Documunt of The World Bank FOR OFFICIAL USE ONLY Report No. 11997 PROJECT COMPLETION REPORT INDONESIA SECOND NUTRITION AND COMMUNITY HEALTH PROJECT (LOAN 2636-IND) JUNE 16, 1993 Population and Human Resources Operations Division Country Department III East Asia and Pacific Regional Office This document hasa restricteddistribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized
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Documunt of
The World Bank
FOR OFFICIAL USE ONLY
Report No. 11997
PROJECT COMPLETION REPORT
INDONESIA
SECOND NUTRITION AND COMMUNITY HEALTH PROJECT(LOAN 2636-IND)
JUNE 16, 1993
Population and Human Resources Operations DivisionCountry Department IIIEast Asia and Pacific Regional Office
This document has a restricted distribution and may be used by recipients only in the performance oftheir official duties. Its contents may not otherwise be disclosed without World Bank authorization.
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CURRENCY EQUIVALENTS
NAME OF CURRENCY: RuPIAH
AT APPRAIsAL (10/85): US$ = RuPIAH 1,100
1986/87: US$1 = RuPIAH 1,1001987/88: US$1 = RUPIAm 1,6441988/89: US$1 = RUPLAH 1,6861989/90: US$1 = RUPIAH 1,7701990/91: US$1 = RUPLAH 1,843
FISCAL YEAR
APRIL 1 - MARCH 31
ABBREVIATIONS
BAPPENAS : NATIONAL DEVELOPMENT PLANNING AGENCYBPGD : INTERSECTORAL NUTRITION IMPROVEMENT BOARD
CHNIII THIRD COMMUNITY HEALTH AND NUTRITION PROJECT
CRDN CENTER FOR RESEARCH AND DEVELOPMENT IN NUTRITION
GMSK DEPARTMENT OF COMMUNITY NUTRITION AND FAMILY
RESOURCES
GOI GOVERNMENT OF THE REPUBLIC OF INDONESIA
IPB : INSTITUTE OF AGRICULTURE, BOGOR
KAP KNOWLEDGE, ATTITUDES AND PRACTICES
LKMD VILLAGE SELF-RELIANCE BOARD
MCH MATERNAL AND CHILD HEALTH
MOEC MINISTRY OF EDUCATION AND CULTURE
MOF MINISTRY OF FINANCE
MOH MINISTRY OF HEALTH
NCHII : SECOND NUTRITION AND COMMUNITY HEALTH PROJECT
NFPCB NATIONAL FAMILY PLANNING COORDINATING BoARD
PEM : PROTEIN-ENERGY MALNUTRITION
PKK: WOMEN'S ORGANIZATION IN THE COMMUNITY
PKM CENTER FOR HEALTH EDUCATION
PKMD VILLAGE COMMUNITY HEALTH DEVELOPMENT PROGRAM
PSM DIRECTORATE OF COMMUNITY PARTICIPATION
REPELITA : FIVE-YEAR DEVELOPMENT PLAN
SAR : STAFF APPRAISAL REPORT
SKDN CHILD GROWTH MONITORING SYSTEM
SUSENAS : SOCIOECONOMIC HOUSEHOLD SURVEY
TBA TRADITIONAL BIRTH ATrENDANT
TOR TERMS OF REFERENCE
TPG NUTRITION PROGRAM IMPLEMENTORS
TUA BUDGET ADMINISTRATION
TWIS TIMELY WARNING AND INTERVENTION SYSTEM
UNICEF UNITED NATIONS CHILDREN'S FUND
UPGK FAMILY NUTRITION IMPROVEMENT PROGRAM
USAID UNITED STATES AGENCY FOR INTERNATIONAL DEVELOPMENT
VCDC VILLAGE CONTRACEPTIVE DISTRIBUTION CENTER
WHO WORLD HEALTH ORGANIZATION
FOR OFFICIAL USE ONLYTHE WORLD BANK
Washington, D.C. 20433U.S.A.
Offic o Diredor-GeneralOprautons Evaluation June 16, 1993
MEMORANDUM TO THE EXECUTIVE DIRECTORS AND THE PRESIDENT
SUBJECT: Project Completion Report on IndonesiaSecond Nutrition and Community Health Project (Loan 2636-IND)
Attached is the Project Completion Report on Indonesia - Second Nutrition and CommunityHealth Project (Loan 2636-IND) prepared by the East Asia and Pacific Regional Office. Part II wasprepared by the Borrower.
This project aimed to improve the effectiveness of nutrition and community health programsin reducing infant, child, and maternal mortality. The principal method of doing so was to strengthenindividual services and to deliver them as an integrated package through health posts owned andoperated by the communities themselves.
The outcome is rated as satisfactory. The project approach is likely to prove sustainablebecause of commitment to the approach at the community as well as at national level and the signingof a follow-on project to continue the expansion of the system. Institutional development is ratedas partial: a great deal remains to be done to sustain field staff motivation, improve counselling andhealth education techniques, decentralize program administration and build a research policy and self-evaluation capability.
The PCR provides an informative account of project implementation. An audit is planned.
Attachment
This documrent has a restrcted distribution and may be used by recipients only In the performance oftheir oftcial duties. fts contents may not otherwise be disclosed without World Bank authorization.
FOR OFFICIAL USE ONLY
PROJECT COMPLEIION REPORT
INDONESIASECOND NUTRITON AND COMMUNITY HEALTH
(LOAN 2636-IND)
TABLE OF CONTENTS
Page No.
PREFACE ...............................................
EVALUATION SUMMARY ........ ......................... i
PART I PROJECT REVIEW AND BANK'S PERSPECTIVE
Project Identity ............... ...................... 11. Background. 12. Project Objectives and Description. 23. Project Design and Organization. 54. Project Implementation. 75. Project Results .136. Project Sustainability .157. Borrowers Performance .188. Bank Performance .199. Project Relationships .2010. Consulting Services .2011. Project Documentation and Data .2012. Lessons Learned .21
PART Ik BORROWER'S REVIEW
1. Description of the Project .242. General Conclusion of the Achievement .283. The Strength and the Weakness of NCH-II Project .354. The Bank and Project Performance .365. Problems .38
PART I[L STATISTICAL INFORMATION
1. Related Bank Loans .402. Project Timetable .413. Cumulative Estimated and Actual Disbursement .424. Project Implementation .435. Project Costs and Financing .466. Status of Covenants .487. Use of Bank Resources .49& Studies .51
I This document has a restricted distribution and may be used by recipients only in the performanceof their official duties. Its contents may not otherwise be disclosed without World Bank authorization.
PROJECI CDOWMPLETION REPORT
ERDONESIASECOND NUTRMON AND COMMUNrIY HEALTH
(LOAN 2636IND
PREFACE
This is the Project Completion Report (PCR) for the Second Nutrition andCommunity Health Project, for which a loan of USS 33.4 million to the Government of theRepublic of Indonesia (GOI) was approved in December 1985. The project was closed inDecember 1991, as originally scheduled. About 95 percent of the loan was disbursed.
The Preface, Evaluation Summary, Part I and Part HI of this PCR were preparedVicente B. Paqueo (EA3PH) and Dr. Iswandi (RSI) and reviewed by EA3PH. Part II wasprepared by GOI. The PCR was prepared in accordance with the guidelines for preparing PCRs,issued in June 1989. The report is based on data provided by GOI, a review of World Bankrecords, evaluation studies, and field visits in Indonesia in 1991 and 1992.
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PROJECT COMPLETION REPORT
INDONESIASECOND NURITION AND COMMUNITY HEALTH
(LOAN 2636-IND)
EVALUATION SUMMARY
Objectives
At the time of appraisal in July 1985, overall health status of the Indonesianpopulation, especially of mothers and children, remained far from satisfactory despite gains duringthe previous twenty years. Under those circumstances, improved maternal and child health (MCH)services together with a strengthened nutrition program were an obvious priority.
The project, therefore, aimed at increasing the effectiveness and efficiency of theGovernment's nutrition and community health programs to reduce infant, child, and maternalmortality. This objective would be achieved by: (a) strengthening the coordination and managementof the five key community health programs (family planning, maternal and child care, nutrition,immunizations, and diarrhoeal disease control) in eleven priority provinces, including directoperational support to each of these five programs; (b) further developing Indonesia's nutritionsurveillance capability in four areas (timely warning and intervention, nutrition monitoring andassessment, nutrition policy and program studies, and nutrition information); and (c) strengtheningnutrition manpower development at the paramedical and graduate levels.
The main emphasis was to strengthen the coordination of the five priority communityhealth programs at integrated service delivery posts (posyandu). These are health posts organized,owned and operated by the community themselves. The underlying hypothesis was that by makingall five health interventions simultaneously available at predictable times (e.g. once a month) and atan easily accessible place, their utilization would increase, as access to them would become moreconvenient. Moreover, this expected effect would be reinforced by a promotion campaign based onsocial marketing methodology.
Implementation Experience
Overall implementation was satisfactory. Although compliance was at times delayed,GOI generally followed the loan covenants. And where adjustments had to be made, they werecarried out with Bank agreement and in conformity with the objectives of the loan. GOI's ownershipof the project was quite high; and so was its commitment to sustained implementation. Hence,despite problems encountered during the first few years of project implementation, governmentnevertheless completed the project, as originally scheduled.
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Out of the total loan of $ 33.4 million, GOI spent $ 31.8 million. About five percentof the loan fund remained unspent. All the activities prescribed in the SAR, however, (with someadjustments) were fully carried out. The unspent balance was partly due to the depreciation of thelocal currency.
The discussion in Section 4 presents the project's "physical" accomplishments in termsof the type of project assistance provided and in relation to targets. On the whole, it would appearthat the physical targets had been achieved. In fact, in some cases, they had even been exceeded.The project had implemented the training activities, the promotional campaigns and the provision ofsupplies/equipment to facilitate the expansion and improvement of posyandu and other MCHinitiatives. Construction of facilities had been completed. Staff and curriculum development had beencarried out. The various studies and activities intended to improve Indonesia's nutrition surveillancecapability had also been implemented.
The quality of implementation, however, suffered for a number of reasons. Forexample, the cascade training provided to "kaders" (posyandu volunteer workers) was quite poor; thefeasibility studies for the Timely Warning and Intervention System (TWIS) were inadequate; and thesupervision manuals were not user-friendly. One reason for poor quality implementation was thatsupervision and training resources were spread too thinly over 11 eleven provinces (more, in someinstances). Other reasons include: lack of familiarity with procedures, standards and timing relatingto the processing of Bank-funded projects; failure to fully and expeditiously staff the ProjectSecretariat; inadequate GOI funds for supervision; and lack of counterpart funds due tomacroeconomic problems.
Nevertheless, the timely completion of the project could be justly considered anoteworthy achievement, especially when compared to other projects in Indonesia and in view of thefollowing results.
Proiect Results
A definitive assessment of health and nutrition outcomes due to the project is notavailable at present. But, to the extent possible, Section 5 provides some clues. The overalconclusion from available survey data is that the project had most likely achieved significant positiveresults. The following selected information gives a flavor of those results:
(a) The number of posyandus had expanded from about 89,000 in 1986 to over 170,000 in1991 in the eleven provinces.
(b) Utilization of posyandu has also increased considerably between 1986 to 1991. Inparticular, the number of mothers who had been to a posyandu had increased from 66percent to 80 percent.
(c) The percentage of respondent mothers' youngest children who had ever been weighedrose from 41 percent to 77 percent.
(d) Growth charts are now widespread, with 77 percent of mothers claiming to have onechart for their youngest child.
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(e) Immunization coverage had increased substantially between 1986 and 1991 (see tableon page 14). For example, the percentage of youngest children immunized for DPT1(diphtheria, polio, tetanus) rose from 47 percent to 96 percent. Of these, 70 percentobtained their immunization at posyandus (up from 30 percent in 1986).
(f) Clearly, the posyandus have now become the most important vehicle for DPT1, polio,and measles immunizations and, to some extent, for tetanus shots for pregnant mothers.In this regard, it is noteworthy that over 70 percent of mothers also claimed that theyhad received their education about immunization at a posyandu.
The project's impact is further illustrated by its child feeding action sheets that weredistributed at the posyandus. Roughly half a million mothers had received those action sheets. Ofthose who had them, 80 percent claimed that they had changed their child feeding practices(primarily, by increasing feeding frequency) as a result of the information.
Finally, analysis of the above-mentioned survey data had noted these two importantresults: (1) 90 percent of mothers regard posyandu services to be beneficial; and (2) communities nowhave a strong sense of ownership of posyandus. The project has contributed to these results byimproving the credibility of the posyandu and by supporting a social marketing strategy that promotednot only the use of posyandu services but also the idea of community ownership and participation.
