Document of

The World Bank

FOR OFFICIAL USE ONLY

Repwt No. 9133

PROJECT COMPLETION REPORT

INDONESIA

PROVINCIAL HEALTH PROJECT(LOAN 2235-IND)

NOVEMBER 16, 1990

aId Human Resources Divisionrtment V1 Office

restricted distribution and may be used by recipients only in the performance ofIts contents may not otherwise be disclosed without World Bank authorization.

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CURRENCY EQUIVALENTS

Currency: Rupiah

Rate of Exchange: Appraisal (May 1982) US$1.00 = Rp. 660

January 31, 1983 - September 11, 1986 US$1.00 = Rp. 970-1100September 12, 1986 - present US$1.00 = Rp. 1640-1795

ABBREVIATIONS

BAPPENAS = National Development Planning AgencyBOR = Bed Occupancy RateDIP = Dafter Isian ProyekGOI = Government of IndonesiaINPRES = National Suibsidy for Local GovernmentsMCH = Maternal and Child HealthMOHA = Ministry of Home AffairsMOH = Ministry of HealthO&M = Operations and MaintenancePCR = Project Completion ReportPHA Provincial Health AdministrationPTC = Provincial Training CenterREPELITA = Five-Year Development Plan

FISCAL YEAR OF BORROWER

Government of Indonesia: April 1 - March 31

OMICAL w ONLYTHE WORLD BANK

Washngtlon D C 20433USA

Otc. d~ Otw.C.EwfaI0pwali lvatt"

November 16, 1990

MEMORANDUM TO THE EXECUTIVE DIRECTORS AND THE PRESIDENT

SUBJECT: Project Completioa% Report - IndonesiaProvincial Health Proiect (Ln. 2235-IND)

Attached, for information, is a copy of a report entitled "ProjectCompletion Report - Indonesia Provincial Health Project (Ln. 2235-IND)",prepared by the Asia Regional Office. No audit of this project has beenmade by the Operations Evaluation Department at this time.

Attachment

This document has a restricted distribution and may be used by recipients only in the perfomanceof their omfcial dutie. Its contents may not otherwise be disclesd without World lank authoriation.

PROJECT COMPLETION REPORT

INDONESIA

PROVINCIAL HEALTH PROJECT(LOAN 2235-IND)

TABLE OF CONTENTS

Page No.

Preface....................................................

Evaluation Summary ............................ iii

PART I PROJECT REVIEW FROM BANK'S PERSPECTIVE

Project Identity.. 1Background ......... ........................................... 1Project Objectives and Description .1Project Design and Organization. 2Project Implementation. 3Project Results. 5Project Sustainability. 6Bank Performance. 7Borrower Performance. 8Project Relationship. 8Consulting Services ........................................... 8Project documentation and data ...... 9

PART II PROJECT REVIEW FROM BORROWER'S PERSPECTIVE

General ...................................................... .. 11Bank's Performance .11Borrower's Performance ......................................... 12Relationship Between the Bank and the Borrower .14

PART III STATISTICAL INFORMATION

Table 1. Related Bank Loans and Credits .................................. 15Table 2. Project Timetable .......................,,,,,,,,,,,,.,.,,, . 16Table 3. Loan Disbursements ... . ........................................ 17Table 4. Project Implementation .......................... 18Table 5. Project Costs and Financing ........ 20Table 6. Project Results ............................ 21Table 7. Status of Covenants ............................ ,. 23Table 8. Use of Staff Resources ............................ 23

ANNEXES

ANNEX 1 .25

MAP IBRD 22611

This document has a restricted distribution and may be used by recipients only in 'he performanceof their official duties. Its contents may not otherwise be disclosed without World Bank authorization,

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PROJECT COMPLETION REPORT

INDONESIA

PROVINCIAL HEALTH PROJECT(Loan 2235-IND)

PREFACE

This is the Project Completion Report (PCR) for the Provincial HealthProject in Indonesia, for which Loan 2235-IND in the amount of $27.0 miillionwas approved on February 15, 1983. During the course of implementati.n $2.6million was cancelled. The loan was closed on September 30, 1989, fifteenmonths behind schedule. The last disbursement took place on February 12,1990.

The PCR was jointly prepared by the Population and Human ResourcesDivision of Country Department V, Asia Region (Preface, Evaluation Summary,Parts I and III and the Annex), and the Borrower (Part II).

Preparation of this PCR is based, inter alia, on the Staff AppraisalReport; the Loan Agreement; supervision reports; correspondence between theBank and the Borrower; and internal Bank memoranda.

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PROJECT COMPLETION REPORT

INDONESIA

PROVINCIAL HEALTH PROJECTLoan 2235' -IND

EVALUATION SUMMARY

Background

Indonesia had achieved considerable success in improving the health andnutrition status of its population and in the implementation of its nationalfamily planning program in the 1970's. At the time of the appraisal of theProvincial Health Project in 1982, GOI had also established the infra-structure for delivering basic health services nationwide. This progressnotwithstanding, life expectancy was still low and morbidity and mortalityrates high in comparison with countries with similar income levels. Thehealth system's effectiveness remained limited due to the poor quality of careand the failure to develop an effective referral system. The ProvincialHealth Project was designed to help GOI address these issues in selected OuterIsland provinces.

Obiectives

The project objectives were to: (a) improve the quality and increase theutilization of health services through improvements in the health center,referral and outreach system, health manpower development and strengthening ofdistrict level management; and (b) extend and intensify malaria control. Italso aimed to strengthen the in-titutional capacity of the provincial anddistrict health administrations in order to support GOI's policy ofdecentralizing health care planning and administration. The project areacomprised the provinces of Central, South and South-East Sulawesi (para. 3.1).

Implementation

Since the bulk of the loan (55%) was allocated for civil works, the majorvariance between planned and actual project implementation related to delaysin completing the physical works (10 district hospitals, 15 health centers,and 3 provincial training centers (PTC's)). The factors responsible for thedelays were a combination of GOI regulations and procedures which were genericacross all sectors and management problems peculiar to the project. Examplesof the Thrmer included GOI's cumbersome and centralized budgetary and approvalprocesses and central authority (Sekneg) approval requirements for all civil.!ork contracts, and examples of the latter included delays in land acquisitionand the preparation and review of architectural designs and drawings. Thedelay, however, was not excessive relative to the implementation experience ofother projects in the population and nutrition sub-sectors (paras. 5.1-5.2).

Inadequate counterpart funding was particularly deleterious to the malariacontrol program where the successful momentum of house spraying was seriouslycurtailed, and vitally necessary vehicles were never provided by GOI.District infrastructure was also not completed due to lack of funds.Systematic attempts to provide the recurrent financing necessary for the

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health facilities, particularly district hospitals, were successfullyundertaken only during the latter stages of project implementation.

The level of institutional strengthening achieved was more than envisagedat appraisal due to a reallocation of funds from consultancies to fellowiships.The project was, however, not fully implemented by the provincialadministrations as expected, as all major decisions were made in central HOH.There was no major follow-up to the original studies on health financing,information system and service utilization financed under the project. Otherstudies, subsequently introduced, for example on government expenditureaccounts were used as an input for Repelita V and Bank sector work.

