Extenal Assessment of Canadian CIDASupported Safe Motherhood Programme

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TABLE OF CONTENTS

Letter of Transmittal

List of Tables.................................................................................................™

List of Figures........................................................................................................................................... (v)

Acronyms and Abbreviations.................................................................................................................(vi)

Executive Summary ..............................................................................................................................(xiii)

1 BACKGROUND TO ASSESSMENT............................................................................................. 1-1

l. l UNICEF COUNTRY PLAN/UNICEF-GOI MASTER PLAN OF OPERATIONS 1995 - 2000... 1-11.2 CIDA-UNICEF CONTRIBUTION AGREEMENT................................................................... 1-2l .3 THE SAFE MOTHERHOOD IN INDONESIA, MARCH-APRIL 1998 EVALUATION REPORT ..... 1-21.4 UNICEF 1998 MID-TERM REVIEW.................................................................................... 1-3

2 TERMS OF REFERENCE, FRAMEWORK AND METHODOLOGY OF ASSESSMENT... 2-1

2.1 TERMS OF REFERENCE........................................................................................................ 2-12.2 FRAMEWORK ...................................................................................................................... 2-2

2.2.1 Difficulties in Doing and Reporting on Safe Motherhood Programmes............... 2-22.3 ASSESSMENT DESIGN ......................................................................................................... 2-4

2.3.7 Assessment Framework......................................................................................... 2-42.3.2 Assessment Activities............................................................................................. 2-42.3.3 Data Collection.....................................................................................................2-52.3.4 Limitations............................................................................................................. 2-5

3 THE CONTEXT OF THE PROJECT............................................................................................ 3-1

3.1 INDONESIAN CONTEXT....................................................................................................... 3-13.1.1 The Government Administrative System................................................................ 3-13.1.2 Village Organization............................................................................................. 3-23.1.3 Socio-Cultural Issues............................................................................................ 3-33.1.4 Political and Economic Development................................................................... 3-3

3.2 UNICEF CONTEXT............................................................................................................. 3-4

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TABLE OF CONTENTS

4 COMMUNITY CAPACITY-BUILDING COMPONENT........................................................... 4-1

4.1 TERMS OF REFERENCE FOR COMMUNITY CAPACITY-BUILDINX;........................................ 4-14.1.1 Clarification of Concepts and Terms Central to CCB .......................................... 4-34.1.2 Levels of Participation .......................................................................................... 4-4

4.2 COMMUNITY CAPACITY-BUILDING-SOUTH SULAWESI ................................................... 4-54.2.1 Finding Direction: yision..................................................................................... 4-54.2.2 Implementing Programs........................................................................................ 4-5

4.2.2.1 UNICEF-Identified Lessons and Outputs................................................ 4-64.2.3 CCB Assessment Comments.................................................................................. 4-7

4.2.3.1 1996-1998 Safe Motherhood Programming South Sulawesi ...................4-74.2.3.2 1999-2000 Safe Motherhood Programming South Sulawesi................... 4-9

4.3 COMMUNITY CAPACITY-BUILDING--EAST JAVA ........................................................... 4-124.3.1 Finding Direction: Vision................................................................................... 4-124.3.2 Implementing Programs...................................................................................... 4-12

4.3.2.1 Overview of SM Program/Preparations................................................. 4-124.3.2.2 SM-CCB Activities in EJ 1999-2000.....................................................4-134.3.2.3 Pesantren Cooperative Loan Program.................................................... 4-134.3.2.4 Posyandu Revitalization......................................................................... 4-154.3.2.5 Monitoring.............................................................................................. 4-164.3.2.6 UNICEF Self-Critique Comments ......................................................... 4-16

4.3.3 CCB Assessment Comments................................................................................ 4-174.4 COMMUNITY CAPACITY-BUILDING-CENTRAL JAVA..................................................... 4-18

4.4.1 Finding Direction: Vision.................................................................................... 4-184.4.2 Implementing Programs...................................................................................... 4-194.4.3 CCB Assessment Comments................................................................................ 4-26

4.5 MAIN LESSONS LEARNED................................................................................................. 4-304.6 RECOMMENDATIONS ........................................................................................................4-314.7 RECOMMENDATIONS COMMUNITY CAPACITY-BUILDING ............................................... 4-34

5 MATERNAL HEALTH COMPONENT........................................................................................ 5-1

5.1 MATERNAL HEALTH CARE IN INDONESIA-GENERAL ISSUES .......................................... 5-15.1.1 Maternal Health Care Statistics............................................................................ 5-15.1.2 GOIMaternal Health Policy.................................................................................5-2

5.1.2.1 Governmental Sectors Related to Safe Motherhood Initiatives ............... 5-45.7.3 GOI Policy on Privatization.................................................................................. 5-65.1.4 GOI Policy on Decentralization............................................................................ 5-65.1.5 GOI Monitoring of Maternal Health Indicators.................................................... 5-85.1.6 Donors' Roles in Maternal Health Care Service Deliveiy.................................. 5-135.1.7 GOI Maternal Health Care Service Delivery System.......................................... 5-14

5.2 EVALUATION OF MATERNAL HEALTH COMPONENT........................................................ 5-14

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5.2.1 Theoretical Framework....................................................................................... 5-145.2.2 Issues Common to All Three Project Provinces.................................................. 5-15

5.2.2.1 Institutional Capacity Building.............................................................. 5-175.2.2.2 The Social Safety Net Factor.................................................................. 5-195.2.2.3 Monitoring and Evaluation - Reporting for Results .............................. 5-205.2.2.4 The Maternal-Perinatal Audit (AMP) Process....................................... 5-245.2.2.5 District Hospital Services....................................................................... 5-255.2.2.6 Puskesmas Services................................................................................ 5-265.2.2.7 Training Programmes for Service Providers.......................................... 5-275.2.2.8 Village Midwives (Bidan Di Desa)........................................................ 5-275.2.2.9 The Dukun.............................................................................................. 5-335.2.2.10The Role of the Village Health Volunteer (Kader)................................ 5-33

5.3 FINDINGS SPECIFIC TO EACH PROJECT PROVINCE ........................................................... 5-345.3.1 South Sulawesi..................................................................................................... 5-345.3.2 East Java.............................................................................................................5-385.3.3 Central Java........................................................................................................ 5-41

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Appendix A: Terms of Reference

Appendix B: Itinerary of Mission

Appendix C: Selection Process for Subdistricts and Villages

Appendix D: List of Safe Motherhood/GSI Villages - UNICEF South Salawesi

Appendix E: Community Analysis of SM Situation in Village Kambuno, Bulumkumba

Appendix F: Model VillageAppendix G: GOI Budget for Safe Motherhood Activities, Sinjai District, Year 2000

Appendix H: UMCEF-GOI Planning Processes (after '98, UNICEF Omitted PUA)

Appendix I: South Sulawesi Province PA-1 Logframe for Year 2000

Appendix J: List of Activities to Support the Safe Motherhood Programme - East Java 1996-2000

Appendix K: List of Pesantren Receiving Seed Funds and List of UNICEF Project Villages - East Java

Appendix L: Pesantren Fund - Related Educational Poster Directed at Fathers-in-WaitingAppendix M: Sample Form for "Target" Number of Pregnant or Delivering Mothers or InfantsAppendix N: Summary of Selected Donor Supported Projects in Reproductive Health

LIST OF TABLES

Table 1-1: Recommendations from Anne Bernard's 1998 Evaluation................................................ 1-3

Table 2-1: Safe Motherhood Project Objectives from 1995 Contribution Agreement........................... 2-1Table 4-1: Spectrum of SM/RH Programming....................................................................................... 4-4

Table4-2: Program Profile By Major Characteristics Province: South Sulawesi Phase 1: 1997-19984-8

Table 4-3: Program Profile By Major Characteristics Province: South Sulawesi Phase 2: 1998-19994-9

Table 4-4: Program Profile By Major Characteristics Province: East Java......................................... 4-17Table 4-5: Program Profile By Major Characteristics Province: Central Java..................................... 4-27Table 5-1: Outcome and Process Indicators for Monitoring Maternal Health Goals* ......................... 5-23Table 5-2: Maternal Health Statistics from Bulumkumba District Hospital, 1994-99......................... 5-37Table 5-3: Neonatal Mortality Ratio per 1000 Live Births - 1995-98.................................................. 5-40

Table 5-4: Maternal Health Statistics from Muntilan District Hospital - 1997-1999........................... 5-42

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LIST OF FIGURES

Figure 2-1: Summary of Main Findings of Review of Safe Motherhood Programmes........................... 2-3

Figure 3-1: Indonesian Context................................................................................................................ 3-2Figure 3-2: UNICEF Context..................................................................................................................3-5

Figure 5-1: GOI Sectors Related to SMP............................................................................................. 5-5Figure 5-2: Internal Monitoring System — Considerations.................................................................5-12

Figure 5-3: Theoretical Framework for Evaluation of MH Component................................................ 5-16

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ACRONYMS AND ABBREVIATIONS

AIDSAMPANCAPBD

APBN

BahasaBangda

Bangdes

BAPPEDA

BAPPENAS

BEOC/PONEDBFHBidan di Desa/BDDBinkes

BKKBN

BPS

Bupati

C-sectionCamatCCBCBRCDDCEDAW

CFICFRCJ

Acquired Immune Deficiency SyndromeAudit Maternal-Perinatal/ Maternal-Perinatal Death AuditAnte-Natal CareAnggaran Pendapatan dan Belanja DaerahBudget generated and allocated by Provincial and District GovernmentAnggaran Pendapatan dan Belanja NegaraBudget generated and allocated by national government

Language, as in Bahasa Indonesia, language of IndonesiaDirektorat Jenderal Pembangunan Daerah, Departemen Dalam NegeriDirectorate General for Regional Development, Ministry of Home AffairsDirektorat Jenderal Pembangunan Desa, Departemen Dalam NegeriDirectorate General for Rural Development, Ministry of Home AffairsBadan Perencanaan Pembangunan DaerahDevelopment Planning Agency at Provincial and DistrictBadan Perencanaan Pembangunan NasionalDevelopment Planning Agency at National LevelBasic Essential Obstetrical and Neonatal CareBaby Friendly HospitalCommunity MidwifeDirektorat Jenderal Pembinaan Kesehatan Masyarakat, Departmen KesehatanDirectorate General of Community Health, Ministry of HealthBadan Koordinasi Keluarga Berencana NasionalNational Family Planning Coordinating AgencyBiro Pusat StatistikCentral Bureau of StatisticsDistrict Head - Badan Urusan LogistikState Logistics Agency

Cesarean section, operative deliverySub-direct HeadCommunity Capacity BuildingCrude Birth RateControl of Diarrhoeal DiseasesThe Convention for the Elimination of All Forms of Discrimination AgainstWomenComplementary Feeding InitiativeCase Fatality RateCentral Java

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ACRONYMS AND ABBREVIATIONS

CIDACIE/IEC

CSD

Canadian International Development AgencyCommunication, Information and Education/Information, Education andCommunicationChild Survival and Development

Dana SehatDasawisma

DHDOBDukunDukun Bayi

EJEOCEPI

Health insurance schemeNeighbourhood unit of 10 households served by one female volunteer of thefamily welfare movement (PKK)District HospitalDate of BirthTraditional Birth AttendantTraditional Birth Attendant with Major Role of Caring for the Newborn

East JavaEmergency/Essential Obstetrical CareExpanded Programme of Immunization

FFLFO

Facts for LifeField Office/Field Officer

GBHN

GFRGNPGOIGotong-Royong

GPGSI

HfAHHHIVHKIHRDHQ

Garis-garis Besar Haluan NegaraBroad Guidelines of State/Government PoliciesGeneral Fertility RateGross National Product