The above results are only part of the potential contribution of NCH H. There areothers, but they cannot be quantified in terms of health outcomes or indicators. For instance, theroughly five hundred staff members who had completed their followships (about 400 local and 100overseas) would be an important source of trained personnel for further nutrition and communityhealth development effort. Those fellowships are mostly likely to lead to institutional strengthening.
Not all the project activities, however, have resulted in positive outcomes. For example,the supervision manuals provided by the project were hardly used. Moreover, TWIS proved not tobe very usefuL
Project Sustainability
Many of the beneficial effects of the project appear to be sustainable. Among thefactors favorable to sustained implementation of initiatives supported by NCH II are: strongintersectoral consensus among Indonesian policy-makers (including Indonesia's President Suharto)about the posyandu strategy and other MCH initiatives based on community ownership andparticipation; a strong sense of community ownership of posyandu; acceptance by the communitiesof the responsibility of delivering the five basic family services; and a positive perception by mothersthat posyandus provide beneficial services. In addition, economic growth and continued reductionin poverty throughout Indonesia are expected to enable many more communities to shoulder agreater percentage share of the cost of community health services over time. Moreover, withimproving public finance, GOI would be able to fund puskesmas (health centers) and higher levelhealth bureaucracies to support community-based health and nutrition interventions. On themanpower development goal, commitment from top government officials is quite strong. In addition,although they remain in need of further strengthening, government units at the center and localgovernment levels now have a relatively stronger manpower and institutional capacity on which to
vi
build more ambitious and more decentralized community health and nutrition projects (compared tofive years ago).
There are, however, critical constraints that must be recognized to avoid unrealisticexpectations. Some of those constraints prevent full realization of the benefits that could be derivedfrom NCH II. The issues here include: the lack of capacity of health centers to supply consistent,integrated services to all posyandus; the high 'kader" dropout rate; the need for central and provincialcapacity to regularly produce fresh counselling, promotional, and health education materials; thestifling effect of bureaucratic fragmentation and top-down decision-making on communityparticipation and coordinated support of posyandus; and the continuing need of the Institute ofAgriculture (Bogor) to further develop the staff of its Department of Community Nutrition andFamily Resources (GMSK).
GOI and the Bank have taken steps to ensure that the accomplishments achieved underNCH H would be carried forward. Foremost of these is the Community Health and Nutrition Project(CHN E), which had recently been approved by the Board. This project aims at improving thehealth status of mothers and children based on community participation and enhanced local capacityat planning, implementation and evaluation of Safe Motherhood, Child Survival and Nutritioninterventions. Another related initiative is the ongoing Third Health Project, which includesinnovative pilot activities designed to address issues regarding decentralized and integrated planningand budgeting.
Lessons Leamed
The following highlights some selected lessons from the NCH II experience (See Section12 for more details):
(a) The most important lesson is thatposyandu works to a considerable extent, and that itcould be made to work even better. Five main elements underpin the relativelysuccessful posyandu strategy for improving community nutrition and family health: (i)choice of effective but underutilized interventions with high potential demand andsimple technological and delivery requirements; (ii) coordinated delivery of thoseinterventions, making them available simultaneously at predictable times (e.g., once amonth) and at easily accessible places in the community; (iii) a strong sense ofcommunity ownership and commitment to supportposyandu operations and ensure theireffectiveness through vigorous community participation (e.g., contribution of volunteerlabor and other resources); (iv) a broad national consensus, from the President down tothe community; and (v) promotion based on social marketing methodology.
(b) The posyandu, however, is not a panacea: There are serious limitations to what theposyandu system can deliver.
(c) Implementation of a workable Timely Warning and Intervention System (TWIS) is quitecomplex and its apparent conceptual simplicity can be misleading.
(d) Successful economic development could overtake in a relatively short period of timeimplementation of certain project activities and, consequently, cast doubt on theircontinued relevance (e.g. TWIS).
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(e) The value of training puskesmas staff in planning can be quite high; but training benefitscan be fully realized only if key decentralization issues are effectively addressed.
(f) The project successes and failures appear to depend on the following design andorganizational factors:
(i) choice of components based on realistic appraisal;(ii) involvement of all relevant bureaucracies;(iii) scale of the project or extent of coverage;(iv) drive and capacity of the Project Secretariat;(v) flexibility to adjust to changing local conditions;(vi) a solid and constructive mid-term review; and(vii) effective supervision.
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PROJEC COMPLEON RT
INDONESIASECOND NtllRTION AND COMMUNrTY HEALTH
PART k PROJECr REVEEW AND BANICS
Prnijet idetity
Project Name : Second Nutrition and Community HealthLoan No. : Loan 2636-INDLoan Amount : US$33.4 million equivalentRVP Unit : East Asia and Pacific RegionCountry : IndonesiaSector : Population and Human ResourcesSubsector : Population, Health and Nutrition
1. Bm*pd
1.1 At the time of appraisal in July 1985, overall health status of theIndonesian population remained far from satisfactory despite gains during the previoustwenty years. Health status had lagged behind that of comparable countries, and itsepidemiological profile had essentially remained unchanged during the past decade. Themost prevalent causes of mortality and morbidity continued to include infectious,parasitic and gastrointestinal diseases that were mostly preventable or treatable throughsimple, low-cost therapy. Moreover, despite the fact that available calories and proteinwere sufficient in the aggregate to meet minimum daily requirements, protein-malnutrition (PEM) remained a serious problem and a major contributor to Indonesia'sstill high infant mortality rate. Under those circumstances, and considering the highlevels of maternal, child and infant mortality, improved maternal and child health(MCH) services together with a strengthened nutrition program were an obviouspriority.
1.2 The Fourth National Five-Year Development Plan, 1984-89 (RepelitaIV), aimed, among others, at reducing infant mortality rate (IMR) by 30 percent by1988iS9. GOI recognized that IMR was not only a key indicator of the population'soverall health status but also a crucial determinant of contraceptive use.
13 Against this background, Repelita IV emphasized the need for widespreadaccess to and effective delivery of health (including nutrition and family planning)services through two principal avenues. The first was through strengthening of healthcenters and subcenters. This included expansion of primary health care facilities to
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hitherto underserved areas and improvement of their services and utilization bydeveloping additional paramedical personnel those facilities. The second avenue wasthrough improved outreach from these centers and strengthening community-levelprograms and activities. GOI's main emphasis here was to strengthen the coordinationof five priority community-level programs-namely family planning, nutrition,iununization, diarrheal disease control, and maternal and child health-at integratedservice delivery posts (posyandu), organized by the community themselves.
2. Project Objectives and Description
2.1 Objectives. The project's objective was to increase the effectiveness andefficiency of the Government's nutrition and community health programs to reduceinfant, child, and maternal mortality by: (a) strengthening the coordination andmanagement of the five key community health programs in eleven priority provinces,including direct operational support to each these five programs; (b) further developingIndonesia's nutrition surveillance capability in four areas (timely warning andintervention, nutrition monitoring and assessment, nutrition policy and program studies,and nutrition information); and (c) strengthening nutrition human resource developmentat the paramedical and graduate levels. These objectives would be accomplishedthrough various project components described below.
2.2 Project Description. The following activities were to be undertakenfrom 1986 to 1991.
Strengthening Coordination and Management of Community Health (US$21.0,excluding taxes and contingencies)
2.3 This component was to be implemented in 11 provinces, selected for amajor focused effort to implement coordinated delivery of the five key communityhealth programs during Repelita IV. These provinces, which represent 80 percent ofIndonesia's population, included East, Central and West Java, DKI Jakarta, North,South, and West Sumatra, East and West Nusa Tenggara, Lampung, and SouthSulawesi.
2.4 The objective of this component was to support coordinated communityhealth activities through common services delivery posts (posyandu). This process wasalready ongoing in some localities. In these areas, village volunteers conducted theabove-mentioned five key programs and were responsible to the village reliance boards(LIKMDs) that are affiliated with the Ministry of Interior. The MOH Directorate ofCommunity Health had begun a policy of encouraging communities to establish commonservice delivery posts, using Family Nutrition Improvement Program child weighing
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posts (UPGK) and family planning VCDCs (Village Contraceptive Distribution Centers)as entry points.I/
2.5 Support for this process was to be provided through the three MOHunits 2/ concerned with community participation; planning, management andsupervision; and communications. In addition, the project would support improvedmanagement (including monitoring and evaluation) by the Directorate-General ofCommunity Health and provide operation support for supplies that might be needed inthe five programs.
2.6 Community Partidpation. The project would support two kinds ofactivities in about 16,500 villages in all 11 provinces: training and orientation of villageleaders in the organization of common service delivery posts and in the purposes of thefive key community health programs; and training of village volunteers in motivationand in the basic technical content and activities of the aforementioned five keyprograms. In addition, this component would support the strengthening the newlyestablished MOH Directorate of Community Participation through provision offellowships, vehicles, technical assistance, travel and subsistence costs (required forprogram implementation and supervision).
2.7 Communications. This subcomponent would provide support to theCenter for Community Health Education for two types of activities: a nationwidepromotional campaign relating to the significance of the five key community healthprograms to the goal of reducing infant and child mortality; and the development ofcommunications materials and messages for the individual programs in support of theircommunity activities. In addition, the project would support the institutionaldevelopment of the recently established Center, through provision of fellowships,technical assistance, vehicles and funds for annual planning workshops.
2.8 Programs Operations Support Funds. The project would provide funds($5 million) for program supplies (equipment, drugs, vaccines, consumable materials,etc. that might be needed at the community health center or below. Unlike the familyplanning and UPGK programs, maternal and child health, immunization and diarrhealdisease control programs had not yet attracted significant resources, owing partly totheir still limited coverage and absorptive capacity.
I/ In 1984, the largely successful pilot UPGK, which focused on comnmunity nutrition educationusing grwth monitoring (weighing) a an entry point, had expanded to about 30,000 villagesin Java and Bali. The rapid expansion of this MOH progrnm had been brought about byattaching UPGK's core package of activities onto the National Family Planning CoordinatingBoard's village contraceptive distribution centers (VCDCs), which had been operating in over30,000 villages. Along with UPGKs ad VCDCs, there was another MOH village healthprogram (PKMD) being pilot in a few hundred villages. In this program, which wa then onlymodestly successful, vilage volunteer wom expec to provide simple preventive and curativeprimary health care service to their respective communities.
2/ Thes refer to the two directortes of Community Participation and Community Health Centersand the Center for Community Health Education.
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Developing Nutrition Surveillance (US$10.3 million, excluding taxes andcontingencies)
2.9 This component would assist the Directorate of Nutrition in implementingtwo elements of its master plan for nutrition surveillance for Repelita IV and beyond.These elements included the replication of timely warning and intervention system(TWIS) and the broadening of the country's nutrition surveillance. The assistance herewould be in the form of technical assistance, consultancies, training, equipment,vehicles and materials, travel and subsistence costs, research/survey costs, honorariaand staff allowances, and funds for acquisition and replication of nutrition books andperiodicals.
2.10 rTmely Warning and Invention System. This subcomponent wouldprovide support for the replication of TWIS, which had been piloted earlier in twodistricts of Lombok and Central Java to avert or mitigate the worst consequences ofshort-term food deficits. TWIS would be expanded to 37 selected districts in 11provinces, after appropriate studies and workshops (to be supported by the project) hadbeen conducted.
2.11 Broadening of Nutrition Surveillace. The project would support thegradual broadening of Indonesia's nutrition surveillance activities to improve its database and information dissemination capacity. Specific activities included: (a) nutritionmonitoring and assessment (covering systematically nutritional status, programs andactivities); (b) nutrition policy and program studies; and (c) nutrition information(specifically, project support for the development of a new nutrition information unitin the Directorate of Nutrition).
Improving Nutrition Manpower Development (US$13.7 million, excluding taxes andcontingencies)
2.12 To alleviate the expected shortage of paramedical nutrition personnel, thisproject component would support the development of 8 (two academies and six schools)out of the 15 paramedical institutions planned under Repelita IV in Aceh, Bali, East,Central and West Java, North and Southeast Sulawesi and West Nusa Tengara. Fundswould be provided for physical development (civil works, equipment, and vehicles) andfor books and teaching aids and materials. In addition, the project would also help IPB(Institute of Agriculture, BogOr) to strengthen existing graduate degree programs,develop a nutrition course for staff of the Ministry of Agriculture, and establish adoctoral program in nutrition. This subcomponent would also provide funds for thephysical development of improved and expanded administrative, classroom andlaboratory space (civil works, equipment, furniture and teaching aids and materials) forIPB's existing bachelor's, master's and proposed doctoral degree programs in nutrition;and computing facilities, training and technical assistance required for the establishmentof a food and nutrition policy analysis unit at IPB.
