Form Proposal Dana Desa

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Ministry of Health
Asian Development Bank

Support for Health Sector Policy Reforms
TA 3579-INO, August 2004 - August 2008

Final Report
December 2008

                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
EPOS Health            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
Final Report
                       5.4         Quality of Services make a Difference........................................................45
                       5.5         New Financial Regulations Every year Cause Difficulties ..........................45
December 2008          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

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

                       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

EPOS Health

Final Report

December 2008

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

                Abbreviations and Acronyms

                     ADB          Asian Development Bank
                     ANC          Ante-natal Care
                     AusAID       Australian Agency for International Development
                                  Badan Perencanaan Pembangunan Daerah
                                  (Provincial Planning Agency)
                                  Badan Perencanaan Pembangunan Nasional
                                  National Development Planning Agency
                     BCC          Behavior Change Communication
                     BEONC        Basic Emergency Obstetric Neonatal Care (PONED)
                                  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        First Decentralized Health Services Project
                     DHS 2        Second Decentralized Health Services Project
                                  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
EPOS Health
                     GOI          Government of Indonesia
                                  Deutsche Gesellschaft für Technische Zusammenarbeit
                                  (German Agency for Technical Cooperation)
Final Report
                     HIS          Health Information System
                     HNSDP        Health and Nutrition Sector Development Program
December 2008        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                         IV
                                                                          Abbreviations and Acronyms

                     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)
                                  Jaring Pengaman Sosial – Bidang Kesehatan
                                  (Social Safety Net Program for Health)
                     KAP          Knowledge, Attitudes, and Practices
                     KIA          Kesehatan Ibu & Anak (Maternal and Child Health)
                                  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
                                  Pusat Desentralisasi Kesehatan
                                  Decentralization Unit
                     Pemda        Pemerintah Daerah (local government)
                     PHP          Provincial Health Project
EPOS Health
Consultants                       Petugas Lapangan Keluarga Berencana
                                  Family Planning Field Worker
                     PMS          Performance Monitoring System
Final Report
                     Polindes     Pondok Persalinan Desa (Village Birthing Post)
                     PPM          Provincial Project Manager
December 2008        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                        V
                                                                        Abbreviations and Acronyms

                     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
                                  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
                                  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

EPOS Health

Final Report

December 2008

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

                1    Executive Summary

                     TA-3579-INO has successfully com-         TA-3579-INO telah berhasil menyelesaikan
                     pleted four years of Technical Assis-     empat tahun sebagai Technical Assistance
                     tance to the Ministry of Health to sup-   untuk Depkes dalam mendukung reformasi
                     port health sector reform.                sektor kesehatan.

                     The final report reviews the terms of     Laporan akhir meninjau kerangka acuan dari
                     reference from the original request for   permintaan awal untuk proposal, melalui
                     proposal, through loan negotiation,       negosiasi pinjaman, dan proyek
                     and project inception, and then dis-      pendahuluan, dan kemudian mendiskusikan
                     cusses the activities undertaken as       kegiatan yang diambil sebagai bagian dari
                     parts of the terms of reference.          kerangka acuan.

                     The team composition varied during
                                                               Susunan tim berubah selama proyek ini, dan
                     this project, and a discussion of the
                                                               suatu diskusi tentang susunan tim, dan
                     team composition, and the responsi-
                                                               tanggung jawab dari berbagai anggota tim
                     bilities of the various team members
                                                               adalah suatu pendahuluan bagi tinjauan
                     are a prelude to the review of travel
                                                               perjalanan selama TA.
                     during the TA.

                     Various issues in the execution the TA
                                                               Berbagai masalah dalam menjalankan TA
                     are discussed, and the report con-
                                                               dibahas, dan laporan ditutup dengan
                     cludes with some suggestion for im-
                                                               beberapa saran untuk meningkatkan mutu
                     proving the quality of technical assis-
                                                               technical assistance selama tiga tahun
                     tance during the final three years of
                                                               terakhir bagi DHS-2.

                     The TA has documented many of the         TA telah mendukumentasikan banyak hal
                     health sector reforms initiate by the     mengenai reformasi kesehatan yang
                     project in various locations. We in-      diperlukan oleh proyek di berbagai lokasi
                     cluded these case studies to docu-        Kami memasukkan pembelajaran masalah

EPOS Health          ment some of the innovations under-       ini untuk mencatat beberapa inovasi yang
Consultants          taken by the DHS-1 project.               dilaksanakan oleh Proyek DHS-1

                     The primary objective of the DHS
Final Report                                                   Tujuan utama dari pendanan DHS adalah
                     loans was to improve health status of
                                                               untuk meningkatkan status kesehatan ibu
                     mothers, and children by improving
                                                               dan anak dengan meningkatakan akses
December 2008        access to basic primary health care
                                                               pada kegiatan kesehatan dasar.

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

                                                                 Meski proyek telah berhasil dalam
                     While the project was successful in
                                                                 peningkatanan kesehatan di beberapa
                     utilization of health care in some prov-
                                                                 provinsi dan kabupaten; masih banyak
                     inces and districts, there are still many
                                                                 kendala dalam masalah kesehatan dan
                     barriers to health care and health
                                                                 status kesehatan di daerah proyek. Kami
                     status with the project areas. We re-
                                                                 meninjau kendala-kendala ini untuk
                     view these barriers in order to help
                                                                 kepentingan dukungan masalah
                     future support for decentralization fo-
                                                                 desentralisasi dimasa depan yang
                     cus on issues that might help improve
                                                                 diharapkan dapat meningkatakan status
                     health status and utilization of primary
                                                                 kesehatan dan pelaksanaan pelayanan
                     health care services.

EPOS Health

Final Report

December 2008

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                  2
                                                                                                  Activity Summary

                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
EPOS Health
Consultants                   needs, health planning policy issues.

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December 2008
                      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.
                      Terms of reference from “Request for Proposal” TA-3579-INO, ADB August 2002

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                              3
                                                                                              Activity Summary

                        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
EPOS Health     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.
Final Report

December 2008

                      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

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                           4
                                                                                                 Activity Summary

                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 Darmawan (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

                                       Supervision fact                                     Support ADB    Total
                           Inception                        Advocacy         Planning
                                           finding                                           missions      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
EPOS Health
Consultants     attend a meeting, or to assist with proposal development or advocacy.

Final Report

December 2008
                    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.
                    Salary and contract for this consultant was directly with ADB.

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                           5
                                                                                             Activity Summary

                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-

EPOS Health     tivities described in the logical framework will be discussed.

                2.6    Activities undertaken to support the ToR
Final Report
                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
December 2008   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.

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                   6
                                                                                             Activity Summary

                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
EPOS Health
Consultants     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-
Final Report    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
December 2008
                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-

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                         7
                                                                                          Activity Summary

                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

EPOS Health
                MNCH when the Minister of Health requested that all loans focus on supporting the reduction
Consultants     of maternal mortality. However it should be noted that promotion of maternal health was al-
                ways central to the objectives of DHS-1.
Final Report
                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
December 2008   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

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                   8
                                                                                           Activity Summary

                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

EPOS Health
                estimates (300-400 deaths per 100,000 live-births), than local health records collected na-
Consultants     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
Final Report    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
December 2008
                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.

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                   9
                                                                                             Activity Summary

                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.
EPOS Health
Consultants     3)     Liaison with MOH counterparts at national, provincial and local levels

                3-a)   Short “Project Preparation Technical Assistance” (PPTA) for DHS-1 refocus: As
Final Report
                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-
December 2008   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.

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                     10
                                                                                                Activity Summary

                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.

EPOS Health     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
Final Report
                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
December 2008
                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.

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                         11
                                                                                              Activity Summary

                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
EPOS Health     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
Final Report
                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
December 2008
                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;

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                       12
                                                                                           Activity Summary

                       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.
EPOS Health
Consultants     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

Final Report    Desa Siaga initiative, and analyzed several approaches to mobilize this program. This is
                included as annex 8.7

December 2008
                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-

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                    13
                                                                                            Activity Summary

                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
EPOS Health
Consultants     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
Final Report    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.

December 2008   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.

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                    14
                                                                                             Activity Summary

                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.
EPOS Health
                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.
Final Report
                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
December 2008   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.

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                     15
                                                                                             Activity Summary

                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.
EPOS Health

Final Report

December 2008

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                    16
                                                                                  Logical Framework Review

                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.
EPOS Health     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.
Final Report

                3.2    Outputs of TA-3579
December 2008
                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.

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                    17
                                                                                   Logical Framework Review

                       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
EPOS Health
Consultants     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
Final Report    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.

December 2008   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.

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                    18
                                                                                    Logical Framework Review

                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.

EPOS Health     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-
Final Report
                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
December 2008   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”.

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                        19
                                                             Policy Dialogue: Access Barriers to Health Care

                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.

EPOS Health                                                                Government    % of Total
Consultants                                         Health                  Health Ex-    Govern      Life Ex-
                                                 Expdenditure               pend. Per    expend on    pect at
                    Country                        US$ 2002       %GDP      capita US      health      birth

Final Report        Indonesia                          20         2.8%           5        3.5%          68
                    Malaysia                           294        3.3%          156       6.1%          72
                    Myanmar                            28         2.2%          4         1.2%          59
December 2008
                    Philippines                        169        3.4%          80        7.0%          69
                    Singapore                          993        3.6%          329       6.7%          80
                    Thailand                           237        3.6%          138       11.8%         70

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                        20
                                                              Policy Dialogue: Access Barriers to Health Care

                                                                             Government    % of Total
                                                       Health                 Health Ex-    Govern      Life Ex-
                                                    Expdenditure              pend. Per    expend on    pect at
                   Country                            US$ 2002     %GDP       capita US      health      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
EPOS Health     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
Final Report    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

December 2008   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-

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                                                           Policy Dialogue: Access Barriers to Health Care

                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:

EPOS Health

Final Report

December 2008

                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

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                    22
                                                           Policy Dialogue: Access Barriers to Health Care

                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-
EPOS Health
Consultants     porting over 54% of married women between the age of 15 and 45 reporting using some type
                of contraception within the last month.
Final Report    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

December 2008   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.

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                                                           Policy Dialogue: Access Barriers to Health Care

                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

                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.

EPOS Health     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-
Final Report
                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.
December 2008   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.

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                     24
                                                             Policy Dialogue: Access Barriers to Health Care

                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
EPOS Health
                public health programs.

                DHS-1 and its TA has been proposing and advocating a major reform in the fiscal de-
Final Report    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-
December 2008
                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.

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                                                              Policy Dialogue: Access Barriers to Health Care

                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.

