Document of The World Bank Report No: 75211-ID RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF HEALTH PROFESSIONAL EDUCATION QUALITY PROJECT LOAN 7737 BOARD APPROVAL DATE: AUGUST 28, 2009 TO THE REPUBLIC OF INDONESIA February 28, 2013 \ ABBREVIATIONS AND ACRONYMS AIPGI Association of Indonesia Nutritionist Education Institutions (Asosiasi Institusi Pendidikan Gizi Indonesia) AIPTKMI Association of Indonesia Public Health Education Institutions (Asosiasi Institusi Pendidikan Tinggi Kesehatan Masyarakat Indonesia) APTFI Association of Indonesia Pharmacist Education Institutions (Asosiasi Pendidikan Tinggi Farmasi Indonesia) CBE Computer Based Examination CPCU Central Project Coordinating Unit DGHE Directorate General of Higher Education FAP Financial Assistance Package GOI Government of Indonesia IAI Indonesia Pharmacist Association (Ikatan Apoteker Indonesia) IAKMI Indonesia Public Health Specialist Association (Ikatan Ahli Kesehatan Masyarakat Indonesia) IMC Indonesian Medical Council KBE Knowledge Based Examination LAM-PTKes Independent accreditation body for health professional education (Lembaga Akreditasi Mandiri Pendidikan Tinggi Kesehatan) LPUK Independent agency for developing national competency testing of health professionals (Lembaga Pengembangan Uji Kompetensi) MOEC Ministry of Education and Culture MOH Ministry of Health MOU Memorandum of Understanding NAA National Accreditation Agency NACEHealth Pro National Agency for Competency Examination for Health Professionals OSCE Objective Structured Clinical Evaluation PDO Project Development Objectives PERSAGI Indonesia Nutritionist Association (Persatuan Ahli Gizi Indonesia) UNCEN University of Cendrawasih UNDANA University of Nusa Cendana Regional Vice President: Axel van Trotsenburg Country Director: Stefan G. Koeberle Sector Director: Xiaoqing Yu Sector Manager: Toomas Palu Task Team Leader: Pandu Harimurti INDONESIA HEALTH PROFESSIONAL EDUCATION QUALITY PROJECT P113341 CONTENTS Page A. SUMMARY ........................................................................................................................... 1 B. PROJECT STATUS .............................................................................................................. 1 C. PROPOSED CHANGES ...................................................................................................... 2 D. ANNEX 1: RESULTS FRAMEWORK AND MONITORING ........................................ 6 DATA SHEET INDONESIA HEALTH PROFESSIONAL EDUCATION QUALITY PROJECT LOAN 7737 PROJECT RESTRUCTURING Restructuring Status: Draft Restructuring Type: Level two Last modified on date : 02/14/2013 1. Basic Information Project ID & Name P113341: ID-Health Professional Education Quality Country Indonesia Task Team Leader Pandu Harimurti Sector Manager/Director Toomas Palu Country Director Stefan G. Koeberle Original Board Approval Date 09/24/2009 Original Closing Date: 12/31/2014 Current Closing Date 12/31/2014 Proposed Closing Date [if applicable] EA Category C-Not Required Revised EA Category C-Not Required-Not Required EA Completion Date 12/02/2008 Revised EA Completion Date 2. Revised Financing Plan (US$m) Source Original Revised BORR 2.50 2.50 IBRD 77.82 77.82 OLBC 6.40 6.40 Total 86.72 86.72 3. Borrower Organization Department Location Republic of Indonesia Indonesia 4. Implementing Agency Organization Department Location Directorate General of Higher Education Indonesia Ministry of Education and Culture i 5. Disbursement Estimates (US$m) Actual amount disbursed as of 02/14/2013 43.87 Fiscal Year Annual Cumulative 2013 7.41 51.28 2014 24.12 75.40 2015 2.42 77.82 Total 77.82 6. Policy Exceptions and Safeguard Policies  Does the restructured project require any exceptions to Bank policies? N  Does the restructured project trigger any new safeguard policies? If yes, please select N from the checklist below and update ISDS accordingly before submitting the package. 7a. Project Development Objectives/Outcomes Original/Current Project Development Objectives/Outcomes The specific Project Development Objectives are to strengthen quality assurance policies governing the education of health professionals in Indonesia. This will be achieved by: 1) rationalizing and assuring competency-focused accreditation of public and private health professional training institutions; 2) developing national competency standards and testing procedures for certification and licensing of health professionals; and 3) building institutional capacity to employ results-based grants for encouraging the use of accreditation and certification standards in the development of medical school quality. 