JOSol A WORLD BANK Population OPERATIONS STUDY and the World Bank IMPLICATIONS FROM EIGHT CASE STUDIES Operations Evaluation Department FLE O cY Population and the World Bank IMPLICATIONS FROM EIGHT CASE STUDIES Other Titles in the Series PREPARED BY THE WORLD BANK OPERATIONS EVALUATION DEPARTMENT Forestry: The World Ban]k Experieince (1992; contains summaries in French and Spanish Evaluation Results for 1989 (1991; contains summaries in French and Spanish) The Aga Khan Rural Support Program in Pakistan: Second Interim Evaluation (1990; contains summaries in French and Spanish) Evaluation Results for 1988: Issues in World Bank Lending Over Two Decades (1990; also available in French) Agricultural Marketing: The World Bank's Experience 1974-85 (1990; contains summaries in French and Spanish Project Performance Results for 1987 (1989; also available in French) Renewable Resource Management in Agriculture (1989) Educational Development in Thailand: The Role of World Bank Lending (1989) Rural Development: World Bank Experience, 1965-86 (1988; also available in French and Spanish) Project Performance Results for 1986 (1988; also available in French) Cotton Development Programs in Burkina Faso, C6te d'Ivoire, and Togo (1988; also available in French) Sri Lanka and the World Bank A Review of a Relationship (1987) The Jengka Triangle Projects in Malaysia: Impact Evaluation Report (1987) The Twelfth Annual Review of Performance Results (1987; also available in French) The Aga Khan Rural Support Program in Pakistan: An Interim Evaluation (1987) Population and the World Bank IMPLICATIONS FROM EIGHT CASE STUDIES Operations Evaluation Department The World Bank Washington, D.C. Copyright @ 1992 The International Bank for Reconstruction and Development/THE WORLD BANK 1818 H Street, N.W. Washington, D.C. 20433, U.S.A. All rights reserved Manufactured in the United States of America First printing June 1991 The opinions expressed in this report do not necessarily represent the views of the World Bank or its member governments. The World Bank does not guarantee the accuracy of the data included in this publication and accepts no responsibility whatsoever for any consequence of their use. Any maps that accompany the text have been prepared solely for the convenience of readers; the designations and presentation of material in them do not imply the expression of any opinion whatsoever on the part of the World Bank, its affiliates, or its Board or member countries concerning the legal status of any country, territory, city, or area or of the authorities thereof or concerning the delimitation of its boundaries or its national affiliation. 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The complete backlist of publications from the World Bank is shown in the annual Index of Publica- tions, which contains an alphabetical title list (with full ordering information) and indexes of subjects, authors, and countries and regions. The latest edition is available free of charge from Distribution Unit, Office of the Publisher, Department F, The World Bank, 1818 H Street, N.W., Washington, D.C. 20433, U.S.A., or from Publications, The World Bank, 66, avenue d'I6na, 75116 Paris, France. ISSN: 1011-0984 Library of Congress Cataloging-in-Publication Data Population and the World Bank: implications from eight case studies. p. cm.-(A World Bank operations evaluation study, ISSN 1011-0984) Includes bibliographical references. ISBN 0-8213-2081-5 1. Developing countries-Population policy-Case studies. 2. World Bank-Developing countries-Case studies. I. International Bank for Reconstruction and Development. Operations Evaluation Dept. II. Series. HB884.P663 1992 363.9'09172'dc2O 92-13541 CIP Foreword This is the first assessment that the Operations and Eval- that should make the Bank's future population activities uation Department has undertaken of the Bank's role in the more effective. population field. It differs from evaluations undertaken by The study was written by Ronald Ridker of the OED others over the past 25 years in that it is based on a series of with substantial contributions from Ronald Freedman. It is detailed case studies of experiences in individual countries. based on a set of detailed case studies prepared by consult- This allows the authors more scope to investigate reasons ants working under Mr. Ridker's direction: Ronald Freed- for decisions and outcomes, and it provides a more solid man (Indonesia), Jay Satia (India). James Phillips foundation on which to build a picture of what can be done (Bangladesh), Warren Robinson (Kenya), Sara Seims (Sene- to improve performance in this area. gal), and Thomas Merrick (Colombia, Brazil, and Mexico). The study begins by reviewing and assessing develop- John Kantner provided valuable comments, especially on ments in eight countries, in each case asking how demo- the India case study. The major sources for these studies graphic and related social and economic developments were Bank documents, both published and internal, non- unfolded during the last 20-25 years and what role the gov- Bank studies and reports, field visits, and interviews with ernment, other donors, and the Bank played during this pe- government officials and the staffs of both the Bank and riod. It tries to bring the picture up to date, asking whether other donor organizations. Governments of all countries in- recent changes in Bank approach adequately take the les- cluded in this study have had an opportunity to comment. sons of earlier experience into account. Using these materi- This study, plus two of the case studies, have been distrib- als as a starting point, the last section discusses major issues uted to and discussed by the Bank's Executive Directors; all of concern to the Bank that have implications for its future three are presented in this document. efforts in this field. The picture that emerges is one of considerable diversity of activities and experiences, from which it is not easy to Yves Rovani generalize. The presentation tries to give some feel for this Director General diversity without overburdening the reader. Nevertheless, Operations Evaluation the study offers concrete suggestions for a shift in emphasis February 1992 v Prologo Esta es la primera evaluación que realiza el Departa- población, lo que redundará en una mayor eficacia de di- mento de Evaluación de Operaciones sobre la función del chas actividades. Banco en el sector de población. Difiere de otras evalua- El estudio fue preparado por Ronald Ridker del Depar- ciones efectuadas en los últimos 25 años en que se sustenta tamento de Evaluación de Operaciones, con la importante en una serie de estudios detallados de casos prácticos en colaboración de Ronald Freedman. Se basa en un conjunto determinados países. Esto permite a los autores un mayor de estudios detallados de casos prácticos preparados por campo de acción para investigar las razones en cuanto a de- consultores bajo la dirección del Sr. Ridker: Ronald Freed- cisiones y resultados, y proporciona una base más sólida man (Indonesia), Jay Satia (India), James Phillips para establecer una visión de conjunto de lo que puede hac- (Bangladesh), Warren Robinson (Kenya), Sara Seims erse a fin de mejorar el desempeño en esta esfera. (Senegal) y Thomas Merrick (Colombia, Brasil y México). El estudio comienza por examinar y evaluar los cambios John Kantner proporcionó valiosos comentarios, en espe- demográficos y socioeconómicos conexos que se han pro- cial sobre el estudio de casos de la India. La principal fuente ducido en ocho países en los últimos 20 a 25 años y la fun- de información de estos estudios fueron los documentos ción que han desempeñado los gobiernos, otros donantes y del Banco, tanto publicados como internos, estudios e in- el Banco en este período. Se intenta actualizar esta visión formes ajenos al Banco, visitas en el terreno y entrevistas general, y se plantea el interrogante de si los últimos cam- con funcionarios de gobierno y del Banco y de otros organ- bios en el enfoque empleado por el Banco toman en cuenta ismos donantes. Los gobiernos de todos los países inclui- en forma adecuada las enseñanzas derivadas de experien- dos en este estudio han tenido la oportunidad de formular cias anteriores. Utilizando esta información como punto de comentarios. Este estudio, más dos de los estudios de casos partida, en la última sección se analizan los principales te- prácticos, se han distribuido a los Directores Ejecutivos del mas que revisten interés para el Banco y que tienen reper- Banco quienes los han examinado; los tres se presentan en cusiones en sus programas futuros en este ámbito. este documento. El panorama resultante es de una considerable diver- sidad de actividades y experiencias que hace difícil llegar a una generalización. La presentación trata de dar una idea Yves Rovani de esta diversidad sin abrumar al lector. Sin embargo, el Director General estudio ofrece sugerencias concretas para un cambio de ori- Departamento de Evaluación de Operaciones entación en las actividades futuras del Banco en materia de Febrero de 1992 vi Avant-Propos C'est la première fois que le Département de l'évalua- toutefois des suggestions concrètes en vue d'infléchir l'ac- tion rétrospective des opérations (OED) entreprend d'étud- tion de la Banque et d'accroître son efficacité future. ier le rôle joué par la Banque dans le domaine de la L'étude a été établie par Ronald Ridker, de l'OED, qui a population. Cette étude diffère de celles qui ont été effec- bénéficié d'un apport substantiel de Ronald Freedman. Les tuées ailleurs au cours des 25 dernières années en ce sens monographies détaillées sur lesquelles elle s'appuie ont été qu'elle se fonde sur une série de monographies détaillées rédigées par des consultants dirigés par M. Ridker. Ce sont: consacrées à divers pays. Les auteurs ont eu ainsi plus de Ronald Freedman (Indonésie), Jay Satia (Inde), James latitude pour examiner les raisons qui sont à l'origine des Phillips (Bangladesh), Warren Robinson (Kenya), Sara décisions et de leurs conséquences. Le résultat obtenu con- Seims (Sénégal) et Thomas Merrick (Colombie, Brésil et stitue une base de départ plus solide pour la recherche des Mexique). John Kantner a présenté des observations moyens d'améliorer les programmes de population. précieuses, particulièrement sur le cas de l'Inde. Les princi- L'étude commence par un tour d'horizon et une analyse pales sources utilisées sont des documents internes et des de la manière dont la situation a évolué dans huit pays. Les publications de la Banque, des études et des rapports ex- auteurs ont suivi le déroulement des événements dans les ternes, des observations sur le terrain et des entretiens avec domaines démographique, social et économique au cours des membres du gouvernement intéressé et des agents de la des 20 à 25 dernières années, et le rôle joué par les autorités Banque et d'autres organisations donatrices. Les nationales, les autres bailleurs de fonds et la Banque pen- gouvernements intéressés ont tous eu la possibilité de for- dant cette période. Ils ont tenté de donner un aperçu de la muler leurs observations. La présente étude, ainsi que deux situation actuelle en se demandant si les changements ap- des monographies, qui sont incluses dans ce document, ont portés récemment à l'approche de la Banque tiennent été distribuées aux Administrateurs de la Banque et compte comme il convient de l'expérience acquise. A partir examinées par eux, de cela, la dernière partie analyse les principales questions qui se posent à la Banque dans l'optique de ses interven- tions futures. Yves Rovani Il apparaît que les activités et les résultats présentent Directeur général une diversité considérable, si bien qu'il est malaisé de tirer Evaluation rétrospective des conclusions générales. Les auteurs se sont efforcés de des opérations dépeindre cette diversité sans lasser le lecteur. Ils proposent Février 1992 vii Contents Foreword v Prologo vi Avant-Propos vii Executive Summary 1 Resumen Ejecutivo 8 Rjsumj Analytique 16 1. Introduction 25 2. Indonesia 27 Demographic Trends 27 Social and Economic Changes 27 Indonesia's Family Planning Program 28 World Bank Involvement 29 3. India 32 Demographic and Socioeconomic Trends 32 The Indian Family Welfare Program 33 The Bank's Role Prior to 1987-88 35 Developments since 1987-88 37 4. Bangladesh 39 Demographic and Socioeconomic Trends 39 The Bangladesh Family Planning Program 40 The Foreign Assistance Community and the Bank 41 Implications and Lessons 43 5. Brazil, Colombia, Mexico 46 Demographic Trends, Development, and the Role of Government 46 External Assistance and the Role of the Bank 47 ix 6. Kenya 50 Demographic Developments and Principal Determinants 50 Foreign Assistance and the Role of the Bank 52 Implications and Lessons 55 7. Senegal 56 Demographic and Socioeconomic Trends 56 Population Policies and Family Planning Programs 57 Foreign Assistance and World Bank Involvement 58 8. Major Issues for the World Bank 60 Neglect of Population Issues in Non-Population Sectors 60 Dialogue, Policy Promotion, and Sector Work 61 Project-related Issues 62 Donor Coordination and Involvement of Non-Governmental Agencies 65 Country Organization of Population and Family Planning Activities 65 Need for a Long-run Programmatic Approach 66 The Extent and Allocation of Bank Resources 66 Implications for Evaluating and Staffing Bank Population Activities 68 Figures 1.1 Case Study Countries, Birth, Death and Population Growth Rates, 1970-87 26 1.2 Case Study Countries, Total Fertility Rates, 1960-89 26 6.1 Family Planning Accessibility and Prevalence in Kenya: Travel Time, by Year Facility Started 52 8.1 Staff-weeks per Project, PHN vs. All Sectors 65 Statistical Appendix 1.1 Demographic and Socioeconomic Indicators, Selected Countries and Years 70 2.1 Donor Expenditures for Population Programs in Selected Countries, 1982-89 73 3.1 Summary Data for Population and Population-related Projects in Case Study Countries, FY70-FY90 74 3.2 Project Costs by Component in Population and Population-related Projects for Case Study Countries 75 3.3 Appraisal Project Costs and Bank Financing, by Category of Expenditure, for Population Projects in Case Study Countries 76 4.1 Bank Lending by Sector, Case Study Countries 1970-90 77 5.1 Civil Works, Furniture, and Equipment in Bank Population Projects, Appraisal Estimates 79 6.1 Commitments for International Population Assistance by World Bank and Other Donors, 1952-89 80 References 81 Annex 1: The World Bank and Bangladesh's Population Program 85 Annex 2: The World Bank and Indonesia's Population Program 125 x Acronyms ADB Asia Development Bank ASCOFAME Association of Colombian Medical Schools BAPPENAS Indonesia National Development Planning Agency BEMFAM Brazil's IPPF affiliate BFS Bangladesh Fertility Survey BKKBN Indonesian National Family Planning Program BR Crude birth rate (total live births per 1,000 population) CONAPOP National Population Commission of Senegal CPR Contraceptive prevalence rate (percent of married couples in reproductive age group using some means of contraception) DHS Demographic and health surveys DR Crude death rate (total deaths excluding stillborn per 1,000 population) FP Family planning GDP Gross domestic product GOB Government of Bangladesh GOK Government of Kenya HRD Human resources development IDA International Development Association IEC Information, education, and communication IFS International financial statistics INPRES Indonesia National subsidy for local governments IPPF International Planned Parenthood Federation KAPS Knowledge aptitude and practice survey KDHS Kenya Demographic Health Survey LDC Less-developed country MCH Maternal and child health MIES Management information and evaluation system MIS Management information service MOH Ministry of Health MOHFW Bangladesh Ministry of Health and Family Welfare (formerly Ministry of Health and Family Planning) MOHPP Bangladesh Ministry of Health and Population Planning MSD Ministry of Social Development NCPD National Council on Population and Development of Kenya NICIPS National Indonesia Contraceptive Prevalence Survey NGO Non-governmental organization NPCC Bangladesh National Population Control Council NPFP National Program in Family Planning NRR Net reproductive rate OECD Organization for Economic Cooperation and Development OED Operations Evaluation Department ORG Operations Research Group, Baroda, India PAIP Population Action and Investment Plan PCR Project completion report PHC Primary health center PHN Population, health and nutrition PHR Population & human resources PPAR Project performance audit report PROFAMILIA Colombia's IPPF affiliate REPELITA Five-Year Development Plan RMB Resident Mission in Bangladesh SMP Social Marketing Project Xi TFR Total fertility rate (number of live births per woman expected over a women's lifetime if her child-bearing experience at each age is the same as that of existing women at various ages) UNESCAP United Nations Economic and Social Commission for Asia and the Pacific UNFPA United Nations Fund for Population Activities UNICEF United Nations Children's Fund USAID United States Agency for International Development VCDC Village contraceptive distribution centers WHO World Health Organization WID Women in Development xii Executive Summary This study examines the Bank's activities in the popula- infant and child mortality in particular, have also declined tion sector by reviewing its role in eight countries. For each substantially-in the Latin countries, by about 50 percent country, it begins by asking what demographic and related since 1960. However, fertility, mortality, and population socioeconomic changes have occurred since 1968, when the growth rates remain high by most standards, especially in Bank announced that it would begin lending for this sector. Asia and Africa. Given the very young age structure of It also asks what government policies affecting these trends these countries, plus present rates of change in fertility and were instituted and what role was played by the Bank vis- mortality, their population growth rates are likely to remain A-vis other donors during this period. The conclusions near or above 2 percent per year for some time to come. reached are based on field visits, interviews, and a review Between two thirds and three fourths of this fertility de- of operations documents and literature. cline has been due to increased use of modem contracep- The picture that emerges is one of considerable diversity tive methods. Most of the remainder of the decline is of activities and experiences, from which it is not easy to accounted for by increasing age of marriage. These chang- generalize. Leaving this diversity and the qualifications es, in turn, have resulted from a combination of improve- aside for the moment, the study's overall conclusion is that, ments in social and economic characteristics favoring after slow, halting, and sometimes faulty starts, the Bank smaller families and later age of marriage. These include, has become progressively more effective in this field, for example, improvements in the educational, employ- though it could have done and achieved more. From this ment, and social status of women; declines in infant mortal- point onward-assuming forceful and consistent imple- ity; decreasing opportunities for child labor; and mentation of recent changes in the Bank's mode of operat- decreasing dependence on children for old age security. ing in this sector-most of what is required to effect the They also include family planning (FP) programs which en- desired demographic changes implicit in Bank sector policy deavor to make modem contraceptives readily available involves re-orientations and shifts in emphasis rather and provide information and education about them. than radical departures from recent practices and levels of In the three Latin countries, both factors-significant im- funding. provements in these social and economic indicators and sizeable and effective family planning services, in these cas- Demographic and Socioeconomic Trends es provided by non-governmental organizations (NGOs), quasi-public organizations, and commercial channels- Total fertility rates (TFRs) have declined in all case study have combined to bring about the observed demographic countries: marginally in Senegal; 20 percent of the distance changes. Indonesia has also experienced sizeable social and between the peak level of eight children per woman to a re- economic improvements, but remains a more rural, tradi- placement level of 2.1 in Kenya; 40 percent in Bangladesh; tional society with higher maternal and child mortality 50 percent in India; 60 percent in Indonesia; and !hore than rates. Its government-sponsored family planning program 70 percent in Brazil, Colombia, and Mexico. This news is has compensated for this difference in a variety of ways. particularly encouraging in the case of Bangladesh and Perhaps the most important of these is the large and effec- Kenya where, until very recently, there has been little to