                                                                Management of Public
                      Level           Public Services                                            Private Services

                                                               Midwife, Women’s               Traditional Birth At-
                 Neighborhoods    Posyandu                     Group(PKK), health cen-        tendants, Shaman,
                                                               ter staff                      "Healers"
                                  Midwives (Birthing
                                  Huts), family planning                                      Religious boarding
                                                               Health Center Staff, Vil-
                 Village          coordinators                                                schools, private physi-
                                                               lage Head man
                                  Sub health centers
                                                                                              Private physicians,
                                  Health Center (outpa-        District Health Office
                                                                                              Public physicians after
                                  tient care, in some          which is under the control
                 Sub District                                                                 hours treatment, mid-
                                  places delivery referral,    of "Bupati", and local par-
                                                                                              wives, nurses, mid-
                                  delivery management          liament

                                                               District Hospital office not
                                                                                              Private physicians,
                                                               linked with public health
                                                                                              Private Hospitals
                 District         District Hospital            office, but also under the
                                                                                              (profit, and non-profit
                                                               control of Bupati and local

                                  Provencal Hospital
                                                                                              Private physicians,
                                  Training of public health
                                                               Governor, provincial fam-      Private Hospitals
                 Province         staff
                                                               ily planning offices           (profit, and non-profit
                                  Coordination of district                                    facilities)

                                  Teaching hospitals,          Ministry of Education,
                                                               Ministry of Health, family
                                  Public health programs       planning
EPOS Health
Consultants                       Community Health Ser-        National Development           Private physicians,
                                  vices                        Planning agency,               private Hospitals, poly
                                  Communicable Disease                                        clinics, family planning
                 National                                      Parliament
                                  control,                                                    services.
Final Report                                                   Ministry of Finance
                                                               Ministry of home affairs
                                  Licensing                                                   Food manufactures
                                                               Food and Drug Admini-
December 2008                     Food Safety                  stration
                                  Nutrition                    Agriculture

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                                                                      Policy Dialogue: Access Barriers to Health Care

                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
                                                                                                           Menu for capacity
                                                                   Placing MNCH high on                         building
                                 Advocacy                          district policy agendas                  IT/GIS, Surveillance,
                                                                                                           IHPB, DHA, Prospect,
                                                                                                           Supervision, DTPS, etc

                     Capacity to      Planning &                   Partnership with NGOs                    SSN for
                      supervise       Budgeting                        & other sectors                      the poor
                          MIS            Puskesmas,                                                                            BCC
                                         Midwives,                     Cost effective                                         Health
                    Infrastructure                                                                        Local             promotion
                                           Private      Supply         interventions         Demand    community
                    & equipment
                     HRH                                                                                                 Transportation
                          Incentive                                                                      Community
                           system                                                                        participation
                                                                MCH, FP, Immunization,
                                                       Delivery by Health Staff, Maternal Nutrition,
                                                        Breastfeeding Nutrient, Under-5 Nutrient,
                                                      Infant Nutrition, IMCI, Environment Hygiene,
                                                                Household Sanitation, etc

                                                                    DHS supports

                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
EPOS Health
Consultants     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-

Final Report    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).

December 2008

                        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

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                                 27
                                                           Policy Dialogue: Access Barriers to Health Care

                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-
EPOS Health
Consultants     developed countries, countries with “free market” health care.

                We will start our investigation into barriers to utilization of public health and primary health
Final Report    care with the hypothesis that socio economic attainment and disparity is the primary
                determinant of utilization of health services.

December 2008   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.

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                      28
                                                            Policy Dialogue: Access Barriers to Health Care

                                                            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
EPOS Health
                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
Final Report    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
December 2008
                start analysing national data and discuss information gathered through personal observation
                and interviews with various health care providers and consumers across Indonesia.

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                                                            Policy Dialogue: Access Barriers to Health Care

                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

EPOS Health

Final Report
                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
December 2008   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.

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                                                              Policy Dialogue: Access Barriers to Health Care

                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.
EPOS Health
Consultants     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.
Final Report    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.
December 2008

                       2007 Susenas Core Data Individual data set

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                                                          Policy Dialogue: Access Barriers to Health Care

                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

EPOS Health

Final Report

December 2008

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                                                           Policy Dialogue: Access Barriers to Health Care

                         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.
EPOS Health
Consultants     4.7.3 Utilisation of in-patient services

                Differences in inpatient utilisation rates between the rich and the poor is much greater than
Final Report    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
December 2008
                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.

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                                                           Policy Dialogue: Access Barriers to Health Care

                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-

EPOS Health     lenge because of the income differentials between urban and rural specialty practices.
                4.7.4 Assisted birthing rates

Final Report    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,
December 2008
                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-

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                                                           Policy Dialogue: Access Barriers to Health Care

                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-

                               Figure 8, Equity Index for assisted Delivery – Susenas 2007

                4.7.5 Contraceptive prevalence

                       Figure 8A, Equity Index for Contraceptive Prevalence Rate – Susenas 2007

EPOS Health

Final Report

December 2008

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                    35
                                                          Policy Dialogue: Access Barriers to Health Care

                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

EPOS Health

Final Report

                The limitations of the immunization service system do not affect the contact with the various
December 2008
                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.

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                   36
                                                           Policy Dialogue: Access Barriers to Health Care

                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

EPOS Health

Final Report

December 2008

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                                                               Policy Dialogue: Access Barriers to Health Care

                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

EPOS Health

                It is also interesting to note in figure 13 below, that NTT has very high levels of outpatient
Final Report
                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
December 2008   not likely to utilize health staff for assisted birthing. They are however likely to utilize outpa-
                tient services.

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                       38
                                                           Policy Dialogue: Access Barriers to Health Care

                                        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
EPOS Health
                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.

Final Report    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
December 2008
                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.

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                     39
                                                               Policy Dialogue: Access Barriers to Health Care

                                   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

                 Table 2 Rural urban population of Indonesia by household expenditure quintile 2007

                                                                           % Rural
                  household                                                               Mean Per-
                                       Total           Total Popu-       Population                       household
                 expenditure                                                             capita Daily
                                    Households            lation          living in                          size
                   quintile                                                              Expenditure
                                                                         rural areas
                         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
EPOS Health              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
Final Report
                 Total                56,878,513       225,177,410         56.3%              11,048        3.96

December 2008   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.

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                                                                        Policy Dialogue: Access Barriers to Health Care

                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


                 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.

EPOS Health     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
Final Report    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

December 2008   maintaining the professional spirit and involvement with the community.

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                              41
                                                                    Lessons Learned and Recommendations

                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
EPOS Health
Consultants     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
Final Report    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
December 2008
                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.

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                      42
                                                                    Lessons Learned and Recommendations

                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
EPOS Health     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-
Final Report
                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.
December 2008

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                                                                    Lessons Learned and Recommendations

                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.

EPOS Health
Consultants     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
Final Report    clinic, there are other indicators that community members will take as a sign of how the
                community health workers feel toward them.

December 2008   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),

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                      44
                                                                     Lessons Learned and Recommendations

                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
EPOS Health     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.

Final Report    5.5    New Financial Regulations Every year Cause Difficulties

                Decentralization has lead to new fund channelling mechanisms, and the establishment of
December 2008   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.

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                        45
                                                                    Lessons Learned and Recommendations

                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-
EPOS Health
Consultants     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
Final Report    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-
December 2008
                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.

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                       46

                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
EPOS Health
Consultants     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.
Final Report

                6.2   Impact on Decentralisation and Health Sector Reform
December 2008
                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

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                    47

                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-
EPOS Health     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.
Final Report

                6.3      Impact on Millennium Development Goals
December 2008   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

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                      48

                      •    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.

EPOS Health

Final Report

December 2008

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                     49

                7     Annexes

                7.1   TA-3579-INO Logical Framework

EPOS Health

Final Report

December 2008

                Support for Health Sector Policy Reforms, ADB TA 3579-INO        50

                                                                                TA 3579-INO LOGICAL FRAMEWORK

                         Narrative Summary of                                Performance Targets                              Monitoring Mechanisms                         Assumptions
                          Project Strategies                                 (Verifiable Indicators)                          (Sources of Information)

                 A. GOAL: TA 3579-INO shares the             DHS-1 Goal Targets: by 2010, in DHS-1 project districts:     DHS-1 Goal Monitoring Mechs:         DHS-1 Goal Assumptions:
                     goals of the DHS Projects:              •  Maternal mortality ratio (MMR) 200 / 100,000 live         •  Annual district health profiles   •  Political stability in DHS-1 project
                                                                births or at least 30% lower than benchmark data          •  United Nations Children’s Fund       area
                 GOAL of DHS-1:                              •  Infant mortality rate (IMR) : 30 / 1000 live births, or      (UNICEF) and World Health         •  Continued economic recovery
                                                                at least 30% lower than local benchmark data                 Organization (WHO) data or
                     Improved health status of the           •  Under-5 mortality rate (U5MR) : 40 / 1000 children           estimates
                     population in all Project districts        under 5 years, or at least 30% lower than local
                                                                benchmark data
                                                             •  Life expectancy at birth (LEB) : 70 years, or at least    DHS-2 Goal Monitoring Mechs:         DHS-2 Goal Assumptions:
                 Goal of DHS-2:                                 2 years more than local benchmark                         •  BPS and SUSENS data
                                                             DHS-2 Goal Targets: by 2010 in the project area:             •  BKKBN data                                      [None listed]
                     Improved health status of the           •  MDG: reduce child malnut. from 34%(1995) to 22%           •  UNICEF and WHO data
                     population, especially the poor         •  MDG: reduce U5MR from 51 (2000) to 35/1000 births         •  Demographic & Health Surveys
                     and vulnerable groups                   •  MDG: reduce IMR from 41 (2000) to 25 live births          •  Poverty line indicators from
                                                             •  MDG: reduce MMR from 470 (1995) to 175/100,000               SMERU, SUSENAS, World Bank,
                                                             •  LEB increased >2 years from local benchmark data.            and BKKBN.

                 B. PURPOSE of TA 3579-INO                   TA 3579-INO Performance Targets:                             TA 3579-INO Monitoring Mechs:        TA 3579-INO Assumptions:
EPOS Health                                                  •   Comprehensive local health sector development            •   Periodic reports of TA team      •   Definition of health sector
                 1. Assist MOH and selected local                plans developed and in use in all Project districts          members and DHS-1 staff              development plans unchanged
                    governments identify, implement          •   Increased public expenditure budgeted for health in      •   DHS evaluation of budgets and    •   No unexpected crisis in other
                    and evaluate health sector reforms           all Project districts                                        expenditures of selected sites       sectors limiting budget available
                    in the context of decentralisation.      •   Local health social safety net programs functioning in   •   Local government budget review   •   No major influxes of poor into
Final Report     2. Support DHS in meeting its                   all districts                                                and assessment by experts            project districts
                    purposes:                                                                                                                                  •   No major unrest in Project areas
                   a) improved health and family             •   Timely provision of technical assistance to improve
                        planning services in project areas       DHS Project implementation at Center, provinces,         •   DHS monitoring mechanisms
                     b) guaranteed access of poor to             and districts                                                                                 •   DHS assumptions are met
December 2008           essential health and family
                        planning services

                   Number of maternal deaths per 100,000 live births. National MMR is estimated between 390 and 450 (1999).
                   Number of deaths of children between 0 and 1 year of age per 1,000 live births. National IMR is estimated at 40 (1999).
                   Number of deaths of children less than 5 years old per 1.000 live births. National U5MR is estimated at 56 (1998).
                   National LEB is estimated at 68 years (1999).

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                                                                                                51

                        Narrative Summary of                                     Performance Targets                                Monitoring Mechanisms                            Assumptions
                         Project Strategies                                      (Verifiable Indicators)                            (Sources of Information)

                 C. TA 3579-INO OUTPUTS:                                                                                        •   Experts’ assessments of the
                                                             •      HSR identified in 100% of Project districts                     need and quality of local            •   Commitment of personnel at all
                 1. Health sector reform (HRS) at            •      HSR guidelines developed and disseminated                       reforms                                  levels to review and reform
                    decentralised levels                     •      Ten percent increase per year in achievement of             •   Performance monitoring               •   Flexible national regulations
                 2. Human capacity for health systems               minimum service standards in DHS districts                      system; field visits                 •   Personnel deployment system
                    management & delivery                    •      Health services unit costs determined in at least one       •   Reports and expert                       stabilised
                 3. Health plans based on actual costs              district of every Project province                              assessments                          •   Local governments’ commitment to
                 4. Decision maker understanding of          •      Proportion of local public health budgets allocated to      •   Review of district budgets               the health sector
                    public health priorities                        prevention/promotion/basic services up by >20%              •   Experts’ assessment of the           •   Access to project areas is not
                 5. Operational research capacity            •      More than 80% of operational research carried out               need and quality of OR                   compromised by security problems
                 6. Project management                              judged relevant to "operation" of health services               implemented
                                                             •      TA services accessible to all DHS districts                 •   Yearly and 6-mo TA reports

