field visit Bone Bolango district &

Boalemo district

12 – 13 Kendari (South East Sulawesi) NN Visit Kolaka District

16 – 18 Medan (North Sumatera) AG Field visit on District & infrastruc-

ture with all heads of Kepri district

17 – 20 Pekanbaru (Riau) RT, NN Strategic Plan and Proposal De-velopment 2

27– 28 Bitung City (North Sulawesi) RT, NN Visit Bitung city of North Sulawesi

August

5 – 11 Bali (Denpasar) RT, NN, AG

International Health Sector Reform Meeting 3

20 Sekayu (South Sumatera) RT, NN Visit Banyuasin and Musi Banyua-

sin District

21 – 24 Palembang (South Sumatera) RT, NN Visit DHS-2 program at Palem-

bang City 3

Annexes



Final Report

December 2008


Advo-cacy Planning

30 Bengkulu (Beng-kulu) AG MNCH Advocacy

September

3 – 4 Kota Baru (South Kalimantan) All Visit 2 puskesmas in Kota Baru

District and meeting with Bupati

5 Kota Baru (South Kalimantan) RT, NN

Visit pustu (assisted puskesmas) in isolated area (Tanjung Lalah District in Lontar Island)

7 – 9 Gorontalo (Goron-talo) NN Visit Boalemo District

27 Mataram (West Nusa Tenggara) RT, NN Visit Desa Siaga in West Lombok

28 Karang Anyar (Central Java)

RT, NN, AG

Visit Desa Siaga in Karang Anyar

October

8 Makassar, South Sulawesi NN Visit DHS 2 South Sulawesi Prov. 1

November

14 – 16 Denpasar, Bali RT Field Vsit to Polindes, Pskesmas, Desa Siaga at Karang Asam Distr. 2

19 - 20 Central Sulawesi NN Exit Strategy Workshop at Parigi District & Demand Creation work-shop at Palu City

1 1

22 - 23 Pangkal Pinang, Bangka Belitung RT,NN Workshop on DHS 2 program 2

December

3 – 5 Bengkulu NN Workshop on Data validation 1

10 Jeneponto, S.Sulawesi NN Sosialization DHS proeject

application 1

12 - 13 Makassar, S.Sulawesi RT Provincial DHS 2 Meeting 1

16 – 18 Kendari, South East Sulawesi NN Workshop on policy dialogue Ko-

laka Dstrict 1

16 - 17 Palu, Central Su-lawesi AG HSR Advocacy 1

Total 2007 80 12 9 59


When Province Who Purpose Super-vision

Advo-cacy

Plan-ning

January

Annexes



Final Report

December 2008

When Province Who Purpose Super-vision

Advo-cacy

Plan-ning

11 - 13 South-East Su-lawesi All Feld visit Bau-Bau District Advo-

cacy Grand Design MNCH 4

18 - 20 Kendari, South-East Sulawesi NN Workshop Grand Design MNCH

Kolaka Utara District 1

26 - 30 Bengkulu RT,NN Develop plan for in-service training 1

April

9 - 11 Banjarmasin, South Kalimantan All Field visit Kotabaru District, OR

undertaken on barriers to care 4

14 - 17 Kupang, NTT RT,AG Field visit to NTT to review the District Health Account Proposal, in coordination with AusAID

2

June

19 - 22 Manado, North Sulawesi All

Field visit with K. Saleh and Boni (Sitaro District & Meet with Bupati and BAPPEDA)

July

25 Bandung, West Java NN Socialization DHS 2 at National

Occupational Health meeting. 1

August

13 – 14 Gorontalo RT,NN Field visit to Bualemo and Bone Bolango Districts 2

19 – 20 Banjarmasin (South Kaliman-tan)

AG Supervision Project DHS-2 1

20 - 21 Palu, Central Su-lawesi RT,NN,

Field visit with Mission (K.Saleh & S. Latief), DHS-2 Synchronization Meeting West Sulawesi

4

22 - 24 Denpasar, Bali RT,AG Field visit with Mission (K.Saleh & S. Latief) to Jimbarana District 4

Total 2008: 23 8 6 9

7.3 Publications and Presentations

7.3.1 Technical Documents Produced

No. Name of Document

October 2004

Criteria for Operations Research

Information for Applicants to Research Grants and simplified Application Form

List of Operation Research Topics

April 2005

Revised MOU for DHS 1

Annexes



Final Report

December 2008


Reviewed Plan of Action for TA 3579-INO DHS-ADB Project (Presentation)

Basic Concepts of Operation Research

GAP Analysis (review of program outcomes as compared to the goals of the log frame,) undertaken at the re-quest of the director of planning, to the director of Social Services for SE Asia – 1 1st draft

Enhancing the impact of Health Sector Reform

May 2005

Second revision of the GAP analysis based on comments and review by MOH, and ADB

ADB Health Sector Reform Project - 1st Progress report & Annual Work plan 2005

Policy Paper: ADB Health Sector Reform

June 2005

Grand Design for MNCH

Developing TOR of expanding MNCH services in the DHS-1 program

July 2005

Policy Paper: HSR for the Poor

Proposal for DHS 1 Project extension

Short PPTA MNCH

MNCH Proposal

August 2005

TOR for Socialization & Advocacy of Grand Design

District utilization of trained health personnel for delivery

Socialization Plan

Utilization of private & public health services (Presentation)

Socialization, Grand Design in Indonesian

Revised Project Logical FrameworkDHS-1 to focus on MNCH

September 2005

MNCH TOR

TOR, Health Information Management System

October 2005

Results of developing a model for predicting Maternal Mortality Risk

Concept paper: “Why has Bali been more successful than others in improving health status: a study in positive deviance”

Concept paper: “Piloting a Unifying Strategy for Clinical Care”

Progress Report: Bali Integrated Care

Profile DHS-1 Provinces (Power-point)

Draft: articles for DHS-1 Bulletin Newsletter Invitation

November 2005

TOR: Study Tour to Philippines for MNCH Focus (edit of Bali Province Document)

Overview packet (for DHS socialization of MNCH)

Annexes



Final Report

December 2008


Reflection: What to do about the “Demand Side” of the DHS project

Mortality rates by district

District Team Problem Solving (DTPS) Basic concept of DTPS

Maternal mortality risk distribution within Indonesia

Grand Design Strategy (English & Bahasa Indonesia)

Develop new RRP for DHS-1 as requested by project team leader ADBf 27 August 2004

December 2005

Initial Aceh tsunami health damage assessment (TOR)

Birthing by District (Power-point)

Total Quality Management of health service delivery Sulteng (Power-point)

Exit policy DHS-2

Potential Focal Points for Community Side Interventions

Existing community health system

Edit: Implementation Schedule 2006-2008, DHS-1, by province & by project component

Edit: Section V. Project Benefits, Impacts & Risks

Implementation Schedule December 2005

Revision MNCH Proposal based on district and provincial input

Power-point presentation: Recommended new Logical Framework for DHS-1

DHS-1 amendment proposal

Presentation to USAID presentation of DHS-1 new Grand Strategy

Power-point presentation on MNCH for Bali Province district: “Demand Side”

Revision and edits: TA 3579 annual Work Plan

Preparing for “Meeting of the minds” to add more HSR Focus to DHS-2

Development of first description of Best Practice within DHS-1

January 2006

Edit: Article on Health Sector Reform written by Ibu ist published in DHS-1 bullentini

The map of health services in the Riau archipelago)

Edit: Appendix 4. Economic Analysis (for DHS-1 extension “Short RRP”)

DHS-2 baseline survey (proposal for baseline survey)

Format for communicating evaluation of 2006-2008 strategic plans to ADB

Revisi renstra MENKES (Rencana Strategis = Strategic Plan of MoH) English

Model predicting MMR by district draft 7

DHS-1 Amendment proposal rev4

Format evaluasi renstra 2006-2008

Cost effectiveness of MNCH investment

February 2006

Master Plan for DHS-1 after socialization of Grand Design, and Planning excercise

Annexes



Final Report

December 2008


Draft summary rmaster plan introduction rev

DHS-1 Renstra (Rencana Strategis = Strategic Plan) 2006-2008 rev 2

Mini RRP DHS-1

DHS-1 Strategic Planning 2006-2008

Short RRP DHS-1 revision 7

Result of Strategic Planning Evaluation 2006-2008 (English)

Recommendation for activities priority and fund source map 2006-2008

Fourth evaluation of DHS-1 strategic plan (post revision by the districts)

Edit: DHS-1 power-point presentation for proposal to extend DHS-1 to focus on MNCH

Utilization DHS Prov 2000 & 2004

DHS-2 cost tabs by district

Comments on strategic planning process

March 2006

Request for Proposal Baseline Assessment DHS-2

DHS-2 indicator table (excel table created from Susenas)

Proposal for DHS-1 project extension rev

Suggestion for DHS-1 Lessons Learned Exercise

DHS-1 Exit Strategy suggestions

DHS-2 Baseline survey revision of RFP

Outline for evaluation & monitoring of DHS-2 Project

Strategic planning evaluation of DHS-2

Kepulauan Riau strategic planning, NAD strategic planning, Bengkulu strategic planning, Riau strategic planning, Central Sulawesi strategic planning, Southeast Sulawesi strategic planning, North Sulawesi strategic planning

Develop Checklists for strategic planning

Powerpoint presentation: monitoring (criteria for strategic planning)

District Team Problem Solving (DTPS) a guide line to develop DTPS team at the province and district

Proposal MNCH 2006-2008 Final (North Sulawesi)

Surveillance of MNCH

April 2006

2 Discussing HSR (Power-point)

4 MCH Workshop material Power-point)

5 Outline documentation HSR

May 2006

6 TOR for assessment of maternal health indicators

June 2006

7 TOR for Epidemiologic surveillance training

8 Training material socialization & advocacy of MNCH(Excel)

9 Policy Paper: Issues for improving health services performance

Annexes



Final Report

December 2008


11 Proposal for TA extension rev 2

12 INO DHS-2 June’06 review mission AM

July 2006

Strategic Planning DHS-1

Public Health Surveillance

HSR Issues paper developed by TA

Matrix strategic planning (Excel)

Numbers of manpower health (by function and location - Excel)

Decentralization of HRD / Human resources for health in INA-issues paper

Health information & epidemiologic surveillance (issue paper) (N3)

HSR issues paper rev 5

August 2006

Revision of DHS-1 performance indicators with most recent Susenas Data

Review of operational research studies undertaken (Power-point)

Data on availability of health staff for DHS1 area

Degree program (a gude line for selecting fellowship participants)

Final draft Post Grand Design RRP for DHS-1

Format training & fellowship Karima (Excel)

Issue Paper: Health manpower

Income distribution of populations and its relationship to maternal health access

Development of various TOR for different types of consultants proposed for DHS-1 (Word)

Policy Paper: The development of in-service Training (Excel)

Model predicting MMR by district draft 7 (Excel)

TOR for study tour for DHS-1 (Word)

DHS-2 Cost tabs South Sulawesi (Excel)

Growth faltering & income (Power-point)

Distribution of village size by province (Power-.point)

Susenas curve & graph 1 English-updated (Excel)

The trip to Togian District (Power-point)

Guidelines for assuring training programs

Strategic planning manpower health (Excel)

September 2006

Conceptual framework for DTPS (Power-point)

Guidelines for DTPS (District Team Problem Solving)

HSR issues paper developed by TA 8 Rev (Word)

October 2006

Presentation Description Project DHS-2 in BKKBN Meeting

Annexes



Final Report

December 2008


Millennium Development Goals rev4

Indicator DHS-2

November 2006

Natuna District: What Can We Learn?

Training DTPS

December 2006

Providing Health Service for Poor Community

New Guidelines

January 2007

Analysis Evaluation of DHS-1

HSR Guidelines December 2006

Recapitulation Master Plan & Annual Plan DHS-2

February 2007

Health Human Resources development for DHS project

Matrix Summary HSR Book

Summary of Fellowship for Year 2001-2004 DHS-1

Training Programs, management and technical training program in DHS 2

Total Health Manpower

Decentralization Health Human Resources Development

Design Advocacy Southeast Sulawesi

Surveillance HMIS

Evaluation Strategic Planning

March 2007

Outline Bakesra (Balai Kesehatan Rakyat) HSR model for health services at remove village in South East Su-lawesi

Partnership TBA with Midwife in Siak District, Riau Province

HSR Case Studies February 2007

July –August 2008

Evaluation of impact of Desa Siaga, a Guideline

Desa Siaga Model, a Guideline

Surveillance model for Desa Siaga

Training Desa Siaga Facilitators

Cost Tables for DHS-2 2009-2010

Barriers to Health Care in Indonesia

7.3.2 Meetings attended

When Province Purpose

2004

Annexes



Final Report

December 2008


02.09. Jakarta (DKI) Draft Review Circulated by Central Technical Committee

10.09. Jakarta (DKI) Recommendations with ADB from Draft Review

20.09. Jakarta (DKI) Submitting Inception Report to MoH

22 – 25.11. Denpasar (Bali) Finalizing Revised Inception Report , Planning the 1st Six-Month Report, and Preparing Plans for the Next 6 Months

2005

07.04. Jakarta (DKI) Meeting OR Guidelines

17.04. Jakarta (DKI) Meeting at DHS-1 for ADB Mission

18 – 19.04. Jakarta (DKI) Meeting at DHS-1 with ADB Mission

20.04. Jakarta (DKI) Meeting with Province executives

21.04. Jakarta (DKI) Wrap-up Meeting with ADB Mission

22 – 23.04. Jakarta (DKI) Meeting with ADB Mission at IRM

25.04. Jakarta (DKI) Meeting ADB Mission with MOH

11.05. Jakarta (DKI) Meeting GAP Analysis Presentation

12.05. Jakarta (DKI) Seminar on UI and GAMA finding

07 – 9.06. Makassar (South Su-lawesi) National Seminar on Decentralization

13.06. Jakarta (DKI) Mission Meeting with DHS-2 Staff

02– 4.06. Cisarua (West Java) Workshop Preparation to Increase Health Effort DHS (ADB)

22 – 24.06. Cisarua (West Java) Workshop HSR Implementation Evaluation

04. 07. Jakarta (DKI) TA Meeting with Executive Secretary

11.07. Jakarta (DKI) Presentation, project extension proposal

25.07. Jakarta (DKI) Meeting Ext. Proposal at Bappenas

26 – 27.07. Cipayung (West Java) Workshop Finalizing Proposal for Loan Extension

09.08. Jakarta (DKI) Seminar with UGM and UI Presentation

26.08. Jakarta (DKI) Ta Meeting with Executive Secretary

04 – 06.09. Bandung (West Java) Workshop to prepare Socialization, Presentation material for Socialization, Prepare time schedule for visit

24 – 26.09. Denpasar (Bali) Meeting TOR for strategic Retreat

01.10. Cisarua (West Java) Meeting review plan for 2006 by provinces

09.10. Jakarta (DKI) TA Consulting Meeting

17 – 19.10. Cisarua (West Java) Workshop sharing experiences DHS-1

21 – 22.10. Jakarta (DKI) TA Consulting Meeting

14.11. Jakarta (DKI) Meeting with Secretary Executive DHS-1

15.11. Jakarta (DKI) Meeting Team TA

20 - 22.11. Jakarta (DKI) Seminar of National Action Call for Increasing Public Health Degree

28 – 29.11. Jakarta (DKI) Mission Briefing meeting.

