Indonesia - Health Workforce & Services (php 3)

 ICRR 13192 Report Number : ICRR13192 IEG ICR Review Independent Evaluation Group 1. Project Data: Date Posted : 01/27/2010 PROJ ID : P073772 Appraisal Actual Project Name : Health Workforce & US$M ): Project Costs (US$M): 429.37 599.37 Services (php 3) Country : Indonesia Loan /Credit (US$M): Loan/ US$M ): 105.6 57.49 Sector Board : HE US$M): Cofinancing (US$M ): Sector (s): Health (70%) Sub-national government administration (15%) Tertiary education (15%) Theme (s): Child health (25% - P) Health system performance (25% - P) Decentralization (24% - P) Vulnerability assessment and monitoring (13% - S) Education for the knowledge economy (13% - S) L/C Number : C3784; L4702 Board Approval Date : 06/12/2003 Partners involved : Closing Date : 12/31/2008 12/31/2008 Evaluator : Panel Reviewer : Group Manager : Group : Alemayehu A. Ambel Kris Hallberg IEGSE ICR Reviews IEGSE 2. Project Objectives and Components: a. Objectives: The Development Credit Agreement (DCA) states that "the objective of the Project is to assist the Borrower in achieving the effective delivery of health services in Indonesia in a decentralized setting by strengthening : (i) the financing and delivery of health services in the Borrower's provinces of Jambi, East Kalimantan, West Kalimantan and West Sumatera, so as to enhance the quality of care and health outcomes at the District level; and (ii) health workforce policy, management and development at the national and sub -national levels so as to improve allocational efficiencies and equity in the distribution and use of health resources ." The Loan Agreement (LA) does not state the project development objectives (PDOs), but refers back to the DCA. The Project Appraisal Document (PAD ) states the objectives slightly differently . Unlike the DCA, the PAD distinguishes district level objectives as "primary" and national level objectives as "corollary". The "primary" PDO was "to support health sector decentralization in four provinces for sustainable financing and client -centered delivery of health services. More specifically, the main objectives of the project are to (i) improve financing and delivery of health essential health services in the provinces of Jambi, East Kalimantan, West Kalimantan, and West Sumatera to enhance access to care, quality of care and health outcomes at the district level; and (ii) strengthen health work force policy, management and development in a decentralized context in order to improve allocational efficiencies and equity in the distribution and use of health resources in the districts ." The " corollary" PDO was "to empower the Ministry of Health (MOH), the Ministry of National Education (MONE), and the Indonesian Medical Association (IMA), the three key stakeholders in the sector, through : (i) assistance to redefine their roles and responsibilities vis -a-vis health work force policy, planning and management; and (ii) building their institutional capacity for effective stewardship in fulfilling the functions of policy making, legislation, regulation, quality assurance /control and technical assistance to provinces and districts ." (PAD p.3) This ICR Review evaluates the achievement of objectives as stated in the DCA . b.Were the project objectives/key associated outcome targets revised during implementation? No c. Components (or Key Conditions in the case of DPLs, as appropriate): The project had the following components . The ICR does not report the actual cost estimate by component . A. District Health Offices and Health Facilities (Appraisal Estimate: US$ 374.67 million). A.1. Improved access to and quality of health services : Support for improved service delivery based on (a) the health development master plan; and (b) the use of block grants for District -Funding -Allocation (DFA) for increased efficiency in resource allocation and utilization . A.2. Project Management : Support to the District Implementation Unit (DIU) including training limited to project implementation, consultant services, and operational costs (salaries, minor office equipment, stationery, communications, etc.) B. Provincial Health Offices and Health Facilities . B.1. Health workforce development (Appraisal Estimate: US$ 22.93 million). To support the health work force planning and management by : (i) adapting the minimum service standards to local conditions and means; (ii) determining the numbers, skills, and specialization of existing and future health work forces needed at provincial and district levels; and (iii) implementing measures to ensure appropriate numbers of adequately trained staff in health facilities . The project would then support studies, pilot tests, and operational research concerning incentives and motivation, performance appraisals, and other initiatives for improving workforce performance. B.2. Health system coordination, planning and management (Appraisal Estimate: US$ 3.91 million). To support provincial health offices (PHO) to strengthen the performance of districts in the following areas : (i) health information, education and promotion campaigns; (ii) epidemiological surveillance and outbreak response; (iii) cooperation and health development planning; and (iv) health systems financing. The project would support: minor civil works and equipment for the PHO, transport for supervision, training in health administration and management, and incremental costs (for periodic meetings and supervision, etc . ) B.3. Project management ( Appraisal Estimate: US$ 2.12 million). To support the Provincial Coordination and Implementation Unit (PCIU) which would have responsibilities in areas of planning, procurement, financial management, and monitoring and evaluation . The project would finance consultant services, office equipment and supplies, workshops, project management and related training, and operational costs associated with routine activities and supervision and biannual monitoring of project performance . C. Central Level At the central level, the project focused on three institutions (MOH, MONE, and IMA that have key roles in the improvement of health service delivery in the country . C.1. Effective Health System Stewardship (MOH) MOH ) (Appraisal Estimate: US$ 11.34 million). Support included financing the following activities : limited renovations, technical assistance (studies, study tours, development of training guidelines and modules, short and long term training, and workshops ), equipment, instructional materials, and operational costs . C.2. Enhancing the quality of medical education (MONE)MONE ) (Appraisal Estimate: US$ 14.39 million). Technical assistance, study tour, degree and non -degree training, consulting services, workshops, working group meetings and internships. d. Comments on Project Cost, Financing, Borrower Contribution, and Dates: US$ 105.6 million Bank financing was provided in the form of an IDA credit (US$ 74.5 million) and IBRD loan (US$ 31.1 million). There were no revisions in the project development objectives (PDO), but more emphasis was given on  improving maternal and child health (MCH) as per the recommendations of the mid term review (MTR) that noted the need to simplify the project by focusing only on some of its activities . Only 54 percent of the original credit/loan was disbursed by the closing date . The bank suggested an extension of the closing date, but the Government declined . The ICR reports that the Bank approved the cancellation request of the Government in December 2008 for the amount of US$ 48.9 million (US$ 30.8 million of the Loan and US$18.1 million of the credit). On the other hand, the information provided by the Country Office in response to the draft ICR review, shows that the Government's actual expenditure was US$ 541.88 million, which is US$218.11 million over the appraisal estimate of US$ 323.77 million. 3. Relevance of Objectives & Design: Relevance of objectives (Substantial ): The development objectives are in line with the prevailing Country Partnership Strategy (CPS). For instance, reducing maternal and under five mortality rates are indicated as one of strategic long term country outcomes in the CPS for FY 09-12. The CPS also underlines the role of increased health services utilization especially by the poorest segment of the population, which is consistent with the project's equity objective. Among the constraints to achieving these objectives, institutional issues such as decentralization and local capacities were identified by the CPS . Relevance of design (Negligible): The project was based on a decentralized governance framework that was only a “work in progress