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February 2010

Improving Health Service Provision through Incentivized Block Grants to Communities: The Experience of PNPM Generasi . February 2010. Introduction. Intro: Indonesia PNPM Why Community-based approach to SP? How does it work? What was achieved? Where to go from here?.

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February 2010

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  1. Improving Health Service Provision through Incentivized Block Grants to Communities: The Experience of PNPM Generasi February 2010

  2. Introduction • Intro: Indonesia PNPM • Why Community-based approach to SP? • How does it work? • What was achieved? • Where to go from here?

  3. Why a Community-Based Approach? • Indonesia has made good strides in key human development indicators • However, key indicators lagging: • Infant mortality • Child malnutrition • Maternal mortality • Strongly associated with • Levels of poverty • Geographical disparities: poorer outcomes in rural and remote areas • Patterns of vulnerability: a large cluster of the near poor (40%) Learning: How can communities and local service providers target demand and small supply side constraints to improve access to and use of health and education services.

  4. Why a Community-Based Approach? • State: • Challenge matching supply-side and demand-side • Weak institutional capacities to administer complex programs • Providers • Poor provision of social services in poor regions • Poor targeting in previous cash transfer and other programs • Citizens/clients • Challenges with elite capture • Accountability • Lesson from CDD: specific role of communities

  5. How does it work? PNPM Generasi is an incentivized block grant program targeting 3 Millennium Development Goals lagging in Indonesia: • Reducing child mortality • Reducing maternal mortality, and • Ensuring universal coverage of basic education Villages, with assistance from trained facilitators and service providers, use a participatory planning process and block grant funds to reach 12 health and education indicators.

  6. Generasi Project Cycle

  7. How does it work? • Communities can use the funds flexibly, for example: • Improve service quality and performance directly and contract private providers if public provision of services is considered sub-optimal. • Help mitigate against external shocks and avoid negative coping strategies such as pulling children into the workforce • Adjust use of resources over time

  8. Generasi Facts Program Start: July 2007 Scope: 5 Provinces (West/East Java, Gorontalo, North Sulawesi and East Nusa Tenggara), 21 Districts, 178 sub-districts and 2144 villages. Total Budget: USD 110 million (2007 /2008) Community Contribution: USD 720,000 (2007/2008) Average Block Grant Amount: USD185,000 (2009) Total Beneficiaries: 3,100,000villagers (2007/2008) Implementing Agency: Ministry of Home Affairs Source of Funds:The World Bank, The Royal Netherlands Embassy and the PSF Support Facility. 2010 will see additional grant funding from AusAID.

  9. Generasi Facts: 12 Health & Education Indicators Indictors for pregnant mothers • Four prenatal care visits during pregnancy • Taking iron tablets during pregnancy • Delivery assisted by trained professional • Two postnatal care visits Indicators for children under five • Complete childhood immunization • Ensuring monthly weight increases for infants • Regular weighing for under-fives • Taking Vitamin A twice a year for under-fives Indicators for school-aged children (NB these indicators will change) • Primary school enrolment (7-12 year olds) • Regular primary school attendance (>85%) • Junior secondary school enrolment (13-15 year olds) • Regular secondary school attendance (>85%)

  10. Evaluations Built Into Project Design • Uses a 3 Wave randomized evaluation • Baseline (2007, with HH CCT) • One-year follow-up (2008, Generasi only) • Two-year follow-up (2009, with HH CCT) • Initial Design Randomized subdistricts into three groups: • with performance incentives, • without performance incentives*, and • Controls • Subdistrict randomization addresses spillovers and crowding out • Design structure allows comparison with HH-CCT • Common survey instruments for HH-CCT and Generasi evaluation *The 2008 evaluation showed better performance in incentivized locations. In third year of implementation all locations used performance incentives.

  11. What was achieved? • Impact on Indicators • Strengthened governance and accountability through: • Increased demand • Improved targeting • Improvements in quality of service delivery including coordination of various agencies

  12. Health Impacts in the Community Year 1 Results suggest that a major contribution of Generasi was a revitalization of the existing village health post system that brought more mothers and children into the health care net. • The first 15-18 months of Generasi saw: • 20% increase in children weighed • 32% increase in children receiving supplementary feeding • 59% increase in children receiving intensive supplementary feeding • 27% increase in immunization rates • 20% increase in children receiving Vitamin A tablets • 42% increase in the number of pregnant mothers receiving antenatal care • 48% increase in pregnant mothers receiving iron pills

  13. Long Term Health Impacts in the Community Year 1 • Large reductions in neonatal and infant mortality • Neonatal mortality reduced by 47% compared to control groups • Infant mortality reduced by 28% compared to control • Significant reductions in malnutrition in NTT and Sulawesi • Among children under-three in seasonal famine-prone NTT, children were 17.6% less likely to be malnourished compared to control groups.

  14. Stimulating demand • Stimulates demand by providing the means to access basic health services • Stronger demand improved services • Improvements in thequality of village integrated health postsmeasured by the content of services mothers received during the village health post sessions. COMMUNITIES IN ACTION: Short term contracts for midwives–North Sulawesi Communities in remote villages off the coast of North Sulawesi used Generasi funds to contract midwives to provide routine health services to women and children in the local community. In consultation with the local health clinic, midwives are funded for one year and placed in villages that do not currently have a midwife until a permanent placement is found.

  15. Targeting Targeting the poor and vulnerable: • Communities identify the poor and vulnerable through social mapping. • The program requires that 10% of the total funds for each village in Java and 25% of those outside of Java specifically target those not yet receiving the relevant health and education services, and who are performing poorly against the 12 health and education indicators e.g. out-of-school-children and malnourished children. • Facilitators and health service providers monitor and record information about the services obtained for all villages in the target group. • Villages and local governments are now using data collected by Generasi as their official data

  16. Improvements in quality of service delivery • Increased Outreach Services • Many communities used funds to provide transportation money and assistance to poor pregnant mothers. As a result, there were: • 22% increases in women using trained midwives for deliveries • Midwives were significantly more active in providing maternal, neonatal and child health services; and • Midwives spent more time providing outreach services, especially in Java. • Incentive for various agencies to collaborate and coordinate • Coordination Team Against Malnutrition-North Central Timor, NTT • Eleven organizations, including the Health Department, PNPM Generasi, International NGOs such as CARE, and local NGOs fighting chronic malnutrition now hold coordination meetings monthly to target activities and funds. • Combating Malnutrition with Local Harvest Menus- East Flores, NTT • In coordination with a local NGO and Generasi, health posts are teaching women in rural areas how to cook nutritious menus using food growing on their land. Local harvest menus are substantially cheaper to make, and offer a variety of well-balanced dishes so children want to eat.

  17. Improvements in quality of service delivery Improved Education for Health Post Volunteers-Magetan, East Java Increased community interest and enthusiasm has spurred the Health Department to provide monthly seminars for health center volunteers who, along with midwives, are front line service providers in monthly health post.

  18. Where to go from here? • Linkages with other CDD efforts • Consolidation of participatory process • Earmarking of resources? • Operationalizing integration in sectoral policy framework • Strengthening linkages with District level budgeting and planning processes • Main lesson: tapping into synergies leverages impact • What are the comparative advantages of various actors? • How can we bring these to bear?

  19. Thank you

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