tive network of outreach workers extending down to the show for the efforts that have been made over the last smallest village. The Indian program has also compensated 20 years to reduce population growth rates. Mortality rates, for even more modest social and economic progress, but in 1 a different way: by focusing quite narrowly but effectively fashion; provided little in the way of technical assistance in on sterilization. Its program, however, has been set back at the preparation or implemention of projects in this field; times by political backlash resulting from periodic coercive and within projects, focused on providing civil works and campaigns. Because of its success in reaching a large frac- hardware. The Bank did help develop and support a major tion of couples desiring to terminate the reproductive population education program. In other software areas phase of their lives, the Indian program is now reaching a however, it tended to support implementation of projects point of diminishing returns. The Kenyan case is interest- developed by the Indonesian National Family Planning ing because the substantial social and economic progress of Program (BKKBN) with the technical assistance of other the last 25 years seems to have built up a pool of latent donors. For most of the period covered, there was no resi- demand for limiting family size which has not become op- dent technical staff member responsible for this sector and erative until very recently. A long period of program devel- sector work was limited. opment which has finally reached a critical threshold of Except perhaps for the first few years of its involvement effectiveness, plus active encouragement from the with the program, the Bank's approach was perfectly ap- President and other major leaders, finally appears to be propriate. The Indonesian authorities knew what they making a difference. Senegal provides an example of a wanted and proved to be good at implementation. Indeed, country with too little social and economic development the BKKBN is commonly considered one of the most effec- and too little program development to have a significant tive family planning organizations in the world. Other do- impact on fertility nors-in particular, the United States Agency for The Bangladesh case is particularly interesting because International Development (USAID)-were very active in there has been substantial program development but very developing operational policies and implementation tac- little social and economic progress-an almost classic case tics. This proved to be a good de facto division of labor in which a supply side approach was utilized in a situation which was well-appreciated by the Indonesian authorities. in which one would not expect to find much demand. The report discusses five areas in which the Bank might Sufficient latent demand must have been present even here, have done more or operated differently in Indonesia. (1) A however, to lead to the contraceptive prevalence and fertil- Bank specialist resident in the country for a longer period ity decline that have occurred so far. Just how much longer of time and with a mandate to become actively involved in progress can continue in the absence of significant program development and implementation would have structural changes that affect demand is an open question.' been useful. (2) Cooperation and collaboration with other The paper considers several possible explanations and calls donors could have been better during the first 15 years of for an investigation. Such research is important for the Bank participation. Since then, this aspect of the program future of the Bangladesh program and also for what it has improved substantially (3) The Bank could have en- might say about appropriate programs for countries with couraged earlier and stronger initiatives in the health sec- similar circumstances. tor, especially by more forcefully promoting maternal and child health (MCH) and its integration with family plan- The Bank's Role in Individual Countries ning. It is just now beginning to do this. (4) The Bank could have encouraged the development of non-family planning Indonesia. While the Bank has provided quite substantial strategies to enhance demand for smaller families, for ex- financial assistance to Indonesia's overall development ef- ample, by helping develop projects aimed at improving fort, lending for population has amounted to just 1 percent women's educational and employment opportunities. of the total. This amount has contributed about 10 percent Substantially more effort is still needed in this area. (5) to the total expenditures of the Government on its popula- Research and evaluation continues to need strengthening tion program. Other donors, including NGOs, have con- for at least two reasons: to extract lessons from this success- tributed another 20 percent. In providing these funds, the ful case for use elsewhere2 and to build research and Bank played a fairly traditional role, in the sense that it op- evaluation capacity into BKKBN where this function has erated more as a bank than as a development institution. been neglected. That is, by and large, it reacted to project proposals submit- Improvements in these areas were obviously not re- ted to it by the Indonesian authorities in an "arms-length"- quired, however, for the substantial progress that has been made so far. Moreover, Bank efforts in these spheres might 1. This way of stating things implicitly classifies information, education, have been resisted by BKKBN and other donors who pre- and communications (IEC) programs as being a part of a family planning program; that is, a supply-side measure. The idea behind this is that while IEC can disseminate information and encourage demand, there must be 2. For example, what factors explain this country's successful community- some proclivity already present-some latent demand created by more fun- based operations? Are they unique to Indonesia, or can they be applied to as- damental cultural, social, or economic forces-for these efforts to work on. sist other countries? 2 ferred the Bank to focus mainly on provision of resources accountability structure to give more weight to non-termi- for buildings and equipment. The Bank responded specifi- nal methods. Nor were there sufficient staff inputs-not in cally to the client's desires, and in this case, it was the right residence and also not in Washington-to do much more response, because of the considerable capacity of the client than pursue an arms-length approach. and the assistance of other donors. Since 1987, several significant changes have occurred. In Indonesia, the future may require different approach- Both the Government and the Bank appear to have become es from those of the past in three important respects. First, disappointed with results of the area projects and are will- there is much less need for massive infrastructure pro- ing to try a different approach. The sixth and seventh grams. Second, USAID has signaled its intention to scale projects, started in 1989 and 1990, reflect this through their back its inputs, in part because it believes Indonesia now focus on priority program components at the state level. needs less technical assistance and grant funds. BKKBN, They also include support for NGOs and social marketing. with USAII, assistance, has responded by establishing pro- Second, since 1987, several good pieces of sector work have grams to promote private marketing and service delivery. been produced which appear to be having an effect on In- Third, the formula that has worked to bring fertility down dian thinking and the nature of the dialogue. The proposed from 5.5 to 3.5 children per woman may not work to lower Child Survival and Safe Motherhood Project for the first it further to a replacement level of 2.1. The Bank could ad- time focuses major attention on health issues of importance just to these changes by scaling back its activities as USAID for influencing fertility decisions. It also includes more de- is doing or by trying to fill the gap left by USAID. The re- tailed attention to field-level operations, which in,the past port suggests that, depending on the issue, both approach- have proven a major bottleneck to implementing policy es are needed. changes. Finally, Bank efforts in the education field-pay- India. As in Indonesia, until recently, the Bank has per- ing particular attention to women-have increased sub- formed more like a traditional bank in India than a devel- stantially. opment institution. In this case, however, this role was While these are all promising initiatives, much will de- much less appropriate because of strategic problems with pend on how forcefully and consistently they are pursued. the program. These problems include: excessive focus on The Bank will have to continue producing sector work and sterilization, which ignores younger couples' needs for research aimed at developing practical ways to resolve spacing and (as noted above) is running into diminishing structural problems; continue arguing-forcefully when returns; insufficient attention to program operations and necessary-for the application of the results of such work; quality (as opposed to program expansion); excessive cen- put more effort into enlisting the help of other donors in tralization and reliance on a single delivery system; and ne- this process; and increase the amount of time and effort de- glect of factors that can influence demand. These problems voted to supervision of field-level operations. All this is have persisted and been recognized for at least as long as likely to require more inputs by staff conversant with the the Bank has been involved in the Indian program. substantive issues, both at headquarters and in the field. The Bank's failure to have a significant influence on the Bangladesh. The Bangladesh program suffers from many Indian program is attributable to a variety of factors. of the same weaknesses as the India program. While there (1) The Bank's first population project in India started in has been less focus on sterilizations, the quality of family 1972, long after the country's approach was firmly en- planning services is poor, the MCH program is weak and trenched. (2) While the amounts lent constituted 28 percent not well- integrated with family planning, and scarce man- of the Bank's entire population portfolio up to 1988, these agerial talent plus ingrained administrative patterns make sums represented a small fraction-3.6 percent between improvements difficult. In addition, of course, the program 1980 and 1988-of total expenditures on India's Family operates in an extremely difficult physical environment in Welfare Program. All donors together contributed 12-14 which periodic crises which require priority constantly percent of government expenditures but have never threaten to wipe out progress. formed themselves into an effective coalition. (3) The na- Nevertheless, most of the progress achieved in increas- ture of the first five projects, called area projects, inhibited ing contraceptive prevalence and reducing fertility is attrib- the Bank from becoming involved in policy issues lying outside these (geographical) areas and discouraged experi- mental innovations even within those areas.3 (4) Both sec- 3. This is a disputable point. The original argument for this approach was tor work and staff inputs into the program have been that the Bank would have more influence within these areas than it could have in the overall program. It is more likely that it did not happen this way, inadequate. Prior to 1988, little sector work was done-cer- not because the concept was wrong, but because it was never accepted on the tainly not enough to provide the Bank with a basis for pro- Indian side that Bank-supported areas could be different from others, and posing tactical changes, for example, suggesting just how because the Bank never took the initiative to develop detailed designs for these projects that would have spelled this point out prior to implements. the program could change its incentive, monitoring, and tion. 3 utable to program inputs. The outreach program, which is economic improvements, further declines would be more more extensive and active than that in India despite its lim- certain and more rapid if structural changes could be itations, is probably the feature that makes the difference. achieved that enhance the demand for smaller families. In addition, donors have played a more intensive and ac- Brazil, Colombia, and Mexico. In contrast to other coun- tive role in both planning and operations; in effect, expand- tries, these countries received only a small part of their ex- ing the Government's implementation capacity many-fold. penditures on family planning from external sources, and The Bank, which in this case has played an active, leading most of that was provided by NGOs rather than multilater- role, deserves considerable credit. al or bilateral agencies.4 Bank inputs were minimal. There The report lists seven factors that appear to have been have been no Bank- financed population projects in these critical. (1) The Government is clearly committed to solving countries. (One was prepared for Mexico, but was with- its population problem; has devoted a sizeable percentage drawn when a new government came to power.) Little was of its limited budget and managerial talent to the program; done to implement the few family planning subcompo- and has actively requested and utilized foreign assistance nents included with MCH in Bank-funded health projects, and advice. (2) The magnitude of foreign financial and tech- and policy dialogue seldom raised the topic. At least up to nical assistance has been substantial. (3) A considerable 1989, there has been very little sector work focused directly amount of the financial assistance, even within the five on population or family planning. In addition, lending to Bank-assisted population projects so far agreed to, has been other sectors, while it undoubtedly has had some indirect in the form of grants provided by co-financiers. This has al- impacts, was never undertaken with demographic consid- lowed more flexibility and greater focus on software com- erations in mind. ponents and has helped pay for additional Bank staff Three factors appear to account for this apparent neglect. inputs, both at headquarters and in the field. (4) With these (1) Political sensitivities about "population control"policies additional staff inputs and with the encouragement of the of foreigners made it difficult for Bank staff to broach the Government, the Bank has played an active role in all phas- topic with governments. These governments viewed Bank es of these projects-design, fund-raising, donor coordina- management as holding an unacceptable view and Bank tion, implementation, and evaluation-far more active than staff, caught in the middle, reacted by doing little. (2) By the is typical in Bank- assisted projects. (5) Collaboration time the Bank began lending for health services, which amongst donors has been substantial and co-financiers, might have provided a more acceptable approach to FP, who have typically provided more than half the funds in contraceptive prevalence was already comparatively high these projects, have played an increasingly active role. and the structure of service delivery well-established. Their involvement has now reached the stage where the (3) The lead agencies in these countries were NGOs or fourth project can be described more accurately as a semi-public agencies. Given government attitudes, the consortium project than a Bank project. (6) With the help of Bank lacked a way (unlike USAID) to work directly with the grant funds, flexibility has been built into the program these agencies or even to work indirectly with them, as it by, among other things, establishing an "Innovative has found in Kenya and elsewhere. Projects Fund"and a "Project Finance Cell."(7) Advantage The Bank's current approach in Latin America is to focus has been taken of findings from pilot projects to improve on reproductive health and safe motherhood as the ratio- program performance. nale for family planning. This seems to be appropriate. A In this case, there are reasons to believe that program more aggressive approach is unwarranted and politically efforts should continue along present lines for the next few unwise. However, important issues of equity, service qual- years. Surveys indicate the existence of a pool of potential ity, and choice remain and are, in any case, part of a broader users who have not yet been reached and evidence that set of issues the Bank is working on in the health sector.5 prevalence is higher where density of service points is These Latin American cases are important because they greater, where frequency of contacts with family planning bring to the fore questions about the rationale of Bank lend- workers is greater, and where better-quality services are ing for population. If the Bank wants to work in countries provided. However, even if prevalence is increased from its that do not accept population control as the rationale, it current level of 35 to the 50 percent level obtained in the must base its population program on a broader and more Matlab pilot area-very unlikely on a national scale-the flexible set of principles. This could start from a recognition total fertility rate would be about 3.7, still well above re- placement. To achieve lower levels in a reasonable period, a change in program directions to include more than the 4. Some international NGOs, however, have been supported from bilateral supply-oriented approach currently in use is likely to be and multilateral sources; in particular, USAID and United Nations Fund for needed. While desired family size appears to have de- Population Activites (UNFPA). 5. One dimension of such issues is the very high numbers of illegally-in- creased in Bangladesh even without significant social and duced abortions in these countries. See Singh and Wolf, 1991. 