. Government of IndonesiaTraditional system of mutual help and cooperation in Javanese village life,nowadays mainly an Indonesia wide politico-ideological catchword to summonpopular cooperation (mutual self-help within community)General Practitioner (medical doctor)Gerakan Sayag IbuMother Care or Mother-Friendly Movement

Height for AgeHouseholdHuman Immunodeficiency VirusHelen Keller InternationalHuman Resource DevelopmentHeadquarters

IBI

IDT

Ikatan Bidan IndonesiaThe Indonesian Midwives' AssociationInpres Desa Tertinggal

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A CRONYMS AND ABBREVIA TIONS

IGAInpres

IMFIMRIRH

Funds allocated by Presidential Instruction for improving quality of life of thepoorest villagesIncome Generating ActivitiesInstruksi PresidenPresidential InstructionInternational Monetary FundInfant Mortality RateIntegrated Reproductive Health

JaTengJaTimJHU/CCPJHPIEGO

JICA

KlK4KNKader(s)KAPKelompok ArisanKepala Desa

Java Tengara/Central JavaJava Timur/ East JavaJohns Hopkins University/ Centre for Communication ProgramsJohns Hopkins University-affiliated program to promote training-relatedinitiatives as a vehicle for achieving improvements in reproductive healthworldwideJapan International Cooperation Agency

One ante-natal visit completedFour ante-natal visits completedPost-parrum visitCadre, also used as singular to mean a volunteerKnowledge, Attitude and PracticesInformal community-based saving groupsVillage Head

LAMLBWLKMD

LMLLSS

Local Area MonitoringLow Birth WeightLembaga Ketahanan Masyarakat DesaVillage Community Resilience Committee or Village Development Council"Environmentally Friendly Institution", name of a training NGOLife Saving Skills

MCHMCH-LAMMCSDP/KHPPIAMFHMHMISMMRMNHMOAMOEMOH

Maternal and Child HealthMaternal and Child Health Local Area Monitoring SystemMother and Child Survival, Development and ProtectionMother Friendly HospitalMaternal HealthManagement Information SystemMaternal Mortality RateMaternal and Neo-natal HealthMinistry of AgricultureMinistry of Education and CultureMinistry of Health

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ACRONYMS AND ABBREVIA TIONS

MOHAMORAMOSAMOUMPOMTRMUACMusbang

Musyawarah Desa

NCTN-RHNGONMR

Ob/GynORSORT

PAPAR/PRAPATHPerinasia

PesantrenPIA

PKK

PKMD

PMD

PMI

PNPOGI

Pokja

Pokjanal Posyandu

Ministry of Home AffairsMinistry of Religious AffairsMinistry of Social AffairsMemorandum of UnderstandingMaster Plan of OperationsMid Term ReviewMiddle Upper Arm CircumferenceMusyawarah PembangunanDevelopment consultation at village levelVillage Level Consultation / Planning

National Clinical Training Network for Reproductive HealthNon-Governmental OrganizationNeonatal Mortality Rate

Obstetrician/GynecologistOral Rehydration SaltsOral Rehydration Therapy

Programme AreaParticipatory Action Research/ Participatory Rural AppraisalProgram for Appropriate Technology for HealthPerkumpulan Perinatologi IndonesiaThe Indonesian Society for PerinatologyReligious schools for Moslem studentsPaket Informasi AreaOutcome of consolidation of sectoral requirements from area-based annualplanning processPembinaan Kesejahteraan KeluargaFamily Welfare MovementPembangunan Kesehatan Masyarakat DesaPrimary Health CarePembangunan Masyarakat Desa, Departemen Dalam NegeriDirectorate General for Rural Development, Ministry of Home AffairsPalang Merah IndonesiaThe Indonesia Red CrossDelivery by a trained health professionalPersatuan Obstetric dan Ginekolog IndonesiaThe Indonesian Obstetric and Gynaecologist AssociationKelompok KerjaWorking GroupKelompok Kerja Operasional Pos Pelayanan TerpaduPosyandu Operational Working Group

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A CRONYMS AND ABBREVIA TIONS

Polindes

Posyandu

PROTAPPUA

Puskesmas

Rakercam

Rakerda

Rakerda terpadu

Rakorbang

ReformasiRepelita

Rp

Poliklinik DesaVillage maternity clinicPos Pelayanan TerpaduVillage Integrated Service PostStandard Emergency Obstetric ProceduresPaket Usulan AreaArea specific information package on proposed yearly government budgetallocations. It precedes PIA.Pusat Kesehatan MasyarakatCommunity Health Centre

Rapat Kerja KecamatanSub-district level planning and evaluation meetingsRapat Kerja DaerahDistrict planning and review meetingsRapat Kerja Daerah terpaduIntegrated local planning meeting at provincial and district levelsRapat koordinasi PembangunanDevelopment coordination meetingReformRencana Pembangunan Lima TahunFive Year Development PlanRupiah, Indonesian currency

SKRT Survei Kesehatan Rumah TanggaNational Household Health Survey

SM/SMI/SMP Safe Motherhood/ Safe Motherhood Initiative or ProgrammeSPC Senior Programme CoordinatorSS South SulawesiSSN/JPS Social Safety NetSTD Sexually Transmitted DiseaseSulSel Sulawesi Seletan/ South SulawesiSusenas Survei Sosial-Ekonomi Nasional

National Socio-Economic Survey

TA Technical assistanceTabulin Tabungan Ibu Bersalin

Pregnant mothers saving schemeTabumas Tabungan Masyarakat

Community savings schemeTB TuberculosisTEA Traditional Birth AttendantTOR Terms of ReferenceExternal Assessment ofClDA-Supponed Safe MotherhoodProgramme Within the Cooperation ofUNICEFandGovernment of Indonesia in 1995-2000

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ACRONYMS AND ABBREVIATIONS______________________

TOT Training of TrainersTT Tetanus Toxoid

UNFPA United Nations Family Planning AgencyUS AID United States Agency for International DevelopmentU5MR Under-five Mortality Rate

Vitadele trade name for packaged complementary foodVMW Village Midwife/Bidan di Desa

WATSAN Water and SanitationWB World BankWfA Weight for AgeWHO World Health OrganizationWSC World Summit for Children

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EXECUTIVE SUMMARY

Project Overview and General Comments

In October 1995, CIDA and UNICEF-Indonesia signed a five year, CAD $14.5 million agreement tosupport Government of Indonesia (GOI) Repelita VI Safe Motherhood Programme-related activities inthree provinces (South Sulawesi, East Java and Central Java). The agreement outlines CIDA support tothe three particular areas of the 1995-2000 UNICEF-GOI Master Plan of Operation: Community Capacity(CCB), Maternal Health Service Delivery (MH), and Access to Water and Sanitation. The main projectgoal was to contribute to the reduction of maternal and neonatal mortality and morbidity in the threeprovinces. This contract is due to end March 31, 2000. A team of two Canadian consultants, supportedby two Indonesian consultants, carried out an assessment of the Community Capacity Building andMaternal Health Service Delivery activities from January 15 to February 9, 2000.

The general objective of this mission was to "review and assess the implementation progress vis-a-visstated objectives of the Maternal Health and Community Capacity building components of the SafeMotherhood Programme in the CIDA-assisted provinces of South Sulawesi, Central Java and East Java".The stated objectives against which progress was to be measured were taken from the ContributionAgreement and the revised objectives as outlined in the May 1999, Third Annual Progress Report forCIDA on the Safe Motherhood Programme Initiative (Table 2-1). Qualitative and quantitative data wascollected via group and individual interviews; focus group sessions; field visits, and review of allpertinent documentation.

The situation in Indonesia during the life of the Safe Motherhood project has created a challengingworking environment. The monetary crisis, a dramatic increase in the proportion of the population livingbelow the poverty line, and repeated outbursts of violence across the country have all caused increasedpersonal and social insecurity. The elections brought the promise of reform, increasing democracy anddecentralization. Even in a country eager to embrace reform, the transition will be difficult given apredominant culture that values hierarchy, paternalism, central authority, directive guidelines and indirectcommunication. Without strong leadership, the promise of these changes has also heightened uncertaintyand insecurity. The huge influx of Social Safety Net funds at the project's midpoint added an unexpectedcomplication that undercut programming that had community capacity building and self-reliance at itsheart.

Within the dramatically changing landscape of Indonesia in the last five years, UNICEF-Indonesia alsofaced challenging transitions. Foremost among these, and unforeseen by the Indonesia office, was theslashing of its general resources budget (UN contribution) from a USD $12 million annual ceiling in 1995to $5 million in 1999. The second major change was a shift from a "project" to a "programme" approach.Before 1995, the Country Program consisted of 28 to 30 different projects with a focus on child survival.The 1995-2000 CP saw these projects organized as fourteen components under three main components:Service Delivery, Capacity Building and Advocacy and Planning. While this reorganization was plannedprior to 1995, it was first implemented during 1995-2000 - the time period under consideration. The 1998

External Assessment afCIDA-Suppartea'Safe Motherhood Agriteam Canada Consulting Lid. andProgramme Within the Cooperation of t '\IC£F and Luz de Luna InternationalGovernment of Indonesia in I VIS-2000 xiii April 2000

EXECUTIVE SUMMARY

Mid Term Review resulted in another realignment, this time into four main programme areas in order to"focus on a limited number of interventions and do them properly". The third major shift was the focuson developing an urgent response to Indonesia's multiple crises (environmental, economic, and political)in 1997-98. Approximately one-fifth of UNICEFs total budget now is allocated to Crisis Response1.The decision to decentralize UNICEF operations was the fourth major change. Within the last five years,field offices opened in Central Java, Moluku and Irian Jaya and the East Java office was moved fromMataram to Surabaya.

These transitions placed serious pressures on UNICEF capacity. UNICEF experienced gaps in staffing atboth the headquarters and field office levels. When key technical advisory positions were vacant inJakarta, other Jakarta personnel had to provide the needed assistance, sometimes outside their area ofexpertise.

UNICEF also has had to cope with the deficiencies of the GOI monitoring systems. GOI counterparts,not UNICEF, identified project sub-districts and villages. The difference in fiscal years between the GOI,UNICEF and its major donors has made planning and accountability complicated. The various Ministriesand Departments involved in the GOI Safe Motherhood Program all have separate budgets with noprotected or guaranteed funds for Safe Motherhood from year to year.

UNICEF has recognized the need to improve its own planning, monitoring and evaluation processes.AusAID funded technical teams to work intensively with UNICEF between Oct 1997 and June 1998 todevelop a logframe for Australian funded programme components. UNICEF funded seminars onlogframes and workplans for all UNICEF staff at the provincial and district levels.

Currently, all UNICEF programme planning is based on the logframe approach as reflected in the Year2000 workplans. While the application of the logframe approach to the 2000 workplans is relativelyrecent, the work meant to improve reporting on results has been going on since late 1997 but has yet to bereflected in improved reporting on results to donors.

Key Findings and General Recommendations

In the process of assessing specific UNICEF programming, a number of a core issues came to light thatrelate more broadly to UNICEF as a development organization and to CIDA in its role as a donor. Theseissues are presented here as organizational recommendations. These recommendations are followed by asynopsis of key findings under each of the Community Capacity-Building (CCB) and Maternal Health

1 Quote from interview with Stephen Woodhouse, Jan. 17th; "One quarter to one third of UNICEF's global budgetnow goes to Emergency Support worldwide. Now approximately one-fifth of the UNICEF-Indonesia total budget isallocated to Emergency Support and it is expected that this will continue." It is noted that Regular and Other(Supplementary) Resources have been consolidated towards the four main programming areas (PA 1-4) and fundsfor emergency response have come from additional (supplementary) funds. However, the fact that UNICEF's roleworldwide is changing to take up more Emergency Support and that 1/5 of the total budget in Indonesia is nowdirected to this programming is a significant transition that has occurred within the assessment period of thismission._______________________________________________________________External Assessment of CIDA-Supponed Safe Motherhood Agriteam Canada Consulting Ltd. andProgramme Within the Cooperation of UNICEF and Lul de Luna InternacionalGovernment of Indonesia in 1995-2000 xiv April 2000

EXECUTIVE SUMMAR Y

Service Delivery (MH) components and recommendations relevant to provincial programming under eachcomponent.