Results

The project has been largely successful in achieving its major objectivesas the quality of services and the utilization of the district hospitals as areferral system will continue to increase as they are fully commissioned, theincidence of the major endemic disease malaria has declined to a level lowerthan the project goal, and significant institutional strengthening at thelocal level has been accomplished. It- also established the precedent forfuture provincial level projects to support GOI's decentralization policies.The project has been less sucrossful in providing the benefits envisaged fromthe health centers constructr a nd not all district level improvements ininfrastructure and financing %Ize achieved (para. 6.2).

Sustainability

All efforts have been made to ensure the sustainability of the majorproject investments, the district hospitals. Recurrent budgets, based onstaffing and other operation and maintenance norms (O&M) have beenestablished, and commitments have been obtained from the local governmentsthat all hospital revenues wi]l be returned to the hospitals. With respect tothe PTC's, they have been institutionalized ensuring their O&M requirements.All the necessary infrastructure and staff are in place for the malariaprogram, and GOI has provided assurances that the Sulawesi provinces would begiven priority in future budgetary allocations for the Communicable DiseaseControl Programs (para. 7.1).

Findings and Lessons

The major lessons learnt for future Bank projects are: (a) the need foradequate project preparation, including greater involvement of end users, inmajor construction works and adequate supervision; (b) establishment, atappraisal, of all funding requirements to ensure sustainability of projectinvestments; (c) more decision making and management authority to be given tcthe provinces if implementation is to be decentralized; and (d) establishmentof realistic indicators for project monitoring and evaluation, and studiesshould be agreed with the Government and recommendations followed-up. Themajor lessons for the Borrower are: (a) to fulfill commitments for counterpartfinancing; and (b) the need to establish full-time proiect management forsuccessful implementation and adequate recording, reporting, financial andmonitoring systems. All the above lessons were incorporated into the ThirdHealth Project (Loan 3042-IND) which was the next provincial project.

INDONESIA

pROVINCIAL HEALTH PROJECT(LOAN 2235-IND)

PROJECT COMPLETION REPORT

Part 1. PROJECT REVIEW FROM BLNK'S PERSPECTIVE

1. Proiect Identity

Project Name: Provincial Health ProjectLoan No: 2235-INDRVP Unit: AsiaCountry: IndonesiaSector: Population Health NutritionSub-Sector: Health

2. Background

2.1 Indonesia had achieved considerable success in improving the health andnutrition status of its people and in the implementation of its family planningprogram in the 1970's. At the time of appraisal of the Provincial HealthProject in 1982, life expectancy had risen from 47 years to 53 years, and theinfant mortality rate decreased from about 140/1000 live births to about 93/1000between 1969 and 1980. This progress notwithstanding, life expectancy was stilllow and morbidity and mortality rates high in comparison with countries withsimilar income level.s. Furthermore, while the GOI had established theinfrastructure for delivering basic health services nationwide, the system'seffectiveness remained limited due to the poor quality of health care at theprimary level and a failure to develop an effective referral system.

2.2 To redress this situation, the GOI had shifted the focus of its healthpolicies and programs from further expansion of the health network to improvingservice utilization and effectiveness. Responsibility for planning andimplementing health progranms was also being progressively shifted to theprovinces with GOI building up planning and technical capacity at the provincialand district levels. The Bank project was conceived to help GOI meet its policyobjectives in selected Outer Island provinces in four main areas; (i)development of an effective referral system to support outreach activities; (ii)health manpower development; (iii) malaria control; and (iv) strengthening theinstitutional capacity of the provincial and district health administrations.

3. Project Objectives and Description

3.1 The project area comprised the provinces of Central, South and South-EastSulawesi and were chosen because they consisted of three less developedprovinces which were also the primary receiving transmigration areas in EasternIndonesia. Malaria was also a major endemic disease in these areas.

3.2 The specific project objectives were to: (a) improve the quality andincrease the utilization of health services through improvements in the healthcenter, referral and outreach system, health manpower development andstrengthening of district level management; and (b) extend and intensify malaria

control. The project also aimed to strengthen the institutional capacity of theprovincial and district health administrations in order to support GOI's policyof decentralizing health care planning and administration.

3.3 The oroiect components were: (a) Strengthening the referral system: (i)improvement of services in 10 district hospitals through replacement of existingphysical facilities, the provision of equipment and vehicles, technicalassistance and fellowshlips for hospital administration and maintenance; and (ii)expansion and improvement in the quality of services in 15 health centersthrough the provision of in-patient facilities and additional medical equipment;(b) Staff training: (i) the establishment of 3 Provincial Training Centers(PTC's) with equipment, materials, vehicles and training expenses; (c)Mara&ement and Administration: (i) strengthening district health administrationby constructing, equipping and furnishing 19 district health offices, each withdrug storage facilities and vehicles; the setting up of a drug managementsystem; organization and management of training courses for district medicalofficers; and consulting services for strengthening the existing healthinformation system (HIS) and for the study of health care financing; and (ii)the provision of vehicles, equipment, fellowshic and support for incrementaloperating costs for project implementation, including consultant s¢.rvices formonJ iring and evaluation, and preparation of a second Bank assisted healthprojL.t; (d) Malaria control: (i) extension and strengthening of malaria controlin the project area by providing equipment, vehicles, insecticides and drugs,technical assistance and support for incremental operating costs; and (e)Technical assistance and studies: (i) provision of about 228 man-months cfconsultant services to carry out studies and individual project components.

4. Proiect Design and Organization

4.1 The project was the first Bank assisted project to be fully implementedby the Ministry of Health (MOH). The project was identified and prepared by theProvincial Health Administration (PHA), with technical guidance andadministrative support from the central MOH. Project options discussed atpreparation were a program approach supporting one or two nation-wide programsor an area-oriented approach supporting the comprehensive development of healthservices in a well defined geographical area. The area approach wassubsequently adopted to ensure a project of modest size and limited complexity.

4.2 Project design was constrained, partly due to the lack of finance fordetailed preparation, insufficient experience of those responsible fotpreparation in GOI, and inadequate attention to details, for example, the lackof coordination between hospital building designers and equipment speci.alists.The key end users of the hospital investments, the hospital directors, were alsonot involved in the planning and preparation of the hospitals or choice ofequipment. Further, although the hardware aspects of the project design, theconstruction and provision of equipment for facilities and support for themalaria component were well understood some of the policy aspects, such assupport for GOI's emerging decentralization policy for health services, werepossibly less clearly defined and understood at appraisal. There was also nomajor involvement of the Ministry of Home Affairs (MONA), which is responsiblefor the provincial governments and, thus, for the implementation ofdecentralization policies. Key studies, such as health financing andinformation systems, were not discussed and agreed at the preparation stageswith GOI but were introduced after appraisal.

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4.3 Changes in the project design during implementation included thiesubstitution of fellowships for consultancies, and the provision of Bank fundsfor proposed GOI investments such as vehicles and operational costs.