7b. Revised Project Development Objectives/Outcomes Not applicable ii HEALTH PROFESSIONAL EDUCATION QUALITY PROJECT RESTRUCTURING PAPER A. SUMMARY 1. Following a request from the Government of Indonesia (GOI) dated 20 December 2012, this is to request your approval of a Level II restructuring of the Health Professional Education Quality Project (HPEQ) as follows: (i) expand the activities to include three additional professions; (ii) reallocate the proceeds of the Loan; and (iii) update the reference to the national regulation on procurement for the clarifications relating to National Competitive Bidding Procedures. 2. In addition, the target date in the result matrix is being modified to take into account implementation delays. The Project Development Objectives (PDO) are not affected by the proposed changes. The government’s request is to cover the activities above (estimated cost at US$4,786,194) will be done through a reallocation of loan proceeds across project components. B. PROJECT STATUS 3. HPEQ was declared effective on December 9, 2009. Achievement of PDO is rated moderately unsatisfactory, and Implementation progress is rated moderately satisfactory. The latest available financial audit report (for CY 2011) was received by the Bank in a timely manner and without qualifications. Project Development Objectives: 4. Certain key performance indicators have not been achieved. The flux in the legal and regulation context of higher education has hampered the establishment of the independent bodies for accreditation (LAM PTKes) and competency testing (LPUK). By end 2012, the establishment of these independent bodies was not completed as planned, which consequently affected other key performance indicators, especially those related to implementation of accreditation activities. During the Mid-Term Review the GOI confirmed its commitment to prioritize and finalize the legal status for the establishment of the independent bodies. The Central Project Coordinating Unit (CPCU) has taken measures to ensure involvement and support from major stakeholders such as the National Accreditation Body and the Indonesia Health Professional Council. 5. As of end 2012, overall disbursement rate of the Project reached only 43.5% and behind the target of 59%; this is due primarily to slow disbursements of the Financial Assistance Package (FAP) grants. The CPCU has carried out a capacity assessment of FAP grantees and has incorporated estimates of maximum capacity in the restructuring plan. 1 Implementation Progress: 6. The project has nevertheless made important progress as follows:  Establishment of the Quality Assurance System for the education of doctors, dentists, midwives and nurses (the four initial professions), through the strengthening of school accreditation and graduate certification systems.  Draft regulation for the establishment of an independent accreditation body for health professional education (Lembaga Akreditasi Mandiri or LAM-PTKes), standard competencies and education of the four professions, and accreditation instruments for the medical schools.  Certification of graduates using a national competency based examination .  Final draft of Ministry of Education and Culture (MOEC) / Ministry of Health (MOH) joint decree to legalize the establishment of an independent agency for developing national competency testing of health professionals (Lembaga Pengembangan Uji Kompetensi or LPUK).  Examination blue print and the examination items for the four health professionals.  The first national computer based examination (CBE) of doctors and dentists was conducted in 2010 and used nation-wide for the examination of medical and dental students prior to graduation.  The trial for introducing Objective Structured Clinical Evaluation (OSCE) for medicine was completed in 2012, and OSCE will be implemented to accompany the CBE in 2013.  The examination blue print for the midwives and nurses is now available, and the examination trials (paper and computer based examinations) were successfully completed this year. 7. The progress of FAPs to medical schools is equally satisfactory. The selection of grantees and contract signing with 41 grantees were completed by December 2010 and the grants program started implementation in 2011 as scheduled. The implementation of the FAP provides valuable lessons in establishing partnership between weaker and stronger medical schools to accelerate the attainment of accreditation standards in all medical schools in Indonesia. Despite the above progress under implementation, the disbursement of FAP funds is lagging behind. 