4 that the overall objective is promotion of sustainable im- fairly strongly on many of these issues and seems to have provements in living standards, and that family planning taken advantage of opportunities as they emerged. In this programs assist at the micro level-by improving family case, the absence of resident staff assigned to the sector health and choice-as well as at the macro level. In this does not appear to have been a serious barrier to progress, context, these programs are appropriate topics for policy given the liberal budgets for supervision and travel and in- dialogue and sector analysis to determine how, if at all, they puts from other donors with technical staff in the field. should be developed and used in specific circumstances. In The program appears to be more or less on the right track addition, these cases raise questions about the advisability for the time being and should continue to expand, though in some circumstances of lending for free-standing with substantially more emphasis placed on quality of ser- population projects, as opposed to health projects that in- vices, outreach, and IEC. However, even if the gap between clude family planning components. Had this approach desired and actual family size were totally closed, the TFR been used earlier and more consistently, the Bank may not would decline to only the 4-5 child range, which implies a have faced so much opposition and suspicion of its motives population growth rate that is still above 2 percent per year. in these countries. Between 1984 and 1987, the mean desired number of chil- Kenya. This case study provides a good illustration of the dren decreased from 5.8 to 4.4. To accelerate such change, virtue of-and need for-patience and perseverance in the something more than supply-side changes are needed. The population field. While donor efforts to persuade the report suggests some possibilities, but also indicates that Government to establish a major program have been research and pilot studies are extremely important in this substantial since the late 1960s, it was only in 1988-89 that case because of our limited knowledge about how to make clear evidence of the beginnings of a fertility decline began significant progress in reducing desired family size in the to emerge. face of a strong, pro-natalist family system. Besides supporting general economic development that Senegal. Apart from a rural health project designed in included substantial education funding, the Bank's inputs 1982 that focused on the provision of buildings and equip- have proceeded along two general lines. Starting in 1974, ment for expansion of basic health services, the Bank, four projects have been funded. The first two provided until recently, concentrated its efforts on helping the Gov- funds to the Ministry of Health (MOH) to establish a net- ernment develop a comprehensive population policy. A work of rural health facilities and training schools; family 1985-86 sector review, which concluded that USAID and planning components in these projects were weak and UNFPA were doing as much as could usefully be done to largely ignored during implementation. During this peri- develop FP services, recommended this focus. It was imple- od, the population growth rate actually increased. The third mented, among other ways, by making development of and fourth projects have had more substantial components such a policy statement a condition of a structural adjust- related to population and family planning, but were initiat- ment loan. While some government officials may have ed too late (1988 and 1990) to have influenced the change in gone along with this request because it appeared innocuous fertility trends. The second strand of Bank inputs has in- enough, the policy statement and the process of developing volved policy dialogue, sector work, and efforts to influ- it have taken on a life of their own and resulted in substan- ence the evolution of the program in a variety of ways. tive progress that would have occurred more slowly in its Examples of the latter included successful efforts to per- absence, given stagnant social or economic development in suade the Government to establish an inter-ministerial co- recent years. This strategy may be especially important in ordinating -agency for population outside the MOH Francophone Africa, because of its pro-natalist colonial her- (included as a condition in the second structural adjust- itage that had to be explicitly and publicly broken with to ment loan), and then to provide it with more responsibili- legitimize family planning activities. ties; and efforts to persuade the MOH to liberalize The decision by the Bank to focus on policy development guidelines for providing contraceptives, to integrate FP was probably correct at the time because the Bank, unlike into the mainstream of MOH activities, and to offer steril- other major donors, lacked field staff to help implement ization services. Both strands of work have been important more complex operations, but did have access to senior pol- components of an overall package that included technical icy circles because of its much broader policy agenda. More assistance and commodity support from other donors and, recently, the Bank has decided to become more pro-active perhaps most important, clear signals from Kenya's presi- by developing a project that, among other things, aims to dent that family planning was to be taken seriously. extend family planning and other services to the lowest tier Could the Bank have done anything to speed up this pro- in Senegal's health delivery system. This is a risky ap- cess? While far more effort could have been made to devel- proach. USAID, for example, has restricted itself to operat- op effective IEC, outreach, monitoring, evaluation, and ing at the next level up because the Government's capacity research components, the Bank pressed the Government to administer and deliver services is so limited. Given the 5 urgency of the problem, these risks are probably worth tak- is well established, for example, that educating women-or ing and can be kept within acceptable bounds by starting simply keeping them in school for a few more years--en- on a small scale and escalating slowly; but they require courages later marriage and lower fertility rates within much more intensive and more intimate supervision than marriage. Other promising interventions include programs has been typical of Bank projects in Senegal. specifically directed to raise the probability that children will survive to adulthood, opening up job opportunities for Major Issues for the Bank women in occupations that are competitive with child rear- ing (e.g., factory or office jobs rather than farm jobs), and The experience of the past 20 years clearly demonstrates improving social security programs so that adults feel less that even in poor countries that have not experienced much need of large families to provide such security. social and economic progress, a process of fertility decline Previous reviews of the Bank population program have can be initiated by a typical family planning program that called for more emphasis on such demand-oriented factors, focuses on the provision of contraceptive supplies, services, but very little has been done to turn this call into operation- and associated information. ]It will proceed more rapidly if al programs. Reasons include skepticism about the impor- that program includes a strong outreach component and tance of the argument for the necessity of demand-side provides high-quality services based on clients' percep- interventions; doubts about what can be accomplished; and tions of needs. This requires good field supervision, good staff compartmentalization and inertia. Underlying these training, and good motivation-all features that are diffi- factors may be the fact that population is typically treated cult to develop in poor, rural areas. as a sector with responsibility assigned to a specific admin- However, there is little evidence that even the best run of istrative unit, implicitly leaving other sectoral units free such programs can do much more than meet the needs of from this responsibility. Population is not a discrete sector those who are already predisposed to accept family plan- any more than economic development or poverty allevia- ning services.6 In all the cases studied, even if all such per- tion. All three are more in the nature of strategic objectives sons were enrolled in a family planning program-or even that should be the responsibility of all sectors. if the highest contraceptive prevalence rates achieved in the Since 1987, several changes have occurred that are hav- best-run pilot programs were achieved throughout the ing promising impacts on this situation within the Bank. country-there is no country in the group of eight, except The administrative integration of education, population, perhaps the three Latin American countries, in which the health, and nutrition has allowed and encouraged thoughts total fertility rate would drop to acceptable levels.7 Other about how each sector can help achieve the others' goals. kinds of interventions will be required to go farther. Sup- The Women in Development and Child Survival initiatives are ply-oriented strategies may be sufficient to reduce the total forcing a focus on two of the most important possibilities.8 fertility rate from six to four, but in the absence of strong so- A few promising components are beginning to show up in cial and economic change, a different strategy is likely to be education projects. Much more can and should be done. needed to reduce it from four to two. The Bank is uniquely qualified to do it. The Bank has been remiss in failing to develop programs Besides pointing up the need to broaden the scope of that focus on this issue. The most important thing it has population activities, the case studies suggest several im- done in this direction has been to promote general social provements that can be made within population projects and economic development. Above all else, this is probably and more traditional lines of activity. Early projects tended the strongest force we know of to reduce desired family size to emphasize expansion of the physical infrastructure at the and encourage spacing. However, these efforts were not expense of "software"elements, the implicit assumption be- undertaken with their potential demographic effect in ing that the latter would be provided by government or mind. Had that been done-had the Bank searched for se- other donors. This assumption is now recognized as wrong lective interventions into the development process that had in more instances than it is correct and steps have been tak- the possibility of changing implicit benefits and costs of en to right the balance within projects. The case studies sug- large families-far more might have been accomplished. It gest, however, that there is still a way to go in some 6. Study of the Bangladesh case may require modification of this state- 8. Another recent initiative-the effort to develop integrated human re- ment. It is plausible that in this case, the successful IEC efforts and the dem- source projects-is worth trying, but in the end may not bear much fruit. The onstration effect of increasing prevalence played a role in decreasing desired danger is that such projects may end up being "Christmas trees"of indepen- family size, despite the absence of social and economic change. dent components that are administrative nightmares to implement. A more 7. There are, however, regions with.n some of these countries where fertil- practical approach may be to develop separate projects which incorporate ity has approached replacement: Yogyakarta (2.1), Bali (2.5), East Java (2.6), population concerns-for example, education projects that include concen- Kerala (2.2), and Tamil Nadu (2.6). In all cases, social and economic develop- trated efforts on enrolling and keeping girls in school for a longer period of ment and/or administrative capacity is above the national average. time, industrial projects that set aside specific jobs for women, etc. 6 countries. The tendency for population projects to grow in loan and grant funds and ways that it can be done. All these size and fund increasing quantities of recurrent costs needs points suggest that the population "sector" is more staff- careful monitoring to ensure that absorptive capacity and intensive than most others and that greater allowance sustainability limits are not being overwhelmed. For asso- needs to be made for this difference. ciated reasons, more concern about cost containment and Finally, what can be said about the overall level of Bank internal. efficiency within family planning projects and pro- effort in this field, an issue that has resulted in substantial grams its needed. Before becoming heavily committed to criticism of the Bank in recent years? In judging this issue, funding contraceptive supplies, more thought should be it must be remembered that financial input alone is a poor given to funding contraceptive production facilities in larg- indicator of level of effort, especially in the population er countries. Bank and country ability to assess project and field, and that the Bank's efforts cannot be assessed inde- program effectiveness is poor and will continue to be poor pendently of what other donors, with grant funds at their as long as project components associated with monitoring disposal, are doing. and evaluation and the establishment of research capacity Within the case study countries we find no evidence that are neglected. additional financial resources for the type of projects the The case studies also suggest several broader lessons. Bank is currently funding in these countries would have Efforts in the population field require patience but eventu- made much difference. Some additional funds could be ally pay off. This fact should influence the way targets and usefully used in specific instances: to allow more staff in- criteria for assessment of population activities are estab- puts for supervision and technical assistance functions; to lished. Non-project activities-dialogue; sector work; ef- undertake more non-project activities (more sector work, forts to establish policies, improve organizational more collaboration and coordination with other donors, arrangements, and change rules and regulations-are very and a more pro-active role in some countries); to expand important. At some stages, they are more important than population-related activities in non-population sectors. development of a project. Such activities need to be specif- Additional resources will also be necessary to develop ac- ically rewarded and encouraged. An impressive example is tivities in countries in which the Bank does not now have the Bank effort of the past year to establish a policy consen- programs. But such changes would represent a modest re- sus in Africa, which incidentally is now bearing fruit in pro- orientation and expansion of a program which, on the posals for useful projects. The Bangladesh case is especially whole, appears to be on the right track. important in suggesting the value of joint programming of 7 Resumen Ejecutivo En este estudio se analizan las actividades que ha venido ses en que, hasta hace muy poco, no se habían logrado cumpliendo el Banco en el sector de la población de ocho muchos resultados en relación con los esfuerzos desplega- países. Se comienza por indagar, en el caso de cada uno de dos durante los últimos 20 años a fin de reducir las tasas de ellos, acerca de los cambios demográficos y socioeconómi- crecimiento de la población. Las tasas de mortalidad, espe- cos conexos que se han producido desde 1968, momento en cialmente en la infancia y en la niñez, también han dismi- que el Banco anunció que comenzaría a otorgar préstamos nuido considerablemente, en un 50% en los países de para dicho sector. También se identifican las políticas oficia- América Latina a partir de 1960. Sin embargo, cualesquiera les establecidas que influyeron en estas tendencias y la fun- sean las pautas que se utilicen, las tasas de fecundidad, ción que cumplió el Banco frente a otros donantes durante mortalidad y crecimiento de la población siguen siendo al- el período mencionado. Las conclusiones a que se ha llega- tas, especialmente en Asia y Africa. Habida cuenta de la es- do se basan en viajes de observación, entrevistas y un aná- tructura demográfica de estos países en la que predomina lisis de documentos y trabajos en materia de operaciones. la población joven, además de las tasas actuales de varia- El panorama resultante es de una considerable diversi- ción de la fecundiad y la mortalidad, es probable que en dad de actividades y experiencias que dificultan hacer una esas naciones las tasas de crecimiento de la población se generalización. La conclusión general del estudio, dejando mantengan en un nivel anual cercano al 2% o aun superior de lado esta diversidad y sus distinciones por el momento, durante algún tiempo. es que, después de unos primeros pasos lentos, vacilantes y Entre las dos terceras y las tres cuartas partes de esta dis- a veces equivocados, el Banco se ha vuelto cada vez más efi- minución de la fecundidad ha obedecido al mayor uso de caz en este ámbito, pero su labor y logros podrían haber los métodos anticonceptivos modernos, en tanto que casi sido mayores. De ahora en adelante -en el supuesto de todo el resto de esta reducción se debe a que las personas se una aplicación firme y homogénea de las últimas innova- casan a una edad cada vez mayor. A su vez, estas modifica- ciones en materia de operaciones del Banco en este sector- ciones obedecen a la combinación de mejoras registradas en la mayor parte de lo que hace falta para lograr las reformas las características sociales y económicas que propician la re- demográficas pretendidas implícitas en la política sectorial ducción del tamaño de la familia y una edad mayor para del Banco comprende cambios de orientación y del énfasis contraer matrimonio. Se trata, por ejemplo, de mejoras de puesto, en lugar de apartamientos radicales de las prácticas las condiciones de la mujer en cuanto a educación, empleo y niveles de financiamiento recientes. y situación social; la disminución de la mortalidad infantil; menos oportunidades de trabajo para los niños, y una me- Tendencias demográficas y socioeconómicas nor dependencia de éstos para la seguridad en la vejez. Dichas mejoras también comprenden programas de plani- Las tasas de fecundidad total han bajado en todos los ficación familiar con los que se procura que los anticoncep- países objeto del estudio de casos: marginalmente en Sene- tivos modernos sean más accesibles y se suministre gal; 20% de la distancia entre el nivel máximo de ocho niños información y educación a su respecto. por mujer a un nivel de reemplazo de 2,1 en Kenya; 40% en En la producción de los cambios demográficos observa- Bangladesh; 50% en India; 60% en Indonesia, y más del 70% dos en los tres países de América Latina se han combinado en Brasil, Colombia y México. Estas noticias son particular- ambos factores -es decir, mejoras importantes en estos in- mente alentadoras en los casos de Bangladesh y Kenya, paí- dicadores sociales y económicos y servicios de planificación 8 familiar apreciables y eficaces suministrados, en estos ca- consideran varias posibilidades y se propugna una investi- sos, por organizaciones no gubernamentales (ONG), orga- gación. Dicha investigación reviste importancia para el fu- nizaciones semipúblicas e intermediarios comerciales. Si turo del programa de Bangladesh y también por lo que bien en Indonesia también se han registrado mejoras socia- podría revelar acerca de cuáles serían los programas ade- les y económicas importantes, la sociedad en ese país sigue cuados para países en circunstancias similares. siendo más rural y tradicional con tasas más altas de mor- talidad derivada de la maternidad y en la niñez. Su progra- La función del Banco en los distintos países ma de planificación familiar auspiciado por el Gobierno ha compensado esta diferencia de diversas maneras. La más Indonesia. Si bien el Banco ha prestado considerable asis- importante de ellas tal vez sea la red importante y eficaz de tencia financiera a las medidas de desarrollo generales de agentes de planificación familiar que llega hasta las aldeas Indonesia, las operaciones crediticias para el sector de la más pequeñas. Con el programa de la India también ha población han ascendido a tan sólo el 1% del total. Esta compensado un progreso social y económico aún más mo- suma ha aportado los fondos necesarios para sufragar derado, pero de distinta manera: centrándose estrictamente aproximadamente el 10% del total de gastos públicos en el pero de modo eficaz en la esterilización. Sin embargo, dicho programa referido a la población, en tanto que otros donan- programa se ha visto frenado a veces por la reacción políti- tes, incluidas las organizaciones no gubernamentales ca que han provocado las campañas coercitivas periódicas. (ONG) han aportado otro 20%. Al suministrar estos fondos, Debido al éxito que ha tenido en llegar a una gran propor- el Banco desempeñó un papel bastante tradicional, en el ción de parejas que querían poner fin a la etapa reproducti- sentido de que se trataba de operaciones de un banco más va de sus vidas, el programa indio está ahora alcanzando que de una institución de desarrollo. Es decir, en general re- su punto de rendimientos decrecientes. El caso de Kenya es accionó con cautela ante las propuestas de proyectos pre- interesante puesto que el considerable progreso social y sentadas por las autoridades de Indonesia; fue poco lo que económico de los últimos 25 años al parecer ha dado lugar proporcionó a modo de asistencia técnica en la preparación a que se hiciera latente la necesidad de limitar el tamaño de o ejecución de los proyectos en este ámbito, y en los proyec- la familia, la que recién se manifestó hace muy poco. El lar- tos mismos se centró en la construcción de obras civiles y el go período de *preparación del programa que finalmente suministro de componentes físicos. Sin embargo, el Banco ha llegado al umbral crítico de eficacia, sumado al estímulo sí contribuyó a la formulación y el respaldo de un progra- que le infundieron el Presidente y otros dirigentes impor- ma importante de educación de la población. Empero, en tantes, al final parece estar dando resultados. Senegal es un otras esferas de componentes lógicos tendió a apoyar la eje- ejemplo de país que tiene muy poco desarrollo social y eco- cución de proyectos preparados por el Programa Nacional nómico y donde se preparan muy pocos programas como de Planificación Familiar de Indonesia con la asistencia téc- para que se pueda ejercer una gran influencia en la tasa de nica de otros donantes. Durante la mayor parte del período fecundidad. comprendido, no hubo ningún miembro del personal técni- Bangladesh constituye un caso de especial interés debido co residente que fuera responsable de este sector y los estu- a que se trata de una nación en la que ha habido una formu- dios sectoriales fueron limitados. lación importante de programas pero muy poco adelanto Salvo, tal vez, en los primeros años de su participación social y económico, y es casi un caso clásico de aplicación en el programa, el enfoque del Banco era perfectamente del enfoque de la oferta en condiciones en que no se preveía adecuado. Las autoridades de Indonesia sabían lo que que- encontrar mucha demanda. Sin embargo, aun así debe ha- rían y demostraron ser capaces de una buena ejecución. De ber existido suficiente demanda latente como para redun- hecho, el mencionado programa de planificación familiar dar en la prevalencia del uso de anticonceptivos y la normalmente es considerado como uno de los más eficaces disminución de la tasa de fecundidad que se han registrado en el mundo. Otros donantes -en especial, la Agencia para hasta ahora. Queda sin contestar el interrogante de cuánto el Desarrollo Internacional EUA (USAID)- participaron más se puede avanzar sin contar con cambios estructurales activamente en la formulación de políticas operacionales y importantes que influyan en la demanda'. En el estudio se tácticas de ejecución. Esta resultó ser una buena división de hecho de las tareas que mereció el elogio de las autoridades de Indonesia. 