4.4 Project implementationi, in line with COI policies for decentralizedhealth care administration (para. 2.2), was to be done at the provincial leveland coordination of components only at the national level. The SecretaryGeneral, MOH, was the Project Director and a central level project coordinatorwith full time staff, and provincial level project officers with full timesupport staff were to be appointed. However, most of the project management andsupport staff were only part-time leading to problems discussed in para. 9.1.

5. Project Implementation

5.1. Civil Works. Since the bulk of the original loan (about 55%) wasallocated for civil works, the major variance between planned and actual projectimplementation related to delays in completing the physical works. ThE districthospitals, health centers with beds, PTC's and part of the district warehouseswith drug storage were completed, on average, about two years behind schedule.FurthAr, only 8 of the 19 district health offices with drug storage andassociated housing to be built under the project were completed due toinadequate budgetary funds (para. 5.3 below). The delays in the physical workswere, however, not excessive relative to the experience of other projects in thepopulation and nutrition sub-sectors.

5.2 The factors responsible for the delays in t.ie civil works were partly GOIregulations and procedures which were generic across all sectors, and partlymanagement probleals. The major issues were: (a) GOI's cumbersome andcentralized budgetary and approval processes, particularly the allocation offunds in several DIP's (central budgets) and delays in the *. ision of Dl''s,(b) the use of single year rather than multi-year contracts, and the separationof building contracts from those for utilities and site works which led to thefragmentation of contracts; (c) Sekneg or central authority approvalrequirements for all civil work contracts; (d) delays in land acquisition1 andchanges in hospital sites and for the PTC in Ujung Pandang; (e) delays in thepreparation and review of architectural designs and drawings; and (f) majordevaluations (1984 and 1986) when all contractors halted work until contractswere re-negotiated for price escalation. The Bank tried to resolve some of theabove issues. The Bank pointed out that construction contracts for externallyfunded projects could be done through multi-year DIP's, but this recommendationwas not adopted. The Bank had asked for the appointment of additional staff atthe provinces, architectural consultants to monitor and coordinate theconstruction program to minimize the risk of delays, and a Deputy at the centerfor better coordination with the provinces, but the appointments were not made.

5.3 Budgets. Inadequate counterpart funding from GOI also seriouslyconstrained project implementation. This was particularly deleterious to themalaria component. After significant budget increases which enabled SAR house

1 Audit reports for this project have expressed a qualified opinion on the account due to Improperland acquis.tion expenditures from GOI budgets for sites for two of the hospitals (Pare Pare andBulukumba). The original sites were changed, and Land Certificates confirming MOH's rights to thenew sites were subsequently provided to the Bank by MOH.

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spraying targets to be largely met, inadequate and delayed fund releasesseriously affected program activities after 1986 (Part III, Table 4).Additionally, vchicles vitally necessary for the success of the program, werenever provided by GOI. As indicated above, the full complement of districthealth offices with drug storage facilities were not completed and inadequatefunds were provided for the supervision of project locations which was alsoresponsible for the delays in the civil works.

5.4 Operations and Maintenance. Given the complexity of GOI's budgetarysystem, the issue of the provision of recurrent costs for the health facilitieswhen fully functional was discussed, but not resolved during appraisal. In thecourse of the project, largely due to the devaluations, considerable loansavings became available (originally estimated at $3.8 million). Given emergingproblems in initiallv commissioning and operating the hospitals (and otherfacilities) due to the inadequate recurrent funds, GOI requested the use of partof the savings ($1.7 million) for both operational costs of the hospitals, drugsand operational costs and vehicles for the malaria program. The Bank agreed tothe use of the savings on tl,e basis of actions agreed by GOI as follo.ts: (a)submission of budgets showing the estimated requirements for the hospital non-salary operational costs and the sources of funds; (b) local governmentcommitments that all necessary funds would be provided for the recurrentexpenditures, including the returnt of all hospital revenues to the hospitals;(c) all incremental staffing being provided; and (d) ICB procedures agreed forthe procurement of drugs and vehicles. The latter, in particular, was a majorpolicy breakthrough, since Bank financing for vehicles and drugs was notpreviously possible as they were subject -o reserved procurement.

5.5 Institutional Strengthening. An important feature of the project was itssupport for d& entralized health care administration. Institutionalstrengthening at the district level was, thus, an important component throughimproved in-service training, upgrading managerial skills of district medicalofficers and training of hospital directors. Significantly more staff weretrained than estimated at appraisal. The project had provided for 228 man-months of consultancy services (local and foreign) for studies and projectcomponents but only about 141 were used (Part 111, Table 6, B). The funds savedfrom the consultancies, together with additional rupiahs available as a resultof the devaluations, were used with positive effects for additional trainingthrough the provision of local and overseas fellowships. The total. number ofstaff that were provided fellowships was 164 as against an appraisal estimate of10. Further, at appraisal only hospital administrators were expected to beprovided with fellowships, blt staff from the districts (118) and center (46)were p-ovided with training on health related issues.

5.6 Studies. Although most of the original studies (Part III, Table 6, B)under the project (health financing, informations systems and serviceutilization) were completed ahead of schedule, there was no major follow-up ofthe recommendations. The project also financed additional studies nct envisagedat appraisal. First, it financed major sttudies on health center and hospitalunit costs and government expenditures accounts. These studies provided usefulinformation for the planning of Repelita V but were also used in the preparationof Bank sector work2. Secondly, the project financed a report on an Automation

2 'Indonesia - Issues in Health Planning and Budgeting" - Report No. 7291-IND, dated February 28.1989.

Strategy for an Integrated Health Information System (HIS), which is to be usedas the basis for major reforms to the national HIS. mwpact, coverage and healthstatus indicators were developed for monitoring and sva.luation of the project,but the system is not yet fully operational due to delays in the commissioningof the facilities, and inconsistent reporting from the field.

5.7 Project costs. These changed substantially during implementation due tothe devaluations (the exchange rate at appraisal was $1/Rp. 660 and at Loanclosing $1/Rp. 1795). The total project cost, as currently estimated, isUS$43.2 million against an appraisal estimate of US$54.4 million. 'Tne revisedtotal Bank loan is US$24.4 million (after cancellation of US$2.2 million inDecember 1987 and $0.4 million in February 1990), 'OI's estimated contributionofUS$18.8 million is significantly less than agreed at appraisal of US$27.8million. The Closing Date was extended twice, initially from June 30, 1988 toJune 30, 1989 and then to September 30, 1989.

6. Prolect Re'ults

6.1 The total impact of the project cannot be currently assessed but,overall, the project has been largely successful in achieving its majorobjactives as the quality and utilization of health services (particularly thedistrict hospitals) will continue to increase as they are fully commissioned,the incidence of the major endemic disease malaria has been reduced beloworoject goals and significant institutional strengthening a. the local level hasbeen accomplished. The under-utilization of the health centers cons.ructedunder the project, possibly due to a lick of public confidence in the services,remains an issue, and district level improv7ements in infrastructure andfinancing were not fully achieved.

6.2 Specific results are as follows:

(a) The project has helped im?rove the effectiveness of health services beingprovided through the provision of well staffed and equipped districthospitals as a credible referral to the primary health care network.Although, the performance of the hospitals is varied (outpatients visitsvary from 24/day to 133/day and BOR's vary from 16.1% to 48.7%), itshould be noted that some of the hospitals have just commencedoperations, some need resolution of transportation problems and forothers the addition of specialists (surgeons) is expected to increaseutilization.