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3. Project Design and Organization
3.1 The project had a clear conceptual foundation overall and a reasonabledesign, given existing institutional and human resources constraints. The linkcagesbetween project objectives and components were relatively well defined and understoodby relevant parties. On the whole, the project, which had many innovative components,was carefully assessed at appraisal.
3.2 The assumption that underpinned the project was well taken. This wasthat while there were technologically simple community health interventions (familyplanning, maternal and child care, nutrition, imTmunization and diarrhoeal diseasecontrol) to reduce fertility, malnutrition, and mortality (infant, child and maternal),difficulty in access and lack of awareness or appreciation of the value of those serviceshad prevented mothers and children from benefitting from them. A conventionalsolution would have been to strengthen each of these programs separately. What wasinnovative about the project design was to try to improve each of these services in thecontext of a coordinated, community-based delivery system. The hypothesis was thatsuch a system would stimulate use of those services by target mothers and their childrenthan what could be achieved by separate improvements of the above services. Thereason was that a coordinated, community-based approach (implemented through theposyandu) would make it more convenient for mothers to get those services. Demandfor them was expected to increase considerably as posyandu would effectively reducetime cost to mothers.
3.3 This idea was generally understood and shared by relevant policy-makersand implementors. It was also understood that the above strategy to be highly effectivewould require strengthened community participation and ownership; training of kaders(volunteer village workers) and community leaders; coordinated planning, managementand supervision of the five programs; an integrated community healtheducation/communications support strategy; and strengthened program of monitoringand evaluation. Moreover, the project design rightly provided a flexible programoperational support fund in anticipation of possible financial constraints to meet growingdemands for services.
3.4 The nutrition surveillance and nutrition human resource developmentcomponents complemented the above strategy and laid the ground for suswtaining anddeepening Indonesia's nutrition program. At the time of appraisal, there was consensusregarding the need to build the quality of health and nutrition policy formulation,sectoral planning, and program development and evaluation; and the need to increasethe output and availability of qualified nutrition personnel at the paramedical andgraduate levels.
3.5 This project, however, had some design and organizational weaknesses.An example was the Timely Warning and Intervention System (TWIS). While TWISwas a laudable and innovative idea, it was too ambitious, considering the existing database and local analytical and implementation capacity. In this regard, the difficulty ofdeveloping a reasonable set of leading indicators or a relatively accurate forecasting
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model to predict impending food crises in a particular locality was much greater thananticipated. In short, the true complexity and requirements of establishing a workableTWIS was not realistically appraised.
3.6 With respect to overall organization and management,3/ the projectadhered to existing structures and patterns within the individual implementing units.4/This approach was sensible, considering the institutional capacity of local governmentsat the time and the determination of GOI to use existing structures. This adherencecould mean that institutionalization and, hence, sustainability of project activities andideas would be greater. On the other hand, the strategy imposed major limitations onwhat could be achieved efficiently. Because responsibilities under the existing set-upwere usually fragmented and overlapping, many coordination problems had arisenduring project implementation, contributing to delays and duplications as well as failureto fully exploit opportunities for synergistic interactions.5/ These inadequacies werecompounded by another feature of the institutional arrangement-the highly top-downcharacter of project planning, funding channelling and implementation. This feature
3/ The MOH Directorate-General of Community Health was responsible for overall projectcoordination, with individual project implementing departments/units handling specific projectcomponents, as follows:
(a) Directorate General of Community CommunityHealth Health
(b) Directorate of Nutrition Nutrition Surveillance
(c) Center for Education and Training Nutrition Manpowerof Health Personnel (PUSDIKLAT) (paramedical)
(d) Department of Commity Health and Nutrition ManpowerFamily Resources (GMSK), IPB (graduate).
41 Project implementation was under the overall gudance of the Directorate General of CommunityHealth (with the Director Genal as project officer). But, operationally, each department/unitwas responsible for carrying out the project activities within their purview, including theprocuremnnt of civil works, goods and services, project finances (including counterpart fundingand loan reimburements) and project morutoring and progress reporting. Accordingly, projectimplementation officers were designted by each of the above-mentioned departments or unitsand were assisted by full-time or part-time staff responsible for the administrative and technicalaspects of project/component activities and coordination.
S/ For example, there was confusion in terms of development of certain materials between theDirectorate of Community Participation (PSM) and the Center for Community Health Education(PKM). A specific case was their production of two differeat newsletters with the same title(Warta Posyandu). Initially, both were aimed at kaders. (Subsequently, PSM decided to changethe focus of its newsletter for policy makr and progrm magers.) Tho numerousumoordinted sdies wore another example. Coordination of thes studies, timely syntheis of
their findins ad their wider dissemination among the various parties involved in the project (aswell as other relevant agencies) would have had enhanced the quality of their thinking aboutcommunity health and nutrition intervention strategies.
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limited the scope for participation by the community and by local government and madethe project less responsive to local demands and conditions.
3.7 These institutional limitations were recognized at appraisal, and thedesign included certain measures to alleviate them. Some of the measures weresuccessful; others were not. For example, the Project Steering Committee, which wasestablished to ensure appropriate intra- and inter-ministerial coordination, did not meetas required.t/ Another example is the strengthening of the Secretariat of theDirectorate General of Community Health. The project called for the assignment (tothe Secretariat) of at least ten full-time staff who would coordinate and manage allactivities relating to the community health component specifically and liaise with theircounterpart teams in other departments/units responsible for nutrition surveillance andnutrition manpower development components. The failure to fully and immediatelycomply with this measure hampered project coordination, supervision, monitoring anddisbursements. Issues regarding design and organizational factors as they affect qualityof implementation and project effectiveness are further discussed in para 4.47
3.8 Regarding the timing, the project can be evaluated from two perspectives.On the one hand, it can be argued that the project was ill-timed because of theunforeseen emergence of shortages in counterpart funding during the first few years ofproject implementation. GOI had to exercise tight fiscal restraint due to deterioratingmacroeconomic conditions following the decline in oil prices. On the other hand, thetiming was propitious, because as GOI funds for the health sector became less available,the project helped provide much needed funds to protect implementation of high priorityhealth initiatives. Implementation of posyandu and institutional capacity building by thenew directorates of community participation and health education suffered less becauseof the availability of project funds at the time when government budget became verytight. On this point, inclusion of a flexible programs operations support fund in theproject proved to be an excellent strategy.
4. Project Implementation
4.1 The project became effective on February 21, 1986. It started with abaseline study (MOH Integrated Family Health Package) to provide informationnecessary to tailor specific strategies and activities to actual needs. A rmid-term reviewwas undertaken in 1988 by a group of reputable local and international consultants, whoanalyzed the progress and quality of project implementation and gave well-consideredrecommendations for strengthening project effectiveness. In the final year of projectimplementation, some field assessments (albeit, limited) of selected project activities
6/ The Steering Comnmttee compnsed the Director General of Community Health (Chairman), theSecretary General (MOH), the Director General for Communicable Disease Control (MOH), theDeputy Chairman for Social and Cultural Affairs (BAPPENAS), the Vice Rector (IPB), theDirector General of Higher Education (MOEC), and the Director General of InternationalMonetary Affairs (MOF). The Project Steering Committee was expecd to meet quarterly toreview overall project progress, approve plans and budgets for all project components, andresolve any issues affecting project goals and implementation.
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were conducted to find out, to the extent possible, project impact. On December 31,1991 the project was closed, as scheduled.
4.2 Out of the total loan of $ 33.4 million, GOI spent $ 31.81 million.Although about five percent of the loan fund remained unspent, all the activitiesprescribed in the SAR (with some adjustments) were fully carried out (see MOH 1992Achievement Report). There were several reasons for the unspent balance. One wasthe depreciation of the local currency, which made unit costs (in dollar terms) of somemajor activities like construction and training lower than estimated at appraisal.Anoer is the reduction in the unit cost of traning kaders.7/ Further, there was thecancellation of $231,130 due to misprocurement of vehicles. Fially, a year and a halfprior to project closing date, the Bank and GOI decided that it was not worth extendingthe project just to spend the remaiing balance of about $1.5 million, since a newproject on community health and nutrition (CHN Ill was being prepared. CHN mwould be the new vehicle for assisting GOI further in promoting community health.
4.3 The discussion below gives a flavor of the project's "physicalaccomplishments in terms of the type of project assistance provided and in relation totargets, where they had been set. On the whole, it would appear that the physicaltargets have been achieved, in some cases even exceeded. The quality ofimplementation, however, is mixed.
4.4 Component I: Strengthening the Coordination and Manement ofCommunity Health. The implementation strategy for this component was shaped bythe findings of the above-mentioned baseline study (MOH Integrated Health Package)as well as other situation analyses (e.g., the formative study for the communicationssubconponent). To help understand the project's implementation strategy, some ofthose findings are presented below.1/ It was clear that:
(a) Only a limited amount of counselling was taking place at posyandu,particularly related to nutrition, due to poor kader training andsupervision.
(b) Kaders communication tasks needed to be targeted better and simplified.
(c) Puskesmas staff seemed motivated, but many logistical and staffingconstraints existed.
2/ UNICEF was spporting a similar taining prgram with a unit cost tat wa about half of whatthe NCH II inteded to spad. In respom to UNICEF's reques and with Buak's agreennnt,MOH cut the NCH E1 unit cost and mae it the - as UNICEF's.
1/ Although ths fict, _uimd by Richad Polluad (1992), FIa Report: Posyndu PromoiomProjet 1987-1992, Mnoff Group had been pre_nted in rsatio to the drvelopnu.nt of to--omllficatioea abofconat, theyweethen facto d ahdped the plaing of the
odhr -.
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(d) There were not enough active kaders to run posyandu effectively.
(e) Awareness of and trial use of posyandu was high but regular use of fullservices was low.
(f) Mothers had many atttudinal and practical barriers to using posyanduservices.
(g) The potential reach of mass media was about 50 percent; actual reachwas about 30 percent.
(h) Many villagers remained untouched by the program.
4.5 Community Participain. Based on the above situation, the projectprovided the following training in 11 provinces (16,500 villages): 5,622 providers(target: 5600) in commnity participation and Health for All leadership. In addition,32,273 kaders (target: 32,000) were trained in Basic Program (or Acceleration)Training to establish new posyandus (In this connection, 32,273 new posyandus weredicly established.) Escalation Training was then conducted in the eleven provincesand covered 29,810 villages to upgrade the motivation and effectiveness of trainedcomumnity leaders and kader coordinators in community leadership, organization, andresource mobilization. (Trining of kaders in the technical content and activities of thefive basic programs was also included.) Further, the project initated regular village-level meetings (covering 338 subdistricts) that intended to open better communicationbetween provider and kader. lhese activitie were undertaken by MOH's Directorateof Comnmnity Participation in collaboration of Ministry of the Interior's LKMDs(Village Resilience Group) and women's organizations in the conmnunities (PKK).
4.6 The project objectives in ternm of number of kaders trained were met.However, the training was not of high quality, demonstrating the lack of skill intraining at provincial, district and puskesmas levels. The training undertalien by PKKappeared to be of a higher quality.
4.7 Communkations. In tanden with the above training, the Ministry ofHealth's Center for Health Educaton (PKM Pusat) initiated a four-year program topromoted public udlization of posyandu (called te Posyandu Promotion Project). PKMPutat formulaed a te-phased promotion campaign (based on social marketingmethodology) for which it received substanial asistace from an intrnational firmspcializi in social market. Phase I ws launched in mid-1988. It was animage-building campaign, designed to srenghen the image and importance ofpreventive health and the community's sense of ownership of posyandu; to motivate useof posyandu by consumers; and to enhance the importane of providers' work in theirown eyes. The next phase was then lainched in 1989 to "sell each of thde specificsevices (antenmtal care, grwth monitoring, diral disease control, vitamin A, antfamily planing) to the appropriate consumer target group and to motivate heathworkers to provide more reliable and effective services. Finaily, in late 1990 the third
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phase was started. It focused on nutrition education, specifically counselling by kadersafter monitoring growth.
4.8 In this connection, innovative counselling tools were developed andprovided to kaders and posyandus. These included counselling cards to assist kadersand child feeding action sheets given to about half a million mothers. Communityparticipation in these efforts was instituted at various levels, concentrating on workshopsand community meetings for village leaders, school teachers, and religious leaders.Mass media supported this task through messages to strengthen self-ownership.
4.9 Programs Operations Support Fund. Utilization of posyandu criticallydepends on the availability of drugs, measuring instruments (e.g., weighing scales), andother material support needed for delivery of the five basic services. Due to tightbudgetary constraint, many posyandus and kaders did not have those requirements.Consequently, their credibility were being undermined. Accordingly, the project'sprograms operations support fund was used to purchase those commodities (see Table4), including kits for traditional birth attendants and other materials to support safemotherhood. Those commodities were purchased by relevant Central MOH directoratesand distributed to the provinces, districts and puskesmas in a top-down manner.
