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The World Bank

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1eptPwti. 5840-IND

STAPF APPRAISAL REPORT

INDONESIA

SECOND NUTRITION AND COMHDNITY REALrH PROJECT

November 1, 1985

Population, Health & Nutrition Department

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CURRENCY EQUIVALENTS

Currency Unit - Rupiah (Rp)US$1.00 - Rp. 1,100 (October 1985)Rp. 1 million - US$9U9

GOVERNMENT OF INDONESIA FISCAL YEAR

April 1 - March 31

ACRONYMS AND INITIALS

ADB : Asian Development BankBAPPENAS : National Development Planning AgencyBPGD : Intersectoral Nutrition Improvement BoardCDD : Diarrhoeal Disease ControlCRDN : Center for Research and Develcpment in NutritionEPI : Expanded Program of ImmunizationFh)C : Food Technology Development CenterGMSK : Department of Community Nutrition and Family

ResourcesICB : International Competitive BiddingIPB : Institute of Agriculture, BogereKAP ; Knowledge, Attitudes and PracticesLCB e Local Competitive BiddingLKMD : Village Self-Reliance BoardMCE: Maternal and Child HealthMOH Ministry of HealthNFPCB : National Family Planning Coordinating BoardPCM Protein-Calorie MalnutritionPHN Population, Health an1 NutritionPIMPRO : Provincial Project Of.'icerPKMD : Village Community Health Development ProgramPUSDIKLAT : Center for Education and Training of Health

PersonnelREPELITA : Five-Year Development PlanSKDN : Growth Monitoring SystemSKN : National Health SystemTWIS : Timely Warning and Intervention SystemUNICEF : United Nations Children's FundUPGK : Family Nutrition Improvement ProgramUSAID : United States Agency for International DevelopmentVAT : Value Added TaxVCDC : Village Contraceptive Distribution CenterWHO : World Health Organization

FOR OMCIAL USE ONLY

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INDONESIA

SECOND NUTRITION AND COMMUNITY HEALTH PROJECT

Loan and Project Sumary

Borrower: Republic of Indonesia

Amount: US$33.4 million equivaleut

Terms: Repayable in 20 years, including 5 years of grace, atthe standard variable rate

Project Description: The project's objectives would be threefold: (a) tostrengthen the coordination and management of fivecommunity health programs aimed at significantlyreducing infant, child and maternal mortality ineleven priority provinces, including directop;._.t sonal support to these five programsindividually; (b) to further develop Indonesia'snutrition surveillance capability in four areas:timely warning and intervention, nutrition monitoringand asses3ment, nutrition policy and program studies,and nutrition information; and (c) to improvenutrition manpower development at the paramedical andgrad-ate levels. The project's principal directbenefits would include: improved coordination andmanagement, and thus increased effectiveness andefficiency, of village-level community health (familyplanning, health and nutrition) services; enhancednational capability to predict and influence changesin nutrition status, strengthened program monitor'ngand evaluation capacity, and improved food andnutrition policies; and, a more adequate stock oftrained nutrition manpower for program management andimplementation and for policy formulation andplanning. The project's main risk is that thedesired 'oordination of the five counity healthprograms at the village level may not be fullyachieved, or be substantially delayed. This risk isubavoidable in an integrated approach or process ofthis nature; and, the project's design, which placesconsid-'-able emphasis on strengthening the planning,managerial and monitoring capacity of the keyMinistry of Health units concerned with programimplementation, should serve to minimize the risk.

This document has a resiced distribution and may be used by recipients only in the performance oftheir offrcial duties. Its contents may not otherwise be disclosed without World Bank authorization.

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Estimated Costs:Local Foreign Total

(US$ million)

A. Strengthening Coordination and Manage-ment of Community Health

1. Community Participation 6.0 0.1 6.12. Planning, Management & Supervision 4.7 0.5 5.23. Communications 2.5 1.2 3.74. Community Health Secretariat 0.8 0.2 1.05. Program Operations Support Funds - 5.0 5.0

Subtotal 14.0 7.0 21.0

B. Developing Nutrition Surveillance1. Timely Warning & Intervention 3.3 0.6 3.92. Nutrition Monitoring & Assessment 3.9 0.5 4.43. Nutrition Policy & Program Studies 0.6 0.5 1.14. Nutrition Information 0.5 0.4 0.9

Subtotal 8.3 2.0 10.3

C. Improving Nutrition Manpower Development_. Paramedical Manpower Development 6.6 2.1 8.72. Graduate Manpower Development 3.3 1.7 5.0

Subtotal 9.9 3.8 13.7

Total Base Cost (excl. taxes) 32.2 12.8 45.0

Physical Contingencies 0.8 0.4 1.2Price Contingencies 8.5 1.5 10.0

Total Project Cost (excl. taxes) 41.5 14.7 56.2

Taxes (incl. contingencies) 1.5 - 1.5

Total Project Cost (incl. taxes) 43.0 *4.7 57.7

Financing Plan:Local Foreign Total

(US$ million) -

IBRD 19.1 14.3 33.4Government a/ 23.9 0.4 24.3

Total 43.0 14.7 57.7

Estimated Disbursements:Bank FY 1986 1987 1988 1989 1990 1991

(U1$ million)

Annual 0.4 4.3 8.0 8.0 10.0 2.7Cumulative 0.4 4.7 12.7 20.7 30.7 33.4

Rate of Return: Not applicable

a/ Including taxes (US$1.5 million) and reserved procurement of vehicles(US$0.6 million).

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INDONESIA

SECOND NUTRITION AND COMMUNITY HEALTH PROJECT

STAFF APPRAISAL REPORT,i

Table of Contents

Page No.

Loan and Project Sunmary . . .......... .Table of Contents ... . . ............ iiBasic Data . . . . . . . . . . . . . . . . . . . . . vDefinitions . . . . . . . . . a . . a . . . * vi

I. INTRODUCTION . . . . . . . . . . . . . . . . * . . . . 1

II. SECTOR ISSUES AND STRATEGY. ..... .. . . . . 2

A. The Health and Nutrition Sector in Indonesia . . . . 2Population Status . .. . .. .. .a. . . . .. . 2Health Status . . . . . . a . . a . . . . . o a 3Nutrition Status . . . . . . . . . . . . . . . . . 3Health Sector Development . . . . . . . . . . . . 4Health Organization and System . . . . . . . . . - 5Health Financing . . . . . . . . . .a . . . . . . 7Repelita IV - Health and Nutrition Policies . . . 8

B. Nutrition and Comimity Health ...... . . . . 9

C. Nutrition Surveillance.... . .... . .. 13

D. Nutrition Manpower Development . . . . . 0. a . 14

E. Bank Role and Assistance Strategy ... .. . . . . 15

III. THE PROJECT . . . . . . . . . . . . . . . . . . . . . . 17

A. Project Concept and Main Features . . . . . . 17B. Project Composition . . . . . . . . . . . . . . . . 18C. Detailed Pro'ect Description . . . . . . . . . . . . 20

This report is based on the findings of an appraisal mission that visitedIndonesia in March, 1985, and incorporates the outcome of post-appraisaldiscussions held in Jakarta between July 1-19, 1985. The personnelinvolved were: Messrs. D. Pearce (mission leader), A. Berg, and A.Williams, and Mss. C. Fogle and N. Sirur (PHN); Mr. R.M. Brooks and Ms.M. Griffiths (consultants).

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Table of Contents (Cont'd)

Page No.

IV. PROJECT COSTS AND FINANCING . . . . . . . . . . . . . . 28

A. Cost Estimate . . . . . . . . . . . . . . . . . . . . 28B. Financing Plan . . . ... a. . *..... a. . . . ... 32C. Procurement * * a * * * * * .0 * * . * * . . . * 33D. Disbursements . . .. . . . . . . . . . . . . . . . 35E. Accounts and Audit ..e ... ... ........ 36

V. PROJECT ORGANIZATION, MANAGEMENT AND IMPLEMENTATION . . . 36

A. Project Organization and Management . . . . . . . . . 36B. Project Implementation ...... ... .. . 37

VI. PRJECT BENEFITS AND RISKS . . . . . . . .. 38

A. Project Benefits . . . . .. .... .. ..... 38B. Project Risks . .. . . . . . .. . . . . .. . . . 38

VII. AGREEMENTS REAChED AND RECOMMENDATION . . . . . . . . . 39

ANNEXES

1. Schedule of Disbursements.......... go..... 412. Project Costs and Financing (COSTAB) . . . . . . . . . . . 423. Implementation Schedule . . . . .-. . . . . . . . . . . . 484. Selected Documents and Data Available in Project File . . . 53

CHARTS

C-1. Organigram of the Ministry of Health . . . . . . . . . 55

MAPIBID No. 19285

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INDONESIA

SECOND NUTRITION AND COMMUNITY HEALTk PROJECT

BASIC DATA

Total area (thousanue km2) . ... . 1,919Total population (mid-1983 in millions) . . . . . . . . . . . 155.7

Density per k( (id-1983) .................. 78Density per km2 of agricultural land (mid-1983) . . . . . . . 471Annual rate of natural increase (1983) (Z) . . . . . . . . . . 2.1

Crude birth rate (1983) ........ ........ a.......... s..... 34

Crude death rate (1983) .... ..................... 13Life expectancy at birth (1983) (years) .o. . . . . .. o.. 54Infant mortality rate (1983) ... .. .. ....... .. 101

Child mortality rate (1983).. . 13Haternal ortality rate (1983) .... ............ 3Urban population as percentage of total population. (1983) . . 24Adult literacy rate (1981) (Z) . . . . . . 62Population per physician (1979) ... . . . . . . . . . . . . 11,530Nutrition:Daily calorie supply per capita (1981) . . . . . . . . . . . 2,342

As percentage of requirement (1981) . .. ....... 110Per capita GNP (1983 in US$) ... *6....... .... 560

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DEFINITIONS

Child Mortality Rate: 8 Annual deaths of children 1-4 years per 1,000children in the same age group.

Crude Death Rate: Number of deaths per year per 1,000 people.

Infant Mortality Rate: Annual deaths of infants under one year per1,000 live births during the same year.

Life Expectancy at Birth: Number of years a new-born child would live ifsubject to the mortality risks prevailing forthe cross-section of population at time ofbirth.

Maternal Mortality Rate: Number of maternal deaths per 1,000 births ina given year attributable to pregnancy,c-hildbirth or puerperal complications.

Dinas Kesehatan: Province Health Officer.

Dukun: Traditional healer.

Kakanwil: MOR Provincial Officer.

Kanwil: MOa Provincial Office.

Panca Karya Husada: Five key principles of health policy.

I. INTRODUCTION

1.01 Until the early 1970s, Indonesia's efforts to deal with malnutri-tion, both its causes and consequences, were relatively small-scale andineffective, owing to weak political commitment and direction, lack ofbasic data, an inadequate institutional framework for policy formulationand program development, and insufficient and poorly trained nutritionmanpower. Duriag the last two development plan periods (1974-84), however,the government, with assistance mainly from UNICEF, USAID, WHO and theBank, has made remarkable progress in addressing these constraints. First,a national family nutrition improvement program (UPGK), initially focussedon child growth monitoring and nutrition education and later broadened (inEast Java and Bali with USAID assis-ance through the National FamilyPlanning Coordinating Board, NFPCB) to include family planning and, morerecently, maternal and child health, diarrheal disease control andwimunization activities, is now in place. By early 1984, this UPGK

program, for which the Directorate-General, Community Health of theMinistry of Health (MOe) is responsible, was estimated to cover, at varyinglevels of intensity and effectiveness, about half of the country's 65,000villages. vxtended coverage of UPGK and the coordinated delivery of familyplanning, health and nutrition activities and programs at the communitylevel is now the government's principal operational strategy for achievingmajor declines in infant, child and maternal mortality and morbidity, and afurther reduction in fertility, during Repelita IV (1984-89) and beyond.Second, the government has developed an overall food and nutrition policy,initiated nutrition surveillance activities in one province, and, throughthe National Development Planning Agency (BAPPENAS), institutionalizednutrition considerations and perspectives into its overall macroeconomicplanning process. Third, the MOH's Academy of Nutrition in Jakarta, thecountry's principal nutrition manpower training institution, and its Centerfor Research & Development in Nutrition (CRDN), have both beensubstantially strengthened; and, a new institution, the Food TechnologyDevelopment Center (FTDC), has been established at the Institute ofAgriculture, Bogor (IPB). Partly as a result of these activities,nutrition now plays so large a role that, like the family planning program,it is frequently referred to in Indonesia as a movement. Indeed, Indonesiais now recognized internationally as one of the countries in the forefrontof nutrition development.

1.02 In 1984, upon completion of the Nutrition Development Project(Loan 1353-IND) which contributed to many of the above developments, thegovernment submitted to the Bank three proposals, together comprising asecond nutrition and community health project, as follows: strengtheningcoordination and management of community health; developing nutritionsurveillance; and, improving nutrition manpower development. All threeproposals follow up and build upon the policy, program and institutionaldevelopment initiatives noted above. A Bank preparation mission visitedIndonesia in October, 1984 to review and assist in project preparation anda Banlk-financed consultant subsequently provided intermittent assistancethrough early 1985. The project was appraised in March, 1985.

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1.03 The project described later in this report is the third in asequence of three operations appraised during the last year comprising acoordinated package of financial and technical assistance to Indonesia'spopulation, health and nutrition (PHN) subsectors and institutions. Thepreceding two were the fourth population project (Loan 2529-IND), approvedMay 7, 1985 and the second health (manpower development) project (Loan2542-IND), approved May 14, 1985. All three projects complement each otherand, considered together, they support the comprehensive view of, andcoordinated strategy for, PHN sector development reflected in thegovernment's fourth five-year development plan (Repelita IV).

II. SECTOR ISSUES AND STRATEGY

A. Health and Nutrition in Indonesia 'I

Population Status

2.01 Indonesia's population of about 155.7 million (mid-1983)increased at an annual average rate of 2.1X between 1965-73 and 2.3Zbetween 1973-83. However, this increase in the average growth rate betweenthe two decades as a whole masks a significant declining trend in annualgrowth rates during the latter period: from 2.6% in 1970 to 2.1% by 1980,owing to lower fertility which, in turn, is attributable inter alia torising average age of marriage and to increasing and widespread contra-ceptive use, particularly in Java and Bali. Assuming a reduced 1.9%verage annual growth rate through the rest of this century, Indonesia'spopulation is projected to increase to 179 million by 1990 and to about 212million by the year 2000. In addition to the population's absolute size,the fifth largest in the world, and still high growth rate, two other demo-graphic factors have important implications for the country's overalldevelopment efforts: regional extremes in density, ranging from an averageof 690 persons per km2 in Java, where over 60% of all Indonesians live onless than 7% of the country's total land area, to about 3 in Iriar Jaya,which accounts for more than 20% of total land area; and, increasing urban-ization, owing partly to rural-urban migration and partly to higher birthrates in urban, compared to rural, areas. In 1983, urban dwellers account-ed for about 24% of total population (up from 15% in 1960) and this propor-tion is expected to increase to about 36% by the year 2000. The main goalsof Indonesia's comprehensive population policy are to reduce further the

11 A more detailed treatment of population, health and nutrition statusand sectoral development issues is given in the following Bank reports:Indonesia - Health Sector Overview (Report No. 237q-IND); Indonesia -Provincial Health Project (Report No. 4131-IND); Indonesia - FourthPopulation Project (Report No. 5404-IND); and Indonesia - Second Health(Manpower Development) Project (Report No. 5442-IND). Data cited inparas. 2.01-2.04 are from World Development Report, 1985.

overall rate of population growth and to improve its distribution; thegovernment's family planning and transmigration programs are the principalinstruments of this policy.

Health Status

2.02 Despite considerable improvements during the last 20 years, theoverall health status of Indonesia's population remains far from satisfac-tory and is inferior to that of comparable middle income countries. In1983, life expectancy at birth was 54 years, up from 41 years two decadesearlier; the crude death rate was 13 per thousand, about 37% lower than in1965; and the infant mortality and child death rates were about 101 perthousand live births and 13 per thousand children aged 1-4 years respec-tively, compared to 138 and 20 in 1965. Significant disparities exist inboth mortality and morbidity among Indonesia's widely dispersed regionsand, within regions and provinces, between the rural and urban areas-rwiththe average urban resident in Java enjoying much better health status andaccess to health services than the average rural dweller in the OtherIslands. For example, life expectanc) at birth in Yogyakarta is 61 yearsand in Sulawesi and West Nusa Tenggara only 52 years and 44 yearsrespectively (1980).

2.03 Although Indonesia's epidemiological profile has not changedmarkedly during the last decade or so, some differences in disease patternsbetween the economically more advanced urban centers and the less developedrural areas are starting to emerge. Assuming continued socio-economicdevelopment and increasing urbanization, this trend can be expected tocontinue and to have important consequences for the longer-term developmentof the country's health system. In the short- and medium-term, however,the most prevalent causes of overall morbidity and mortality continue toinclude respiratory and gastro-intestinal diseases, skin and eye infec-tions, intestinal parasites, and vector-borne diseases, principallymalaria. Up to one-half of total mortality (about 992,000 deaths perannum) occurs among children below 5 years of age; and, the leading causesof death among infants (0-12 months) are diarrhea and lower respiratoryinfections, exacerbated by malnutrition, and neonatal tetanus. It isestimated that about 80X of the over half a million infant deaths per annumcould be avoided through simple, low-cost therapy and prevention.Considering the high levels of infant and child mortality, the fact thatless than half of pregnant women receive basic prenatal care, and that onlyabout 15Z of all deliveries are attended by trained personnel of any kind,improved maternal and child health (KCH) services are an obvious priority.