                 D. TA 3579-INO ACTIVITIES
                                                                    Assistance provided to review and improve health                 Six-month summaries and                 Local health sector personnel and
                 1. Review and monitor status and                  sector policies / practices at all levels;                       reports of the TA team                   decision makers are willing to share
                 changes in the following areas:                    Clearer understanding of national health sector policy at        Trip report of team members             planning and development with
                  a) Health Sector Reform to improve               peripheral levels;                                                Technical reviews as requested          professionals including TA from
                      access to and quality of health               Improved understanding of local health status and               by counterparts                          outside the local area
                      services from public and private             health services trends;                                           Topical technical papers                Lessons learned and experience
                      sources;                                      Key areas of health services reform schemes evaluated           produced and disseminated                elsewhere may be relevant to the
                  b) Protection of the health of the poor          in at least one area:                                            relating to health services              project areas
EPOS Health           and most vulnerable;                       a) local health insurance schemes,                                 reform that contribute                   Adequate complementary financial
Consultants       c) Human and non-human health                  b) strategic resources allocation,                                 information from elsewhere in            resources will be provided by DHS
                      resources;                                 c) health financing advocacy                                       Indonesia and the world                  and GOI counterpart funding.
                  d) Operations research in health               d) performance-based payments,                                      Plans, methodology, findings,           Effective communications in
                      services;                                  e) health care efficiency,                                         and critical review of operational       Indonesian.
Final Report      e) Management communications                   f) drugs use management,                                           research undertaken.
                      including health information               g) workforce management,
                      systems, monitoring;                       h) local health information systems,
                  f)  Communications for liaison and             i) health care quality improvement,
December 2008         advocacy;                                  j) operational research studies,
                  g) Evaluation                                  k) organizational culture supporting reform,
                                                                 l) management of capital assets,
                                                                 m) management of supplies,
                 2. Assist the health sector to identify         n) consumer participation,
                 opportunities for reform at service             o) public-private partnerships.
                 delivery, district, province, and central          Methods in place at all levels to monitor access to
                 levels.                                           health services;
                 3. Assist health sector personnel to               Partnership with private sector increasing;
                 develop, test, implement, and evaluate             MOH/BKKBN partnership improving;

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                                                                                                       52

                 develop, test, implement, and evaluate                        p         p p         g;
                 reforms, particularly at district and         Collaboration with other social sectors increasing in all
                 service delivery levels.                     provinces and districts;
                 4. Develop guidelines, training materials,    Methods to monitor health services quality in place for
                 and strategies for designing,                use by all provinces, districts, cities;
                 implementing, and evaluating reforms.         Access to health services by poor and most vulnerable
                 5. Assist in the evaluation,                 implemented in all districts/cities;
                 documentation, and sharing of lessons         Options for reform identified and appraised in
                 learnt.                                      consultation with all stakeholders;
                 6. Design and contract operations             Lessons documented and disseminated within project
                 research relevant to need of health          areas and more broadly;
                 sector reform                                Increased opportunities for community participation
                                                              within all districts and provinces;
                                                              Operations research for health services reform
                                                              designed, implemented, analyzed.

EPOS Health

Final Report

December 2008

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                       53

                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

                                                                                                                           Nr of
                       When         Province         Who                               Purpose
                                                              Learning current condition of health sector in Bengkulu
                      9 – 11    Bengkulu            JD                                                                       1
                                                              and meeting with PHO
                      11 –
                                Pekanbaru (Riau)    JD, JS    Province Visit ; Meeting with PHO and stake holder             2
                      18 –      South east Su-                Meeting with PHO and stake holder of Southeas Su-
                                                    JS                                                                       1
                      20        lawesi (Kendari)              lawesi
                      18 –      Manado (North
                                                    DH        Meeting with PHO and stake holders                             1
                      20        Sulawes
                      23 –
                                Denpasar (Bali)     JD, DH    Visit Puskesmas model and Pustu                                2
                                                              Riau Province Visit to find current conditions, status
                      4–6       Pekanbaru (Riau)    JS, NN                                                                   2
                                                              plan and progress of Health sector Reform in the area.
                                                              Kepulauan Riau Province Visit to find current condition
                      7–8       Batam               JS, NN                                                                   2
                                                              of the area.
                      25 –      Puncak (Jawa        JS, NN,
                                                              Seminar on OR program and HSR Implementation                   4
                      27        Barat)              DH
                      2–3       Pekanbaru           DK, NN    Riau Province Visit                                            2
                      9 – 10    Banda Aceh          NN        Banda Aceh Province Visit                                      1
                      16 –      Southeast Su-
                                                    NN        Visit South East Sulawesi                                      1
                      19        lawesi (Kendari)
                      21 –                          JS, NN,
                                Denpasar (Bali)               TA meeting on IR revision                                      3
                      24                            DK
                      27 –      Palu (Central Su-
                                                    NN        Visit Central Sulawesi                                         1
EPOS Health           30        lawesi)
                                                              Attend seminar on HSR implementation, develop of OR
                      1–4       Pekanbaru (Riau)    NN                                                                       1
Final Report                                                  proposal and Unit cost for Puskesmas
                      9 – 10    Banda Aceh          NN        Banda Aceh Province Visit                                      1
                      16 –      Southeast Su-
December 2008                                       NN        Field Visit in Puskesmas and PHO                               1
                      17        lawesi (Kendari)
                      27 –      Palu (Central Su-
                                                    NN        Visit Central Sulawesi                                         1
                      29        lawesi)
                      Total 2004:                                                                                           27

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                        54

                Table 4 - Field Visits by TA Team Members, 2005

                                                                                                          Advo-   Plan-    ADB
                When           Province        Who                   Purpose                Supervision
                                                                                                          cacy    ning    mission

                13 –
                           Banda Aceh         RT       Visit Banda Aceh Tsunami disaster                                    1
                13 –                          RT,
                           Pekanbaru (Riau)            Field Visit                              2
                16                            NN
                25 –
                           Jogyakarta         RT       Meeting at UGM                           1
                10 –       Southeast Su-      RT,      Field Visit to Kendari and Kolaka
                12         lawesi (Kendari)   NN       District
                13 –       Manado (North      RT,      Field Visit to Manado and Bitung
                16         Sulawesi)          NN       City
                                                       Field Visit to with P. Fedon (ADB)
                27 –                                   to Tabanan District Hospital,
                           Denpasar (Bali)    JD, JS                                                                        3
                29                                     Indera Hospital, Puskesmas Den-
                                                       pasar Barat 3, Puskesmas Mengui
                26 –       Banda Aceh         RT,
                                                       Field Visit                                                          2
                29         (NAD)              NN
                18 –                                   Field Visit to Tabanan District,
                           Denpasar (Bali)    RT, JS                                            2
                22                                     Klungkung, Bangli
                                                       Field Visit to Bengkulu Selatan,
                26 –                          RT,
                           Bengkulu                    Suka Makmur District, and Beng-          2
                28                            NN
                                                       kulu City
                           Cisarua (West               Workshop Preparation to Increase
                2–4                           All
                           Java)                       Health Effort DHS (ADB)
                11 –       Southeast Su-
                                              NN       Field visit with Karima Saleh                       4       4        1
                12         lawesi (Kendari)
                22 –       Cisarua (West               Lokakarya Evaluasi pelaksanaan
                24         Java)                       HSR
EPOS Health     July
                25 –       Cipayung (West              Workshop Finalizing Proposal for
                                              All                                                                  4
                27         Java)                       Loan Extension
Final Report    August
                           Palu (Central               Field Visit with EPOS (M. Niech-
                1–5                           All                                                                  4
                           Sulawesi)                   zial)
December 2008
                22 –       Palu (Central      RT,
                                                       Field Visit To Palu                      2
                25         Sulawesi)          NN

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                     55

                                                                                                           Advo-   Plan-    ADB
                When          Province          Who                Purpose                   Supervision
                                                                                                           cacy    ning    mission

                                                      Workshop on Socialization, Pres-
                          Bandung (West        NN,
                4–6                                   entation material for Socialization,                          4
                          Java)                AG,
                                                      Prepare time schedule for visit
                          Palu (Central        RT,
                8 -10                                                                                       2
                          Sulawesi)            NN
                          Manado (North        AG,
                8 -9                                                                                        2
                          Sulawesi)            JS
                12 –      Southeast Su-        RT,
                14        lawesi (Kendari)     NN
                13 –                           AG,
                          Pekanbaru (Riau)            Field Visit (Socialization Grand                      2
                14                             JS
                                                      Design to Provinces)
                18 –
                          Bengkulu             NN,                                                          3
                21 –                           NN,
                          Denpasar (Bali)                                                                   2
                23                             JS
                22 –      Banda Aceh           RT,
                23        (NAD)                AG
                24 –
                          Sanur (Bali)         All    TA strategic Retreat to review TOR                                     4
                29 –      Cisarua (West               Grand Design Finalization Plan-
                                               NN,                                                                  3
                30        Java)                       ning 2006
                          Cisarua (West               Review Meeting plan 2006 by
                1                              All                                                                  4
                          Java)                       provinces
                17 –      Cisarua (West               Workshop sharing experiences
                                               All                                                                  4
                19        Java)                       DHS-1
                23 –      Palu (Central
                                               NN     Seminar on exit strategy                                      1
                25        Sulawesi)
                15 –      Manado (North               Analysis health North Sulawesi
                                               AG                                                           1
                16        Sulawesi)                   (Province & District)
                29 –      Bengkulu (Beng-
                                               NN     Workshop on DTPS                                              1
EPOS Health     30        kulu)
                          Cisarua (West               Workshop on project achievement
                2–3                            All                                                                  4
Final Report              Java)                       review & planning for year 2006
                          Manado (North
                7 – 10    Sulawesi), Palu      AG     Advocacy to Province DHS-1                            2
December 2008             (Central Sulawesi)
                                                      Visit West Sulawesi for DHS2,
                          West Sulawesi
                8–9                            NN     district Polewali and District Ma-                            1

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                      56

                                                                                                             Advo-     Plan-       ADB
                When           Province        Who                 Purpose                   Supervision
                                                                                                             cacy      ning       mission

                           Palu (Central       RT,
                9 – 11                                Advocacy to Province DHS-1                               2
                           Sulawesi)           AG
                11 –       Bengkulu (Beng-            District Training for Health Plan-
                                               NN                                                                           1
                12         kulu)                      ning
                                                      Meeting Advocation & Socialization
                           Makassar (Ujung
                17                             NN     of Project DHS-2 in South Su-                            2
                18 –
                           Bali (Denpasar)     AG     Advocacy                                                 1
                20 –       Banda Aceh
                                               AG     TA for NAD strategic planning                                         1
                21         (NAD)
                TOTAL 2005: 87                                                                     13         27         36         11

                Table 5 - Field Visits by TA Team Members, 2006

                                                                                                           Advo-                   ADB
                When           Province         Who               Purpose                  Supervision

                19 –       Riau (Pekan
                                               RT     Strategic planning to district                                    1
                20         Baru)
                21 –       Kepulauan Riau
                                               RT     Strategic planning to district                                    1
                23         (Batam)
                23 –       Banda Aceh                 TA for strategic planning review
                                               AG                                                                       1
                24         (NAD)                      (NAD)
                22 –       Kendari (South-
                                               NN     Workshop on District proposals                                    1
                24         east Sulawesi)
                26 –       Cisarua (West
                                               All    District strategic plan evaluation                                4
                28         Java)
                           Manado (North              Field Visit to Bolaang Man-
                           Sulawesi)                  gando District,

                8 – 10                                Visit PHO & DHO, meeting                 2
                           Gorontalo (Goron-          Bappeda (Regional Develop-
                           talo)                      ment Board) & Governor of
EPOS Health                                           Visit provincial hospital, PHO,
                18 –       Banda Aceh                 and health centres, pustu &
                                               NN                                                                                   2
                22         (NAD)                      polindes; meeting with ADB
                                                      Mission (K. Saleh);
Final Report

                16 –       Riau (Pekan         NN     Workshop on Strategic plan-
December 2008   18         Baru)               JS     ning, Riau

                20 –       Cisarua (West
                                               All    Evaluation of strategic plan                                      4
                22         Java)
                27 –       Bengkulu (Beng-            Workshop on strategic plan-
                                               NN                                                                       1
                29         kulu)                      ning, Bengkulu

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                               57

                                                                                                     Advo-               ADB
                When        Province        Who                 Purpose                Supervision