4.10 Planning, Management, and Supervision. The implementation recordhere was mixed. The project provided brief training on planning and management to18,362 persons from central (44) , provincial (1,870), and district (16,448) levels.Training of Puskesmas staff in community health assessment and planning through' Mmini lokakarya" (staff planning workshops), micro-planning, and stratification atpuskesmas level was undertaken in designated areas, in accordance with the SAR. Theassessment of microplanning was also undertaken, as agreed upon.
4.11 All puskesmas had developed their plans and have been regularlyconducting their "mini lokakarya". But the usefulness of these plans has been limited;and intersectoral coordination, which was a key tactical objective, was difficult toimplement. Although Puskesmas staff knew the principles of planning, they did not andstill do not have the incentive to make realistic plans. Hence, in many places, planningis merely a mechanical exercise. Aside from not knowing their budget, they do nothave discretionary power to allocate resources according to their plans: what getscarried out are the priorities set at the top. This approach is being converted to bottom-up planning and implementation under the ongoing Third Health (FY89) and the ThirdCommunity health and Nutrition Project which was approved by the ExecutiveDirectors in December 1992.
4.12 As called for in the SAR, annal supervision schedules had been preparedand supervision manuals/guidelines had been developed and produced. Field visitsrevealed that the intended beneficiaries in the provinces, districts and puskesmas hadreceived those guidelines. However, these were not used, generally. Beneficiariesfound them too complex and not responsive to their needs. Again, the problem isrooted in the top-down nature of the assistance. Finally, supervision plans submittedto the Bank were not fully carried out most of the time, essentially because of lack of
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government funds and a general government policy minimizing supervisory visits to theprovinces and below. This policy had been introduced as part of government fiscaltightening due to the deterioration in the macroeconomic environment.
4.13 Maternal and Child Health (MCH). One of the recommendations ofthe Mid-term Review was greater emphasis on safe motherhood and MCH services.The project adopted this recommendation and made the Directorate of Family Healthresponsible for NCH 1I activities on MCH. This subcomponent trained midwives (in1890 health centers) and supported 1,714 health centers for training kaders on motherawareness. Training of nurses on antenatal care was also provided for 3,859 healthcenters nurses. The project also supported the training of 13,510 Traditional BirthAttendants (TBA). Field visits revealed that training TBAs and providing them withTBA kits was an effective way to promote safe motherhood by health professionals andby the TBAs themselves.
4.14 Component II: Developing Nutrition Surveillance. The plan was forthe project to support feasibility studies for selecting 37 districts in 11 provinces whereTWIS could be implemented. Implementation was relatively rapid: 32 districts in 9provinces were completed after the second year of the project. Consequently,additional districts and provinces were included. Ultimately, these feasibility studieswere undertaken in 24 provinces over five years. As a result, to date, 55 districts in13 provinces started implementation of TWIS. It is clear, however, that the use ofTWIS as a tool of district government to provide timely warning and intervention infood crisis situation is still minimal.
4.15 The rapid expansion of TWIS coverage, its inherent complexity and poorcoordination 2/ have resulted in poor quality of implementation. In this regard, arecent assessment commissioned by GOI with Bank and UNICEF support has reachedthe following conclusion: "TWIS does not appear to be achieving its original objectivesin many, if not most, of the areas in which it has been established. This would appearto be due to lack of specificity in the feasibility studies and in the indicators being usedand changes which may have occurred in the food system since the introduction ofTWIS. At best it provides monitoring of current consumption patterns." p.8 .101
4.16 With regard to the other subcomponents, the project provided support (inthe form of technical assistance, training, travel and subsistence costs and honoraria)for the implementation of the operational research projects/surveys planned in the SAR.Included here, inter alia, was support of the evaluation and improvement of UPGK'sgrowth monitoring system (SKDN) and the development of nutrition indicators and theirinclusion in the SUSENAS (a national socioeconomic survey) in 1986, 1987, and 1989.
9/ The Directorate of Nutritionwas responsible for the implementation and operation of TWIS withtechnical and research support from Bogor Agricultural Institute (IPB)-assisted by Cornell-andthe Center for Research and Development of Nutrition (CRDN).
10/ Heywood P. and Gunnawan S. Assessment of the Indonesian Nutrition Program, October 1990.
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Moreover, nutrition policy and program studies had been conducted, much of whichwere used for the formulation of Repelita V 's nutrition policies and programs.
4.17 Nutrition Personnel Development. Five academies of nutrition andthree assistant nutritionist schools were constructed. Three more academies (and threeless assistant nutritionist schools) were built than originally planned to accommodategovernment's policy to upgrade the status of the Assistant Nutritionist Schools (Diploma1) in Semarang, Bandung and Medan to Academy of Nutrition (Diploma III).Il/ Inaddition to civil works, the project provided support for laboratory equipment, booksand other facilities as well as technical assistance in curriculum and staff development.All of these institutions are now operational.
4.18 Under this component, training of Nutrition Program Implementors(TPG) was also undertaken to address the shortage of nutrition workers in healthcenters. This activity was carried out in collaboration with UNICEF, who providedresources for the development of the trahiing curriculum and modules. In this regard,the project had trained 1,158 middle level nutrition workers and another 219 personsfrom district (165) and provincial (54) offices.
4.19 To address the dearth of qualified and experienced senior nutritionprofessionals, the project assisted IPB develop its teaching, research and public servicecapacity. Construction of a new 3-story GMSK building (5,980 sq. meters) wascompleted in Jamnary 1989. Laboratory equipment, furniture, books and educationalmaterials had been procured. In addition, NCH II provided consultant services,including reputable overseas consultants, to assist IPB in developing its curriculum,research facilities and strategies, and staff. Only about half of the budget for overseasconsultants, however, was used, diluting technical assistance, which IPB badly needed.Finally, seven overseas fellowships were funded (two for doctoral and five for masterof science degrees). Two of the latter had completed their studies, while one is nowenrolled in a doctoral program. Short-term overseas fellowships were also provided tofive persons.
4.20 With respect to local fellowships, NCH II supported two fellows whowere expected to get their doctoral (S3) degrees last year. In addition, 21 graduatestudents were given fellowships at GMSK IPB. Of these, seven had gotten theirmaster's degree, while others were still doing research as of November 1991.Furthermore, 41 undergraduate students of GMSK received assistance of which 21 hadcompleted their studies, also as of last year.
4.21 Besides the development of GMSK Department, NCH 1I supported thedevelopment of the Food and Nutrition Policy Analysis Unit, which since 1989 hasbecome Food and Nutrition Policy Studies Center. In this connection, IPB had
Il/ Funding of the school planned for Matamm was shifted to Medan, sinco the former came unhnird Health Project
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completed its studies regarding TWIS. Those studies, however, do not appear adequateyet.
4.22 To round out the discussion on human resource development, it isimportant to note that the project had supported a total of about 500 fellows from allcomponents. These fellows will be an important source of trained personnel in nutritionand community health. Of these, about 100 were overseas fellowships of whichroughly 40% were enrolled in doctoral and master's degree programs. Of about 400recipients of local fellowships, 44 did graduate studies. Except for a few, recipientsof overseas fellowships had returned to Indonesia.
5. Project Results
5.1 The above discusion above presents an input-oriented assessment of theprojct and the quality of its design and implmentation. In the final analysis, however,the key question is how effective the project has been in achieving its health andnutrition objectives. The following discussion addresses this difficult question, to theextent possible.
5.2 A definitive answer to the above question is not available. However,there are intermediate health indicators that are worth presenting. A survey of 360villages and 4,000 households in four provinces was conducted in early 1991 by theBureau of Statistics in West Sumatra, Central Java, NTB and South Sulawesi. Takentogether, these provinces could be deemed as roughly representative of the areascovered by the project. One kader and 100 mothers were interviewed in each village.
5.3 The survey data indicate the following changes in the number ofposyandu and service coverage between 1986 and 1991: 12/
(a) The number of posyandu in eleven covered provinces increased from89,000 to 172,577, which is equivalent to 75 percent of the e.z-.umatednumber (by MOH norm) needed for 100 children to be served by aposyandu. Over 70 percent of total reported posyandu v ere operatingin April 1991.
(b) The number of mothers who ever heard of posyandu increased from 78percent to 95 percent.
(c) The number of mothers who had ever been to a posyandu increased from66 percent to 80 percent.
(d) The percentage 'of mothers' youngest children who had ever beenweighed rose to 77 percent from probably about 41 percent. About77 percent of mothers claimed to have a growth chart for their youngest
JW For morm deails, we Rchard Pollard (1992) gRi&1
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child, although a little over half of them had not weighed their childrenevery month. (In 1991, the percentage weighed in the last month was51 percent.)
(e) Immunization coverage appeared to have increased significantly as shownby the following data:
Coverage Rate (%) La % at Posyandu
1986 1991 1986 1991
DPT1 (diphtheria, 47 96 30 70polio, tetanus)Polio 3 30 87 51 72Measles 71 67Tetanus 47 49 21 32
La For DPT1, polio and measles, coverage is defined as the percentageof mothers' youngest children immunized. For tetanus, the referenceis to pregnant mothers.
(f) It would appear that the percentage of immunizations done at posyanduhad increased to substantial proportions. Interestingly, over 70 percentof mothers said they had received education about immunization atposyandu.
Analysis of survey data also showed the following findings, which are directly relatedto the project's communications efforts:
(g) Some 55 percent of target mothers heard program messages over radioand 54 percent over television; while 62 percent were counseled directlyby kaders.
(h) Some 55 percent of mothers received nutrition education at posyandu.(This was given mainly by health center staff rather than kaders.)
(i) Roughly 66 percent of existing posyandu received promotional andcounselling materials. (Program target was 100,000 posyandu.)
(j) Roughly half a million mothers received child feeding action sheets, with80 percent of them claiming that they had changed their child feedingpractices (primarily, by increasing feeding frequency) as a result of theinformation.
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(k) Posyandus have a high trial use of 95 percent (as measured by thepercentage of families who ever used them), with 51 percent availingthemselves of aU posyandu services.
(1) Finally, there is now a strong sense of ownership of posyandu in theminds of villagers, although mitdgated by an attitude that theresponsibility for supply rests with the health center.
5.4 Conditions clearly changed considerably, in comparison to the situationin 1986, as described earlier. To what extent these changes were due to the project isdifficult to firmly establish. Neverhekss, the survey data show that 92 percent ofpuskesmas staff felt that the posyandu promotion activity had helped kaderscommunicate with mothers. Of those staff, close to half said that the kaders werehelped a lot. Further, 67 percent of puskesmas staff felt that promotional activities hadhelped a lot in getting mothers to come to posyandu-with another 32 percent sayingit helped somewhaL Finally, 90 percent of mothers claimed that the services atposyandu were beneficial.
5.5 Field visits and intern with intended beneficiaries during finalsupervision missions confirmed the above findings. In general, intended beneficiariesreported that they had received the assistance provided by NCH II and that, on thewhole, they found them useful.
5.6 Some of the benefits from cerain project activities, however, were quitelimited. For example, while the project had contributed significantly to thedevelopment of staff capacity in micro-planning, the benefit from this increased capacityhas been limited by the lack of incentive to formulate realistic plans. Such benefits willcontinue to be limited until institutional changes are brought out giving puskesmas staffa certain degree of discretionary authority over resource allocation decisions.
5.7 With respect to nutrition surveillance, the results are mixed. Forexample, on the one hand, one can definitely argue that the impact of TWIS and thebenefits from it are minimal. On the other hand, improving the SKDN (growthmonitoring system for children aged 0-5) is probably of considerable value. Theimproved SKDN system has been firmly established and used for targeting priorityproblems and focusing community action on the problem of malnutrition amongchildren.
6 Project SsWtnability
6.1 Many of the beneficial effecs of the project appear to be sustainable.GOI and the Bank have taken steps to ensure that the accomplishments achieved underNCH 11 are carried forward. However, there are cridcal constraints that must berecognized to avoid unrelistic expectatons. There are also risks that need to be dealtwith in the long-run, if those benefits are to be fully realized.
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6.2 To sustain the progress that has been achieved, it is important to addressthe following critical issues:
(a) Continued improvement in the posyandu system lies in the capacity ofhealth centers to supply consistent, integrated service to all posyandu,including provision of adequate supplies, vaccinators, and midwives.This is important to further enhance and maintain the credibility ofposyandu.
(b) The high kader drop out rate requires substantial resources to fundcontinuous training activities for replacement and new kaders, while atthe same time condtuing the upgrading of old kaders to further reducemothers' lack of confidence in them. In this regard and for reasonsspelled out in (c) below, it is highly probable that under the current set-up the posyandu could get stuck at an equilibrium level (in terms ofquality and/or coverage) that is lower than expected, given MOH targets.