Annexes



Final Report

December 2008


02 – 3.12. Cisarua (West Java) Workshop on project achievement review & planning for year 2006

04 – 7.12. Jakarta (DKI) Meeting with ADB Mission Team & Review DHS-2 Plan of Action

09.12. Jakarta (DKI) Wrap-up meeting project DHS-1, 2 & ETESP

14 – 15.12. Jakarta (DKI) Workshop review & Development Japan Fund for poverty reduction

17.12. Makassar (South Su-lawesi) Meeting Advocation & Socialization of Project DHS-2 in South Sulawesi

22.12. Jakarta (DKI) Presentation Health Situation Analysis at DHS-2 Region

2006

05.01. Jakarta (DKI) TA Meeting

06.01. Jakarta (DKI) Meeting evaluation & setting work plan of center technical committee year 2006

11.01. Jakarta (DKI) TA and DHS1&2 Executives meeting

12.01. Jakarta (DKI) Meeting preparation for strategic planning evaluation 2006 – 2008

16 – 17.01. Jakarta (DKI) Workshop on proposal Review (DHS-1)

25.01. Jakarta (DKI) Meeting with BKKBN

26 – 28.01. Cisarua (West Java) Meeting district strategic planning evaluation

01.02. Jakarta (DKI) Meeting with GTZ/ADB

14-17.02. Jakarta (DKI) Meeting TA, ADB Mission and DHS-1 & DHS-2 staffs & with head of Plan-ning Bureau of MOH

23.02. Jakarta (DKI) Meeting DHS-1 extension program present at the Bappenas (National Plan-ning Board)

03.03. Jakarta (DKI) Invitation of workshop for Ausaid women & child health programming mis-sion to East Nusa Tenggara

06.03. Jakarta (DKI) Meeting with EPOS

07.03. Jakarta (DKI) TA meeting for semester report

10.03. Jakarta (DKI) TA Meeting with Director of DHS 2

17.03. Jakarta (DKI) Preparation meeting for evaluation result & finishing project fund calculation

20 – 22.03. Cisarua (West Java) Strategic planning evaluation meeting

04 – 07.04. Jakarta (DKI) - OR guideline finalization - Meeting with DHS-1, preparing OR presentation

12 – 14.04. Cisarua (West Java) HSR workshop, report presentation on HSR Guideline DHS-1

17 – 19.04. Jakarta (DKI) Revise HSR guideline

24 – 26.04. Jakarta (DKI) Finalize OR guideline

02 – 03.05. Jakarta (DKI) Coordination meeting baseline survey DHS-2

08 – 11.05. Makassar (South Su-lawesi) Review Strategic Planning Riau & Kepri

16.05. Pekanbaru (Riau) Strat.plan workshop

16 – 19.05. Jakarta (DKI) Meeting stakeholders program of child health to develop strat.plan 2007

17 – 19.05. Tanjung Pinang (Bangka Belitung) Strat.plan workshop

Annexes



Final Report

December 2008


22.05. Jakarta (DKI) TOR baseline survey DHS-2

22 – 24.05. Jakarta (DKI) Meeting stakeholders program of maternal health to develop strat.plan 2007

26.05. Jakarta (DKI) Review analysis MNCH program EBM

29 – 31.05. Kendari (Southeast Sulawesi) Strat.plan workshop

05 – 08.06. Bandung (West Java) National meeting on decentralization

09 – 14.06. Jakarta (DKI) Meeting ADB mission with DHS-2 staff

15 – 17.06. Mataram (West Nusa Tenggara) Meeting coordination development health plan 2007 for DHS-2

21 – 22.06. Jakarta (DKI) ADB mission with MOH & wrap up meeting with Bappenas

27 – 30.06. Jakarta (DKI) Review issue paper, meeting ES DHS-2, presentation DHS-2 action plan 2006/07

01 – 03.07. Jakarta (DKI) Review strat.plan Bengkulu Province

03 – 05.07. Jakarta (DKI) Design baseline Bengkulu Province, & finalize issue paper

03 – 05.07. Bali (Denpasar) WHO meeting, edit issue paper, & review Bali districts plan

04 – 05.07. Bengkulu (Bengkulu) MNCH planning seminar, advocacy & strategic planning

06 – 08.07. Mataram (West Nusa Tenggara) Discussion DHS-2 future programs, training technical review team NTB-NTT

14.07. Jakarta (DKI) Meeting DHS-2 with Bappenas

17 – 19.07. Jakarta (DKI) DHS-1: Meeting & presentation DHS-1 extension, develop guideline for EMOC

21 – 24.07. Kendari (Southeast Sulawesi) Meeting ES Southeast Sulawesi & Head of Dinkes

01.08. Jakarta (DKI) Meeting with ADB mission

02 – 04.08. Cisarua (West Java) Planning worskhop DHS-1 with all provinces, review centre technical 2007

05 – 07.08. Jakarta (DKI) Meeting with ADB mission (aide memoire)

08 – 09.08. Makassar (South Su-lawesi) Seminar at Wahidin Hospital

10.08. Cisarua (West Java) 3 yrs planning

22 – 25.08. Cisarua (West Java) Revise IHPB module

23.08. Makassar (South Su-lawesi) Meeting with DHS-2 staffs

22 – 26.08. Palu (Central Sulawesi) Workshop Acceleration of Reducing Maternal Mortality Rate in Tojo Unauna District

24 – 26.08. Makassar (South Su-lawesi) Workshop on district work plan

28.08. Jakarta (DKI) Report advocacy Bali

29.08. Jakarta (DKI) Meeting with Director of Decentralize Unit

30.08. – 01.09. Jogjakarta (DIY ) Annual Opr. Budget DHS-2, Exit Strategy Workshop

13 – 15.09. Bali (Denpasar) Workshop monitoring & evaluation DHS-1, DIP (part of Annual Opr. Budget) DHS-2

Annexes



Final Report

December 2008


16 – 17.09. Jakarta (DKI) Report advocacy

18 – 19.09. Surabaya (East Java) Workshop Synchronizing DHS-2 Activities

20 – 22.09. Surabaya (East Java) Workshop Synchronizing DHS-2 Activities

25 - 26.09. Jakarta (DKI) Policy dialog

27 – 29.09. Jakarta (DKI) Meeting DHS-1 for Exit Strategy Workshop, developing TOR for workshop in Manado

5 – 6.10. Bandung (West Java) BKKBN West Regional Workshop on Family Planning

06.10. Jakarta (DKI) Meeting with DHS1 Executive Secretary

09 – 11.10. Manado (North Su-lawesi) Workshop on exit strategy DHS1

12.10. Banjarmasin (South Kalimantan) DHS2 Planning Meeting

12 – 13.10. Mataram (West Nusa Tenggara) BKKBN East Regional Workshop on Family Planning

12 – 14.10. Palembang (South Sumatera) Strategic Planning

18 – 19.10. Bandung (West Java) Meeting MNCH advocacy

30.10. – 01.11.

Makassar (South Su-lawesi) DHS2 District Officer Training

06.11. Jakarta (DKI) Meeting with DHS1 Executive Secretary

07 – 09 .11. Mataram (West Nusa Tenggara) Workshop on Master Plan DHS2

08 – 10.11. Kupang (North Nusa Tenggara) Workshop arrange proposal & Master Plan 2007-2010 Project DHS2

09 – 12.11. Bengkulu (Bengkulu) Training for based line study

13.11. Selayar (South Su-lawesi) Workshop on DHS2 District Planning

15.11. Pare-pare (South Su-lawesi) Workshop on preparation district health system

19 – 20.11. Kendari (South East Sulawesi) Advocacy Grand Design & Socialization DTPS in South Konawe District

21 – 22.11. Raha (South East Su-lawesi) Advocacy Grand Design & Socialization DTPS in Muna District

23 – 24.11. Bau-bau (South East Sulawesi) Advocacy Grand Design & Socialization DTPS in Bau-bau City

23 – 24.11. Jakarta (DKI) Meeting TOR MNCH with ES DHS1

27 – 30.11. Batam (Kepulauan Riau) Workshop on DTPS action plan

27 – 30.11. Bogor (West Java) P2KT Training

28 – 29.11. Makassar (South Su-lawesi) Workshop arrange & master plan 2007-2010 project DHS2

30.11. – 01.12.

Banjarmasin (South Kalimantan) Workshop arrange proposal & master plan 2007-2010 project DHS2

Annexes



Final Report

December 2008


01.12. Bogor (West Java) MNCH advocacy DHS1

04 – 07.12. Jakarta (DKI) ADB Mission

05 – 07.12. Batam (Kepulauan Riau) P2KT Training

08 – 09.12. Bandung (West Java) Workshop on Lesson Learned & Shared Experience

11 – 13.12. Bogor (West Java) HSR TOT

13 – 14.12. Bogor (West Java) Meeting finalization master plan DHS2

19.12. Surabaya (East Java) MNCH Guideline clinics

20.12. Bogor (West Java) Meeting TRT work plan DHS1

20 - 23.12. Tanjung Pinang (Kepu-lauan Riau) Socialization DTPS

2007

03 – 05.01. Jakarta (DKI) Meeting with DHS2, with TA for book writing

5.01. Jakarta (DKI) Meeting with DHS1

08 – 11.01. Palangkaraya (Central Kalimantan) MNCH assessment

09 – 10.01. Jakarta (DKI) Meeting with DHS1 Executive Secretary

11.01. Jakarta (DKI) Meeting DHS1 review 2007 plan

16 – 21.01. Denpasar (Bali) 1. DHS1 workshop Monev Analysis 2. DHS1 planning activities 2007 3. TA Meeting for book writing

22.01. Jakarta (DKI) DHS2 seminar on HSR & HRD

23.01. Jakarta (DKI) Meeting with ADB

24.01. Jakarta (DKI) TRT meeting with DHS1

26 – 27.01. Surabaya (East Java) MNCH guideline

30.01. Jakarta (DKI) ADB mission meeting

01 – 02.02. Jakarta (DKI) Presenting issue papers & review DHS2 master & annual plan

03.02. Jakarta (DKI) DHS2 kick-off meeting with ADB

07.02. Jakarta (DKI) Meeting DHS2 master & annual plan

08.02. Jakarta (DKI) Wrap up meeting ADB mission

16.02. Jakarta (DKI) Meeting of mind

22 – 23.02. Jakarta (DKI) HSR guideline DHS1

25 – 26.02. Mataram (West Nusa Tenggara) DHS2 integrated planning

07.03. Jakarta (DKI) Preparation consignation meeting reviewing annual and master plan

08 – 10.03. Depok (West Java) Consignation meeting reviewing annual and master plan

27 – 28.03. Bogor (West Java) Compiling work plan TRT DHS1

29.03. Jakarta (DKI) Meet with Michael from EPOS

02 – 04.04. Bandung (West Java) Workshop: mind setting project DHS-2 program coordination

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02 – 05.04. Medan (North Su-matera) Workshop: MNCH advocacy with DTPS project DHS-1

06.04. Jakarta (DKI) Meeting: coordination with DHS-2

10.04. Jakarta (DKI) Meeting: with HSP project team

10.04. Jakarta (DKI) Meeting: advocacy module for MNCH DHS-1

11.04. Jakarta (DKI) Meeting: with Bappenas for DHS-1 & 2

13.04. Jakarta (DKI) Meeting: with EPOS Team Leader (J. Smith) on HR project

17.04. Bogor (West Java) Meeting: presentation Grand Design at HSP training

17 – 19.04. Cianjur (West Java) Training: advocacy module on MNCH

18 - 21.04. Mamuju (West Su-lawesi) Workshop: finalizing Master Plan Mamuju District project DHS-2

24 – 25.04. Bandung (West Java) Workshop: monitoring & evaluation (monev) analysis & preparation Project Completion Report (PCR) & benefit monitoring evaluation (BME)

01.05. Jakarta (DKI) Meeting: coordination DHS-2 with Central Technical Review Team

04.05. Jakarta (DKI) Meeting: follow up the workshop analysis monev project DHS-1

08 – 10.05. Batam (Kepulauan Riau) Workshop: exit strategy for DHS-1

09 – 11.05. Bandung (West Java) Meeting: MNCH division of MoH

14 – 16.05. Jakarta (DKI) Meeting: review master plan of South Sulawesi

22 – 24.05. Surabaya (East Java) Workshop: budget planning for DHS-1

04 – 07.06. Palu (Central Sulawesi) Workshop: improving data management in MNCH program & MNCH surveil-lance in Donggala District

10 – 11.06. Bengkulu (Bengkulu) Workshop: baseline survey proposal development of DHS-1 on operational research

11.06. Jakarta (DKI) Meeting: review annual plan year 2008 and discuss on TOR short course & fellowship abroad for project DHS-2

14 – 16.06. Bandung (West Java) Workshop: generate demand creation on project DHS-1

19 – 20.06. Bengkulu (Bengkulu) Workshop: MNCH surveillance on DTPS DHS-1

21 – 25.06. Jakarta (DKI) Meeting: ADB mission on DHS-1 plan of action 2008 & application of 2007 program

26.06. Jakarta (DKI) Meeting: ADB kick off with Bappenas

27.06. Jakarta (DKI) Meeting: consultation mechanism extension of Central Loan (ADB) to dis-trict/ city government

28.06. Jakarta (DKI) Meeting: ADB wrap up with Bappenas

03 – 05.07. Polewali Mandar (West Sulawesi) Socialization & advocacy for DHS-2

06 – 07.07. Gorontalo (Gorontalo) Socialization & advocacy for DHS-2

11.07. Kendari (Southeast Sulawesi) Meeting: Executive Secretary Southeast Sulawesi

13 – 14.07. Cisarua (West Java) Workshop: advocacy material of MNCH Plan project DHS-1

20.07. Jakarta (DKI) Meeting: with central TRT on Loan Agreement project DHS-1 & 2

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24.07. Makassar (South Su-lawesi) Meeting: Executive Secretary South Sulawesi

25 – 26.07. Manado (North Su-lawesi)

Workshop: on intensification of inter sector collaboration & coordinator for health

06.08. Denpasar (Bali) Meeting: all EPOS team leaders

07 – 09.08. Denpasar (Bali) Workshop: exit strategy of DHS-1

07 – 09.08. Denpasar (Bali) International Seminar: Implementation on Health Decentralization

21 – 24.08. Palembang (South Sumatera) Workshop: socialization for DHS-2

22 – 24.08. Palembang (South Sumatera)

National Seminar: of IAKMI (Indonesian Community Health Expert Associa-tion)

24.08. Jakarta (DKI) Meeting: with DHS-1 data on Desa Siaga

27 – 29.08. Denpasar (Bali) Seminar: Indonesia Senior Policy on Health System by World Bank

27 – 29.08. Jakarta (DKI) Meeting: economic analysis of Desa Siaga

30.08. Bengkulu (Bengkulu) Workshop: on MNCH advocacy DHS-1

03 – 06.09. Kotabaru (South Kali-mantan) Workshop: on research for free health services and TOR information system

17.09. Jakarta (DKI) Meeting: with IRM discussing result of ADB Review Mission

26.09. Jakarta (DKI) Meeting: mid term review ADB mission for DHS-2 Project

10 .10 Jakarta Meeting for the development of GAVI-HSS proposal (at invitatiohn of Bapp-nas)

22.10 Jakarta Meeting DHS 2 prepare for Mid Term Review

24.10 Jakarta Meeting Mid Term Review, & sugestion cancellation

26.10 Jakarta Meeting for the development of GAVI-HSS proposal (at invitatiohn of Bapp-nas)

28.10 Jakarta Meeting with Mission ADB

5 – 10. 11 Puncak, West Java Workshop Mid`Term Review Project DHS 2 with 2 region, East and West

13. 11 Jakarta Meeting pembahasan hasil persiapan tim Design AusAID

14. 11 Jakarta Wrap Up meeting for supervisionary mission for project DHS 2

23. 11 Depok, West Java Workshop on the development of MNCH Maternal

28. 11 – 1.12 Bandung, West Java Workshop “Sharing Experience” Project DHS

5.12 Jakarta Follow up Wrap Up meeting project DHS 2

9 – 10.12 Kndari, South East Sulawesi Resurce person for prject provincial level workshop

12-14 . 12 Denpasar, Bali Meeting to develop guideline for TRT evaluation of various loan initiatives

2008

7-9 .01 Denpasar, Bali Workshop on Nutrition Bappenas-GTZ

22-24.01 Bandung, West Java Meeting, analysis data RisKesDas

25. 01 Jakarta Meeting Report & Advancement discussion Project DHS 2

30 .01 Jakarta Meeting technical for Surveillance activity KIA

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01. 02 Jakarta Meeting with director, Secrt. Executive, & TRT of DHS 2

01 – 02.02 Bandung, West Java Meeting anaysis data base & analysis advanced RisKesDas 2007

15 .02 Jakarta Meeting consolidation DHS 2 Pasca Mid Term Review

19 .02 Jakarta Meeting health Sector Cordinating Committe *(HSCC) and stakeholders in framework arranging proposal GAVI-HSS and GAVI-CSD

20. 02 Jakarta Meeting technical for Surveillance activity KIA

27. 02 Jakarta Invitation project SCHS-UE

21-22. 02 Bandung, West Java Meeting follow up mandat & Analysis long RisKesDas

06. 03 Jakarta Meeting health Sector Cordinating Committe *(HSCC) and stakeholders in framework arranging proposal GAVI-HSS and GAVI-CSD

12 – 15. 03 Bandung,West Java Lokakarya analysis monev DHS 2

08. 04 Jakarta Meeting Policy Dialoque

18-19. 04 Bandung, West Java Meeting analysis RisKesDasADB

16. 05 Jakarta Technical meeting project DHS 2

21-24. 05 Mataram, NTB Workshop review project implementation 2008

27. 05 Jakarta Meeting National Steering Committe Project DHS 2

29. 05 Bandung,West Java Meeting, data analysis RisKesDAS

30. 05 Jakarta Preparation proposal technical Project DHS 1 ADB

13. 06 Jakarta Finalization Proposal Technical Implementation study BME Project DHS 1

17. 06 Jakarta Preparation Mission ADB, including DHS 2 Management team

18. 06 Jakarta Kick Off Meeting project DHS 2

23. 06 Jakarta Meeting TRT, KDP, BKKBN (toether with K.Dsaleh)

24. 06 Jakarta Mission ADB

25. 06 Jakarta Workshop Health Sector Reform in the context of decentraklization in Indo-nesia

26. 06 Jakarta Wrap-Up meeting Project DHS 2

02.07 Jjakarta Meeting with DHS 2 staffs

03. 07 Jkarta Meeting with Dir.General of Comunity Health

10 – 12. 07 Bandung, West Java Meeting to reviuew and modification Logframe

14 – 17. 07 Yogyakarta Meeting withBME teams, National and Provinces

18 – 20. 07. Yogyakarta DHS 2 Start Up meeting for West region.