Organizational Recommendations

The original UNICEF-CIDA project design had a large investment in CCB programming but did notsufficiently address the complexity of social change required for programming success on institutionaland community levels. A more comprehensive, iterative, and less ambitious design would haveincorporated specific and detailed attention to:

the existing patterns of authority which control information flow, decision-making and resourceallocation;the cultural value conflicts between the principles of CCB and the societal /governmental status quo(respect for and submission to authority);the societal tensions incurred with movement toward democratic civil society with decentralizationand reform;the actual institutional capacity of UNICEF to implement change programs in the face of expansionof field offices and few staff available with grounded experience to provide guidance; andthe need for a clearly defined methodology and understanding of the skills required, withaccompanying definition of UNICEF's role (e.g. liaison, monitoring, facilitation, orexecutor/implementor)

Inadequate attention to these factors, particularly when coupled with the major restructuring of the Jakartaoffice that began in 1996 (with significant cuts to staff position), all contributed to making theprogramming time-consuming and difficult. The limitations of the project design and concurrent staff cutsplaced UNICEF on a steep learning curve throughout the five year period.

Based on these observations, and in order to maximize future effectiveness towards "family andcommunity empowerment" and eventual sustainability of change on institutional/social levels, thefollowing recommendations are made.

Organizational Recommendations - UNICEF1. Critically assess UNICEF human resources in terms of personnel, time, cost, responsibilities and

activities in order to realistically review upcoming plans for family and community self-helpprogramming.

UNICEF does well at country situational analysis of well-being of women and children. Equallyimportant, however, is a more thorough and critical analysis of UNICEF's own institutional capacityin real terms. While the 2001 MPO has attempted to scale down programming, the concurrent use of"family empowerment" and "community empowerment" as core concepts and goals still implieslonger, rather than shorter, and larger, rather than smaller, investments of time, staff and energy.UNICEF very likely is still overextending its staff and capacities in the next CP/MPO.

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EXECUTIVE SUMMARY

2. UNICEF's obvious strengths lie in advocacy of child rights and well-being, creation of promotionalresources and situational reports, and collaboration with GOI to build civil society. Given thecurrent human and fiscal resources, this recommendation suggests that the organization bui ld onstrength and revises the expectation that UNICEF should "demonstrate" on-the-ground work2

to empower communities. Instead, UNICEF should collaborate with agencies carrying outcommunity-oriented/based work, gather information about these activities and their results, andconsider acting as a clearinghouse for this information. This information would feed into thesituational analysis reports as well.

3. The news media are critically important in informing the public and influencing policy in Indonesia.UNICEF is an active and respected advocate for health within the country. UNICEF should considerstrengthening its public relations/communications team and budget in order to place and maintainadvocacy for resolution of health issues (e.g. the need for a substantive increase in the GOI healthbudget at the district level) in the first ten pages of the national newspapers.

4. UNICEF needs to be more explicit, both internally and with donors, about actual programmingactivities, progress and problems. This will become critical as UNICEF increasingly communicatesacross distance with provincial staff, with multiple levels of government personnel and systems, andwith private and international funders. Greater clarity and frequency in communication between thefield offices and Jakarta and between CIDA and Jakarta would strengthen the corporate(institutional) culture and improve programming. The assistance of an external consultant whospecializes in communication and organizational change may be helpful. To obtain a more specificgrasp of project developments and hurdles, a permanent staff member who is familiar withprovincial situations should collaborate with the field offices to put together the annual reports toCIDA.

5. UNICEF with its donor partners needs to clarify its position on the provision of "incentives" andpayment for local "technical assistance." For example, reimbursing TBAs or kaders for transportcosts makes sense, however, when this payment exceeds actual transport expenses, it becomes a cashincentive. Similarly, and more costly, the practice of budgeting direct payment to governmentprofessionals for technical assistance is a cause for concern. This bolsters low salaries and buysinterest in the short-term but could be disastrous in the long run for program sustainability andaccountability. This issue goes far beyond reimbursement of transportation costs and payment forsnacks at meetings and requires a firm resolution.

6. UNICEF with its donor partners needs to clarify, and then be consistent with, its position on thefunding of UNICEF-supported SM programming, with corresponding discussion with GOI officials.The issue centers on GOI SM activities being overly dependent on UNICEF monies with variationfrom province to province. While reference is made to UNICEF "leveraging" GOI funds, the

2 Although UNICEF does not directly implement any progammes or projects but supports others to develop andimplement their programmes, Stephen Woodhouse emphasized UNICEF's desire to be able to back up policy advicewith "on-the-ground experience" in our interview with him on Jan. 17th.________________________External Assessment of CIDA-Supported Safe Motherhood Agrileam Canada Compiling Ltd. andProgramme Within the Cooperation of UNICEF and Lui de l.una InternationalGovernment of Indonesia in 1995-2000 xvi </>"' -uno

EXECUTIVE SUMMARY

situation would warrant a complete review prior to end of this project. An official UNICEF positionon percentages or minimum amounts from partners would hopefully assist field offices in theirnegotiations with GOI and others.

7. The adoption of logframes is a positive development within UNICEF. UNICEF should continue andextend the work using logframes (and/or other appropriate planning/monitoring tools), recognizingthe current limited input from the field offices and striving to expand their role beyond activityidentification. UNICEF should work with CIDA to determine the best means to address RBMreporting requirements so that, as much as possible, reporting to different donors can be simplified.

8. Ensure that a qualified gender specialist (in-house or external) assists with review of logframes andMPO in order to incorporate a gender perspective and potentiate activities, paying special attentionto inclusion of rights and empowerment of women.

Organizational Recommendations - CIDA9. Annual or biannual on-site visits to UNICEF even with extensive debriefing are not enough to

provide sufficient guidance for resolution of major problems, given the large and growing programbudget, multiple programs, institutional history and long distance communication with field offices.Consider contracting technical teams, coordinated with UNICEF's other major donors, to assist withidentified priority issues. If carefully synchronized, this type of value-added collaboration could beuseful, both in advancing actual planning and programming and potentially in lessening thepressures arising from the differing expectations of multiple donors. (For example, AusAid hasinvested in UNICEF itself as an institution by sending short-term technical assistance teams to workwith UNICEF on the development of planning logframes over the past few years).

10. Consider allocation of remaining unused funds in the project budget to support theserecommendations. Consider postponement of the project final report until December 2000 to allowreporting on project-related developments within UNICEF up to the time. Consider provision offunds for purchase of 20% or so replacement time for a designated UNICEF staff to coordinatefollow-up on recommendations for several months.

11. With UNICEF, review and re-design external project assessment/evaluation strategies. TheIndonesian cultural norm of visiting project sites with large numbers of people is not conducive todata collection from interviews, focus groups or village meetings. One alternative would be tocontract a Bahasa-speaking consultant who would regularly monitor and report on proceedings.

Key Findings and Component-Specific Recommendations

Community Capacity BuildingThe following section provides a synopsis of key findings for the Community Capacity-Buildingcomponent and presents recommendations.

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EXECUTIVE SUMMAR Y

South SulawesiThe first phase from 1996 to 1998 can be characterised as an enabling approach that was based on PRAand triple A cycles in project villages. During 1999, several professional staff changed in the SS fieldoffice along with a redefinition of programming priorities by UNICEF-Jakarta and UNICEF-SS.Consequently, the SM program altered significantly in South Sulawesi, essentially shifting from anenabling CCB approach based on triple-A cycles in model villages to much more of a socialization ofessential services approach. The socialization approach emphasizes revitalization of posyandu, GOIstandardization for development of village work plans, and development of micro-IGA initiatives viaGOI/PKK. IEC materials were/are very limited, in numbers, in quality, and in use.

Overall, despite the encouraging start, the original design proved difficult to implement and maintaingiven the established government and social culture, the small number of professional staff in SouthSulawesi, each with a vast range of responsibilities, and the limited institutional experience in CCB.Actual outcomes beyond standard establishment of village ambulances are difficult to determine becauseof shifting project parameters and changing project districts over the time period. Current programsustainability is a major issue. It is not known if promising activities and developments have carriedforward.

12. Recommendations for South Sulawesi:a. Work with UNICEF-Jakarta to resolve the issue of technical assistance and incentive payments to

GOI employees and others, keeping program sustainability as a vital consideration.b. As much as possible, retain original project districts (as opposed to selecting new districts for

programming).c. Set up methods to sufficiently document the process, inputs and outputs of the fledging micro-IGA

activities of kaders and posyandus. Building on their current efforts, assist the current districtmedical officer and the PKK leader to plan and fond a limited number of these initiatives in the samesub-districts, paying special attention to marketing and use of funds and income.

d. Provided that additional help is contracted, plan and conduct a low-key but thorough follow-up of asampling of the original villages located in the first project areas to determine SM status and degreeof community ownership of SM activities. Include descriptions and patterns of the training,processes and village learning and actions. If the initial findings warrant further investigation,undertake a comparative study in the later villages in which training and follow-up were significantlyshortened and the GOI guidelines were standardized.

East JavaHaving started training and work with participatory rural appraisal with GOI personnel, the UNICEF-EJprogram focus shifted in late 1998 and, in response to the crisis and Mid-Term Review decisions, supportfor PRA ceased. The basic approach to CCB programming in East Java currently is a top-downsocialization (essential service) model in which poor and/or pregnant families apply for a soft loan to beused for payment of delivery services and/or income generating activities via the local pesantren (Islamicschool). The profit of the economic activity was to be saved for paying for maternal services. A total of39 pesantrens have this credit scheme. To date, UNICEF-EJ has not made any substantive analysis of thepesantren programs. While field officers have demonstrated their ability to create working relationshipsExternal Assessment of'CIDA-SupportedSafe Motherhood Agritcam Canada Consulting Ltd. andProgramme Within the Cooperation ofVNICEFand Lui de Luna InternationalGovernment of Indonesia in 1995-2000 xviii April 2000

EXECUTIVE SUMMAR Y

with religious NGOs on a small scale and believe thatpesantrens are accountable with program funds, thelittle available data/findings from the assessment exercise suggest that the SM program operationalizedthrough pesantrens has had limited value to date. The loan scheme is narrow in concept and criteriaparameters, appears to be causing disagreeable social pressure fa pesantren coordinators, and may not begiven high priority by some, if not most, pesantrens. A sample analysis of actual use of loans by familiesis warranted. No effective educational activities were developed or incorporated into the pesantrenprogram. There is an untapped educational potential via pesantrens' formal curricula for students.

The other focus of community activities is Posyandu revitalization, a village level program run by PKKand supported by UNICEF and GOI-EJ. The program activities include: weighing of children under 5years, supplementary food distribution, a small loan scheme, home visits to encourage attendance, kadertraining, and in some/most posyandus, kaders support VMW activities. Starting in January 1999, "inorder to activate posyandu cadres in providing services \n posyandu voluntarily" "and to "make posyandumore attractive" to families, UNICEF provided seed capital of 500,000 to 1,850 posyandus for the creditscheme. Mothers with U5 children and posyandu kaders can apply for this credit, although it appears thatkaders may be the large majority taking loans. Posyandu revitalization appears to be increasing instrength, and would benefit from closer, more continuous study to determine extent of "showcase" effect,i.e., bursts of concentrated activities in response to visits by external authorities (PKK, donors, GOI) vis avis actual sustained village efforts.