Nutrition Status

2.04 Although, based on the adjusted minimm daily requirement forIndonesia (2,100 calories and 45.9 grams of protein), available caloriesare sufficient and protein is adequate, protein-calorie malnutrition (PCM)remains a serious problem and is a major underlying contributor toIndonesia's still high rate of infant mortality. This is largely due to

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problems of distributioi:, both among and within families. Currentestimates indicate that 15X of the population or about 23 million people,principally the urban poor, small landholders and the rural landless, aremalnourished and that, within families, women and children under 5 yearsare most likely to receive insufficient calories and protein. ludeed,1977/78 survey data show that nationwide about 9 million children aged 1-5years, or about 30% of all preschoolers, suffered from moderate PCM andabout 900,000 from severe PCH. Of the micro-nutrient deficiencics, vitaminA, iron and iodine are the most important. According to 1979 MOHestimates, 15 million people, or 10X of the popularion, had some form ofeye impairment or blindness due to vitamin A deficiLency; iron-deficiencyanemia was found in 28-52% of male workers and in 35-85% of non-pregnantwomen; and iodine defiency, which can retard mental development and insevere cases contribute to deaf mutism and cretinism, was found in 50% ofthose surveyed in certain goiterous areas Java, Bali and Sumatra.

Health Sector Development

2.05 Throughout the 1960s and during the early years of Repelita I(1969-74), the government accorded relatively low priority to health(including nutrition) and the other social sectors. Public healthactivities focussed mainly on general health education and the preventionof epidemics; coneequ-ntly, only modest attention was paid to thedevelopment of hospital or rural health services. During Repelita II(1974-79) however, a period of rapid economic growth, high pr.ority wasgiven to improving access to health services, particularly in rural areas,and, by the late 1970s, each of the country's 3,400 subdistricts had atleast one public community health center. In addition, total public healthpersonnel nearly doubled; about 47,000 traditional healers (dukuns) andbirth attendants were trained; and legislation was promulgated obligatinggraduating physicians to serve in rural areas for between 2-5 years atleast, depending on the province to which they were posted. This expansionof physical infrastructu_o and human resources was accompanied by measuresto reduce financial disincentives to health service utilization: in 1979,health center consultation fees were reilSced from Rp. 450 to Rp. 150(US$0.45 to US$0.15 equivalent). Despite these developments, the publichealth system's effectiveness, and specifically the utilization of itshospitals, health centers and subcenters, remained limited-owing partly tosociocultural and behavioral factors, which will only gradually beovercome, and partly to the poor quality of their services, mainly afunction of inadequate numbers of qualified personnel. During Repelita III(1979-84,, the government's three main priorities were: to continueimproving access to health services (particularly in the Other Islands); tostrengthen the referral system by improving the efficiency andeffectiveness of health facilities; and, to promote improved family healthbehavior and practices in the community itself through village-levelprimary health care programs. In this latter connection, considerableinitial progress has been achieved, particularly in family planning andnutrition: by the NFPCB through its village contraceptive distributioncenters (VCDCs); and by the HOH, through child growth monitoring and

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nutrition education activities at UPGK village weighing posts (para. 2.10below). These advances were accompanied by significant investments inprimary and secondary education and in rural water supply and sanitation,as part of the government's overall approach to improvirg socialinfrastructure and services in the rural areas. The government's healthand nutrition priorities and goals for Repelita IV (1984-89) are elaboratedfurther in paras. 2.12-2.15 below.

Health Grganization and Cystem

2.06 The MOH is responsible for the formulation and implementation ofnational health policy and for the overall administration, coordination andmanagement of the country's health system. It is headed by the Minister,responsible to the President, and consists of the Secretariat-General, theInspectorate-General, and four Directorates-General: for Community Health,Medical Care, Communicable Diseases and Environmental Health, and Food andDrugs. The Directorate-General, Community Health is responsible for thefamily nutrition improvement program (UPGK) and for MC7/family planningservices delivered through health centers and subcenters; and, theDirectorate-General, Communicable Diseases & Environmental Health for theexpanded program of immunization (EPI) and the control of diarrhoealdiseases (CDD). The Secretariat-General consists of Bureaus for Planning,Personnel, Finance, Logistics, Health Legislation and Public Information,Organization, and General Affairs. A National Institute of Health Researchand Development, comprising six separate units, is responsible for healthresearch and its Head reports to the Minister. Finally, there are fiverecently established centers, each responsible directly to the Minister, asfollows: the Health Data Center, the Health Laboratory Center, the HealthEducation Center, the Center for Education of Health Manpower and theCenter for Education and Training of Health Personnel. An MOH orgaLigram,reflecting its recent reorganization (Decree No. 15/1984 dated March 6,1984), is attached as Chart 1.

2.07 At the provincial level, there is a dual management system forpublic health services, as is the case in some other sectors, comprising:an MOM Provincial Officer (Kakanwil), technically responsible to theMinister of Health, and a Province Health Officer (Dinas Kesehatan),administratively responsible to the Provincial Governor* In practice, oneofficial is both MOH Provincial Officer and Province Health Officer. TheKakanwil's office comprises an administrative division, which includesunits for personnel, budget, logistics, and general affairs, and fourdivisions for planning, medical services, communicable disease control, andfood and drugs. Specific programs or projects are the responsibility ofproject officers (PINPROs), who are appointed by and report to theKakanwil. The Province Health Officer is responsible for overall coordina-tion of all public health services in the province. A similar structureprevails at the district level, where the district medical officer isresponsible for coordination and implementation of all health services atdistrict, subdistrict and community/village level.

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2.08 Indonesia's health care delivery system consists of a network ofprimary, secondary and tertiary facilities. However, the principal sourceof modern public health services for the 120 million Indonesians who livein rural areas is the primary-level system of community health centers,subcenters and mobile centers under the technical responsibility of theDirectorate-General of Community Health. Health centers provide bazicmedical care, MCH services, family planning services, communicable diseasecontrol (including immunizations), hygiene and sanitation, nutrition,community health education, school health and dental treatment. Theirstaff are also responsible for recording vital statistics and healthinformation reporting. According to current MOH standards, the number andtype of paramedical staff varies according to region: up to 14 in the 2,536health centers located in Java and Bali; an average of 8-9 in the 1,113centers in North and South Sulawesi, North, South and West Sumatra, andLampung; and 5-6 in the remaining 1,684 centers in other provinces. Inpractice, however, and except for auxiliaries, these staffing standards aresatisfied only ia the larger, urbanized communities, owing to a shortage offully qualified nurses and other technical paramedicals, includingassistant nutritionists. Most health centers are currently staffed onaverage by 1 or 2 nurses and a few auxiliaries, supervised in about 80Z ofcenters by recently graduated physicians fulfilling their rural serviceobligation. In 1983/84, there were about 5,353 health centers throughoutthe country, serving an average population varying from 8,000 to 35,000 percenter, according to province. During Repelita IV, MOH plans to construct500 new health centers; and, to add in-patient facilities (10-15 beds) toabout 170 existing centers, making a total of about 300 centers (5Z of thetotal by 1988/89) with an in-patient capability. In the longer-term, MOHplans to have 20X of all health centers with such in-patient facilities,for which a necessary criterion is a minimum full-time staff of one doctorand six nurses.

2.09 Below and linked to health centers, health subcenters in the mainvillages provide basic MCH care, including vaccination and health educa-tion. Each subcenter, of which there were 13,636 in 1983/84 serving anaverage population varying from 3,000 to 10,000, is supposed to be staffedby 1 nurse and 1-2 auxiliaries, according to region. However, many sub-centers function only on certain days of the week, owing to staffshortages. During Repelita IV, MUH plans to build 6,000 new subcenters,making a total of about 19,636 by 1988/89, at which time its objective of3-4 satellite subcenters per health center would be substanitallyachieved. Finally, there were about 2,479 mobile health centers in1983/84, consisting of an ambulance staffea by a doctor, nurse, auxiliary,sanitarian and driver, and based either at a local district hospital or ahealth center. An additional 1,500 mobile centers, which provide onlybasic health care to surrounding villages, are planned to be introducedduring Repelita IV.

2.10 The outreach of this primary-level system of health centers andsubcenters to the community has been an important governmental concernduring the last few years. In addition to the family nutrition improvement

program (UPGK) formally established in 1974, a village community healthdevelopment program (PKHD) was introduced in 1977, under which villagehealth volunteers were selected by the community and given limited trainingin nearby health centers. Although NOH originally planned to train about100,000 volunteers from 5,000 villages to cover 6% of the population by1983/84, PKMD activities had been initiated in only about 700 villages byearly 1982. Qualitatively, the program was found to have had positiveresults in some pilot villages but a 1982 UNICEF-sponsored evaluationsuggested that its replicability and effective extension would require thedegree of community participation and the level of political commitmentgenerated by the family planning program and, since 1979, by the familynutrition improvement program (UPGK) implying explicit involvement by thelocal government authorities at the community level (the Ministry ofInterior's village self reliance boards - LKMDs); and also, adequatetechnical, supervisory, referral and logistics support, as well as trainingand supervision, by the MOR's community health center staff, implyingimproved staffing of these centers. This evaluation also noted that PKMD'seffectiveness had been inhibited by the fact that its activities were notwell coordinated, and to some extent competed, with the family planning andfamily nutrition improvement programs. Accordingly, the government'soperational strategy for significantly reducing infant, child and maternalmortality during Repelita IV is: to develop additional paramedical healthmanpower at the health center and subcenter level (partly with assistanceunder the recently approved second health (manpower development) project;and, to strengthen the coordination of community-level programs (familyplanning, health and nutrition) at so-called integrated service deliveryposts (pos yandu), using NFPCB's village contraceptive distribution centers(VCDCs) and MOH's (UPGK) village child weighing posts as entry points (cf.paras. 2.16-2.24 below).

Health Financing

2.11 Total health, including nutrition, expenditure in 1982/83 was anestimated Rp. 1,482 billion (US$1.35 billion equivalent), or about Rp.9,712 (US$8.83 equivalent) per capita, and 2.7Z of GDP. Although percapita expenditure has probably doubled in real terms since 1972/73,Indonesia still spends significantly less on health than many othercountries at comparable income levels. Private sources of funding(ho.sehold payments for private and public services, drug purchases andinsurance contributions) account for about 64% of total health expenditureand the private sector provides about 59% of the country's health services,almost exclusively in the main urban areas; by contrast, the public sectoris the principal source of modern health services for the 120 millionIndonesians living in rural areas. in this connection, public healthexpenditure-per capita, as a proportion of GDP and of total centralgovernment spending--remains extremely low in relation to other comparablecountries. For example, although the health sector's share of totalcentral government expenditure increased from about 2% in 1977/78 to about2.5% in 1981/82, it remained substantially below the levels allocated inChina (4.9%), the Philippines (5.0%) ane %ailand (4.3%) in 1981. Health

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sector financing issues in Indonesia are extremely complex and, given thepopulation's low health status and the country's currently constrainedresource position, increasingly important. The government, specificallyBAPPENAS and the MOH, has begun to address some of these issues (healthinsurance, the recurrent cost implications of the Repelita IV health sectorinvestment program, and the pattern of central and provincial governmentfunding of health services) with technical assistance from USAID, WHO and,in the context of economic and sector work, from the Bank.

Repelita IV - Health and Nutrition Policies

2.12 In 1982, the MDH finalized a policy document entitled NationalHealth System (SKN) which, for the first time, establishes a broadconceptual foundation for the long-term development of Indonesia's healthsystem. In addition, it provides a planning and programming framework forRepelita IV within the perspective of specific national public health goalsto be achieved by the year 2000. The latter include: an increase inaverage life expectancy at birth to 60 years; a reduction in infantmortality to 45 per thousand live births; a 50% reduction in the incidenceof most communicable diseases; and, a 67Z reduction in protein-caloriemalnutrition in children under five years. The realism of these long-termgoals is difficult to determine, owing inter alia to the lack of accuratebase-line data for these indicators. Moreover, the MOH and BAPPENAS haveonly recently begun to assess their feasibility in terms of the financialresources required and available. On the other hand, there is no questionabout their appropriateness in terms of the population's basic needs, norabout their complementarity to the government's demographic or fertilityreduction goals. The definition of long-term objectives is also anessential prerequisite for establishing political commitment and formedium-term planning.

2.13 Against this background, Chapter 23 (Health) of the Repelita IVplan document establishes five key principles (Panca Karya Husada) as theunderlying basis for health sector policies, programs and activities duringthe 1984-89 period, as follows: (a) strengthening health service delivery,including measures to support and expand primary health care activities atthe community/village level; (b) strengthening health manpower development;(c) expanding activities to improve nutrition, potable water supply, andenvironmental health; (d) establishing programs to strengther. the overallmanagement of the health system; and (e) improving the supply, distributionand quality of drugs, medicines and medical equipment.

2.14 Similarly, Chapter 10 (Food and Nutrition) of Repelita IVspecifies two main strategies as the policy basis for agricultural andhealth and nutrition programs and activities respectively: expanding anddiversifying the production and consumption of food crops, in particular ofcrops other than rice; and, intensifying efforts to improve nutritionalstatus, particularly of motners and children, in support of the country'sinfant and child mortality and fertility reduction goals. As far as thesecond of these two strategies is concerned, which is the institutional

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responsibility mainly of the MUH, three priorities for programs andactivities are established: (a) extending the coverage and improving thequality of the family nutrition improvement program (UPGK), includingstrengthened coordination of UPGK activities with those of family planning,maternal and child health, imnunization and diarrheal disease control (theso-called integrated community health package); (b) developing further thescope of nutrition surveillance activities, including specifically theextension of a pilot time'ly warning and intervention system and nutritionpolicy, research, evalration and information activities; and (c) improvingnutrition manpower development, at both the diploma (paramedical) andgraduate levels, for program implementation and management and policyplanning.

2.15 In view of their linkage to the project and loan recommendedlater in this report, the three program priorities noted in para. 2.14above-nutrition and community health, nutrition surveillance and nutritionmanpower development-and the government's plans for dealing with them arediscussed in more detail below.

B. Nutrition and Community Health

2.16 The evolution of the government's operational strategy forstrengthened coordination of community level family planning, nutrition,and health activities is described in paras. 2.22-2.24 below, preceded by asummary of the institutional background (paras. 2.17-2.19) and anassessment of the family nutrition improvement program CUPGK) to date(paras. 2.20-2.21). Further details are available in the project file.

Institutional Background

2.17 During the last 15 years, Indonesia's family planning program hasgrown from a modest, mainly clinic-based system in Java and Bali during theearlv years of Repelita I (1969-74) to a nationwide community-based networkof ilage contraceptive distribution centers (VCDCs, for the distributionof pAls and condoms) by the end of Repelita III (1979-84). At present,NFPCB functions in over 48,000 villages and provides support to over100,000 family planning acceptor groups in sub-village communities. Thelatter, especially in Java and Bali where the local tradition of 'gotong-royong" is particularly receptive to mutual self-help and communityparticipation activities, have become a focal point for the development,catalyzed by NFPCB, of related community development programs, includinghealth, nutrition, female literacy and diverse income-generatingactivities.

2.18 By the mid-1970s, lowering infant, child and maternal mortalityand, related to this, improving family nutrition, began to acquire thelevel of political commitment and official support already accorded tofertility reduction and the family planning program. In 1974, a presiden-tial decree established the family nutrition improvement program (UPGK) asa national intersectoral undertaking, involving several ministries

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(principally the MNO) and intersectoral nutrition improvement boards(BPGDs) at the national, provincial and district levels, coordinated by theKinistry of Interior. UPGK's stated purpose is to improve nutrition andthereby to help reduce infant and child mortality and morbidity. Itsactivities, directed at mothers and their preschool aged children, focus onnutrition education through child growth monitoring (monthly weighing) andthe promotion of child survival and development measures such as birth-spacing, breast feeding, oral rehydration therapy and home food production,together with distribution of nutritional 'first aids" (vitamin A capsulesand oral rehydration salts for children and iron folate tablets forpregnant women). The MOH Directorate-General of Community Health(Directorate of Nutrition), assisted by the Ministry of Agriculture andNFPCB, is the lead implementing agency for UPGK; the Ministry of Religionis responsible for srimulating community awareness and participation. By1984, and with substantial UNICEF assistance, UPGK program activities wereunderway, at varying levels of intensity and effectiveness, in more than30,000 villages (paras. 2.20-2.21 below). A detailed snmmary of UPGKprogram activities and progress to date is available in the project file.

2.19 In addition to family planning and nutrition, a third activity-the village conmunity health development program (PKMD)--was started by theMDR in 1977, partly in connection with the WHO-UNICEF internationaldeclaration on Health for All by the year 2000. However, for the reasonsindicated in para. 2.10 above, PKND attracted neither the total governmentcommitment nor the financial resources provided to the family planning andnutrition programs, by the government and the external aid agenciesconcerned. PKMD therefore became and has remained an experimental approachto primary health care in the broadest sense, rather than an operational,service delivery-based program, such as NFPCB for family planning and UPGKfor nutrition.