21 – 22. 07 Palembang, South Sumatera

BKKBN meeting for program development

22 – 24. 07 Padang, West Su-matera BME and Individual neeting to review questionaire.

27 - 29. 07 Surabaya DHS 2 Start Up meeting for East Region.

06. 08 Jakarta Meeting with DHS 2 Executive Secretary with staffs.

07. 08 Jakarta Meeting with National BME team., presentation of Questionaire

11 – 12. 08 Gorontalo Attending workshop of PHO with Ministry of Health

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15 – 18. 08 Banjarmasin, South Kalimantan

Meeti ng for Sinronization program with Districts DHS 2

18. 08 Jakarta TA meeting with ADB Mission (K. Saleh)

19. 08 Jakarta Kick Of f meeting DHS 1 with mission

22 – 24. 08 Mamuju, West Sulawesi Sincronization program meeting with Districts, DHS 2

25. 08 Jakarta BME meeting with mission

26 - 28 Bandung Sharing experience meeting DHS 1

28. 08 Jakarta War up meeting with mission

28 – 30.08 Palembang, South Sumatera Synchronization program meeting with Districts, DHS 2

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7.4 District level participation with Assisted Deliveries, 2004

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7.5 Desa Siaga Guidelines

7.5.1 Summary

The mid-term review of DHS-2 suggested that one component of the project after the MTR

should be to support the Ministry of Health in expanding it “Desa Siaga” program, but en-

couraging each of the districts to develop five model “Desa Siaga” in their districts based on

the national guidelines, but adapted locally to the situation of the village in which it is imple-

mented.

The Desa Siaga concept aims at developing a system that makes the village responsible for

its own health programme under the guidance of a midwife and two volunteers. It also con-

sist of various village committee’s working on health care financing, response to medical

emergencies, and ways to assist various village members to cope with the challenges of in-

patient hospital care. This system made up of village committee’s should also promote com-

pliance to public health programs such as immunization and posyandu, and make sure that

every pregnant women gets appropriate and adequate medical services. As the system ma-

tures, it can also begin to consider issues of community sanitation, particularly school sanita-

tion.

Facilitators will be trained to work with village members to discuss the health needs of the

village, and health problems over the last few years, they will work with the mothers to de-

velop village action plans based on structured meetings, and various village assessments

that the facilitators undertakes with the health committee and village meetings. These facili-

tators will be trained by the project, and in close cooperation with other village development

programs.

The facilitator will assist the village to develop a village action plan, which will be reviewed by

the provincial TRT, and after acceptance, a block grant will go directly from the ministry of

finance to a bank account managed by the village under “oversight” from the district facilita-

tor. This system will work in parallel to other community development programs such as

PNPM, and interaction with this program at the sub district level will enhance its ability to

mobilize resources for the Desa Siaga program in the future.

Surveillance of infectious disease and program compliance will be a central component of

the Desa Siaga. Community mapping and local action plans by health committee’s are a key

component of this activity. Moreover chains of information flow from the Desa Siaga to

higher levels of the government, and feedback to the Desa Siaga are an important element

of these programs.

NGO’s will be encouraged to work with the Desa Siaga in various locations. National NGO’s,

international NGO’s and local NGO’s will be involved in the Desa Siaga component as it is

rolled out, and implemented.

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Infectious disease monitoring and control, particularly malaria and TB will also be part of this

Desa Siaga initiative, as many of the DHS-2 district contain areas endemic for malaria, and

TB continues to be one of the major causes of death and morbidity among adults. Exclusive

breast feeding for children below six months of age will be promoted, and underweight

mother’s pregnancy will be managed by feedings centres set up and managed by the local

health centres.

A schedule of activities to be undertaken in fiscal year 2008 will be outlined. In order to de-

termine its impact a multi-centre study will be undertaken in the 86 villages where the pro-

gram is implemented, that will measure baseline health care utilization, and public health

program participation, and measure it again, one year after the Desa Siaga program has

been implemented in order to review the impact of the Desa Siaga program. The results of

this will be used in advocacy with local government to further expand and support the Desa

Siaga program.

7.5.2 Model development of Desa Siaga

The objective of this activity is to explore and developed a model of Desa Siaga that is effec-

tive in enhancing health program performance and improving the health status of the village

community, with the following characteristics:

a. Adopting the generic elements of Desa Siaga (Poskesdes, health professionals,

Desa Siaga cadres, implementation of local assessment and community participa-

tion)

b. Effective role of the village community in the planning, implementation and

evaluation of specific health interventions relevant to the community’s needs

c. Mobilization of community resources for implementation of sustainable Desa

Siaga

d. Effective support from the community leaders, religious leaders, head of the vil-

lage, Camat (head of sub-district), Puskesmas and DHO for Desa Siaga,

e. Provision of continuous technical assistance for the Desa Siaga by trained facili-

tator from the Puskesmas and district level

f. Improvement of health program coverage and effectiveness that become the pri-

ority of the respective Desa Siaga

In the end this activity will also formulate a policy recommendation and technical guideline for

Desa Siaga based on the evaluation of the model. In the first year 2 Desa Siaga will be es-

tablished (in two villages) of each district. That will give around 172 Desa Siaga in the entire

86 districts under DHS-2. In the second year additional 3 Desa Siaga will be established in

each district or 258 Desa Siaga in the whole DHS-2 districts. So at the end of the project

time in 2010, 430 Desa Siaga will be evaluated.

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7.5.3 Elements and principles of the Desa Siaga Activity

1. Desa Siaga is a concept formally introduced by DOH to improve the prepared-

ness at the village level as to overcome various health problems, including dis-

ease outbreaks. According to the MOH Decree No. 574/SK/VIII/2006, the main

elements of Desa Siaga is (a) the establishment of Village Health Post (Poskes-

des), (b) placement of one health professional at least a midwife, (c) empower-

ment of the community through the training of Desa Siaga cadres. Community

participation is executed trough the SMD and MMD mechanism (participative

planning and implementation). Through this mechanism the community will iden-

tify the priority health problems they are having and determine specific actions

they can do to overcome the problems.

2. Theoretically community empowerment is bound to the social the cultural charac-

teristic of any given community. In this case. Indonesia is a country with diverse

cultures. There is a large variation between regions with respect to the level of

socio-economic condition and culture. Sometime there is also variation between

neighboring villages. Therefore, “one size fit all” approach would not effective in

exploring model for community empowerment. In order to make the model ac-

ceptable and sustainable, it should be developed through a participative and bot-

tom up process. The values believed by the community, their social structure,

strength and weakness as well the local opportunity and constraints; all has to be

taken into consideration in developing the model of community empowerment.

3. Four basic principles have to be kept in mind with respect to Desa Siaga:

- First, Desa Siaga is one of the “meeting points” between the health services

and health programs organized by the government with the organized com-

munity efforts. According to the guideline prepared by the Ministry of Health,

Desa Siaga’s main elements are the existence of medical professional (mid-

wives, nurse) who work in integration with the community. The community or-

ganized themselves as to identify their priority health problems and determine

actions that they can and should do to overcome the problems.

- Second, Desa Siaga has a strong notion of “preparedness” or “alertness”.

Alertness basically starts by “knowing”. Therefore in order to make the com-

munity “alert” of any potential health problem, there must be an accurate and

rapid information flow in the community. This is one of the important elements

in developing Desa Siaga model.

- The third principle is “immediate response”. Once there is a potential health

problem recognized, the community through Desa Siaga will take appropriate

actions and if the actions were not sufficient, the formal health service system

will be informed (including Pustu, Puskesmas, DHO and district hospital in the

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health system hierarchy). Similarly the government line structure will also be

informed (including village head, sub-district head and district government in

the government hierarchy). In technical term, alertness requires an effective

24 hours surveillance system and the ability to take accurate and immediate

response.

- Fourth, Desa Siaga is a “vehicle” for the community and health service sys-

tem to carry out various health programs and activities. Currently the pre-

dominant perception is to see Desa Siaga as only for maternal and child

health or reducing maternal and infant mortality. It is true that alertness is

necessary in order to take prompt action when there is emergency cases of

maternal and child health, but other health problems also requires the same

alertness such as malaria, tuberculosis, dengue, severe malnutrition, etc.

The “meeting point”, alertness, immediate response and vehicles for various

health activities are generic principles in the concept. To implement the princi-

ples, the Desa Siaga guideline describes the basic elements: (a) establishment of

village health post (Poskesdes), (b) placement of health professional, (c) commu-

nity participation in form of self assessment (Survey Mawas Diri or SMD) and

planning through consensus (Musyawarah Masyarakat Desa or MMD) and (d) ac-

tive role of Desa Siaga cadres.

4. As mentioned above, community empowerment is subject to the variation of local

culture and social-economic condition. Therefore, Desa Siaga model should be

adaptive to the local variation. However, the basic and generic principles have to

be maintained. Based on the above consideration, the models of Desa Siaga in

DHS-2 will be developed and adapted to local specific characteristics with the

main focus on empowering the “alertness and rapid response system” in the

community in collaboration and integration with the health service system owned

both by the government and the private sector.

5. Community participation means that the community makes decisions about the

way the Desa Siaga activity is structured within their community. It generates a

sense of self ownership and insures sustainability.

6. Partnership is another term used indicating mutual collaboration and respect be-

tween all parties; the community, the NGOs and the government. The “one size fit

all” policy that usually predominant in the misconception of participation is avoided

and local variation adapted to the local condition – including the local culture – is

very much tolerated and respected.

7. ”Community empowerment” It is true that empowerment sometimes requires

external support such as provision of information, training, provision of technical

assistant, consultant, seed capital, equipments, etc. The provision of the external

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support may lead to creating dependency if the community and local resources

were not mobilized. Therefore it is very essential in the empowerment effort to

transfer the responsibility to the community. The transfer must be well planned in

form of “exit strategy and sustainability plan”. The plan must be developed by the

community themselves.

8. In this activity the community will be given a block grant so that they will have ini-

tial resources to implement whatever plan they have formulated. The block grant

will be channelled through the formal government mechanism of channelling “so-

cial aid fund”. The community with assistance of a trained facilitator will prepare a

budget proposal. The block grant – which mostly covers the operating cost – will

be transferred directly to the community. It is expected that with the block grant all

plan that was made by the community can be implemented.

9. As mentioned above, external support could be vulnerable as far as self reliance

and sustainability is concerned. Therefore, along with the provision of the block

grant, the community should also prepare an exit strategy so that at one point the

financial support is taken over by their own resources. Community financing

scheme is one possibility. Or – in a larger scale, the local government may secure

some funding from APBD to support the community. For example the local gov-

ernment support may be given to well performing Desa Siaga as an award.

7.5.4 Facilitators

Other community based development program, such as KDP, WISLIC-2, and PNPM have

shown that well trained and supervised facilitators are central to the success of community

based programs. DHS-2 will need to recruit, train and mobilize 86 facilitators, and prepare

their training program, and guidance materials for working with the villages. One facilitator

will be trained and based at the district/kecamatan level. The main functions of the facilitator

include the following:

a. Help establish the Desa Siaga following the DOH guideline

b. Assist Desa Siaga in performing SMD, MMD and annual budgeting

c. Review plan and budget proposed by the respective Desa Siaga

d. Assist Desa Siaga in resource mobilization (community financing schemes or

Dana Sehat, and income generating activities)

e. Assist Desa Siaga in maintaining financial recording and reporting system

In order to perform the tasks, the facilitator needs to have the following competency and skill:

a. Basic knowledge on the principles of community development

b. Examples of participative planning and budgeting from other experiences

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c. Basic epidemiological surveillance (such as the one prepared by CDC for village

surveillance system)

d. Standard guidelines and indicators for specific health programs (MPS, malaria, tb,

nutrition, immunization, etc)

e. Performance budgeting system

The facilitator will be trained to have the competencies. The training will be done at the pro-

vincial level. The competency based curriculum for the training will be developed.

Based on the required competency, it is assumed that the Desa Siaga facilitator has to have

a bachelor degree in health science / be a graduate of the School of Public Health. The sub-

stance and curriculum for their training will be prepared following the standard training mod-

ule. The facilitators will be based at the district level. In the first year (2009) they will be re-

sponsible of assisting 2 Desa Siaga and 3 Desa Siaga in the subsequent year (2010). The

facilitators will be contracted and paid on a monthly basis plus also funding to support their

operating activity (travel, per-diem, consumables, etc).

7.5.5 Operational model in selected villages

The basic components of the model

The model consists of two main elements: (a) Community empowerment to manage the

Desa Siaga (demand side) and (b) strengthening health services system (supply side).

A. Desa Siaga and community empowerment

1. The organization

The organization of the Desa Siaga consists of the following:

a. Village Health Council: The village health committee will be selected by the com-

munity member whose functions include providing advice to the Desa Siaga Execu-

tive unit (Pengurus) and resolving any dispute in the operation of Desa Siaga

b. Executive management (Pengurus): Executive management consists of selected

individuals who manage the day to day management of the Desa Siaga. This unit

consists of (a) Chairperson, (b) Secretary, (c) Treasurer and (d) Sections

c. Cadres: Desa Siaga cadres are the community members that has been trained and

assigned to do field activity. Their task varies according to the need of specific pro-

gram. For example, the cadres may functions as FP motivator, finding suspected

case of tb and malaria to be referred for laboratory testing, mapping under fives for

weighting and immunization, mapping pregnant women and their antenatal care

status, etc.

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d. Member (households): The whole village household in the community is the mem-

ber of the Desa Siaga. They are the target of health intervention performed through

the Desa Siaga. They will be involved and have the right to express their voice in the

planning and implementation of Desa Siaga activity. The village member also has to

follow all agreement and consensus that has been achieved under the Desa Siaga,

such as pay their contribution in health financing scheme.