1. Esta modalidad de presentación entraña una clasificación implícita de En el informe se analizan cinco esferas en las que el Ban- los programas de información, educación y comunicación como partes del copdihaehcomáoatu odeanrdfrne programa de planificación familiar; es decir, una medición desde el punto d co podría haber hecho más o actuado de manera diferente vista de la oferta. Ello se basa en la idea de que si bien se puede difundir la en dicha nación. 1) Habría sido útil contar con un especia- información y alentar la demanda a través de las actividades de información, lista del Banco residente en el país por un período más lar- educación y comunicación, ya debe existir cierta pmclividad --cierta deman- go y con la función de participar activamente en la da latente generada por fuerzas culturales, sociales o econóncas más esen- ciales- para que estas medidas produzcan algún efecto. preparación y ejecución del programa. 2) La coordinación y 9 colaboración con otros donantes podría haber sido mejor vidades como lo está haciendo la mencionada USAID, o durante los primeros 15 años de participación del Banco. bien tratando de llenar el vacío dejado por ésta. En el infor- Desde entonces, este aspecto del programa ha mejorado me se indica que, según el problema de que se trate, es pre- considerablemente. 3) El Banco podría haber propugnado ciso aplicar ambos métodos. en forma más temprana y decidida proyectos en el sector India. Al igual que en el caso de Indonesia, hasta hace de la salud, en especial promoviendo más enérgicamente la muy poco el Banco ha desempeñado más las funciones tra- salud maternoinfantil y su integración en la planificación dicionales de un banco que las de una institución de desa- familiar, lo que recién está comenzando a hacer ahora. 4) El rrollo en la India. Sin embargo, en este caso, el papel que Banco podría haber estimulado la formulación de estrate- cumplió fue mucho menos adecuado en razón de los pro- gias de planificación no familiar a fin de incrementar la ne- blemas estratégicos del programa. Estas dificultades con- cesidad de reducir el tamaño de la familia, por ejemplo, sisten en: excesiva atención prestada a la esterilización, con contribuyendo a preparar proyectos destinados a mejorar lo que se ignora la necesidad de espaciar los nacimientos las oportunidades de educación y empleo de la mujer. Aún que tienen las parejas jóvenes y (como se señaló antes) se es preciso realizar esfuerzos considerables en este ámbito. están observando rendimientos decrecientes; falta de aten- 5) Sigue siendo necesario el fortalecimiento de las activida- ción a las operaciones y la calidad de los programas (por des de investigación y evaluación, al menos por dos razo- oposición a la expansión de éstos); excesiva centralización y nes, a saber: para extraer enseñanzas de este caso en el que dependencia de un único sistema de prestación, y la omi- se obtuvieron buenos resultados a fin de aplicarlas en otros sión de considerar los factores que pueden influir en la de- países2 y para fortalecer la capacidad de investigación y manda. La persistencia e identificación de estos problemas evaluación dentro del Programa Nacional de Planificación data, por lo menos, desde que se inició la participación del Familiar de Indonesia, en el que esta función ha sido des- Banco en el programa de la India. atendida. El hecho de que el Banco no haya podido ejercer una Sin embargo, evidentemente el mejoramiento de estos gran influencia en el programa de la India puede obedecer ámbitos no era necesario para lograr los considerables pro- a diversos factores. 1) El primer proyecto del Banco en ma- gresos que se han registrado hasta el momento. Asimismo, teria de población en la India se inició en 1972, mucho des- la labor del Banco en estas esferas podría haber topado con pués de haberse afianzado firmemente el plan del país. 2) Si resistencia por parte del Programa Nacional de Planifica- bien los montos entregados en préstamo constituían el 28% ción Familiar de Indonesia y otros donantes que preferían de la cartera total del Banco para el sector de la población que el Banco se centrara principalmente en el suministro de hasta 1988, estas sumas representaban una pequeña pro- recursos para edificios y equipo. El Banco dio respuesta es- porción-3,6% entre 1980 y 1988- de los gastos totales en pecífica a los deseos del cliente, y en este caso fue la res- el Programa de Bienestar Familiar de la India. Si bien el to- puesta adecuada en razón de la gran capacidad del cliente tal de donantes aportó entre el 12% y el 14% de los fondos y de la asistencia de otros donantes. necesarios para sufragar los gastos públicos, nunca se cons- En Indonesia, en el futuro tal vez hagan falta enfoques tituyeron en una coalición eficaz. 3) La naturaleza de los distintos de los aplicados en el pasado en lo que hace a tres cinco primeros proyectos, denominados proyectos zonales, aspectos importantes. En primer lugar, hay mucha menos le impidieron al Banco participar en cuestiones de políticas necesidad de programas masivos de obras de infraestructu- que excedieran del marco de estas zonas (geográficas) y ra. En segundo lugar, la USAID ha mostrado su intención desalentaron las innovaciones experimentales incluso den- de disminuir progresivamente sus aportes, en parte porque tro de dichas zonas3. 4) Tanto los estudios sectoriales como considera que Indonesia ahora necesita menos asistencia los aportes de personal para el programa han sido insufi- técnica y fondos a título de donación. El Programa Nacio- cientes. Fueron pocos los estudios sectoriales realizados an- nal de Planificación Familiar de Indonesia, con la asistencia tes de 1988-sin duda no fueron suficientes como para de la USAID, ha reaccionado estableciendo programas en- proporcionar al Banco un fundamento para proponer cam- caminados a promover la comercialización y la prestación bios tácticos como, por ejemplo, recomendar siquiera cómo de servicios por parte del sector privado. En tercer lugar, la fórmula que ha servido para bajar la tasa de fecundidad de 5,5 a 3,5 niños por mujer puede no servir ya para reducirla 3. Se trata de un aspecto discutible. En un principio el fundamento de este aún más, a una de reemplazo de 2,1. El Banco podría adap- sistema era que la influencia que ejercería el Banco dentro de estas zonas se- tarse a estos cambios reduciendo progresivamente sus acti- ría mayor que la que habría tenido en el programa general. Lo más probable es que no haya sucedido así, y ello no se debe a que el concepto estuviera equivocado sino a que la India nunca aceptó que las zonas respaldadas por el Banco pudieran ser diferentes de otras y porque el Banco nunca tomó la 2. Por ejemplo, ¿cuáles son los factores responsables del éxito de estas ope- iniciativa de elaborar estudios técnicos detallados para estos proyectos, en raciones del país basadas en la comunidad? ¿Son exclusivos de Indonesia, o los que se hubiera explicitado minuciosamente esta cuestión antes de la eje- pueden servir de ayuda a otros países? cución. 10 podría modificarse la estructura de incentivos, seguimiento dicas que exigen prioridad ponen constantemente en peli- y rendición de cuentas del programa a fin de dar mayor im- gro el provecho de los adelantos alcanzados. portancia a métodos menos drásticos que la esterilización. Sin embargo, la mayor parte del progreso logrado en ma- Tampoco hubo suficiente aporte de personal -en condi- teria de aumento de la prevalencia del uso de anticoncepti- ción de residente ni en Washington- como para hacer mu- vos y reducción de la tasa de fecundidad puede atribuirse cho más que emplear un enfoque distante. a los aportes del programa. Es probable que la diferencia ra- A partir de 1987 se produjeron varios cambios importan- dique en el programa de divulgación que, pese a sus limi- tes. Al parecer el Gobierno y el Banco se sintieron decepcio- taciones, es más amplio y activo que en la India. Además, nados con los resultados de los proyectos zonales y están los donantes han desempeñado una función más intensa y dispuestos a probar un método diferente. Esto se refleja en activa en la planificación y las operaciones, ampliando en la el sexto y el séptimo proyectos, iniciados en 1989 y 1990, realidad la capacidad de ejecución del Gobierno. Debe atri- por la atención que se presta en ellos a los componentes buirse un gran mérito al Banco, que en este caso ha cumpli- prioritarios del programa a nivel de los estados. En ellos do un papel activo y de liderazgo. también se incluye el apoyo a las ventas subvencionadas y En el informe se enumeran siete factores que al parecer las organizaciones no gubernamentales. En segundo lugar, han tenido importancia trascendental. 1) Es evidente que el a partir de 1987, se han hecho varios estudios sectoriales Gobierno está empeñado en resolver el problema relaciona- buenos que al parecer están influyendo en el modo de pen- do con la población; ha dedicado un porcentaje apreciable sar de la India y la naturaleza del diálogo. El Proyecto de de sus escasos presupuesto y talento directivo al programa, Supervivencia Infantil y Maternidad sin Riesgos que ha y ha procurado con ahínco y utilizado asistencia y asesora- sido propuesto presta por primera vez gran atención a los miento externos. 2) La asistencia financiera y técnica exter- problemas de la salud que revisten importancia como para na ha sido de considerable magnitud. 3) Gran parte de la influir en las decisiones en materia de fecundidad. En dicho asistencia financiera, incluso dentro de los cinco proyectos proyecto también se presta atención minuciosa a las opera- para la población respaldados por el Banco que han sido ciones a nivel de poblado, que en el pasado han demostra- aceptados hasta ahora, consiste en donaciones proporcio- do ser un punto de estrangulamiento importante para la nadas por los cofinanciadores. Ello ha permitido una mayor aplicación de los cambios de políticas. Por último, han au- flexibilidad y una mayor concentración de la atención en mentado considerablemente los esfuerzos realizados por el los componentes lógicos y ha contribuido a sufragar los Banco en el ámbito de la educación, prestándose atención gastos por concepto de aportes adicionales de personal del especial a la mujer. Banco, tanto en la sede como en el terreno. 4) Gracias a estos Si bien las mencionadas son todas propuestas que pro- aportes adicionales de personal y con el estímulo del Go- meten dar buenos resultados, mucho dependerá de la deci- bierno, el Banco ha desempeñado un activo papel en todas sión y homogeneidad con que se las aplique. El Banco las etapas de estos proyectos -diseño, captación de fon- deberá continuar realizando estudios sectoriales y de in- dos, coordinación de la ayuda de los donantes, ejecución y vestigación con miras a encontrar maneras prácticas de re- evaluación ex post-, mucho más intenso de lo que suele solver los problemas estructurales; deberá seguir serlo en los proyectos que respalda. 5) La labor de coordi- defendiendo -enérgicamente cuando sea necesario- la nación entre los donantes ha sido importante y los cofinan- aplicación de los resultados de dicha labor; deberá poner ciadores, que por lo general han suministrado más de la más empeño en captar la ayuda de otros donantes en este mitad de los fondos para estos proyectos, han desempeña- proceso, y dedicar más tiempo y esfuerzos a la supervisión do un papel cada vez más activo. Su participación en estos de las operaciones a nivel de poblado. Es probable que momentos ha llegado a la etapa que permite describir con todo ello requiera un mayor aporte por parte de funciona- mayor precisión al cuarto proyecto como de un consorcio y rios familiarizados con los problemas de fondo, tanto en la no del Banco. 6) Con la ayuda de los fondos de donación se sede como en el terreno. ha dotado de flexibilidad al programa gracias a que, entre Bangladesh. El programa de Bangladesh adolece de mu- otras cosas, se ha establecido un "Fondo para proyectos no- chas de las deficiencias del programa de la India. Si bien se vedosos" y una "Unidad de financiación de proyectos". ha centrado menos la atención en las esterilizaciones, la ca- 7) Se han aprovechado los resultados de proyectos experi- lidad de los servicios de planificación familiar no es buena, mentales para mejorar el desempeño del programa. el programa de salud maternoinfantil es endeble y no está En este caso, hay motivos para considerar que las medi- bien integrado en la planificación familiar; además, la falta das del programa deben seguir la misma orientación actual de talento en la dirección sumada a estructuras administra- durante los próximos años. Según las encuestas, hay un nú- tivas profundamente arraigadas dificultan las mejoras. Por cleo de usuarios potenciales a los que aún no se ha llegado añadidura, desde luego que el programa se desarrolla en y hay pruebas de que la prevalencia es mayor cuanto ma- un medio físico sumamente difícil en el que las crisis perió- yor es la densidad de los puntos de servicio, cuanto más 11 frecuentes son los contactos con los agentes de planifica- prevalencia del uso de anticonceptivos ya era comparativa- ción familiar y cuanto mejor es la calidad de los servicios mente elevada y la estructura de prestación de servicios es- suministrados. Sin embargo, incluso si aumentara el nivel taba bien afianzada. 3) Los principales organismos de estos de la prevalencia al 50% que se obtuvo en la zona experi- países eran organizaciones no gubernamentales o institu- mental de Matlab, frente al actual nivel de 35% -lo que es ciones mixtas. En vista de la actitud de los gobiernos, el poco probable a escala nacional- la tasa de fecundidad Banco (a diferencia Population Project I Population Project II Population Project III Population Project IVd z GOB GOB GOB GOB Component Cofin- Count- Cofin- Count- Cofin- Count- Cofin- Count- IDA anced erpart IDA anced erpart IDA anced erpart IDA anced erpart Loan Grants Funds Total Loan Grants Funds Total Loan Grants Funds Total Loan Grants Funds Total Total Civil works 4.18 7.27 2.37 13.82 18.60 24.62 3.14 46.36 41.15 0.00 3.32 45.07 64.2 19.7 8.2 92.1 197.35 (percent) (27.8) (28.6) (44.6) (30.2) (58.1) (36.7) (28.5) (41.1) (52.8) (0.0) (10.8) (21.1) (35.7) (7.7) (5.0) (15.4) (20.35) Equipment/ Supplies 6.64 3.35 0.21 6.20 5.50 7.82 3.30 16.62 31.26 23.03 5.58 59.87 26.8 17.8 15.1 59.7 1429 (percent) (17.6) (13.2) (3.9) (13.6) (17.2) (11.7) (30.0) (15.1) (40.1) (23.2) (15.3) (28.0) (14.9) (7.0) (9.2) (10.0) (14.69) Training 0.43 0.27 0.00 0.70 0.10 1.78 0.37 2.25 0.58 18.55 1.02 20.15 37.7 40.4 1.5 79.6 102.70 (percent) (2.9) (1.1) (0.0) (1.5) (0.3) (2.7) (3.4) (2.0) (0.7) (18.7) (2.8) (9.4) (20.9) (15.8) (0.9) (13.3) (10.59) Salariesa 1.83 5.52 0.02 7.37 0.73 21.05 2.50 24.28 0.00 35.86 15.71 51.57 5.5 32.3 134.1 171.9 255.12 (percent) (12.2) (21.7) (0.4) (16.1) (2.3) (31.4) (22.7) (22.1) (0.0) (36.1) (43.1) (24.1) (3.1) (12.7) (81.3) (28.7) (26.31) Special Activitiesh 0.30 0.05 0.00 0.35 1.46 0.54 0.00 2.00 5.01 21:96 10.22 37.19 45.8 144.8 6.1 196.7 236.24 (percent) (2.0) (0.2) (0.0) (0.8) (4.6) (0.8) (0.0) (1.8) (6.4) (22.1) (28.0) (17.4) (25.4) (56.8) (3.7) (32.8) (24.36) Unallocatedc 5.62 8.93 2.72 17.27 5.6 11.20 1.69 18.49 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 35.76 (percent) (37.5) (35.2) (51.1) (37.8) (17.3) (16.7) (15.4) (16.8) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (3.7) Total 15.00 25.39 5.32 45.71 31.99 67.01 11.00 110.00 78.00 99.40 36.45 213.85 180.0 255.0 165.0 600.00 969.56 (percent) (100.0) (100.0) (100.0) (100.0) (100.0) (100.0) (100.0) (100.0) (100.0) (100.0) (100.0) (100.0) (100.0) (100.0) (100.0) (100.0) (100.0) Percent of Total (32.81) (55.55) (11.64) (100.0) (29.08) (60.92) (10.0) (100.0) (36.47) (46.48) (17.05) (100.0) (30.0) (42.5) (27.5) (100.0) a. Public sector salaries and related operating costs. b. Research, innovative activities, and special NGO projects (including salaries). c. Physical and price contingencies unallocated at appraisal, but consigned to specific components during implementation. d. Budget at preappraisal (subject to modification). ANNEX 1 Table 2: Estimates of the Proximate Determinants of Fertility in the Bangladesh Fertility Surveys of 1975 and 1989 Fertility Component Survey Year 1975a 1989b Total Fecundity (TF) 15.3 15.3 Contraceptive Prevalanece (u) 7.7 31.4 Contraceptive Effectiveness (e) 0.779 0.849 Lactational Infecundity (i) 17.5 16.6c Bongaarts indices: - Marriage [CIm 0.92 0.86 Abortion [Cla 0.93d 0.93 Postpartum Infecundity (Cli 0.56 0.57c Contraception [C]c 0.93 0.71 Total Fertility Rate (TFR) 6.7 4.9 a. Ministry of Health and Population Control Bangladesh Fertility Survey 1979; Kabir and Rob 1990 b. Huq and Cleland 1990. c. Assuming estimated rather than observed durations of amenorrhea. d. 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The Population Program of the Govern- P and M Consultants. 1977. "Management Study" Report ment of Bangladesh: A Sector Review, World Bank, Pop- of a group of consultants to the Ministry of Health ulation and Nutrition Projects Department, and Population Control, People's Republic of Washington, D.C. Bangladesh. Dhaka (unpublished). Yunus, M., J. E Phillips, M. Koblinsky, and R. Simmons. Rahman, M. 1984. "Determinants of Areal Variation in Con- 1984. "Strategies for Implementing Change in a Rural traceptive Practice in Bangladesh."A thesis presented Health and Family Planning Programme in for the degree of Doctor of Philosophy at the Bangladesh." Paper presented at the annual meeting Research School of Social Sciences, The Australian of the National Council for International Health, National University, Canberra. Washington, D.C. 124 Annex 2 The World Bank and Indonesia's Population Program u ANNEX 2 Executive Summary Introduction tional infrastructure which facilitated the work of the na- tional family planning program. In this developmental In the 20 years since 1970, Indonesia's fertility rates have context, the BKKBN helped to legitimize small planned fallen by 40 percent, mainly as a result of the increasing use families and provided the contraceptive supplies and ser- of contraception. The Indonesian family planning program vices to make that possible. There is little doubt that both (BKKBN) has been immediately responsible for the increas- the favorable developmental trends and the effective fami- ing use of contraception by providing information, contra- ly planning program contributed to the fertility decline, al- ceptive supplies, and services. It has legitimated the though this cannot be quantified. concept of family planning in the thinking of Indonesians through a remarkable, pervasive, community-based pro- Indonesia's Family Planning Program gram. As one of the international donors that has given the program financial support and technical assistance, the The BKKBN has created a program which operates effec- World Bank has played a significant, although limited, role tively at every level-the nation, the 27 provinces, the 301 in these developments. Support by the Bank and other do- districts, the subdistricts, and eventually at the village and nors also has helped to legitimize the family planning pro- hamlet level. Through this hierarchy, it has succeeded in gram which has been somewhat controversial, especially in reaching the mass of married couples in the several hun- its earlier years. The Bank has also had an effect on popula- dred thousand hamlets below the village level. BKKBN, tion trends through its major support of Indonesia's broad- formally a coordinating agency rather than a line agency, based development program. works through such such ministries as those for health, ed- ucation, home affairs, information, rligion, and the armed Causes of Indonesia's Fertility Decline services. However, BKKBN also has important implemen- tation capacities which enable it to carry out directly some Indonesia's total fertility rate declined from about 5.5 to important activities and o test, expand, and hasten new in- 3.3 between 1967-70 and 1984-87. An increase in the age at itiatives. While many family planning programs espouse marriage accounted for part of the decline, but the main the goal of country-wide, community-based activities, cause was a substantial increase in the use of contraception Indonesia is one of only a few developing countries in by couples of childbearing age, from less than 10 percent in which this is a reality. the 1960s to 48 percent by 1987. The other factors which The success of the family planning program is attribut- potentially might have affected the decline-abortion, able to: divorce, fecundity, delayed marriage-consummation, brasfedngapea n omintonno t av.hd 1. The continuing strong political support of