                12 –    Cisarua, West               HSR workshop, report presen-
                                           AG,                                                                  4
                14      Java                        tation on HSR Guideline DHS-1
                                           NN, JS
                25 –
                        Bali (Denpasar)    RT       Socialization                                     1
                        Bali (Buleleng
                1                          JS, AG   District plans review                                       2
                08 –    South Sulawesi
                                           NN       Review Strategic Planning                                   1
                11      (Makassar)
                10 –
                        Aceh               AG       Assisting strategic planning                                1
                15 –    Central Sulawesi
                                           AG       Advocacy                                          1
                16      (Palu)
                16      Riau (Pekanbaru)   NN       Strat.plan workshop                                         1
                17 –    Kepri (Tanjung     RT,
                                                    Strat.plan workshop                                         2
                19      Pinang)            NN
                29 –    Southeast Su-      RT,
                                                    Strat.plan workshop                                         2
                31      lawesi (Kendari)   NN
                05 –    West Java                   National meeting on decentrali-
                                           NN,                                                                  3
                08      (Bandung)                   zation
                        South Sulawesi              Field visit ADB mission & DHS-
                19                         RT,                                                                  3
                        (Makassar)                  2
                                                    Meeting coordination develop-
                15 –    West Nusa Teng-
                                           All      ment health plan 2007 for DHS-                              5
                17      gara (Mataram)
                23 –                                Filed visit to Polewali and Ma-
                        West Sulawesi      NN                                                                   1
                24                                  jene
                        North Sulawesi
                23 –                                Socialization data Susenas
                        (Manado, To-       RT                                                                   1
                24                                  maternal & neonatal death rate
EPOS Health
Consultants     July
                03 –                                WHO meeting, edit issue paper,
                        Bali (Denpasar)    JS                                                         1
                05                                  & review Bali districts plan
Final Report
                04 –    Bengkulu (Beng-    AG,      MNCH planning seminar, advo-
                05      kulu)              NN       cacy & strategic planning

December 2008                                       Discussion DHS-2 future pro-
                06 –    West Nusa Teng-             grams, training technical review
                                           All                                                                            3
                08      gara (Mataram)              team NTB-NTT with ADB mis-
                                                    sion (K. Saleh)
                11 –                       RT,
                        Riau (Pekanbaru)            Strategic plan province DHS-1                               2
                13                         NN

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                     58

                                                                                                   Advo-               ADB
                When         Province        Who              Purpose                Supervision

                11 –
                         Bali (Denpasar)    JS     Review Bali strategic Plan                                 1
                21 –     Southeast Su-             Meeting ES Southeast Su-
                                            NN                                                      1
                24       lawesi (Kendari)          lawesi & Head of Dinkes
                26 –     Kepulauan Riau     RT,
                                                   Final review strategic plan           2
                28       (Natuna)           RW
                26 –     South Sulawesi            Review strategic plan South-
                                            NN                                                                1
                28       (Makassar)                east & Central Sulawesi
                                                   Collect material strategic plan
                21 –     Southeast Su-
                                            NN     all districts & HSR Kolaka dis-       2
                24       lawesi (Kendari)
                                                   Planning workshop DHS-1 with
                02 –     West Java (Cisa-
                                            All    all provinces, technical review                  4
                04       rua)
                08 –     South Sulawesi
                                            NN     Seminar at Wahidin Hospital           1
                09       (Makassar)
                         West Java (Cisa-
                10                          All    3 yrs planning                                             4
                15 –     West Nusa Teng-
                                            RT     Evaluation project DHS-2                                   1
                16       gara (Mataram)
                22 –     West Java (Cisa-
                                            AG     Revise IHPB module                                         2
                25       rua)
                         South Sulawesi
                23                          NN     Meeting with DHS-2 staff              1
                                                   Visit Dinkes Poso District &
                22 –     Central Sulawesi   RT,
                                                   puskesmas, visit puskesmas            2
                26       (Palu)             RW
                                                   Ampana Tete
                29       Bali (Denpasar)    AG     Advocacy                                         1
                30.-                        AG,    Annual Opr. Budget DHS-2,
                         Jogjakarta (DIY)                                                                     4
                1.9.                        NN,    Exit Strategy Workshop
                09 –     Southeast Su-             Advocacy at Konawe District,
                                            NN                                           3
EPOS Health     14       lawesi (Kendari)          Kendari City, & Kolaka District
                10 –     Bali (Nusa         RT,    Evaluation Poned & Ponek at
                12       Penida)            RW     Nusa Penida District
Final Report                                RT,    Workshop monitoring & evalua-
                13 –
                         Bali (Denpasar)    AG,    tion DHS-1, DIP (part of Annual                  3
                                            RW     Opr. Budget) DHS-2
December 2008   17 –     North Sumatera     NN,
                                                   Training DTPS for NAD                                      2
                21       (Medan)            RW
                18 –     East Java (Sura-          Workshop Synchronizing DHS-
                                            RT                                                                1
                19       baya)                     2 Activities

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                 59

                                                                                                  Advo-               ADB
                When          Province       Who               Purpose              Supervision

                18 –      Southeast Su-
                                             AG    Advocacy MNCH                                   1
                19        lawesi (Kendari)
                20 –      East Java (Sura-   RT,   Workshop Synchronizing DHS-
                22        baya)              NN    2 Activities
                21 -      South Sumatera     RM,
                                                   Planning workshop DHS-2                                   1
                22        (Palembang)        RW
                21 –
                          Kepulauan Riau     AG    Strategic planning & advocacy                             1
                          South East Su-
                2–4                          RW    Socialization DTPS                                        1
                          lawesi (Kendari)
                          West Java                BKKBN West Regional Work-
                5–6                          NN,                                                   3
                          (Bandung)                shop on Family Planning
                          North Sulawesi     NN,   Workshop on exit strategy
                9 – 11                                                                                       4
                          (Manado)           RW,   DHS1
                          South Kalimantan
                12                           AG    DHS2 Planning Meeting                                     1
                12 –      West Nusa Teng-    NN,   BKKBN East Regional Work-
                13        gara (Mataram)     RT    shop on Family Planning
                12 –      South Sumatera
                                             RW    Strategic Planning                                        1
                14        (Palembang)
                18 –      West Java
                                             RT,   Meeting MNCH advocacy                           3
                19        (Bandung)
                30 –      South Sulawesi
                                             NN    DHS2 District Officer Training                  1
                1.11.     (Makassar)
                          West Nusa Teng-
                6–7                          RT                                         1
                          gara (Mataram)           MNCH Assessment at remote
                          West Nusa Teng-          area
                7–8                          RW                                         1
                          gara (Mataram)
                          West Nusa Teng-
                7–9                          NN    Strategic planning to district                            1
EPOS Health               gara (Mataram)
                          North Nusa               Workshop arrange proposal &
                8 – 10    Tenggara (Ku-            Master Plan 2007-2010 Project                             2
                          pang)                    DHS2
Final Report
                          Bengkulu (Beng-
                9 – 12                       RW    Training for based line study                   1
December 2008             South Sulawesi     NN,   Workshop on DHS2 District
                13                                                                                           2
                          (Selayar)          RT    Planning
                          South Sulawesi           Visit Health Center and Sub
                14                           NN
                          (Selayar)                Health Center

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                60

                                                                                                   Advo-               ADB
                When         Province       Who              Purpose                 Supervision

                         South Sulawesi     NN,   Workshop on preparation dis-
                15                                                                                            2
                         (Pare-pare)        RT    trict health system
                17 –     Central Sulawesi         Research proposal of DHS1
                                            NN                                                                1
                18       (Palu)                   local program
                                            NN,   Advocacy Grand Design &
                19 –     South East Su-
                                            RW,   Socialization DTPS in South                       3
                20       lawesi (Kendari)
                                            RT    Konawe District
                                            NN,   Advocacy Grand Design &
                21 –     South East Su-
                                            RW,   Socialization DTPS in Muna                        3
                22       lawesi (Raha)
                                            RT    District
                                            NN,   Advocacy Grand Design &
                23 –     South East Su-
                                            RW,   Socialization DTPS in Bau-bau                     3
                24       lawesi (Bau-bau)
                                            RT    City
                28 –     South Sulawesi           Visit to Bappeda (Local Plan-
                                            RT                                                                          1
                29       (Ujung Pandang)          ning & Development Agency)

                27 –     Kepulauan Riau     NN
                                                  Workshop on DTPS action plan                                3
                30       (Batam)            RW
                         Banjarmasin              Workshop arrange proposal &
                30 –
                         (South Kaliman-    RT    master plan 2007-2010 project                                         1
                         tan)                     DHS2
                         West Java (Bo-
                1                           AG    MNCH advocacy DHS1                                1
                         Kepulauan Riau           Integrated Health Planning and
                5–7                         AG                                           1
                         (Batam)                  Budgeting (IHPB) Training
                         West Java                Workshop on Lesson Learned
                8–9                         RT,                                                               3
                         (Bandung)                & Shared Experience
                11 –     West Java (Bo-     AG,
                                                  HSR TOT                                                     1
                13       gor)               RT
                13 –     West Java (Bo-           Meeting finalization master plan
                                            NN                                                                1
                14       gor)                     DHS2
                         East Java (Sura-
                19                          RW    MNCH Guideline clinics                                      1
                         West Java (Bo-
                20                          RT    Meeting TRT work plan DHS2                                  1
EPOS Health              gor)
                18 –
                         Bali (Denpasar)    NN    WHO SEARO Meeting for ADB                                             1

Final Report    20 -     Kepulauan Riau           Socialization for District Team
                                            RW                                                                1
                23       (Tanjung Pinang)         Problem Solving (DTPS)
                26 –     South Sulawesi
                                            NN    Visit for advocacy DHS2                           1
December 2008
                27       (Jeneponto)
                Total 2006:151                                                           18         36       89         8

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                   61

                Table 5 - Field Visits by TA Team Members, 2007

                                                                                              Supervi-   Advo-
                When       Province             Who      Purpose                               sion      cacy

                                                RT,      Meet with Head Health Office,
                           Central Kaliman-
                7–8                             NN,      Field Visit Poned & Ponek District      2
                           tan (Palangkaraya)
                                                RW       Project DHS2
                           Central Kaliman-
                                                         Visit Kasongan District & Tumbang
                9 – 11     tan (Kasongan        RT, NN                                           2
                                                         Habangoi Village
                           East Java (Sura-              Preparation for workshop comple-
                15 – 16                         RW                                               1
                           baya)                         tion of MNCH guideline
                                                         DHS1 workshop Monev Analysis
                                                RT, NN                                                                2
                16 – 21    Bali (Denpasar)               DHS1 planning activities 2007
                                                All      TA Meeting for book writing
                           East Java (Sura-              Preparation workshop for IPHB
                26 – 27                         RW                                                                    1
                           baya)                         Improvement
                8          Bali (Denpasar)      RT       Socialization DHS-1                                          1
                                                         Visit Riau Province
                13 – 15    Riau (Pekanbaru)     NN,      Visit Siak District                                          3
                                                         Partnership TBA with midwives
                                                         Visit villages with Bakesra (com-
                           South East Su-
                21 – 24                         RT, NN   munity health hall) in Kolaka Dis-                           2
                           lawesi (Kendari)
                                                         Workshop IHPB improvement of
                           West Nusa Teng-               the district health system in East
                25 – 27                         RT, AG                                                    2
                           gara (Mataram)                Nusa Tenggara & West Nusa
                           South Sulawesi       RW,      Workshop monev management
                26 – 27                                                                                               2
                           (Ujung Pandang)      NN       DHS
                           Central Sulawesi              Work on Palu Total Quality Man-
                12 – 15                         RT, NN                                                                2
                           (Palu)                        agement (TQM )chapter
                                                         Socialization DHS1 & visit to Jim-
EPOS Health     21 – 22    Bali (Denpasar)      RT, AG                                                                2
Consultants                                              brana District
                27 – 28    West Java (Bogor)    All      Compiling work plan TRT DHS1                                 4
                           South East Su-
Final Report    28 – 29                         NN       Socialization DHS1                               1
                           lawesi (Kendari)
December 2008              Bandung (Jawa                 Workshop DHS2 on Program Co-
                2–4                             RT, NN                                                                2
                           Barat)                        ordination
                           North Sumatera       RW,
                2–6                                      Workshop DTPS                                                1
                           (Medan)              AG