2. Main activity

a. Surveillance and mapping

The secretariat and the cadres will manage a routine surveillance system in form of map-

ping all household in the respective village. Any health condition in each household will be

identified such as the presence of eligible couple for FP, pregnant woman and her ANC

status, delivery, newborn and under-fives, school children and elderly. In other project (such

as the Family Health and Nutrition project), any health condition requires intervention will be

marked under certain color. For example, red color for tb denoting that the household has its

member with suspect tb. The color will be changed to yellow whenever the person has been

treated or given any medical intervention. The color will be changed to green if the person

has successfully cured. All of the household information will be mapped spatially and the

map is displayed in the Poskesdes.

In addition to the routine surveillance, the Desa Siaga also will manage surveillance for

communicable disease outbreak. The cadres work closely with the community member to

detect the incidence of certain disease that has the potential for epidemiological outbreak

such as measles, dengue, diarrhea, bird flue, etc. Any suspected potential outbreak will be

reported immediately to Poskesdes (health professional), head of the village and Puskes-

mas.

In addition to the routine surveillance, the Desa Siaga will also manage surveillance for communicable disease outbreak. The cadres work closely with the community to monitor

the incidence of certain diseases that have the potential for epidemiological outbreaks such

as measles, malaria, dengue, diarrhea, bird flue, etc… Cluster of cases will be reported im-

mediately to Poskesdes (health professional), head of the village and Puskesmas.

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Example of Family Health Card (would be improved after pre-testing)

Household ID:Address:

Indicators Red Yellow Green1 PUS2 Pregnant women

* ANC (K4)* TT* Fe

3 Delivery* Hlth profesionals* Referal for emergency

4 Post natal care5 <5 weigthing6 Immunization

* BCG* DPT* Polio* Measles

7 Tbc case8 Malaria case9 Ibu KEK

10 Dll

b. Participative planning

Participative planning has been introduced and implemented in many community develop-

ment projects. In health sector, this has been done in the PKMD (Pembangunan Kesehatan

Masyarakat Desa) in the 70s, Posyandu in the 80s and 90s, WSLIC project for water and

sanitation, etc. The Posyandu and Desa Siaga guideline introduce the SMD (Survey Mawas

Diri or Village Self Assessment) and MMD (Musyawarah Masyarakat Desa or Village forum

for consensus) mechanisms for participative planning.

In the model, the participative planning will adopt the (1) SMD, (2) MMD mechanism and ad-

ditional step for (3) budgeting. Through the SMD process, the Desa Siaga will organize a

households meeting to determine priority health problems to be address in the coming year.

The summary of the surveillance data and mapping is presented in the SMD forum, to be

used as the basis for identifying priority problems and issues.

In the MMD process, the villagers will determine the targets to be achieved in the coming

year and what actions should be taken to achieve the target. The main objective is to trans-

form as much as possible the “red colour households” to become “green colour households”

The third step in the planning process is for the Desa Siaga to estimate the necessary cost to

perform the actions that will be proposed as the budget. Unless it is very much needed and

has a very strong reason, the emphasis of the budgeting is only for securing operating

budget (not capital investment). The sequential process of budgeting from target to activity

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and to cost input to carry out the activity, a performance budgeting will hopefully is assured.

Any cost spent must be linked to specific outputs related to specific target.

A set of user’s friendly tables/matrix will be prepared for the three steps of the participatory

planning and budgeting process. The use of these instruments will be assisted by a trained

facilitator. For example, to help the villagers identifying the necessary action, the facilitator

may help by explaining the standard action for TB (case detection based on symptoms), how

the confirmations is made through laboratory test, what is the treatment procedure for TB

cases including the important of DOTS, and what the DS cadres could to support these pro-

cedures. A simple ABC (Activity Based Costing) method is recommended for estimating the

cost and budget of the community activity. This is also will be assisted by the filed facilitator.

c. Mobilization of community resources

Mobilization of local resources is essential in the model as to assure that the model will be

sustainable beyond the project period. The villagers are urged to explore the possibility of

collecting contribution from households who have the ability to contribute. The collected con-

tribution may cover partially the operating cost in their annual budget, complementary to the

“block grant” be given by the project. Another possibility is to link this community financing

scheme with a certain income generating activity.

d. Implementing specific actions

As mentioned above, the facilitator will help the Desa Siaga (in MMD process) to identify cost

effective intervention for any specific health problems. The basis of selecting the intervention

would be the available standardized guidelines such as the management of malaria program,

tbc, immunization, MPS, IMCI, etc. For an illustration, if the Desa Siaga has determined that

malaria is one of their priorities, the facilitators will explain that malaria control requires the

following activities:

• case detection with laboratory confirmation (blood smear or RDT)

• prompt treatment and assuring compliance of the patient to take the anti-malaria

drugs properly

• distribution of impregnated bed net

• various measures for vector control (elimination of breeding and resting places,

spraying, etc).

In the MMD forum the Desa Siaga and the community then use the information to determine

what action they can do to support the standardized actions in malaria control.

e. Performance monitoring

As the main objective of this model is to accelerate the achievement of selective MDGs tar-

gets, a monitoring system using household mapping will be introduced. Each household with

certain health condition under consideration will be given a “health card” which contains:

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• Household ID and address

• Lists of priority health condition/problems

• Coloured boxes following each health condition/problem:

- Red box denotes that the respective household has its member in need of

medical intervention

- Yellow box denotes that the respected person has already under treatment

- Green box denotes that the person has successfully treated

Each household location will be plotted in the village map along with specific problems and

colour of the respective household. Desa Siaga will use the map to monitor progress of its

performance visually, i.e. by evaluating the transfer of red colour to yellow and then to green

colour.

f. Financial management

The Desa Siaga will be given a block grant annually to support their activity. The size of the

grant will be in accordance to their proposed budget that has been reviewed by the Desa

Siaga Advisory Committee, the Facilitator, the head of the village and the Puskesmas.

In order to assure accountability and transparency, the Desa Siaga will use the grant accord-

ingly and managed financial recording and reporting (book keeping) using a prepared stan-

dard financial report forms. The use of the fund should be reported and reviewed monthly by

the Facilitator, Head of the Village and Puskesmas.

In the end of the year all revenue and expenditure will be audited. The result of the auditing

will be made transparent to all village community (in some places the financial balance is

displayed in a board at specific places (in this case as Desa Siaga).

3. Provision of the block grant

The purpose of providing block grant to the Desa Siaga is to cover the start up and operat-ing costs of specific activities related to achieving certain health programme targets.

This is necessary to convince the villagers that their proposed activity will be supported by

adequate financial sources. The provision of the block grant is also to prove if assuring suffi-

cient operating cost will improve health program performance.

The start up (establishment) cost of the DS model include the cost for Poskesdes construc-

tion and its standard equipment, the training of facilitators and the establishment of DS or-

ganization by the community, including the cost of initial participative planning and budget-

ing (SDM and MMD). A certain amount of cost for consumable is also needed, such as drug,

producing household health cards for surveillance and mapping. Earlier calculation estimated

that the start up cost is around Rp 310,000,000, consist of:

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• Capital start up cost Rp 260.000.000,-

(Civil work, equipment, training)

• Operating cost: Rp 50.000.000,-

(Drugs, participative planning, other operational cost)

The subsequent operating cost will depend on the annual activity proposed by each Desa

Siaga. The plan is for the project to allocate a block grant to the respective village to cover

the total cost of Rp 310.000.000. This grant will be channeled using Deconcentration budget

allocation mechanism. This is explained as follow:

Planning process:

1. At the village level, a Community Health Committee and Desa Siaga executive

management will be established to manage Desa Siaga, consist of a chairman, sec-

retary, treasurer and 3 members.

2. With the assistance of the facilitator and bidan (especially related to medical aspect

of the planning (planning for drugs, FP, etc), the Desa Siaga management perform a

planning and budgeting process. For the first year the planning include the planning

of the “star up” or initial budget, and the first year operating budget.

(1) Start up budget including

(a) Poskesdes construction,

(b) its necessary equipment and

(c) initial training for the Desa Siaga cadres.

(d) other start up or investment cost

(2) Operating budget

(a) Administrative operating cost (health cards, recording and reporting,

meeting, etc)

(b) Specific activity related to specific performance target (FP, ANC, Li-

nakes, KN, KBayi, CDR tb, CDR malaria, etc

3. Puskesmas will review the plan for technical aspects of health services

4. The head of the village also review the plan for his/her approval, especially related

to the site location for Poskesdes

5. The DHO review the proposal for approval

6. The proposal is submitted by the Desa Siaga management, endorsed by the Village

Health Committee, to the PHO and forward the proposal to MoH

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Fund channelling:

1. At the village level, the Chair person of the Desa Siaga executing management

open an account in the local bank (Kecamatan)

2. Based on the submitted proposal, the central level (MoH) will authorize KPPN to

transfer the amount to the account of the respective Desa Siaga

3. The amount disburses to the Desa Siaga account is treated as a package of budget

for the respective Desa Siaga.

Assuring financial Accountability

Provision of a “block grant” to the village level requires a mechanism for assuring the ac-

countability of the use of the resources. The mechanism starts from the planning and budget-

ing process in which each budget (funding) link to specific indicator and activity. This follows

the process of preparing “performance planning and budgeting”. The proposed plan will be

reviewed by different level, including the facilitator, Village Chief (who also given the author-

ity to endorse the proposed plan a budget), the Puskesmas, and the DHO staff.

Disbursement of the fund is directly to the account of the respective Desa Siaga under a col-

lective account. It is considered that withdrawing of the funds from the bank should be signed

by three individuals (The DS Manager (Ketua), DS Treasurer, the Facilitator and/or Bidan).

A set of financial reporting system will be developed with clear flow of the fund (cash inflow,

cash outflow, balance, line item budget reporting system, performance budget reporting sys-

tem). The financial report will be exposed in the DS meeting every month. At the end of the

year, an annual audit will be performed by DHO office.

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Role of other institutions

• Village Chief

- Help establish the Desa Siaga

- Help provide the land for the site of the Poskesdes

- Mobilize PKK to support the DS

- Review and endorse the plan and budget proposed by the DS

• Puskesmas

- Help with the establishment of the DS

- Review and endorse DS proposed plan and budget and submit to DHO

- Link DS surveillance system with the Puskesmas system

- Response adequately to any sign of outbreak reported by the DS

- Provide BEONC

- Assist the baseline and evaluation survey

- Cross check that the block grant has been transferred correctly

• District Health Office

- Help determine the location of DS model and the control village

- Advocate the Village Chief to support the DS model

- Propose candidate for facilitator (see the above criteria)

- Supervise and monitor the facilitator

- Cross check that the block grant has been transferred correctly

- Assist the baseline and evaluation survey

- Advocate the result of the evaluation to the Bupati/Walikota

• Local Pemda/Bappeda

- Mobilize PKK to support DS

- Replicate if the model turned out to be cost effective

• Provincial Health Office

- Help the training of facilitators

- Assist the evaluation of the model for the whole province

- Help formulate policy recommendation generated from the evaluation

• Central level

- Review all proposal and budget of DS model

- Assure timely allocation and disbursement of the block grant

- Develop instruments for the baseline and evaluation

- Develop curriculum for the facilitator training

- Evaluate the whole DS model in the 8 provinces

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- Help formulate policy recommendation generated from the evaluation

7.5.6 Impact Evaluation of Desa Siaga

An important purpose of this activity is to formulate policy recommendation with regard to

Desa Siaga. Therefore there must be valid evidence demonstrating that the model is really

cost effective. Consequently, the implementation of the model development requires a spe-

cific design that will allow a scientific evaluation.

Testing effectiveness of the model

In each district 2 villages will be chosen as the site for the model development. In addition,

another 2 will be selected for controls. The selection of those villages will be done through

intensive discussion with DHO and district government. Specific criteria will be developed by

technical assistance so that the control villages will match the model villages.

The objective of this activity is to explore and developed a model of Desa Siaga that is effec-

tive in enhancing health program performance and improving the health status of the village

community. It is hope that this activity in collaboration with PNPM and there is a possibility

that this model in some districts might become activities sponsored by other communities.

In the end of this activity as a trial of Desa Siaga under DHS 2 project, it will also formulate a

policy recommendation and technical guideline for Desa Siaga based on the evaluation of

the model. The results of this activity must meet the needs of the national, provincial and dis-

trict governments.

In the first year (2008) there will be 2 Desa Siaga established in the 2 villages of each district

and that will give a total of 172 Desa Siaga in the entire 86 districts under DHS 2. Information

collected in the evaluation of the first year experience will be used to improve the project per-

formance as it is expanded. In the second year (2009) additional 3 Desa Siaga will be estab-

lished in each district or totally 258 Desa Siaga in the whole DHS 2 district.

Design

The model is consists of two main elements (1) community empowerment to manage the

Desa Siaga (demand side) and (2) strengthening health services system (supply side).

The model will be designed based on Quasy Experimental Design. From each district there

will be 2 villages chosen as the site for model development (as experimental object for inter-

vention) and 2 others will be selected for control.

The selection of those villages will be done through intensive discussion with DHO and dis-

trict government. Specific criteria will be developed by technical assistance so that the con-

trol villages will match the model (experimental) village. Each desa siaga village will be

matched with similar village in a neighboring sub district on the following attributes: size, de-

velopment level, education, poverty, occupation, proximity to nearest market.

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Evaluation of the model

Before any intervention was implemented, a base line survey will be done in all dose villages

(both experimental and control village). The base line survey will include variables explaining

the basic characteristic of the community and the villages as well as indicators denoting the

expected outputs of the model development (such as community contribution, regularity of

village organization, coverage or output of certain health program, etc). The information will

be collected quarterly for one year at both case and control villages.

The following indicators will be measured:

• Indicators related to the community empowerment :

- Regularity of village organization,

- Ability of village to manage medical emergency

- Ability of village in self support for financial needed

- Ability of village to sustain the Desa Siaga model

• Indicators related to MDG targets

- MDG 1: reduction of hunger

- MDG 4: reduction of IMR

- MDG 5: reduction of MMR

- MDG 6: reduction of communicable disease

• Indicators related to other health program such as outpatient utilization, school

health programs, water supply and sanitation, etc.

This evaluation should be contracted to a consortium of universities with the multi center sys-

tem and all local public university will be involved under coordination of one center (Gajah

Mada or University of Indonesia).

Indicators

Community empowerment Program performance Outcome indicators

1. Regularity of village organization

• Survey Mawas Diri (SMD),

• Musyawarah Masyarakat Desa (MMD)

• Role of the community in the planning, implemen-tation and evaluation

• Effective support from community leaders, head of the village, Camat

• Implementation of SMD & MMD

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Community empowerment Program performance Outcome indicators

2. Ability of the village to manage emergency

Preparedness / alertness of the community

• Availability of village ambu-lance

• KAP of alertness • Effective 24 hour surveil-

lance system • List of the blood type of the

whole adult population • Ability of village manage

medical emergency

3. Ability of the village to mobilize resources for implementation

Financial and budgeting sys-tem

• Collecting community con-tribution have developed

• Availability of financial if needed

4. Ability of the village to support the sustain-ability of Desa Siaga

Mobilization of all community resources

• Availability of community saving system

• Availability of exit strategy MDG Target Program performance Outcome indicators

1. MDG 1: Reduc-tion the hunger

Coverage of under five weighing (90%), LBW and SKDN, N/D etc.

Number reported cases of malnutri-tion % children with under weight de-creased

2. MDG 4: reduction of IMR

PNC (2 times), referral of emer-gency cases, immunization cov-erage (85%)

No of life birth, infant death, mea-sles outbreak and number of case of communicable diseases

3. MDG 5: reduction of MMR

CPR, ANC (K4), Assisted deliv-ery, Post Natal Care (PNC 2x) Referral of emergency cases

Number of delivery, emergency cases and referral emergency cases, maternal death

4. 4. MDG 6: re-duction of communicable disease

CDR, SR and CR of Tuberculosis and Malaria

Number of reported Tbc cases Number of reported Malaria cases

Types of program Program performance Outcome indicators

1. Out patient services Utilization of health services • % increase of person seeking

treatment if Sick • % increase of outpatient

2. Sanitation and drinking water supply

Latrine at home and at school, source of drinking water

• % household with latrine • % household with clean wa-

ter supply • % of school have latrine and

hand washing

3. Posyandu attendance Revitalization of Posyandu • Number of active Posyandu • Posyandu attendance in-

crease

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4. Sustainability of cadre Number of cadre have train-ing • % of cadre drop out

7.5.7 Cost effectiveness

All inputs given to the model development will be accounted and their cost will be calculated.