UNICEF-EJ has recognized its difficulty with leveraging GOI-EJ funding for SM, calling into questionlong-term sustainability of SM programming. The East Java UNICEF field staff were overstretched tocarry out the assigned responsibilities and programs.

13. Recommendations for East Java:a. As the priority for 2000, conduct a summative evaluation of the pesantren SM loan program using a

cross-sectional sample of sites, and include detailed tracking of loans and their use in comparison topopulation and economic need. As planned, do not expand the loan program until this is done.

b. Given the apparent lower priority placed on the program by pesantren coordinators, draw conclusivestatements on overall effectiveness to date vis a vis level of effort and needs. Decide on theexpansion/continuation of the loan program versus exploration of UNICEF collaboration onalternative SM strategies with pesantren organizations and the Ministry for Religious Affairs.Weigh out the advantages of a change of programming focus with Islamic organizations.

Central JavaIn essence, the Tabulin program currently provides a limited subsidy for health services directly related toantenatal care, assisted-delivery, postpartum care, and emergency delivery care that are incurred byprogram members who, for the most part, are women of lower-middle and middle class. Themethodology used is top-down socialization (essential service model) through established governmentlines and the PKK with a major emphasis on financial management of program funds and little attentionto the empowerment of women through education. By definition, this methodology reinforces existingpower structures, the dominant patterns for decision-making, and the control of information andresources. "Participation" per se is defined numerically by donations received and memberships/claims.External Assessment ofCIDA-Supported Safe Motherhood Agriteam Canada Consulting Ltd. andProgramme rMlhin the Cooperation of UNICEF and Lui de Luna InternationalGovernment of Indonesia in 1995-2000 - xix April 2000

EXECUTIVE SUMMAR Y

Shortly after Tabulin began, the GOI SSN program seriously affected the use and potential of Tabulinthrough its provision of free health care for the poor and the distribution of complementary feedingsupplements to the undernourished. According to field interviews, an estimated half of registeredTabulin-vilhge programs are active1; this estimate needs verification.

Prior to any further expansion in either numbers of participating villages or program scope (including any"merge" withposyandu), UNICEF must be more than reasonably certain that Tabulin 1) is sufficientlyrelevant, addressing unmet needs of poor villagers, especially women, particularly in view of theunknown future of SSN; 2) provides comprehensive value for money and effort at village level; and 3) isoperational within government and with midwives establishing private practice. This is of particularconcern given the small subsidy benefit, the majority middle-class recipients, the uncertainty of donationson a continuing basis, and the conflicting pressures on VMWs.

14. Recommendations for Central Java:a. Invest funds in formative evaluative study of the larger-scale Tabulin program prior to any further

expansion or inclusion in the CP/MPO 2001-2005.b. Caution is needed in UNICEF's continuing role in community resource mobilization, and UNICEF

has little experience in operational research related to Safe Motherhood. Hire an external researcherwith demonstrated skills in evidence-based program development, critical assessment of qualitativeas well as quantitative data, in teamwork, and in teaching operational research. Designing,conducting, analysing and interpreting an evaluative study of Tabulin would be a valuable exercisefor all those who accompany the work. In the research design, include consideration of sources forsub-district operational funding, and also, investigation into support for broader, more substantivehealth insurance or co-financing schemes.

General CCB Programming Recommendations15. Invest central and provincial time to grapple with community program "methodology" — definition

of terms, identification of principles, objectives, responsibilities, processes, monitoring. Avoidjumping to identification of indicators prior to clarification of these aspects.

16. UNICEF wishes to promote community empowerment through collaboration with NGOs. Cautionis needed here because of the paucity of NGOs and existing NGOs' inexperience with communitydevelopmental initiatives. UNICEF states that internal monitoring has been weak. Monitoring(contracted) NGO partners will not be any easier. A careful analysis of the range of potential NGOpartners for any program should be conducted in order to adequately assess pros and cons prior toentering into any agreements. This includes working with religious NGOs.

17. Considering the unevenness of availability and quality of teaching/learning resources of all typesand their actual minimal use, take stock of available resources related to SM and CCB across

3 This estimate was provided during our Central Java field office briefing Feb 2, 2000: "approximately 50% ofvillages are active [in Tabulin] and we \\ant to increase focus on these." This impression was verified in interviewswith the District PKK and LKMD leaders who, upon review of their lists of project villages, said that about half ofthe villages were "active".__________________________________________________External Assessment ofClDA-Supponed Sajr Slnthrrhood Agriteam Canada Consulting Ltd. andProgramme Within the Cooperation of ('\ICt.r'and Luz deLuna InternacionalGovernment of Indonesia in 1995-2000 xx April 2000

EXECUTIVE SUMMARY

agencies and programs. Investigate the agencies that are developing resources beyond technicalguidelines and print resources, including theatre, puppets, cassettes, radio. Increase work withprovincial staff to match learning needs at village, kader and health professional levels with existingand new materials/media4. Thoroughly pilot-test trial resources on-site prior to mass production.Build on the advocacy/public relations strength of UNICEF through the development of a formalcollaboration with another agency that has extensive experience in the production and use oflEC/learning resources for the field.

Maternal Health Service Delivery Component

The MH component of this project had three clear objectives: to increase the percentage of women,specifically from low-income groups, having antenatal care, deliveries assisted by trained healthpersonnel, and having at least two post-partum visits. The assessment team's examination of maternalhealth service delivery data from the three project provinces revealed that each field office should be ableto report small to moderate increases in coverage indicators (K4, PN and KM) over time in projectvillages and sub-districts. Unfortunately, up until now this has not been clearly reported to CIDA.This sub-optimal reporting is partly due to the constraints of the GOI monitoring system but is also due topoor presentation of data (e.g., using a mix of absolute numbers and percentages, not defining terms ordenominators) on the part of UNICEF.

Reliance upon the GOI monitoring system has meant reporting on these same indicators from dataaggregated at the district level. It is unlikely that change seen from this data can be attributed to projectactivities when there are relatively few project villages in most districts and the vast majority of thesevillages have become involved with the project just in the last one to two years. The confounding factorof the Social Safety Net funds covering the cost of maternal health care services further complicates theability of UNICEF field offices to report on changes that are meant to reflect the impact of projectactivities.

Besides improved maternal health service coverage in project villages, a number of other clear benefits ofthe UNICEF-GOI MH component were identified. The assessment team witnessed excellent collegialrelationships and communication between UNICEF Field Officers and the various levels of governmentworking on the Safe Motherhood Programme. The joint planning of Maternal and Child Survival,Development and Protection programmes initiated by UNICEF has resulted in a broader and deeperunderstanding of Safe Motherhood issues, particularly at the provincial level. The standardization ofvillage emergency transport plans and village ambulances were in evidence as was the presence of writtenStandard Operating Procedures (PROTAP) for treatment of obstetric emergencies at every level of healthservice delivery. In South Sulawesi, where few project districts have hospitals with a blood bank, theblood donor pairing programme may be of vital importance although the assessment team suggests thatthere are some ethical considerations that need to be reviewed.

4 The director of one large pesantren and the Ministry of Religious Affairs representative both said that they wouldwelcome SM teaching materials so that this information could be included in pesantren curricula.___________External Assessment ofCIDA-Supportcd Safe Motherhood Agriteam Canada Consulting Lid. andProgramme Wtihin the Cooperation of VNICEF and Lui de Luna InternationalGovernment of Indonesia in 1995-2000 xxi April 2000

EXECUTIVE SUM MAR Y

The future of Safe Motherhood activities in general in Indonesia continue to rely on the village midwifeor Bidan di Desa (BDD) who occupies the central role of linking communities to community healthservices. The future of the BDD is uncertain and many analysts suggest that within the next few yearsthere will be a mass exodus of BDD from village posts. The situation of the BDD demands urgentattention. The GOI and its development partners must carefully examine the issues and the GOI needs todeclare a clear policy on how this issue will be addressed.

General recommendations MH component18. UNICEF-lndonesia add its support to a recommended multi-donor funded evaluation of the many

recording and reporting pilot projects underway with a goal to making concrete recommendations tothe GOI on how to standardize reporting and make the system more useful.

19. UNICEF-lndonesia establish an internal monitoring system to gather data on key MCH indicatorsfrom at least the project village level and the district hospital. Some of the considerations fordeveloping such a system are discussed in this report (Table 5-1 and Figure 5-2). This data wouldideally be collected quarterly, entered into a FO database and analyzed and reported against projectgoals at least biannually within UNICEF (as previously suggested by Anne Bernard -recommendation #8) and annually to donors.

20. UNICEF-lndonesia should remain an active member of the donor coordination group and SafeMotherhood Task Force, taking advantage of the opportunities to collaborate and harmonize projectactivities with other donors when possible. UNICEF may be particularly interested in following theJHPIEGO efforts regarding SMP-related IEC materials in its efforts to find materials appropriate toits project areas.

21. In order to monitor the effectiveness of the efforts to improve planning and funding of SMI/MCSDPactivities at the district level, two process indicators that UNICEF could report are the 'on-timeproduction of the PIA' and the figures on UNICEF vs. GOI contribution to these activities. Giventhe difference in fiscal years, this reporting might have to be retrospective but UNICEF and GOIfinancial figures should report on the same time period.

22. While the AMP process is potentially valuable, it does not yet have clearly understood goals andobjectives. If UNICEF chooses to continue funding the AMP, it should allocate funds for operationsresearch into how to make the process more effective and how its conclusions can be translated intoactions that could positively impact maternal health.

23. The Bidan di Desa (BDD) is the key agent in the UNICEF-GOI Safe Motherhood Programme. Thesustainability of the programme offering primary care including MCH care at the village level is ingreat jeopardy should large numbers of Bidan de Desa leave their village posts once theirgovernment contracts are over. The following recommendations pertain to the future of the BDD andtheir role in UNICEF-supported programming:

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EXECUTIVE SUMMAR Y

a. UNICEF join other donors in pressing the GOI to state a clear plan re: how to deal with thepotential loss ofBidan di Desa from their village posts.

b. UNICEF support essential operations research to define the issues that lead Bidan di Desa toleave village health posts.

c. UNICEF included the Bidan di Desa in discussions of various projects (Tabulin, Pesantrenfunds) and look closely at the real or potential effects of these projects on the BDD's practice.

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%\**&

1 BACKGROUND TO ASSESSMENT

In October 1995, CIDA and UNICEF-Indonesia signed a five year, CAD $14.5 million agreement tosupport Government of Indonesia (GOI) Repelita VI Safe Motherhood Programme-related activities inthree provinces (South Sulawesi, East Java and Central Java). This contract is due to end March 31,2000.

A team of two Canadian consultants, supported by two Indonesian consultants carried out an assessmentof these activities from January 15 to February 9, 2000. The essential background to this assessment isoutlined in the following key documents, reviewed in brief below: the UNICEF Country Plan/Master Planof Operations for 1995-2000; the October 1995 Contribution Agreement Between the Government ofCanada and UNICEF Concerning Canadian Participation in the Safe Motherhood Project; The SafeMotherhood in Indonesia, March-April 1998 Evaluation Report by Anne Bernard; and The UNICEF 1998Mid-Term Review.