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                 62

                                                                                                Supervi-   Advo-
                When      Province             Who      Purpose                                  sion      cacy

                          Banda Aceh
                10                             NN       Socialization DHS1
                                               RT,      Present at workshop on advocacy
                17        Bogor (West Java)    NN,      for mother & child with HSP                                     3
                                               RW       (USAID)
                          Ujung Pandang                 Visit Mamuju District and working
                18 – 21                        RT, NN                                                                   2
                          (South Sulawesi)              on master plan West Sulawesi
                                                        Workshop Analysis monev & per-
                                               RT,      siapan project completion report
                          Bandung (West
                24 – 26                        NN,      (PCR) & Benefit Monitoring                                      3
                                               AG       Evaluation (BME) & Field visit
                                                        SUbang District
                8 – 11    Batam (Kepri)        RT, AG   Workshop exit strategy DHS1                                     2
                          Surabaya (East       NN,      Meeting Work Plan Years Project
                22 – 24                                                                                                 2
                          Java)                AG       DHS1
                                                        Participate in DTPS for maternal
                          Palu (Central Su-
                4–8                            RT, NN   health, develop annual MNCH                                     2
                                               RT,      Demand Creation Technical sup-
                          Bandung (West
                7 - 10                         NN,      port for DHS-1, and prepartion for                              3
                                               AG       mission
                          Bengkulu (Beng-
                19 – 20                        RT, NN   DTPS, DHS impact survey,                                        3
                          Polewali Mandar               Visit Polewali District : two Pusk-
                3–6                            RT, NN                                                                   3
                          (West Sulawesi)               esmas at two Subdistricts
                          Gorontalo (Goron-             Field visit Bone Bolango district &
                08 – 09                        RT, NN
                          talo)                         Boalemo district
                          Kendari (South
                12 – 13                        NN       Visit Kolaka District
                          East Sulawesi)
                          Medan (North                  Field visit on District & infrastruc-
                16 – 18                        AG
                          Sumatera)                     ture with all heads of Kepri district
                                                        Strategic Plan and Proposal De-
                17 – 20   Pekanbaru (Riau)     RT, NN                                                                   2
EPOS Health                                             velopment
                          Bitung City (North
                27– 28                         RT, NN   Visit Bitung city of North Sulawesi
Final Report    August
                                                        International Health Sector Reform
                5 – 11    Bali (Denpasar)      NN,                                                                      3
December 2008                                  AG
                          Sekayu (South                 Visit Banyuasin and Musi Banyua-
                20                             RT, NN
                          Sumatera)                     sin District
                          Palembang (South              Visit DHS-2 program at Palem-
                21 – 24                        RT, NN                                                                   3
                          Sumatera)                     bang City

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                   63

                                                                                              Supervi-   Advo-
                When         Province            Who      Purpose                              sion      cacy

                             Bengkulu (Beng-
                30                               AG       MNCH Advocacy
                             Kota Baru (South             Visit 2 puskesmas in Kota Baru
                3–4                              All
                             Kalimantan)                  District and meeting with Bupati
                                                          Visit pustu (assisted puskesmas)
                             Kota Baru (South
                5                                RT, NN   in isolated area (Tanjung Lalah
                                                          District in Lontar Island)
                             Gorontalo (Goron-
                7–9                              NN       Visit Boalemo District
                             Mataram (West
                27                               RT, NN   Visit Desa Siaga in West Lombok
                             Nusa Tenggara)
                             Karang Anyar
                28                               NN,      Visit Desa Siaga in Karang Anyar
                             (Central Java)
                             Makassar, South
                8                                NN       Visit DHS 2 South Sulawesi Prov.       1
                                                          Field Vsit to Polindes, Pskesmas,
                14 – 16      Denpasar, Bali      RT                                              2
                                                          Desa Siaga at Karang Asam Distr.

                                                          Exit Strategy Workshop at Parigi
                19 - 20      Central Sulawesi    NN       District & Demand Creation work-       1        1
                                                          shop at Palu City

                             Pangkal Pinang,
                22 - 23                          RT,NN    Workshop on DHS 2 program                       2
                             Bangka Belitung

                3–5          Bengkulu            NN       Workshop on Data validation            1
                             Jeneponto,                   Sosialization DHS proeject
                10                               NN                                                       1
                             S.Sulawesi                   application
                12 - 13                          RT       Provincial DHS 2 Meeting               1
                             Kendari, South               Workshop on policy dialogue Ko-
                16 – 18                          NN                                                       1
EPOS Health                  East Sulawesi                laka Dstrict
                             Palu, Central Su-
                16 - 17                          AG       HSR Advocacy                                    1

Final Report    Total 2007   80                                                                 12        9          59

                Table 5 - Field Visits by TA Team Members, 2008
December 2008
                                                                                              Super-     Advo-      Plan-
                When         Province            Who      Purpose
                                                                                              vision     cacy       ning

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                 64

                                                                                                         Super-   Advo-     Plan-
                When             Province              Who        Purpose
                                                                                                         vision   cacy      ning
                                 South-East Su-                   Feld visit Bau-Bau District Advo-
                11 - 13                                All                                                         4
                                 lawesi                           cacy Grand Design MNCH
                                 Kendari, South-                  Workshop Grand Design MNCH
                18 - 20                                NN                                                          1
                                 East Sulawesi                    Kolaka Utara District
                26 - 30          Bengkulu              RT,NN      Develop plan for in-service training                        1
                                 Banjarmasin,                     Field visit Kotabaru District, OR
                9 - 11                                 All                                                 4
                                 South Kalimantan                 undertaken on barriers to care
                                                                  Field visit to NTT to review the
                14 - 17          Kupang, NTT           RT,AG      District Health Account Proposal,        2
                                                                  in coordination with AusAID
                                                                  Field visit with K. Saleh and Boni
                                 Manado, North
                19 - 22                                All        (Sitaro District & Meet with Bupati
                                                                  and BAPPEDA)
                                 Bandung, West                    Socialization DHS 2 at National
                25                                     NN                                                          1
                                 Java                             Occupational Health meeting.
                                                                  Field visit to Bualemo and Bone
                13 – 14          Gorontalo             RT,NN                                               2
                                                                  Bolango Districts
                19 – 20          (South Kaliman-       AG         Supervision Project DHS-2                1
                                                                  Field visit with Mission (K.Saleh &
                                 Palu, Central Su-
                20 - 21                                RT,NN,     S. Latief), DHS-2 Synchronization                           4
                                                                  Meeting West Sulawesi
                                                                  Field visit with Mission (K.Saleh &
                22 - 24          Denpasar, Bali        RT,AG                                                                  4
                                                                  S. Latief) to Jimbarana District
                Total 2008: 23                                                                             8       6          9

                7.3       Publications and Presentations

EPOS Health     7.3.1 Technical Documents Produced

                No.      Name of Document
Final Report             October 2004
                         Criteria for Operations Research
                         Information for Applicants to Research Grants and simplified Application Form
December 2008
                         List of Operation Research Topics
                         April 2005
                         Revised MOU for DHS 1

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                         65

                No.   Name of Document
                      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
EPOS Health
                      Concept paper: “Why has Bali been more successful than others in improving health status: a study in positive
                      Concept paper: “Piloting a Unifying Strategy for Clinical Care”
Final Report
                      Progress Report: Bali Integrated Care
                      Profile DHS-1 Provinces (Power-point)

December 2008         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)

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                          66

                No.   Name of Document
                      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)
EPOS Health
Consultants           Format for communicating evaluation of 2006-2008 strategic plans to ADB
                      Revisi renstra MENKES (Rencana Strategis = Strategic Plan of MoH) English
Final Report          Model predicting MMR by district draft 7
                      DHS-1 Amendment proposal rev4
                      Format evaluasi renstra 2006-2008
December 2008
                      Cost effectiveness of MNCH investment
                      February 2006
                      Master Plan for DHS-1 after socialization of Grand Design, and Planning excercise

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                           67

                No.   Name of Document
                      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
EPOS Health
                2     Discussing HSR (Power-point)
                4     MCH Workshop material Power-point)
                5     Outline documentation HSR
Final Report
                      May 2006
                6     TOR for assessment of maternal health indicators
December 2008
                      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

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                         68

                No.   Name of Document
                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)
EPOS Health
Consultants           Guidelines for assuring training programs
                      Strategic planning manpower health (Excel)
Final Report          September 2006
                      Conceptual framework for DTPS (Power-point)
                      Guidelines for DTPS (District Team Problem Solving)
December 2008
                      HSR issues paper developed by TA 8 Rev (Word)
                      October 2006
                      Presentation Description Project DHS-2 in BKKBN Meeting

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                            69

                No.    Name of Document
                       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-
                       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
EPOS Health
                       Desa Siaga Model, a Guideline
                       Surveillance model for Desa Siaga
                       Training Desa Siaga Facilitators
Final Report
                       Cost Tables for DHS-2 2009-2010
                       Barriers to Health Care in Indonesia
December 2008
                7.3.2 Meetings attended

                When           Province                       Purpose

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                           70

                When          Province               Purpose
                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
                                                     Finalizing Revised Inception Report , Planning the 1st Six-Month Report, and
                22 – 25.11.   Denpasar (Bali)
                                                     Preparing Plans for the Next 6 Months
                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
                              Makassar (South Su-
                07 – 9.06.                           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
                                                     Workshop to prepare Socialization,
                04 – 06.09.   Bandung (West Java)    Presentation material for Socialization,
                                                     Prepare time schedule for visit
                24 – 26.09.   Denpasar (Bali)        Meeting TOR for strategic Retreat
EPOS Health
Consultants     01.10.        Cisarua (West Java)    Meeting review plan for 2006 by provinces
                09.10.        Jakarta (DKI)          TA Consulting Meeting

Final Report    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
December 2008
                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.

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                     71

                When          Province              Purpose
                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
                              Makassar (South Su-
                17.12.                              Meeting Advocation & Socialization of Project DHS-2 in South Sulawesi
                22.12.        Jakarta (DKI)         Presentation Health Situation Analysis at DHS-2 Region
                05.01.        Jakarta (DKI)         TA Meeting
                                                    Meeting evaluation & setting work plan of center technical committee year
                06.01.        Jakarta (DKI)
                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
                                                    Meeting TA, ADB Mission and DHS-1 & DHS-2 staffs & with head of Plan-
                14-17.02.     Jakarta (DKI)
                                                    ning Bureau of MOH
                                                    Meeting DHS-1 extension program present at the Bappenas (National Plan-
                23.02.        Jakarta (DKI)
                                                    ning Board)
                                                    Invitation of workshop for Ausaid women & child health programming mis-
                03.03.        Jakarta (DKI)
                                                    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
                                                    - OR guideline finalization
                04 – 07.04.   Jakarta (DKI)
                                                    - Meeting with DHS-1, preparing OR presentation
                12 – 14.04.   Cisarua (West Java)   HSR workshop, report presentation on HSR Guideline DHS-1
EPOS Health
Consultants     17 – 19.04.   Jakarta (DKI)         Revise HSR guideline
                24 – 26.04.   Jakarta (DKI)         Finalize OR guideline

Final Report    02 – 03.05.   Jakarta (DKI)         Coordination meeting baseline survey DHS-2
                              Makassar (South Su-
                08 – 11.05.                         Review Strategic Planning Riau & Kepri
December 2008   16.05.        Pekanbaru (Riau)      Strat.plan workshop
                16 – 19.05.   Jakarta (DKI)         Meeting stakeholders program of child health to develop strat.plan 2007
                              Tanjung Pinang
                17 – 19.05.                         Strat.plan workshop
                              (Bangka Belitung)