Family Nutrition Improvemeut Program (UPGK). 1979-84

2.20 During Repelita III, with NFPCB's family planning program alreadywell established at the community level in Java and Bali and the UPGKfamily nutrition improvement program ready to be extended from anessentially pilot scale to wider geographical coverage, the governmentdecided that its objective of expanding UPGK to about 30,000 villages by1984 could best be achieved by attaching UPGK's core package of activitiesonto the family planning program. This way of rapidly extending UPGKcoverage was considered practicable because elements of the nutritionprogram package had already been successfully tested (partly with Bankassistance under two components of Loan 1353-IND: Nutrition InterventionPilot Project and Nutrition Communication & Behavioral Change) and becauseNPPCB's network of VCDCs, including its cadre of fieldworkers, covered morethan 20,000 villages in Java and Bali alone. Moreover, this strategy wasconsistent with NFPCB's growing need to develop innovative (beyond familyplanning) approacbes, particularly in East Java and Bali wherecontraceptive prevalence had increased dramatically and the individual andcommunity benefits of family planning acceptance and continued use needed

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to be visibly demonstrated. NFPCB thus perceived UPGK as a means ofsupplementing, and thereby reinforcing, the family plannirg effort and,simultaneously, of strengthening hitherto neglected links between familyplanning and improved maternal and child health. Hence, with UNICEF a8dbilateral assistance totalling about US$17 million, UPGK was extended tosome 31,000 villages in all 27 provinces by December, 1983. In addition,with USAID technical assistance through NFPCB, an integrated familyplanning/nutrition program, jointly coordinated by NFPCB and the MOH at theprovince level, was introduced in some 3,000 villages of East Java and Baliin 1979/80.

2.21 Although an independent, program-wide impact evaluation of UPGKremains to be undertaken (during Repelita IV under the proposed project),baseline data collected in about 100 villages (covering 15,500 under-fivechildren) in 1982 and an intensive seven-village case study undertaken in1983 suggest that UPGK is having a positive influence on the knowledge,attitude and practices (KAP) of mothers concerning maternal and childhealth and nutrition. The seven-village case study, for example, indicatedthat all mothers interviewed knew the significance of weight gain or lossof their infants and 75Z stated that they attended monthly child weighingsessions to learn if their child was healthy-thus confirming their graspof UPGK's central message (a growing child is a healthy child). Knowledgeand behavior with respect to breast feeding, supplementary foods, diet, andoral rehydration were also impressive. UNICEF's own staff evaluation,conducted in September 1983, concluded that UPGK had tremendous potentialfor reducing infant and child mortality and improving the health andnutrition status of children under five years old, the most vulnerablegroup. It also made several recommendations designed to strengthen theprogram, including the following:

(a) that UPGK program villages required sustained operationalsupport in the form of technical guidance and supervision,village cadre retraining, and continuo;is supply of growthcharts, educational materials and nutrient supplements;

(b) that community health center paramedical staff (includingassistant nutritionists where available) should be givenadditional resources and support for more intensivetechnical supervision and program management andmonitoring;

(c) that immunization and other community health interven-tions, in addition to family planning, should becoordinated with UPGK activities to improve effectivenessand efficiency; and

(d) that, as the program expanded, periodic independentevaluations of program impact on nutritional status shouldbe undertaken.

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These recommendations are now being followed up by the MOH as the programexpands further, with additional UNICEF assistance totalling about US$22million for UPGK specifically during Repelita IV.

Coordinating Community Level Family Planning, Nutrition and HealthActivities

2.22 With the program development experience adumbrated above asbackground, the government decided in late 1983 that its principaloperational strategy for further reducing infant, child and maternalmortality (as well as fertility) during Repelita IV and beyond should be tostrengthen coordination of family planning, health and nutrition servicedelivery, both at the lowest level of the formal health system (communityhealth centers and subcenters) and in the communities and villagesthemselves. Specifically, it decided that five priority community healthinterventions or services-namely, family planning, nutrition,immunization, diarrheal disease ;ontrol, and maternal and childhealth--should be planned, funded and implemented in a coordinated fashionby the executing agencies concerned, i.e. the NFPCB (family planning), theMDI Directorate-General of Community Health (nutrition and maternal andctild lealth) and the MOH Directorate-General of Communicable DiseaseControl [expanded program of immunization (EPI) and diarrheal diseasecontrol (CDD)I. The basic rationales for proceeding with this coordinatedapproach are broadly twofold: improved effectiveness, e.g. instead offamilies having to make five separate visits to village service deliverypoints (sometimes at different locations and on different days), a singlecoordinated session would provide access to all five services during onevisit and in a more coherent technical manner; and, second, increasedefficiency, e.g. the amount of travel time and number of staff required, atleast in the longer-term, would be less than for five separate progrems,since some services and activities could ultimately be handled by the sameworker.

2.23 From the policy and overall sectoral planniug point of view, thisstrategy or approach is neither new nor. in theory, particularly difficultto contemplate-particularly in Indonesia, whose policy-makers have forlong recognized the inter-relationships lietween fertility, mortality andmorbidity. In practice, however, coordinated service delivery will be noeasier to implement in Indonesia than elsewhere and must therefore beregarded as a gradual, long-term process. It will also entail at least twosignificant risks: first, that the relative strengths and effectiveness ofthe individual programs (family planning and nutrition, for example) maybecome diluted in the interests of the coordinated whole; and second, thattwo, somewhat unequal government agencies-the relatively strong, semi-autonomous, decentralized and well-endowed NFPCB and the relatively weak,centralized and underfunded MOH Directorates-General--may have difficultyachieving meaningful collaboration between their staffs, at national,provincial and district levels.

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2.24 While these risks cannot be avoided, they are fully appreciatedat the highest levels of the agencies concerned. Indeed, their officialsacknowledge that a necessary prerequisite for successful implementation ofthe coordinated strategy is a substantial strengthening of each programindividually, in particular the maternal and child health, diarrhealdisease and immunization programs. In addition, the strategy will reauireaction to mobilize increased community participation; coordination offinancial resource allocation at the central, provincial, and district/subdistrict levels (implying improved planning capability); coordination ofeach program's training and communications (IEC) activities at all levels(implying strengthened community health education and training capability);and, strengthened management and supervision (including monitoring andevaluation) of both the programs themselves and, in time, of theirindividual and collective impact on the population's fertility, mortalityand morbidity. It is in these areas-community participation, planning,management and supervision, and commt"cations-that the government hasrequested Bank assistance under the community health component of theproposed project (paras. 3.05-3.13 below).

C. Nutrition Surveillance

Background

2.25 Nutrition surveillance, a term widely used only since theUN-sponsored World Food Conference in 1974, encompasses a broad variety ofactivities that have been developed for three main purposes: (a) nationalnutrition policy formulation and planning; (b) national nutrition programdevelopment, management and evaluation; and (c) local 'timely warning andintervention systems designed to avert, or mitigate the worst consequencesof, short-term food deficits and accompanying nutritional emergencies. Atthe 1974 UN conference referred to above, all member countries wereencouraged to establish comprehensive nutrition surveillance systems: tomonitor food and nutrition conditions among the most vulnerable groups;and, to develop the national data collection and analysis capabilityrequired to identify the variables affecting food consumption andnutritional status. During the last decade, several countries haveinitiated a wide range of nutrition surveillance activities, includingIndonesia.

Nutrition Surveillance in Indonesia

2.26 Partly in response to the above international initiatives andpartly as a result of growing national concerns about malnutrition and itslink to infant and child mortality, nutrition surveillance in Indonesiaduring Repelita III developed along two lines: first, the analysis ofhotsehold data collected under the National Socioeconomic Survey (SUSENAS)by the Central Bureau of Statistics, assisted by a Bank research grant(672-19: 'Poverty, Fertility & Human Resources in Iu.onesia'); and second,the design of a pilot timely warning and intervention system (TWIS) in twodistricts of Lombok and Central Java. Regarding the latter, these two

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provinces were chosen because they satisfied the basic criterion ofpotential vulnerability to periodic, short-term and localized food deficitsand malnutrition; in addition, sufficient food consumption and nutritionalstatus baseline data was available and the provincial and districtauthorities concerned were both interested in and committed toparticipation. Accordingly, during the following four years, the MOH'sCRDN, together with the Institute of Agriculture, Bogor (IPB) and the MOH'sDirectorate of Nutrition (with USAID-financed technical assistance)designed and set up the fully operational TWIS that is now in place inLombok and central Java.

2.27 In January, 1984, a national food and nutrition surveillanceseminar was held to review the progress and results of the pilot TWIS inLombok and to- consider how additional nutrition surveillance activitiesshould be further developed during Repelita IV. Three important recommend-ations emerged from this seminar, which were subsequently accepted by thegovernment and incorporated into the food and nutrition chapter of theRepelita IV plan document, as follows:

(a) the Lombok TWIS should be replicated and introduced inphases in (up to 40) selected districts in 12 provinces;

(b) the scope of Indonesia's nutrition surveillance activitiesshould be gradually broadened to include: monitoring andassessment activities, policy and program studies, anddata collection and infor-ation systems, in support ofnational and provincial health and nutrition planning andprogram evaluation (e.g. UPGK); and

(c) the MOH's Directorate of Nutrition should be the principalcoordinating agency for food and nutrition surveillance inIndonesia, although specific assignments, projects andtasks would be carried out by whichever government depart-ment and/or non-government organization was approlriate.

Against this background and with the mandate indicated in (c, above, theDirectorate of Nutrition set up a task force in mid-1984, consisting ofmembers of its own staff and representatives of the CRDN, IPB and otheragencies, to prepare a master development plan for nutrition surveillancefor Repelita IV and beyond. A copy of this master plan, constituting theoverall framework for the nutrition surveillance component of the proposedproject (paras. 3.14-3.17 below) is available in the project file.

D. Nutrition Manpower Development

2.28 Indonesia's national commitment to nutrition, in general, and itsincreasing number of nutrition and nutrition-related activities andprograms, in particular, has created a demand for additional manpower withprofessional skills, training and experience in nutrition. Although theAcademy of Nutrition and School for Assistant Nutritionist in Jakarta, both

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supported under Loan 1353-IND, helped bridge the gap between supply anddemand through Repelita III, many more nutritionists will be required inthe meditum- and longer-term. This requirement manifests itself at twolevels: at the diploma or paramedical level, i.e. nutritionists andassistant nutritionists required mainly for MOH provincial and districtoffices, hospitals and, in particular, community health centers--the basefor outreach guidance, management and supervision of the village-levelcommunity health programs described earlier in this report. (paras.2.17-2.24 above); and, at the university graduate and post-graduate level,i.e. nutrition professionals and specialists needed for senior policy,planning and research positions in the main government ministries anddepartments concerned. Regarding the latter, BAPPENAS' Health andNutrition Bureau, for example, is currently staffed by only thi e seniorprofessionals with university-level training in nutrition, although thereis provision for ten positions during Repelita IV. At present, there areonly four fully functioning nutrition manpower training institutions in thecountry: the academy of nutrition and school for assistant nutritionistsnoted above; a private sector academy in West Java; and, the Department ofCommunity Nutrition & Family Resources (GMSK) at IPB.

2.29 During Repelita IV, the MOB plans to increase its overallmanpower by about 75%, from about 162,000 at present to about 284,000 by1988/89.2/ Of this total, paramedicals would double, from about 56,700 toabout 114,700, of which nutritionists and assistant nutritionists wouldincrease from about 1,100 to about 6,100. This is to be achieved bydeveloping 4 new nutrition academies and 11 new assistant nutritionistschools, of which 3 have started operations in temporary premises in SouthSulawesi, and South and West Sumatra respectively. Further details of theMOE's overall health manpower development policies, programs and plans arecontained in the second health (manpower development) project staffaPpraisal report (Report No. 5442-IND dated April 24, 1985). As far asuniversity graduate level manpower is concerned, IPB's Department ofCommunity Nutrition & Family Resources (under the Ministry of Education andCulture) plans to introduce a new S3 (Ph.D) program, in addition to itsexisting small SI (bachelor's) and S2 (master's) degree programs.

2.30 The proposed investments in paramedical and university levelnutrition manpower education and training noted above constitute theframework for the autrition manpower development component of the projectand loan recommended later in this report (paras. 3.18-3.20 below).

E. Bank Role and Assistance Strategy

Experience with Past Lending and Rationale for Bank Involvement

2.31 Bank Group assistance to Indonesia for population, health andnutrition to date totals US$197.7 million comprising: one credit and three

2/ Further details of the government's plans and investment priorities fordeveloping health and nutrition manpower are available in the StaffAppraisal Report on the Second Health (Manpower Development) Project(No. 5442-IND).

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loans for population amounting to US$118.7 million; two loans for healthamounting to US$66 million; and a single US$13 million loan for nutrition.Four of these projects have been satisfactorily completed and fullydisbursed (net of cancellations owing to local currency devaluations); two(for the fourth population and second health (manpower development)projects respectively) were approved in May, 1985 and (are expected to bedeclared effective shortly); and one (Loan 2235-IND for provincial health)is in the second full year of implementation and, compared with appraisalestimates, about nine months behind schedule, owing mainly to delays in itscivil works components. Subject to minor caveats with respect to initialimplementation delays in the first population, health and nutritionprojects, the Bank's overall experience with PUN projects in Indonesia sofar has been satisfactory, particularly in terms of achieving their programdevelopment and institution-building objectives.

2.32 A completion report for the first nutrition project (Loan1373-IND) was submitted to the Operations Evaluation Department in July,1985. Its principal conclusions were: that the base for nutrition-relatedactivities in Indonesia was far better today than at project inception;that the project's three major objectives-institution-building, thetesting of field-level nutrition interventions, and policy formulation anddevelopment-had been largely met; and, that the government's proposals forfollow-up activities to further strengthen its national nutrition effortsdeserved serious consideration by the Bank and other external aidagencies. The explicit rationale for Bank assistance for the proposedsecond nutrition and community health project is thus to follow up andbuild upon the policy, program and institutional development initiativesstarted by the government, partly with assistance under the first project.This second project also takes into account, and will indeed complement,existing and proposed UNICEF, USAID and WHO financial and technicalassistance to Indonesia for health and nutrition.

PHN Sectoral Assistance Strategy

2.33 In a broader context, the Bank's sectoral assistance strategy inIndonesia is to assist government efforts to improve coordination betweenits population, health and nutrition subsectors and institutions, insupport of the country's ambitious fertility and infant and child mortalityreduction goals. Such improved coordination is necessary in policy andprogram implementation terms because of the interdependence of efforts toreduce fertility, mortality and morbidity. The implications of thisstrategy for Bank operations in the immediate future include: continuingassistance for population and family planning per se, through the NFPCB andthe Ministry of Population & Environment (e.g. the recently approved fourthpopulation project); and, because of their relative weakness and, untilrecently, perceived lack of priority, substantially increased assistancefor health and nutrition, mainly through the various MOH institutionsconcerned. The recently approved second health (manpower development)project and the proposed second nutrition and community health projecttogether comprise the second element of this coordinated PHN strategy. Inaddition, a second provincial health project is being identified andprepared during the coming year for proposed Bank lending.

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III. THE PROJECT

A. Project Concept and Main Features

3.01 Indonesia's policy, program and institutional development effortsto deal with malnutrition since the mid-1970s and its priorities fornutrition and community health during Repelita IV were outlined in paras.2.12-2.30 above. Against this background, the project's concept and mainfeatures may be summarized briefly as follows.

3.02 First, one of the government's main national public health goalsis to reduce infant mortality from about 95 per thousand live births in1983/84 to around 70 per thousand live births by 1988/89. This goal is apriority health sector objective in and of itself, as one key indicator ofthe population's overall health status. It is also a prerequisite for, anda necessary complement to, the equally important national imperative ofsustaining (and, if possible, accelerating) the decline in overallfertility already underway. The attainment of these infant mortality andfertility reduction goals depends inter alia on widespread access to andthe effective delivery of a technologically simple package of communityhealth services (family planning, maternal & child health, nutrition,immunization and diarrhoeal disease control) which, if properlycoordinated, reinforce each other and, in the longer term, can result intheir improved effectiveness and increased efficiency. Experience to datewith the family planning and family nutrition improvement programs,particularly in East Java and Bali, has demonstrated the potential for suchcoordination at the village and/or community level. Thus, while thegovernment intends to further extend and strengthen both family planningand nutrition activities in currently underserved areas, it also plans toutilize their respective institutional infrastructures and presence (i.e.existing contraceptive distribution centers, family planning acceptorgroups, and child weighing posts in villages and subvillage communities)not only to support each other's activitieA but also to promote and extendthe coverage of maternal & child health, imLmnization and diarroeal diseasecontrol activities. This coordinated approach to community healthservice delivery, by definition a gradual, long-term process, will require:strengthened community participation; coordinated planning, management andsupervision of these five programs; an integrated community healtheducation/communications support strategy; and strengthened programmonitoring and evaluation.

3.03 Second, as far as nutrition-specific policies, programs andactivities are concerned, the government's operational priorities forRepelita IV are broadly threefold: to extend UPGK program coverage fromabout 31,000 villages at present to all Indonesia's 65,000 villages by1988/89, if possible; to intensify and broaden the limited nutritionsurveillance activities initiated during Repelita III and thereby improvethe quality of health and nutrition policy formulation, sectoral planning,and program development and evaluation; and, related to both, to increase

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the output and availability of qualified nutrition manpower at theparamedical and graduate levels. The government, with UNICEF assistance,has already committed very substantial resources to the UPGK program forRepelita IV and little or no further external aid is required in theimmediate future. However, both nutrition surveillance and nutritionmanpower development require external financial and technical assistance tocomplement the limited government resources available.