1.1 UNICEF Country Plan/UNICEF-GOI Master Plan of Operations 1995 - 2000

National development in Indonesia has been planned via a series of 5-year plans called Repelita over aperiod of 30 years. UNICEF support to the GOI during Repelita V (1990-95) had a relatively narrowChild Survival and Development (CSD) focus. In supporting Indonesian's last 5-year plan, Repelita VI(95-00), UNICEF chose to broaden this focus to include the health and protection of mothers andchildren. This shift to Maternal and Child Survival, Development and Protection (MCSDP) prioritizedsupport based on those program areas that most clearly meshed with the 29 goals outlined in the 1990World Summit for Children. In particular, UNICEF planned to support goals that:

a. appeared to be achievable based on current trends;b. strongly influenced other goals and therefore merited special attention; andc. were especially important to achieving the primary goals of decreasing MMR, IMR, under 5MR and

child malnutrition.

UNICEF support took the form of 14 sub-components grouped under three major components: ServiceDelivery (sub-components 1-7), Advocacy and Social Mobilization, (8-11) and Local Government andCommunity Capacity Building (12-14). The MPO states that government program financial andmanpower resources are guaranteed under Repelita VI with monitoring and evaluation relying on GOImonitoring of relevant indicators for the Repelita VI targets. The MPO further states that UNICEF-supported components would be balanced between rural and urban with the rural focus on IDT or "left-behind" villages.

Problems to be addressed by the Service Delivery component included shortage of staff, poor qualitystaff, lack of integrated services and lack of IEC programs/materials. The Community Capacity Buildingcomponent sought to increase the capacity of communities to create demand for support to MCSDPservices via such activities as strengthening and training of village volunteers (kaders) to

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BACKGROUND TO ASSESSMENT

motivate/socialize, mobilizing community resources for self-financing activities and improving datagathering and analysis.

1.2 CIDA-UNICEF Contribution Agreement

The CIDA-funded Safe Motherhood Project was based on the goals and strategies outlined in the existingUNICEF Country Program/UNICEF-GOI MPO 1995-2000. Early in the project implementation, twosenior UNICEF staff, closely involved in the elaboration of the agreement, were transferred to postingsoutside of Indonesia.

The main project goal was to contribute to the reduction of maternal and neonatal mortality and morbidityin the three provinces. The agreement outlines CIDA support to three particular areas of the UNICEF-GOI Master Plan of Operation:

Community Capacity Building - MPO sub-component #13 and #14;

Maternal Health Service Delivery - sub-component # 1; and

Access to Water and Sanitation - sub-component #7.

Coverage for all components was to be in five districts in each province with replication to other districtswithin two years. A district needs assessment for each province was a prerequisite in order to producequantitative and qualitative baseline data.

Table 2-1 cites the project objectives for the Maternal Health (MH) and the Community Capacity-Building (CCB) components.

The project goal under the CCB component was to be achieved through "affecting a range of communitybehaviours relating to outcomes of pregnancy, delivery and post-partum neonatal periods".

The project goal under the MH component was to be achieved through "improving the quality of, andwomen's access to, ante-natal, safe delivery and post-natal services". Specifics of the design of thiscomponent are less well elaborated in the contribution agreement in comparison with the CCBcomponent.

1.3 The Safe Motherhood in Indonesia, March-April 1998 Evaluation Report

In March-April of 1998, as part of UNICEF's mid-term review process, Canadian consultant AnneBernard and Indonesian consultant Hadi Pratomo carried out an expressly formative evaluation of theCIDA-funded Safe Motherhood activities. The goal of the evaluation was to "suggest ways in whichelements of the project might be reconsidered, redirected or strengthened to realize better progress toward(the project's) goals". The twelve specific recommendations from this report are shown in Table 1-1.

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BACKGROUND TO ASSESSMENT

Table 1-1: Recommendations from Anne Bernard's 1998 EvaluationIt is recommended that:1. More explicit and concerted attention by senior management and technical officers in UNICEF, in

conjunction with GOI counterparts and relevant other donors, to clarifying the Safe Motherhoodconcept, resource implications and outcome expectations in explicitly operational terms._________

2. Conceptual frameworks already developed by UNICEF through different sub-components andactivities considered for their possible use in evolving (a Safe Motherhood) model.

3. Consequent to developing a more operationally focussed and integrated profile for the SM paradigm,UNICEF become much more strategically proactive at senior policy levels.___________________In order to move forward on realizing Safe Motherhood as a priority policy and foundationprogramme, the SM programme of work (must be) recognized in more expressly structural terms.

5. Consideration (should be given) to providing a senior professional technical advisor to ensurecontinued conceptual clarity and coordination for the SM initiative._______________________

6. UNICEF pursues with greater energy and focus the "health systems" issues implied by the third"supply-side" circle of the SM framework._____________________________

7. Evaluation and monitoring made a central feature of the project at all levels of its implementation.8. A strategy and/or mechanism be developed whereby the various monitoring data being generated by

the field offices are regularly and consistently gathered together and "displayed" at a central point.9. A more explicit "research" aspect be built into the SM project.10. Initiatives recently begun to develop a SM mass media campaign (be) pursued with even greater

vigour, including especially the efforts to coordinate with the technical officers in Jakarta and theprovincial offices.____pnjvuioiai uiiioca.______

11. Options and opportunities need to be explored for incorporating SM messages into locally availableand managed formal and informal media.______________________________________

12. Consideration to raising the profile of morbidity as a mobilizing issue for SM, especially atcommunity levels.

The fundamental problem identified by this report was "one of incongruence between ends and means: ofseeking to conceive SM as an integrated whole, while causing it to be planned, delivered and budgeted onthe basis of discrete sub-components". UNICEF National Office staff emphasized the importance of theidentification of this fundamental problem to their Mid-Term Review process and the subsequentrestructuring of the Safe Motherhood Programme.

1.4 UNICEF 1998 Mid-Term Review

According to the Senior Programme Coordinator (SPC), the major outcome of the 1998 Mid TermReview (MTR) was a significant re-alignment of the County Programme of Cooperation in an effort tobetter address the effects of the economic crises in Indonesia while remaining consistent with the goalsand principles of the 1995-2000 MPO.

During the first two years of the programme, each component had its own GOI technical team, making itdifficult to bring all of the counterparts together. For example, representatives under the Ministry of

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BACKGROUND TO ASSESSMENT

Health made up the Service Delivery technical team; Religious Affairs and Empowerment of Women saton the CCB team; and Home Affairs and the PKK comprised the Advocacy and Social Mobilizationtechnical team. The restructured programme changed the programme structure from fourteen separatesub-components to four main programming areas (PA):

PA 1 - Community Self-Help for Maternal and Child Health;PA 2 - Control of Diarrhoeal Diseases and Water Supply and Environmental Sanitation;PA 3 - Revitalization of the "posyandu" integrated service posts and provision of low-cost, fortifiedcomplementary food for children aged 6-12 months; andPA 4 - Basic Education for All.

Three integrated support activities cut across all programme areas: local planning and management, CIEand civil partnerships, and monitoring and evaluation. The GOI counterparts comprising the technicalteam for PA 1 now combine representatives under the Ministries of Health, Home Affairs (including thePKK), Empowerment of Women, Religious Affairs, and Education. Funds are still mainly tracked underthe previous sub-component system.

Programme Area 1 brought together the CIDA-supported MPO sub-components pertaining to CCB (#12and 13) and MH (#1) along with elements from the Universal Child Immunization initiative.

As a result of the MTR, UNICEF stated that it planned to focus on nine parameters5 that are paraphrasedhere:

1. "Focus on a limited number of interventions and do them properly".2. Focus on interventions that are direct responses to the most critical problems facing women and

children.3. Work much more with major NGOs.4. Ensure interventions are consistent with and supportive of the principles of UNICEF for the

establishment of Indonesia's Social Safety Net5. Demonstrate approaches that work.6. Focus on the family, strengthening family (and local community) capacity to meet the needs of

women and children in the most cost-effective manner.7. Maximize and build on UNICEF's local comparative advantages and strengths: good links with

provincial government, strong civil society link, good media and private sector links and goodrelationships with NGOs.

8. Ensure that supplementary funded activities are well implemented and modified in agreement withother donors.

9. Work in close concert with other UN agencies.

1 UNICEF Mid-Term Review, 1998. P.7External Assessment of CIDA-Supporled Safe MotherhoodProgramme Within the Cooperation of UNICEF andGovernment of Indonesia in 1995-2000 1-4

Agriteam Canada Consulting Ltd. andLui de Luna International

April 2000

TERMS OF REFERENCE, FRAMEWORK ANDMETHODOLOGY OF ASSESSMENT

2.1 Terms of Reference

The general objective of this mission was to "review and assess the implementation progress vis-a-visstated objectives of the Maternal Health and Community Capacity building components of the SafeMotherhood Programme in the CIDA-assisted provinces of South Sulawesi, Central Java and East Java".The stated objectives against which progress was to be measured were taken from the ContributionAgreement (Project Objectives A and B - page A-3) and the revised objectives as outlined in the May1999, Third Annual Progress Report for CIDA on the Safe Motherhood Programme Initiative (pp. 11 -14). These objectives are listed in Table 2-1.

Table 2-1: Safe Motherhood Project Objectives from 1995 Contribution Agreement

1.

2.

3.

4.

5.

Project Objectives CCB ComponentImprove community's (women of reproductiveage, their husbands and families) recognition ofdanger signs threatening lives of women duringpregnancy, childbirth, post-partum period andtheir newboms.Improve community's awareness and capacity totake 'timely' and 'adequate' actions needed whenface with these risks.Improve community's awareness of direct andunderlying causes of these risksituations/problems.Improve community's capacity to lower theincidence of such problem situations throughbetter preventative care at community and familylevels.To build the capacity of local governments andcommunity institutions to facilitate the process ofproblem assessment, analysis and action planningby the community, particularly women, and tomanage project implementation and expansionand replication to other districts.

Project Objectives MH Component1 . To increase the percentage of women, especially those

from low-income groups, having a minimum of 4antenatal visits during their pregnancy, from 50-90%by the end of 1999.

2. To increase the percentage of deliveries assisted bytrained health personnel from 38 to 55% by the end of1999.

3. To increase the percentage of women having at least 2post-partum visits within one monthly of delivery to60%.

Proviso: Technical skill and facilities improvements inHospital Services will be taken care of by GOI or otherdonor funds outside the CIDA project, in these projectprovinces and areas.

The specific objective for the Community Capacity Building (CCB) Component was "to assess thestrategy, format and operational mechanism of Community Participatory Processes needed to reducematernal mortality and neonatal morbidity, including the adequacy and appropriateness of indicators usedand system of data collection, analysis and feed-back mechanisms or this component vis-a-vis results-based programme management". The intent was to examine the strengths and weaknesses of the CCBoperations, assessments and activities with a focus on replicability, sustainability and expansion.Pertinent questions included: lessons-learned, possible alternative approaches, and identification ofaspects for continuation or expansion. Of special interest was the development of a methodology toobtain information from communities regarding the results of the Safe Motherhood Programme.

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2 TERMS OF REFERENCE, FRAMEWORK AND METHODOLOGY OF ASSESSMENT

The specific objective for the Maternal Health (MH) Component was "to assess the Maternal Health Careservice delivery, monitoring and evaluation aspects, including adequacy and appropriateness of activitiesconducted, the indicators used and system of data collection, analysis and feed-back mechanism forresults-based programme management". The intent was to examine the GDI's system for monitoringmaternal health indicators and UNICEF's own monitoring mechanisms for reporting on results to donorslooking at data collection, validity and reliability. Of particular interest was the identification of ways topotentially improve the monitoring and evaluation of programme activities. The assessment also aimed tolook for evidence that MH services had improved in accessibility and quality over the life span of theprogramme in the UNICEF-assisted villages and districts. The team leader was also requested to addressthe broader issues of GOI policies relating to maternal health, the possible effects of recent legislation onfinancial resources and decentralization on service delivery, and human resource allocation for thiscomponent.