(b) The staff in-service training provided through the establishment of thePTC's, the provision of overseas and local fellowships, additionalspecializcd training provided including for the operation and maintenanceof new hospital equipment and computer training, have proved beneficialin improving the technical and institutional capabilities of healthpersonnel both at the local and central levels. A limited and briefassessment of the fellowship training provie&d3 indicates that thetraining was relevant to work assignments, the skills a-quired had beenused to improve performance and the majotity of the trainees felt thattheir training was essential or very effective in carrying out their job.

3 Follow up of Staff Trai.ing under the first Provincial Health ProJect-Pack-to-Office Report fromM3. C. Bayulken dated November 29, 1989.

Most project staff have also developed management and operational skills.The use of the PTC's for the provision of training programs for otherMinistries is an additional project benefit.

(c) The strengthening of district health management and administration tosupport GOI's policy nf decentralization has been partially successful.As indicated above, the training provided to provincial and districtstaff which was above appraisal estimates, has significantly improved theinstitutional capacity. But the project was not fully implemented by theprovincial administrations as envisaged as all major decisions were madein central MOH. All complementary measures were also not fullyimplemented. The proposed infrastructure program was only partiallycompleted and measures to improve the linkage between managerial andfinancial responsibilities, and improve district level recording andreporting systems were not fully undertaken;

(d) The malaria component initially had tremendous success and the malariaincidence in many of the protected areas had declined below 50 cases per1000, the project goal. It was unfortunate that the momentum was notmaintained from 1986 due to funding problems. However, all necessaryinfrastructure is in place, DDT is available in storage, the provinceshave developed expertise in planning and budgeting, spraying, sourcereduction, biological control and other technical aspects with onlylimited support now required from the center. Thus, the operationalmanagement system has been decentralized. Further, the previousscattered and spotty anti-malaria activities have been geared toorganized malaria control efforts;

(e) An indirect benefit has been the stimulation of the domestic constructionindustry with over 50 contractors involved in the infrastructureconstruction.

6.3 The project was conceived at a time when GOI had started to shift theresponsibility for planning and implementing health programs to the provincialand district lcvels. Consequently, some of the difficulties encountered was dueto the pioneering nature of the project in supporting GOI's nascentdecentralization policies. GOI policies for decentralization are betterformulated now, and Bank support for the policies would be through a series ofprovincial health projects, the precedent for which was established by thisproject.

7. Project Sustainabilitv

7.1 During the latter stages of project implementation, significant effortswere undertaken to ensure project sustainability. As indicated in para. 5.4recurrent budgets, based on staffing and O&M norms, and indicating all sourcesof funds have been prepared for the district hospitals. This is expected to becontinued on an annual basis and form the basis of future budgetary requests ofthe hospitals. The commitments from the Local Governments that 100% of hospitalrevenues will be returned to the hospitals, would ensure part of the O&Mfunding. All medical staffing is in place, although non-medical staff stillremains an issue. All PTC's have been institutionalized, which would ensuretheir O&M requirements. The utilization and sustainability of the healthcenters with beds is a national problem which will shortly be reviewed by GOI.The sustainabiiity of the malaria program has two elements. The first is to

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maintain the gains in protected areas and the second is to meet program needs inthe hard core malarial areas which have been identified, particularly thetransmigration areas. GOI has agreed that priority will be given to the malariacomponent in Sulawesi in future budgetary allocations for the CommunicableDisease Control programs.

8. Bank Performance

8.1 Project preparation was subject to constraints (para. 6.3), and resultedin the problems identified in para. 4.2. Supervision deteriorated significantlyin 1985 (Part 111, Table 8) at a critical phase in project implementation.During this time Bank staff were involved in multi-purpose missions, thus,supervision issues were not adequately dealt with or followed up, for example,the lack of adequate staff to deal with the project at the provincial level andproposed modifications to hospital designs, recommended by Bank consultants, butnot adopted. The latter has led to current problems in functional relationshipsof various departments in the hospitals. Bank missions paid insufficient visitsto the project provinces, and there has been lack of continuity in staff workingon the project partly due to the Bank's reorganization in 1987.

8.2 The lessons learned for future Bank projects are:

(a) Project Preparation. Adequate project preparation and design,particularly for major construction works, should be ensured. Createrinvolvement of the end users (eg. hospital and PTC directors) during theplanning and preparation stage is essential. Better coordination betweenbuilding designers and the equipment specialists and intensive andqualified supervision during the construction process would help minimizesubsequent problems.

(b) Operations and Maintenance. The O&M requirements following completion ofproject investments should be identified at project appraisal on thebasis of realistic norms. PTC's need to be institutionalized immediatelyafter their construction is completed. If funding problems seriouslyconstrain the impact of a successful program, every effort should be madeto give priority to this component in funding allocations.

(c) Decentralization. The provinces need to be provided with more decisionmaking and management authority if responsibility is to be trulydecentrali.zed. Although designated a Provincial Health Project, the termwas appropriate in the geographical sense only. In future provincialrespects, major decisions and contract approvals, and most administrativework including financial control should not be centralized as in thisproject.

(d) Key project Indicators/Studies. Project indicators should be realisticand take into account time legs between the completion of the project andfinal outcomes, f-or example, the assumption that the BOR of the hospitalswould rise immediately to 80% once all construction was complete (from58% at appraisal) was highly unlikely given the many difficultiesinvolved in fully commissioning hospitals. Indicators should also besystematically monitored during implementation. Studies should be fullyagreed with the Gc- rnment and recommendations followed up.

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8.3 All the above lessons (and those in para. 9.2 below) have been fullytaken into consideration in designing the Third Health Project (Loan 3042-IND)which also deals with provincial and district governments and decentralizationissues.

9. Borrower Performance

9.1 Inadequate counterpart funding has been a major problem on the Borrower'sside. Although continuity in project management at the central level has beengood, the lack of full-time project management staff, both at the central andprovincial levels, has also significantly constrained project implementation.The project management team have done a very good job under difficultcircumstances in terms of completing the project, following up on major issuesraised, time spent on supervision despite inadequate funds and widely dispersedproject sites, and adapting the project design. No incentives, other than sometraining, were provided to them. The lack of full time staff has resulted inreporting, recording and monitoring and evaluation systems established that areless than adequate. The financial reporting system has been particularly poor.Many of the problems and difficulties encountered during the project may havebeen minimized if the project management team had been full-time or providedwith the full-time staff as envisaged at appraisal.

9.2 The lessons learned for the Borrower are: (a) to fulfil commitments forcounterpart financing since the malaria program, in particular, would havesucceeded beyond all expectations if the necessary funding had been available;and (b) full time project management is required for effective projectimplementation and successful completion. Additionally, qualified and full-timestaff should be provided to the project coordinators in order to ensure adequatesupervision, monitoring and reporting of project progress. The considerableknowledge gained by the project management team, e.g. poor performance ofcontractors and equipment suppliers, good fellowship programs, and studiescompleted should be institutionalized. Supervision of all constructedfacilities should be continued for at least 3-5 years after completion offacilities.