Project ObJectives

3.04 The project's overall goal is to assist Indonesia's efforts tocombat malnutrition (particularly in mothers and children under five yearsof age) and thereby to help reduce infant, child and maternal mortality andmorbidity. Its specific operational objectives would be threefold:

(a) to strengthen the coordination and management of fivecommunity health programs through support for: communityparticlpation; planning, management and supervision;communications; and the secretariat of the Directorate-General, Community Health; and through direct operationalsupport to these programs individually;

Cb) to develop further Indonesia's capacity for nutritionsurveillance through support for: extending its timelywarning and intervention system (TWIS), nutrition statusmonitoring and assessment activities, nutrition policy andprograa studies, and, nutrition information; and,

(c) to improve and strengthen nutrition program implementationand policy planning through support for: nutrition manpowerdevelopment at the paramedical and graduate levelsrespectively.

These separate but inter-related objectives would be accomplished by theproject inputs described in paras. 3.05-3.22 below.

B. Project Composition

3.05 The project would have three major components, each with a numberof subcomponents as follows:

A. Strengthening the Coordination and Management of Community Health

A.1 Strengthening community participation through:

(i) training and orientation of village leaders in the purpose of thefive key community health programs and in the organization ofcommon service delivery posts (pos yandu);

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(ii) training of village volunteers (kader) in organization andmotivation and in the basic technical content of the five healthprograms; and

(iii) assisting in the institutional development of the Directorate kfCommunity Participation.

A.2 Improving planning, management and supervision through:

ti) assisting in the development of a systematic process for theplanning of health activities, based on a reliable assessment ofcommunity health needs;

(ii) helping to generate broad commitment to the coordinated healthservices delivery approach among community leaders at thenational, provincial, district and subdistrict levels; and

fiii) strengthening supervision and monitoring at the provincial,district, subdistrict and community levels, includingdevelopment/production of supervision manuals and determinationof appropriate indicators to monitor program progress.

A .3 Improving communications through:

Ci) developing and implementing a nationwide promotional campaignrelating to the coordinated health programs;

(ii) developing and producing communications materials and messagesfor the individual health and nutrition programs in support oftheir community activities;

(iii) developing instructional materials and training of kader trainersat the provincial, district and subdistrict levels in support ofA.1(i) and (ii); and

(iv) assisting in the institutional development of the recently-established Center for Community Health Education.

A.4 Strengthening the planning, managerial and coordination capacityof the Community Health Secretariat.

A.5 Providing operations support funds for program supplies as neededfor service delivery at the community health centers or below.

B. Developing Nutrition Surveillance

B.1 Strengthening and extending the timely warning and interventionsystem (TWIS) to about 37 districts in up to 11 provinces through:

(i) carrying out of feasibility studies to determine the districtsfor TWIS expansion; and

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(ii) strengthening the naticnal TWIS support unit and establishingprovince- and distri_t-level TWIS teams.

B.2 Strengthening nutrition monitoring and assessment through supportfor the implementation of five operational research projects/surveys.

B.3 Supporting nutrition policy and program studies in four priorityareas to assist in national and local policy formulation and programdevelopment.

B.4 Improving nutrition information dissemination throughstrengthenirg the nutrition information unit in the Directo-ate ofNutrition.

C. Improving Nutrition Manpower Development

C.1 Strengthening paramedical nutrition manpower development through:

(i) establishing two nutrition academies and six assistantnutritionist schools; and

(ii) helping to improve educational quality at paramedical nutritioninstitutions.

C.2 Strengthening of graduate nutrition manpower development through:

vi) physical development of the Institute of Agriculture's (IPB's)facilities for existing bachelor's, master's and proposeddoctoral degree programs in nutrition;

(ii) developing a nutrition course for staff of the Ministry ofAgriculture; and

(iii) establishing a food and nutrition policy analysis unit at IPB.

C. Detailed Project Description

Strengthening Coordination & Management of Community Health (US$21.0million)-5/

3.06 To achieve its infant, child and maternal mortality reductiongoals, the government is focussing its main effort and resources on thecoordinated delivery of the five key community health programs in 11provinces-East, Central and West Java, DKI Jakarta, North, South and WestSumatra, East and West Nusa Tenggara, Lampung and South Sulawesi. These 11provinces include about 80% of Indonesia's population and account for about82% of total infant deaths. Depending on local circumstances, the familynutrition improvement and/or family planning programs' community-levelactivities, Which have hitherto developed and functioned independently

3/ Project costs cited in Chapter III Section C exclude taxes andcontingencies.

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(except in East Java and Bali), are being utilized as the principal entrypoints for the development of so-called common service delivery posts orpos yandu, organized by the communities themselves, to which immunization,diarrhoeal disease control and other maternal and child health services areadded with technical support and guidance from the local community healthcenter or subcenter. Thus, the five key programs' actitivies are conductedby village kader (volunteers) who are responsible to the Ministry ofInterior's village self-reliance boards (LKMDs), with the technicalassistance and support of trained family planning, health and nutritionstaff from NFPCB's subdistrict offices and the MOH's health centers andsubcenters. Moreover, program activities, since they are organized and runby the communities themselves, are conducted at the same time and place,making it easier and more effective and efficient for the principalbeneficiaries-i.e. mothers and their children-to participate in all fiveprograms. This process of coordinating community health activities throughcommon service delivery posts or pos yandu is already underway in someareas, based on local initiatives and the experience already gained in EastJava and Bali, and the objective of this component of the project would beto strengthen the process and the three 10 institutions concerned in threeareas: community participation (Directorate of Community Participation);planning, management and supervision (Directorate of Community HealthCenters); and, communications (Center for Community Health Education). Inaddition, the project would provide support for management (includingmonitoring and evaluation) of the Directorate-General, Community Healthitself and also for additional supplies that may be needed for any or allof the five programs, supplementing resources already committed by UNICEFand other donors.

3.07 Community Participation (US$6.1 million). The role of the MOH'srecently established Directorate of Community Participation (a departmentof the Directorate-General, Community Health) is to promote and supportcommunity involvement and participation in activities related to the basichealth of mothers and children. To this end, the Directorate will work inclose collaboration with the Ministry of Interior's LKMDs, the women'sorganization ifL the communities (PKK) and other village-level institu-tions. The project would thus support two kinds of activities: trainingand orientation of village leaders in the organization of pos yandu and inthe purpose of the five key community health programs (about 16,500villages in 11 provinces); and, training of village kader in organizationand motivation and in the basic technical content and activities of thefive programs (about 16,500 villages in 11 provinces). In addition, theproject would assist in the institutional development of the Directorate ofCommunity Participation through provision of fellowships, vehicles, traveland subsistence costs, honoraria and technical assistance (required forprogram implementation and supervision). Further details of theseactivities are available in the project proposal available in the projectfile.

3.08 Planning, Management and Supervision (US$5.2 million).Coordination of the five key programs will require sigrificant assistanceand support from outside the community and from two major sources: thelocal community health center or subcenter which is responsible for allhealth activities within its coverage area; and, the LKMD, under the

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Ministry of Interior's Directorate, Community Development which overseesall village-level activities across sectors. The MOH's Directorate,Community Health Centers is responsible for planning, managing andsupervising the activities of health centers and subcenters and theiroutreach support and guidance to the community (pos yandu), incollaboration with the Directorate of Community Participation, the NFPCB(for family planning) and the Ministry of Interior's Directorate ofCommunity Development.

3.09 One necessary precondition for the effective coordination ofvillage-level service delivery is the systematic planning of activities,based on a reliable assessment of the communityts overall health status,problems and perceived needs. Such community health assessments and thedefinition of locally relevant health plans need to be undertaken at thelowest possible level of the health system, i.e. the community healthcenter. Aggregation of these plans at the district level, and of districtplans at the province level, should then facilitate rational resourceallocation, by locality and by program, and provide a baseline forsupervision and for program monitoring and evaluation. This process ofcommunity health assessment and planning, termed "microplanning' by theMON, has already been tried in selected areas of West Java and Bengelu,with WHO technical assistance, and, using a similar 'functional analysis'methodology, is to be continued in five districts of West Java by theUniversity of Indonesia, School of Public Health (with UNDP/USAIDassistance). Meanwhile, the MOM is proceeding with the introduction of'microplanning" in 8 of the 11 priority provinces noted in para. 3.05above, although no evaluation of its effectiveness in terms of improvedresource allocation and program implementation has yet been undertaken.

3.10 To complete the introduction of the 'microplanning' process inthe 3 remaining priority provinces of North & South Sumatra and Lampung,the project would provide support to the Directorate, Community HealthCenters for staff orientation and training (including fellowships),community health assessments and plans, and planning workshops in 31districts, comprising about 1,203 sub-district couminity health centers orsubcenters. In addition, an evaluation of "microplanning" experience todate in a representative sample of subdistricts would be undertaken as thebasis for targetting future incremental resource inputs that may berequired to strengthen the entire process. During negotiations, assuranceswere obtained that this evaluation would be undertaken and completed bySeptember 30, 1986.

3.11 As suggested in pars. 2.10 above, the process of coordinatedservice delivery itself will need to be encouraged and supported by(i) increased political commitment; and (ii) strengthened supervisionparticularly at the province, district, subdistrict and community levels.To help generate the requisite commitment, the project would provide fundsto the Directorate, Community Health Centers to conduct training meetingsfor community leaders at the national, provincial, district and subdistrictlevels to increase their awareness and knowledge of the coordinated

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programs. And, to strengthen field supervision at the province, district,subdistrict and community levels, with particular emphasis on technicaladvice and assistance for coordination of the five comunity healthservices, the project would provide support for the development ofsupervision manuals and travel and subsistence costs of supervisionactivities in the 11 priority provinces (comprising about 180 districts andover 3,100 subdistrict community health centers) over 4 years. Forpurposes of project preparation and project cost estimates, the followingperiodicity and duration of supervisory visits was assumed: province/district - thrice annually for 5 days each; district/subdistrict - thriceannually for 3 days each; and subdistrict/village or community - thriceannually for 2 days each. These field supervision activities would becarried out in the 2nd through the 5th year of project implementation, withthe field-testing and reproduction of the supervision protocols or manuals(already being prepared with WHO technical assistance) being completedduring the 1st year. During negotiations, assurances were obtained that:appropriate supervision guidelines/manuals would be available by September30, 1986 and that annual supervision schedules would be prepared by March31 each year for review by the Bank during project supervision.Supervision would thereafter be implemented, taking into account the Bank'scomments. In addition, to ensure adequate monitoring of the progress ofthe coordinated approach, assurances were obtained that an index ofreporting/monitoring indicators for the five community health services,based on data already being collected, would be developed by September 30,1986.

3.12 Communications (US$3.7 million). Motivating collaborativeefforts by officials and staff of different institutions (MOH and NFPCB)and of different departments and programs within the same institution(Directorates of Community Health and Communicable Disease Control)requires inter alia that the rationale for and the overall benefits of suchcollaboration be clearly understood and accepted by individuals concernedat all levels. This involves leadership skills by the principal officersconcerned and, for a process as complex and evolutionary as the integratedapproach to community health, staff orientation and in-service training.In addition, the (largely uneducated) target population in the communityitself needs to understand better the inter-relationships between specifichealth service interventions and family health knowledge, behaviour andpractices; for example, breast feeding and child nutrition or oralrehydration and diarrhoea. This involves an oEten innovative andculturally acceptable health education and communications support strategy,which was pioneered and successfully tested on a large scale under thefirst nutrition project. Experience throughout the world and in Indonesiaitself has proven that the effectiveness of community health activities isgreatly enhanced by well managed and focussed information, education andcommunications (IEC) acivities. The responsibility for these activities inthe MOH lieo with the Center for Community Health Education and the projectwould provide support to this Center for three types of activities: {i) anationwide promotional campaign relating the significance of the five keycommunity health programs to the goal of reducing infant and childmortality; (ii) the development of communications materials and messages

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for four of the five programs (excluding family planning which has its ownIEC apparatus) in support of their activities in the communities; and(iii) development of instructional materials and training of village cadretrainers at the provincial, district and subdistrict levels in their use,and in the broader teaching techniques required to successfully implementthe community level training (para. 3.07). In some cases, both developmentand production work would be contracted out to appropriately qualifiedprivate firms and agencies. In addition, the project would assist in theinstitutional development of the recently-established Center for CommunityHealth Education through provision of fellowships, technical assistance,vehicles and funds for annual planning workshops.

3.13 Community Health Secretariat (US$1 million). In order to managethe community health component of the project, as well as coordinate theactivities of the other two components, (i.e., nutrition surveillance andmanpower development) the project would provide support for incrementalstaff required for the existing secretariat of the Directorate-General,Community Health: 2 finance officers, 2 procurement officers, 3 planningand evaluation officers, a deputy executive secretary and 2 supportstaff-a total of 10 full-time staffz In addition to their overallmanagerial and supervisory responsibilities, these additional staff wouldalso direct the carry4;g out of two evaluations of the coordinatedcommunlity health programs: a baseline survey to assess the current statusand coverage of the five programs in the 11 provinces focussed on thedevelopment of pos yandu, to be carried during the first six months ofproject implementation; and, a mid-project evaluation of progress, to becarried out in 1987/88, the results of Which would be available by April30, 1988 for planning for Repelita V, commencing April 1, 1989. Duringnegotiations, assurances were obtained concerning the timetable, scope andterms of reference for these two evaluations. In addition, the appointmentof the 10 additional staff referred to above is a condition ofeffectiveness of the proposed loan. Finally, to strengthen its longer-termmanagement, supervision and coordination capacity, the project wouldprovide the secretariat with technical assistance in planning andmanagement; office equipment and vehicles; fellowships; and funds forsupervision, monitoring and meetings.

3.14 Programs Operations Support Funds (US$5 million). Although thefamily planning (NFPCB) and family nutrition improvement (UPGK) programsreceive substantial government and external financial assistance (fromUNFPA, USAID and the Bank, and from UNICEF respectively), the maternal &child health, immunization and diarrhoeal disease control programs have sofar not attracted significant resources, owing partly to their stilllimited coverage and absorptive capacity. If, as planned, the coordinatedapproach to community health generates increasing demand for more intensiveor extensive activities in these three areas, it is possible that theseprograms' development could be constrained by lack of resources. Toobviate this eventuality and because it is impossible to forecast preciselytheir actual needs over a 5 year period of potentially rapid progress, theproject would provide funds in the amount of US$5 million for programsupplies (equipment, drugs, vaccines, consumable materials, etc.) that maybe needed for service delivery activities at the community health center orbelow. While it is intended that, for the reasons indicated above,

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maternal and child, immunization and diarrhoeal disease control activitieswould have first call on this fund and thus be its principal beneficiaries,family planning and nutrition program surplies would not be excluded.

3.15 The programs operations support funds would be administered bythe Project Steering Committee (para 5.02), chaired by the Director-Generalof Community Health. During negotiations it was agreed that no withdrawalswould be made in respect of these funds until the Steering Committee hassubmitted recommendations satisfactory to the Bank for their use. Suchrecommendations would include: (i) requirements for supplies forindividual community health programs; (ii) availability of domestic andother external financial support for these programs; and (iii) proposed useof funds covering to the extent possible requirements for two-yearperiods. In this connection, if specific program requests includedequipment, materials and/or supplies available through UNICEF's catalog orinternational procurement system, the government would request UNICEF toprocure on its behalf and the Bank to reimburse UNICEF directly.

Developing Nutrition Surveillance (US$10.3 million)

3.16 Timely Warning and Intervention (US$3.9 million). DuringRepelita IV, it is planned to extend the pilot timely warning &intervention system (TWIS) developed in Lombok (paras. 2.26-2.27 above) to37 districts in up to 11 provinces, most vulnerable to periodic foodconsumption problems and nutrition emergencies. The 37 districts would beselected following feasibility studies at the province level. Thesestudies would also identify staffing and the other inputs required in theselected districts and provide the basis for provincial TWIS planning anddevelopment workshops. In addition to the 37 district-level TWISactivities, province-level TWIS teams (about 10 individuals from both localgovernments and universities) would be developed, with assistance from theexisting national TWIS team, to design and support the district-levelTWIS. Finally, because of the large volume of provincial anddistrict-level development work to be undertaken, the project wouldstrengthen the national TWIS support team in the Directorate of Nutrition.To this end, the Directorate of Nutrition would be assisted by IPE, CRDN,BULOG and Ministry.of Agriculture staff aE needed. The project wouldtherefore provide support in the form of local and foreign consultancies,training, equipment, vehicles and materials, travel and subsistence costsand honoraria for the above purposes. During negotiations, assuranceswere obtained that annual TWIS development plans would be prepared by May31, 1986 and by March 31 in each year thereafter for review by the Bankduring project supervision.

3.17 Nutrition Monitoring & Assessment (US$4.4 million). Despiteincreasing knowledge about the causes and consequences of malnutrition,Indonesia's data base is still inadequate for a country of its size anddiversity. Thus, one important element of the government's strategy forbroadening the scope of nutrition surveillance activities is the systematicmonitoring and assessment of nutritional status and nutrition problems,programs and activities. To this end, the project would provide support(in the form of technical assistance, training, equipment, vehicles,materials, travel and subsistence costs and honoraria) for five operational

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research projects/surveys in the following areas: (a) proteinr-energymalnutrition (PEM), mortality and UPGK program participation at thesubdistrict and village levels in eight provinces & DKI Jakarta;(b) anthropometric measurement of preschool-aged children through the 1986,1987, and 1988 SUSENAS sample surveys carried out by the Central Bureau ofStatistics at the national and provincial levels; (c) goiter prevalenceamong primary school children (a national sample survey) and revision of anational goiter prevalence map; (d) prevalence of vitamin A deficiencyamong preschoolers in six provinces; and (e) an evaluation of the UPGKprogram's growth monitoring system (SKDN) and the development of additionalSKDN indicators. Further details of these monitoring and asses3smentactivities are available in the project file. The scope, general terms ofreference, and implementation schedule for the above activities werediscussed and agreed at loan negotiations.