This will allow a cost effectiveness analysis to be performed. This evaluation will show the

comparison of cost and effectiveness between the villages with the model (Desa Siaga) and

villages without the model.

With this design, the analysis will compare the marginal cost of any output (see the above

indicators) in the two setting: villages with Desa Siaga model and village without the model.

The evaluation of the model will be based on the assessment of all inputs, process, outputs

and outcome of piloting the model. This is explained in the following table.

Inputs Process Outputs Outcomes1 Poskesdes establishment 1 Surveillance 1 Coverage of speciific

program1 Under nutrition

2 Placement of health professional

SMD and MMD 2 Exit strategy plan 2 Rate of pregnancy

3 Training and placement of facilitator

2 Desa Siaga activity 3 Financial cash flow performance

3 Number of delivery and reported maternal death

4 Block grant to Desa Siaga 3 Desa Siaga management activity

4 Community financial contribution

4 Number reported infant death

5 etc 4 Community financing scheme

5 Number of tb and malaria cases

5 Income generating 6 Frequency of measles outbreak

Non Government Organization’s role

The involvement of non-government organizations will be a feature of the desa siaga DHS

pilot program. This will include international NGO’s (where appropriate), national NGO’s,

and domestic NGO’s. They will be encouraged to partner with the villages, district health

offices, and with the surveillance component. This will start with the national meeting with

various international and national NGO’s, and will role out to the provincial and district level

during 2008.

Surveillance

It is convenient to analyze a surveillance system in terms of its structure, process and output.

Structure consists of objectives, resources and organizational procedures i.e. the input to the

system. The epidemiological surveillance process may be divided into a) observation, com-

munication and confirmation of the event/s and b) interpretation, presentation and communi-

cation of the findings to decision-makers. The final output of the surveillance system often

takes the shape of a communication or report to the decision-makers. The use to which that

report will be put (its impact) is the ultimate test of whether the surveillance system works.

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Surveillance systems provide essential information for designing, implementing, and evaluat-

ing disease prevention and control activities. There will be four main regular activities:

• Data collection,

• Data analysis

• Interpretation, and

• Dissemination of data.

1. Data collection

To improve quality of data collection, it is important to have an understanding of who report, what skills are required to report, and what motivates individual to report. For these rea-

sons, to develop a good surveillance programs, it is needed to provided special training to

health staffs who will responsible to work on surveillance.

2. Data Analysis and Interpretation

Most of the data was only tabulated and aggregated by demographic categories, and then

process end at this level. In some provinces there are trained field epidemiologists (PETPs)

who are responsible for analyzing and interpreting surveillance data, but since the system

was not work, very few surveillance data available at province level.

The objective of this work is to carry out surveillance system in Desa Siaga model of DHS 2

with 172 villages in 86 districts for the first year (2008) and additional 258 villages for the

second year (2009) to become 430 villages at the end of the project.

The result of the surveillance system will be use to develop national surveillance system

based on village and district data information. The surveillance system for desa siaga will be

divided in two main programs: (1) surveillance based on the data from base line survey and

will be present in mapping system, (2) surveillance of communicable diseases that has po-

tential for outbreak.

Surveillance and Mapping

Cadres at Desa Siaga will be given training in:

1. How to conduct a base line survey.

2. Collecting data and develop a mapping system.

3. How to identify certain communicable diseases base on the disease symp-

toms and health problems.

Training for cadres will take place at the Puskesmas in the same subdistrict of the selected

villages, and field study will be at the same selected village. The secretariat and the cadres

will manage a routine surveillance system in form of mapping all household in the village.

Any health condition in each household will be identified and will include in the map:

• the present of eligible couple for FP program (special colours for FP acceptor),

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• Pregnant women and her ANC status (different colours for normal, for risk and for

high risk pregnant mother), blood type and estimate time for delivery.

• Number of children (newborn, under five and school children) and elderly.

• Nutrition status of children (different colours for mild and severe nutrition / colour

will be changed every time the condition changes).

• Tuberculosis patients for different colours in each condition.

The mapping exercise will also include location of spring water, households with latrine, and

other indicators.

Communicable Diseases Surveillance

In addition to the routine surveillance, the Desa Siaga will also manage surveillance for

communicable diseases that have the potential for epidemic outbreak.

Disease surveillance conducted by cadre in Desa Siaga is observation of disease through

disease symptoms and situation threatening the raise of health problem to be immediately

reported to the village chief of village and health officer.

The cadres will work closely with the community members to detect the incidence of certain

diseases that have the potential for epidemiological outbreak such as, and will receive basic

training from facilitators to be knowledgeable about the symptoms of:

1. Avian Flu 5. Malaria 9. Poliomyelitis

2. Pneumonia 6. Severe nutrition 10. Infant /neonatal tetanus

3. Diarrhea 7. Measles 11. Vitamin A deficiency

4. Dengue (Dengue Hem-orrhagic Fever)

8. Diphtheria 12. Lung Tuberculosis

Reporting procedures

Any suspected potential outbreak will be reported immediately to Poskesdes (health profes-

sional) and to village government (RT or RW) and to posyandu / UKM if available and do

simple preventive effort and simple handling. In addition, the cadres can also find symptoms

and sign of health problems in the community from posyandu or report directly from commu-

nity. All cases will be reported include : name, address (name of the head of household),

age, gender and occupation (of parent for children case), symptoms and disease signs or

thing threatening health problems (see sample form report by cadres ). All reports have to

be registered in Poskesdes and then immediately send to the nearest Puskesmas and to

Head of the village (see chart below).

Report can be done by using SMS or phone or any kind of electronic communication for a

QUICK action and prevent the disease in spread to others.

Feeding centers established in health centers for “ibu Kek”

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Mothers will be classified as to nutritional status using mid-upper arm circ. Mothers that are

underweight will be referred to feeding centers developed at local health centers for feeding

and nutrition education. It is proposed that mothers in their second and third trimesters of

pregnancy be given supplemental feeding. This should be procured locally but be in line with

recommendations on nutritional requirements for pregnancy. All efforts will be made to in-

sure that the Desa Siaga becomes responsible for supplying supplemental feeding to under-

weight mothers in the “alert village”. In addition, the desa siaga will undertake the promotion

of exclusive breast feeding for infants under the age of six months.

Control of Infectious Diseases

Many of the DHS-2 districts are still endemic for malaria, and tuberculosis remains one of the

most important causes of mortality for adults in all of Indonesia. Two approaches will be

used in DHS-2 to address the management of these diseases in desa siaga, villages. One

will be training for malaria control for the midwife, health center and district health offices,

and the other will be advocacy with local government on the importance of the control, man-

agement and prevention of these diseases. Additional Desa Siaga village committee’s will

be asked specifically to develop plans on the management of these diseases.

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7.6 Economic and Financial Analysis of Desa Siaga

7.6.1 Background and Objective of the Analysis

Desa Siaga is a national program to strengthen the capacity and self reliance of the village

community in improving and maintaining their health. The program has a strong national

support, but it is expected that in the process of its development the local government and

local community will take over the responsibility of continuing and maintaining its existence

and operation.

Affordability and sustainability has been an important issue in various health initiatives as

experience in the past in Indonesia. This economic issue is critical especially if the initiative

is aimed at transferring the responsibility to the community, such as the village community.

There were a number of such initiatives that had “come” and “go” such as “Community Fi-

nancing Scheme” (Dana Sehat), Village Community Health Development (PKMD or Pem-

bangungan Kesehatan Masyarakat Desa), Village Drug Post (Pos Obat Desa), Village Inte-

grated Health Post (Posyandu), etc.

Every health initiative has its cost implications, including the start up (investment), operating,

and maintenance costs. The economic analysis shall help answering the following questions:

• How much does it cost to establish Desa Siaga (start up or investment cost)

• How much does it cost to operate the Desa Siaga (operating cost)

• Is the cost affordable within the capacity of local resources (especially operating

and maintenance cost)

• Is it sustainable if Desa Siaga is to be funded by local or village community and

local government?

Answers to these questions are needed for planning and budgeting Desa Siaga, including

finding ways of sustaining it. Moreover, if the costs were related to performance indicators of

Desa Siaga, one can make a judgment on whether the programme was efficient or not.

7.6.2 The Concept of Desa Siaga

Desa Siaga (Alert Village) is a village where the community has the capacity and willingness

to mobilize resources, to prevent and overcome health problems, disaster and emergency

situations in their respective village. The goal of DS is improved health status of the village

community.

The specific objectives of Desa Siaga are:

a) Increase knowledge and awareness of the village community on the importance

of their health

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b) Increase the awareness, alertness and preparedness of the village community

about the risks and health hazards that threaten their health, including disasters,

disease outbreaks and emergencies.

c) Increase awareness of the family on their nutritional problems and adopt healthy

life style including personal hygiene.

d) Improve the village environmental health.

e) Improve the ability and willingness of the village community to be self reliant in

improving and maintaining their health.

7.6.3 Pos Kesehatan Desa (Village Health Post) and Desa Siaga

The concept

Poskesdes is the prime mover of Desa Siaga. In order to become a Desa Siaga, a village

has to have an operating Poskesdes. Pos Kesehatan Desa (Poskesdes) is a type of com-

munity based activity aimed at improving access to basic health services to the village com-

munity. Poskesdes is a meeting point between community based activity and government

support activity. It carries out health promotion, prevention and treatment, undertaken by

health personnel (primarily bidan or midwife) in collaboration with cadres and other voluntary

workers.

Tasks and functions

There are at least four main tasks or functions implemented under the Poskesdes:

1. Simple epidemiological surveillance especially communicable diseases that is po-

tential to become epidemic (outbreak) along with risk factors related to the dis-

eases such as nutritional status and vulnerable pregnant women;

2. Overcome the diseases especially communicable diseases that is potential to be-

come epidemic (outbreak) along with risk factors related to the diseases such as

nutritional status and vulnerable pregnant women;

3. Maintain preparedness to overcome disaster and health emergency;

4. Provision of basic health services in accordance to the health workers compe-

tency available in the Poskesdes.

There are also additional tasks of Poskesdes, including the following:

5. Health promotion to improve the awareness of family on nutrition, improve healthy

life style and environmental health.

6. Support and coordinate other community based activities such as village drug

post, community financing scheme, etc.

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Human resources and infrastructures

The personnel of Poskesdes at least should consist of health personnel (at least one mid-

wife), supported by at least 2 cadres. The physical infrastructure of a Poskesdes include (a)

building, (b) furniture, (c) medical equipment, and (d) communication instruments (such as

telephone, cellular phone, etc).

Various ways of establishing Poskesdes building are converting Polindes (Village Maternity

House) to become a Poskesdes, converting any village building (for example village commu-

nity hall), or constructing a new building funded by government, donor, private enterprise or

community self help.

7.6.4 Establishment and Operation of Desa Siaga

The following table describes the process of DS establishment as well as its recurrent activ-

ity. The table also specified the role of various levels including central, provincial, district,

Puskesmas and village (MoH Letter No: 574/MENKES/SK/VIIIThe activity related to Desa

Siaga development can be classified into (1) indirect or support activity and (2) direct activity.

And each of the classifications consists of: (a) investment or start up activity and (b) regular

or recurrent activity. The list of those activity is important as to be used as the basis of iden-

tifying and estimating the cost related to it.

7.6.5 Economic Analysis

There are a number of analytical methods available for an economic analysis of a certain

program such as the Desa Siaga. The analysis include (a) just merely estimating the cost,

(b) relating the cost to certain specific output resulting at an estimate of unit cost of output,

(c) comparing unit cost of several alternative interventions to produce a specified output

(Cost Effectiveness Analysis), (d) comparing the cost of input and benefit of output measured

in monetary term (Cost Benefit Analysis), (e) comparing the cost with the existing resources

(affordability and sustainability), (f) maximizing output given mixed inputs (production possi-

bility frontier), (g) exploring efficiency (economic, technical and scale efficiency), etc.

The feasibility of implementing the analysis is depending on the (a) setting of the intervention

(for example: is a control or baseline data available), (b) clarity and measurability of the out-

put, (c) availability of cost data.

As for the Desa Siaga, there are conditions limiting the execution of all of the above analysis.

At the present time, Desa Siaga is still in its development phase and therefore measuring its

outputs is difficult. There is no alternative intervention to be compared with Desa Siaga as to

see which one was “cost effective”.

One possibility with respect to trying CEA is to compare the performance of the health sys-

tem (for example at the village setting) between the two situations: (a) without Desa Siaga

and (b) with Desa Siaga.

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In order words, incremental improvement of certain health performance resulting from intro-

ducing Desa Siaga must first be calculated before CEA is executed. However, due to un-

availability of data, CEA was not done in the analysis.

The Cost Analysis

The cost analysis will answer the following questions:

• How much it cost to established Desa Siaga (start up or investment cost)

• How much it cost to operate the Desa Siaga (recurrent or operating cost)

The cost analysis will produce the estimate of the total cost of developing and operating

Desa Siaga. The total cost include all indirect cost provided by various sources as well as

direct cost which usually is incurred at the Desa Siaga (village) level.

The indirect cost include all cost spent for the indirect activity as described in the previous

sections. This cost mostly is spent at the central, provincial, district and Puskesmas levels.

This cost consist of (a) fixed cost or capital investment cost) and (b) variable cost or recur-

rent cost. Similarly, there is direct cost which mostly spent at the Desa Siaga levels. The di-

rect cost also can be classified into (a) fixed cost and (b) variable cost.

INDIRECT (SUPORT) ACTIVITY Level/ Target Accounted1 Start up (Investment) Institution or not

* Guideline development Central Not included* Training modules Central Not included* TOT Central Not included* TOT for district level District DHO staff Included* Training of health personnel - Puskesmas staff to suppport Desa Siaga District Pusk staff Included - Midwife (Desa Siaga) District DS bidan Included* Improving Puskesmas capacity Central Poned (BEON) Not included* Improving Hospital capacity Central Ponek (CEON) Not included* Establishing Puskesmas Team Puskesmas Pusk. Staff Included

2 Recurrent* Monitor and evaluate Desa Siaga Puskesmas Pusk. Staff Included* Reporting progress of Desa Siaga Puskesmas Pusk. Staff Included* Implementing Local Area Monitoring Puskesmas Pusk. Staff Included* Supervision of DS by Puskesmas (regular) Puskesmas Pusk. Staff IncludedDIRECT ACTIVITY

1 Establishment of Desa Siaga (start up)* Establishment of Village Team Village Desa Siaga Included* Village Self Assessment (SMD) Village Desa Siaga Included* Village Consultative Meeting (MMD) Village Desa Siaga Included* Formulation of organization and personnel of DS Village Desa Siaga Included* Cadres training Village Desa Siaga Included* Constructin/establisment of Poskesdes Village Desa Siaga Included

2 Recurrent activity* Poskesdes activity (see below) Village Included(1) Epidemiological surveilance Village Desa Siaga Included(2) Diagnosis and treatment Village Desa Siaga Included(3) Manage risk and outbreak and dissaster) Village Desa Siaga Included(4) Improve nutrition (especially the vulnerable group) Village Desa Siaga Included(5) Identify and manage vulnerable pregrant women Village Desa Siaga Included(6) Basic treatment Village Desa Siaga Included(7) Health promotion Village Desa Siaga Included(8)Cordinate/collaborate with other comm.based activty Village Desa Siaga Included

Annexes



Final Report

December 2008

In order to calculate the Unit Cost (UC) of one Desa Siaga, the indirect cost has to be divided

by the number of Desa Siaga supported using the respective indirect cost. This is compli-

cated knowing the fact that the central government cost (one element of the indirect cost) is

caused by all Desa Siaga across the country. In a lesser degree, the same situation is found

at the level of province, district and Puskesmas. Therefore, a “backward” method is used to

estimate the indirect unit costs. This is done by estimating unit cost of specific input to carry

out indirect as well as direct activities. This is displayed in the table above.