10. Project Relationship

10.1 The Bank Borrower relationship on this project has been good despite thelack of continuity in Bank staff working on the project. The workingrelationships have been supportive with a high degree of professionalism on bothsides.

11. Consulting Services

11.1 Over 50 contractors were used in the project and contractor performancehas been very mixed, illustrating the variability of expertise at the provinciallevel. The output of the consultants used were also varied. Some consultantsprovided valuable assistance to the project such as the malariologist, thehospital equipment specialist and the hospital training and administrationconsultants. The work of other consultants, such as the one used for the healthfinancing study, were nevev- used and the study recommendations largely shelved.

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12. Project Documentation and Data

12.1 The SAR and the Loan Agreement was the main reference for the Bank andBorrower during implementation. They were generally found adequate. However,the compilation of project documentation and data during implementation wasunsatisfactory, particularly cost and budgetary data which lacked accuracy andconsistency (para. 9.1).

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Part II. PROJECT REVIEW FROM BORROWER'S PERSPECTIVE

General

1.1 To obtain data, information and opinions needed for the preparation ofthe PCR, a four day workshop was held with officials from the district,provincial and central levels who were significantly involved in projectimplementation. The compiled data from this workshop were then used selectivelyfor preparing this document by the ex project coordinator who took part in mostof the project preparation, project negotiation and acted as project coordinatorduring the project implemenw.ation.

a. Comments on Part III: Statistical Information

Statistical tables to the extent feasible, have been updated. Additionalinformation was provided on the government's funding contribution to themalaria control program, which has increased the local contribution tothe project.

b. Comments on the Analysis Contained in Part I of the PCR.

The analysis provided in this part is correct and adequate. Thefollowing paragraphs contain additional information complementary to theanalysis.

2. Bank's Performance.

2.1 Project Identification and Preparation. The selection of the (3)Sulawesi Provinces, namely Central -, South- and South-East Sulawesi is regardedas very relevant for three main reasons. First, Indonesia government policy isgiving priority to the development of the eastern part of Indonesia. Second,there is potential for economic growth in these three provinces and third,because of basic data are available from Canadian International Developmentagency studies.

2.2 The Project Health Development Model is appropriate because it uses anarea approach, an integrated health programme approach along withdecentralization of project preparation and implementation. The SAR is clearand provides a good reference for project implementation.

2.3 As well, the project financing method was most helpful. Financing eachcategory by almost 100 percent out of the loan or 100 percent by GOI was verybeneficial for the GOI in 1985/86 when GOI counterpart funds were limited.Compared to similar Bank projects, the Loan absorption in this project was nothampered.

2.4 The participation consistent knowledgeable mission members during projectidentification and preparation helped to speed up the start of the project.

2.5 Lessons Learned For Future Project Preparati a. Detailed projectplanning is necessary to avoid site changes and minimize delays. Adequate fundsshould be made available for project preparation. A clear mechanism fordecentralization should be introduced along with improvement of the capabilityof district and provincial health officials.

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2.6 An in-depth review of existing standard design(s) for hospitals should bemade. Then an updated and better standard design which takes into considerationthe need for low operation and maintenance cost should be developed.

2.7 More time should be provided for equipment consultants to complete thedetailed equipment list which was finalized by project staff with limited timeand limited knowledge of hospital equipment. Local consultant(s) should berecruited along with foreign consultant(s) and together continue to work withproject staff to complete the equipment procurement process.

2.8 A study should be undertaken on the utilization of Health Centers (HC)with beds before planning of in-patient facilities for other health centers.

2.9 Instead of Annual Parasitic Incidence (API), Slide Positive Rates (SPR),is used as an indicator for malaria control outside Jawa-Bali. A BOR of 58percent is likely an average for all hospitals in the region while for theproject hospitals the BOR might be lower. As a consequence, target BOR atproject completion is too high. The Bank should encourage and ensure thatrelated studies be used for project preparation.

2.10 Project Implementation. Although there was a neriod when projectsupervision was rather neglected, the mission members provided guidance,correction and support to the project directors and project staff in manyaspects of project implementation. The Indonesian counterpart gained thereforea lot of understanding, knowledge and invaluable experiences in projectadministration, project and hospital financing, hospital design and equipmentprovision, preparation of tender documents, ICB and handling equipmentprocurement. To allow GOI to spend the savings for commissioning of thefacilities constructed by the project was very helpful as limited fundavailable was encountered by the GOI.

2.11. Lessons Learned For Future Project Implementation

- Using secondary data not supported by detailed studies for projectplanning may speed up project preparation that could createdifficulties in project implementation.

- A strong and consistent supervision mission emphasizing follow upactions is more favorable for project success.

- A team of consultants responsible for hospital design, construction,procurement of equipment and commissioning of hospital(s) would bebetter than recruiting individual consultants.

- Giving more authority to World Bank RSI for approving proposals wouldaccelerate project implementation.

3. Borrower Performance.

3.1 The inadequate counterpart funding, the complexity of the budgeting, thelate release of the funds, the non full time project management staff, and theinexperience of the project team are the main causes of short comings and delayin project implementation and not achieving some target objectives.

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3.2 The credibility of the construction contractors and equipment suppliersplay an important role in the quality of the services and goods.

3.3 The commitment of the local government to provide sufficient funds foroperation and maintenance of hospitals is difficult to fulfill but all effortswere made to provide the needed funding from the local government.

3.4 The Lessons Learned For Future Bank Projects

Project Management

- If not all at least part of the project management staff and projecttechnical team should have sufficient knowledge and experience inimplementation of similar projects.

- Recruitment of consultant(s) mastering both World Bank and GOIprocedures, would help ensure speedy and correct projectimplementation.

- Keeping good admiristration and financial records will facilitateproject monitoring and evaluation.

- Using a simple monitoring system is usually more effective thanrequiring large amounts of data.

- To obtain good quality of goods and services, only qualified biddersshould participate in the tender. The tender committee should havethe courage to reject unqualified bidders and have sufficientk-owledge regarding market prices to ensure that paying a high costfor goods and services is avoided.

- The international bidder for equipment should be supported by thelocal sole agent, to make sure the equipment functions satisfactoryand after sales service is assured.

Hospital

- The approval of using higher unit costs for construction has improvedthe quality of the constructed district hospitals which wouldfacilitate maintenance of the facilities.

- Reviewing the first completed hospital and modifying the next design,if necessary, would help avoid further shortcomings.

- The allocation of a certain amount of "flexible funds" to thehospital directors could solve the problems caused by non-end usersplanning.

- The availability of technical user hospital personnel should be wellplanned in advance and they should be available when the equipmentarrive...

- The training conducted in relation to the new equipment was highlyappreciated and very helpful in handling minor defects.

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';alaria Control

- Cross-checking of microscopic findings of field and Kabupatenlaboratories needs strengthening both at the kabupaten and provinciallevels.