(c) GOI needs to review the necessity of developing some practical, cost-effective incentives for kaders, while keeping "internal" motivationstrong. Indications, however, are that so-called moral incentives couldno longer be solely relied upon. Unless this and the preceding issues areeffectively addressed, the future role of posyandu, though at presentconsiderable, would be limited. Three factors must be considered here.First, as employment opportunities and wages continue to rise withsustained economic growth, the opportunity cost of voluntary work isalso expected to rise. This evolving situation would make it moredifficult to keep old kaders and recruit new ones, especially if they areexpected to produce at higher levels of competence and performance.Second, rising incomes could have a negative effect on the utilization ofposyandu services, if mothers see them as inferior. Third, althoughproviding incentives costs money, it could also save resources byreducing the cost of training replacement kaders.
(d) The need for central and provincial capacity to regularly produce freshcounselling, promotional and health education materials is also crucial.Field visits revealed that many of these materials, although initiallyeffective, quickly lost their usefulness, as mothers became bored whenkaders kept regurgitating the same materials.
(e) Some institutional issues would have to be addressed. In this regard,some form of decentralization is necessary to allow communities, theirpuskesmas and their local governments to participate more fully in healthplanning and resource allocation. Changes in this area are important tomake Central govermment allocation and assistance more responsive theirpriorities. Unless some form of financial decentralization occurs in thenear future, the capacity for micro-planning would be wasted for reasonsmentioned above. Within the context of a more decentralized
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institutional arrangements, it is also important to address theresponsibility of PKM Pusat relative to the activities of other officesinvolved in nutrition and community health programs. A recentassessment of the situation revealed that these offices do not make useof the PKM Pusat (Center for Health Education) institutional services,despite the fact that they have asked for help from particular staffmembers of PKM Pusat. Institutionally, PKM Pusat had not been givenmuch opportunity recently to use their newly acquired capacity and buildit further through the process of learning by doing. It appears that otherprograms and directorates prefer to develop their owncommunication/health education programs themselves. The risk here isthat the embryonic capacity of PKM Pusat to develop and implement apromotional campaign based on social marketing methodology may bedissipating.
(f) The task of building IPB as a first-class institution capable of running asolid graduate program and research on family health and communitymntrition remains a challenge. IPB must continue to send fellows abroadfor graduate work to strengthen further itS faculty. IPB's developmentcould benefit from continued interaction with first-rate visitingresearchers and professors. Moreover, IPB would need more Ph.Ds inits staff to develop a strong doctoral program, which GOI hopes toestablish soon. This is also important for building a research capacityhat would be adequate for producing credible public policy studies.
6.3 On the positive side, there are several factors that would favor sustainedimplementation of the various initiatives supported by NCH II. One is the strongintersectoral consensus among Indonesian policy-makers (including the President) thatthe posyandu strategy and other MCH initiatives based on community ownership andparticipation is the correct approach to sustainable delivery of basic health services.Second, in fact, there is now a strong sense of community ownership of posyandu andacceptance by the communities of the responsibility of delivering the posyandu's fivebasic family services, as well as a positive perception by mothers that posyanduprovides beneficial services. Third, with regard to MCH activities, MOH andprovincial health offices have also developed a strong sense of ownership of safemotherhood initiatives supported by NCH II. In this connection, observations duringfield visits indicated a strong social demand for early detection of high risk pregnanciesand for trained traditional birth attendants with TBA kits among pregnant women withlittle access to modem health practitioners. Fourth, economic growth and continuedreduction in poverty throughout Indonesia are expected to enable many morecommunities to shoulder a greater percentage share of the cost of community healthservices over time. They will, however, need continued support from higher levels.In this regard, fifth, with improving public finance, capacity will be greater for GOIto fund puskesmas and higher level health bureaucracies to: (a) provide more effectivesupport (both material and technical assistance) and supervision of posyandu and othercommunity health initiatives and (b) support continued development of community-oriented nutrition and health manpower. On this manpower development goal,
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commitment from top government officials is quite strong. Finally, although theyremain in need of further strengthening, government staff at the center and localgovernment levels now have a relatively stronger manpower and institudonal capacityon which to build more ambitious and more decentralized community health andnutridon projects (compared to five years ago).
6.4 Government, with Bank assistance, is dealing with many of the aboveissues in a number of ways. Foremost of these is the Community Health and Nutrition(CHN III), which has recently been approved by the Board. Building on thecontributions of NCH II and using its now expeienced secriat, this project will pushfurther the idea of community participation and move improvements of commnityhealth and nutridon in new directions. In particular, the project would build provincialand kabupaten capacity to plan, implement and evoaluate Safe Motherhood, ChildSurvival and Nutrition interventions, as well as strengthen the capacity of the centralMOH, primarily the Directorate General for Community Health, to support provincialefforts. In addition, there is the ongoing Third Health Project, whose "experimentalm
institudonal innovations have begun to create a more conducive atmosphere for thedevelopment of a decentralized and integrated health planning and budgeting. It shouldalso be noted that GOI with Bank assistance is now in the process of reforming theSUSENAS to further improve inter alla health and utrition data and analysis ofpoverty-related issues. One direction that this initative would take is makingSUSENAS data representative at the district level, which would advance the innovationpioneered by NCH II, which supported the development and collection of nutridonindicators as part of the 1986, 1987, and 1989 SUSENAS surveys.
7 Borrower's Performance
7.1 GOI's performance has been satisfatory on the whole. Despite problemsduring the first few years of implementation of NCH II, government completed theproject on time. GOI's ownership of the project and its comnitment to its successfulimplementation was quite high. Its vision of posyandu was commendable and itsstrategy of community participation was pioneering. With some exception, GOI hascomplied, on the whole, with the loan covenants and implemented the activities asspelled out in the SAR. And where adjustments had to be made, they were carried outwith Bank agreement.
7.2 The quality of its perfonnance, however, particularly with respect tosupervision could have been better, if government effort were not spread too thinly over11 provinces (or more in some intances) and If the first few years of projectimplementation were smoother. Implmentation of the project during the first threeyears had a number of problems. FIrst, there was lack of familiar with procedures,standards, and timing relting to implmentation of Bank-funded projects. Second,some of the measures caLed for in the SAR to facilitate implmentation and ensurecoordination did not work or were not fully carried out. For example, te SteeringCommittee was disconinued due to the busy scheduls of echelon I officials. Hence,strong intersectoral coordination suffered. Anodter example is the appointment of a
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liaison officer in every province. The arrangement was terminated after two years,because it was not effective.
7.3 Further, although GOI had complied with annual submission of itssupervision plans, it could not implement them well for various reasons. ProjectSecretariat in the early years could not carry out its assigned roles very well, not onlybecause of staff's lack of familiarity with implementation procedures for Bank-fundedprojects, but also because of GOI's failure to fully and expeditiously implement thestaffimg of Project Secretariat as envisioned in the SAR. Moreover, the Secretariat didnot have its own DIP budget during the first two years; and the funds made availableto it was inadequate to support effective supervision. For these reasons and theshortages in counterpart funds due to the deterioration in the macroeconomicenvironment, project performance suffered. This is reflected in low actualdisbursement rate compared to planned levels (see Table 3).
7.4 Considering the above problems, the timely completion of the projectcould justly be considered a noteworthy achievement, especially when compared toother projects in Indonesia. Several reasons would account for this achievement. Onewas the strengthening of the project secretariat following the recommendations of theMid-term Review. In this regard, GOI improved the staffing of the Secretariat andgave it adequate (and separate) DIP budget to improve its supervision and coordinationfunctions. Another reason was the setting up of a better working relationship betweenthe Project Secretariat and TUA (Budget Administration) of the Ministry of Finance.For a good part of project implementation, disbursement had seriously lagged behindactual expenditures, mainly because of documentation problems. To speed updisbursement, regular monthly meetings were held between TUA and project staff tofacilitate preparation and documentation of applications for disbursement. Yet anotherimportant factor was the availability of counterpart funds as the economy and thegovernment financial situation began to improve during the late eighties.
8 Bank Performance
8.1 The choice of project objectives and components was the main strengthof Bank's performance. The objectives represented high priority concerns of GOI.Malnutrition and mortality among infants, children, and mothers were (and remain)clearly shared objectives between GOI and the Bank. GOI's support for variouscomponents, particularly Component I, was appropriate. And, the linkge betweenproject activities and objectives was clear overall.
8.2 Formal and informal Bank supervision missions were carried out at leasttwice a year. In supervising project implementation, the Bank exercised flexibility anda problem-solving approach. On average, the number of staff weeks devoted tosupervision of NCH II was about 18 per year.
8.3 Bank's performance, however, suffered from the following weaknesses.Its agreement to GOI's choice of scale was at the expense of quality. The scale ofactivities and the coverage of 11 provinces (ater expanded to 15 in some cases) were
- 20 -
too large, making normal Bank (and GOI) supervision effort inadequate and diluting theeffectiveness of training and other interventions. A related point is that the TWISsubcomponent could have been appraised more realistically and, with regard to itsimplementation, control of the quality and the number of TWIS feasibility studies couldhave been tighter, limiting the coverage to fewer areas Drawing upon these lessons,the scope of subsequent health/nutrition subsector projects was limited to fewer area.Drawing upon these lessons, the scope of subsequent health/nutrition subsector projectswas limited to fewer provinces - Third Health Project (FY89) is being implemented intwo provinces and the Community Health and Nutrition III Project (FY93) will coveronly five provinces.
8.4 These weaknesses were compounded by the fact that during the earlystages of project implementation, the Bank failed to provide effective assistance toProject Secretariat and other relevant staff in familiarizing themselves with proceduresand standards regarding Bank-assisted projects. Frequent changes in task managersmade Bank supervision less effective due to lack of continuity.
9 Project Relationships
9.1 As mentioned above, the Bank took a flexible, problem-solving approachto supervision. It numntained good relationships with the Ministry of Health,BAPPENAS, and other government agencies responsible for project implementation.Moreover, relations with other donors involved in the development of community healthand nutrition in Indonesia (particularly UNICEF and WHO) were also satisfactory.
10 Cosultng Services
10.1 Foreign and domestic consulting services had a substantial role in variousaspects of the project. The foreign consultants carried out various studies (particularly,on nutrition-related issues) and assisted in developing inter alia the communicationscomponent (including its evaluation), TWIS, and the IPB graduate program. The Mid-term Review was undertaken by a group of foreign and local consultants, headed by alocal health expert. On the whole, the foreign consultants, who generally had excellentintemational reputation, were quite helpful. The consulting services for TWIS,however, was of doubtful value.
10.2 The project found local consultant services to be very useful in manyinstances. However, many domestic consultants did not complete their studies atexpected schedule and level of quality.
11 Project Docmentation and Data
11.1 Legal agreements were appropriate. Amendments to these agreements,where they were required to accommodate reasonable changes, had been properlydocumented.
- 21 -
11.2 The Staff Appraisal Report had provided the Bank and GOI a satisfactoryframework during project implementation. Project data relevant to the preparation ofthis PCR are readily available at the Ministry of Health.
12 Lesons Learned
12.1 There are several lessons that are worth highlighting here. These couldbe summnrized as follows:
(a) The most important lesson is that posyandu works to a considerableextent, and that it could be made to work even better. Five mainelements underpin the relatively successful posyandu strategy forimproving community nutridon and family health: (i) choice of effectivebut underutilized interventions with high potential demand and simpletechnological and delivery requirements; (ii) coordinated delivery ofthose interventions, making them available simultaneously at predictabletimes (e.g., once a month) and at easily accessible places in thecommunity; (iii) a strong sense of community ownership andcommitment to support posyandu operations and ensure theireffectiveness through vigorous community pardcipation (e.g.,contribution of volunteer labor and other resources); (iv) a broad nationalconsensus, from the President Ia/ down to the community; and (v)promotion based on social marketing methodology.
(b) The posyandu, however, is not a panacea: There are serious limitationsto what the posyandu system can deliver (as discussed above). Some ofhese limitations can be overcome; others can be dealt with only throughmore difficult structural changes. These involved inter alla a re-definition of the posyandu concept and the role of the health centers andsub-centers.
(c) Implementation of a workable Timely Warning and Intervention System(TWIS) is quite complex and its apparent conceptual simplicity can bemisleading. Underestimation of its complexity and implementationrequirements relative to existing capacity had led to critical mistakes inplanning the number of districts to be studied, in choosing thequalifications of those who conducted and supervised the feasibilitysudies, and in the speed with which implementation of TWIS was beingexpanded, going even beyond the already ambitious original plan.