The table indicates five cost components that were purposely not included in the cost calcu-

lation. They represent costs spent at the central level to prepare the guideline, costs for de-

veloping training modules, training of central and provincial trainers, cost of improving Pusk-

esmas’ and district hospital’s capacity to deal with emergency cases (this is primarily the cost

for establishment and construction of BEON and CEON). Based on the list of direct and indi-

rect activity and cost classification related to them, the next steps is to identify all inputs (line

items) needed to carry out the activity. This is shown in the following tables.

START UP (INVESTMENT)

1 IndirectConstruct-

ion (*)Equip-ment

Vehicle Training Others

* TOT for district level Province Included District x* Training Puskesmas staff to support Desa Siaga District Included Pusk staff x

2 Direct (Desa Siaga)* Establishment of Village Team Village Included Desa Siaga x* Village Self Assessment (SMD) Village Included Desa Siaga x* Village Consultative Meeting (MMD) Village Included Desa Siaga x* Formulation of organization and personnel of DS Village Included Desa Siaga x* Midwife (Desa Siaga) training District Included DS bidan x* Cadres training Village Included Desa Siaga x* Constructin/establisment of Poskesdes Village Included Desa Siaga x* Equipment (medical & non medical) Village Included Desa Siaga x

(*) New or converting Polindes to become Desa SiagaRECURENT (OPERATIONAL)

1 Indirect

Salary per month

Drugs/ med-

supplies

Utilities Fuel/consumable

Mainte-nance

Transport Miscelaneous

* Monitor and evaluate Desa Siaga Puskesmas Included Puskesmas x x x* Reporting progress of Desa Siaga Puskesmas Included Puskesmas x x* Implementing Local Area Monitoring Puskesmas Included Puskesmas x x x* Supervision of DS by Puskesmas (regular) Puskesmas Included Puskesmas x x x* Establishing Puskesmas Team Puskesmas Included Puskesmas x* Refresment training Midwife Desa Siaga Included Desa Siaga x* Refreshment training cadres Desa Siaga Included Desa Siaga x

2 Direct (Desa Siaga)

* Poskesdes activity (see below) Village Included

Salary per month

Drugs/ med-

supplies

Utilities/ month

Fuel & consu-mable

Maintenance

Transport Miscelaneous

(1) Epidemiological surveilance Village Included Desa Siaga x x x x x(2) Basic treatment Village Included Desa Siaga x x x x x(3) Manage risk and outbreak and dissaster) Village Included Desa Siaga x x x x(4) Improve nutrition (especially the vulnerable group) Village Included Desa Siaga x x(5) Identify and manage vulnerable pregrant women Village Included Desa Siaga x x x x(6) Health promotion Village Included Desa Siaga x x x x(7) Cordinate/collaborate with other comm.based activity Village Included Desa Siaga x x x x

1. The start up (investment cost)

According to the guideline as discussed above, the start up or investment cost consist of

building construction and equipment (if new Desa Siaga is constructed) or building renova-

tion (if Polindes is coverted), training and DS organisational development.

The Unit Cost of constructing new Desa Siaga is Rp 62,765,000 and if Polindes is converted

to become a Desa Siaga, the Unit cost would be Rp 15,265,000.

Annexes



Final Report

December 2008

START UP COST UC Unit Unit CostConstructiona. New (6 x 5 m x 1,500,000) 45,000,000 1 45,000,000 b. Converting Polindes 5,000,000 1 7,500,000 Equipment 10,000,000 1 10,000,000 Training* DOH Staffs (3 per 100 villages) 500,000 3 15,000 * Pusk staffs (10 per 20 villages) 250,000 10 125,000 * Midwife 7,250,000 1 7,250,000 * Cadre 100,000 3 300,000 Other* Village Team formation 25,000 1 25,000 * Forming DS orgnztn 50,000 1 50,000

New Desa Siaga 62,765,000 Converted 15,265,000

2. The recurrent (operating) cost

The amount of recurrent cost (per year) to operate a Desa Siaga depends on the size of

population of the village where the Desa Siaga is located. The following table displays the

annual recurrent cost per Desa Siaga for 5 different assumption of the total population in the

respective village.

Village size (pop) ========> 500 1500 2500 5000 10000 15000RECURENT/OPERATING COST UC UnitSalary (per midwives/month) 1,000,000 12 month 12,000,000 12,000,000 12,000,000 12,000,000 12,000,000 12,000,000 Drugs/med supplies (per population/mo) 560 Population 3,360,000 10,080,000 16,800,000 33,600,000 67,200,000 100,800,000 Utilities (per month) 100,000 12 month 1,200,000 1,200,000 1,200,000 1,200,000 1,200,000 1,200,000 Fuel & consumables (permonth) 40,000 12 month 480,000 480,000 480,000 480,000 480,000 480,000 Maintenance (per yr) 1,000,000 1 yr 1,000,000 1,000,000 1,000,000 1,000,000 1,000,000 1,000,000 Transport (per month) 100,000 1 yr 1,200,000 1,200,000 1,200,000 1,200,000 1,200,000 1,200,000 Miscelaneous (permonth) 100,000 12 months 1,200,000 1,200,000 1,200,000 1,200,000 1,200,000 1,200,000 Refreshment training 1 Midwife 500,000 1 yr 500,000 500,000 500,000 500,000 500,000 500,000 Refreshment training 3 Cadres 50,000 1 yr x 3 150,000 150,000 150,000 150,000 150,000 150,000 Replacement trning (midwive) 7,250,000 0.2 per year 1,450,000 1,450,000 1,450,000 1,450,000 1,450,000 1,450,000 Village self assessment (SMD) 50,000 1 x per yr 50,000 50,000 50,000 50,000 50,000 50,000 Village planning meeting (MMD) 50,000 1 x per yr 50,000 50,000 50,000 50,000 50,000 50,000

UC/Desa Siaga 22,640,000 29,360,000 36,080,000 52,880,000 86,480,000 120,080,000 UC/cap 45,280 19,573 14,432 10,576 8,648 8,005

The recurrent cost per year per Desa Siaga ranges from Rp 25.000.000 (village with 500

population) to Rp 120.000.000 (village with over 10.000 population).

Cost Simulation

In order to calculate the total cost of Desa Siaga, a cost simulation is performed in the prov-

inces of DHS-1 project. There are two scenarios for the simulation:

1. New Desa Siaga (with Poskesdes) is established in all villages currently without

health facility (such as Polindes) and all villages with Polindes is converted to be-

come Desa Siaga. In order words, Desa Siaga is introduced in all villages in the

province

2. Desa Siaga is introduced only in the village already having health facility

(Polindes)

The cost implication of the two scenarios is summarized as follow. The figures were derived

from the subsequent tables (assumption: maximum size of the village is 10.000 people).

Annexes



Final Report

December 2008

First scenario (Desa Siaga in all villages)

TotalProvince < 500 500-1500 1500-2500 2500-5000 5000-10000 > 10000NAD 3,159 2,334 266 154 44 - 5,957 Riau 81 487 368 322 138 79 1,475 Bengkulu 241 660 198 90 25 7 1,221 Kepri 15 71 52 53 26 37 254 Bali 2 50 118 301 192 38 701 Sulut 117 633 284 177 55 3 1,269 Sulteng 294 747 239 183 53 11 1,527 Sultra 339 983 224 111 21 6 1,684 Total 4,248 5,965 1,749 1,391 554 181 14,088

Village size

New DS Polindes convrsion Total With facility No facility N village W faclty No facility 60,265,000 5,515,000

NAD 58.1 41.9 5,968 3,469 2,499.00 150,602,235,000 19,131,535,000 169,733,770,000 Riau 77.39 22.61 1,477 1,143 334.00 20,128,510,000 6,303,645,000 26,432,155,000 Bengkulu 68.46 31.54 1,224 838 386.00 23,262,290,000 4,621,570,000 27,883,860,000 Kepri 95.29 4.71 255 243 12.00 723,180,000 1,340,145,000 2,063,325,000 Bali 93.87 6.13 701 658 43.00 2,591,395,000 3,628,870,000 6,220,265,000 Sulut 72.89 27.11 1,269 925 344.00 20,731,160,000 5,101,375,000 25,832,535,000 Sulteng 80.78 19.22 1,530 1,236 294.00 17,717,910,000 6,816,540,000 24,534,450,000 Sultra 50.27 49.73 1,685 847 838.00 50,502,070,000 4,671,205,000 55,173,275,000 Total 66.33 33.67 14,109 9,359 4,750.00 286,258,750,000 51,614,885,000 337,873,635,000

Investment cost

UC (recurrent) 22,640,000 29,360,000 36,080,000 52,880,000 86,480,000 TotalNAD 71,519,760,000 68,526,240,000 9,597,280,000 8,143,520,000 3,805,120,000 161,591,920,000 Riau 1,833,840,000 14,298,320,000 13,277,440,000 17,027,360,000 11,934,240,000 58,371,200,000 Bengkulu 5,456,240,000 19,377,600,000 7,143,840,000 4,759,200,000 2,162,000,000 38,898,880,000 Kepri 339,600,000 2,084,560,000 1,876,160,000 2,802,640,000 2,248,480,000 9,351,440,000 Bali 45,280,000 1,468,000,000 4,257,440,000 15,916,880,000 16,604,160,000 38,291,760,000 Sulut 2,648,880,000 18,584,880,000 10,246,720,000 9,359,760,000 4,756,400,000 45,596,640,000 Sulteng 6,656,160,000 21,931,920,000 8,623,120,000 9,677,040,000 4,583,440,000 51,471,680,000 Sultra 7,674,960,000 28,860,880,000 8,081,920,000 5,869,680,000 1,816,080,000 52,303,520,000 Total 96,174,720,000 175,132,400,000 63,103,920,000 73,556,080,000 47,909,920,000 455,877,040,000

Recurrent cost/year

The cost of introducing Desa Siaga in all villages in the province

Total Recurent TotalNew Desa Siaga Coversion from Polindes (Investment) Cost

NAD 150,602,235,000 19,131,535,000 169,733,770,000 161,591,920,000.00 331,325,690,000 Riau 20,128,510,000 6,303,645,000 26,432,155,000 58,371,200,000.00 84,803,355,000 Bengkulu 23,262,290,000 4,621,570,000 27,883,860,000 38,898,880,000.00 66,782,740,000 Kepri 723,180,000 1,340,145,000 2,063,325,000 9,351,440,000.00 11,414,765,000 Bali 2,591,395,000 3,628,870,000 6,220,265,000 38,291,760,000.00 44,512,025,000 Sulut 20,731,160,000 5,101,375,000 25,832,535,000 45,596,640,000.00 71,429,175,000 Sulteng 17,717,910,000 6,816,540,000 24,534,450,000 51,471,680,000.00 76,006,130,000 Sultra 50,502,070,000 4,671,205,000 55,173,275,000 52,303,520,000.00 107,476,795,000 Total 286,258,750,000 51,614,885,000 337,873,635,000 455,877,040,000.00 793,750,675,000

Start up (Investment Cost)

Annexes



Final Report

December 2008

Second scenario (Desa Siaga only in villages that already have Polindes)

TotalProvince < 500 500-1500 1500-2500 2500-5000 5000-10000 > 10000

NAD 1,840 1,359 155 90 26 - 3,469 Riau 63 377 285 250 107 61 1,143 Bengkulu 165 453 136 62 17 5 838 Kepri 14 68 50 51 25 35 243 Bali 2 47 111 283 180 36 658 Sulut 85 461 207 129 40 2 925 Sulteng 178 453 145 111 32 7 925 Sultra 249 721 164 81 15 4 1,236 Total 2,596 3,940 1,253 1,056 442 150 9,437

Village sizeThe number of Desa Siaga established, converted from Polindes

Investment costProvince N of DS UC (start up) Total Inv. Cost

NAD 3,469 5,515,000 19,131,535,000 Riau 1,143 5,515,000 6,303,645,000 Bengkulu 838 5,515,000 4,621,570,000 Kepri 243 5,515,000 1,340,145,000 Bali 658 5,515,000 3,628,870,000 Sulut 925 5,515,000 5,101,375,000 Sulteng 925 5,515,000 5,101,375,000 Sultra 1,236 5,515,000 6,816,540,000 Total 9,437 5,515,000 52,045,055,000

Recurrent CostProvince < 500 500-1500 1500-2500 2500-5000 5000-10000 Total

UC 22,640,000 29,360,000 36,080,000 52,880,000 86,480,000 NAD 41,648,824,482 39,905,577,734 5,588,881,034 4,742,298,284 2,215,873,977 94,101,455,511 Riau 1,421,070,590 11,079,986,278 10,288,890,793 13,194,761,003 9,248,024,624 45,232,733,288 Bengkulu 3,744,741,294 13,299,286,486 4,902,979,459 3,266,346,929 1,483,829,648 26,697,183,817 Kepri 324,892,913 1,994,283,780 1,794,908,976 2,681,265,827 2,151,104,882 8,946,456,378 Bali 42,502,482 1,377,951,498 3,996,284,622 14,940,523,595 15,585,645,193 35,942,907,389 Sulut 1,930,822,695 13,546,898,345 7,469,043,341 6,822,520,095 3,467,037,037 33,236,321,513 Sulteng 4,032,055,010 13,285,544,204 5,223,566,470 5,861,992,141 2,776,478,062 31,179,635,887 Sultra 5,633,165,416 21,182,926,176 5,931,860,523 4,308,149,929 1,332,942,328 38,389,044,371 Total 58,778,074,882 115,672,454,501 45,196,415,219 55,817,857,803 38,260,935,749 313,725,738,154

The cost of introducing Desa Siaga only in villages that already has Polindes

Province Investment Cost Recurrent Cost Total CostNAD 19,131,535,000 94,101,455,511 113,232,990,511 Riau 6,303,645,000 45,232,733,288 51,536,378,288 Bengkulu 4,621,570,000 26,697,183,817 31,318,753,817 Kepri 1,340,145,000 8,946,456,378 10,286,601,378 Bali 3,628,870,000 35,942,907,389 39,571,777,389 Sulut 5,101,375,000 33,236,321,513 38,337,696,513 Sulteng 5,101,375,000 31,179,635,887 36,281,010,887 Sultra 6,816,540,000 38,389,044,371 45,205,584,371 Total 52,045,055,000 313,725,738,154 365,770,793,154

Affordability

The calculation based on two scenarios as presented above conclude the following:

Annexes



Final Report

December 2008

a) Establishing Desa Saga in all villages in all province of DHS-1 will cost a total

amount of Rp 793,750,000,000. Of this amount, Rp 337,873,000,000 is for in-

vestment (start up) cost and Rp 455,877,000,000 is for recurrent cost.

b) If Desa Siaga is only introduced in villages already having Polindes or other facili-

ties, the total cost would be Rp 365,770,000,000. Of this amount, Rp

52,045,000,000 is for investment cost (start up cost) and Rp 313,725,000,000 is

for recurrent cost.