Another aspect of this evaluation (outlined in the original TOR under "interface between projectcomponents") was to review and comment on the interface between water and sanitation and maternalhealth initiatives. Prior to leaving for the mission, the assessment team was advised by the Project Officerin Ottawa that this aspect was to receive significantly reduced attention in light of a recently completeddetailed assessment of the water and sanitation component. The full Terms of Reference for thisassessment mission are appended in Appendix A.

2.2 Framework

This mission was originally planned for the fall of 1999. Political unrest related to presidential electionsin October and then concerns about potential Y2K-related travel problems caused the assessment to bedelayed until January 2000. The actual time period of mission was January 15 to February 8, 2000.

The initial intent was for the assessment to be formative in nature and to take place in three stages - aninitial assessment, a field trial of recommendations arising from the initial assessment, and a finalassessment. The final phase of the assessment that was to develop a comprehensive set ofrecommendations for future cooperation between CIDA and UNICEF in Indonesia, was originallyplanned to be completed by June 2000. The unavoidable delays outlined above compressed the total timeframe for the assessment from eight to five months. At the outset of this mission, both Ms. Khin SandiLwin, Senior Programme Coordinator, and Mr. Stephen Woodhouse, Director of UNICEF-Indonesia,stated that this shift in timing would make it impossible to carry out the previously envisioned secondstage of a field trial of recommendations. However, they both felt that the findings and recommendationsof this assessment would play a major role in refining the 2000-2001 Annual Plan due to be completed bythe fall of this year.

2.2.1 Difficulties in Doing and Reporting on Safe Motherhood ProgrammesA review of the lessons-learned from the last decade of the Safe Motherhood Initiative, especiallyregarding the difficulties now understood more clearly on "doing" and reporting on the results of SafeMotherhood Programmes helped to frame the evaluation of this project.

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The outcome of the UNICEF-GOI Safe Motherhood Programme is rapid reduction of the MaternalMortality Ratio (MMR). Maternal health experts agree that determining an accurate MMR depends uponcomplete and accurate vital registration, something that is lacking in all but the most developed countries.Obtaining a rough national (or a large population aggregate) estimate is possible using WHO/UNICEFmodels based on a country's general fertility rate (GFR) and the percentage of births delivered by atrained attendant or the sisterhood method, an indirect demographic technique. Each of these methodshas significant constraints that make them useless for measuring change. The WHO/UNICEF model willonly show change as a result of changes in the model inputs (GFR and PN), rather than by observedchanges in the MMR. The sisterhood method gives a retrospective estimate for the past 10 to 12 yearsrather than a current estimate and has wide confidence intervals. Detailed review of Safe Motherhoodprogrammes around the world has shown that most programmes are forced to use process indicators tomeasure the implementation and use of appropriate services, possible supplemented by facility-based dataon morbidity and mortality. Figure 2-1 provides a summary of this problem as well as the other mainfindings of a review of the difficulties in evaluating Safe Motherhood Programmes.

Figure 2-1: Summary of Main Findings of Review of Safe Motherhood Programmes

Safe Motherhood programmes are difficult to evaluate because: a) the interventions are usually acomprehensive package delivered to communities not individuals; and b) it is impractical to measure thepreferred health outcomes of mortality or morbidity. These two points affect a) the study design used forevaluation and b) the indicators chosen.

Design: Descriptive (before and after) rather than experimental (RCTs and CRTs) study designs shouldbe used for evaluation unless the intervention can be generalized broadly to many settings.

Indicators: In most settings, Safe Motherhood programmes are forced to use process indicators tomeasure the implementation and use of appropriate services, possibly supplemented by facility-baseddata on morbidity and mortality,

Health Outcome Indicators:we can obtain rough population-based estimates of maternal mortality but cannot measure change.we cannot easily obtain population-based estimates of direct obstetric morbidity using interviews, butmay be able to substitute facility-based information for some of this.we can measure underlying (chronic) maternal morbidity with health examination surveys.we can measure perceived morbidity of all types.

Process Indicators:we can measure use/coverage of services among all women, and among those experiencingcomplications.we have yet to develop or identify good indicators or approaches for measuring quality of care. Weneed considerable work and documentation in this area.

Tools: We are developing tools for auditing maternal deaths, near-misses, and the processes involved inproviding high quality care. These instruments generate many indicators. The best of these mayultimately enable us to assess quality of maternal health services.Source: Campbell, et. al. Lessons Learnt: a decade of measuring the impact of safe motherhood programmes.

DFID Research Work Programme on Population and Reproductive Health, Maternal and Child EpidemiologyUnit, London School of Hygiene and Tropical Medicine, August 1997. p. 21

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The theoretical frameworks for the evaluation of each of the two components (CCB and MH) areexplained in detail in Chapters 4 and 5.

2.3 Assessment Design

The assessment team included two Canadians selected by CIDA, Dr. Maureen McCall (Agriteam CanadaConsulting Ltd.), a Maternal Health specialist and Dr. Susan Smith (Luz de Luna Intemacional), aCommunity Capacity Building specialist. The Canadian consultants were supported by two Indonesianconsultants selected by UNICEF. Dr. Astrid Sulistomo, Professor of Community Medicine at theUniversity of Indonesia, a specialist in reproductive health and occupational health had previously donean evaluation for UNICEF on the LSS training of Bidan di Desa. Ms. Emy Susanti, Director of theCentre for Women's Studies at Airlangga University, a Sociologist and specialist in gender analysis, hadalso been involved in the UNICEF situation analysis in East Java.

2.3.1 Assessment FrameworkA simple framework, adapted from Cope (1989), helped to organize the assessment by providing acomprehensive model of the various elements to be addressed. The framework uses organizationalstrengths and tensions as a basis for consideration of how an institution sees its vision and implementsprogram activities. The two major components of the framework are "finding direction" which speaks tothe goals, principles, roles and strengths within a specific context, and "implementing programs" whichdiscusses the means by which the organization realizes its vision.

The second component of program implementation identifies actual programming objectives andactivities, supported by descriptions of:

technical capacity for practice (knowledge and skills of personnel to carry out programming);organizational culture (the beliefs, expectations and characteristics of leadership and personnel thatshape attitudes, a working climate, gender policy);relationships (the manner in which the institution relates to and communicates with affiliated otherson programming and policy levels);systems and structures (administration of planning and monitoring, governance, information flow,reporting, infrastructure and staff positions, budgeting); andfinances (the use of funds for actual programming, the ability to raise funds to support programmingand to attain self-sufficiency).

2.3.2 Assessment ActivitiesThe assessment activities included:

Preparation of a general workplan, briefly outlining methodology and data collection;Rev ie\v and suggested revisions to itineraries prepared by UNICEF;Preparation and submission of a draft and Final Assessment Report to CIDA;

tMrrntl .4vtru»Kf» of CIDA-Supported Safe Motherhood Agrlteam Canada Consulting Ltd. andPrtigrammr H 'ithin the Cooperation of UNICEF and Luz de Luna InternationalCavrmmrnt I'flitJ.mnia in 1995-2000 2-4 April 2000

2 TERMS OF REFERENCE, FRAMEWORK AND METHODOLOGY OF ASSESSMENT

Individual and group interviews with UNICEF project personnel at NATIONAL OFFICE and thethree FOs, including briefings and debriefings and detailed review of year 2000 logframc for eachprovince (see Itinerary for details - Annex C);Formal information meetings and informal interviews at the central level with GO1 officials ofvarious Ministries and Departments involved in the SM programme (Annex C);Formal information meetings and informal interviews at the central level with other developmentpartners involved in the SM activities (Annex C);Formal information meetings and informal interviews with GOI officials at the provincial(BAPPEDA I, SMI teams - identified variously as PA 1, GSI, MCSDP, or KHPPIA teams), district(BAPPEDAII, SMI teams), sub-district and village levels (Annex C);Conduction of field site visits to project villages focussing on the activities at the village/communitylevel in each province (see list of project sites visited - Annex D);Conduction of focus group (FG) meetings with village women and men and with communityfacilitators, using simple participatory techniques to explore perceptions/understanding of projectobjectives, activities and process;On-site interviews with health service delivery professionals at all levels (village, sub-district,district and province) using semi-structured questionnaire;Informal visits to health service delivery sites at all levels (posyandu, polindes, puskesmas, districthospitals and provincial hospitals);Review of maternal health data collection forms and methods from village to provincial level;Review of IEC materials and PAR/PRA tools; andDaily debriefing and discussion among team members.

2.3.3 Data CollectionQualitative and quantitative data was collected by:

a. Over 70 group and individual interviews with a total of over 250 individuals;b. 15 focus group sessions;c. Field visits to 3 provinces, 7 districts, 10 sub-districts and 13 villages including 3 district hospitals, 4

Puskesmas, 5 Polindes, 4 Posyandu and 2 Pesantren; andd. Review of all pertinent documentation.

2.3.4 LimitationsThe mission was limited by several factors. While this mission was nearly four weeks in length, thenumber of program activities implemented with many partners at different levels across three provincesmade the assignment complex. An additional level of complexity was added by the fact that the projectwas significantly restructured after the mid-term review (changed from 14 sub-components to fourcomponents) making tracking of the progress of CIDA-funded components that much more difficult.Field staff, understandably, had difficulty in identifying which donors paid for which activities. The teamasked the financial officer in 2 of the 3 provinces to quantify total funds allocated to CIDA-fundedcomponents versus GOI contributions to these components over the program period. In each case we weretold that it was very difficult to separate out the old components from the new PA system when trackingfund allocations.External Assessment of CIDA-Supported Safe Motherhood Agriteam Canada Consulting Ltd. andProgramme Within the Cooperation of UNICEF and £«: dr Luna InternationalGovernment of Indonesia in 1995-2000 2-5 April 2000

TERMS OF REFERENCE, FRAMEWORK AND METHODOLOGY OF ASSESSMENT

Team members were able to visit a limited number of project villages in each province due to timeconstraints created by long distances to travel to project sites and the time required for meetings with GOIpartners at each level. Impressions, therefore, were formed based on this limited exposure and, while theteam is confident that its general impressions are accurate, specific significant findings may have beenmissed.

UNICEF-Indonesia was occupied with a number of other major events during the time of this mission,including the visit by Carol Bellamy, the Director of UNICEF International and renewed violence in someUNICEF project provinces and territories. This may have affected the pre-mission planning andpreparation to a certain extent, necessitating the use of valuable briefing time to finalize itinerary details.There was no opportunity for the Canadian consultants to make contact with the Indonesian consultantsprior to arrival in country; this also limited pre-mission planning.

While some background documents were provided prior to the beginning of the mission, the need toprovide other key documents that would be key to the evaluation (both at National Office and FO levels)was not anticipated by UNICEF National Office or Field Offices. Many documents had to be requestedas their existence and importance became clear to the team as the mission progressed.

The assessment team's original briefing by UNICEF National Office staff was limited due to a last minuteurgent request for Khin Sandi Lwin to attend a meeting in New York. This meant that the Canadianconsultants met with her only informally on the day of their arrival with no opportunity for a moredetailed briefing from, the Senior Programme Coordinator until just past the mid-point of the mission.Ms. Lwin arranged to meet with the team in Surabaya and was able to fill in gaps in our understanding ofkey issues and to ensure the delivery of important background documents.

The assessment team's expectation of being able to focus on activities at the community/village level didnot take into account Indonesian cultural emphasis on formal meetings. GOI officials from all levelsacted as hosts to the team and accompanied us down to the village level. Focus group interviews wereheld at the community level as often as possible, however, our attempts to focus directly on villagers,particularly village women and kaders, most often had limited success due to the continuous presence ofofficials, sometimes in large numbers. Responses had to be interpreted in light of the regular "prompts"and coaching given to the target group members by our hosts.