3.18 Nutrition Policy & Program Studies (US$1.1 million). In additionto the monitoring and assessment activities outlined in the precedingparagraph, special policy-based studies and analyses are required from timeto time, in particular by national planners in BAPPENAS and certainsectoral ministries (Health, Agriculture, Interior, Education andPopulation & Environment, for example) to support improved national andlocal policy formulation and program development. The project wouldtherefore provide support for such policy and program studies in four broadareas: (a) the formulation of food and nutrition policies and pla:1s forRepelita V; (b) an inrdepth independent impact evaluation of the UPGRprogram; (c) a program of discrete, issue-oriented studies required for theannual development planning and budgeting process, mainly by BAPPENAS; and(d) to augment the limited operttional research budget of the FoodTechnology & Development Center (FTDC) established under Loan 1353-IND, astudy or studies in village food technology to be commissioned by theDirectorate of Nutrition in support of its programs. In addition, aproject allocation of US$100,000 would be provided for unidentifiedsmall-scale studies, not exceeding US$10,000 each, that would be definedand agreed during project implementation. While the Directorate ofNutrition would be responsible for the commitment and disbursement ofproject funds for all the policy and program studies noted above,individual studies and research projects would be implemented byappropriately qualified government agencies, university departments and/orindividuals (consultants) as decided by a Steering Committee, chairedjointly by the Directorate of Nutrition and the Health and NutritionBureau, BAPPENAS. Draft outline terms of reference for the studiesspecified above have been prepared and were discussed and agreed duringloan negotiations. In addition, assurances were obtained that anrnal plansfor policy studies would be prepared by May 31, 1986 and by March 31 ineach year thereafter for review by the Bank during supervision. Theestablishment of the Steering Committee noted above is a condition of loaneffectiveness.

3.19 Nutrition Information (US$0.9 million). The effectiveness andpotential impact of the monitoring and assessment and policy and programstudies to be undertaken above, in raw scientific or technical language,will be limited unless it can be presented and disseminated in a

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comprebensible manner to those who can act on such information. Moreover,given Indonesia's size and diversity, it is important that the results ofon-going policy and research work be available promptly and circulated toall interested parties, particularly to provincial and district-levelgovernments and universities throughout the country. Accordingly, theproject would provide support for the development of a nutritioninformation unit, in the Directorate of Nutrition, to assemble, catalog,and disseminate nutrition data; edit, print and distribute policy andresearch documents; and, as required, respond to requests, by governmentoff'^ials and/or the public at large, for nutrition data and information.This support would consist of funds for training, technical assistance,staff allowances, travel and subsistence costs and the acquisition ofnutrition books/periodicals, and equipment. During negotiations,assurances were obtained that the Nutrition Information Unit wouldcommence its activities by May 31, 1986, and be maintained thereafter withappropriate staffing and budgetary resources.

Improving Nutrition Manpower Development (US$13.7 million).

3.20 Paramedical Nutrition Manpower Development (US$8.7 million). Asindicated in paras. 2.28-2.30 above, the expansion of the UPGK program andits technical quality and management is already somewhat constrained byinsufficient numbers of diploma-level nutritionists and assistantnutritionists in MOR provincial district offices and, in particular, at thesubdistrict community health centers-the operational base for logisticssupport and program activities at the village level. To alleviate thisgrowing shortage, part of a much larger overall health manpower developmentplan, the government has sanctioned the development of 15 new nutritionmanpower training institutions (4 academies and 11 assistant nutritionistschools) during Repelita IV. Accordingly, the project would providesupport for the development of 8 of these institutions (2 academies and 6schools) in Aceh, Bali, East, Central and West Java, North and SoutheastSulawesi and West Nusa Tenggara. Funds would be provided for physicaldevelopment (civil works, equipment, furniture and vehicles (2 perinstitution)) and for books and teaching aids and materials. In addition,to improve educational quality at paramedical nutrition institutions, theproject would provide support for staff training, technical workshops andimproved supe.vision.

3.21 Graduate Nutrition Manpower Development (US$5.0 million). Whilethe dearth of qualified and experienced senior nutrition professionals inabsolute terms is quantitatively less dramatic than for paramedicalnutrition manpower, the shortage in relative and qualitatitive terms isjust as important, not least because of the long lead time required for theeducation and training of university-level graduates. Hitherto, thelimited numbers of Indonesian graduates in nutrition at the master's anddoctoral degree level have mostly obtained their tertiary level trainingoverseas, in Europe and the United States. Meanwhile, the Institute ofAgriculture, Bogor (IPB), through its Department of Community Nutrition &Family Resources (GMSK), conducts a small bachelor's (SI) and master's tS2!

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degree level program and plans, with the Ministry of Education & Culture'sapproval, to develop a doctoral (S3) degree level program, the first in thecountry.

3.22 Accordingly, the project would provide funds for the physicaldevelopment of improved and expanded administrative, classroom and labora-tory space (civil works, equipment, furniture and teaching aids andmaterials) for GMSK's existing bachelor's, master's and proposed doctoraldegree programs in nutrition; support for the development of a nutritioncourse for staff of the Ministry of Agriculture; and computing facilities,technical assistance and fellowships required for the establishment of afetd and nutrition policy analysis uinit at IPB. The proposed GMSK facilitywouiL be located at the new campus currently under development as part ofIPB's 20-year long-term plan.

IV. PROJECT COSTS AND FINANCING

A. Cost Estimate

4.01 The project's estimated total cost is Rp. 63.5 billion or US$57.7million equivalent, including value added taxes (VAT) amounting to Rp 1.7billion or US$1.5 million equivalent. The total project cost net of dutiesand taxes, therefore, iq Rp 61.8 billion or US$56.2 million equivalent.Its foreign exchange component is an estimated US$14.7 million, or 26Z ofthe total. Detailed project costs are presented in Annex 2 and aresummarized, by component and exper-diture category, in Tables IV.1 and IV.2below.

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Table IV.1: Summary ProJect Cost by Component a/

- (Rp bilUoo)- -( TS$ zLlnO)- Z orelgLocal Frei= Total Local F ibtal E

A. Si rezO£drg cOwrd:Itiorn aM of

1. namty pzticpeio (PO0 6.6 0.2 6.7 6.0 0.1 6.1 32. Plawig, ge a swper1son (Pupdrms) 5.2 0.5 5.7 4.7 0.5 5.2 93. r rmqcatiom (MO 2.7 1.4 41 2.5 1.2 3.7 334. namity tealth icetwLa 0.8 0.3 1.1 0.8 0.2 1.0 275. Prrorai qoperxo a zt fuizis - 5.5 5.5 - 5.0 5.0 100

Siu-Total 15.3 7.9 23.2 14.0 7.0 21.0 32

S. Dev'e1op Nutrition SurveiUwie

1. Timely wamir ard Iltervemlon 3.5 0.6 4.1 3.3 0.6 3.9 152. Mitritioa uon otDirg ad asmmnt 4.3 0.6 4.9 3.9 0.5 4.4 123. Nution poicy mI Prgz zSwdies 0.7 0.5 1.2 0.6 0.5 1.1 434. Nutrition infouwAtlo 0.5 0.4 0.9 0.5 0.4 0.9 45

Sr-Total 9.0 2.1 11.1 8.3 2.0 10.3 19

C. Tzprovf_g Nitrt1m Mmmr Deve **;t

1. ParsicaL meritlon eor dwelqpmm 7.3 2.3 9.6 6.6 2.1 8.7 242. Grkite nstdtion uwr d re1On± 3.6 1.9 5.5 3.3 1.7 5.0 34

sd,-rTaL 10.9 4.2 15.1 9.9 3.8 13.7 28

Total BElim cots 35.2 14.2 49.4 32.2 12.8 45.0 29Pthyscal G=Ircendes 0.9 0.5 1.4 0.8 0.4 1.2 35Price Cootixeed 9.3 1.7 11.0 8.5 1.5 10.0 15

Total Project Cosm (dml. town) 45.4 16.4 61.8 41.5 14.7 56.2 26

Va3ue-s Tac 1.7 - 1.7 1.5 - 1.5 -

Total Project Costs (iL t) 47.1 16.4 63.5 43.0 14.7 57.7 26

al Duh to rounl!rg, f3ures ury x add up mn±ly.

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Table IV.2: Summary Project Cost by Expenditure Category al

(RapiAh bIlion(US 9=0 %iG

Local Fordog Total LAcal Fore1gcL Total Emft

. Imestm Coss

A. ama 1.4 - 1.4 1.2 - 1.2-B. Cxvl Wofd 5.6 1.6 7.2 5.1 1.5 6.6 22C. Fu&ture, EqupWIt, Vehicles, Materias

1. FuronLe ard Staurd pEqupme 0.6 0.2 0.8 0.5 0.2 0.7 252. SpeaLal q FPt 0.3 1.2 1.5 0.3 1.1 1.4 813. MatedraIBUOOs 2.0 1.2 3.3 1.9 1.1 3.0 374. Vehcles 0.1 0.5 0.5 0.1 0.4 0.5 85

S&-T1tal Flute, Fluipufez, VeCces,1lated.als 3.0 3.1 6.1 2.1 2.8 5.5 47

D. Tehcnical Aseistaze azd FeUlawblp1. Lrcla 1mtants 1.0 1.0 0.9 - 0.9 -2. 'rsMW Qudt=.tts - 1.3 1.3 - 1.2 1.2 1003. Tcal FelowuhPs 2.0 - 2.0 1.9 - 1.9 -4. Qirerseis Fel1zsmblps - 2.1 2.1 - 2.0 2.0 100

S&-tol Tahnl ica AstStas and FeUa1mhLps 3.0 3.5 6.5 2.8 3.2 6.0 54

E. TainuLg 1.5 - 11.5 10.4 - 10.4

F. lrarLa, Trwe ar PerDLems 9.0 - 9.0 8.2 - 8.2 -

G. Studies 1.2 0.4 1.6 1.1 0.4 1.4 25

H. Operatorn SupIDTt Funds - 5.5 5.5 - 5.0 5.0 100

Total Tnvestmet COts 34.7 14.2 48.8 31.6 12.8 45.5 29

II. n.zrre Costs

A. operatiom aoi Maizterier 0.5 - 0.5 0.4 - 0.4 10B. M=SwrA1 salarim 0.1 - 0.1 0.1 - 0.1 _

TtalRemree Cogts 0.6 - 0.6 0.5 - 0.5 8

Toal Uaslrx Costs 35.2 14.2 49.4 32.2 12.8 45.0 29

Mysica10 qa rhI s 0.9 0.5 1.4 0.8 0.4 1.2 35

Price LOa,-fp 9.3 1.7 11.0 8.5 1.5 10.0 15

Total roject Csts (ewl. toxs) 45.4 16.4 61.8 41.5 14.7 56.2 26

ValueAduad Tuc 1.7 - 1.7 1.5 - 1.5 -

To-l Project coss (ifl. tas) 47.1 16.4 635 430 14.7 57.7 26

a/ Ibe to rouIizg, fwursmay r t aid up eactly.

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4.02 The project's base costs are expressed in October, 1985 prices.Construction costs are the product of space standards reviewed duringappraisal and unit prices provided by the government, averaging US$324equivalent per m2 for the university facilities at IPB and US$260equivalent per mk ir the two academies and six schools. Equipment andfurniture costs ar derived from standard lists provided by the projectauthorities concerned; and, the costs of instructional, survey and researchmaterials are based on current prices paid by the institutions concerned.Equipment imported under the project would be exempted from duties octaxes. Import duties aud taxes on building materials have not beenidentified separately in project costs because they are negligible.Technical assistance costs for local consultants include salaries andsubsistence, and for foreign consultants include salaries, subsistence,insurance and airfares. Overseas degree training is estimated at aboutUS$19,200 per staff year and non-degree training (attendance atprofessional conferences and seminars for up to one month) at aboutUS$6,000 per staff month, inclusive of air travel. Local degreefellowships are estimated at US$2,700 equivalent per staff year forundergraduate (SI) training and at US$4,500 equivalent per staff year formaster's (S2) and US$7,300 for doctoral (S3) studies. Local travel and perdiem costs and honoraria are based on current rates for government staff.

4.03 Physical contingencies IUS$1.2 million) represent 20Z of civilworks and 3% of total base costs. Price contingencies (US$10.0 million),equivalent to 22Z of total base costs, are calculated on base costs plusphysical contingencies and a five-year implementation period, during whichthe annual rates of increase are assumed to be as follows: local - 8% for1985-90; and foreign - 5% for 1985; 7.5% for 1986; and 8% for subbaquentyears.

4.04 The project's foreign exchange component, calculated on the basisof experience with similar projects in Indonesia, is estimated as follows:civil works - 19%; furniture and standard equipment - 25X; instructional,survey and research materials - 33%; specialized equipment - 81X; vehicles- 85%; foreign consultants and overseas training - 100%; and the programoperations support fund - 100%.

Recurrent Costs

4.05 The incremental recurrent costs generated directly by projectinvestments (mainly in nutrition manpower development) would amount toabout Rp. 0.5 billion annually in 1989/90, representing less than 0.3Z ofprojected MOB expenditure in that year. These costs would be of two kinds:salaries and benefits for nutritionists, assistant nutritionists andnutrition academy and school faculty and for the incremental staff at thecommunity health secretariat; and, building, equipment and vehicle operat-ing and maintenance expenditures at the expanded GNSK facility (IPB), theschools and academies established under the pro.ect, and the Directorate-General of community health headquarters.

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B. Financing Plan

4.06 The proposed US$33.4 million Bank loan would finance 60% of totalproject costs, net of the cost of vehicles purchased by the governmentunder reserved procurement and taxes and duties, including VAT. The loanwould thus cover US$14.3 million, or 97%, of the foreign exchange cost andUS$19.1 million, or about 45%, of local costs. Bank financing of 60% oftotal costs, including local costs within this limit, is consistent withcurrent project cost sharing guidelines for the social sectors inIndonesia. The balance of total project costs US$24.3 million equivalentwould be financed by the government from its annual development budget.

4.07 The proposed financing plan and loan allocations by category ofexpenditure are indicated in Table IV.3 below.

Table IV.3: Financing Plan

Totals(including

GOI IBRD contingencies)Project Expenditure US$ million -

Land 1.3 - 1.3

Civil Works 2.2 6.5 8.7

Furniture, Equipment, Vehicles,Materials 4.1 3.3 7.4

Technical Assistance andFellowships - 7.2 7.2

Training 3.8 9.6 13.4

Honoraria, Travel, Per Diems 10.6 - 10.6

Studies - 1.8 1.8

Operations Support Funds - 5.0 5.0

Recurrent Costs 0.8 - 0.8

Total Project Cost (excl. taxes) 22.8 33.4 56.2

Value-Added Tax 1.5 - 1.5

Total Project Cost (incl. taxes) 24.3 33.4 57.7

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C. Procurement

4.U8 Project procurement arrangements are summarized in Table IV.4below and described in the following paras. 4.09-4.13.

Table IV.4: Procurement Arrangements (US$ million)

Total Costa/Procurement Method (including

Expenditure Category ICB LCB Otherb/ N.A. contingencies

A. Land - - 1.3 1.3

B. Civil Works 2.1 6.6 - - 8.7(2.1) (4.4) (H) (-) (6.5)

C. Furniture, Equipment. 1.8 3.1 0.9 1.6c/ 7.4Vehicles, Materials (1.8) (1.5) (-) () (3.3)

D. Technical Assistance - - 7.2 - 7.2and Fellowships (-) (-) (7.2) (-) (7.2)

E. Training - - - 13.4 13.4C-) (-) (-) (9.6) (9.6)

F. Honoraria, Travel, - - - 10.6 10.6Per Diems (-) () (-) () ()

G. Studies - - - 1.8 1.8

-) C-) (-) (i.8) (1.8)

R. Operations Support Funds - - 5.0 - 5.0(-) (-) (5.0) (-) (5.0)

I. Recurrent Costs - - - 0.8 0.8(-) (-) (-) (-) (-)

Totals 3.9 9.7 13.1 29.5 56.2(3.9) (5.9) (12.2) (11.4) (33.4)

Note: Figures in parentheses are the respective amounts to be financed bythe proposed Bank loan.

a/ Net of duties and taxes, including VAT.

b/ Other means of procurement include: reserved procurement (vehicles);prudent shopping (off-Vt?e-shelf materials); Bank guidelines (technicalassistance); standard government procedures (fellowships); and UNICEFprocurement (operations support funds).

c/ This portion of materials' cost is listed under N.A. because it refersto costs associated with development and evaluation of materiils.

- 34 -

4.09 One major civil works contract for the GMSK facility at IPB,amounting to about US$2.1 million would be awarded on the basis of ICB, inaccordance with Bank guidelines. The remaining eight smaller civil workscontracts for two nutrition academies and six assistant nutritionists'schools totalling about US$6.6 million are too small (averaging US$0.8million each) and geographically dispersed (in eight different provinces)to attract foreign bidders and would thus be awarded on the basis of LCBprocedures acceptable to the Bank. Building designs and tender documentswould be prepared by local private architectural consultants, on the basisof agreed standards and schedules of accommodation. Constructionsupervision would be performed by local consultants assisted by IPB's ownsite engineers for the GMSK facility and by the Ministry of Works' fieldstaff for the academies and schools in accordance with local governmentpractice. Appropriate sites for all nine project facilities are alreadyavailable.