8. In addition, there have been delays in the procurement packages for the medical schools under FAP financing, but the CPCU has taken the necessary measures to expedite the procurement process. C. PROPOSED CHANGES 1. Expand the activities to include three additional professions 9. The additional professions to be included in the project are for a pharmacist, nutritionist, and public health specialist. The request will finance the system for quality 2 assurance of the three professions, through capacity building of stakeholder commitment, preparation of academic papers, formulating standards and accreditation instruments, developing examination blue prints and other items, and piloting the system overall. In addition, the government has requested the inclusion of Nusa Cendana University (UNDANA) in East Nusa Tenggara, and Cendrawasih University (UNCEN) in Papua in the FAP scheme. Both Universities were not successful in the FAP competition organized by the Directorate General of Higher Education (DGHE MOEC) at the start of the project, however, due to the strategic roles both Universities play in meeting the needs for basic health services in Eastern Indonesia, the government has requested a specially designed scheme for providing FAP financing to both Universities during the remainder of the project. Activities for the three new professions will be included under Components 1 and 2 of the project, while the FAP for UNCEN and UNDANA will be under Component 3. 10. The result indicators will be modified to include the three new professions and the two universities. 11. The result matrix will now be revised to reflect the following: a) Three additional professions (pharmacist, nutritionist, and public health specialist) b) Two additional medical schools (UNCEN and UNDANA) who will receive FAP Grants 12. The intermediate indicators will now reflect new dates: Component # and Name Activity Target Date Component 1: Strengthening Policies and Procedures for School Accreditation Finalization of the accreditation 31 December 2013 instrument and accreditation assessor training Field testing of the accreditation 31 December 2014 process Component 2: Certification of Graduates Using a National Competency-based Examination Finalization of the blue print for the 31 December 2013 national competency testing Field testing of the national 31 December 2014 competency testing Component 3: Results-based Financial Assistance Package (FAP) for Medical Schools The medical study program in both 31 December 2014 universities have gone through the accreditation process Students from both medical study 31 December 2014 programs participated in the national competency testing Revision to the Project Performance Indicators as in the Project Appraisal Document (PAD) (Refer to Annex 1) 3 The above revisions refer to the Annex in the Project Appraisal Document (PAD), and follow agreements made with key stakeholders (example: OSCE will be implemented only for doctors and dentists, and not for nurses and midwives). 2. Reallocations 13. The following redistribution will be made from the loan proceeds under Parts 1, 2, and 3 to cover the above changes. Category of Expenditures Allocation % of Financing (in US Dollar) Current Revised Current Revised Current Revised Training and workshops, No Change 6,584,000 8,335,304 100% No Change incremental operating costs, research expenditure, consultant services and goods under Part 1 of the Project Training and workshops, No Change 12,099,000 14,046,934 100% No Change incremental operating costs, research expenditure, consultant services and goods under Part 2 of the Project FAPs for sub-projects under Part No Change 55,000,000 51,300,762 100% No Change 3 of the Project Training and workshops, No Change 4,139,000 4,139,000 100% No Change incremental operating costs, consultant services and goods under Part 4 of the Project Total Project Cost No Change 77,822,000 77,822,000 No Change 14. By end 2012, disbursement rate for category 3 was 32.5% of the original allocation to the 41 FAP recipients/grantees. Based on this, the addition of FAP financing for UNCEN and UNDANA will amount to US$51,300,762 at project closing date. 3. Procurement 15. Attachment 3 to Schedule 2 of the Loan Agreement on the National Competitive Bidding (NCB) Procedures will be revised to be in accordance to the NCB provisions as agreed by the National Public Procurement Agency (Lembaga Kebijakan Pengadaan Barang/ Jasa Pemerintah) for World Bank financed projects. The procurement plan will include changes to accommodate the participation of UNCEN/UNDANA. 