- Efforts were made to identify hard-core areas in each kabutpaten thatwould need concerted efforts to maintain the gains achieved so far.These areas would need to be surveyed by central laboratory teams torealistically and accurately demarcate the hardcore areas whereefforts should be directed hereafter. The earlier this activity isundertaken, the better would it be for planning and programming fieldactivities in the province. Given that some of the transmigrationareas would fall under hardcore areas, special care would be neededin such areas.

4. Relationship Between The Bank And The Borrower

The Bank/Borrower relationship on this project has always been goodduring project preparation as well as project implementation.

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PART III

STATISTICAL INFORMATION

Table 1: RELATED BANK LOANS AND/OR CREDITS

Year ofLoan/Credit titl Purpose approval Status Comments

1. Fiest Population Increase greatly the scale of FY72 Cloosd 12/1/S1 Tho project contributedthe Government's foolly greatly to strengtheningplanning program and broaden the delivery system asthe range of ectivitieo. well as the national

family plonning programIn Indon-ein. Theimpact of the Institu-tional strengthening,however, was not foltuntil subsequentproj cts.

2. First Nutrition To expand nutrition endeavours FY77 Closed 08/25/63 All throe major objec-Development by strongthening Institutions tives--institution

responsible for nutrition bullding, teoting ofresearch and training person- fiold l Ivol Interven-nol ft- Implementation of tions and policy formu-national nutrition programs. lation were largely mt

and the lossons loornedwere incorporated intothe national familynutrition improvemntprogram (UPGK).

S. Second Population Designed to support the FY77 Closed 04/J0/84 Project targets weronational family planning achieved and the objec-program in Java, Bali and 10 tives of enhancing theprovinceo in the Outer Isionds mobility of field staffto meet medium term objectives and extending decentra-in Repelits III. lizd program activities

in 10 Outer Islandprovinces were met.Population educationactivities wore sloworthan anticipated atappraisal.

4. Third Population Encourage and complete docen- FY61 Clooed OS/Si/89 Objective to decentra-tralization efforts in the lize the managemnt ofOuter Islands I and II, In family planningaddition to expanding IEC notionally, expand IECactivities and strengthening and help improve MCHmaternal and child health services were largolyservices achiev*d.

S. Second Hoelth Strengthening of pro-service FY86 Expected to Ongoing(Manpower D-v.) and in-service training cloos 09/30/90

6. Fourth Population To assist GOI in strengthening FY86 Expected to OngoingIts family planning services close 03/31/91and carry out its populationpolicy

7. Second Nutrition Strengthening, coordination FY86 Expected to Ongoingand Comunity Health and managoent of 5 community close 12/31/91

health programs in 11provinces, developing nutri-tion surveillance capabilityand improving nutritionmanpower

S. Third Health Support sector expenditures in FY69 Expected to Ongoingtwo provinces including policy close 06/30/96oeures for decentralization

and resource mobilization

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Table 2: PROJECT TIMETABLE

Date Date DateItem planned revised actual

Identification 09/30/80 /a 01/15/81 /a 02/09/81(Project Brief)

Preparation (Preappraisal) 1980-82 -- 02/19/82

Appraisal mission 01/82 /b 02/82 /c 05/14/82

Loan negotiations 10/82 /c 10/82 /d 12/01/82

Board approval 12/82 /c 01/83 /d 02/15/83

Loan signature -- -- 02/18!83

Loan effectiveness 05/18/83 -- 05/18/83

Loan completion 10/31/87 -- 06/30/89

Loan closing 06/30/88 06/30/89 09/30/89

/a Back-to-Office report on proposed health project reconnaissance mission,July 31, 1980 and Back-to-Office report December 5, 1980.

/b Back-to-Office report on preparation of health project April 24, 1981.

/c Project Brief, February 9, 1982.

/d Back-to-Office report on Health Preappraisal Mission May 4, 1982 andIndonesia Health Project Issues Paper, June 3, 1982.

Note: The dates were revised a number of times and the dates above are thoseclosest to the actuals.

Comment: The major delays in the project timetable were on the Completionand Closing Dates. These largely resulted from the delays in theoriginal construction schedules for the district hospitals (Part 1,para. 5.1) and the subsequent addition of minor supplementaryfacilities such as VIP rooms.

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Table 3: LOAN DISBURSEMENTS

A. Cumulative Estimated ard Actual Disbursements(US$ million)

Bank FY Appraisal estimate Actual Actual as a Z of estimate

1983 0.4 0.40 100.01984 2.5 0.49 20.01985 5.4 1.03 19.11986 13.5 3.75 27.81987 20.2 9.86 48.81988 27.0 16.61 62.91989 20.21 74.9/a1990 24.40 90.4/a

Date of final disbursement: February 12, 1990

/a Actual as a Z of original loan amount.

Comment: The Bank cancelled US$2.2 million at the Government's request onDecember 4, 1987 and another US$0.4 million was cancelled onFebruary 12, 1990 after payment of final withdrawal applicationsunder the loan.

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Table 4: PROJECT IMPLEMENTATION

Appraisal Actual asindicators estimate Actual Z of

No. Year No. Year estimate

A. Referral System DevelopmentNo. of hospitals constructed, fully /astaffed, equipped and in operation 10 1987 10 1989 100.0

No. of health centers with inpatientfacilities staffed, equipped and inoperation 15 1987 15 1989 100.0

B. Staff Development and TrainingNo. of Provincial Training Centersconstructed, staffed and inoperation 3 1985 3 1987 100.0

No. of staff provided inservicetraining - - 2,542 1988 --

C. Management and AdministrationNo. of district health offices anddrug stores constructed 19 1986 8 1987 42.1

No. of District Health Officerstrained 60 1986 164 /b -- 173.0

D. Malaria Control ProgramNo. of spraymen trained 8,000/c 1986 n.a. -- --No. of malaria supervisors trained 65 1983 116 1989/d 178.0No. of houses sprayed - See separate table belowNo. of cases found and treated - See separate table below

/a All the hospitals appear to have adequate medical staff, but existingstaffing norms do not adequately reflect the need for non-medical staff,such as cleaners, cooks, gardeners, etc.

/b Not all the staff trained were from the District Health offices. About 4f:of the total of 164 were staff from the Central Ministry of Healthincluding from Pusat Data, Yanmed and the Bureau of Planning.

/c Two thousand annually for four years./d The numbers of field supervisors trained were 69 in South Sulawesi, 23 in

Central Sulawesi and 24 in Southeast Sulawesi. The training has variedfrom 10 days to 3 weeks. About 902 of the training in Central andSoutheast Sulawesi was undertaken in 1989. The report on the finalassessment of the malaria control program by Dr. P.G. Kesavalu (submittedin August 1989) states that the total number of personnel trained/retrained over the years exceeded the staff allocations. This was mainlydue to the frequent shifts of staff which meant that a disproportionatelylarge number of staff of certain categories had to be trained andretrained.