President Su- much effect on fertility. harto and, through him, of the whole political-adminis- Substantial social and economic change associated with trative system. Indonesia's considerable development contributed to the 2. An administrative structure which facilitates communi- Indoesi's onsierale evelpmet cntriute tothe cation and mobilization of action at the grass-roots level fertility decline in two important ways: (a) by decreasing co and m ati of acion attes level the demand for children and increasing the demand for for a wide range of development activities, including contraception and (b) by greatly improving the general na- 127 ANNEX 2 family planning. This system is unusually effective for a program, but these generally have not been of central developing country. importance to the program's success. While the Bank 3. Stable and effective leadership. The charismatic chair- has given only limited support to routine field service man of the BKKBN and most of his principal deputies operations, it did provide important initial support for have been in leadership positions for more than 15 salaries when field workers were first employed to ex- years. tend the outreach of health clinics. The Bank generally 4. Significant social and economic development, which has has not played a leading role among donors in such soft- affected attitudes about marriage, family life, and repro- ware aspects of program operations. duction; increased openness to new ideas; and created a 4. Through support for Indonesia's general development transportation and communication infrastructure effort. More indirect, but possibly as important as direct through which the program could function as it expand- program support, has been the Bank's large-scale sup- ed throughout the Indonesian islands. port (15 billion dollars in the last 20 years) for Indone- 5. Considerable financial and technical support from inter- sia's development efforts in education, health, national and bilateral donors. This support does not transportation and communications, electrification, ag- subvert indigenous Indonesian direction of the pro- riculture, and other support for the economy. Develop- gram, in part because the Indonesians themselves have ment in these other sectors is changing Indonesian paid an increasing share of program cost, reaching 70 society in ways which probably affect the population's percent by 1980. The BKKBN has been generally suc- interest in smaller families and family planning. cessful in gaining and coordinating donor assistance for its policies, in contrast to the domination by donor direc- Tedsiciecaatrsiso h akspplto itonolcaaesicoft soe ther onties. It hsorkred- work in Indonesia has resulted in a de facto division of labor tion characteristic of some other countries. It has worked wihscotednrsaUSI,NFAadUICFn cloel wthdoor i dvelpig ewintities with such other donors as USAID, UNFPA, and UNICEF in support of the BKKBN. The Bank has specialized in provid- The Contribution of the'World Bank to Indonesia's ing essential "hardware"infrastructure: buildings and their Family Planning Program furnishings, equipment, and vehicles. Two-thirds of the Bank loans have been for this purpose. The World Bank has contributed to the success of the Even during the first project, when there was more em- in a number of ways: phasis than later on software and program operations, 53 percent of the credit went for buildings, vehicles, and 1. Through population-policy dialogues with top govern- equipment. Part of the explanation for the Bank's emphasis ment leaders, to whom its broad lending program in on hardware was that the Indonesians (like other borrow- other sectors has given it continuing access. Its general ers) preferred grants rather than loans for software compo- prestige, arising from support for the whole range of de- nents. Loans were more acceptable for capital costs and velopment activities, has given legitimation to the pop- other hardware. ulation sector. Especially after the first few years, new ideas for the pro- 2. Through loans for basic program infrastructure: build- gram operations generally were developed and tested by ings, equipment, and vehicles. Two-thirds of Bank loan BKKBN in collaboration with donors other than the Bank. money was for this purpose. This is regarded as the The Bank then sometimes provided the resources for large- Bank's distinctive and principal contribution to program scale extension of such already-tested program initiatives. operations. The buildings provided the physical base for It has been perceived as-and indeed was-the major pro- the program as it expanded throughout the islands. The vider of the physical infrastructure of the buildings and the Bank provided headquarters and supply warehouses, vehicles needed for program activities as they expanded not only in Jakarta and the 27 provincial capitals, but throughout the islands. also in the 301 district capitals. They also provided a net- The fact that, in the software area, the Bank played the work of important training facilities. As the major pro- less glamorous role of complementary extension of the vider of vehicles, the Bank made possible the mobility ideas developed by the BKKBN and other donors is not essential for field services, supplies, training, IEC work, necessarily to the Bank's discredit. It can be seen as a real- and administration. istic recognition of the most effective division of labor, giv- 3. Through specific operational program components: en the local staff and modus operandi of the various training, population education, a hospital post-partum organizations in Indonesia. program, research and evaluation, and information- The program emphases of the Bank were determined in education-communication (IEC). Most of these "soft- part by its operating style and experience. The compo- ware"components have made some contribution to the nents of the Bank's four five-year projects have been de- 128 ANNEX 2 veloped over a period of several years by missions is not perceived as having provided intellectual leadership. recurrently visiting Indonesia. Because the projects are fi- Bank staff have not played an important role in helping the nanced by loans rather than grants, their development al- BKKBN to develop the major ideas guiding the program af- ways involves the planning agency (BAPPENAS) as well ter the first few years. Such a view of the Bank's role in pop- as the BKKBN. This further complicates project develop- ulation is in sharp contrast to its acknowledged important ment and implementation. intellectual leadership role in Indonesia's general develop- Unlike the other major donors, the Bank has not had a ment program and in macro-economic policy for Indonesia. significant resident field staff for population, except for lim- The Bank has population staff capable of exercising such ited periods. Traveling Bank missions from Washington, leadership, but, at least in Indonesia, the implicit or explicit however qualified, could not have the knowledge of Indo- choice was to let other donors who had competent resident nesia or the personal day-to-day relations with BKKBN staff lead the way in policy for software operations. staff necessary for cooperatively developing and testing While the perceptions about the Bank's role in popula- ideas in a very dynamic program. In contrast, USAID, in tion appear to be generally correct, they do not give the addition to a resident staff of three population officers, has Bank sufficient credit for its more limited but useful sup- had many resident expatriate and Indonesian consultants port of specific project components such as training, popu- working day-to-day with the BKKBN in operations re- lation education, and IEC activities. Indonesian officials cite search and in other ways. The Bank has fielded such resi- as an example of unusual Bank "flexibility,"its support for dent staff or consultants only in a very limited way field salaries of the newly recruited field workers when Once developed, the Bank's project components have there was no other support for this crucial first extension of been difficult to change, largely because such decisions had services away from limited fixed clinic sites. to be referred to Washington. In addition, because the The Bank staff was concerned about the management ca- projects were financed as loans rather than grants, time- pability of the BKKBN, especially during its first decade. consuming approvals were required from the Indonesian However, the third loan period Bank reports complimented government. By contrast, USAID reviewed and revised its the BKKBN on improved management and claimed some program annually and had the capacity to authorize new credit for it. Even then, however, the Bank was concerned expenditures locally on short notice. about too frequent administrative reorganizations. BKKBN In the "soft"aspects of social sectors, such as population management no doubt has improved, and the Bank and and health, flexibility is necessary both to adjust projects to other donors may have contributed to the improvement. changing conditions and to seize opportunities to test new However, the BKKBN deserves most of the credit for initiatives. The difficulty of programming such activities creating an indigenous management style and structure five years in advance is less relevant for hardware compo- which has been effective for many years, as judged by its re- nents. Further, the Bank has had successful experience with sults in the field. As for reorganizations, these seem to have hardware components for many sectors and countries. been necessary adjustments for a dynamic program, re- The Bank's undoubted capacity for analytical sector sponding to new ideas and to the problems of extension to work was rarely applied to population in Indonesia during the outer islands. the Bank's early projects. Even when such reports were lat- The criticisms of BKKBN management generally turn er done, they do not appear to have affected the design or out to refer to meeting dissonant administrative require- implementation of the Bank's first four loan projects very ments of the Bank and other very bureaucratic Indonesian much. In at least two instances in which Bank projects in- agencies. Criticisms have been less directed to management cluded potentially important operations research projects of the program in the field. For some time, the BKKBN has to test new ideas, the results were not very useful, in part been generally regarded by both Indonesian and expatriate because of inadequate collaboration with Indonesians in observers as considerably better managed than other Indo- the initial design. However, two recent reports are highly nesian human resource agencies or than other family plan- relevant to programmatic needs and are likely to influence ning programs in the region. the fifth population loan, now being negotiated. One deals The Bank's major contribution to the success of the gen- with the prospects for the program in the 1990s. The other eral Indonesian development program was not designed to is a much-needed economic analysis of the program. meet population policy objectives. However, it had this ef- The net result of the Bank's distinctive operating style fect. The major social and economic changes associated has been that, for most of the past 20 years, it has been per- with the development program are generally believed to ceived by the Indonesians and other donors as well quali- lead to lower fertility. For example, there have been signifi- fied to provide essential hardware infrastructure and to cant improvements in education, a sector in which the Bank support the large-scale extension of ideas tested and devel- has been active and one with recognized links to lower fer- oped by the BKKBN working with other donors. The Bank tility. The Bank has had a much smaller role in the health 129 ANNEX 2 sector, in which Indonesia lags. The health system is impor- in Indonesia's general development program has in- tant for population, because it is a major factor in the creased its credibility in supporting the population pro- delivery of family planning services and because of its ef- gram and in its continuing policy dialogue with the fect on reproductive motivation. The Bank might have highest levels of Indonesian leadership. done more in this sector, both from a welfare and a popula- While primary credit for achievements belongs to the In- tion perspective. donesians, the Bank and other donors have made signifi- cant contributions. Because of its operating style, the Bank's The Bank's Relation to Other Donors role in assisting program operations has been mainly in providing hardware and in implementing software projects The Bank's relations to the other donors were not very developed by others. The division of labor between the good for many years. When interviewed in the late 1970s, Bank and other donors in the past was reasonable and the other donors characterized visiting Bank missions as ar- worked rather well in terms of results. However, if the Bank rogant and poorly informed. A recurrent complaint was is to play a larger role in software projects, it would need to that Bank missions asked for information and reports but change its style of work. The decision not to have a resident did not reciprocate. Happily, when interviewed in 1990, do- staff for most of the period probably has limited the scope nor representatives unanimously reported a complete and effectiveness of the Bank's contribution to the opera- change to relationships of reciprocity and trust in recent tional program. years. Further, there was appreciation of joint or coordinat- ed activity Such coordinated activities may be of increasing Lessons importance as the financial needs of the program expand with growing numbers of both actual and potential contra- What might the Bank have done differently or better ceptive users. that could have increased its contribution to the popula- tion program? A Larger Perspective Especially in the first decade, a resident Bank presence The contributions of both the primary actor, the BKKBN, in the population field might have speeded up imple- and the supporting donors is best understood in larger per- mentation, made the Bank more flexible, and allowed it spective. The BKKBN is responsible for the supply aspects to contribute more to program development and soft- of most of the rise in contraceptive prevalence, which in ware components. turn accounts for most of the fertility decline. However, the * The Bank could have been more sensitive and coopera- BKKBN properly defines itself as an integral part of Indo- tive in its relations with other donors. While relations nesia's comprehensive development program. The sub- have improved over time, even today more regular re- stantial social and economic changes associated with that porting of the division of labor with other donors could development program probably help to account for a sub- still be helpful part of project completion reports, audits, stantial rise in age at marriage, which in turn accounts for and other documents as a basis for evaluating and di- perhaps 20-25 percent of the fertility decline. Beyond that, recting Bank activity. these social changes have helped to produce changes in * Earlier and stronger initiatives in the health sector family life and in reproductive values, which affect the de- would have been useful. mand for contraception and, thus, facilitate the work of the More generally, Indonesia would have been a good BKKBN. It does not denigrate the remarkable success of the place to have tested strategies for intersectoral linkages BKKBN to put it in this broader context. Similarly, the role between population and other sectors, for example edu- of the donors, including the Bank, is placed in proper per- cation, female employment and, of course, health. The spective if it is described as facilitating but not directing the opportunity still exists. work of the distinctively Indonesian BKKBN. * Indonesia's truly successful outreach and community- In this broader perspective, the contribution of the based program needs far more study than it has so far World Bank has three aspects. First, the loans in the popu- gotten to identify the factors associated with that success lation sector have strengthened the program in specific that might be transferable. ways, especially in providing buildings and vehicles, but much less so in software components. Secondly, the much Issues for the Future larger portfolio of Bank loans for other development sec- tors has contributed to social changes, which tend to Indonesia faces major challenges if it is to reach its goal change the desired number of children and the demand for of reducing its total fertility rate fmm 3.4 to the replacement family planning services. Finally, the Bank's important role level of 2.1. The much larger number of contraceptive users 130 ANNEX 2 needed to reach the low fertility targets will require large but with less detailed project development and monitoring increases in program expenditures, with the amount de- by the Bank. If the Bank is to take on more software compo- pending on how rapidly the BKKBN succeeds in its pro- nents, it should consider a resident population staff in In- gram for much greater privatization of contraceptive donesia, unless it decides the BKKBN no longer needs the supply and greater cost recovery in public services. Such resident staff support it has received from USAID. major changes raise issues of reorganization of the Indonesia's broad development program, with contin- program, shifts to more permanent methods of contracep- ued Bank support, should facilitate continuing social and tion, and more reliance on self-motivation of contraceptive economic change, which in turn will facilitate the continu- users. ing success of the family planning program and fertility USAID, the other major source of external funds, plans decline. Such indirect support through other sectors to scale down its participation greatly by 1995. The future strongly complements but is no substitute for strong role of the Bank depends on the extent to which it would support for the BKKBN. The Indonesian population pro- continue what it has done in the past and the extent to gram has had a significant effect going beyond the facilitat- which it might assume some of the financial and program- ing indirect effects of progress in other sectors. The Bank matic contributions that have been carried by USAID. can substantially increase its support for the population Further, the way the Bank structures its assistance will sector without significantly increasing its total Indonesian depend on its assessment of the extent to which BKKBN loan portfolio. can manage its own program with continuing financial aid, 131 ANNEX 2 1 . Introduction Population policy has been an important element in In- The Bank may also have had an effect on fertility and donesia's development program almost from the beginning other demographic variables through its lending for of its New Order government under the leadership of Pres- projects in other sectors. In the 20 years under review there ident Suharto (1966). At that time, Indonesia's population has been considerable social and economic development, as of 107 million was growing at the rapid rate of 2.35 percenti well as a mortality decline in Indonesia. Bank loans and per annum. Indonesian leaders developed a vigorous fam- projects in education, health, transportation and communi- ily planning program because they believed that rapid pop- cation, and more generally for economic development, may ulation growth would impede their plans for social and have contributed to social and economic changes, which in economic development and that the lower fertility required turn could lead to a decrease in the number of children de- to reduce population growth would also improve family sired, an increased demand for controlled fertility, and a welfare. It is significant that Professor Widjojo, an impor- fertility decline. The effects of the family planning program tant leader of Indonesia's development program, was the and other basic social and economic changes could have author of the seminal work on Indonesia's population.2 had synergistic effects. As a result of its development and population programs, The Indonesian case, unlike that of some other countries, Indonesia's fertility rates have declined substantially in the is one in which the Bank's activity in the population and last 20 years. A case study of this significant fertility decline other development sectors might have had an influence. offers an opportunity to evaluate the role of the World Bank There is something important to be explained, because con- in this historic event. The remarkable Indonesian family traceptive use did increase and fertility did decline. The planning program (BKKBN) is generally believed to be re- causes of these changes are in the interactive influence of sponsible for much of Indonesia's fertility