4.10 Equipment, furniture, vehicles and materials would be procured asfollows: about US$3.1 million or 42%, consisting of furniture and standardequipment items manufactured locally in Indonesia at competitive prices,would be procured using LCB procedures under which both local and foreignsuppliers represented in Indonesia would be eligible to bid; and, remainingspecialized items, valued at US$1.8 million, would be grouped to the extentpracticable into bid packages estimated to cost US$100,000 or more andawarded on the basis of ICB, in accordance with Bank guidelines. Localsuppliers would be eligible to bid and, in bid evaluation, would beaccorded a preference margin equal to 15Z of the cif costs of competingimports, or the prevailing customs duty, whichever is lower. Lists ofequipment, materials and furniture to be procured under the project areavailable on the project file. Off-the-shelf items of equipment andmaterials not exceeding US$30,000 per package may, up to an aggregate totalof US$0.3 million, be purchasp' through prudent shopping on the basis ofthree competitive price quotaL'.ons. Vehicles valued at US$0.6 million intotal would be obtained under reserved procurement, in accordance withgovernment policy, which prohibits importation of vehicles. Duringnegotiations, assurances were obtained that the government would financethese vehicles and procure them under a time schedule agreed with the Bank.

4.11 Selection of foreign and local consultants required for technicalassistance services (34 and 101 staffyears respectively) would be carriedout in accordance with Bank guidelines. Overseas and in-countryfellowships (69 and 646 staffyears totalling US$1.9 million and US$2.0million respectively) would be arranged by the project units concerned,with assistance from the Overseas Training Office of the State Ministry forAdministrative Reform, in accordance with standard government policies andprocedures.

4.12 Equipment, supplies and consumable materials required for thefive community health programs (i.e. family planning, nutrition, theexpanded program of immunization, the diarrheal disease control program andmaternal and child health services) and eligible for financing from theprogram operations support funds (cf. paras.3.13-3.14 above and para. 4.14

- 35 -

below) would, to the extent possible, be obtained through UNICEF inaccordarace with UNICEF international procurement procedures, acceptable tothe Bank.

4.13 Prior Bank review would be required for all ICB contracts, allLCB civil works contracts exceeding US$0.5 million equivalent, and allremaining contracts exceeding US$0.1 million. Other contracts would besubject to selective post-award reviews during project supervision.

D. Disbursements

4.14 The proposed US$33.4 million loan would be disbursed over aperiod of five and three quarter years through December 31, 1991, ninemonths after the estimated project completion date, and against thefollowing categories of project expenditures: (a) 75Z of total expenditureson civil works; (b) 1OOZ of foreign expenditures on equipment, furniture,books and materials supplied by suppliers outside Indonesia, 95Z of theex-factory costs of such equipment, furniture and materials procuredlocally or 65% of local expenditures on other items procured locally;(c) 100% of total expenditures on consultants' services, fellowships,studies and items procured through UNICEF under the program operationssupport funds; and (d) 70% of total expenditure on training. For grouptraining activitles, disbursements would be against statements ofexpenditure based on agreed unit costs and verified by the projectexecuting agencies. Disbursements for studies would also be againststatements of expenses. Supporting documentation would be retained by theexecuting agencies in a central location and made available for review asrequested by Bank supervision missions.

4.15 The schedule of estimated disbursements, contained at Annex 1,indicates a rate of loan withdrawal slightly slower than rhe inter-regionalPEN disbursement profile for the first year, but a somewhat faster one forsubsequent years, reflecting PEN's experience in Indonesia and the advancedstatus of preparation of all project components. In addition, since thestandard PEN profile is weighted by slow implementation in first PHNprojects in a number of countries, it is not wholly applicable to Indonesiawhere the government has considerable experience in implementing Bank PHNprojects, the proposed project being the eighth in the sector and thefourth to be executed by the Ministry of Health. Moreover, in order toensure a prompt start to both civil works and degree training at GKSK,expenditures incurred after April 1, 1985 and before loan signing on sitesurveys, detailed designs, draft tender document preparation and fellow-ships would be eligible for retroactive reimbursement up to a limit ofUS$150,000.

4.16 To the extent practicable, loan withdrawal aDplications would beaggregated in amounts of US$100,000 equivalent or more before being sub-mitted to the Bank for payment. Disbursements for all civil works would bemade against individual contracts. Withdrawal applications for goods witha contract value of US$100,000 or more would be supported by fulldocumentation. Other disbursements would be made against statements ofexpenditures, with supporting documentation being retained by the project

- 36 -

executing agencies concerned for selective review by project supervisionmissions.

E. Accounts and Audit

4.17 The principal project coordinating and executing agency (MOHDirectorate-General of Community Health) would establish and maintainseparate accounts for all project expenditures, in accordance with soundaccounting practices. Such project accounts, including documentation insupport of statements of expenditures, would be audited annually by audi-tors satisfactory to the Bank and annual audit reports would be submittedto the Bank as soon as available but not later than nine months after theend of the government's fiscal year. Six months after the closing date,the project director would submit a project completion report (PCR) to theBank.

V. PROJECT ORGANIZATION, MANAGEMENT AND IMPLEMENTATION

A. Project Organization and Management

5.01 The project's overall organization and management would adhere asfar as possible to existing structures and patterns within the individualimplementing units concerned, with the additional strengthening describedin para. 3.12 below. Againat this background, the MOH Directorate-General,Community Health would be responsible for overall project coordination,with individual project implementing departments/units being responsiblefor specific project components, as follows:

Directorate-General, Community Health Community Health

Directorate of Nutrition Nutrition Surveillance

Center for Education & Training of Nutrition Manpower (para-Health Personnel (PUSDIKLAT) medical)

Department of Commnnity Health & Nutrition Manpower (graduate)Family Resources (GMSK), IPB

Under the overall guidance of the Directorate-General, Community Health,each of the above departments/units would be responsible for carrying outthe project activities within their purview, including the procurement ofcivil works, goods and services, project finances (including counterpartfunding and loan reimbursements) and project monitoring and progressreporting.

- 37 -

5.02 The project would be directed by the Director-General, CommunityHealth, whe would also act as Project Officer. To ensure appropriateintra- ane. inter-ministerial coordination, the government would establish aProject Steering Committee, chaired by the Director General, CommunityHealth, consisting of: the Secretary General, MOR; the Director-General,Communicable Disease Control, I4OH; the Deputy Chairman, Programs Operation,NFPCB; the Deputy Chairman for Social and Cultural Affairs, BAPPENAS; theVice-Rector, IPB; the Director General of Higher Education, Ministry ofEducation; and the Director General, International Monetary Affairs,Ministry of Finance. The Steering Committee would meet quarterly to reviewoverall project progress, approve plans and budgets for all projectcomponents, and resolve any issues affecting project goals andimplementation. Establishment of the Project Steering Committee is acondition of loan effectiveness.

5.03 Project implementation officers would be designated by each ofthe departments or units noted in para. 5.01 above, who would be assistedby teams of full- or part-time staff responsible for the administrative andtechnical aspects of projecticomponent activities and coordination. Inthis connection, the Secretariat of the Office of the Directorate-General,Community Health would be strengthened by the assignment of at least tenfull-time staff, who would coordinate and manage all activities relating tothe comunity health component specifically and liaise with theircounterpart teams in other departments/units responsible for the nutritionsurveillance and nutrition manpower development components. In addition,the local and foreign technical assistance services included in the projectwould assist all three component implementation teams and thus strengthenthe project's overall management.

B. Project Implementation

5.04 Project civil works, consisting of the GMSK facility at IPB andeight paramedical shools and academies, would be carried out in accordancewith standard government procedures. The GMSK facility at IPB is one smallpart of an overall long-term development plan for IPB, which is wellequipped to carry out a component of this scope and size. As far as theparamedical schools and academies are concerned, the arrangements in placeand outlined in Report No. 5442-IND dated April 24, 1985 for the recentlyapproved second health (manpower development) project would apply.

5.05 The project would be implemented over a five year period(Annex 3), plus nine months for final payments and full disbursement ofloan proceeds. In view of the geographical dispersion of projectactivities and the large number of governmental agencies involved in theirimplementation, it is considered appropriate to allow nine rather than sixmonths between project completion and loan closing to allow sufficient timefor collection and submission of withdrawal applications. The project isthus expected to be completed by March 31, 1991, with a closing date OfDecember 31, 1991.

- 38 -

VI. PROJECT BENEFITS AND RISKS

A. Project Benefits

6.01 The principal direct benefits of the project would be broadlythreefold. First, the effectiveness and efficiency of five key communityhealth programs would be enhanced through strengthened planning andresource allocation at the national, provincial and district levels;improved community health education and communications support, andsystematic monitoring, evaluation and supervision, particularly at theprovincial and district levels. Second, the scope of Indonesia's nutritionsurveillance activities would be significantly broadened: specifically, itsability to predict and influence changes in food availability, foodconsumption and nutritional status among the population most at risk wouldbe institutionalized in 37 districts in 11 provinces; and, throughnutrition monitoring and evaluation, policy studies, and informationactivities, its health and nutrition policy formulation and planningcapability would be further strengthened. Third, the country's stock oftrained nutrition manpower would be increased, leading to more effectivemanagement and implementation of community health and nutrition programsand a broader human resource base for national policy planning andresearch. Moreover, as the community health and nutrition activities to bestrengthened by the project would be targetted mainly to women and youngchildren in Indonesia's villages, the project can be expected to havesignificant implications for improving social welfare in the country'srelatively poor rural areas.

B. Project Risks

6.02 The project's main risk relates to the community healthcomponent, namely that the desired coordination of the five key communityhealth programs may not be fully achieved, or be substantially delayed. Asindicated earlier (paras. 2.23-2.24), this risk is unavoidable in anintegrated approach of this nature, which must be viewed as a gradual,long-term process. To minimize the risk, however, the proposed projectplaces considerable emphasis on strevgthening the planning, managerial andmonitoring capacity of the key MOB units concerned with implementation ofthe program - particularly the Directorate of Community Health Centers andthe Community Health Secretariat, which would play critical roles insupervising/coordinating program activities. Moreover, the government'scommitment to the policy and process is clear, as is its awareness of thepotential problems involved. In the circumstances, the risk is acceptableand the provision of substantial technical assistance, as well as anabove-average Bank project supervision and implementation assistanceeffort, is planned to minimize its adverse consequences. An initialproject implementation or 'launch' workshop has also been planned to ensurethat the main individuals concerned with project implementation becomethoroughly acquainted with the project's scope, and government and Bankprocedures for projects of this type.

- 39 -

VII. AGREEMENTS REACHED AND RECOMMENDATIONS

7.01 At loan negotiations, assurances were obtained that:

(a) the Borrower would undertake and complete an evaluation of'microplanning" by September 30, 19bi (para. 3.10);

(b) the Borrower would: (i) complete the preparation of fieldsupervision guidelines/manuals by September 30, 1986; (ii) pre-pare annual field supervision schedules by March 31 in each yearthereafter; and (iii) develop an index of reporting/monitoringindicators by September 30, 1986 (para. 3.11);

(c) the Borrower would undertake and complete baseline andmid-project evaluations of the coordinated comamnity healthprograms by October 1, 1986 and by April 30, 1988 respectively(para. 3.13);

Cd) the Borrower would prepare annual timely warning and interventionsystem (TWIS) development plans by May 31, 1986 and by March 31in each year thereafter (para. 3.16);

Ce) the Borrower would prepare annual workplans for nutrition policyand program studies by May 31, 1986 and by March 31 in each yearthereafter (para. 3.18);

(f) the Borrower would establish by May 31, 1986 and thereaftermaintain a Nutrition Information Unit with appropriate staffingand budgetary resources (para. 3.19); and

(g) the Borrower would finance project vehicles and procure themunder a tiAe schedule agreed with the Bank (para. 4.10).

7.02 The following are conditions of loan effectiveness:

(a) the appointment of the ten additional staff required for theCommunity Health Secretariat (para. 3.13);

(b) the establishment of a Steering Committee for nutrition policyand program studies (para. 3.18); and

(c) the establishment of the Project Steering Comittee (para. 5.02).

- 40 -

7.03 The following is a condition of disbursement:

(a) no withdrawJas would be made in respect of prograus operationssupport funds until the Project Steering Committee has furnishedrecommendations satisfactory to the Bank for their use. Suchrecommendations would include: requirements for supplies forindividual community health programs, availability of domesticend other finawcial support for these programs, and proposeduse of these funds (para. 3.15)

7.04 Subject to the above conditions and assurances, the projectherein proposed would constitute a suitable basis for a US$33.4 millionloan to the Republic of Indonesia at the standard variable rate, and for aterm of 20 years including a five-year grace period.

- 41 - ANNEX 1

INDONESIA

SECOND NUTRITION AND COMMlTNITY HEALTH PROJECT

Schedule of Disbursements

Percentage DisbursedIBJD Fiscal Year Semester Cumulative Estimate For All PHNand Semester US$ Millions This Project Projects

1986

Lm- 1-. 0.1 0.1 0.0 1.02nd 0.3 0.4 1.0 4.0

1987

1st 1.3 1.7 5.0 7.02nd 3.0 4.7 14.0 12.0

1988

1st 4.0 8.7 26.0 17.02nd 4.0 12.7 38.0 24.0

1989

1st 3.7 16.4 49.0 31.02nd 4.3 20.7 62.0 39.0

1990

1st 4.7 25.4 76.0 48.02nd 5.3 30.7 92.0 56.0

1991

1st 2.7 33.4 100.0 68.0

- 42 -

MM UIEIilU M C_ IBL CTI 7ATable 10. 0IIII IE10 EITYI 1 C0110111 PSTlSlT (93) Table 1

1ilad Mt Tiall

Totals IcAadti C'UnrwAsha Cast 7tah Inluadhb Cmnltirdow (t D mI

1 2 2 4 5 lotA I 2 3 4 5 Total 1 2 3 4 5 Tbal

1.UrT cuSmn

.- VIUAJE WitEL IMT7 134.9 134.9 1.9 134.9 134.9 674.4 145.9 17. 170.2 103. 1I9.5 9561 12.7 143.3 154.7 17.1 10.5 771.3

3. 36111 VRLL VI.l153 (KM)

1. IlWUTII I 41D a TI I I

UELIPENT OF TM MTn134 3B.5 ah.s - - - 55.0 45.3 21.2 - - - 67.3 41.7 19.3 - - - 0.9D3 Tlne T13b (T1 5 ff1 ) - 790.3 7e0.3 700.3 710.3 29391.3 - 31.1 333.5 954.2 1,070.5 3,136.3 - 743.7 03.2 067.5 926.3 3,351.2SAS 3U.TIT ITEOII.) is 1.7 - - - - 18.7 19.7 - - - - 19.7 17.9 - - - - 17.9LME CUILTIIT3 4TEIDBTJ) /b 134 4.5 - - - 17.1 U.4 5.2 - - - 17.7 13.2 4.7 - - - 17.9

S.-TOtl MeATIm An HrMTI MM 73.6 M.3 703.3 o0e.3 700.3 2#392.? 30.0 W.s 303.5 954.2 le.03.5 3 792. 72.7 767.7 30.2 967.5 936.1 3o447.92. ll P _llom Tl3lS

IWIS4 OF 1 MTRS 30.5 16.5 - - - s55. 15.8 21.2 - - - 67.0 41t. 19.3 - - - °.9TIT0n11W*12E (13lC3 ff ) 556.3 5e.3 5si.3 MM.3 50.3 2101.3 4.0 154.5 A .3B 763.4 324.4 35. 550.9 5.0 442.6 494.0 749.5 3.31.1LErtA ILTAT1M IT11.M4QIT.) Ie 13.4 4.5 - - - 11 14.5 5.2 - - 13-7 3.2 4.7 - - - 17.9

Toe l MsmE "Mm 1 I 612.2 su.2 560.3 563.3 5s0.3 2374.2 466.3 110.9 736.3 763.4 324.4 364. . 05.7 619.0 642.6 94.0 749.5 39310.7

S3b-Total T1 9 VAUE VIM =TIR E 613.3 1m32.5 1,2.6 1.260.6 IU260.o 5.767.1 74J.3 121.4 1.S90.3 19717.6 lss.0 7.414.! 47.4 1,336.7 1.445. 1,542.4 1.d.317u.6C. ITIIC71WTTI S113U31Ili

1. IWISS

TOEL PEt 31 14.1 14.1 14.2 14.1 14.1 70.4 15.3 16.5 17.3 19.2 23.3 39.6 13.9 1.0 1W2 V7. 13.9 31.5K.M T W MtMS 7.3 - - - - 7.3 9.3 - - - - 9P.3 1 - - - - 8.4.D-1W 1.6 1.6 1.6 1.6 1.4 7.3 1.7 1.3 2.0 2.1 2.3 9.9 1.5 1.7 1.9 1.9 2.1 9.0

Su-Tota YL0 23.5 15.7 15.7 15.7 15.7 113.2 26.2 13.3 19.3 21.4 23.1 133.3 23.9 16.7 13.0 19.4 21.0 3.92. FEUWS

LIIUL FELIIS t1) /d 3.1 9.4 9.4 9.4 - 31.2 3.4 10.9 11.3 12.8 - 33.9 3.1 9.9 10.7 11.1 - 35.3Sewi FEUl P S I2 1 2I - 17.2 23.3 25J. 17.2 36.1 - 19.2 31.1 33.6 4.2 4 109. - 17.5 3.3 30.5 22.3 93.2I_ 1 11; 11T tTII113) In 0.9 0.9 - - - 1.9 2.0 1.1 - - - 2.1 0.9 1.0 - - - 1.9SINT-TDIi FIJ301 (Mt_4 hI - 35 13.5 13.5 13.5 54.1 - 15.1 16.3 17.6 19.0 68.0 - 13.7 14. 16.0 17.3 61.3

Sgt-TtlI FEIINS 4.1 41.0 43.7 43.7 33.1 173.3 4.4 46.4 59.2 63.9 43.2 217.0 4.0 42.1 53J. 5.1 39.2 197.33. VOWfS ih - 1.4 - - - 16.4 - 20.3 - - - 20.3 - n13.5 - - - 10.