First scenario

Province Investment Cost Recurrent Cost Total CostNAD 169,733,770,000 161,591,920,000.00 331,325,690,000 Riau 26,432,155,000 58,371,200,000.00 84,803,355,000 Bengkulu 27,883,860,000 38,898,880,000.00 66,782,740,000 Kepri 2,063,325,000 9,351,440,000.00 11,414,765,000 Bali 6,220,265,000 38,291,760,000.00 44,512,025,000 Sulut 25,832,535,000 45,596,640,000.00 71,429,175,000 Sulteng 24,534,450,000 51,471,680,000.00 76,006,130,000 Sultra 55,173,275,000 52,303,520,000.00 107,476,795,000 Total 337,873,635,000 455,877,040,000.00 793,750,675,000

Second scenario

Province Investment Cost Recurrent Cost Total CostNAD 19,131,535,000 94,101,455,511 113,232,990,511 Riau 6,303,645,000 45,232,733,288 51,536,378,288 Bengkulu 4,621,570,000 26,697,183,817 31,318,753,817 Kepri 1,340,145,000 8,946,456,378 10,286,601,378 Bali 3,628,870,000 35,942,907,389 39,571,777,389 Sulut 5,101,375,000 33,236,321,513 38,337,696,513 Sulteng 5,101,375,000 31,179,635,887 36,281,010,887 Sultra 6,816,540,000 38,389,044,371 45,205,584,371 Total 52,045,055,000 313,725,738,154 365,770,793,154

Are these cost affordable? DHS-1 has estimated the amount of budget available for support-

ing Desa Siaga from all sources in 7 out of 8 provinces is Rp 128,541,754,000 (table below).

Province Inv. Cost (TOT midwives only)

Recurrent Cost Total

NAD 2,751,375,000 21,460,090,000 24,211,465,000 Riau 1,354,400,000 17,032,010,000 18,386,410,000 Bengkulu 1,068,700,000 13,368,242,000 14,436,942,000 Bali 1,270,300,000 15,654,546,000 16,924,846,000 North Sulawesi 1,392,600,000 17,196,850,000 18,589,450,000 Central Sulawesi 845,700,000 18,432,673,000 19,278,373,000 South East Sulawesi 2,165,700,000 14,549,568,000 16,715,268,000 Total 10,848,775,000 117,693,979,000 128,542,754,000

Annexes



Final Report

December 2008

This amount is 16% of the total Rp 782,335,910,000 needed in the 7 provinces, i.e. if Desa

Siaga is established in all villages. Or, the available budget would only cover 2,213 villages

in the 7 provinces that have a total of 13,834 villages.

If the available budget is intended to cover villages already having Polindes or other health

facilities, the available budget would cover 35% (3,302 villages) of the total target of 9,437

villages.

Further analysis has been performed to estimate the needed budget the gap is to be closed,

i.e. to cover the remaining villages in the provinces. The following table described the

needed budget, based on two scenarios: (a) all remaining villages will be covered and (b)

only remaining villages with Polindes will be covered.

Needed budget in the coming years

No of village

Investment cost Recurrent cost No of village

Investment cost Recurrent cost

NAD 4,743 285,827,855,250 130,893,831,945.48 2,255 12,435,497,750 62,229,662,958.40 Riau 1,075 64,781,861,750 49,453,180,423.05 743 4,097,369,250 34,179,487,785.76 Bengkulu 928 55,907,840,500 41,380,235,234.71 545 3,004,020,500 24,296,447,269.97 Bali 471 28,366,735,500 28,775,683,823.11 428 2,358,765,500 26,146,930,042.80 Sulut 945 56,965,491,250 34,232,262,269.50 601 3,315,893,750 21,774,290,070.92 Sulteng 1,203 72,513,861,250 41,599,638,389.00 601 3,315,893,750 20,786,854,420.43 Sultra 1,251 75,415,621,000 39,402,751,543.94 803 4,430,751,000 25,296,604,275.53 Total 10,616 639,779,266,500 365,737,583,628.79 5,976 32,958,191,500 214,710,276,823.82 Note: Kepri is not included in this calculation The recurrent cost estimate is adjusted to the village size

ProvinceTarget I (all remaining villages) Target II (remaining villages with Polindes)

The table shows that if all remaining villages would be covered, the needed investment cost

would be Rp 639,779.266,000 and the recurrent cost to run the new Desa Siaga would be

Rp 365,737,583,000.

If only villages already have Polindes would be covered, the needed investment cost is Rp

32,958,191,000 and the recurrent cost to operate the new Desa Siaga would be Rp

214,710,276,000.

The total needed cost per year may less than the amount if the target is broken down into

several years target, fur example 3 years. This is depend on the availability of budget in the

coming years.

7.6.6 Sustainability

The sustainability of the established Desa Siaga will depend on the availability of funds to

cover recurrent costs. There are four potential sources of funding:

1) Budget provided by the (central) government

2) Payment from Askeskin for users of Desa Siaga/Poskesdes for poor people

3) Fees collected by Poskesdes from non-poor users for curative services

4) Local government budget allocation from APBD

Annexes



Final Report

December 2008

For villages with mostly poor people, the sustainability of Desa Siaga will depend primarily on

payments from the Askeskin fund.

There are two important issues regarding Desa Siaga’s reliance to its own revenues:

• The first issue is on fee setting (pricing). Fee setting should be based on cost

analysis of services rendered by Desa Siaga and the fee schedule must be ap-

proved formally (for example through local regulation or PERDA).

• The second issue is on revenue retention. Desa Siaga should be allowed to retain

its revenue but has to report the revenue to Puskesmas and/or Dinas Kesehatan.

7.6.7 Cost Effectiveness

Without information on the incremental change of health service performance that can be

attributed to Desa Siaga activities, it is currently not possible to perform a Cost Effectiveness

Analysis (CEA). Desa Siaga carry out various activities and render specific medical care

services including MCH and treatment.

A specific study is needed in order to estimate the effectiveness of Desa Siaga in improving

the coverage of MNCH, such as ANC coverage (K1 – K4), treatment of under nutrition, TT

Immunization, delivery by medical personnel and neonatal visits. The study also should es-

timate the contact rate to basic treatment.

Desa Siaga is designed to render basic treatment services, in addition to MNCH services

and other public interventions such as surveillance, health promotion and environmental

health. Regarding treatment, experiences in Batam show un-expected results. After the lo-

cal government decided to provide free treatment services in all Puskesmas in Batam in

January 2007, the visits to Puskesmas increased four times as by June 2007. The total costs

for drugs quadrupled. The Puskesmas staff said their workload at Puskesmas has increased

and affect their performance outside the Puskesmas (public heath activities).

Ann

exes

Supp

ort f

or H

ealth

Sec

tor P

olic

y R

efor

ms,

AD

B T

A 3

579-

INO

11

2

EPO

S H

ealth

C

onsu

ltant

s

Fina

l Rep

ort

Dec

embe

r 200

8

7.7

DH

S-2

Dis

tric

t Lev

el H

ealth

Sys

tem

Per

form

ance

Dat

a 20

07

Assisted Delivery

Inpatie

nt Uni‐

tilization in last

year

outpatient use

amon

g ill with

in

last m

onth

Contraceptive

prevalen

ce rate

married

wom

en

age 15

thru 49

years

measles vacina‐

tion am

ong chil‐

dren

12 ‐24 mon

un‐

derw

ght

poverty

(% pop

qu

intile

1&2)

male

female

Total

%

births

at‐

tend

ed

equity

Inde

x %

equity

Inde

x %

equity

Inde

x %

equity

Inde

x

equity

Inde

x

%

SOUTH

SUMATR

A

OGAN KOMER

ING ULU

12

8,36

9 13

0,79

2 25

9,16

1 82.34

1.22

0.58

0.31

19.03

1.21

60.00

0.89

84.23

0.36

23.22

50.7

OGAN KOMER

ING ILIR

339,47

0 33

2,56

7 67

2,03

7 66.03

1.51

0.35

9.52

28.21

0.55

53.85

0.83

75.08

0.82

35.44

62.6

MUARA

ENIM

33

3,91

2 30

9,66

1 64

3,57

3 71.40

1.99

0.41

4.87

42.61

0.78

62.29

0.84

85.15

1.26

15.24

64.0

LAHAT

281,95

6 26

8,17

2 55

0,12

8 61.43

1.59

0.58

1.00

21.41

1.17

66.02

1.06

75.15

1.53

27.09

71.0

MUSI RAWAS

251,74

9 23

2,49

6 48

4,24

5 61.89

1.12

0.38

6.51

25.25

0.56

67.34

1.18

83.29

1.00

30.47

56.5

MUSI BANYU

ASIN

245,02

7 23

9,04

9 48

4,07

6 63.61

1.74

0.55

25.27

20.35

1.91

51.75

0.95

68.37

1.49

31.61

43.5

BANYU

ASIN'

377,61

1 37

9,83

9 75

7,45

0 74.12

0.96

0.68

11.63

28.38

0.76

56.34

0.96

84.85

0.58

30.20

52.1

OGAN KOMER

ING ULU

SELATA

N

167,73

9 15

4,72

7 32

2,46

6 58.33

2.00

0.73

18.74

25.82

1.49

54.49

1.07

75.00

1.57

29.01

68.3

OGAN KOMER

ING ULU

TIM

UR

287,41

4 27

7,72

0 56

5,13

4 50.61

1.72

0.49

25.61

12.42

1.66

72.18

1.24

90.48

1.07

35.35

54.4

OGAN ILIR

181,16

3 18

3,98

5 36

5,14

8 59.26

2.06

0.79

6.85

21.35

2.98

50.40

1.68

83.06

1.17

24.84

54.5

PALEMBA

NG

680,97

1 68

8,27

3 1,36

9,24

4 93.72

1.31

1.78

2.29

29.40

1.74

53.89

0.79

71.73

1.99

24.07

25.4

PRABU

MULIH

64,275

68,018

13

2,29

3 87.23

1.28

0.86

8.89

36.14

1.96

65.08

0.66

86.20

1.13

23.37

33.1

PAGAR ALAM

59,299

55,878

11

5,17

7 79.11

1.45

0.80

4.08

16.74

1.31

71.23

0.70

90.24

1.15

22.15

57.0

LUBU

KLINGGAU

90,728

87,310

17

8,03

8 84.85

1.29

0.79

1.16

42.27

1.60

69.98

0.60

68.53

2.43

17.91

28.2

BANGKA

BELITUNG

Ann

exes

Supp

ort f

or H

ealth

Sec

tor P

olic

y R

efor

ms,

AD

B T

A 3

579-

INO

11

3

EPO

S H

ealth

C

onsu

ltant

s

Fina

l Rep

ort

Dec

embe

r 200

8

Assisted Delivery

Inpatie

nt Uni‐

tilization in last

year

outpatient use

amon

g ill with

in

last m

onth

Contraceptive

prevalen

ce rate

married

wom

en

age 15

thru 49

years

measles vacina‐

tion am

ong chil‐

dren

12 ‐24 mon

un‐

derw

ght

poverty

(% pop

qu

intile

1&2)

male

female

Total

%

births

at‐

tend

ed

equity

Inde

x %

equity

Inde

x %

equity

Inde

x %

equity

Inde

x

equity

Inde

x

%

BANGKA

13

4,14

7 12

2,20

7 25

6,35

4 67.27

1.16

1.77

11.73

27.78

1.64

67.06

0.81

92.08

1.33

23.11

23.8

BELITU

NG

68,932

66,119

13

5,05

1 78.31

1.03

0.99

0.90

28.87

0.98

66.30

1.30

89.91

1.00

27.78

11.3

BANGKA

BARA

T 81,042

72,819

15

3,86

1 68.07

3.15

0.83

2.40

31.31

1.35

60.69

2.45

72.07

1.00

28.24

21.6

BANGKA

TEN

GAH

71,388

66,832

13

8,22

0 70.97

1.01

0.44

2.50

32.17

0.80

62.92

1.83

69.07

0.98

26.54

9.1

BANGKA

SELATA

N

79,167

73,294

15

2,46

1 72.95

1.05

1.18

1.99

34.05

0.91

66.84

1.22

76.60

1.13

35.78

12.9

BELITU

NG TIM

UR

46,300

42,690

88,990

76.08

0.96

0.74

1.25

35.37

1.35

72.84

1.07

91.07

1.00

19.11

7.8

NTB

PANGKA

L PINANG

77,252

73,470

15

0,72

2 91.67

0.95

1.92

0.96

35.76

0.62

50.98

1.09

85.19

1.65

22.86

6.5

LOMBO

K BA

RAT

379,75

5 40

3,26

9 78

3,02

4 63.01

1.68

1.97

2.49

46.89

1.02

60.44

0.72

91.65

1.14

42.16

63.3

LOMBO

K TENGAH

378,66

9 44

7,22

2 82

5,89

1 59.33

1.05

1.57

6.58

39.31

1.61

56.51

0.85

87.61

1.10

27.89

68.5

LOMBO

K TIMUR

480,67

8 57

2,42

2 1,05

3,10

0 67.31

1.85

2.08

3.83

36.88

1.78

55.86

1.01

88.43

1.14

34.08

61.8

SUMBA

WA

209,08

8 19

4,18

4 40

3,27

2 37.98

3.50

1.21

2.29

30.86

1.22

51.52

0.79

77.83

1.08

32.66

50.5

DOMPU

10

4,02

2 10

2,61

9 20

6,64

1 40.51

2.90

2.06

1.88

45.02

1.51

56.19

1.01

69.24

1.50

44.37

71.6

BIMA

205,34

1 20

4,90

0 41

0,24

1 48.76

1.43

1.66

2.56

41.27

0.51

43.38

0.87

80.59

0.63

28.66

75.6

SUMBA

WA BARA

T 48,425

46,891

95,316

54.24

1.86

0.96

2.32

26.65

1.49

43.90

0.94

86.49

1.15

28.63

47.0

MATA

RAM

177,42

5 17

6,82

1 35

4,24

6 79.03

2.21

1.56

4.36

33.44

1.03

64.83

0.90

77.78

0.89

27.42

31.9

BIMA

59,965

65,406

12

5,37

1 60.22

1.81

1.69

3.58

34.61

1.68

53.75

0.99

82.10

1.48

37.25

49.2

NTT

Ann

exes

Supp

ort f

or H

ealth

Sec

tor P

olic

y R

efor

ms,

AD

B T

A 3

579-

INO

11

4

EPO

S H

ealth

C

onsu

ltant

s

Fina

l Rep

ort

Dec

embe

r 200

8

Assisted Delivery

Inpatie

nt Uni‐

tilization in last

year

outpatient use

amon

g ill with

in

last m

onth

Contraceptive

prevalen

ce rate

married

wom

en

age 15

thru 49

years

measles vacina‐

tion am

ong chil‐

dren

12 ‐24 mon

un‐

derw

ght

poverty

(% pop

qu

intile

1&2)