decline, because the family planning program and general social and eco- of its role in increasing the use of contraception. It is plau- nomic development. The Bank's influence could be either sible that the World Bank may have contributed to this re- direct, through its support for the BKKBN, or more indirect, sult by providing funds for the family planning program through its support of the general development program. through loans, through technical assistance, and by its dia- Changes in other such demographic factors as age at mar- logue with Indonesian leaders about population policy and riage could affect fertility independently of any direct pro- related development issues. gram effort, but possibly as a result of social and economic change. A precise evaluation of the Bank's role is not possible be- cause of the complexity of the forces at work: changing 1. United Nations, Department of International Economic and Social Af- mal an epdut valu es a or u n in- fairs, World Population Prospects, 1988, Population Studies No. 106, (New marital and reproductive values and behavior under the in- York: United Nations, 1989). Since Indonesia, like most developing countries, fluence of a complex and dynamic family planning pro- does not have vital statistics adequate to the purpose, such demographic sta- gram as well as social and economic development in a tistics as birth rates, death rates, rates of natural increase, total fertility rates, culturally and economically diverse country. Further, the and life expectancy are necessarily estimnates from census and sample sur- ltrlyadeomilydvrscuny.Fth,te veys. The word "about"or "approximately"should be understood as preced- Bank was only one of several major donors with diverse ing all such cited numbers. However, it is believed that the demographic data but overlapping programs. Neither the Bank's nor other and trends cited are correct in the general order of magnitude. donor interventions were made or could have been made in 2. N. Widjojo, Population Trends in Indonesia (Ithaca, New York: Cornell dnritretoswr aeo ol aebe aei University Press, 1970). terms of an experimental design through which cause and 132 ANNEX 2 effect could be neatly assessed. The best that can be done is of the family planning program and of other social forces in to assess what are plausible or probable influences of the producing these changes is discussed. Only then is it mean- program and the Bank. ingful to discuss the role of the Bank, vis-b-vis other donors, This paper proceeds by first describing the fertility de- in the achievements of the family planning program. cline and its immediate demographic causes. Then, the role 133 ANNEX 2 2. Indonesia's Declining Fertility and its Immediate Causes Since 1970, Indonesia's fertility has fallen more rapidly as to limit the number of births. Increasing the interval be- than anyone had expected at the time, in view of its rela- tween births reduces annual fertility rates, in addition to tively low level of development, cultural diversity, large ar- the effect of the smaller total number of births per couple. eas of Muslim fundamentalism, and a legacy from the Part of the fertility decline is attributable to a steady but Sukarno period of a bloated bureaucracy, political instabil- gradual increase in the age of marriage, which decreased ity, and a poor health structure. the period of risk of pregnancy. The mean age at marriage The total fertility rate, estimated at 5.5 for 1967-70, had increased from 19.3 in 1971 to 21.1 in 1985.5 It is estimated fallen to 3.3 by 1984-87.3 This 40 percent decline, while not that 20-25 percent of the fertility decline between 1967-71 as large or as rapid as that in some other Asian countries, is and 1987 is attributable to changes in marital patterns.6 The substantial in terms of the initial expectations. increasing age at marriage is probably related to greater ed- The most important immediate (proximate) cause of the ucation, fewer arranged marriages, and greater indepen- fertility decline was an increase in the use of contraception dence of young people. Later age at marriage generally by married couples to limit the number of children and to must be a result of such social changes. China increased age increase the spaced interval between births. In the 1960s, at marriage by sanctions and vigorous action through its the contraceptive prevalence rate was probably less than 10 family planning program, but this was not the cause of the percent. By 1976, it had increased to 19 percent, and by 1987 age-at-marriage increase in Indonesia. it was 48 percent.4 There was still significant regional and Other changes in the marriage institution7-declines in provincial variation in 1987. The rate was 51 percent in the incidence of divorce and widowhood-had the effect of Java-Bali, where the program began, and 41 percent in out- increasing fertility, thus partially offsetting the opposite ef- er Java-Bali II, where the program began later. Within the fect of the rising age of marriage. Java-Bali region, the lowest prevalence rate was 46 percent (West Java) and the rates were as high as 68 percent in Bali and Yogyakarta. 5. Terence H. Hull, "Fertility Decline in Indonesia: An Institutionalist In- The increasing use of contraception led to fertility de- terpretation,"Research Note No. 72, International Population Dynamics Pm- cline, not only by reducing the number of children each gram, Department of Demography, Australian National University, May couple had, but also by increasing the interval between 1987. 6. The 25 percent estimate for 1967-71 to 1976 is from T.H. Hull, V Hull, births, as some couples used contraception to space as well and M. Singarimbun, "Indonesia's Family Planning Story: Success and Chal- lenge,"Population Bulletin, Vol.32, No.6, November 1977, p.45. The 20 percent estimate of the percentage of change between 1976 and 1987 attributable to 3. Central Bureau of Statistics, National Indonesia Contraceptive Prevalence contraception and changing marital patterns due to the latter is from M. Adi- Survey, 1987, Jakarta, January 1989, p. 53. This report is abbreviated as NICPS etomo, S. Kitting, and S. Taufik, Fertility Transition in Indonesia: Trends in Prox- in subsequent references. imate Determinants (Jakarta: Lembaga Demografi, 1989). 4. Data for contraceptive prevalence, desired number of children, and oth- 7. The discussion of marriage, divorce, non-consummation, post-partum er aspects of reproductive behavior cited in this paper for 1976 are from Cen- abstinence, and arranged marriages draws on the article by Hull cited in tral Bureau of Statistics and World Fertility Survey, Indonesia Fertility footnote 5, as well as his "Marriage and Divorce Trends in Indonesia,"Re- Survey, 1976: Principal Report, Jakarta, 1978. This report is abbreviated as IFS search Note No.87, International Population Dynamics Program, Depart- in subsequent references. The comparable data for 1987 are from NICPS. ment of Demography, Australian National University, March 1988. 134 ANNEX 2 Traditional marital patterns of early marriage followed more children, more than 50 percent made such a report. In by a period of non-consummation and a practice of post- 1987,21 percent of NICPS respondents said they wanted no partum abstinence - common in some parts of Java - had more children but weren't using contraception. There are the effects of keeping fertility lower than it otherwise might no reliable data on the incidence of abortion in Indonesia, have been. These practices may help to account for the fact but insofar as it occurs because of unwanted or mistimed that fertility was not especially high in Java, even before the pregnancies, it would account for some part of the fertility rise of contraceptive prevalence. The apparent decline in decline. the last 20 years of periods of non-consummation and of Overall, then, it appears that the decline in fertility was postpartum abstinence8 should have had a pro-natalist ef- mainly due to the rise in contraceptive prevalence. The in- fect, further offsetting the effects of rising age at marriage. creasing age at marriage and a possible increase in abor- There is no firm evidence for Indonesia of a decline in the tions could account for some of the fertility decline, but this incidence or duration of breastfeeding which, in some de- was at least partially offset by the decreased incidence of di- veloping countries, has had pro-natalist effects offsetting vorce, widowhood, early non-consummation, and postpar- the early effects of adoption of contraception. Neither the tum abstinence. Thus, the major proximate cause of the 1976 IFS survey nor the 1987 NICPS survey indicates any fertility decline was the increased use of contraception, the change in breastfeeding patterns. However, some micro- factor most subject to the effects of the family planning pro- studies indicate a decline in some sub-populations.' The gram. negative relation of education to mean duration of breast- An important primary cause of increased use of contra- feeding, amenorrhea, and postpartum abstinence0 sug- ception during the transition from high to low fertility is a gests that the antinatalist effects of breastfeeding should be decline in the number of children parents want. There has declining as the education level has been rising. been such a decline in Indonesia. Between 1976 and 1987 A rising incidence of abortion is usually common during the percentage of wives with any specific number of chil- the early period of rises in contraceptive practice. This is be- dren who said they wanted no more children increased and cause, during such a period, many couples have not yet the mean number of children wanted decreased as follows: adopted contraception or have used it ineffectively. As a re- sult, many have unwanted or mistimed pregnancies and Number of Living Percent Wanting Mean Number of are likely to turn to abortion. According to the 1987 NICPS, Children No More Children Children Wanted 6 percent of the births in the preceding five years occurred 1976 1987 1976 1987 to women who wanted no more children and an additional 18 percent occurred earlier than wanted. Further, among 0 4 5 2.9 2.5 those with three or more children, substantial numbers said 1 9 12 3.2 2.7 2 29 42 3.5 2.9 they would have preferred fewer children if they could 3 45 67 4.0 3.3 start family-building over again. Among those with five or 4 or more 57 81 5.7 4.1 Total 39 51 4.2 3.2 8. Geoffrey McNicoll and Masri Singarimbun, Fertility Decline in Indone- Source: 1976 IFS and 1987 NICPS. sia: Analysis and Interpretation, Report No. 20, Committee on Population and Demography, National Academy of Sciences (Washington, D.C.: Nation- Changes in such a fundamental value as the number of al Academy Press, 1983); and Terence H. Hull, "Marriage and Divorce Trends in Indonesia,"Research Note No. 87, International Population Dynamics Pro- children wanted usually arise in large part as a result of gram, Department of Demography, Australian National University March changes in the family and in the society at large. However, 1988.aswwilsethBKB'inesvinomtoaned 9. Geoffrey McNicoll and Masri Singarimbun, Fertility Decline in Indonesia: as we will see, the BKKBN's intensive information and ed- Analysis and Interpretation, Report No. 20, Committee on Population and De- ucation program probably reinforced the effects on de- mography, National Academy of Sciences (Washington, D.C.: National mand for children of considerable social and economic Academy Press, 1983). change. 10. Indicated in both IFS and NICPS. 135 ANNEX 2 * Social Changes as Probable Causes of Rising Use of Contraception Later age at marriage, a decline in the number of chil- cy in linking the younger generation to the world commu- dren desired, and the increasing use of contraception to nication system and to modern technology through the have smaller planned families in Indonesia are plausibly re- mass media, written instructions, advertising, and other sults of profound social and economic changes, the power- messages. ful family planning program, and the interaction between Education was perceived, with some justification, by the social changes and the family planning program in both parents and young people as providing entry to better Indonesia. jobs in the government and in the growing private sector. The dynamic social and economic development pro- Most secondary school graduates, indeed, did get civil ser- grams introduced by the New Order under President Su- vice jobs. harto in the late 1960s must have had profound effects over The expansion of education was a major thrust of the time on family life, on the life view of young married cou- government development program. Under the INPRES ples, on the aspirations of parents for their children, and on program initiated in 1974, there was a 250 percent increase the children's own aspirations. in the education share of the second Repelita Program bud- The success of the Indonesian development program (in- get (1974-78). This program resulted in its first five years in cluding the family planning program) has depended to a over 145,000 new primary schools and the rehabilitation of substantial degree on the stable and effective administra- 56,000 others. Primary school enrollment increased from 13 tive system developed under the New Order. Vertical lines to 27 million between 1973-74 and 1984-85. This education of authority were strengthened to insure that orders and re- expansion brought changes to tens of thousands of villages. sponses flow up and down between various levels. Military It was accompanied by continuing emphasis on the growth personnel have been effectively used in civil positions of new opportunities for the younger generation, both in within the administrative system. Of critical importance the mass media and in communications to the villages has been the ability of this system to mobilize attention, ac- through the political system. tion, and response at the village level. While their political While the increase in educational achievement was sub- systems differ in many respects, Indonesia and China are stantial, a sober view needs to consider also that the quality similar in their effective linkages between the national gov- of education still leaves much to be desired. There is little ernment and the village base. In this respect, they differ support for recurrent essential supplies and equipment. from India. The success of the Indonesian family planning Much learning has been of the rote variety, and textbooks program cannot be understood without reference to the ad- often are lacking. The mobilization of parents to support ministrative-political system within which it operates. schools is commendable, but it often has the effect of the en- A primary development program for a massive increase richment of programs in the urban and wealthier areas. in educational levels succeeded in making primary educa- While the specific ways in which education influences re- tion virtually universal, in greatly increasing secondary productive behavior are not certain, it is clear that educa- school enrollment, and in greater equity of education for tional attainment has been related in Indonesia, as boys and girls." More years in school exposed the new gen- eration to new ideas, in part through the school itself, but 11. The discussion on education in this paper draws on an internal World also through the life-long effect of greater functional litera- Bank report and on interviews with specialists at the Bank on the Indonesian education sector. 136 ANNEX 2 elsewhere, to wanting fewer children, to greater knowledge torized vehicles, radios, blue jeans, commercially-prepared and use of contraception, and to actually having fewer chil- foodstuffs, and other popular goods of the world consumer dren. Longer periods in school probably had the effect, markets. While all Indonesians could not afford all the new also, of making young people more independent of their goods, there is little doubt that even the poor aspired to families, have them. At the same time as educational levels rose, there were T. Hull, a long-time, perceptive student of Indonesian major increases in mass media communications via radio, society, writes that,15 "Even as some people remain poor, television, printed media, and government-organized in- the majority of the society is becoming oriented to higher formation and education programs at the village level. forms of consumption. A wide variety of consumer goods These affected both the educated, younger generation and and services is promoted through advertising and exem- the less literate older generation, linking them not only to plary use, and are distributed through the far-flung archi- the system of ideas involved in government programs, but pelago by a growing network of traders and retailers. Most also to the world-wide communication system, whose mes- of the new consumer goods and the middle class styles are sages transcend the local and the national. Between 1978 outside the reach of the mass of the Indonesians.. .Full par- and 1984 alone, the proportion of the population who ticipation in the new consumerism is not necessary for this watched television in the preceding week increased from 20 innovative institution to have a strong influence on peo- to 58 percent, while the proportion who listened to the ra- ple's decision-making. More important is the strength and dio increased from 50 to 75 percent.12 immediacy of the images of a new life which are created A parallel trend was the development of a more exten- and desired, if not immediately for themselves, then in the sive and improved road network and of buses, trucks, and future for their children. In this way mass consumption.. .is small motorized vehicles, which greatly increased the cir- clearly related to the development of elements of ideology." culation of people, goods, and ideas. The network was es- "There is no traditional village in Indonesia. Change has pecially dense in Java-Bali, where 62 percent of the swept the bulk of the population along quickly, but even Indonesian population lives. There was a considerable in- the backwaters are caught up in new patterns of consump- crease of migration and urbanization. Especially important tion, trade, education, and migration."16 was circulatory migration, in which family members com- Improvements in health, in infant mortality, and in life muted to new employment opportunities, either on a daily expectancy are of special relevance to family decisions basis or for longer periods, while maintaining their links to about childbearing.17 Infant mortality is estimated to have their families in the villages. Circulatory migration helps to declined from 142 in 1971 to 112 by 1980 and to 71 by 1985. integrate villages into larger social, economic, and ideation- Child mortality declined from an estimated 134 in 1972-76 al networks.13 to 101 by 1982-87. Life expectancy is estimated to have in- Between 1972 and 1987 the number of licensed motor- creased from 43-45 in the 1960s to 56 by 1980-84, and to 60 ized vehicles increased as follows:14 by 1988. Lower mortality, especially of infants and children, can contribute to lower fertility through several mecha- 1972 1987 nisms. It is likely that the declines in infant and child mor- (thousands) tality were a result in part of the declines in fertility. Smaller Trucks 131 953 families and greater spacing between births increased fam- Buses 26 303 ily resources and attention for each child and increased the Motorcycles 615 5554 access of many infants to prolonged breastfeeding. Passenger cars 277 1170 Undergirding all of these changes were broad improve- Total 1049 7980 ments in the economy.18 In 1967, Indonesia was still very poor, with a per capita GNP of only US$50 and with a ma- The expansion of the Indonesian transportation and jority of the population classified as below the poverty line. communication network was associated with rapid growth in the availability of consumer goods: bicycles, small mo- 15. Terence H. Hull, "Fertility Decline in Indonesia: An Institutionalist In- terpretation,"Research Note No. 72, International Population Dynamics Pro- 12. Central Bureau of Statistics, Welfare Indicators, Jakarta, 1988, Table 3.4. gram, Department of Demography, Australian National University, May 13. Graeme J. Hugo, "Population Movement, Economic Development, 1987. and Social Change in Indonesia since 1971,"Paper prepared for the Annual 16. Personal communication. Meeting of the Population Association of America, Chicago, April 1987; and 17. Data from NICPS, p. 69; and from World Bank, Indonesia: Family Plan- Graeme J. Hugo, Terence H. Hull, Valerie J. Hull, and Gavin W Jones, The De- ning Perspectives in the 1990s (Washington, D.C.: World Bank, 1990). mographic Dimension in Indonesian Development (Singapore: Oxford Universi- 18. This discussion draws on Graeme J. Hugo, Terence H. Hull, Valerie J. ty Press, 1987). Hull, and Gavin W. Jones, The Demographic Dimension in Indonesian Develop- 14. Central Bureau of Statistics, Environmental Statistics of Indonesia and ment (Singapore: Oxford University Press, 1987); and several internal World Statistical Pocketbook for 1972/1973, Jakarta. Bank reports. 