The need of the Canadian consultants for translation from Bahasa Indonesia to English meant that theIndonesian consultant colleagues played a key role as translators, a tiring task and one that subtractedfrom their ability to concentrate on the content of the interview. This situation also meant that importantinformation was sometimes summarized rather than presented in full. Missions of this type will benefitfrom the presence of a top-quality translator as a full-time member of the team with one full-time localtechnical consultant. Other local technical expertise could be made available as needed.

In general, health personnel at the institutional level (Puskesmas and District Hospital) did not haveaggregated maternal health data available at the time of our visits. About half of the available summariesExternal Assessment ofClDA-Supported Safe Motherhood Agrileam Canada Consulting Ltd. anaProgramme Within the Cooperation of UNICEF and LutdeLuna InternationalGovernment of'Indonesia in 1995-2000 2-6 April 2000

2 TERMS OF REFERENCE, FRAMEWORK AND METHODOLOGY OF ASSESSMENT

of maternal health statistics to be forwarded to us actually arrived. These summaries were oftenincomplete.

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THE CONTEXT OF THE PROJECT

3.1 Indonesian Context

Indonesia is an archipelago made up of thousands of islands, with the island of Java as the physical centreand seat of government. Since its independence more than 50 years ago, and especially in the last 20 to30 years, Indonesia has achieved considerable economic growth, reduction of poverty, and improvementin health conditions. This progress has not been equal in all provinces. The most rapid progress, inalmost all sectors, has been achieved in Java. When speaking about development in Indonesia, it iscommon to divide the country into "Java" and "outside Java" or the "outer islands". Java is the best-developed island in the country while the western and middle islands of Sumatra, Bali, and Sulawesi arebetter developed than the eastern islands of Moluku and Irian Jaya. Among the various sectors, progressin the health sector is lagging furthest behind. According to UNICEF's 1995 State of World's Childrenreport, between 1980 - 1993 Indonesia has had one of the slowest rates of improvement in its under fivemortality rate, comparable only to that of the sub-Saharan African countries6. In contrast, in terms of thegrowth rate (GNP per capita) and the rate of decline in the Total Fertility Rate over that same period,Indonesia was among the best achievers among all developing countries7.

3.1.1 The Government Administrative SystemIndonesia is a unitary state, with unified law and administrative systems. It is divided into three levels ofgovernment: central, provincial and local (district level). A Governor heads the province. A district,headed by a Bupati is divided into sub-districts, each headed by a Camat who is responsible forcoordinating the implementation of policies and programs set by the upper levels of government. Thesub-district consists of villages which are further divided into hamlets. Each village and hamlet has itsown leader or Kepala (headman or woman).

Although the Governor and Bupati are elected by local parliament and, officially, the provincial and localgovernments are considered autonomous, in reality the President or the Minister of Home Affairs has thefinal say. The Camat, appointed by the Bupati, needs the consent of the governor to take any action. Allpolicies are top-down, even to the village level, reflecting the evident desire for central level control. Thelower level is always waiting for "guidelines" for decision-making from the upper level. This is reflectedin the following statement:

Without his (the Camat's) consent, the village headman dares not and will not implementany policies or development programs or even receive a visitor in his village8.

The paternalism of Javanese culture and the echoes of the Dutch colonial system have strongly influencedthe Indonesian government system. These influences are reflected in the government's authoritarianism,

6 State of the World's Children, 1995. UN1CEF. New York.7 Achmad, J. Hollow Development, The Politics of Health in Soeharto's Indonesia, Gramedia, Jakarta, 1999, page 6.8 Achmad, J. Hollow Development, page 25.

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THE CONTEXT OF THE PROJECT

tendency towards bureaucracy, emphasis on unquestioning loyalty to a superior, and concentration ofpolitical power at the central level9.

Figure 3-1: Indonesian Context

Indonesian Context

Monetary crisis

Less $ perhousehold (esp.

urban)

SocialSafety Net

(SSN)

GOI Programming

( Tension )-> v:__y Provincial

JDistrict

1Sub-District

1•y. Village Leaders

f ~~x 1( Tension ) *

»VJ___^/ Village

( Tension j

+---]-——— ——-

Electionsnew: democracy, decentralization

/- — -N^"~( Tension )vZV

/- — \( Tension j

~VOutbursts ofviolence, rio

Predominant culture

• top —>bottom• paternalistic• authority centred• procedure-

oriented"socilization"

• directive"guidelines"

• low buget forhealth

• indirectcommunicationpath

Overall Effects:

• "culture clash" (with CCB Values)• increased uncertainty re: future• increased insecurity (personal and social)• decreased risk-taking

3.1.2 Village OrganizationThe Village Community Resilience (or Development) Board (LKMD), the Village Assembly (LMD), theIslamic Leader's Board and the Village Youth Organization are the key players at the village level. TheLKMD is the main actor for the government. An important organization within LKMD is the localbranch of the PKK (Family Welfare Movement), a national organization of women within the Ministry of

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THE CONTEXT OF THE PROJECT

Home Affairs. The main focus of PKK activities is on the Family Welfare Program that mainly covershealth, family planning and nutrition. The central and local government supports the activities of PKK.

3.1.3 Socio-Cultural IssuesIndonesia's many islands are home to diverse ethnic groups, each with their own language, tradition,culture, characteristics and religious beliefs. Most cultures in Indonesia are paternalistic and Javanesesociety is highly structured. The Javanese language has three different dialects, one for use with peopleof higher rank, one for people of the same level and the third with people of lower rank. The Javanesepeople are known to be "accepting" and "quiet". They almost never disagree with authority. Until veryrecently, it was difficult for someone to openly express his or her opinion. In part this is result of thedidactic and authoritarian educational system. Two-way communication between teachers and thestudents is rare, especially in village schools.

More than 90% of Indonesians are Muslim with smaller numbers of Christians, Buddhists and animists inthe county. The Islamic faith has a big influence on daily life and religious leaders are extremelypowerful. In some areas, divisions and conflict between ethnic, religious and class groups are evident, attimes with tragic consequences as in Timor, Moluku and Aceh. Many analysts believe that these conflictshave been instigated more by outside agitators than by forces within these communities.

Among more internationally educated urban populations, there is socializing across ethnic groups, andintermarriage occurs. While religious tolerance and acceptance of diversity is proclaimed as an importantpart of the national philosophy (Pancasila), devastating riots targeting ethnic Chinese and other minoritiestook place at the height of the political crisis, even in cosmopolitan urban settings such as Jakarta.

3.1.4 Political and Economic DevelopmentDuring the Soeharto era (1965 - 1998), the government held tight control with all sectors undergovernment scrutiny. There was no freedom of the press and people criticizing the government wereharshly punished with the military playing a major role. Under Soeharto's leadership, rapid economicgrowth occurred, however, the gap between rich and poor grew. An estimated 0.05% of the populationbecame super-rich while the majority remained poor. All policies and programs required the open andpersonal support of President Soeharto in order to be implemented. With his support, the immunizationand family planning programs made significant advances. Overall, however, the health sector receivedlittle budgetary support.

The monetary crisis that began in 1997 hit Indonesia very hard and has awakened society.Demonstrations and violent outbursts in response to the crisis precipitated Soeharto's fall. Reformasi orreformation began under B. J. Habibie, successor to Soeharto. He opened the door to democratic reforms,allowing more freedom of the press and freedom of speech. The end of 1999 saw a new government,headed by President Abdurrahman Wahid. Under "Gus Dur" and his government, human rights are anissue that is beginning to be openly addressed. The present government is committed to decentralization,but much uncertainty remains regarding its operations and organization. Some analysts conclude thatIndonesia is not ready for decentralization, concerned about the development of authoritarian "smallkingdoms".fairrnal A*se**mrni of C/DA-Supported Safe Motherhood Agrileam Canada Consulting Lid. andProgramme H'iihin the Cooperation ofUNICEF and Lui de Luna International<i::>-errtmrnt af Indonesia in 1995-2000 3-3 April 2000

THE CONTEXT OF THE PROJECT

Even with these new freedoms and hope for meaningful reform, individual citizens generally feel insecurepersonally. While the economy has shown improvement, the monetary crisis is far from being fullyovercome, crime is on the increase, and political violence continues unabated or threatens to erupt anew.

3.2 UNICEF Context

UNICEF-Indonesia has undergone major transitions in the last five years. Foremost among these was theslashing of its general resources budget (UN contribution) from a USD $12 million annual ceiling in 1995to $9 million in 1996, $7 million in 1997, down to $5 million in 1999. Knowing that large budget cutswere coming, UNICEF-Indonesia hoped that more streamlined programmes would save staff positions.The cuts were much greater than anticipated, resulting in significant organizational restructuring in 1997and the loss of two Programme Coordinator positions (Service Delivery and Capacity Building).

The second major change was a shift from a "project" to a "programme" approach. Before 1995, theCountry Program consisted of 28 to 30 different projects with a focus on child survival. The 1995-2000CP saw these projects organized as fourteen components under three main components: Service Delivery,Capacity Building and Advocacy and Planning. The 1998 Mid Term Review again realigned programs,this time into four main programme areas in order to "focus on a limited number of interventions and dothem properly".

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Figure 3-2: UNICEF Context

UNICEF Context

Decentralization

Expanded # of fieldoffices with increasedneed for long distance

communication

Social SafetyNet (SSN)

Shift from "project" focus to"program" on-the-ground

development (MTR)

Severe general revenuebudget cuts

Loss of centra! staffpositions

Turnovers/shift of keypersonnel

Overall Effects:

Emergency response (disperse $,blanket CFI)

Increase in overall programmingbudget (increased pressure to dispersefunds and report to multiple donors)

increased uncertaintyincreased workload/staff with fewercentral personnelincreased pressure to perform

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The decision to decentralize UNICEF operations was the third transition. Within the last five years, fieldoffices opened in Central Java, Moluku and Irian Jaya and the East Java office was a move from Mataramto Surabaya. These transitions placed serious pressures on UNICEF capacity. Delays inherent in theUNICEF recruitment and hiring procedures meant that the placement of a full complement of field staffdid not occur in the CIDA-funded provinces of East Java and South Sulawesi until early 1998.

UNICEF had major gaps in staffing at both the headquarters and field office levels. The position of MCHOfficer that was created in 1996 was not filled until 1997. That officer left UNICEF-Indonesia in April1999 and the post was again vacant until January 2000. The Chief of Capacity Building, was temporarilyassigned to coordinate the East/West Timor emergency response programmes in East Timor and Molukuemergency in late 1999. When key technical advisory positions were vacant in Jakarta, other Jakartapersonnel have had to provide the needed assistance, sometimes outside their area of expertise.

UNICEF field officers in CIDA-funded positions were/are not recruited as Safe Motherhood technicalexperts, but rather as "process-oriented" people with the skills needed to work with GOI counterparts.This was a joint decision made by CIDA and UNICEF when designing job descriptions. The SeniorProgramme Coordinator stated that in retrospect the CIDA-funded FO posts were classified at too low arank, this low ranking would also make it impossible to hire someone with SM technical expertise even ifthis had been envisaged. The relatively junior rank caused field officers "look to get out as soon as theyarrive". There is limited opportunity for advancement within a posting. For example, a field officercannot be promoted up to the next rank while holding a position with that classification. These factsmake it virtually impossible to reward good job performance and keep experienced personnel in the field.

Staff transfers and moves to more senior postings has meant a fair amount of turnover and loss ofexperienced and effective field officers, particularly in South Sulawesi and East Java during the four yearsof field activities. At this time, UNICEF-Indonesia has at total of 150 employees in Jakarta and eightField Offices. Sixty-five are field office-based while 85 employees are in Jakarta.