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                       72

                When          Province                  Purpose
                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
                              Kendari (Southeast
                29 – 31.05.                             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
                              Mataram (West Nusa
                15 – 17.06.                             Meeting coordination development health plan 2007 for DHS-2
                21 – 22.06.   Jakarta (DKI)             ADB mission with MOH & wrap up meeting with Bappenas
                                                        Review issue paper, meeting ES DHS-2, presentation DHS-2 action plan
                27 – 30.06.   Jakarta (DKI)
                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
                              Mataram (West Nusa
                06 – 08.07.                             Discussion DHS-2 future programs, training technical review team NTB-NTT
                14.07.        Jakarta (DKI)             Meeting DHS-2 with Bappenas
                                                        DHS-1: Meeting & presentation DHS-1 extension, develop guideline for
                17 – 19.07.   Jakarta (DKI)
                              Kendari (Southeast
                21 – 24.07.                             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)
                              Makassar (South Su-
                08 – 09.08.                             Seminar at Wahidin Hospital
                10.08.        Cisarua (West Java)       3 yrs planning
                22 – 25.08.   Cisarua (West Java)       Revise IHPB module
                              Makassar (South Su-
                23.08.                                  Meeting with DHS-2 staffs
EPOS Health
Consultants                                             Workshop Acceleration of Reducing Maternal Mortality Rate in Tojo Unauna
                22 – 26.08.   Palu (Central Sulawesi)
                              Makassar (South Su-
Final Report    24 – 26.08.                             Workshop on district work plan
                28.08.        Jakarta (DKI)             Report advocacy Bali

December 2008   29.08.        Jakarta (DKI)             Meeting with Director of Decentralize Unit
                30.08. –
                              Jogjakarta (DIY )         Annual Opr. Budget DHS-2, Exit Strategy Workshop
                                                        Workshop monitoring & evaluation DHS-1, DIP (part of Annual Opr. Budget)
                13 – 15.09.   Bali (Denpasar)

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                      73

                When           Province               Purpose
                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
                                                      Meeting DHS-1 for Exit Strategy Workshop, developing TOR for workshop in
                27 – 29.09.    Jakarta (DKI)
                5 – 6.10.      Bandung (West Java)    BKKBN West Regional Workshop on Family Planning
                06.10.         Jakarta (DKI)          Meeting with DHS1 Executive Secretary
                               Manado (North Su-
                09 – 11.10.                           Workshop on exit strategy DHS1
                               Banjarmasin (South
                12.10.                                DHS2 Planning Meeting
                               Mataram (West Nusa
                12 – 13.10.                           BKKBN East Regional Workshop on Family Planning
                               Palembang (South
                12 – 14.10.                           Strategic Planning
                18 – 19.10.    Bandung (West Java)    Meeting MNCH advocacy
                30.10. –       Makassar (South Su-
                                                      DHS2 District Officer Training
                01.11.         lawesi)
                06.11.         Jakarta (DKI)          Meeting with DHS1 Executive Secretary
                               Mataram (West Nusa
                07 – 09 .11.                          Workshop on Master Plan DHS2
                               Kupang (North Nusa
                08 – 10.11.                           Workshop arrange proposal & Master Plan 2007-2010 Project DHS2
                09 – 12.11.    Bengkulu (Bengkulu)    Training for based line study
                               Selayar (South Su-
                13.11.                                Workshop on DHS2 District Planning
                               Pare-pare (South Su-
                15.11.                                Workshop on preparation district health system
                               Kendari (South East
                19 – 20.11.                           Advocacy Grand Design & Socialization DTPS in South Konawe District
                               Raha (South East Su-
                21 – 22.11.                           Advocacy Grand Design & Socialization DTPS in Muna District
EPOS Health                    Bau-bau (South East
                23 – 24.11.                           Advocacy Grand Design & Socialization DTPS in Bau-bau City
Consultants                    Sulawesi)
                23 – 24.11.    Jakarta (DKI)          Meeting TOR MNCH with ES DHS1
Final Report                   Batam (Kepulauan
                27 – 30.11.                           Workshop on DTPS action plan
                27 – 30.11.    Bogor (West Java)      P2KT Training
December 2008
                               Makassar (South Su-
                28 – 29.11.                           Workshop arrange & master plan 2007-2010 project DHS2
                30.11. –       Banjarmasin (South
                                                      Workshop arrange proposal & master plan 2007-2010 project DHS2
                01.12.         Kalimantan)

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                   74

                When          Province                Purpose
                01.12.        Bogor (West Java)       MNCH advocacy DHS1
                04 – 07.12.   Jakarta (DKI)           ADB Mission
                              Batam (Kepulauan
                05 – 07.12.                           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
                              Tanjung Pinang (Kepu-
                20 - 23.12.                           Socialization DTPS
                              lauan Riau)
                03 – 05.01.   Jakarta (DKI)           Meeting with DHS2, with TA for book writing
                5.01.         Jakarta (DKI)           Meeting with DHS1
                              Palangkaraya (Central
                08 – 11.01.                           MNCH assessment
                09 – 10.01.   Jakarta (DKI)           Meeting with DHS1 Executive Secretary
                11.01.        Jakarta (DKI)           Meeting DHS1 review 2007 plan
                                                      1.   DHS1 workshop Monev Analysis
                16 – 21.01.   Denpasar (Bali)         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
EPOS Health     16.02.        Jakarta (DKI)           Meeting of mind
                22 – 23.02.   Jakarta (DKI)           HSR guideline DHS1
                              Mataram (West Nusa
                25 – 26.02.                           DHS2 integrated planning
Final Report                  Tenggara)
                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
December 2008
                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

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                 75

                When          Province                  Purpose
                              Medan (North Su-
                02 – 05.04.                             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
                              Mamuju (West Su-
                18 - 21.04.                             Workshop: finalizing Master Plan Mamuju District project DHS-2
                                                        Workshop: monitoring & evaluation (monev) analysis & preparation Project
                24 – 25.04.   Bandung (West Java)
                                                        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
                              Batam (Kepulauan
                08 – 10.05.                             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
                                                        Workshop: improving data management in MNCH program & MNCH surveil-
                04 – 07.06.   Palu (Central Sulawesi)
                                                        lance in Donggala District
                                                        Workshop: baseline survey proposal development of DHS-1 on operational
                10 – 11.06.   Bengkulu (Bengkulu)
                                                        Meeting: review annual plan year 2008 and discuss on TOR short course &
                11.06.        Jakarta (DKI)
                                                        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
                                                        Meeting: ADB mission on DHS-1 plan of action 2008 & application of 2007
                21 – 25.06.   Jakarta (DKI)
                26.06.        Jakarta (DKI)             Meeting: ADB kick off with Bappenas
                                                        Meeting: consultation mechanism extension of Central Loan (ADB) to dis-
EPOS Health     27.06.        Jakarta (DKI)
                                                        trict/ city government
                28.06.        Jakarta (DKI)             Meeting: ADB wrap up with Bappenas
                              Polewali Mandar (West
Final Report    03 – 05.07.                             Socialization & advocacy for DHS-2
                06 – 07.07.   Gorontalo (Gorontalo)     Socialization & advocacy for DHS-2
                              Kendari (Southeast
December 2008   11.07.                                  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

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                         76

                When          Province                Purpose
                              Makassar (South Su-
                24.07.                                Meeting: Executive Secretary South Sulawesi
                              Manado (North Su-       Workshop: on intensification of inter sector collaboration & coordinator for
                25 – 26.07.
                              lawesi)                 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
                              Palembang (South
                21 – 24.08.                           Workshop: socialization for DHS-2
                              Palembang (South        National Seminar: of IAKMI (Indonesian Community Health Expert Associa-
                22 – 24.08.
                              Sumatera)               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
                              Kotabaru (South Kali-
                03 – 06.09.                           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
                                                      Meeting for the development of GAVI-HSS proposal (at invitatiohn of Bapp-
                10 .10        Jakarta
                22.10         Jakarta                 Meeting DHS 2 prepare for Mid Term Review
                24.10         Jakarta                 Meeting Mid Term Review, & sugestion cancellation
                                                      Meeting for the development of GAVI-HSS proposal (at invitatiohn of Bapp-
                26.10         Jakarta
                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 –
                              Bandung, West Java      Workshop “Sharing Experience” Project DHS
EPOS Health
Consultants     5.12          Jakarta                 Follow up Wrap Up meeting project DHS 2
                              Kndari, South East
                9 – 10.12                             Resurce person for prject provincial level workshop
Final Report
                12-14 . 12    Denpasar, Bali          Meeting to develop guideline for TRT evaluation of various loan initiatives
December 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

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                            77

                When           Province             Purpose
                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
                                                    Meeting health Sector Cordinating Committe *(HSCC) and stakeholders in
                19 .02         Jakarta
                                                    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
                                                    Meeting health Sector Cordinating Committe *(HSCC) and stakeholders in
                06. 03         Jakarta
                                                    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
                                                    Workshop Health Sector Reform in the context of decentraklization in Indo-
                25. 06         Jakarta
                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
EPOS Health
Consultants     18 – 20. 07.   Yogyakarta           DHS 2 Start Up meeting for West region.
                               Palembang, South
                21 – 22. 07                         BKKBN meeting for program development
Final Report
                               Padang, West Su-
                22 – 24. 07                         BME and Individual neeting to review questionaire.
December 2008   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

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                   78

                When          Province                Purpose
                              Banjarmasin, South
                15 – 18. 08                           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
                              Palembang, South
                28 – 30.08                            Synchronization program meeting with Districts, DHS 2

EPOS Health

Final Report

December 2008

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                            79

                7.4   District level participation with Assisted Deliveries, 2004

EPOS Health

Final Report

December 2008

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                80

                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-

                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-

                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

                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.

EPOS Health     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
Final Report
                higher levels of the government, and feedback to the Desa Siaga are an important element
                of these programs.
December 2008
                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.

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                       81

                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-

                      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

                      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
EPOS Health
                      f.   Improvement of health program coverage and effectiveness that become the pri-
                           ority of the respective Desa Siaga
Final Report
                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-
December 2008
                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.

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                      82

                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.
EPOS Health                -   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
Final Report
                               rapid information flow in the community. This is one of the important elements
                               in developing Desa Siaga model.
December 2008              -   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
                          -   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

EPOS Health               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
Final Report
                          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
December 2008             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
EPOS Health
                       c.   Review plan and budget proposed by the respective Desa Siaga

                       d.   Assist Desa Siaga in resource mobilization (community financing schemes or
Final Report                Dana Sehat, and income generating activities)

                       e.   Assist Desa Siaga in maintaining financial recording and reporting system
December 2008
                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
EPOS Health                   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

Final Report                  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
December 2008
                              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-

                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.
EPOS Health

Final Report

December 2008

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                Example of Family Health Card (would be improved after pre-testing)

                                    Household ID:
                                            Indicators           Red        Yellow     Green
                                1   PUS
                                2   Pregnant women
                                    * ANC (K4)
                                    * TT
                                    * Fe
                                3   Delivery
                                    * Hlth profesionals
                                    * Referal for emergency
                                4   Post natal care
                                5   <5 weigthing
                                6   Immunization
                                    * BCG
                                    * DPT
                                    * Polio
                                    * Measles
                                7   Tbc case
                                8   Malaria case
                                9   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
EPOS Health     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

Final Report    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”

December 2008
                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
EPOS Health            •    various measures for vector control (elimination of breeding and resting places,
                            spraying, etc).

Final Report
                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
December 2008

                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

                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-
EPOS Health     cient operating cost will improve health program performance.
                The start up (establishment) cost of the DS model include the cost for Poskesdes construc-

Final Report    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,
December 2008
                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

EPOS Health         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
Final Report
                    5.       The DHO review the proposal for approval

December 2008       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.
EPOS Health
                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
Final Report    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,
December 2008   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
EPOS Health
Consultants               -   Assist the evaluation of the model for the whole province
                          -   Help formulate policy recommendation generated from the evaluation
Final Report
                      •   Central level

                          -   Review all proposal and budget of DS model
December 2008             -   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.


                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).
EPOS Health
Consultants     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.
Final Report

                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-
December 2008
                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).