137 ANNEX 2 The New Order government made a commitment to broad- The scope of economic change should not be exaggerat- based economic development and, especially, to rural de- ed, since very considerable numbers of Indonesians still are velopment. With the oil boom, there was a surge in eco- just above the poverty level. Per capita GNP is still not nomic growth, with emphasis on productive use of labor high, but in the last two decades, enough Indonesians have and resources, and with relatively little in the way of direct improved their standard of living so there is some evident transfers, consumer subsidies, or public employment. Be- basis for aspirations for a better material standard of living. tween 1974 and 1978, economic growth was rapid, but the Associated with the social and economic changes re- effect on poverty reduction was modest due to slower ini- viewed have been fundamental changes in the outlook of tial growth in the rural sector. There was considerable re- the young adult generation and in its relation to the older duction in poverty beginning in 1978, as the Indonesian generation.20 Young people are more independent of fa- version of the Green Revolution dramatically increased rice milial direction. This is evident in later marriages, a sharp production and the government invested more heavily in decline in arranged marriages, and increased influence of rural development. peer groups. Greater education links the younger genera- Beginning in 1983, the sharp drop in oil income and tion to new ideas transcending the family and the commu- changes in the international economy led to some sharp, nity. The mass media brings images of romantic rather drastic shocks and retrenchment in some development ac- than traditional relations between husbands and wives tivities. However, Indonesia is credited by World Bank and constantly reinforces the consumption orientation of economists with mounting a successful macro-economic young adults and their children. The family is becoming adjustment program, so that per capita incomes increased more child-centered and less oriented toward service to between 1984 and 1987. In these new adjustment initiatives, parents. private investment was stressed and did increase substan- These basic ideational changes probably have contrib- tially. Non-oil sectors have grown considerably Agricul- uted to the openness of young couples to the family plan- ture, with some government protection, continued to do ning program's message that the small planned happy well. The manufacturing sector has grown rapidly. While family is good for them and for Indonesia. This message the resource-based plywood sector has been number one, has been widely and repetitively transmitted through the number two has been in textiles and clothing. This is espe- mass media and the political and administrative system. It cially important for the population, since this sector pre- is so pervasive that it may well have contributed to, as dominantly employs women. In general, the government well as being strengthened by, the broader ideational acted to free up the private sector. It stimulated labor-inten- changes affecting the younger generation. sive, export-oriented production and helped to develop a The ongoing transformation of Indonesian society just supporting infrastructure. described is relevant to understanding the success of the It is estimated that as much as 50 percent of rural house- family planning program. The changes in education, holds in Java-Bali have significant income from the non-ag- health, transportation and communication networks, con- ricultural sector.19 Another indicator of rising standards of sumption levels and aspirations, standards of living, the living is an increase in the proportion of households with family, and the increasing linkage to the world system of electricity, from 6 percent in 1971 to 31 percent in 1985. ideas are in directions generally believed to be conducive According to an internal World Bank study, the net result to lower fertility.21 of economic changes is the following estimated decline in Based on the 1976 and 1987 studies, there is specific evi- the proportion of the population below the poverty level: dence for Indonesia that the number of children desired is negatively, and the use of contraception positively related to education.2 There is also evidence from the 1976 study Percent Below that the rapid rise in contraceptive use from 1970 to 1976 in- Time Poverty Line Early 1960s 70-75 Late 1970s 40 20. This discussion draws on Terence H. Hull, "Fertility Decline in Indone- Late 1980s 22 sia: An Institutionalist Interpretation,"Research Note No. 72, International Population Dynamics Program, Department of Demography, Australian Na- tional University, May 1987; Nathan Keyfitsz, "An East Javanese Village in 1953 and 1985: Observations on Development,"Population and Development Such estimates depend heavily on the concepts used to Review, Vol.11, No.4, December 1985, pp. 695-719; and interviews with Indo- define poverty and are affected by the relatively poor data nesian social scientists. base. However, it is likely that the basic trend is correct. 21. Ansley J. Coale, "The Demographic Transition Reconsidered,"Interna- tional Union for the Scientific Study of Population, International Population Conference, Liege, 1973, Vol. 1, pp. 53-72; John C. Caldwell, "Toward a Restate- ment of Demographic Transition Theory,"Population and Development Review, Vol.2, Nos. 3-4, September-December 1976, pp. 321-366. 19. Verbal report from scholars at Gadja Mada University. 22. In IFS and NICPS. 138 ANNEX 2 volved relatively high use rates for those with a high stan- conventional wisdom has been that the very poor in LDCs dard of living, high ownership of consumer durables, high want to have a large number of children because for them, household income, and high occupational status. This sug- even young children are a net economic asset, apart from gests that the general social and economic trends previous- the security they offer in old age. However, a contrary argu- ly discussed were sufficiently favorable to a reduced ment is that there are situations in which the resources per demand for children and an increased use of contraception capita are so low that having additional children is not ratio- so that they should have facilitated the work of the family nal from the point of view of the individuals involved. It is planning program. possible that in rural Indonesia, where there often was ex- However, a simple explanation in terms of moderniza- treme pressure of population on very limited land, the fam- tion trends and higher living standards is not sufficient for ily planning program may have helped large numbers of Indonesia, because contraceptive use was also relatively couples to define their desperate situation as being a result high among the very poor, among those with low living of having too many children. Large numbers of poor villag- standards and low household income, and among those in ers, while ambivalent about such a definition, might under farming. For example, consider the following 1976 data for their circumstances be led to adopt it by the pressure of au- a standard of living index which includes components for thority figures in the local community. housing, lighting, water supply, and ownership of modern It seems very unlikely that the most disadvantaged cou- consumer durables:23 ples would have adopted contraception so quickly and in such large numbers without the influence of the family Standard of living index Percent Using Modern Contraception planning program. For them, the role of the program was Unadjusted Adjusted' probably particularly important in the early part of the 1970s, before the substantial effect of the social and eco- Very low 38 39 nomic changes could have their significant effects later in Low 31 35 the decade. Medium 31 36 Medium-high 30 37 It does not detract from the appreciation of the achieve- High 42 55 ments of the family planning program to take into account the changing social setting in which it operated. For those aAdjusted for effects of region, number of living children, wife's age, wife's h e better off, mernizain may exain thoti education, and husband's occupation. who were better off, modernization may explain the moti- vation to accept program services. In the case of the disad- This is illustrative of a curvilinear relationship for a num- vantaged-the mass of the Indonesian population-the ber of economic variables with relatively high rates for the program probably had to work much harder to crystallize most disadvantaged and the most advantaged groups. The latent demand. relatively high rate of use for the very poor with the lowest Apart from its effect on the motivation of potential ac- standard of living is remarkable. These were couples in ceptors, social change produced an infrastructure which fa- housing made of the poorest materials, without electricity, cilitated the work of the family planning program. For with water available only from a river or public well, and example, improvements in transportation and communica- tions strengthened the program's capacity to interact with without any of the 13 moder consumer durables entering its staff, both face to face and through the exchange of mes- the index. sages, to transmit IEC messages to the public, and to man- It has been suggested24 that two different processes pro- age an efficit pl le. ducethee pttens o cotraeptve se. he onvntinal age an efficient supply line. duce these patterns of contraceptive use. The conventional Lapham and Mauldin25 have shown that the strength of modernization effects of better education, higher occupa- family planning program effort depends on a country's tional status, and higher living standards produce the rising development level. Sixteen of 17 countries ranked low on levels of use as expected among those who are better off. At social setting (as of 1970) were ranked "weak"or "very the same time, a Malthusian principle is at work for the very weak or none"on program effort (as of 1982). Fifteen of 18 poor. The hypothesis is that those who live in the most dire ranked "low-middle"on social setting were "weak"or poverty adopt contraception when they are linked to the "very weak or none"on program effort. Indonesia's social outside world with higher living standards and are present- and economic development improved its capacity to mount ed with the idea and means for family limitation by a legit- an effective population program, but its program effort imate organization that reaches the village level. The ranked higher than that of other countries with similar de- velopment levels. 23. Ronald Freedman, Siew-Ean Khoo, and Bondan Supraptilah, "Modem Contraceptive Use in Indonesia: A Challenge to Conventional Wisdom," 25. Robert J. Lapham and W. Parker Mauldin, "Contraceptive Prevalence: World Fertility Survey, Scientific Reports, No. 20, March 1981. The Influence of Organized Family Planning Programs,"Studies in Family 24. ibid. Planning, Vol 16, No. 2, May/June 1985, Table 4. 139 ANNEX 2 4. The Role of the National Family Planning Program The Indonesian family planning program (BKKBN) has sources were more common, 78 percent still reported such been immediately responsible for the rise in contraceptive program-based sources in 1987. prevalence and, therefore, for much of the fertility decline, The number and variety of service points has expanded at least in the sense that contraceptive information and sup- rapidly. During its first phase (1970-73), a clinic-based fam- plies have come to the increasing millions of users through ily planning program worked through the Ministry of its network of services. BKKBN clearly deserves credit for Health's maternal and child health program. In this initial what happened on the supply side. To what extent it is also period, 2,200 clinics were built and 6,600 field workers were responsible for creation of demand-the motivation for recruited. In subsequent stages, the outreach of the pro- contraception-is a more difficult question, to be discussed gram was greatly expanded to provide community-based later. service points, first in Java-Bali and then in successive phas- Prior to the inception of the BKKBN in 1970, there was es to the outer islands. By 1988, there were 63,000 village little use or knowledge about modern contraception. Up to and more than 190,000 sub-village posts (VCDC) which are 1967, the subject was taboo in the mass media and not men- operated by village family planning volunteers organized tioned by public officials. In a 1968 KAP survey in Jakarta, and supervised by family planning workers. This means three-quarters of the respondents claimed not to know of that there are VCDC posts in virtually every village and in any method of fertility regulation.26 There was then a pro- a large number of hamlets in addition-a remarkable out- found change, as family planning became an important is- reach network. In addition, as of 1988, there were about sue for the New Order Government, with strong leadership 225,000 Posyandus scheduled to serve children under five by President Suharto. By 1976, three-quarters of the mar- in villages once a month, through a mobile team which ried women under 50 surveyed in Jakarta said that they brings not only clinical family planning services, but also had heard of at least one modern method, and the percent- MCH services-immunization, nutrition, and oral rehydra- age was similar for Java-Bali as a whole. By 1987, 94 percent tion therapy It should not be surprising that all these sup- indicated knowledge of at least one modem method. plementary services are not always available every month. The rapid rise in the use of modern contraceptives from It was estimated in 1990 that about 85 percent of the Po- very low levels to 26 percent (in Java-Bali) by 1976 and 51 syandus were in place and that they were covering 50 per- percent by 1987 (48 percent for all of Indonesia) occurred cent of the targeted children.27 through the rapidly expanding information and service An important additional instrument of the program is network coordinated by the BKKBN. The source of contra- the acceptor groups that are intended to reinforce efforts to ceptive services in 1987 was still overwhelmingly (87 per- recruit users and maintain practice. An estimated 240,000 cent) reported as facilities organized and coordinated by such groups in 1986 may have included three to six million the BKKBN: family planning clinics, hospitals, health cen- individuals. ters, and various other public services at the village and BKKBN is a coordinating agency, not a line ministry. It hamlet level. Even in urban areas, where private sector works to a substantial degree by organizing information and supply services through the Ministry of Health and 26. Haryono Suyono, The Adoption of Innovation in a Developing Country. The Case of Family Planning in Indonesia, (Chicago: University of Chicago, Community and Family Study Center, 1974). 27. Estimates by UNICEF personnel in February 1990 interview. 140 ANNEX 2 through the Home Ministry's civil administration at the "The government's strategy in recruiting implement- provincial, district, subdistrict, and village levels. It also in- ers has been to work downward in the administrative volves such other ministries as Education, Religion, De- hierarchy and then outward. Senior officials began by fense, and Information. Because it is not a line ministry, putting pressure for results on those below them, who BKKBN has had the flexibility needed for its bold policy of did the same with their subordinates. Officials at each decentralization and for varying the program to meet the level then worked outward to involve others, starting circumstances of different provinces. It has been able to use with their wives and close acquaintances. Since in innovative approaches crossing bureaucratic boundaries. most cases clients are recruited in their village of resi- While the BKKBN is primarily a coordinating agency, it dence, the activities of village heads were particularly also has important direct implementation capacities, for ex- important... Sometimes these potential program im- ample, by using its field workers to organize local volun- plementers co-operated with little urging, but in other teer groups, through its considerable IEC activities, its cases regional government leaders spoke of ordering massive training activities, and in the important area of or obliging subordinates... contraceptive supply. "The core strategy for recruiting clients has been a In its coordinating activity, the BKKBN staff works very combination of individual persuasion and community closely with the government officials at every level, as well influence. Our village studies suggest the following as with relevant officials from other ministries. characterization of the style of field operations in the Free-standing, coordinating agencies such as the BKKBN Indonesian family planning program in the 1970s and have failed in a number of other countries because they did early 1980.. .If an intended program client.. .was unre- not have the power or skill to win the cooperation of line sponsive to persuasion or accepted but later dropped agencies. The success of the BKKBN in mobilizing action, out of the program, the village head, other administra- despite the rigidity and sometimes the opposition of line tors, their wives, or members of acceptors' groups agencies, is due in no small part to the high level of political were likely to stop by to talk about family planning. commitment of President Suharto to the family planning Local religious leaders may have argued.. .that fertili- program. This is evident not only in his frequent public ty control was not only not against religion, but.. .was statements, but also in strong financial support from the a religious obligation. The greater the number of local central Government. Success in meeting family planning program implementers, the greater were the opportu- targets is one important way in which officials at every ad- nities for them to exert an influence on unresponsive ministrative level have their work appraised. Failure to members of the community. And the larger the num- achieve targets at one level is quickly followed by an inqui- ber of acceptors, the smaller was the room of move- ry from a higher level and by steps to correct the situation. ment for holdout. Particularly strong influence could A major source of strength of the BKKBN has been the be exerted on poorer members of the community, unusual continuity of its able leadership. The charismatic who, moreover, were highly susceptible to influence chairman and his principal deputies have led the program from motivators." for more than 15 years. Such unusual continuity might Such a comprehensive community-based program is the have had a stultifying effect, but the program continues to goal of many other developing countries and even exists on be innovative. Further, there is a consensus among observ- paper in many places where the reality on the ground is dif- ers that the leadership has been politically adept in the dif- ferent from program rhetoric. However, successful imple- ficult task of working through line agencies jealous of their mentation of such a program is rare. China may be the only authority and prerogatives. The BKKBN has also been skill- other country to be as successful as Indonesia in such a ful in getting strong financial support and technical assis- strategy. tance from international donor agencies. Donors have been Given the ethnic and socioeconomic diversity of Indone- happy to share the credit that comes from supporting a suc- sia and the thousands of villages and sub-villages of vary- cessful program. ing size and population to be covered, it should not be The BKKBN has mobilized local governments and local surprising that the degree of implementation varies consid- groups on an awesome scale to bring informal community erably. Warwick29 has done an important study of how the pressure on couples to practice contraception. It has also variation in program inputs at the village level is related to made contraceptive supplies so universally available at the local level that supply is not the major issue for the decision 28. Donald P. Warwick, "The Indonesian Family Planning Program: Gov- to use or not to use them typical in many other developing emient Influence and Client Choice,"Population and Development Review, countries. Vol. 12, No. 3, September 1986, pp. 470-471. Key aspects of the operation are summarized by War- 29. Donald P. Warwick, "The Indonesian Family Planning Program: Gov- ernment Influence and Client Choice," Population and Development Review, wick28 on the basis of study of a good sample of villages: Vol. 12, No. 3, September 1986, p. 477. 