(d) Successful economic development could overtake in a relatively shortperiod of dme the relevance of certain project activities. For example,TWIS is an idea whose relevance in Indonesia has been diminished
j/ In Novembr 1986, on the National Health Day, Prsidton Suharto declared a policy ofacce_emto of posyanda tmrghout the country.
- 22 -
considerably, as local food crises have become much less frequent(compared to the mid-eighties or earlier) as a consequence of vigorousdevelopments in agriculture, trade and infrastructure. There is thereforea serious question as to the value of TWIS in Indonesia today.
(e) The value of training puskesmas staff in planning can be quite high; butits benefits can be fully realized only if key decentralization issues areeffectively addressed. The current assignment of bureaucratic powersand responsibilities, which is predominantly top-down, do not give thepuskesmas heads meaningful resource allocation authority. Thus, while,puskesmas doctors appreciated their training in micro-planning, there wasno incentive for health centers to make realistic plans, as observedduring field visits and the Mid-term Review. (Some, in fact, felt thatmicro-planning was a futile exercise.) Still, as government tries toresolve the difficult issue of decentralization over the coming years, themicro-planning experience in conjunction with lessons from the ThirdHealth (FY89) and CHN III (FY93) Projects could prove to be importantin the long-run.
(f) Project successes and failures in health/nutrition subsectors appear todepend on the following design and organization factors:
(i) choice of components based on realistic appraisal of technicaldoability, implementation requirements, and behavioral soundness(particularly regarding issues of demand; community ownership,participation and commitment; and national consensus). In thisregard, Component I was more successful than TWIS, becausethe former was responsive to the above issues much better thanthe latter. Potential demand forposyandu services was high; thenational political commitment for it was solid; and, equallyimportant, community ownership and participation permeated thewhole idea of Component I (see para * above). Moreover, theappraisal of Component I regarding its potential andimplementation requirements was relatively more realistic.
(ii) involvement of all existing, relevant bureaucracies in theproject, despite the risk of duplications and overlapping activities,has increased their understanding of project objectives andstrengthened their interest, to do those activities assigned to them,instead of choosing to be apathetic and uncooperative. The poorperformance of the TWIS subcomponent was partly traceable tothis factor.
(iii) scale of the project: The quality of implmentation andeffectiveness of various project activities suffered becaue of thevast expanse of the area covered by the project and the magnitudeof the number of persons that had to be trained by a relative
- 23 -
small cadre of experienced and knowledgeable trainers. Limitedsupervision resources were spread too thinly and the effectivensof training activities was diluted.
(iv) drive and capacity of the Project Secretariat to coordinate Ndsupervise activities planned and carried out by the variousresponsible agencies. After seriously lagging behind about twoyears, project completion was put back on schedule, as a suroProject Secretariat started to emerge after the mid-term review.
(v) flexibility: The availability of a flexible program operationsupport fund was an excellent strategy. It proved propit nthe project was able to fund (within the scope of its objetves)high priority purchases and activities that would not have booecarried out because of shortages of GOI funds arising fommacroeconomic adjustments. Further, the support &nd enabledthe project to respond positively to the recommendation of tbeMid-term Review to give greater emphasis to ahmotherhood/MCH than originally contemplated. Anothrexample of the importance of flexibility relates to the fimding ofsupervision. In light of the above-mentioned funding shortaes,the Bank agreed to a 100 percent financing of GOI supervisionexpenses, to improved the supervision effectiveness.
(vi) the indusion of a mid-term review in the design of dXproject. The review gave responsible agencies a sense ofaccountability; equally important, it provided good advice on howto improve the quality of project implementation and adjutplanned expenditures in light of project experience and thechanged economic environment.
-24-
PART II. BORROWER'S VIEW
1. DESCRtPTrON OP THE PROJECT
Name of the Project: Second NuLrLi.ton andl Commujnity HealLh,Number of Loan : 2636-IND, IBRDDate of Agrcement : December 19, 1985Efrective date : February 2, 1986Closing dale : December 31, 1991Total Original Loan: US $ 33,400,000.00Not Loan Amoount : US $ 33,168,875.00
The budget allocation by category had been amanded dated
April 4, 1990 and October 10, 1991l. The reallocation budget
by category are as follows (in US $)
Calegory Original Loan Amanded Loan Amanded LoanApril 4, 1990 Oct 10, 1991
…________ -------------- ------------- ------------
1. Civil Work 6,175,000.00 2,997,000.00 3,500,000.002. Equipment
Furniturc,Books,Naterial s 3,135,000.00 6j300,000.00 6,000,000.00
3. Equipment andMaterials for 4,750,000.00 8,370,875.00 * 9,118,875.00Part A.5
4. Consultant andFellowship 6,840,000.00 6,695,000.00 5,650,000.00
5. Training 9,120, 000.00 5,096,000.00 5,750,000.00
* Cencelled 231,125.00…___________ ------------- ________ ----
Total 33,400,000.00 33,400,000.00 33,168,875.00
The composition of the project:
(A). Strengthening the Coordination and Management of
Community Ilealth, namely Component I.
(i) Strengthening commtunity participation through
training of five basic program in the service dclivery
-25-poasl, (posyaeidiu) in organization and motivation for
cadres (about 16,500 villages in 11 provinces), and
assisting the institutional developmenL of the
Directorate of Community Participation.
The responsible unit for the impletmentation is
Dircotoratc of Community rartioipotion
(ii) Improving planning, management and si4pervision
throtugh assisting Lhe t.he development of a systematic
healtlh planning process; develop broad commitment to the
coordinated health services delivery approach among
community leaders at all administrative levels; and
strengthening supervision and monitoring all levels,
including determination of the indicators of program
progress. and almo to compleLe the introduction of the
microplanning process in 3 provinces (North Sumatera,
South Sumatera, and Lampung).
The responsible unit for the implemerntation is
Directorate of Health Center Development
(iii) Improving communications through developing and
implementing a nationwide campaign relating Lo Lhe
coordinating health programs; developing azid producing
nmed ia for the individual health and nuLrition programs
in support of Lhe community activities; developing
instructional malerial and Lraining of kader trainers;
assisLing the institutional development of the
recenLly-established Center for Community Health
Education.
The r.spon;inhl tinit for tho. implementation i9 Center
for EHcalth Education
(iv) Strengthening the planning, managerial and
coordination capacity of the Community Health
-26-Secretariat.
Thc rceponsthle uniL for Lhe imnlementation i; Project
Secretariat
(v) rroviding operations support funds for progrAm
supplies as ncedcd for serviccs delivery at the
community health centers or below. The operations
support funds was allocated for the provision of
equtipment, drugs, vaccine, consumable materials etc.
The program supplies were to support the program of MCH,
Immunization, diarrhoeal disease control, family
nutrition improvement and family planning.
The implementation unit of operntions support fund are
Component I, ComponenL II and Directorutc General of
Communicable Disease Control and Environmental Health
(5). Developing Nutrition Surveillance namcly Component II.
(i) SLrengthening and extending the timely warning and
intervention systcm (TWIS) to about 37 districs in up to
11 provinces through : carrying out feasibility studies
to determine the districts for TWIS exparnsion and
national TWIS support unit and establishing province and
districts level TWIS teams.
(ii) Strengthening nutrition monitoring and assesment
throuSh support for the implementation of five
operational research surveys.
(iit) Supporting nutrition policy and program studies in
four priority areas to assist in naLional and local
policy formulation and program development.
(iv) strengthening the nutrition information unit in the
Directorate of Nutrition.
-27-The rcsponsiblc unlit for the implementation is
Directorate of Community Nutrition
(C). Improving Nutrition Manpdwer Development namely
Component III.
{i) StrengLheni.rg paramedi.cal nukLrition manpower
development through establishing two ac.ademic% and aix
assistant nutritionisL schoolo I; helping improving
educational quality at paramedical nutrition insLitution
Thc responsiblc unit for thc implementation is Center
for EducaLion and Training Health Personriel as Component
IrIA
(it) Strengthening of graduate nutrition manpower
devclopmcnt through physical dcevelopment of the IPE's
facilities for cxisting dcgrcc programs in nutrition;
development a nutrition coursc for staff of Ministry of
Agriculture; and establishing a food and nutrition
policy analysis unit.
The r,eponsible unit for the implenernLation is Community
Nutrition and Family Resources Institute of Agriculture
as Componcnt III3
Based on thc Midterm review done by DR.Ale. Papilaya, it was
recommended to include MCII training for midwives and HealLh
Centre nurses, to improve the MCH program aL Health Centre
level . Started in FY. 1989/1990 the Directorate of Family
Health is included as onc of the subcomponent in the NCH-Ir
Project . The activities of this subcomponent were training
for midwives and health center nurses, cadre, TBA. and
provided the supporting facilities for improving MCH program.
-28-2. GENERAL CONCLUSION OF TIIE AChIEVEMENT
As a whole the Project has achievcd about one hundred
percent of the target. In some categories had been Achieved
more than the targeL such as Lraining , and in country
fellowships.
The Larget for equipmenLt is not clearly stated in the Sttff
Appraisal Report, so the achivement could not be compared by
the target.
The LoLal disbursement an of October, 1992 is US $ 31,807,973
or 95.9 % out of net the net loan.
DisbursementL by caLegory are as follows (in US $)
Category Aianded Loan Disbursement
Oct 10, 1991 Oct, 1992
1. Civil Work 3,500,000.00 3,499,148.43
2. Equipment
Furniture,Books,
Materials 6,000,000.00 5,840,967.70
3. Equipment and
MKtterials for 9,118,875.00 8,811,401.22
Part A.5
4. Consultant and
Fellowship 5,650,000.00 5,272,886.87
5. Training 5,750,000.00 5,377,701.05
6. Studics 3,150,000.00 3,005,697.52
Fund 171.11
Total 33,168,875.00 31,807,973.90
-29-
Tbc remaining revolving fund amounting IJS $ 52,329.86 liftn been
repatd by GOI in September 1992.
The evaluation of thc implementaLion of Lhe projcct by sub
component arc as follows.
1. Sub Component Community Participation
a. Training.
All of training for Community had bccn carried out by all
Provinces based on the guidancc book. Generally trairning were
stated as contributed usefullness to the community.
The escalation training to improve ..the capabiliLy of caders
was very userull. It is showed by improvement of Posyandu's
acLivities increasinig the cuve.age ur oLildrvwi ui±iiw±r'viw,
pregnant mother, and the community health fund.
b. Equiipment and materials.
The materials and equipment provided by Directorate of
Coummunity Participation received by Health Ccntre, and Health
Centre distributed to Posyandu.
At Posyandu could find guidance books for cader, and cader
kit. Not all cadcr got cader kit due the lack of budgeL. The
cadcr kit made the cader focling so proudly and exited to do
their job.
c. Fellowship
Most of staff. who are sponsored to have continuing edtucation
and training cither overseas or incountry, stlll being
utilized to deal with Community Participation program. However
some of them could not be utilized appropriately because of
muLaLion and moved to other city
-30-2. Sub component Hcalt.h Cenl.re Development.
a. Eqiaipmenl..
Most of the health centre had reccived paramcdic kit and
man.uals utskQsmav, Generel.ly, A11 nf thAt. equipment are very
usefull to sutpport health centre activities. IL scems that the
manual Puskesmas could guide the health cenl.re staff to do the
better job and improve the quality of services.
The liealth cenLc-e who reccivcd thc special equipment. such as
cold chain stated that it is very usefull.
By the time the data collection fulfilled, the mannual for
supervision (mannual supervisi) had not sent yet by Lhe
Directorate of IIcalth Ccntcr DcvcJlopmcnt.
Iowever, thcy uscd the similar manual which was published
years before.
b. Training.
All of training activities had bccn carried out.
In general, that the training was fclt vcry usefull.
.However noL all of the tr ainees still being utilized to
perL'orme the programme, because of movement to other job.
c. Fellowship
All or sLafr who were attended Liaining or continuing
education either overseas or incountry still beirng uLilized to
deal which the programs,
3. Sub Component Mother Child Health.
a. Training
In gencral all training have been carried out Lnci the RC staff
at atad4 thpt ha tr yi n n WAn: I=,, fzll . AImrct nil 1 part iii,arit
of the training arc still uLilized to implement the programme.
Most of the participant received the packagc of training
maL0riald. All participant who received equipment sLaLed that
the equipment is usefull.
The anti natal care training is felt very uscfull. They said
-31-that after training they are ab[c to improve the quality of
services, increase the coverage of pregnant mother.
b. Eqtuipment..
'l'here are about 14 equipment have been provided by this
component to support MCH progr.am.
In gerieral, all of F.he eqijipnierit. have been rcceived by health
centre. All provincial office that are supposed to reccivcd
moLorcycle to support MCH program at health ccntre had got
the motorcycle anti distributed to health centre.
Meanwhile, the gynoecological beds have been received by
health centre.