4 4. Financial management 16. The revised FAP manual will accommodate the participation of UNCEN and UNDANA in Component 3 of the Project. Participation of both Universities will be based on a Memorandum of Understanding (MOU) between the Director General of Higher Education and the Rector of each university. The revised FAP manual and the MOU were submitted and approved by the WB on December 15, 2012. 5. Institutional arrangements 17. With the addition of the three professions outlined above, new stakeholders will participate in project implementation. These are:  Pharmacists: The Indonesian Pharmacist Association (IAI) and The Association for Higher Education Institutions of Pharmacy (APTFI)  Nutritionists: The Indonesian Nutritionist Association (PERSAGI) and The Association for Higher Education Institutions of Nutrition (AIPGI)  Public Health Specialists: The Indonesian Public Health Association (IAKMI) and The Association for Schools of Public Health (AIPTKMI). 18. Each will send their representatives to sit in the Project Technical Committee and the task forces for components 1 and 2 under the Project CPCU. 5 ANNEX 1: Results Framework and Monitoring INDONESIA: HEALTH PROFESSIONAL EDUCATION QUALITY PROJECT A. Outcome Indicators Project Development Objective (PDO): The specific Project Development Objectives are to strengthen quality assurance policies governing the education of health professionals in Indonesia. This will be achieved by: 1) rationalizing and assuring competency-focused accreditation of public and private health professional training institutions; 2) developing national competency standards and testing procedures for certification and licensing of health professionals; and 3) building institutional capacity to employ results-based grants for encouraging the use of accreditation and certification standards in the development of medical school quality. Revised Project Development Objective: No Change D=Dropped Cumulative Target Values** C=Continue Responsibility Core PDO Level Results N= New Unit of Data Source/ Baseline Frequency for Data Indicators* R=Revised Measure 2010 2011 2012 2013 2014 Methodology Collection Indicator One: C Current Establishment Annual Project CPCU Establishment of the arrangement of the Charter progress independent NAA of the NAA report Indicator Two: C Current Establishment Annual Project CPCU Establishment of the arrangement of the Charter progress independent of the NACE report NACEHealthPro Healthpro Indicator Three: C INTERMEDIATE RESULTS Intermediate Result Indicator Component One: Percentage of health professional schools that have gone through the accreditation process and publicize results Medical C Study 17% 42% programs Dental C Study 29% 42% programs Nursing C Study Results of field 10% programs testing of accreditation process Midwifery C Study Results of field 10% programs testing of accreditation process 6 D=Dropped Cumulative Target Values** Responsibility Core PDO Level Results C=Continue Unit of Data Source/ N= New Baseline Frequency for Data Indicators* Measure 2010 2011 2012 2013 2014 Methodology R=Revised Collection Pharmacist N Draft standard Final accreditation Results of field Annual Project progress CPCU competencies instrument and testing of report assessor training accreditation process Nutritionist N Draft standard Final accreditation Results of field Annual Project progress CPCU competencies instrument and testing of report assessor training accreditation process Public Health Specialist N Draft standard Final accreditation Results of field Annual Project progress CPCU competencies instrument and testing of report assessor training accreditation process Intermediate Result Indicator Component Two: Percent of graduates of health professional schools passing the national competency testing at first attempt Medical C Annual Project progress CPCU report Dental C 79% 80% 80% 81% 82% 86% Annual Project progress CPCU report Nursing C Results of field 50% Annual Project progress CPCU testing report Midwifery C Results of field 50% Annual Project progress CPCU testing report Pharmacist N Final blue print for Results of field Annual Project progress CPCU national testing of national report competency competency exam testing Nutritionist N Final blue print Results of field Annual Project CPCU for national testing of national progress report competency competency exam Public Health Specialist N Final blue print Results of field Annual Project CPCU for national testing of national progress report competency competency exam Intermediate Result Indicator Component Three: UNDANA and UNCEN Completion of Accreditation process Participation in the National Competency Examination 7 B. Component Indicators D=Dropped Cumulative Target Values** Responsibility Core