                                                   Program performance                     Outcome indicators

                                               •    Survey Mawas Diri
                                                    (SMD),                        •    Effective support from
EPOS Health                                    •    Musyawarah Masyarakat              community leaders, head
Consultants     1.   Regularity of village                                             of the village, Camat
                                                    Desa (MMD)
                                               •    Role of the community in      •    Implementation of SMD &
                                                    the planning, implemen-            MMD
Final Report
                                                    tation and evaluation

December 2008

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                                                     Program performance                      Outcome indicators

                                                                                       •     Availability of village ambu-
                                                                                       •     KAP of alertness
                                                                                       •     Effective 24 hour surveil-
                2.   Ability of the village to   Preparedness / alertness of the
                     manage emergency            community
                                                                                             lance system
                                                                                       •     List of the blood type of the
                                                                                             whole adult population
                                                                                       •     Ability of village manage
                                                                                             medical emergency
                                                                                       •     Collecting community con-
                3.   Ability of the village to                                               tribution have developed
                                                 Financial and budgeting sys-
                     mobilize resources
                     for implementation
                                                 tem                                   •     Availability of financial if

                4.   Ability of the village to                                         •     Availability of community
                                                 Mobilization of all community               saving system
                     support the sustain-
                     ability of Desa Siaga                                             •     Availability of exit strategy

                MDG Target                       Program performance                         Outcome indicators
                                                                                   Number reported cases of malnutri-
                1.   MDG 1: Reduc-          Coverage of under five weighing        tion
                     tion the hunger        (90%), LBW and SKDN, N/D etc.          % children with under weight de-
                                            PNC (2 times), referral of emer-       No of life birth, infant death, mea-
                2.   MDG 4: reduction
                                            gency cases, immunization cov-         sles outbreak and number of case
                     of IMR
                                            erage (85%)                            of communicable diseases
                                            CPR, ANC (K4), Assisted deliv-         Number of delivery, emergency
                3.   MDG 5: reduction
                                            ery, Post Natal Care (PNC 2x)          cases and referral emergency
                     of MMR
                                            Referral of emergency cases            cases, maternal death
                4.   4. MDG 6: re-
                     duction of             CDR, SR and CR of Tuberculosis         Number of reported Tbc cases
                     communicable           and Malaria                            Number of reported Malaria cases

                     Types of program               Program performance                      Outcome indicators

                                                                                   •       % increase of person seeking
                1.   Out patient services         Utilization of health services           treatment if Sick
EPOS Health
Consultants                                                                        •       % increase of outpatient
                                                                                   •       % household with latrine
Final Report                                      Latrine at home and at           •       % household with clean wa-
                2.   Sanitation and drinking
                                                  school, source of drinking               ter supply
                     water supply
                                                                                   •       % of school have latrine and
                                                                                           hand washing
December 2008
                                                                                   •       Number of active Posyandu
                3.   Posyandu attendance          Revitalization of Posyandu       •       Posyandu attendance in-

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                                                   Number of cadre have train-
                4.     Sustainability of cadre
                                                                                     •    % 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               Outcomes
                     1 Poskesdes establishment     1 Surveillance          1 Coverage of speciific   1 Under nutrition
                     2 Placement of health          SMD and MMD            2 Exit strategy plan      2 Rate of pregnancy
                     3 Training and placement of   2 Desa Siaga activity   3 Financial cash flow     3 Number of delivery
                       facilitator                                           performance               and reported
                                                                                                       maternal death
                     4 Block grant to Desa Siaga   3 Desa Siaga            4 Community financial     4 Number reported
                                                     management              contribution              infant death
                     5 etc                         4 Community                                       5 Number of tb and
                                                     financing scheme                                  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.

EPOS Health
                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
Final Report
                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-
December 2008   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.
EPOS Health
Consultants                2.   Collecting data and develop a mapping system.
                           3.   How to identify certain communicable diseases base on the disease symp-

Final Report                    toms and health problems.

                Training for cadres will take place at the Puskesmas in the same subdistrict of the selected

December 2008   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-          8.   Diphtheria                  12. Lung Tuberculosis
                     orrhagic Fever)

                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-
EPOS Health
Consultants     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
Final Report    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).
December 2008
                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.

EPOS Health

Final Report

December 2008

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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

EPOS Health     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
Final Report

                The specific objectives of Desa Siaga are:
December 2008
                       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

                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;

EPOS Health           4.   Provision of basic health services in accordance to the health workers compe-
                           tency available in the Poskesdes.

Final Report    There are also additional tasks of Poskesdes, including the following:

                      5.   Health promotion to improve the awareness of family on nutrition, improve healthy

December 2008
                           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-
EPOS Health
                put, (c) availability of cost data.

                As for the Desa Siaga, there are conditions limiting the execution of all of the above analysis.
Final Report    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”.
December 2008
                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           Accounted
                  1 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    Included
                    DIRECT ACTIVITY
                  1 Establishment of Desa Siaga (start up)
                    * Establishment of Village Team                           Village       Desa Siaga     Included
                    * Village Self Assessment (SMD)                           Village       Desa Siaga     Included
EPOS Health         * Village Consultative Meeting (MMD)                      Village       Desa Siaga     Included
Consultants         * 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
Final Report
                    * 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
December 2008
                    (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

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                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)
                                                                                                                   Construct-   Equip-     Vehicle      Training      Others
                 1 Indirect                                                                                         ion (*)     ment
                   * 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 Siaga
                   RECURENT (OPERATIONAL)
                                                                                                                   Salary per    Drugs/    Utilities    Fuel/cons    Mainte-    Transport Miscelane
                                                                                                                    month        med-                    umable      nance                   ous
                 1 Indirect                                                                                                     supplies
                   * 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)
                                                                                                                   Salary per    Drugs/    Utilities/    Fuel &     Maintenanc Transport Miscelane
                                                                                                                    month        med-      month         consu-          e                  ous
                   * Poskesdes activity (see below)                           Village      Included                             supplies                 mable
                   (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)
EPOS Health
Consultants     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-
Final Report    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
December 2008   to become a Desa Siaga, the Unit cost would be Rp 15,265,000.

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                START UP COST                                                                   UC                   Unit                    Unit Cost
                a. 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
                * 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
                * 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         15000
                RECURENT/OPERATING COST                  UC              Unit
                Salary (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
EPOS Health                        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
Final Report
                            2.     Desa Siaga is introduced only in the village already having health facility
December 2008
                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).

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                                                    106

                First scenario (Desa Siaga in all villages)

                                                                            Village size                                             Total
                Province                    < 500       500-1500       1500-2500     2500-5000 5000-10000               > 10000
                NAD                           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

                                                                                                            Investment cost
                                                                                          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

                                                                                Recurrent cost/year
                UC (recurrent)             22,640,000        29,360,000        36,080,000       52,880,000         86,480,000         Total
                NAD                    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

                                  The cost of introducing Desa Siaga in all villages in the province

                                        Start up (Investment Cost)                    Total              Recurent                     Total
                                 New 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
EPOS Health     Sulut             20,731,160,000             5,101,375,000       25,832,535,000       45,596,640,000.00          71,429,175,000
Consultants     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

Final Report

December 2008

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                                      107

                Second scenario (Desa Siaga only in villages that already have Polindes)

                                   The number of Desa Siaga established, converted from Polindes
                                                             Village size                                                         Total
                 Province           < 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

                Investment cost
                     Province        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 Cost
                     Province          < 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 Cost
                NAD                                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
EPOS Health     Kepri                               1,340,145,000                  8,946,456,378                  10,286,601,378
Consultants     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
Final Report
                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
December 2008

                The calculation based on two scenarios as presented above conclude the following:

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                                108

                      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 Cost
                NAD               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 Cost
                NAD                      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      Recurrent Cost              Total
EPOS Health                              midwives only)
Consultants     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
Final Report
                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
December 2008   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

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                    109

                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

                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
                                              Target I (all remaining villages)               Target II (remaining villages with Polindes)
                     Province        No of     Investment cost         Recurrent cost     No of      Investment cost        Recurrent cost
                                     village                                              village
                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

                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

                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
EPOS Health
Consultants     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:

Final Report         1)     Budget provided by the (central) government

                     2)     Payment from Askeskin for users of Desa Siaga/Poskesdes for poor people
December 2008
                     3)     Fees collected by Poskesdes from non-poor users for curative services

                     4)     Local government budget allocation from APBD

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                             110

                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).

EPOS Health

Final Report

December 2008

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                     111

                7.7      DHS-2 District Level Health System Performance Data 2007

                                                                                                                                                  prevalence rate                                  poverty 
                                                                                                         Inpatient Uni‐        outpatient use     married women      measles vacina‐      un‐      (% pop 
                                                                                                        tilization in last    among ill within    age 15 thru 49     tion among chil‐   derwgh     quintile 
                                                                                   Assisted Delivery           year             last month             years         dren 12 ‐24 mon       t        1&2) 

                                                                                   tende     equity               equity               equity              equity             equity 
                                                  male    female          Total       d      Index       %        Index        %       Index       %       Index              Index                   % 

                SOUTH SUMATRA                                                                                                                                                                           
                OGAN KOMERING ULU            128,369      130,792     259,161      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 KOMERING ILIR           339,470      332,567     672,037      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                   333,912      309,661     643,573      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                        281,956      268,172     550,128      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                   251,749      232,496     484,245      61.89      1.12      0.38       6.51       25.25     0.56      67.34     1.18     83.29     1.00     30.47       56.5 

EPOS Health     MUSI BANYU ASIN              245,027      239,049     484,076      63.61      1.74      0.55      25.27       20.35     1.91      51.75     0.95     68.37     1.49     31.61       43.5 
Consultants     BANYU ASIN'                  377,611      379,839     757,450      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 KOMERING ULU SELATAN    167,739      154,727     322,466      58.33      2.00      0.73      18.74       25.82     1.49      54.49     1.07     75.00     1.57     29.01       68.3 

Final Report    OGAN KOMERING ULU TIMUR      287,414      277,720     565,134      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                    181,163      183,985     365,148      59.26      2.06      0.79       6.85       21.35     2.98      50.40     1.68     83.06     1.17     24.84       54.5 
                PALEMBANG                    680,971      688,273    1,369,244     93.72      1.31      1.78       2.29       29.40     1.74      53.89     0.79     71.73     1.99     24.07       25.4 
December 2008
                PRABUMULIH                    64,275       68,018     132,293      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     115,177      79.11      1.45      0.80       4.08       16.74     1.31      71.23     0.70     90.24     1.15     22.15       57.0 
                LUBUKLINGGAU                  90,728       87,310     178,038      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                                                                                                                                                                         

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                                                                                             112

                                                                                                                                               prevalence rate                                  poverty 
                                                                                                      Inpatient Uni‐        outpatient use     married women      measles vacina‐      un‐      (% pop 
                                                                                                     tilization in last    among ill within    age 15 thru 49     tion among chil‐   derwgh     quintile 
                                                                                Assisted Delivery           year             last month             years         dren 12 ‐24 mon       t        1&2) 

                                                                                tende     equity               equity               equity              equity             equity 
                                              male    female          Total        d      Index       %        Index        %       Index       %       Index              Index                   % 

                BANGKA                   134,147      122,207     256,354       67.27      1.16      1.77      11.73       27.78     1.64      67.06     0.81     92.08     1.33     23.11       23.8 
                BELITUNG                  68,932       66,119     135,051       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 BARAT              81,042       72,819     153,861       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 TENGAH             71,388       66,832     138,220       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 SELATAN            79,167       73,294     152,461       72.95      1.05      1.18       1.99       34.05     0.91      66.84     1.22     76.60     1.13     35.78       12.9 
                BELITUNG TIMUR            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 
                PANGKAL PINANG            77,252       73,470     150,722       91.67      0.95      1.92       0.96       35.76     0.62      50.98     1.09     85.19     1.65     22.86        6.5 