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Malaria Control Program (cont'd)

1983 1984 1986 1988 1987 1988

No. of houses sproyedTargtt 280,000 380,000 480,000 696,000 569,000 --

Actual 816,901 828,250 432,464 878,967 95,940 147,805

No. of cases found andtrested Target 167,000 262,000 385,000 460,000 400,000 --

Actual 144,193 128,624 137,764 122,580 121,200 135,710PCD /a 3,876eL 2,668/c 3,0960 3,043 4,745 4,472

L Thls refers to Possivo Case Detection only In both the Puskesmas and hospital.lb South S Iswesi cnl--Lc South and Southoset Sulawesi.

Soureo: Ministry of Hoalth, June 1990 and 'Provincial Health Projoct Indoneo a, Malaria ControlProgram South/Contral, Southeast Sulawosei. Roport of Annual Assessment, Dr. P.C.Kesavalu.

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Tabl' 6: PROJECT COSTS AND FINANCING

A. Prolect CostsCUS$ million)

Aebraisal estimate Revigod estimate ActualCategory/componont IBRO G00 Totsl ISRO 00C Total IBRO 00! Total

Civil Works 14.79 1.80 La 83.09 13.40 12.05 25.45 12.48 12.05 24.58

Hospital Eaulpment/DDT 3.62 0.10 8 72 7 .6 0 90 I 60 7 90 0 90 90.0

Vehicles 0.00 1.40 1.40 0.86 0.15 0.51 0.46 0.15 0.68

9E2 rational Cost 0.00 83.0 3830 0.67 2.20 2.87 0.68 3.77 Lb 4.40(including drugs)

Consultants and Fellowships 2.19 0.30 2.49 2.19 1.90 4.09 2.48 1.90 4.38Consul tnts

Fee 0.40 0.00 0.40 0.40 0.00 0.40 0.40 0.00 0.40

Continsency/Unallocated 1.00 4.40 6.40 0.16 0.00 0.16 0.00 0.00 0.00

Total 27.00 27.60 64.80 24.80 17.20 42.00 24.37 16.77 43.14

,L GOI contribution includes investment costs for land.

tb During the review of the PCR, CO1 contibution was increased to incorporate funds for thoMalaria program from individual program budgets additional to the central budgot allocations(APBN)

Comment: Figures may not add up due to rounding.

B. Proiect Financing

Planned Revisod FinalSource (US3 millions) (N) (USE milliono) (N) (US3 millions) (N)

IBRD 27.0 49.3 24.8 69,0 24.4 56.6GOI 27.9 60.7 17.2 41.0 186. 4386

Total 64.8 100.0 42.0 100.0 43.2 100.0

Comment: At appraisal it was estimated that the Bank would finance approximately S0X of the totalproject cost except 11.1 million ropresenting the foreign exchange coat of vehicles.Howevor, subsequently the Bank financed the vehicles and other operational c,sts sinceGOI counterpart funds were not provided for these expenditures. The additional fundswere available due to the devaluations of the ruplah. The Bank also reviewed the totalproject costs for this loan and revised the appraisal estimate from 364.6 million to342.0 million (a 23.3X reduction) following the devaluation In 1986. Additionally, acancellation of 32.2 million was undertaken in Docember 1987. A further 30.4 millionwas cancelled at the loan closing on February 12, 1990.

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Table 6: PROJECT RESULTS

A. Direct Benefits

Appraisal Estimated atPerformance Indicators Actual target closing date

(1982) (1987) (1989 data)/a

No. of outpatient consultationsper month per hospital 1,100 2,400 1,889

Average length of stay 7 days -- 5.5Bed occupancy rate 582 802 36.62/bNo. of deliveries/hospit&l/month 10-40 -- 21No. of maternal deaths/hospital 22 2X --

Mothers and children seeking careat health center/subcenter 1.5 riuillion 3.0 million --

No. of consultations/day/healthcenter 15-40 60 --

Annual parasitic incidence 142 52 n.a./c

la All estimates are averages, for example, the number of outpatientconsultations is the average for the 10 hrc;pitals.

/b The evaluation data presented as of the 8.ssing Date is unreliable as itis under-reported and possibly inconsis -. t. Although data was collectedfor the Monitor_ng and Evaluation Ind4cOtitrs established for the project,they have not been systematically collectc' or analyzed, given the delaysin commissioning the facilities and, con e-.ently, delays in acquiringdata. Further some of the indicators ¢stp) ished during the appraisal arealso unrealistic. For example, in genera' given initial problems incommissioning hospitals, an 80% BOR immedi :.Ily hospital construction iscompleted is over-optimistic. Data for tbh: -hree hospitals that iuststarted operations in 1989 are excluded.

/c Annual parasitic incidence cannot be obtainid 'rom Passive Case Detectiondata only and requires special surveys. Ava:,lble information from theMOH indicates that the pirasitic rate decreased from 4.5% (1983) to 1.2Z(1987) in Southeast Sulawesi and from 10.0X ;1183) to 4.8% (1986) inCentral Sulawesi. No estimates have been prolided for South Sulawesi.

Source: Ministry of Health, June 1990.

-22-_

B. Project Studies and Technical Assistance

Status andPurposend enxnma onthe (am) manmonthe (mm) Impact

A. Studies

Health Finance To review ways to elmplify health finance Coapleted Limited since recommendations not implemented assystem at the district level and examine (9 as) some measures propoxsd, e.g.. retention of feespocsibilities for additional resource in health facilities wmre againmt existingmobilization through appropriate cost reguletions. Used *e ,n input for the Healthrecovery mechanism. Also to study Financing Study in thf follos-up project, theappropriate uwer fees for district Third Health Project.hospitals and ways to retain these fundsto supplement operating coats. (6 m-)

Health Information To roview the exi&ting system for report- Coakpleted Used as an input for the development of a pilotSystem (HIS) ing and recording activities of health (10.5 6m) projset for a HIS *ith the Suls-i Provinces

centers *nd the district offices and bing part of the pilot. The pilot project isthereafter mke recommendations for *till bein a*s" d Two other HIS studiostrengthening the systIm to effectively mre also financed under the project (i) Orclesupport planning activitieso. (6 _) Robbin: Study, and Hii) Automated Strategy Study

for an Integrated HIS. The latter mil l form thebasis of a proposed HIS component in the nextproject.

Utilization of Health To review present trends of tutilization Coobined with --S-rvices of health centers and to maes recomeenda- study below

tion for improving them. (None include*dao a covenant).

Outreach Activities To study the performnne of .PKMD, parti- Completed No follow-up.cularly its impact on utilization ofhealth services in order to establishoptimal conditions for proora-m sainte-nonce and to plan for its expansion oralternative prograsm for improvingoutreach. (None, included am acovenant).

Administration To review present procedures for district Comnpleted Used successfully in the provinces but nothospital adainistration, design and (22 w) repli cated notionallyconduct training course for hospitaladministrators, and evaluate the coursefor national replication. (46 me)

Hospital Equipment To determine (i) maintenane needs of Consultancy Prototypes of workshops to be built mereMaintenance district hospitals based on an inventory unused developed with the architectural designs for the

of medical equipment, and (ii) the appro- hospitals.priate number, location ond staffing formann.enance workshops. and prepare preli-minery architectural drawingo for theseworkshops. (6 mm)

Hospital Equipment To asist MOH to prepare specifications Completed All hospital equipment purchased based on theof hospital equipment. (2 me) (coebinlad with consultant studies.

hosp i tsadmin.)