C=Continue Unit of Data Source/ Performance Indicators N= New Baseline Frequency for Data Measure 2010 2011 2012 2013 2014 Methodology R=Revised Collection Component Indicators Component 1 : Strengthening Policies and Procedures for School Accreditation Completion status of C preparatory activities for establishment of the NAA Standard of Competencies and Standard of Education for the four health professions are available C Validation of Annual Project progress report CPCU Standards released Medical Standards by by IMC in 2006 IMC C Validation of Annual Project progress report CPCU Standards released Dental Standards by by IMC in 2006 IMC C Standards of Annual Project progress report CPCU Draft of both competencies and Nursing standards available education are validated C Standard of Standards of Annual Project progress report CPCU Competencies competencies and released by MOH in education are Midwifery 2007 validated Draft standard of Education available Accreditation instrument for the four health professional schools are ready for use C International Annual Project progress report CPCU Medical Draft available Peer Review C Piloting and Annual Project progress report CPCU Dental dissemination C Piloting and Annual Project progress report CPCU Nursing dissemination C Piloting and Annual Project progress report CPCU Midwifery dissemination 8 D=Dropped Cumulative Target Values** Responsibility Core C=Continue Unit of Data Source/ for Data Performance Indicators N= New Baseline Frequency Measure 2010 2011 2012 2013 2014 Methodology Collection R=Revised Component 2 Introduction of CBT and OSCE for NCE C CBT + OSCE CBT + OSCE Annual Project progress report CPCU Medical (formative) C CBT + OSCE CBT + OSCE Annual Project progress report CPCU Dental C KBT + OSCE KBT + OSCE Annual Project progress report CPCU Nursing Preparation try out C KBT + OSCE KBT + OSCE Annual Project progress report CPCU Midwifery Preparation try out Annual Project progress report CPCU Number of National C 36 for Doctors 72 for Doctors Annual Project progress report CPCU OSCE Examiners and Dentists and Dentists Number of National C 36/ profession Annual Project progress report CPCU MCQ Item Writers Number of National C 36 for Doctors 72for Doctors Annual Project progress report CPCU OSCE Item Writers and and Dentists and Dentists Reviewers Number of Regional C 150/ profession 300/ profession Annual Project progress report CPCU MCQ Writers and Reviewers Number of Regional C 80/ profession 160/profession Annual Project progress report CPCU OSCE Item Writers and Reviewers *Please indicate whether the indicator is a Core Sector Indicator (see further http://coreindicators) **Target values should be entered for the years data will be available, not necessarily annually. 9 ANNEX 2: Reallocation of Proceeds INDONESIA – HEALTH PROFESSIONAL EDUCATION QUALITY PROJECT P113341 – LOAN 7737 Restructuring Paper 1. Proceeds for the Indonesia Health Professional Education Quality Project (Loan 7737) P113341, will be reallocated as follow: Category of Expenditures Allocation % of Financing (in US Dollar) Current Revised Current Revised Current Revised Training and workshops, No Change 6,584,000 8,335,304 100% No Change incremental operating costs, research expenditure, consultant services and goods under Part 1 of the Project Training and workshops, No Change 12,099,000 14,046,934 100% No Change incremental operating costs, research expenditure, consultant services and goods under Part 2 of the Project FAPs for sub-projects under Part 3 No Change 55,000,000 51,300,762 100% No Change of the Project Training and workshops, No Change 4,139,000 4,139,000 100% No Change incremental operating costs, consultant services and goods under Part 4 of the Project Total Project Cost No Change 77,822,000 77,822,000 No Change 2. Project Implementation Progress: The project has made progress in a number of areas such as the establishment of a Quality Assurance System for the education of doctors, dentists, midwives and nurses (the four initial professions), through the strengthening of school accreditation and graduate certification systems; establishment of draft regulation, improved coordination, enactment of standard competencies, certification, clinical evaluation and testing. However, there are delays in disbursements. However this should improve through the strengthening of the procurement system. 3. The proposed reallocation is necessary to take into account the three new professions added to the project, and the full complement of activities that goes with those additions regarding training, regulatory processes, competencies, evaluation and testing. 10