Sub-Tot ETI1 IOI S _3 27.5 73.2 64.4 64.4 4i.4 276.0 30.6 15.0 79.0 95.3 66.2 346.1 27.3 77.3 71.3 77.5 10.2 314.7

Tht IKST1ET tlS15 345.2 1,510.6 1.459.9 1U459.9 1.41.9 6717.6 922.3 1U743.0 11139.5 I.M7 2.'19.7 9,36.7 O.9 1f607.3 1.2.3 1.36.1 1,927.0 79151.5

II-. mltOSIS

A. IW13 IS EDINI E ( 0M - 2.3 2.3 2.3 2.3 9.3 - 2.7 2.9 3.2 3.4 12.2 - 2.5 2.7 2.9 3.1 11.1

Total IEUlT 05CT - 2-3 2.3 2.3 2.3 9.3 - 2.7 2.9 3.2 3.4 1.2 - 2.5 2.7 2.9 3.1 11.1taam Wa taat n..ss. e, stt __a sea _a _n nm Sw Stn _nm _na aes _ _

Toti 36.2 1.5)2.9 1.4*2.2 1.462.: 1.44.S 6,727.0 922.8 1,77.7 13642.4 19919.8 2.13.2 0,44.9 M.9 1,609.7 1,674.9 1.135.P 1P30.1 7312J.7

/a I I LTIST FM 2 IIT6CMT Ul3tO0 PEN mIIIi I T411T *11 TIIDT FE iillK EB.IC I CI1LT1T I UTIIST FM On EL.id 5 PUS FMlO T 1 EA./i 2 MM FM 2105 ELIt 2 3l3NS1 3 6NM M.

hI 3 1 Fl1 3 M U.bI 1DS ST Tlt4 111111

TORe W3. ujmniSIw wN"T LiD IU. ammiMM111WIMS(FIVIM

Mm gnu 'rotdo IMIMM Clatiod-11111Total IMad 1atiSwt

1 2 3 4 5 TaOl 1 2 3 4 5 TdA 1 4 TatLd

a. RS 456 smaan

I. MMU UtilE iLt? SClr C0111111? LEMUI

MT?in.SMUM 546 LI7 - - 9.3 6.0 4.3 - - - 1L.4 3.5 M4 - -MMICa NMrs p1 4a6 - - - 11a na. .MJ - - - IAs do e1.9 136.lilis)' MEIGIsa, W - A? wV.1 ma - - - 3ma 121.7 ito . -. 26M$SISiRIET £111401 - 121.6 - - - ~~~~~~ ~~~~~~~~122.6 - 142.1 - - - 14241 - ia - 29.2 1.

Mu4-otW $111T Willi 16.1N BMW. 0313 LEER 20243 2624 - - LI 212.9 422.4-A 6433 ii 3111a . . . 242. FIRM$ ftS. te1l.

Cut.W LEUL T151111 7.7 - .7 3.4 1A - - . 7.6 - - - 7.6FIEJnA ULE. isisB 13-3 - - 1. 14.4 - - - - 14.4 1M. - - - 11.1st3R11t Lrn Tawr. 35., - - s., d.a. - - - a sa - - - iA£31301130 37.4 - - - 2.4 48.5 - - . - 40. M4 - - - 3*.LiES S.TUIW iIEWMSgT.) la 3.9 - - - - 3.9 4.7 - - - - 1.33 - - - - ie

SWAPTotal RULESm 1 . a2NW. 132.3 - - 0. 1233. - - -13. 121.2 - - -12.

1. …. .m R.,

I. aNMFM inmnt

KC8nIIU sUWIS. FESISiA6.3 0 2 - - f*QJ 394 - 304LIES IULTUT (TEDN. ASIST.: ab 3.9 - - .9 9.7 - LI-0. - - - - BswSINIR IS NMI TO Pas TUNh 123.7 - - 13&7 144.6 - - - -144.4 121.3 - -- 13114

SeR-Tot a m 5 PSm CUVTIB 173.A - - 13. 1W7.1 - - - 17.I 19.2 - - - -170.:2. CISUE) Mg3CPATIN

lisRiaD Fmnuinz34.3 - - - - 34.3 404 - - 40.3 274 - 7.1'Wa M"TM (TC. ASIT LI - - - - 9.7 - *-3. - - - 33n33111 Tom I mini - 712.7 712. 712.7' 712.7 2,0304 - 332W 31.1 MA71.jq4407 3. M514-71. 74U20 943404

se-mW suNny 5oflgJpy 431 72. 713. M M712.7 127 644 50.4 Ci. 399.1 M.14 i,067 3.3014 64 156* 37A 3102.3 M 99.41.4

36k-Total SVUViI lUM he111r 2J ; -12.7 717 7127 3,072.6 2.474332.4 31I. MA.. 1141C- s.maU Ma0 i. 67.4 IM2.3 " 1 3.43.43C. 03339.1 FMiNI heuhIT film. MIWILI

KIEVOMi FMn,mCM 17.4 17.4 - - - 24.6 20.0 3.A - .: 13.9 20.4 - - - 39.2SEL. 033TUT (lEE. MSII.p /d 443 4.5 - - - 3.9 4.3 3.2 - - .0 4.4 4.7 - - - 9.1RSE CUJSTif CJa I.iSLm.I O 14.2 14.2 - - - 234 1ILA 16.6 -3- E 14W0 15.1 - - - 240.9MRII1UJULm:xTDPUV - A., 443 645 65 24. - 7.6 3.2 3.9 9.6 14.2 - 1.9 7,3 341 L7 31.1sewin: pm. M Omn. - aq.i *.9 49.9 *?.? ±9.6 - 533 2. 43.0 A. 73.4 *26. - 314 57.2 Ma 44 23311SewONLg: nu. TOin KR - =6 .: 2U.1 21.1 MI6 1,024.2 - -,".I 323.0 243.' V76J 1,167. - v72.9 2M37 3172 362.1,233.

luouLs ~~~~~~~- 6.3 . 6. 3 . 6.3 27.1 7.9 3.6 9.2 13.0 25.7- 7.2 7.3 3.4 9. 3245

se-rail POEM Kmws MD srnir (DCM. MEas 3.1 33.4 311.2 21'.2 319.2 L.3493 41.0 417.2 402.7, 433.1 V 1695170.: 27.3 379.2 346.1 31A. 421.1 1.430.3. IUTITOTiUL IWUTIS

1. FaLnK

tEA rnwmAws M5) /ft - 17.2 17.2 17.2 17.2 £3.1 - 20.0 21.6 3.A 213 MI. - 111.2 19.7 21.3 23.0 32.1AMISS FaLSIPS (521 1 121.2 123.2 121.2 121.2 @4.3 135.3 153.0 1574 130.1 433A - 122.0 A 1226 :2 154.6 553

IMPAUE 133131 A i.i 4.1 3.1 - - 10.3 3.3 4.3 3.9 1 - 22. 3. 4.4 LI - 11.0

meb-Tot al m~mii 14 142. 142.5 133. 133. U' 3.1 U16.2 171.4 110.9 195.4 71214 3.0 16.6 155J 164.4 A 1.644645

N.h-Tail lUTUljta Sh3ESflStA 2.1 142.3. 1414 223.4 133.A SP 1 234 164.2 171.4 J30.9 1n'5 u. 340 16.6 155. 114.4 11A,6446.1

Total 565. 1.572.2 1.173.4 j,170.3 1.1733 5,6720 6442.1 1,032.3 j.4?3. 1.1136.91.7j3. 7.2IA 314.4 1,44.7 1,3393 1.442.6 1.S0.1 o,91.AS *'Sh W**~~~~~.S "WOr WWWWWWW BassiS t--i~Zf

Jr 93t39. OF FI9UMCJIl Ci. FM 6 NM2M4 FMt Mg. `11111M.:i COS. FM0 MMI. FOR ELV. 1`111iED.:i CM FOR 3Nms/f 1 1 I FM21E0EQ./ i M1 FM5921M. LA.lb lbU IFM3NMMUE*.

a12

TrU, Iii. uim InuIMITin N a CIMMICATUU 1W8ATalh HeT t BLTble

Totls l duao C1 1mmocieslW .Tols IKI 1 i1 Cmtile, (333 300!

I : 2 4 5 bT l 1 : 3 4 5 TOtl 1 2 3 4 S Totl_m __aa *. _, _n uu uum m u . ._~ *_U uSU _a.. 8E.._ au_e _..

I. TMET conST

A. cmiIu t_7EID PM P_TIIIIIJ

1. EIEMI w SM IT IESI

I1 S mm 7.7 - - - - 7.7 9.2 - - - 9.2 3.4 - - - - 8.4UIUI COLTI3T5 (MM01. AS5515.1 , 13.4 - - - - 1.4 14. - -- - 14.5 12.2 - - - - . 2

Sub-TolI EVELfENT OF 51313TTEDIE 21.1 - - - - 21.1 2.7 - - - - 23.7 21.5 - - - - 21.52. IUE1117I I MM 144.2 34.1 - - - 113.3 163.3 45.0 - - - 213.3 153.0 40.9 - - - 192.93. EAJMTI IIF UW

Nwiam NW - 4.0 - - - 4.0 - SL1 - - - 5.1 - 4.7 - - - 4.71L1 CLTMTO (TIER. AG51IT. h - 4.5 - - 4.5 - 5.2 - - - 5.2 - 4.7 - - - 4.7

-TOtaI EMlTIN ItF 3 UUIN - L5 - - - .5 - 1 0.4 0.4 - 9.4 - 4- - *4

Sit>-Tol CWVIE (13MM1T1D PENDN PUMP 115.3 44.5 - - - 2. 192.0 55.3 - - -:47.3 174.5 50.3 _ _ - 24.3. IEK KI3BhlUS EL. 10 5 PUIMS

1. F4IIIATIN OF STIR

AUESSE TlbSISISFIENMWu 17.1 - - - - 174 21.2 - - - - 21.2 19.3 - - - - 19.3UIUL ITUT W(WM. 9IST.1 IC t.9 - - - - .9 9.7 - - - - 9.7 LI - - - - 34EuESm MOLTRST lTECI. AMR51.) id 13.7 - - - - 11.7 19.7 - - - - 1. 17.9 - - - - 1.9

Sib-Total RAT W SMTBY 45.4 - - - - 45.4 50.5 - - - - 5.5 45.9 - - - - 45.92. EELINIOT W UITEKIS

11jaN: 1 lI-. STAWFF - 4.0 6.0 4.0 4.0 23.9 - 7.7 1.3 9.0 9.7 34.4 - 7.0 7.5 3.1 3.3 31.5nEiT/MNSISIS U rTERMLS 29.3 29.3 J.3 29.3 117.0 - 37.4 40.6 43.B 47.4 149.4 - 34.2 3Y.9 3t.9 43.L 154.0

31W5i SATRNLSiE - 1.0 1.4 1.0 1.0 4.2 - 1.3 1.4 1.6 1.7 6.0 - 1.2 1.3 1.4 1.5 5.5EITESTINAAL.. IFICiI U MT - 12.2 12.2 12.2 12.2 46.9 - 11.7 11.0 13.3 19.3 70.3 - 14.3 15.4 14.7 13.0 4.4

1.11 l0LIS tlD. SSIST.I h - -.9 3.? 1.9 3.? 35.7 - lu. 11. 12.2 13.1 V.0 - 9.5 10.2 11.1 11.9 2.7

Sub-otal EVELWTU MItMS - 57.4 57.4 57.4 7.4 2J.7 - 72. 70.4 34.7 91.7 37.8 - f.1 71.4 77.1 03.3 29.03. 3TOI3 UF UIEIEULS - 39.0 39.0 39.0 39.0 1236.0 - 35.4 415.7 44.9 44. 1.734.8 - 350.4 377.7 401.1 443.7 1.577.14. EVUIMTIS U 3T1E33NSAII

M1M 6 331311TED1. STAFF - - 3.1 4.1 3.1 10.3 - - 3.3 5.5 4.5 13.0 - - 3.5 5.0 4.1 12.5F-.O AERMINT/YtS - - 24.2 35.0 24.2 3.4 - - 32.6 47.1 3.0 117.4 - - J.7 42.7 34.4 104.9MIrIAFICAI U M T13NS1A3 - - 0.9 1.2 0.9 3.1 - - 1.3 1.9 1.5 4.7 - - 1.2 1.7 1.4 4.3LtDL 1U.T0TS CTMN. M5MS.) /n - - 5.4 7.1 5.4 17.3 - - .3B 9.7 7.9 24.4 - - 4.1 *.0 7.2 22.1

SWi-Total E4WM U E1 .MBI* - - 5. 47.4 35.4 11.6 - - ".5 64.1 51.9 140.5 -- 40.5 5.3 47.2 145.

Sub-To aEC 1KTEUINS EL. T0 5 MM 4.4 346.4 402.0 413.9 402.0 1M2.3 3.5 43.2 53.7 597.9 63.4 2WM3 45.9 414.5 40.3 543.5 71.3 2,0669

/a 3 0CI3LT.T UTF11 O RI FNK. F SI1T.. 2 FM IE. UF 110*) FM 3 UKIII E4./b FOR E(MUIIDIN: I CULT*NrT FIR 3111KIc FRA 511TEil FORDTIM: I 1M B Y4T FOR A NS/d Wl 5ITM0 F*TIOI: I CU3LTUBT FMl 2 NIMSit 2 M.LTWIS ll FOR MUG6 BIIIV 1 TI 331TE3I11S 3Eib) B. FIR 3 MM W ECF W 4 TISIt 2 2ONSIM (1 FM N iS 33 I FM 11N1F1*1100 W MT. 0G FEZ N Oll U EDC U 3 TMS

SECOND NWTIKT!ON AND C01NUDEITT UNALTR PItOJECT Fpg 2 of 2Table 103, 3TRENqfiE3No COMNUNITI NEALTEs CONHUNICATIONN (PEN)

DeCalled Cost TableCRUPIAN MIlliom)

MIN35 OSJPAEOU. PETF - 3.2 3.2 3.2 3.2 12.6 - 4.0 4.4 4.7 3.1 23.2 - 3.7 4.0 4.3 4.6 16.6LEk CUIILTS3T hEa. *3033) is - 1.5 13. 2.5 1.5 5.9 - 1.7 1.9 2.3 2.2 7.3 - 1.6 1.7 1.3 2. 0 7.3

Sub-Total E'JWIDIF OF T*I3IN 9303 - 4.6 4.6 4.6 4.6 13.6 - 5.3 6.2 6.7 7.3 26.1 - s.3 3.7 161 6.6 23.2. IRI2I 5633W (11N1TII

MU. PETF 1161N - 13.2 - - - 13.2 - 15.4 - - - 15.4 - 14.0 - - - 14.0MIT. SINFFT 1INI35 - £24.0 . . . 124.0 - 144.9 - - - 144.9 - 3. - - - 111.7FE-lIS. Psta 1361f1 - 53.9 . . . W10. - 93M.3 - - - 593.3 - 539.3 - - - 539.3

Suh-Tota 131125 EMiES 1i11111.3 - 645.1 - - - 665.1 - m3 - - 753.6 - 459.1 - - £15.13. MINIM 3316 SZSIuBUpIuI

P . PETF I3*1MM3 - - 3. 13.3 3.1 24.4 - - 10.2 11.3 11.9 33.4 - - 9.2 10.3 10.3 30.3KSTI. ltINFT 13313 - - 61.1 43. 61.1 Am. - - 17.1 59.1 90,3 252.V - - 70.3 13.0 31.3 229.9SU3-1R5T. SlTAF m*3mi5 - am.1 259.5 251.3 763.1 - - 317.7 353.5 370.6 IP041.11 - - m0E 321.4 236.9 94M.