Management Training of To design and carry out a management Consultancy Although no specific course was demigned,District Medical training course for district medical unused district medical officers mere provided withOfficers officers. (36 me) overseas and local training courses.

Drug Management System To establish a drug ;nvsntory system at Consultancy --the district level. (6 m) unusd because

of a studydone by WHOconsul tents

Fntosologist and To assist in malaria surveillance and Completed Excellent assessments mere provided on theMalariologist elpidemiological assessment. (106 mex) The original progress of the program, recommendations for

intention was improvements and measures for susteinability.to provide forlong-termconsultants,but due to thedifficultiesin obtainingthem, short-term consul-tancies wereused. (44 mm)

Honitoring and To assist MOH in evaluating project Completed and Due to the delays in commissioning facilitiesEvaluation impact. (6 m) monitoring end the data collection and analysis has been

evaluating incomplete and poor The syst needs to beindicators institut iona ized as the real impact of theestablished project can only be assessed in the future.(consul tentsnot used)

Project Preparation To assist MOH in preparing a s?cord Completed Consultancies were used not for the secondhealth project for Bank financing. Used for project but the Third Health Project. Technical(6 -al) project prepa- a" istance was also provided for health sector

ration as well work, for studies on health center unit costs,as health hospital unit costs and government expenditurelector work accounts.(42 mm)

ntp Additional consultancis u-el but not provided for in the SAR were for: (1) training in planning for health development(3 my, (2) comwuter training (about S _m); and (3) Audit reports (6 m).

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Table 7: STATUS OF COVENANTS

LoanAgreement ubject Deadlino Status

Section 3.02(b) Employ full comploemnt of staff and 03/31/84 Completed but not on schoduloconsultants for malaria control

Section 3.02(c) Appointment of technical staff for -- Not fully compliod withplanning and construction of civil works

Section 8.05 Acquire land in accordanco with a -- Completed although the landtimotable satisfactory to the Bank was not acquirod according to

schedulo.

Section 3.06(a) Study on trends In hoalth conter 12/31/84 Completedutilization and rocommndations forImproving outreach services

Section 3.06(b) Study In ten districts to review 12/31/84 Completedways of improving health financesystem at district level andpossibilities of cost rocovery

Section 3.06(c) Study of recording and reporting of 04/30/86 Completedhealth centers and methods ofimproving collection of information

Section 3.07 Monitor and evaluate project -- Completed and collection andactivities according to satisfactory analysis of data ongoingindicators

Table 8: USE OF BANK RESOURCES

Staff Inputs

A. Staff Weeks by Stage

FY 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990

Preappraisal 34.8 55.0Appraisal 25.5 15.2Negotiations 5.1Supervision 11.1 14.1 4.0 26.3 16.1 17.4 12.2 8.2Other 7.7

Total Project 34.8 80.5 31.4 14.1 4.0 26.3 16.1 17.4 12.2 15.9

Comment: The supervision of the project was badly neglected in FY85. Thisoccurred during an 18 months period when three new projects -- FourthPopulation (FY85), Second Health (Manpower Development) (FY85) andSecond Nutrition and Community Health (FY86) -- were negotiated andapproved. Consequently, much less attention was paid to supervisionissues. The project may have also benefited from more visits to theprovinces by supervision missions.

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B. Mission Data

Days Perf. Rating TypeNo. in Specialties status trend prob.

Mo./Yr. Pers. Field represented/a /b /c /d

Identification I 07/80 2 12 p, f/ePreparation I 11/80 3 18 p, f/d, f/ePreparation II 03/81; 08/81 4 25/e p, 1, mPreparation III 11-12/81 3 20 p, f/d, aPre-appraisal 3-4/82 2 26 p, aAppraisal 05/82 2 14 p, f/dSupv. I 03/83 2 19 p. f/d 1 1 -Supv. II 09/83 2 5 p, f/d 1 2 -Supv. III 04/84 2 6 a. f/d 1 1 -Supv. IV 12/84 1 6 fld 2 1 MSupv. V 07/85 2 n.a./f o, r 2 - M,FSupv. VI 12/85 1 n.a./f 0 3 - M,DISupv. VII 10/86 L& 3 n.a./f o, p, r 2 - F,M,DISupv. VIII 09/87 2 6 e 2 - F,M,DISupv. IX 04/88 1 5 e 2 - F,M,DISupv. X 2-3/89 2 13 e, p 2 - F,M,DISupv. XI 08/89 3 16 e, pi a 2 - F,M,DI

la Specialty Codes: a: Architect; e: economist; f/e: finance/economist;f/d: finance/demography; 1: loan officer; m: manpower specialist;o: organization and management specialist; p: public health specialist;r: operations assistant.

/b 1: Problem Free or Minor Problems; 2: Moderate Problems; 3: MajorProblems.

/c 1: Improving; 2: Stationary; 3: Deteriorating (only applicable until12/84 Spn.).

/d M: Managerial; F: Financial; DI: Development Impact./e This includes a brief 5-day visit by a public health specialist./f Supervision and preparation missions for a number of projects were

combined making it difficult to disaggregate the staffdays in the fieldon individual projects. Consultants used for the subsequent HealthManpower Development Project have, to the extent feasible, also beenexcluded.

/g Although reference is made to a supervision mission in April 1986, thereis no record of this mission in the files.

ANNEX 1

-2r .

INDONESIA

PROJECT COMPLETION REPORT

Provincial Health Project (IBRD-Ln. 2235-IND)Hospital Investment Costs

(Rp million/S million equivalent)

Year Gf Investment CostsName of Hospital Operation Construction Equipment Total

(Cost /a) (Cost /)

Rp S /b Rp $ /d Rp $

Class C

1 Luwu 1987 1,407 0.97 1,075 0.63 2,482 1.602 Pare-Pare 1986 2,251 1.55 1,051 0.61 3,302 2.163 Bone 1987 2,150 1.34 1,053 0.61 3,203 1.954 Masamba 1989 2,207 1.30 1,090 0.63 3,297 1.93

"lass D

5 Toli-Toli 1989 1,751 1.03 1,098 0.64 2,849 1.676 Ampana 1988 2,091 1.31 1,048 0.61 3,138 1.927 Majene 1986 1,480 1.02 1,017 0.59 2,497 1.618 Bulukumba 1987 1,497 0.94 1,008 0.59 2,505 1:539 Tana-Toraja 1989 1,717 1.01 986 0.57 2,703 1.5810 Unaaha 1989 1,657 0.98 988 0.58 2,645 1.56

Total 18,208 11.45 10,413 6.06 28,621 17.51

/a Including: Land and Master Plans./b Construction costs - Exchange rates

- Luwuk Pare-Pare and Majene Hospitals $1 - Rp 1,450- Bone, Bulukumba and Ampana Hospitals $1 - Rp 1,600- Toli-Toli, Masamba, Tana-Toraja, Unaaha $ - Rp 1,696

/c Including: medical, non medical, and other supporting equipment./d Equipment costs - Exchange rate $1 - Rp 1,718.

Source: Planning Bureau, MOH, January 1990.

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