4. Sub Component Community Health Education
a. Training,
Trainirig on Posyandu promotion have been carried out in all
administrativc lcvcl.
This training for caders should have not only wa3 funded by
IBRD, but somc provinces had carried out the Lraining
auipporL;ed by GOI development budget or from the comuaunlty it
sclf, bccause the training was considered very usefull for
the community.
c. Media and Material
In general, most of medias provided by the Center for
Community lIealth Education were received by all provinccs, and
had distributed to health cerntre. Some medias were sent from
central lcvcl directly Lo district hcalth office.
Thte distribution from district health office to health centre,
in somc ways
- distribute directly to parLiciparit when thcy were trained or
meeting.
- carried out to health ccntre while district health office
staff do the supervision.
- sent them by post.
-32-- some health centre took them when they come to district
health office.
Irn Posyandun, the most effective diedia to be utilized is
Posters, while the Counscling Cassette is the second, and the
thlird positioni i the Counseling Card.
Reasons are that the Posters are morc clear cither picture or
writing, understandable and interesting.
Counseling Cassette is interesting, nice to be heard, the
messages are understandable, however, some are useless
bccautse Lhc ta4c recorder is not available. Counseling
Card is pracLicable and the material of the message have
provided, and easy to use it. Several Caders did not bring
along whenever they do their job because they were alrcady
understand the message.
d. Fellowship.
All of sLaff who were attended training or continuing
ediucaLion eiLlher overseam and incountry still being utilized
to deal with the program.
5. Component Community Nutrition.
a. Nutrition Mfonitoring arid Asresment.
This activities had been carried ouL in all of the Provinces
and Lhe result had been used by intcr sectoral, specially
local government through intersectoral Nutrition Improvement
Board (BPGD).
Tho utilication of tho reocult aro mootly for planning and
nuLriLiozi policy inputs, beside evaluation and program
monitoring.
There are two training implemcnted in-order to carry out
Nutrition Monitoring and Assesment, such as training for
trainer and training for health worker.
-33-b. T W I S (Timcly WaarnIng Intervention System)
Thc activiLies for TWIS had been implemented in particular
provinces. The result had bccn discAis.4ed in BPGs nieeting and
as an irxpIit. for further action and working group of Nutrition
Surveilance. Some districts in Wesal Java, Cent.ral Java, EastJava and SouLh Sulawesi , the TWIS activities was funded by
local government.
But is still somc problems relating to the implementation of
TWIS in several districts, such as lack of support from local
government, and intersectoral coordination weakness.
c. Equiipment.
Body length measured have been distributed to all provinces,
to support the implementation of Nutrition Status Monitoring.Directorate of Nutrition had provided Posyandu kits andweighing scale and had been distributed to the provinces. The
problcm was in field rather difficult to identify thoseequipment provided by IBRD fund because there are another
donors such as UNICEF and US-AID who had sponsored in
providing the similar equipment.
e. Pellowship.
Most of staffs who werc sponsored to havo continuing education
and training cither overseaa or in counLry, still beinguLilized to deal with nutrition program.
6. ComponenL Paramedical Nutrition Manpower Development.
1. Civil Work.
There are eight buildings had been contructed for Academics ofNuLritlon and School of Assistant Nutritionist .
Generally, all of them have been used as education activitiesinstitution.
However two of them, i.- School of Assistant Nutritionist in
Surabaya and Academy of Nutrition Semarang, are not full
-34-uLilized, because several rooin such as kitchern & laborntory
arc unwell condition due to the delay of utilization, so the
damage was not early delected until the period of maintenance
by the contractors was over.
b. Fqtuipment.
All of furnitture have been utilized appropriately
While vehicle, in general the condition are good, except onc
was damaged becausc of car crash.
The utilization of the vehicle are approriatc, especially for
the field work purpose.
c. Training
In general all training on nutrition program management have
been carried ouL in all Provinccs, and most of the trainees
have been utilized to deal with the nuLrition programme.
However there are several trainees who are not bcing utilized
because of many reasons such as changes Job and moved to other
area.
Training for health centre staff on nutrition program is very
usefull, especially for health centre that did not have
assistant nutritionist.
After the training, the nuLritLion worker is able to display
"SKDN" d&La properly and able to analize "SKDN" data related
with nutrition problems, and more competencc to do nutrition
education.
d. Fcllowship.
Most of the Teaching staff who were sent to got continuing
education have been utilized in the education institution
-35-3. THE STHRFN.G AND TH1F WFAKNESS OF NCH-1I E-ROJECI'
The sthreng of the projoct
- St.rengthening community participation through Posyandu program.
The awareness of commuinit.y on posyandu and the number of
posyandu increased
- 'rht faltlm ratrv' qar.-rir= Tl)l ivar-y wqcz imrp-nmv *hi.nw:h 4h.
provision of prograri suppies (equipment, drugs, vaccine,
mnanuals) and supervision
- Early detection of nutrition problem by TWIS (Timely Warning
and Intervention Systcm) program -
- Developinent of nationwide health campaign
- ImprovemcnL the number of nutrition worker through Educational
Institution carried out by Pusdiklat and IPB.
- The sustainability of the project such as
a. Thc concept of Posyandu lia.s been adopted -by community
b. The concept of NuLriLion Surveilance by Twrs program has
been adopted by Local Govcrnmcnt and will be continued as
"Local Area Monitorins" for nutrition.
c. The massage of health campaign has been accepted by
community it is showed b.y the increase number of
immunization , thc u:c of ov-ulit cLc:.
The weakness of the project
- In thc SAR (staff Appraigal Report) the target of the project
Wwvt IiuL duCitiud quutiLiLa.Liv:ly, iL :iulAy miuL ULw uvuluLLd
properly *after the project completion.
- The changes of financial procedure Bank (Prefinancing
-36-procedure to Special Account procedure) make the difficulties
in rcplanishmcnt proccs3.
- 'he project covers many provinces (11 provinccs), and each
provinces implemented the project by five project of!icers, it
nmiy cause i.he dirtriculty Of coll.ect.lng project document and
regular project report
- Difficult to find old project document due the mutation of
project personnel and poor filling
- Program niAnager at every level are not well inform about the
administrative procedure of the IBRD loan
- There are problems relating to the distribution of equipment
and material, due to lack of coordination between programme
orficer and the logigLic sLarf in thc Province.
- It is difficult to identify some of equipment which is similar
to the equipment sponsored by another donors such as Unicef,
WHO and USAID.
4. THE BANK AND PROJECT PERFORMANCE
Within five-year proJect there were no signiricant difficulty
wiLh the World Bank in relation with the adminisLrative
aspects, especially to get ".Yo obJection' from the World
Bank. Sometime it took 2 months, but sometime only 3 days to
get "No Objection"
Small problem we got was that some information jusL came out
from the World Bank in the last moment before the closing date
such as the project should conduct a study on Lhe impact of
the project (actually we have to be aware in Lhb beginning of
the project that the evaluaLion should be carried out at the
of Lhe projecL). By that timo the budget was not allocated in
the "DIP". To conduct this study need more time for
-37-
preparation and on the other hand the project didn't have
any basc line data to compare with the project's achivement.
1L Is required by Lhe Barik that any activity before
implemented should be approved by the Hank. To get those
approvals the project should submit the Term of Reference of
all activities that. will be implemented in a certain fiscal
year. TIhe prohlem was, it needec3 more time for components to
prcparc the TORs, so it made the secretariat sent. the TORs not
in orie Lime. Sometimes the TORs came soo late or right before
thc implementation time, it madc the secretariat did'nt have
enough time to review the TOR's.
Usually the secretariat sent TORs 'in Hay and June and the
approval camc in July or August. This would not be influenced
for Lhe implemenLaLlon the activity of training, workshop, and
fellowship, but it made delay the implementaLion of
procurement, study and civil work.
AfLer the project goL approval for the TORs of the procurement
-of materials, books, equipment, and civil work in July or
August the project should request another "No Objection" for
the bidding document, and then "No Objection" for the
cornLrzacL. Consequently the process of procurcmcnts will take
more than one fiscal year.
Since all the activities had been appraised by IBRD is it
still needed thc "No objecLion" for the TORs of all the
activities ?
IL will help the project to speed up the implementation if the
Bank limits the TORs of the activities that should be approved
such as for study and technical assistant.
-38-
Z. PRHT.FMS
There are several constrains thatshave been occured during
the iinplementaLion of the projecL :
a. Problem in preparing anual finance report
February 1936-March 1988 the project followed the
Prefinancing system and starting April 1988 finance
regulaltion change to SpeCial Accoujnt.. The changes of the
regulatiorn mtoide the problem of disbursement and annual
finance report, becca:se the tinit, thriL responsible for
disbursement of Prefinancing separate with the unit that
responsible for Special Account in the Ministry of Finance.
The Project Secretariat that responsible for the finance
report got difficulty in searching documents due to the
unmatch report made by Prefinance unit arid Special Account
Unit. It took more time to match the figures.
b. Problem on disbursement acceleration:
The responasible unLit in the MinisLry of Finance process the
replenishment based on the document cojining from the
provincial Finance Office. Thosc documcnt stated the number
of money that had been used by Lhe project paid by Bank of
Indonesia at provincial level. Periodically the Bank of
Indonesia made report to MOF and based on thaL report the
MOF did the replenishment. Moreoften the document was not
compleLe to back up thc replcnishment. This document was
suppposed to be sent to MOF by Provincial Finance Office.
Lack of document needed fox the replcnishment made the
disbursement was very low. To overcome those problem the
secretariat developed a collaboration with the responsible
unit in M.OF by periodically meeting and work togcther to do
Lhe rcplenishmcnt. The Projcct Sccrctariat collected document
of payment and other suppoting document needed for
replenishment directly from the Project Officer at Central
and Provincial level. This kind of collaboration could help
to speed up the disbursoment.
-39-
c.At provincial level there were no coordinating untt to
coordinaLe and supervise the impldhentation of the project.
There was only one person of each province appointed as
liaison officer as a part timc job with very small incentive.
This person could not do much, each project officer made
direct conl.act with Project nirector through project
secretat,iat at central level, so in the last two years of the
project there was no liaison appointed. The secretariat had
made direct corntact with each of Project Officer at
provincial levCl or through CenLral Component.
For tie next project a secretariat unit &L provincial level
is needed to help project officer in administrative aspects
beside to coordinate and supervise the project implementation.
d. Program manager and projcct officer aL every level were
not well informed about the administrative procedure of IERD
Loan, make the different perception.
c. Tho mechanism and flow of reporting was not working well
f. Diffictult to find out the old project's document due to
poor filing system and mutation of project personnel
This weakness of the projecL implementation is a good leouon
learn for the next proJect.
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PART III. STATISTICAL INFORMATION
1. Related Bank Loans
Loan/Credit Year ofTitle Purpose Approval Status
Cr. 1373-IND To enhance GO( capacity to M a r c h CompletedFwrst Nutrition formulate and execute nutrition 14, 1977 March 31,Development programs, operations, 1982Project research, manpower training
and monitoring and evaluationby strengthening andexpanding the existing nucleusof personnel and institution
Ln. 2529-IND To assist GOI in strengthening July 18, C I o s e dP o u r t h its family planning services 1985 December 31,Population and carry out its population 1992Project policy development and
planning
Ln. 3042-IND To assist GOI improve the June 1, OngoingThird Health delivery of health services and 1989Project raise health status in NTB and
Kaltim through better andmore decentralized healthsector planning, budgeting andmanagement
Ln. 3298-IND To assist GOI in further May 1, OngoingFifth Population reducing fertility and maternal 1991Project mortality by strengthening the
family planning and maternalhealth programs
Ln.3550-IND To elevate infant, child and December GOI informedT h i r d maternal health status in five 22, 1992 of boardCommunity provinces by (a) building approvalHealth and provincial capacity to plan,N u t r i t i o n manage and evaluate relevantProject interventions and
(b) strengthening central MOHto support provincial efforts
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2. Project Timetable
Date Date DateItem Planned Revised Actual
Identification(Executive ProjectSummary) May 14, 1985
Preparation August 1984 October 18, 1984 October 18,1984
Appraisal Mission March 1985 July 1, 1985
Loan Negotiation August 16, 1985 September 9, 1985 October 21, 1985
Board Approval September 14, 1985 October 29, 1985 Nonbor 26, 1985
Loan Signature December 19, 1985 Deamlib 19, 1985
Loan Effectiveness February 21, 1986 Febuary 21, 1986
Loan Closing December 31, 1991 D1amtw 31, 1991
Loan Completion March 31, 1991 May 11, 1992
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3. Cumubathve Estimated and Actulb Disbursement(USS 000)
1986 1987 1988 1989 1990 1991 1992
Appraial Edimate 400.00 4,700.00 12,700.00 20,700.00 30,700.00 33,4000.00 33,168.88
Actud 2,678.44 8,57S.OS 8,7S7.05 12,219.48 19,951.94 25,786.07 31,807.97
Actlul Sof Entimte 669.61 18245 68.95 59.03 64.99 77.20 95.30
Deb of Final DiAusmewn May 11, 1992
Odi&iWl Loan Anmoun wsu USS33,400.0Canelled US$1,592.03
Cumulative, Estimated and Actual Diburmmeent
35
3 0.. . . . . . . . . . . .. . .