Nub-T!"TaLU 13165563 431UPGWS - 321.0220.8321.0 97.38 405.0 450.7 472.4A 32. -26O3U.2 409.7 429.4 19207.3

Sub-4otl TRA1.21N6 533( KAM 120 (pI. FpI, poM 2 - 649.7M3.7 2A25. S.71.636. 759.3 411.2 457.4 4792.72107.7 - 903 373.9 415.8 436411 16.1*3. INSNTTUTIUhII STIOUIEIs

1. PLMUINI

KgBJASf OF 59A1334S - 1.3 1.3 1.3 1.3 7.1 - 2.3 2.5 2.6 2.9 10.2 - 2.1 2.2 2.4 2.6 9.3amES 631329 - 35.5 15.5 15.5 15.5 61.9 - 13.1 19.5 21.1 22.8 31.5 1 6.4 1V.3 19.2 23.7 74.1

Nob-Total 91A1311 - 17.2 17.2 17.2 17.2 19.0 - 20.4 22.0 23.7 2S.6 91.7 13.5 20.3 21.6 23.3 83.42. DJJU3IIP

LrAL FEMLiUVS 611) /h 12.3 12.5 12.5 6.2 43.7 - 14.6 13. 37.0 9.22 56.5 - 13.3 14.3 15.3 3.3 51.4MW NEi.FBJ.3HI (52) /I - u.J 3.1 43.1 - 215.3 - 6. 103.6 55.9 - M.7 - 4 94.2 13.9 Z122.4Lou" T131N3i6l 2.3 1.9 - - - 4.7 3.0 2.2 - - - 'i 2 2.3 2.0 - - 4.7SO-T-IM A.SUS (64ERSE* A - .13.5 13.3 13. 3.5 54.1 - 15.1 116.3 17.6 19.8 61.0 - 13.7 14.3 36.0 17.3 61.0IIIIEmnUTISNEETI5N,s1 - 6.2 6.2 6.2 - 13.53 - 6.9 71.4 3.0 - 22.3 - 6.2 6. 7.3 - 23.2

Sub-Total FELLHIPS 2.1 123.1 111.3 75.2 19.3 336.2 2.0 134.9 143.0 90.3 21.2 407.6 2.3 122.6 130.0 396 25.6 370.63. TEOCILU 6SSSTOM

0.0t(4 OIILTMIT is 33.7 131.1 33.7 - - IM3.4 35.4 112.9 40.5 - - lBS9 32.2 102.6 36.9 - -11.L.(6 CUISL.T*3T 1. 5.4 16.1 5.4 - - 26.3 5.3 13L3 6.31 - 31.3 5.3 17.1 6.1 - - 20.5

Sub-Total TM1302CAL NMI3TUM 39.0 117.13 1.0 - - 193.2 41.2 13.6 47.3 - - 220.1 37.4 119.7 43.0 - -233.14. VIEAIIJ -o 16.4 - - - 16.4 - 20.3 - - - 20.2 - 13.5 - - - 33.3

Nu.h-Total IMMUIIIJTIOEL n 41.9 270.9 174. 92. 37.0 616.3 44.2 W0.2 212.3 122.3 53.3 739.3 40.2 239.3 193.0 311.1 43.9 612.3

Total RVESTNE111 C361 M.6 19331.6 902.2 341.7 764.7 4.092.1 236.7 IPM3.0 1.312.3 19177.3 1I161.9 5,343.4 260.7 1,416.4 1.56.6 19073. 1.56.2 4.1W.4

ir. sewof com

.1. IPEDTIS NO 102II1IflCE 3(3130ME2 2.3 2.3 2J 2.3 9.3 - 2.7 22.9 3.2 2.4 12.2 2.5 2.7 I..9 3.1 11.1

Total FLNJT COST 2.3 2.3 2.3 2.3 9.3 ___2.7 _ 2.9 3.2 __3.4 1.. 22 _ -_2.5 2.7 2.9 3.1 31.1

TOUI ~~~~~~~~~~~~252.6 I.334.3 904.6 364.1 767.0 4v132.3 23I.7 1.5.3 19113.2 1,133.7 1.135.3 5,30.7 260.7 1.431.9 1O.35. 1.,073.3 I.0.4 4901.5

/I I C3ISLT*T FM 3 N0fUV EMU W 4 ERSlb 73 FORTE2 M EA./I SP3NOFgt2 MEA.Ii S P6M FM 3333134 El.Ik 3 FOR3I3JM4NEA.Il FM 6 NTIN9S/a 6(N. I 036.TUiT FOR ia niw;. 913 cOiuICATIgla I OLIMO CIILTA5 FOR 13 11T31

IiI ImlIS S161J310223

1. IIMTMIff con ~ ~ ~ ~ ~ ~ 513 UII

"Am lm /a ~ ~ ~ bteiea.10..Tada 1 1to Immul~ ~ ~ ~ ~ ~~~~~~~~~~~~i e

3 234A 4 . 1. STaIS 224 WTI 7. 13 4W29. .s ILI

2. m e c-ow

lam"P131005 P~304 3.4- 34.4 2610.43.4 MA. 31. 32.2 32.1 44 35. 3L 41.0 13. 114 31.9 32. 3L2. £3.

m edo 330 .0 .3 3 29.9 3.69.1 14.3 349U 3507 .1 649.2 9.9 3.7 44.

640-.3. J '*T 04 Z.4 15.4 23A2.4 3 112.80 1 39.323.132 31.1 27.3 366. MI. 29.1 236 .1 31.32 164.7

skTa U i 1U4 432.12. 4:3., 3. 3. 34 33 4 3..0 3.7 23.4 22. 3.3 U-2 256.9

ISMe 3osE1.3 13.3 U. 12.1 13.3 L 1. 2. 33.3 tA14.9 U .6 1 17. 493. 1.2 133. 1.41.635 43

m eGWI 23. 23.4 3. 2.4 2A2.4 3Mt. 234 U7 9. 3.1.3 04 4 24.24. 24.3 23.3 3.9 23.2 114.4J-Ota 31 1i11nS 22.4 22.4 23.4.4 22.4 126 .1 2231 4 .63.4 14.84 3 4U 23.0 24.6 2.3 3.9 31I 124.

110-laid IUmI 3739, 7 71 771.4 77I.M 6 .2 144 .0 3.7 ; 9 3 .034. 432. 71.3 3 .539. 91. 13. 4479

I. ni ANa Nv =

3.31333 IMPAWE gm.1 3.11121 . 3 46 . 1.2 1.4 3.3 1.4 349 3. 14.32 .3 1.42 .22.U3D T1T13 IB30 l .1r 2.4 2, 24 . 2.4 12.9 2.42. 3. 2.3 .35 3J 2.4 -. 2.7 -. 349 32.3

4.lW.931W L3U 7.ldIL - - 7. - 34.2 7.7 - - 9. - 17.3417.0 - - -. - 1Lu

n4*-ToW mSsm to 32. 6.46.4 33.3 1. 4.2 342.6 74 . 1.49.4 3.4 13.3 a.3 7 47 369 '3.7-

mTd miiw. v Dow 2o b1.6 -L 2 71 .6 13.3 CA9 1.7 M.54 33. 9 2.6 - m 4. .3 32.,

UM CDWTMN is 4.4 -. 24.6 23- 43.4 396.5 263.1 3.23 1-6 9. 24 244 4 7.5 2L 3.A 22.

me-lad jrWiMiT AmE It ZI 32.3 - 324 12.0 29.1 4.8 .3 2.17.17. 19.3 40.0 2.7 -2. 1 54 7 17. 4.J2M2. FUMIPI

3511MNIMS mJd I 713 7.2 1 - - 15l .2 64 .1 - - 16.3 . 14.3- - - - 14.3FlMU S 3341? IP 1a n ImA -34 - 40.1 -533 7.4 2. IL 74.7 - 14 21.3 -13.5 1 6.9 - 4.9 31.3

Wt" FUUNWS -~73. -40.2 7 - 50. 9.3 23.3 - 7.72 -1 04.4 .1 71.4 -2. 147. - -. :.

Ta-Ia U13 M ITIMIID 966g Wb .S 2 7 - 71 LI.. 7.3 - 914 - -102. 37. 334 3.2 - 94234.

YmU in3iUS lb 4.1 4214222..3 133. MA 1. 5. 14. 7 -. 2314 -O 42.7 441r03 -7 9.

I.eTod "AIMIE mef COM 22. 452441 3 33 61.3 I. 7U 4 .33953 2. 2. ZI0 67.41273.06 203

4. LUM IT1A33 I. -1. -2 - - 27.2 33.1 1. - -- 3. - 1 2.7 3.3 . - . 734

Tow -toai CIM~ 9 7.4 311.2 I 32.3 -0 1- 723.4 24.2 7 44L -X 14.9 70.7 227.0 14.0 MA -I 1946.3

2. 956135 imp

31225I # VIPEIT2L 13.1 21.3 * . 2- .129 A2626.3. 14. 1. MA 25.0 29.3 12.5 n- M -. U223

1.4-laid fl.11m ~1313561 26.4 16.2 I - - 3734. - - - - 1. 233.4 - - - 4.

TdI4 355133313L3 2 2.13.01. 321.5330.7A 5.022 24.423 MI7291705 .1.22.9 247 .797.07. 191. 292. 1.1944

lotl 2134 20.7 29.1171.2 241.351.39.3 294.3 24.9239.3222.7 24.93I.43242 .0 219.32267237.63J19.61I312

lb 56,34. PR-MUM17 V M FOIu. I3NM.MOIC I cmZE! 132 =M Fe o3 j..Id 66139FM/O v"9 56fLB 3936356.If IIAUIUS0L Iscro W TE PS.4

' S If P iMIT CIMUN. U9 umiev p221. 56 1 15lb U 1E P11W06. TT

A I ITIUS N3u31.3

mMmms mniwm asMIT "tosw inu"~

T LUW5,M1100 I TIMI 14I4 I

hi. CaILI ?et~~~~~~~us laedtr C 't 1*10 ii

. .. . ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ .....

3 Jt. 2 3 4 5 Toa 245 15

I. ZIIFMIIU 05111

A. WI bMOT PA

*tNKasiM s= bK msi.0 sW0 26". VlW NOMA01 241.1044o- MV. 220:444: 22o.40.0 MiM44.4 2XPW40. 1.140.N400. 24040::. 140.W. 246.1, loo". 41.* 1.4U.0.4M U rN ANN .CHICO "To 00.0 220,40.4 224,00.420 44. 22MM 4MIMS1.104440V. 220.400.4 224,014104 210.04.0 2204,440 224o.*10100014 .144 NO9.oU0 244.00. muss. 2e,u.0 2tmw., :.w.o

CwAIIT omm . 2040. 2040. 220,4. 22m0,4. 22400 11144.4400 22004 224,4,0 220,400.0 220,100,19,00.6 01.114441. 200.1 ,444 l00.0 2 441144,9 NO.100.0 mmA MW.S 1.4uv444FM421. ?UItd 220f,805 L69.00.0 224,444. 220,40 2204900.0 litIM4040 220P.0410 2NsM,OS, 2M0,O4. MM,oo. Wift*. 1000,0.64. M,u.in Xmo.w. ou.mo 20,aso u,.w.o i."4wo

WWTeI a4 5415 vim 1.4,4. .4.141104.1144.0,1.4. 1S499 ,.oo4144 01.10.1004, 1144,40.0 1.140".9 Mild0"444 i.s.ooeo s.41.0. 1I.4N0W.4l.*.1OvI' 1.16411 ,0' s.oo.4

J11ii i.l40.440.0 1,1044.10 1.10.00. I,l00.m0. 1,10101,441.W.0 1.144.0 1 4.0 1.1449 .0 Itit a .li osflfSflUS . . .f ...... . ....................... b ,m

.......... S .......... ............ - *--'S . . ......... ......... fii ....... ____

|1~~~ ___

--

0- X

;~ 3l1$i i: ,i 11111

- 49 -

&M 3Pp 2 of 5

Cardar Year 1985 1986 1987 1988 1989 1990 1991

moo 1 Iuly-Jure) ra 6 1 r17 1r rn89 r1 Y9 91 I

Gowt. IN (rlt-Hrd) 85/86 86187 87/88 88189 89/90 SD/91 91/92

k2 PPiamltL., I_*e__t & ___-ewisiom …

0)- meriamzl1ui

- Plwamg (TEg.) Activiti_

- Evabistlon

- Pla=iuLrg Fe1aluhb4ps

DLatrit, Stb1ditrict)

(ll) Supetvisdon and! QIIweiweIndtLig !Mdtoriig)

Dervelq t of MateiCalsad! marirdig Imt1Awiuao

- SFvon d_oaitorl __

(1 NtiDlom Cqafgn

(ii)ive prgr E MaterLas

- FozmtioL n of S tIatMI

- DwtA/rW. of materials -

- Evabhtion of Mateials

(iii Traini of lader ntralm

- Tradn!ig MateriAlta Den.

- Tra1iiL

(IV) Irtiu=iocat Streigtlunix

-p1aun&ig !m1zms

~Fe1Uslp - - - ---

- &q*lation of Vehic3es

-Teclwd aAssiftam - --

- 50 -

AMR 3Pqe 3 of 5

-. ar Yew 1986 1- 98 i 1987 1988 1989 1l99 1991

I) ni (ur-ji _ flM6 r7 FM8 FMl9 FM90 FY91

Gmt. T (jz11-urr 85/86 86/87 87/88 88/89 89/9_ 90/91 91/92

A.4 Izdty Health Se___ iat

-ILtxxevmEA Stof f

-Prcgrma W~aalitloi

- kqusitln of Vd_ele/IEquipt.

-FeLlobuLpsIII I I III I If

-TeducalAinuta I--- _ _

A.5 0Rntlo SupIWozt F mx

W Cesi)Ebility SNtxdi

(Ii) Eutdhalamtt oE TWIS Tetwlztlu & District Im_els) - - - t

(il) E.tblIJu.i of NatloAa.suppm unit

(iv) Acquition of Vehic]eEpt.

B.2 MmtritionMnodtoritg & Aoemm

(i) Su_vey/eAr c _ _ + _ _ _ _ _ - + I

(ii) Mqusition of Velclmes/qpt.

|B3 NtritlonPblily &PrPgruStum - -_ _ _ - _ _ _ _ _ _ + _ -

|A Nutrition InEo riton Unit

(i) EatdbisIu.it ',f Undt

(ii) Staff Dewt._Tra_nirg

W il)hoEquiain _f Equi__ _NoterUas-- --- ~- - - ~ .I. ----

- 51 -J3

Fqp . of 5

CalAdr Year 198i 1986i 1987 198"8 1'99 1919

IW F! TJuly-J) Fm i 7 Pm m9 19 I 91

wt. nY (Ag1-Had3) _ /6 __/87 W87/88 88/89 _9_9 _ _ /91 919_

C. micritlon MuW"2sm ftwe1oiu.1

C.1 Parqical M_rmm

(1) DwilpelM of Sdh~ooWkKisf.

I Prefration of loIamms

-cipdtion of Ruftgwe,Equdipia, Vebdc3es,

(IL) dzziDl Q~a1ity

- II&VmmAdWLI -n

C.2 Grakmte MwAwpm

- Preparation of Doauetits

- ThnkLr

- Omiutmin

- Acdabton of wTwe

Vebicles

(1 ivitstry of Agricul tuewizu

- DwupelW of Ctwm

- ILsm3r.a*sn of Ome

-52 - aa

co1 Yew 198 1987 1988 1989 19wD 1991m ., I .,I I ., 'I JzI TY _ ae6 ns I 86 FMM) nm FMGwt. 2Y (41-Mwdi) F . _ 86/87 - A_87/88 88/89 _ 9 9D/91 ,1!

0I1 FoW aid ltiU l1Tcy

- Ruldsr _ _ lat

- kquiaitlou of &q1dwm

- 53 -ANNEX 4Page 1 of 2

INDONESIA

SECOND NUTRITION AND COMMUNITY HEALTH PROJECT

Selected Documents and Data in the Proiect File

A. Selected Reference Materials Related to the Sector

A.1 Indonesia: Health Sector Overview. Report No. 2379-IND, February,1979.

A.2 Indonesia: Health Sector Update. (White cover drsft). September,1981.

A.3 Indonesia: Health Sector Review. (White cover draft). March, 1983.

A.4 Indonesia: Public Investment Review - Health Sector (draft).Decedber, 1984.

A.5 Indonesia: Financial Resources and Human Development in the Eighties.Report No. 3795-IND. May, 1982.

A.6 Indonesia; Selected Issues in Spatial Development. Report No.4776-IND. April, 1984.

A.7 The Health Situation of Indonesia: (Statistical Profile). Compiled bythe Bureau of Planning, Department of Health, Indonesia, for the ESCAPProgramme on Health and Development: Health Technical PaperNo.70/PDH 20, 1984.

A.8 Government of Indonesia: Fourth Five-Year Development Plan(Repelita IV), Chapters 10, 23 and 25.

A.9 Health and Population Sector Profile (draft). Asian DevelopmentBank. February, 1983.

A.10 Background Information for USAID/Indonesia: Indonesia NutritionStrategy - January, 1983.

A.11 Evaluation of the Indonesia Nutrition Development Project, Vol.I.Ministry of Health, September, 1982.

A.12 Nutrition Review. Population, Health and Nutrition Department, WorldBank, April, 1984.

- 54 -

ANNEX 4Page 2 of 2

A.13 Working Paper to Formulate a Strategy for the Integrated Approach toCommunity Health Services, Ministry of Health, January 10, 1985.

A.14 Child Survi'al and Development in Indonesia, 1985-1989. Master Planof Operations, UNICEF.

A.15 Fajans, Peter and H. Sudioan. The Indonesian National FamilyNutrition Improvement Programme (UPGX): A Case Study of SevenVillages. Submitted to UNICEF/Jakarta. September, 1983.

A.16 UPGK Evaluation, Nutrition Research and Development Center, BogorAgricultural University, June, 1982.

A.17 Village Family Planning/Mother Child Welfare - Mid ProjectEvaluation. USAID/Jakarta, November 1982 (Document 2285A).

A.18 Nutrition I Project (Loan 1373), Project Completion Report.

B. Selected Materials Related to the ProJect

3.1 Architect's Working Papers, Paramedical Nutrition Manpower DevelopmentComponent, November, 1984.

B.2 Nutrition Manpower Development Proposal, Ministry of Health, March,1985.

B.3 Integrated Health, Nutrition and Family Planning Proposal, Ministry ofHealth, March, 1985.

B.4 Master Plan for the Food and Nutrition Surveillance System for1984-1990, Directorate of Nutrition, Ministry of Health.

- 55-IlNDONESIA_

Second Nutrition and Co=mmity Health ProJett

The Structure of the Ministry of Health

.w Gom "W NWa_ a

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I t[StX1 Q$Et1~~~~~~~~~~~W .d

.~~~~~~~a SW l - " .

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