male

female

Total

%

births

at‐

tend

ed

equity

Inde

x %

equity

Inde

x %

equity

Inde

x %

equity

Inde

x

equity

Inde

x

%

SUMBA

BARA

T 21

7,11

0 19

2,80

6 40

9,91

6 29.31

3.95

1.15

3.71

47.13

0.86

18.67

2.46

61.05

0.78

51.45

85.3

SUMBA

TIM

UR

114,26

2 10

3,22

9 21

7,49

1 34.43

3.73

2.25

2.06

53.68

1.02

23.18

2.70

86.07

1.20

29.47

82.0

KUPA

NG

185,64

0 17

7,66

0 36

3,30

0 35.66

2.19

0.70

8.97

42.38

1.34

38.20

0.74

83.33

1.22

40.96

83.0

TIMOR TENGAH SELATA

N

209,81

1 20

2,48

5 41

2,29

6 23.95

2.62

0.32

10.88

43.24

1.58

39.60

1.10

88.95

1.13

53.53

89.9

TIMOR TENGAH UTA

RA

107,51

7 10

1,46

8 20

8,98

5 58.41

1.64

1.74

4.01

54.21

1.32

45.46

1.46

95.03

1.06

45.38

82.8

BELU

19

7,67

6 19

6,99

2 39

4,66

8 42.55

1.01

1.60

8.22

49.93

0.44

27.37

1.71

91.77

1.10

46.37

74.3

ALO

R 89,063

88,022

17

7,08

5 28.23

3.61

1.01

3.38

34.88

0.92

33.27

0.71

50.77

0.45

46.93

79.7

LEMBA

TA

47,490

54,849

10

2,33

9 59.10

1.03

3.68

1.95

50.05

1.08

24.05

1.48

83.24

1.21

38.00

74.3

FLORE

S TIMUR

107,57

2 11

7,78

4 22

5,35

6 68.24

1.52

0.56

1.38

52.34

0.71

28.03

1.31

98.23

1.00

36.77

88.8

SIKK

A

131,90

6 14

3,96

8 27

5,87

4 75.83

1.37

3.09

4.09

51.31

0.51

39.07

1.00

85.31

1.18

43.40

89.7

ENDE

111,62

1 12

6,49

8 23

8,11

9 46.15

1.75

1.54

7.21

49.89

1.57

20.13

1.76

88.23

1.23

41.60

69.4

NGADA

123,13

6 12

7,18

4 25

0,32

0 68.88

1.54

1.34

2.20

55.99

2.22

25.63

2.50

97.78

0.94

24.69

72.9

MANGGARA

I 25

1,48

6 24

3,66

0 49

5,14

6 49.61

2.01

0.41

13.08

25.85

0.00

48.95

0.89

85.42

1.21

38.56

84.3

ROTE NDA

57,158

53,471

11

0,62

9 33.55

1.58

0.60

0.96

41.59

0.81

28.73

1.71

40.40

1.38

42.96

88.6

MANGGARA

I BARA

T 96,483

99,122

19

5,60

5 26.19

5.83

0.76

3.00

37.34

2.23

38.07

1.43

92.60

1.13

41.84

76.2

KUPA

NG

139,73

7 13

9,33

5 27

9,07

2 72.39

1.57

1.81

2.08

41.56

0.87

36.50

1.28

89.37

1.08

39.79

35.8

CENTR

AL KA

LIMANTA

N

KOTA

WARINGIN BARA

T 10

6,45

4 98,135

20

4,58

9 74.11

1.24

0.67

1.62

28.27

1.05

65.24

1.25

10

0.00

1.00

31.37

20.1

Ann

exes

Supp

ort f

or H

ealth

Sec

tor P

olic

y R

efor

ms,

AD

B T

A 3

579-

INO

11

5

EPO

S H

ealth

C

onsu

ltant

s

Fina

l Rep

ort

Dec

embe

r 200

8

Assisted Delivery

Inpatie

nt Uni‐

tilization in last

year

outpatient use

amon

g ill with

in

last m

onth

Contraceptive

prevalen

ce rate

married

wom

en

age 15

thru 49

years

measles vacina‐

tion am

ong chil‐

dren

12 ‐24 mon

un‐

derw

ght

poverty

(% pop

qu

intile

1&2)

male

female

Total

%

births

at‐

tend

ed

equity

Inde

x %

equity

Inde

x %

equity

Inde

x %

equity

Inde

x

equity

Inde

x

%

KOTA

WARINGIN TIM

UR

158,22

6 14

8,22

2 30

6,44

8 53.22

1.42

0.64

6.53

28.81

0.90

68.26

0.71

83.69

1.50

24.37

34.4

KAPU

AS

180,90

4 17

3,79

6 35

4,70

0 73.24

1.32

0.50

3.38

24.24

1.48

72.61

0.80

96.39

1.00

40.11

64.2

BARITO

SELATA

N

61,630

56,670

11

8,30

0 62.27

2.64

0.40

1.59

27.17

1.35

71.55

0.71

87.70

0.83

30.99

10.6

BARITO

UTA

RA

59,630

55,720

11

5,35

0 78.12

1.66

0.40

12.11

8.75

5.90

65.84

0.79

50.79

1.10

34.95

44.4

SUKA

MARA

17,927

16,073

34,000

60.72

1.04

0.08

2.63

14.67

4.90

71.11

1.23

85.82

2.00

18.13

20.0

LAMANDAU

50,290

44,600

94,890

75.93

1.13

0.24

0.65

16.23

1.22

65.04

0.57

76.92

0.50

43.79

47.2

SERU

YAN

61,534

54,532

11

6,06

6 53.23

2.99

0.14

14.83

32.64

1.23

62.02

0.60

75.15

1.66

21.49

42.9

KATINGAN

42,428

39,196

81,624

58.36

1.79

0.17

3.96

29.49

0.87

67.61

0.67

82.19

1.15

45.34

11.8

PULANG PISAU

40,229

40,805

81,034

47.40

2.29

0.51

2.32

23.29

0.97

73.40

0.77

93.47

1.09

23.21

45.7

GUNUNG M

AS

85,796

86,898

17

2,69

4 56.93

1.99

0.18

1.38

21.26

3.13

66.62

0.54

76.53

2.85

30.43

18.7

BARITO

TIM

UR

136,63

4 12

4,10

8 26

0,74

2 78.60

1.21

1.03

2.67

16.31

0.74

75.94

0.77

86.89

1.08

25.79

30.8

MURU

NG RAYA

13

8,69

0 13

0,33

4 26

9,02

4 30.56

17.81

0.00

0.00

23.64

1.13

53.05

0.49

47.95

0.31

25.00

31.6

PALANGKA

RAYA

24

1,12

4 22

9,03

6 47

0,16

0 91.71

1.08

0.92

2.00

19.16

0.80

56.40

1.24

85.82

1.02

20.67

33.7

BANJARM

ASIN

134,73

2 13

1,56

6 26

6,29

8 88.26

1.42

1.58

2.00

34.22

1.59

62.38

0.76

73.64

2.09

27.50

51.4

SOUTH

KALIMANTA

N

TANAH LAUT

76,329

74,347

15

0,67

6 71.40

1.97

1.31

6.00

32.02

1.74

67.00

0.95

82.18

1.82

41.55

47.2

BANJAR

101,82

0 10

4,18

0 20

6,00

0 71.60

1.20

1.15

3.77

24.37

1.27

64.46

0.85

69.95

2.25

40.31

41.2

BARITO

KUALA

11

7,36

6 12

2,32

6 23

9,69

2 54.12

1.61

0.35

4.53

24.41

2.91

63.73

0.97

83.36

0.88

34.99

53.4

Ann

exes

Supp

ort f

or H

ealth

Sec

tor P

olic

y R

efor

ms,

AD

B T

A 3

579-

INO

11

6

EPO

S H

ealth

C

onsu

ltant

s

Fina

l Rep

ort

Dec

embe

r 200

8

Assisted Delivery

Inpatie

nt Uni‐

tilization in last

year

outpatient use

amon

g ill with

in

last m

onth

Contraceptive

prevalen

ce rate

married

wom

en

age 15

thru 49

years

measles vacina‐

tion am

ong chil‐

dren

12 ‐24 mon

un‐

derw

ght

poverty

(% pop

qu

intile

1&2)

male

female

Total

%

births

at‐

tend

ed

equity

Inde

x %

equity

Inde

x %

equity

Inde

x %

equity

Inde

x

equity

Inde

x

%

TAPIN

103,50

9 10

8,22

5 21

1,73

4 73.95

1.80

0.23

3.41

23.80

1.66

70.90

1.07

81.30

1.30

50.79

58.1

HULU

SUNGAI SELATA

N

25,944

22,974

48,918

78.13

1.51

0.51

2.11

41.25

1.57

60.74

0.90

63.55

1.34

57.32

25.7

HULU

SUNGAI TEN

GAH

94,114

95,249

18

9,36

3 69.87

1.24

0.66

2.96

16.88

2.59

71.55

1.38

79.17

1.22

41.30

38.6

HULU

SUNGAI U

TARA

67,932

63,410

13

1,34

2 70.05

1.87

0.39

14.83

25.31

2.76

60.01

0.85

79.18

1.42

36.92

44.0

TABA

LONG

108,95

5 10

7,39

3 21

6,34

8 73.20

1.68

0.72

1.77

26.16

2.43

68.98

0.84

78.61

1.84

33.84

35.5

TANAH BUMBU

39,963

38,002

77,965

61.82

1.63

0.49

1.54

12.60

1.32

67.23

0.95

75.78

1.60

24.82

20.7

BALANGAN

50,985

50,040

10

1,02

5 52.94

1.75

0.15

6.31

16.55

2.21

63.90

1.23

77.08

1.35

29.91

60.6

BANJAR BA

RU

300,57

3 30

2,13

4 60

2,70

7 88.16

1.22

1.69

4.65

28.96

3.03

69.52

0.77

91.26

1.17

31.35

19.0

SOUTH

SULA

WESI

SELAYA

R 55,200

61,215

11

6,41

5 52.67

0.83

0.99

0.87

24.12

1.46

23.48

1.00

63.28

1.90

28.47

66.2

KOTA

BARU

17

5,49

4 20

8,23

6 38

3,73

0 58.67

2.05

0.98

3.48

17.86

6.67

59.81

1.17

61.41

1.54

40.16

64.1

BULU

KUMBA

80,416

90,132

17

0,54

8 46.91

1.78

0.70

3.42

34.87

0.85

37.67

0.49

71.52

1.02

31.47

72.3

BANTA

ENG

160,00

0 16

9,02

8 32

9,02

8 39.87

2.22

0.45

15.12

27.95

2.33

57.77

0.42

71.09

1.62

31.16

77.7

JENEPONTO

12

0,60

4 12

9,87

6 25

0,48

0 35.26

1.82

1.27

9.00

28.62

1.52

61.97

0.99

84.75

0.76

32.05

56.3

TAKA

LAR

294,59

9 29

1,79

9 58

6,39

8 53.03

1.63

1.76

5.59

32.40

1.98

56.80

0.50

60.58

1.46

31.25

51.9

GOWA

108,90

5 11

3,01

0 22

1,91

5 67.52

1.76

0.95

14.37

25.20

3.32

55.92

0.78

63.74

2.34

29.52

76.1

SINJAI

145,34

1 15

2,29

8 29

7,63

9 52.81

1.75

0.35

4.91

40.30

1.99

27.80

1.29

64.07

0.90

43.98

57.2

MARO

S 14

0,18

8 14

9,11

4 28

9,30

2 83.38

1.30

1.09

2.83

28.95

1.32

50.82

0.81

67.90

1.50

29.80

55.8

Ann

exes

Supp

ort f

or H

ealth

Sec

tor P

olic

y R

efor

ms,

AD

B T

A 3

579-

INO

11

7

EPO

S H

ealth

C

onsu

ltant

s

Fina

l Rep

ort

Dec

embe

r 200

8

Assisted Delivery

Inpatie

nt Uni‐

tilization in last

year

outpatient use

amon

g ill with

in

last m

onth

Contraceptive

prevalen

ce rate

married

wom

en

age 15

thru 49

years

measles vacina‐

tion am

ong chil‐

dren

12 ‐24 mon

un‐

derw

ght

poverty

(% pop

qu

intile

1&2)

male

female

Total

%

births

at‐

tend

ed

equity

Inde

x %

equity

Inde

x %

equity

Inde

x %

equity

Inde

x

equity

Inde

x

%

PANGKA

JENE KEPU

LAUAN

74,590

84,368

15

8,95

8 64.94

1.15

0.37

0.59

22.45

1.39

34.00

0.84

72.80

1.55

46.67

53.5

BARR

U

320,90

0 37

5,79

8 69

6,69

8 37.10

3.19

0.56

0.96

25.92

1.79

45.77

0.93

79.39

1.48

30.86

77.6

BONE

106,77

6 12

0,41

4 22

7,19

0 63.37

1.67

0.43

3.89

22.74

1.59

33.22

1.11

59.82

2.18

35.38

61.6

SOPP

ENG

81,120

81,935

16

3,05

5 59.60

1.93

0.36

4.03

21.37

1.88

45.37

1.14

94.93

1.13

28.10

17.2

WAJO

17

9,09

3 19

4,89

6 37

3,98

9 46.73

2.07

0.20

7.21

16.97

2.28

34.18

0.57

72.10

1.14

24.82

53.3

SIDEN

RENG RAPP

ANG

117,51

2 12

9,36

8 24

6,88

0 71.18

1.41

0.32

0.31

19.46

0.38

51.66

1.01

97.83

1.14

22.33

55.2

PINRA

NG

169,66

4 17

0,52

4 34

0,18

8 75.13

1.63

1.10

10.62

17.97

2.40

39.09

0.87

83.65

0.64

32.02

60.3

ENRE

KANG

94,765

89,096

18

3,86

1 60.49

1.67

0.32

4.12

25.75

1.43

32.64

0.87

89.78

1.05

21.76

81.2

LUWU

160,55

4 15

7,26

0 31

7,81

4 41.52

2.81

0.89

4.58

22.98

1.24

37.13

1.34

77.08

1.36

31.21

57.4

TANA TORA

JA

236,31

3 21

0,46

9 44

6,78

2 53.06

2.02

0.15

10.00

12.00

1.04

29.60

0.53

87.64

1.19

28.89

74.5

LUWU UTA

RA

151,91

5 14

6,94

8 29

8,86

3 49.39

1.73

1.07

2.32

19.73

2.82

52.55

0.99

82.86

1.31

32.92

66.5

LUWU TIM

UR

114,62

1 10

4,87

1 21

9,49

2 64.78

1.83

0.42

6.27

21.41

1.63

54.07

0.60

85.88

1.09

24.50

52.9

UJUNG PANDANG

611,04

4 61

2,48

6 1,22

3,53

0 91.88

1.06

1.74

2.18

32.27

1.52

41.87

1.09

87.67

1.33

41.23

28.2

PARE

‐PARE

54,769

60,307

11

5,07

6 91.27

1.52

2.36

4.43

36.82

1.94

43.98

0.46

86.81

1.11

30.95

32.1

PALO

PO

65,138

69,224

13

4,36

2 65.10

3.14

1.28

19.07

28.75

2.32

38.75

0.84

90.55

0.91

28.50

40.9

GORO

NTA

LO

BOALEMO

60,527

57,555

11

8,08

2 62.17

1.18

0.66

1.42

23.23

0.47

56.45

0.78

75.79

1.39

45.82

75.6

GORO

NTA

LO

213,27

1 21

4,91

5 42

8,18

6 50.18

2.03

0.99

13.15

33.76

1.48

60.87

0.89

80.12

1.35

36.54

70.7

Ann

exes

Supp

ort f

or H

ealth

Sec

tor P

olic

y R

efor

ms,

AD

B T

A 3

579-

INO

11

8

EPO

S H

ealth

C

onsu

ltant

s

Fina

l Rep

ort

Dec

embe

r 200

8

Assisted Delivery

Inpatie

nt Uni‐

tilization in last

year

outpatient use

amon

g ill with

in

last m

onth

Contraceptive

prevalen

ce rate

married

wom

en

age 15

thru 49

years

measles vacina‐

tion am

ong chil‐

dren

12 ‐24 mon

un‐

derw

ght

poverty

(% pop

qu

intile

1&2)

male

female

Total

%

births

at‐

tend

ed

equity

Inde

x %

equity

Inde

x %

equity

Inde

x %

equity

Inde

x

equity

Inde

x

%

POHUWATO

54,825

54,997

10

9,82

2 60.91

1.94

0.68

10.55

31.00

0.49

63.52

0.83

57.58

0.00

61.40

68.0

BONE BO

LANGO

62,798

64,158

12

6,95

6 53.79

1.66

0.54

3.06

36.78

1.58

62.52

0.92

87.99

1.24

36.44

71.2

GORO

NTA

LO

77,022

81,330

15

8,35

2 81.31

1.43

2.50

1.48

41.93

2.14

54.82

0.63

91.42

1.14

45.69

25.6

WEST SU

LAWESI

POLM

AS

64,928

66,704

13

1,63

2 39.32

1.49

0.14

28.63

15.23

2.77

24.81

1.50

51.69

1.82

38.53

75.8

MAJENE

175,55

2 17

9,84

0 35

5,39

2 65.08

0.78

0.37

15.00

30.92

1.38

25.19

0.48

67.17

0.91

39.24

73.7

MAMUJU

61,248

60,096

12

1,34

4 40.88

1.94

0.37

28.63

15.44

2.77

33.32

1.50

59.64

1.83

32.35

83.8

MAMASA

14

6,15

2 13

7,94

7 28

4,09

9 18.33

6.45

0.54

2.72

19.66

1.06

60.76

0.87

60.00

1.84

31.93

57.9

MAMUJU UTA

RA

50,502

48,222

98,724

37.24

2.30

0.71

5.36

24.39

3.58

42.63

0.49

54.55

1.82

10.68

12.9