1 5_320 .. . . . ... . .. . .. .... .....
2 0 .. . . . .. .. . . . . . ... . ....... . . . .. .
1 5 - -. ...... . . ..... ... . . . . . . . . . . . . .
1 0 ... ....... ... ....... . . . . . . . . . . . . . . . .
S 5 ......... . -..... i ... . . . .. . . . .. . . .
8Be 8 7 8 889 9 0 91 9 2
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4. Project Implementation
Appraisal Actual(PCR Estimate)
1.0 Community Participation
1.1 Training and orientation of village 16,500villagesin 33,000 keyleaders in the organization of 11 provinces persons andposyandu and purpose of the five I e a d e r shealth programs participated.
1.2 Training of village kaders in in 16,500 villages 32,273posyandusorganization and motivation and the in 11 provinces (Acceleration/basic technical content and activities Basic training)of the five health programs
2.0 Planning, Management and Supervision
2.1 Micro-planning 1,200 health 187 districts incenters/sub- project provincescenters in 31districts
2.2 Planning and management training forintegrated FP and Health 44 persons- National 1,870 persons- Province 16,488 persons- District
2.3 Supervision- Health center manuals 18,000 copies- Supervision manuals 6,000 copies
3.0 Communication
3.1 Equipment/materials- Posters 1.5 million- Counselling cards 1.1 million- Manuals for kaders 426,500- Manuals for providers 126,500- Action sheets 500,000- Counselling cassettes 110,000- Others (e.g., radio, TV campaign)
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Appraisal Actual(PCR Estimate)
3.2 Training in- health education 4,889- counselling cards
Villages 5,400Subdistrict 7,613 personsDistrict/Province 543 persons
4.0 Mother and Child Health
4.1 Mother awareness training for- Health center (HC) nurse 1,890 nurses- Kader 1,714 kaders- ANC training for HC nurse 3,859 nurses- TBA 13,510 persons- Guidance for TBA 149,665
5.0 rumely Warning and Intervention (FWIS)
5.1 Feasibility studies 37 districts in all At least 5511 provinces districts in 24
provinces
5.2 Start TWIS implementation 5 5 i n 1 3provinces
6.0 Nutrition Monitoring and Assessment
6.1 Anthropometric measuresment for 1986 Done in 1986,SUSENAS 1987 1987, 1988
1988SUSENAS
6.2 Research/studies (see Table 9 for Completed (all)studies)
7.0 Improving Nutrition Manpower Development
7.1 Paramedical Nutrition Manpower 2 nutrition CompletedDevelopment academics 5 academies
3 schools6 assistant 1,158 middlenutritionist level nutritionschools works trained
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Appraisal Actual(PCR Estimate)
7.2 Graduate nutrition manpower GMSK-IPB Completed 3-development building story GMSK
building(5,980 sq m)
Staff 7 overseasdevelopment fellowships
(doctoral/masters degree)
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5. Project Costs and Financing
A. Project Costs(US$ million)
Aopraisal Estimate Revised Estimate ActualForeign Foreign Foreign
Local Exchange Local Exchange Local ExchangeItems Cost Costs Total Cost Costs Total Coat Coats Total
A. StrengtheningCoordination andManagement ofCommunity Health
Community Participation 6.00 0.10 6.10 0 0 0 4.65 0.14 4.79Planning, Managementand Supervision 4.70 0.50 5.20 0 0 0 8.56 0.23 2.59
Communications 2.50 1.20 3.70 0 0 0 1.77 0.87 2.64Community HealthSecretariat 0.80 0.20 1.00 0 0 0 0.68 0.25 0.93
Program OperationsSupport Funds 0 5.00 5.00 0 0 0 0 8.80 8.80
Subtotal 14.00 7.00 21.00 0 0 0 15.66 10.30 25.96
B. Development of NutritionSurveillance
Timely Warning andIntervention 3.30 0.60 3.90 0 0 0 0.65 0.11 0.76
Nutrition Monitoringand Assment 3.90 0.50 4.40 0 0 0 2.42 0.33 2.75Nutrition Policy andProgram Studies 0.60 0.50 1.10 0 0 0 1.05 0.79 1.85Nutrition Information 0.50 0.40 0.90 0 0 0 0.40 0.33 0.73
Subtotal 8.30 2.00 10.30 0 0 0 4.52 1.57 6.08
C. Improvement NutritionManpower Development
Paramedical ManpowerDevelopment 6.60 2.10 8.70 0 0 0 4.88 1.54 6.42
Graduate ManpowerDevelopment 3.30 1.70 5.00 0 0 0 2.00 1.03 3.03
Subtotal 9.90 3.80 13.70 0 0 0 6.88 2.57 9.45
Toal Baselioe Cost 322 12.80 45.00 4 2 L 4.44 41.49(excl. taxes)
Physical contingencies 0.80 0.40 1.20 0 0 0 0.67 0.36 1.04Price contingencies 8.50 1.50 10.00 0 0 0 8.82 1.56 10.37
Tobl Project Cost 41 14.70 56.20 2 2 2 3 13 52(excl. taxes)
Taxes (incl. contingencies) 1.50 0 1.50 0 0 0 1.54 0 1.54
Total Project Cost 1 14.70 ,57.70 2 2 2 38.09 1i6 3(incl. taxes)
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5. Project Costs and Financing
B. Project Flnandng
Percent of PlannedDisburemnent Loan
Source Agremcnt Rcvisod FIl(USS '000) (USS'O000) (%) (USS'O000) (%)
IBRDExpenditureCategories 33,400.0 33,168.88 99.31 31,807.97 9530
Civil workm 75% 6,175.00 2,997.00 48.53 3,499.15 116.76Equ./Furn Ex.Al&AS 100%,95%,65% 3,135.00 6,300.00 200.96 5,840.97 92.71Equip/Matl PT.S 100% 4,750.00 8,370.88 176.23 8,811.40 105.25Consul/Pllowshps 100% 6,840.00 5,695.00 83.26 5,272.89 92.59Tnining 70% 9,120.00 5,096.00 55.88 5,377.70 105.53Studies 100% 1,710.00 2,820.00 164.91 3,005.70 106.59Unalcated 1,670.00 1,890.00 113.17 0 0Undisbursed (-) 0 0 0 1,592.03 0
CofinancingInxliuton 0 0 0
Other ExternalSource 0 0 0
Domestic n.a 24,300.00 24,283.23 99.93 7,688.31 31.641A
TOWa VM.ffZ 57.452.11 629L2iI I75
Comment
t TIe large discrepancy in domestic expenditure (in USS) is due to the depreciation of the local currency.
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6. Status of Covenants
Deadline forCovenants Subject Compliance Status
Ln. 2636-IND E v a I u a t i o n o f September 30, Completed"Microplanning" 1986 1987
Ln. 2636-IND Preparation of supervision September 30, Completedguidelines/manuals 1986 1990
Ln. 2636-IND Preparation of supervision March 31, each Complianceschedules year
Ln. 2636-IND Baseline survey, (Evaluation October 1, 1986 Completedof Integrated Health 1987Program)
Ln. 2636-IND Mid-project Evaluation April 30, 1988 Completed1989
Ln. 2636-IND Annual plans of Timely May 31, 1986 CompletedWarning and Intervention and every year 1 9 8 6System March 31 Compliance
until 1989
Ln'. 2636-IND Annual workplans for May 31, 1986 Completednutrition policy and programs and every year 1 9 8 6studies March 31 Compliance
until 1988
Ln. 2636-IND Establishment of Nutrition May 31, 1986 CompletedInformation Unit 1987
Ln. 2636-IND Project vehicles:- Strengthening proj. March 31, 1987 Completed
secretariat (2 SWs) 1990
- Strengthening operational March 31, 1987 Completedactivity (2 FWDs) 1991
- Support school activity March 31, 1988 Completed(16 SWs) 1 9 91
(9 SWs)
- Support for Safe - CompletedMotherhood activity 1 9 9 1(motorcycles) (200 MCs)
CommentsFWS - four-wheel driveSW - station wagonMC - motorcycle
At appraisal, GOI was expected to finance and procure the vehicles. However, duringproject implmentation the Bank agreed to loan financing for their purchase. GOI wasm financial difficulties during project implementation and the number of vehiclesinvolved was relatively small.
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7. Use of Bank Resources
A. STAFF INP1TS (STAFF WEEKS)
Stage of Project Cycle Planned Fmal
Through Appraisal n/a 31.8
Appraisal through Board Approval n/a 52.3
Board Approval through Effectiveness n/a 10.0
Supervision n/a 92.5
PCR 7.0 4.0
Totl n/a
7. USE OF BANK RESOURCES B. MISSIONS
Days Special- Performance Rating StatusNo. of in izations Available Project Development Overall
Month/Year Persons Field Represented Funds Management Impact Status Covenant
TIhrough Appraisal 3/84 n.a n.a n.a10/84 n.a n.a n.a
Appraisal 3/85 n.a n.a n.aAppraisal through 11/85 n.a n.a n.aBoard Approvalthru effectiveness 3/86 n.a n.a n.a
Supervision 10/86 5 20 n.a I 1 1 1Supervision 8/87 9 24 n.a 2 1 2 1Supervision 3/88 3 23 n.a 3 2 2 3
Mid-term Review 10/88 6 13 n.a 2 2 2 2Supervision 2/89 6 13 E,L 1 1 2 2Review of Progress 9/89 1 12 1 1 2 2 1Supervision 6/90 2 5 E,L 1 1 2 2 1
Supervision 2/91 2 10 E,L I 1 2 2 1Supervision 11/91 2 8 E,L 1 1 1 1PCR 12/92 2 E,L
SWecializations E=Economist, H=Health Specialist (local staff)
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8. Studies
Purpose as Defined ImpactStudies at Appraisal Status of Studies
Study of training To review existing materials and Completed Used in developingmaterials for develop training module for 1987 standards for kaderkaders posyandu kaders training nationwide.
Assessment of To collect and analyze base line Completed Basic data underpinnedIntegrated Family data 1986 development ofHealth Package posyandu and
President's declartionextending it throughoutthe country on theNational Health DayNovember 12, 1986.
S t u d y o f To assess the 'Microplanning Completed Improved planning atMicroplanning Program' 1986 PuskesmasPrograms
Study of media To define social marketing Completed More effective posyandum a t e r i a I s , strategy and appropriate media 1 9 8 8 , promotion, kaderincluding KAP for posyandu promotion in 1989, 1991 counselling, communitystudies in nine project provinces participation andprovinces utilization of the five
health services.
Mid-term Review T o r e v i e w p r o j e c t Completed Reprogramming ofimplementation 1988 project implementation
Privatecommunity To explore use of Rapid Completed Data base for CHN mmidwives roles in Assessment Procedures to 1991 ProjectMCH activities at collect health data for 1986grassroot level. Household Survey
Clearing house for Completed System not installed yet.community health 1991studies
Anthropometric To define nutrition status and its Completed Use to define welfaremeasurement of measure for SUSENAS 1 9 8 7 , indicatorspreschool-age 1988, 1989children
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Purpose as Defined ImpoctStudies at Appraisal Status of Studios
Evaluation of To improve monitorirg of Completed Natonwide utilintionUPGK's monthly nutrition status of children 19M7 of improved SKDNgrowth monitoringsystem (SKDN)and developmentof additionalSKDN indicators
Protein-energy To assess prevalence of PEM Completed U n d e r p i n no dmalnutrition androleofUPOK 1988 development of(PEM) mortality Nutrition Statusa nd UPGK Monitoring (NSM)p r o g r a m prograparticipation
Assessment of To evaluate the NSM CompletedNutrition Status 1990Monitoring
Assessment of Vit To define Vit A and other Completed Data used in p _A and other nutrition deficiency pmoblome 1991 Cimmity Hl andn u t r i t i o n a I better NUtritiIn I (CEN IIdeficiency Prjectproblems ineastern part of
TWIS feasibility To identify aroea for TWIS Completed Bsis for uleton ofstudies implemation 1986/1987 areas for implementing
through TWIS198911990
Formulation of To collect and analyze data for Completed Underpinned RepitVfood and nutrition naionl planing 1990 mntrition policy andpolicy and plan streyfor PELITA V
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