EPOS Health     LOMBOK BARAT             379,755      403,269     783,024       63.01      1.68      1.97       2.49       46.89     1.02      60.44     0.72     91.65     1.14     42.16       63.3 
                LOMBOK TENGAH            378,669      447,222     825,891       59.33      1.05      1.57       6.58       39.31     1.61      56.51     0.85     87.61     1.10     27.89       68.5 
                LOMBOK TIMUR             480,678      572,422    1,053,100      67.31      1.85      2.08       3.83       36.88     1.78      55.86     1.01     88.43     1.14     34.08       61.8 
Final Report    SUMBAWA                  209,088      194,184     403,272       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                    104,022      102,619     206,641       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                     205,341      204,900     410,241       48.76      1.43      1.66       2.56       41.27     0.51      43.38     0.87     80.59     0.63     28.66       75.6 
December 2008
                SUMBAWA BARAT             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 
                MATARAM                  177,425      176,821     354,246       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     125,371       60.22      1.81      1.69       3.58       34.61     1.68      53.75     0.99     82.10     1.48     37.25       49.2 

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                                                                                          113

                                                                                                                                              prevalence rate                                   poverty 
                                                                                                     Inpatient Uni‐        outpatient use     married women      measles vacina‐       un‐      (% pop 
                                                                                                    tilization in last    among ill within    age 15 thru 49     tion among chil‐    derwgh     quintile 
                                                                               Assisted Delivery           year             last month             years         dren 12 ‐24 mon        t        1&2) 

                                                                               tende     equity               equity               equity              equity              equity 
                                              male    female          Total       d      Index       %        Index        %       Index       %       Index               Index                   % 

                SUMBA BARAT              217,110      192,806     409,916      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 TIMUR              114,262      103,229     217,491      34.43      3.73      2.25       2.06       53.68     1.02      23.18     2.70     86.07      1.20     29.47       82.0 
                KUPANG                   185,640      177,660     363,300      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 SELATAN     209,811      202,485     412,296      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 UTARA       107,517      101,468     208,985      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                     197,676      196,992     394,668      42.55      1.01      1.60       8.22       49.93     0.44      27.37     1.71     91.77      1.10     46.37       74.3 
                ALOR                      89,063       88,022     177,085      28.23      3.61      1.01       3.38       34.88     0.92      33.27     0.71     50.77      0.45     46.93       79.7 
                LEMBATA                   47,490       54,849     102,339      59.10      1.03      3.68       1.95       50.05     1.08      24.05     1.48     83.24      1.21     38.00       74.3 

EPOS Health     FLORES TIMUR             107,572      117,784     225,356      68.24      1.52      0.56       1.38       52.34     0.71      28.03     1.31     98.23      1.00     36.77       88.8 
                SIKKA                    131,906      143,968     275,874      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                     111,621      126,498     238,119      46.15      1.75      1.54       7.21       49.89     1.57      20.13     1.76     88.23      1.23     41.60       69.4 
Final Report    NGADA                    123,136      127,184     250,320      68.88      1.54      1.34       2.20       55.99     2.22      25.63     2.50     97.78      0.94     24.69       72.9 
                MANGGARAI                251,486      243,660     495,146      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     110,629      33.55      1.58      0.60       0.96       41.59     0.81      28.73     1.71     40.40      1.38     42.96       88.6 
December 2008
                MANGGARAI BARAT           96,483       99,122     195,605      26.19      5.83      0.76       3.00       37.34     2.23      38.07     1.43     92.60      1.13     41.84       76.2 
                KUPANG                   139,737      139,335     279,072      72.39      1.57      1.81       2.08       41.56     0.87      36.50     1.28     89.37      1.08     39.79       35.8 
                CENTRAL KALIMANTAN                                                                                                                                                                   
                KOTAWARINGIN BARAT       106,454       98,135     204,589      74.11      1.24      0.67       1.62       28.27     1.05      65.24     1.25     100.00     1.00     31.37       20.1 

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                                                                                          114

                                                                                                                                               prevalence rate                                  poverty 
                                                                                                      Inpatient Uni‐        outpatient use     married women      measles vacina‐      un‐      (% pop 
                                                                                                     tilization in last    among ill within    age 15 thru 49     tion among chil‐   derwgh     quintile 
                                                                                Assisted Delivery           year             last month             years         dren 12 ‐24 mon       t        1&2) 

                                                                                tende     equity               equity               equity              equity             equity 
                                              male    female          Total        d      Index       %        Index        %       Index       %       Index              Index                   % 

                KOTAWARINGIN TIMUR       158,226      148,222     306,448       53.22      1.42      0.64       6.53       28.81     0.90      68.26     0.71     83.69     1.50     24.37       34.4 
                KAPUAS                   180,904      173,796     354,700       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 SELATAN            61,630       56,670     118,300       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 UTARA              59,630       55,720     115,350       78.12      1.66      0.40      12.11       8.75      5.90      65.84     0.79     50.79     1.10     34.95       44.4 
                SUKAMARA                  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 
                SERUYAN                   61,534       54,532     116,066       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 

EPOS Health     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 MAS                85,796       86,898     172,694       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 TIMUR             136,634      124,108     260,742       78.60      1.21      1.03       2.67       16.31     0.74      75.94     0.77     86.89     1.08     25.79       30.8 
Final Report    MURUNG RAYA              138,690      130,334     269,024       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            241,124      229,036     470,160       91.71      1.08      0.92       2.00       19.16     0.80      56.40     1.24     85.82     1.02     20.67       33.7 
                BANJARMASIN              134,732      131,566     266,298       88.26      1.42      1.58       2.00       34.22     1.59      62.38     0.76     73.64     2.09     27.50       51.4 
December 2008
                SOUTH KALIMANTAN                                                                                                                                                                     
                TANAH LAUT                76,329       74,347     150,676       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                   101,820      104,180     206,000       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             117,366      122,326     239,692       54.12      1.61      0.35       4.53       24.41     2.91      63.73     0.97     83.36     0.88     34.99       53.4 

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                                                                                          115

                                                                                                                                                  prevalence rate                                  poverty 
                                                                                                         Inpatient Uni‐        outpatient use     married women      measles vacina‐      un‐      (% pop 
                                                                                                        tilization in last    among ill within    age 15 thru 49     tion among chil‐   derwgh     quintile 
                                                                                   Assisted Delivery           year             last month             years         dren 12 ‐24 mon       t        1&2) 

                                                                                   tende     equity               equity               equity              equity             equity 
                                              male    female             Total        d      Index       %        Index        %       Index       %       Index              Index                   % 

                TAPIN                    103,509      108,225           211,734    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 SELATAN       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 TENGAH        94,114          95,249        189,363    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 UTARA         67,932          63,410        131,342    70.05      1.87      0.39      14.83       25.31     2.76      60.01     0.85     79.18     1.42     36.92       44.0 
                TABALONG                 108,955      107,393           216,348    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        101,025    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 BARU              300,573      302,134           602,707    88.16      1.22      1.69       4.65       28.96     3.03      69.52     0.77     91.26     1.17     31.35       19.0 

EPOS Health     SOUTH SULAWESI                                                                                                                                                                          
                SELAYAR                   55,200          61,215        116,415    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                175,494      208,236           383,730    58.67      2.05      0.98       3.48       17.86     6.67      59.81     1.17     61.41     1.54     40.16       64.1 
Final Report    BULUKUMBA                 80,416          90,132        170,548    46.91      1.78      0.70       3.42       34.87     0.85      37.67     0.49     71.52     1.02     31.47       72.3 
                BANTAENG                 160,000      169,028           329,028    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                120,604      129,876           250,480    35.26      1.82      1.27       9.00       28.62     1.52      61.97     0.99     84.75     0.76     32.05       56.3 
December 2008
                TAKALAR                  294,599      291,799           586,398    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                     108,905      113,010           221,915    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                   145,341      152,298           297,639    52.81      1.75      0.35       4.91       40.30     1.99      27.80     1.29     64.07     0.90     43.98       57.2 
                MAROS                    140,188      149,114           289,302    83.38      1.30      1.09       2.83       28.95     1.32      50.82     0.81     67.90     1.50     29.80       55.8 

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                                                                                             116

                                                                                                                                              prevalence rate                                  poverty 
                                                                                                     Inpatient Uni‐        outpatient use     married women      measles vacina‐      un‐      (% pop 
                                                                                                    tilization in last    among ill within    age 15 thru 49     tion among chil‐   derwgh     quintile 
                                                                               Assisted Delivery           year             last month             years         dren 12 ‐24 mon       t        1&2) 

                                                                               tende     equity               equity               equity              equity             equity 
                                              male    female          Total       d      Index       %        Index        %       Index       %       Index              Index                   % 

                PANGKAJENE KEPULAUAN      74,590       84,368     158,958      64.94      1.15      0.37       0.59       22.45     1.39      34.00     0.84     72.80     1.55     46.67       53.5 
                BARRU                    320,900      375,798     696,698      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                     106,776      120,414     227,190      63.37      1.67      0.43       3.89       22.74     1.59      33.22     1.11     59.82     2.18     35.38       61.6 
                SOPPENG                   81,120       81,935     163,055      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                     179,093      194,896     373,989      46.73      2.07      0.20       7.21       16.97     2.28      34.18     0.57     72.10     1.14     24.82       53.3 
                SIDENRENG RAPPANG        117,512      129,368     246,880      71.18      1.41      0.32       0.31       19.46     0.38      51.66     1.01     97.83     1.14     22.33       55.2 
                PINRANG                  169,664      170,524     340,188      75.13      1.63      1.10      10.62       17.97     2.40      39.09     0.87     83.65     0.64     32.02       60.3 
                ENREKANG                  94,765       89,096     183,861      60.49      1.67      0.32       4.12       25.75     1.43      32.64     0.87     89.78     1.05     21.76       81.2 

EPOS Health     LUWU                     160,554      157,260     317,814      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 TORAJA              236,313      210,469     446,782      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 UTARA               151,915      146,948     298,863      49.39      1.73      1.07       2.32       19.73     2.82      52.55     0.99     82.86     1.31     32.92       66.5 
Final Report    LUWU TIMUR               114,621      104,871     219,492      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            611,044      612,486    1,223,530     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     115,076      91.27      1.52      2.36       4.43       36.82     1.94      43.98     0.46     86.81     1.11     30.95       32.1 
December 2008
                PALOPO                    65,138       69,224     134,362      65.10      3.14      1.28      19.07       28.75     2.32      38.75     0.84     90.55     0.91     28.50       40.9 
                BOALEMO                   60,527       57,555     118,082      62.17      1.18      0.66       1.42       23.23     0.47      56.45     0.78     75.79     1.39     45.82       75.6 
                GORONTALO                213,271      214,915     428,186      50.18      2.03      0.99      13.15       33.76     1.48      60.87     0.89     80.12     1.35     36.54       70.7 

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                                                                                         117

                                                                                                                                               prevalence rate                                  poverty 
                                                                                                      Inpatient Uni‐        outpatient use     married women      measles vacina‐      un‐      (% pop 
                                                                                                     tilization in last    among ill within    age 15 thru 49     tion among chil‐   derwgh     quintile 
                                                                                Assisted Delivery           year             last month             years         dren 12 ‐24 mon       t        1&2) 

                                                                                tende     equity               equity               equity              equity             equity 
                                              male    female          Total        d      Index       %        Index        %       Index       %       Index              Index                   % 

                POHUWATO                  54,825       54,997     109,822       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 BOLANGO              62,798       64,158     126,956       53.79      1.66      0.54       3.06       36.78     1.58      62.52     0.92     87.99     1.24     36.44       71.2 
                GORONTALO                 77,022       81,330     158,352       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 SULAWESI                                                                                                                                                                        
                POLMAS                    64,928       66,704     131,632       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                   175,552      179,840     355,392       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     121,344       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                   146,152      137,947     284,099       18.33      6.45      0.54       2.72       19.66     1.06      60.76     0.87     60.00     1.84     31.93       57.9 

EPOS Health     MAMUJU UTARA              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 

Final Report

December 2008

                Support for Health Sector Policy Reforms, ADB TA 3579-INO                                                                                                                          118

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