UNICEF has worked to improve its planning, monitoring and evaluation processes. AusAID fundedtechnical teams to work intensively with UNICEF between Oct 1997 and June 1998 to develop alogframe for Australian funded programme components. UNICEF funded seminars for all UNICEF staffon logframes and workplans and took these seminars to the provincial and district level. While much ofthe detail of this planning was lost when UNICEF's focus shifted to Crisis Response (particularly inMoluku), many staff clearly found the exercise valuable. Currently, all UNICEF programme planning isbased on the logframe approach as reflected in the Year 2000 workplans. Central and field offices areworking on improving coordination for this new approach. While the application of the logframeapproach to the 2000 workplans is relatively recent, the work meant to improve reporting on results hasbeen going on since late 1997 but has yet to be reflected in improved reporting on results to donors.UNICEF also has had to cope with the deficiencies of the GOI monitoring systems. GOI counterparts,

not UNICEF, identified project sub-districts and villages. The difference in fiscal years between the GOI,UNICEF and its major donors has made planning and accountability complicated. The various Ministriesand Departments involved in the GOI Safe Motherhood Program all have separate budgets with no

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protected or guaranteed funds for Safe Motherhood from year to year. The GOT timeline from planning todisbursement of funds is generally 18 months.

External Assessment ofClDA-Supported Safe Motherhood Agriteam Canada Consulting Ltd. andProgramme Within the Cooperation ofUNlCEFand Lui de Luna InternationalGovernment of Indonesia in 1995-2000 3-g April 2000

COMMUNITY CAPACITY-BUILDING COMPONENT

4.1 Terms of Reference for Community Capacity-Building

The CIDA TORs for the community capacity-building component stated that the objective was to assessthe strategy, format and operational mechanism of community participatory processes needed to reducematernal mortality and neonatal morbidity, including the adequacy and appropriateness of indicators usedand system of data collection, analysis and feed-back mechanism for this components vis-a-vis a result-based programme management. The task was to examine the strengths and weaknesses of the communityprogram operations, assessments and activities with a focus on replicability, sustainability and expansion.Pertinent questions included: lessons learned, possible alternative approaches, and identification ofaspects for continuation or expansion. The development of a methodology to obtain information fromcommunities regarding the results of the safe motherhood project was of special interest.

The TORs for this Assessment included specific questions as follows:

1. UNICEF has introduced three different pilot initiatives to empower communities to ensure safermotherhood in the three provinces of the CIDA-assisted project. It is not fully known how successfulthese activities are; hence the basic questions will focus on: What are the lessons learned? Whatshould be expanded? What should be dropped? Are there alternative approaches that should beexplored?

2. Assess the CCB component in each province:

South SulawesiExamine the success of the village assessment and analysis process that resulted in 75 villageworkplans containing about 500 innovative activities for improving maternal care, supported byblock grants given to them. The review should cover issues such as: How successful have thesegrants been in helping establish trading kiosks as an income generating venture to support thecommunication programmes about health dangers of early marriage and pregnancy? How has theblock grant approach affected local government budget allocation for safe motherhood initiative?

Central JavaThe "Tabulin" is a social mobilization mechanism which allows villagers to support maternal healththrough insurance for a basic package of services. This has rapidly expanded to cover more than1,000 villages. The review will include issues such as: How successful is the revolving fund and themanagement of the insurance scheme? How is this mobilization approach affecting the communityparticipatory processes? What are the issues faced in the rapid expansion of Tabulinl How doesthis social mobilization approach deal with the variety of village level situations?

External Assessment of CIDA-Supported Safe Mothrrhmtd Agriteam Canada Consulting Ltd. andProgramme Within the Cooperation of UN/CEF and Lui de Luna InternationalGovernment of Indonesia in 1995-2000 4-1 April 2000

COMMUNITY CAPACITY-BUILDING COMPONENT

East JavaThe attempt taken in this province is to modify community behaviour toward better family maternalcare by targeting religious leaders as agents of change as well as providing seed capital to expand thereligious group cooperatives to provide loans scheme for meeting maternal health needs of theirmembers. The examination will include issues such as - How effective is the religious leaders asagent of change for community behaviour? How do these leaders and the cooperatives interact withgovernment systems? How effective is the loan scheme as compared to health insurance scheme?How do the cooperatives deals with non-members who have maternal health needs? How has theseed capital affected the loan-policy of these cooperatives?

Additionally, examine the dynamics between traditional birth attendants, Bidan di Desa (BDD or VillageMidwives VMW) and health service providers. The issues of focus include: How is the link betweencommunities and health service providers? What is the role of Bidan di Desa in this linkage and howeffective are they? What is the role of Bidan di Desa in the community participatory processes and howeffective are they?

The CIDA-UNICEF Contribution Agreement (1995) outlined aspects of the CCB philosophy and design,as extracted here:10

philosophy: the target community should take control of its situation and make collective decisionsto improve it, with government staff facilitating and helping the community in deciding actions andconverting decisions into actions; "learning with the target community and learning by doing."

key elements: promotion of GOI intersectoral agreement and support to the goals of reduction ofMMR and IMR; forging and strengthening cooperation between local government agencies andNGOs.

method: to influence people's lives in small communities by introducing programme specificTriple-A cycles through all layers (national, provincial, district, sub-district, community and familycycles) to reach the individual.

specific requirements: facilitators "need to be equipped with skills to enter into participatorydialogues with target community members to help them assess their problems accurately, analyzedirect, underlying and basic causes correctly and decide on feasible actions to solve problems

10 The CCB objectives and Triple-A methodology are as stated in the Contribution Agreement and then carriedforward into the annual reports - this was the starting point for this assessment. The definitions of terms that followhere are included to facilitate discussion and consistent labeling of approaches and actions. In the MTR in October,1998, UNICEF acknowledged the difficulty of CCB/community-based work and so, given the economic crisis, re-oriented its programming to a socialization of essential services and crisis response. Up to 1999, in both SS and EJand less so in CJ, UNICEF used the Triple-A/PRO language and activities as presented in the ContributionAgreement. While the objectives were re-grouped in four programming areas in the MTR, the subsequentdocuments do not contain re-written objectives nor methodology to concur with the re-defined Pas and programmingdecisions.__________________________________________________________External Assessment ofCIDA-Supported Safe Motherhood Agrileam Canada Consulting Ltd. andProgramme Within the Cooperation of UNICEF and Luz de Luna InternacionalGovernment of Indonesia in 1995-2000 4-2 April 2000

COMMUNITY CAPACITY-BUILDING COMPONENT

effectively;" TOT for community participation facilitators; development of learning materials, and"annual participatory evaluation."

4.1.1 Clarification of Concepts and Terms Central to CCBThe spectrum of SM/RH programming (see Table 4-1) organizes safe motherhood programming intothree broad (and overlapping) approaches — emergency, essential, and enabling approaches. Thespectrum captures the goals, types of activities, primary players, and roles, incorporating the "demand"and "supply" issues. "Emergency" health care is tertiary level, patient-centred care that providestreatment and management of difficult cases. The "essential" services consists of fairly standardized"packages" of client-centred, community-oriented services that are provided for individuals, for example,primary care, antenatal care, family planning, referrals, immunizations, safe home/clinic deliveries, andhealth education. This is the supply side — the provision of adequate or better services. "Enabling"programming focuses on community-based developmental processes that help people to build theircapacities and act on SM and health issues in context.

The aim of an enabling approach is to assist people at the community/subdistrict/district level to activelyaddress issues in ongoing processes of reflection and implementation of action. Creating opportunitiesfor people to engage in participatory, community-based processes" that act on SM increases thepossibilities of changes in SM and health status on individual and community levels. Supporting thisapproach requires a longer term, developmental view in order to build community members' andgovernment personnel's capacities to respond to communities and to SM issues. A group learns by doing,identifies its own needs, questions and priorities, investigates alternatives, and takes actions as determinedby the members themselves. An enabling approach is open-ended, process-oriented and community-responsive, allowing people to learn by doing, and giving attention to both supply and demand.

11 Community-Oriented versus Community-Based. A community-oriented program essentially provides servicesfor people. This may mean such activities as health talks with specified messages or the construction ofdemonstration latrines. If done well, many are helpful activities. A community-based program works with groupsof people. The methodology will incorporate aspects of service provision but will be based on authenticparticipation, a process-orientation, and the use of enabling strategies that create opportunities for thoughtful action,learning, and empowerment. Often a program is incorrectly labelled as community-based when it actually iscommunity-oriented because it operates out of a centre or an institution located in an area where people live, orbecause personnel interact with mothers in their homes or in small clinics. But the important distinction is notlocation but purpose and methodology._____________________________________________External Asanamritl of ClOA-Suppaned Safe Motherhood Agriteam Canada Consulting Ltd. andProgramme Within tke Cooperation of UNICEF and Ln de Luna InternacionalGovernment of Indonesia in I1VS-1000 4-3 April 2000

COMMUNITY CAPACITY-BUILDING COMPONENT

Table 4-1; Spectrum of SM/RH ProgrammingDimension Emergency

Health CareEssential Programming Enabling Programming

Approach Hospital-based; Patient-centred Community-oriented; client-centred

Community-based; Group-centred

Key Focus Biomedical treatment:hospital/clinic treatment and casemanagement of pregnant women,especially those withcomplications.

Health services provision:clinic and outreach servicesfor individual pregnantwomen and childbearing agedwomen in communities,including involvement offamily decision makers.___

Community development,Empowerment of women:Groups in community act onmaternal health/SM issues incontext, and build capacities ofparticipants and of the group.

Types of Activity Treatment of complications ofpregnancy; safe labour anddelivery; address third delay (intreatment, in transport);improvement of service quality.

Essential service "package":primary care; ante- andpostnatal care; familyplanning; referrals;immunizations; safehome/clinic deliveries;counselling; RH education foradolescents, health and AIDSeducation.

Establishment of local cross-sector committees; knowledgeof context and dynamics;establishment of relationships;identification of SM/health-related problems/strengths;ongoing cycles of action-reflection; district alliances forpolitical leverage._______

Role ofIndividual

Patient: receives benefits ofservices and treatment.

Client: seeks service andadvice; receive benefits ofhealth services; participate inplanning and implementationof personal care.

Participant: actively engages inongoing group process, withauthentic influence regardingdecision-making, use ofresources, actions andobtainment of information.

ROLE OFSERVICE

PERSONNEL

Professional; expert: informpatient of treatment decisions;implement treatment.

Professional; consultant,community motivator: informclients of problem andalternatives for care/services;give needed/ requestedinformation; provide care andservices.

Facilitator; resource person;trainer; participant: work withcommunity groups over timewith changing roles dependingon collective needs, experience,capacities, and decisions.

Source: S. E. Smith

4.1.2 Levels of ParticipationGenerally, there are four levels of participation: to receive benefits, to take actions essentially prescribedby others, to be consulted, and to plan and undertake actions and solutions to problems. Only the lastlevel is full participation and what is meant by "community participation" in developmental terms. TheCCB Triple A cycle approach referred to full participation, however, UNICEF personnel acknowledgedthe difficulty with implementation of this in the 1998 MTR document, and continue with a vaguenessabout "community participation" per se.

Comment: The village level CCB Triple-A cycles that were described in the UNICEF-CIDAContribution Agreement were very consistent with an enabling approach, albeit with less emphasis oncontext and on the development of relationships between stakeholders.

External Assessment of CIDA-Supportcd Safe MotherhoodProgramme Within the Cooperation of UNICEF andGovernment of Indonesia in 1995-2000

Agriteam Canada Consulting Ltd. andLuz de Luna Internacionat

April 2000