141 ANNEX 2 contraceptive prevalence rates. He summarizes his findings reorganizations of the BKKBN, which troubled Bank staff, as follows: who preferred a more stable organization. The BKKBN has been unusually successful in working "...the best quantitative predictors of success in the .h KB a enuuull ucsfli okn the bestaqntitprogavereitorsesces n acth- with Muslim religious leaders, in contrast to programs in family planning program were the presence and activ most other Muslim countries. This has been facilitated by ity level of implementers, acceptors' groups, and anIdesntriioofwkngutpblmthuh trained birth attendants and lateral integration without problems through tern brthr andant anlalitermdal era . wfrequent conferences and discussions in which confronta- other programs and availability of medical backup. tinsavdeadacom ainadcnesuar tion is avoided and accommodation and consensus are These data strongly support the strategy of the Indo- stressed. Muslim leaders were asked for advice and co-opt- nesian family planning program, which puts heavy ed to a common enterprise. The effectiveness of this ap- emphasis on persuading clients and supplying servic- proach is evident in the relatively high acceptance rates in es with proper medical backup." areas of Java known to be more orthodox in their Muslim The fact that such program inputs are strongly related to identification. It is also relevant that Muslim fundamental- the desired program outcome in a study independently col- ism is not strong in some parts of Indonesia. lecting data at the village level is good evidence that the A comparative view of the standing of the Indonesian program does make a substantial difference. Negating this family planning program can be derived from the Mauldin- proposition would require evidence that program inputs Lapham rankings30 for 1982 of the strength of family plan- are placed where demand is greatest, which might have led ning program effort for 100 developing countries. Indone- to higher contraceptive prevalence rates there even without sia ranked fifth among 100 countries. It ranked first for the the program. There is undoubtedly some bias in the place- service and service-related activities,"fourth with respect ment of medical facilities, because these follow the pro- to "policy and stage setting,"and third with respect to gram of the health department and are not controlled by "record-keeping and evaluation."Its overall ranking would BKKBN. A recent Bank study has indicated that the place- have been higher were it not for its ranking of 24th on ment of such health facilities affects the availability of such "availability and accessibility"of different fertility control effective, more permanent methods as the IUD, steriliza- services, resulting from the fact that safe sterilization and tion, and implants. This affects the mix of available contra- abortion services were not easily available. Indonesia was ceptives which, in turn, affects the prevalence rate. also one of only nine countries (among the 88 rated) whose The scale of the management, personnel, and logistical overall program effort score increased by at least 25 percent problems on such a large and growing program, operating between 1972 and 1982.31 Indonesia was the only country in so many diverse places, and dealing with sensitive is- classified as having "strong"program effort (as of 1982) sues, is impressive. An essential element is the steady and among the 18 countries ranked as "low-middle"on the de- appropriate flow of contraceptive supplies to service velopment level of its social setting (as of 1970). This sug- points, varying in their contraceptive mix. Further, tens of gests that Indonesia's program success exceeded thousands of workers of different types had to be selected expectations on the basis of its development level. Howev- and trained. During the Third Five-Year Plan alone, 323,000 er, the considerable social and economic change since 1970 people were trained for over 100 categories of work. In might have reduced this discrepancy. 1990, BKKBN had a staff of 42,000: about 1,000 at national BKKBN's performance was very favorably assessed as a headquarters, 25,000 field workers and supervisors, and model for other agencies in an internal Bank report on In- 16,000 at provincial and district offices. A sophisticated donesia's management development done in the mid- communication and management information system had 1980s. to be developed to send and receive messages to and from As a further indication of reputation among external ob- the thousands of service training, supply, and other facili- servers, the family planning program was cited as a "suc- ties. Large numbers of buildings had to be planned, built, cess,"exemplifying a high quality of strategic management, and maintained for clinics, supply depots, training schools, and BKKBN offices at various administrative levels. The evolution of the program from an initial clinic basis to outreach by field workers, and then a radical expansion through use of village volunteers, followed small-scale ex- 30. W. Parker Mauldin and Robert J. Lapham, "The Measurement of Fam- perimental trials of the new approaches. Since the small- ily Planning Inputs,"in Robert J. Lapham and George B. Simmons, eds., Or- scale trials were supervised by the program managers, their ganizing for Effective Family Planning Programs, (Washington, D.C.: National replication on a large scale did not face the problems asso- Academy Press, 1987), pp. 545-582. 31. W. Parker Mauldin and Robert J. Lapham, "Conditions of Fertility De- ciated with pilot projects external to the system. These ma- cline in LDCs: 1965-1980,"Paper prepared for Annual Meeting of the Popu- jor changes in the scale of activity were associated with lation Association of America, Minneapolis, May 1984. 142 ANNEX 2 in the highly regarded book by Samuel Paul32 on the man- 15-20 absolute percentage points resulted in gross overesti- agement of development programs. mates of resources needed for maintenance and gross un- The success of the BKKBN in designing and managing derestimates of new users required to reach targeted levels. the complex and changing program is impressive both in The illusion that abnormally large reported prevalence in- absolute terms and in comparison with other countries. creases were real created a temporary euphoria that was However, a proper perspective also requires consideration misleading about what was possible in a short time period. of the limitations and problems of the program as well as Independent measurement of contraceptive use in good so- the achievements. cial surveys is more reliable for national and provincial es- First, the achievement of about a 50 percent contracep- timates, but it does not provide estimates needed for tive prevalence rate in about 20 years is notable, but did not assessing and modifying performance in local areas. The go as far or as rapidly as the rise in Thailand, China, Korea, accuracy of the program's system of local estimates is a con- and Taiwan, China. To be sure, those countries had some fa- tinuing problem. Changes made since a Bank internal re- cilitating cultural and socioeconomic factors not found in view of these problems in the mid-1980s are still producing Indonesia. The comparison underscores the fact that the prevalence rates acknowledged to be too high by the BKK- achievement of family planning programs is not simply de- BN official in charge of the system in February 1989. termined by their vigor, resources, and intelligent manage- Fourth, some critics of the Indonesian family planning ment. It is also affected by the social, economic, and cultural program allege that acceptance of family-planning services circumstances of the country. Unfortunately in Indonesia, sometimes results from strong social and administrative very large population increases going well into the next pressures that are morally coercive. It is probable that there century are almost inevitable, unless the already significant were such pressures in East Java in the 1970s. Acceptances pace of progress in family planning is accelerated. in "special"high-pressure drives near the end of the pro- Second, in the drive to meet quantitative targets in a rel- gram's fiscal year were shown to have lower continuation atively short time period, less-than-optimal attention has use rates than those in the normal program.35 This suggests been given to the quality of services, as indicated by the lev- that special drive acceptances involved a lower level of vol- el of understanding by acceptors of the methods offered untary commitment. Something of the same character may and accepted and by the availability of adequate medical have been involved more recently in "safari"drives, in backup for the problems of acceptors. A number of pro- which thousands were brought together for carnival lia gram observers have called for higher-quality services, events, including recruitment for family planning. The con- even at the cost of a possibly slower pace.33 These are prob- sequences of social pressure in the program are much less lems of which the BKKBN is aware. The Chairman of the in Indonesia than in India or China, because abortion and BKKBN indicated in 1986 that the program must do more sterilization are not part of the program. The line between to provide "... accurate, true, and honest information education and information, on the one hand, and occasion- [about contraception] without intimidation and false ex- ally heavy-handed persuasion by local groups and author- pectations."34 ities, on the other, is sometimes hard to draw. There has Third, the Indonesian program, like others which have a been a tension between social pressure to meet targets and strong target-achievement orientation, faces the problem of encouragement of genuinely voluntary, community-based over-reporting of performance by local service points. The support for the program.36 Insofar as the program depends information system, which produced credible estimates of on external influence rather than personal choice, it does prevalence until at least 1976, subsequently greatly exag- not bode well for recent program initiatives for major shifts gerated. the rise of prevalence rates, especially between of program services to the private sector. It is also problem- 1982-83 and 1985-86. Exaggeration of prevalence rates by atic for intentions to scale down promotion of community socialization for family planning, on the assumption that self-motivation is enough because "small-family"values 32. Samuel Paul, Managing Development Programs: The Lessons of Success, have already been internalized. The BKKBN leadership has (Boulder, Colorado: Westview Press, 1982). expressed concern as to whether contraceptive prevalence 33. T. H. Hull and V. J. Hull, "Health Care and Birth Control in Indonesia: Links through Time,"paper presented at the Annual Meeting of the Popula- tion Association of America, San Francisco, 1986, mimeo, p. 15; cited in Don- ald P. Warwick, "The Indonesian Family Planning Program: Government Influence and Client Choice,"Population and Development Review, Vol. 12, No. 35. J. Sullivan, H. Suyono, W. Bahrawi, A. Hartoadi, "Contracepcive Use- 3, September 1986. Effectiveness in Mojokerto Regency, Indonesia: A Comparison of Regular 34. H. Suyono, "Success, Challenge and Future Prospect of National Fam- Program and Special Drive Acceptors,"Studies in Family Planning, Vol. 7, No. ily Planning Program in Indonesia,"National Family Planning Coordinating 7, July 1976, pp. 188-196. Board, 1986, mimeo, p. 7; cited in Donald P. Warwick, "The Indonesian Fam- 36. T. H. Hull and V J. Hull, "Health Care and Birth Control in Indonesia: ily Planning Program: Government Influence and Client Choice,"Population Links through Time,"paper presented at the Annual Meeting of the Popula- and Development Review, Vol. 12, No. 3, September 1986. tion Association of America, San Francisco, 1986. 143 ANNEX 2 rates would continue to rise if the government relaxed ef- crystallize latent demand for smaller numbers of children forts to mobilize community influence for acceptance. created by other social changes. However, the extent to Fifth, representatives of all the major donors believe the which it independently, substantially changed values about BKKBN is currently administratively top-heavy.37 While family size is an open question. It is likely that the overall insisting that administrative and technical staff at provin- increase in effective demand was a synergistic joint effect of cial and district headquarters are essential, BKKBN leader- the broad social changes and the strong family planning ship has been moving to reduce higher-level administrative program. Given what is at stake and the independent value staff levels. of both development and the service aspects of the pro- Despite these problems, there is no doubt that the family gram, it is prudent to consider both as essential parts of the planning program was successful on the supply side. On Indonesian population policy. the demand side, whether the program has persuaded The program very probably led to more rapid adoption many couples to want fewer children is more difficult to as- of contraception by those who wanted no more children. It sess. The program certainly conveyed such a message to probably also led many ambivalent couples to decide they millions through its community-based information and ed- wanted no more children. What is less certain is whether it ucation system. That message could have reinforced the ef- converted many who definitely wanted more children to fects of the social and economic forces which were working decide to have no more. in this direction. The role of the program was probably par- Assessing whether population programs reduce fertility ticularly important in the early 1970s, especially for poor, requires cross-national analyses. There is support for the rural couples, before the substantial effects of the social and proposition that they do in such studies.39 For Indonesia economic changes came into play later in the decade. specifically, it is possible to say in summary that it is very However, no one has yet developed a methodology for probable that the program contributed substantially to the disentangling the changes in the desired number of chil- fertility decline, because: dren which are induced by social change, and those which * fertility fell mainly because of the increased use of con- arise from the direct communication of such ideas by an or- ganized program or in other ways. That such ideas have an traception, and the pgram is responsible for most of autonomous force and are not simply a reflexive result of soc-al change is part of the "ideational hypothesis."3 It is * Indonesia's family planning effort and contraceptive socil cang ispar ofthe"idetioal ypohess."8 I isprevalence were both higher than expected on the basis very plausible that the strong social pressure of the pro- ofethescioeoi iicatr an e n gram and its extensive IEC and service programs helped to o h oieooi niaosaoe n * it is unlikely that, without the program, the unexpected considerable adoption of family planning by poor, uneducated, and rural couples would have occurred so 37. As of January 1990, BKKBN had 42,180 employees: 25,026 were field workers and supervisors; 980 were adiministrative and other support staff at rapidly. national headquarters; and 16,174 were administrative and support staff at 27 provincial and 301 regency/ municipal offices. 38. John Cleland and Christopher Wilson, "Demand Theories of the Fertil- 39. Robert J. Lapham and W. Parker Maulding, "Family Planning Program ity Transition: An Iconoclastic view,"Population Studies, Vol. 41, No. 1, March Effort and Birthrate Decline in Developing Countries,"International Family 1987, pp. 5-30. Planning Perspectives, Vol. 10, No. 4, December 1984, pp. 109-118. 144 ANNEX2 5 , The Bank's Contribution to the Indonesian Program's Success Overview and Background The Bank's distinctive characteristics affected its role in population in Indonesia, as in many other countries: The World Bank plausibly can be credited with contrib- 1. The Bank-uniquely-was involved in the broad range uting to the success of the Indonesian family planning pro- of development activities which affect population gram. A continuing series of Bank loans have supported trends, although these were not designed for that both specific family planning projects and Indonesia's gen- purpose. eral development program from the beginning of the New 2. Because it made very large loans for all major aspects of Order Government. Three Bank projects have been com- development, it had access to the highest levels of lead- pleted, a fourth is almost completed,4o and the negotiations ership in the Government. are underway for the fifth. The loans for the first four 3. Its sector analysis and research had an excellent reputa- projects totalled US$122.4 million.41 The population sector tion, so it was potentially influential. loans have financed important specific aspects of the pro- 4. It was able to finance large projects, and the Bank's sys- gram. Especially after the first project, the major emphasis tem of accounting for time and overhead appears to fa- was on buildings, equipment, and vehicles, but there was vor larger rather than smaller loans. also more limited input into such software components as 5. The Bank's operational style in population in Indonesia training programs, population education, research and involved: evaluation, and field staff. More diffuse is the Bank's influ- * Loans for five-year periods, corresponding more or ence through policy dialogue with top Indonesian leaders less to the Indonesian plan periods (Repelita) and and the reported influence in the development of the pro- specifying projects and budgets for the whole gram's management structure. period. More indirect, but possibly as important as the Bank's * Project development, supervision, and review by specific work in the population sector, has been the Bank's staff members based in Washington who made re- large-scale support (almost US$15 billion) for Indonesia's current trips to Indonesia. Unlike other donors, the development efforts in education, health, transportation Bank did not have resident field representatives for and communications, electrification, agriculture, and other population for most of the period covered. support for the economy. Development in these other sec- 6. The fact that the Bank made loans rather than grants tors has been changing Indonesian society in ways which probably helps to account for its emphasis on hardware probably affect the population's interest in smaller families (buildings, equipment, and vehicles) rather than soft- and family planning. ware (training, service, IEC, etc.). Third World borrow- ers generally prefer grant rather than loan funds to support software activities. Software grants are avail- 40. Information about the four Bank projects as reported by the Bank was able from other donors less prepared to fund capital drawn from the four appraisal reports, project completion reports for the three completed projects, and audit reports for the first two projects. hardware projects. 41. Includes actual disbursement for the first three projects and the amount of the loan for the fourth. 145 ANNEX 2 These distinctive characteristics of the Bank both facili- leadership, who favored an aggressive population policy tated and limited what it could accomplish in various as- throughout this period. However, the Bank's support prob- pects of its work. ably helped to legitimate the BKKBN's strong policy within Indonesia, where there has always been some ideological The Bank and Policy Dialogue and bureaucratic opposition. The Bank has had much less influence over the last 20 Compared with other donors, the Bank potentially has years, as compared with USAID, with respect to more spe- an important advantage in policy dialogue about popula- cific operational policies through which the broad policies tion because Bank officials and staff are frequently negoti- are implemented. The first project (joint between IDA and ating with such key government officials as ministers of UNFPA) involved more software and less hardware (53 finance, planning officials, and even with presidents or percent) than later projects and influenced the early course rime ministers. This results partly from the fact that the of the program. However, during most of the 1970s, when Bank makes loans rather than grants, but mainly because the basic Indonesian program was further developed, US- its loan portfolio is so large. While countries naturally pre- AID had continuously resident in the country three officers fer grants rather than loans, especially for the social sectors, who spoke Indonesian, were in almost daily contact with this is offset, at least in part, by their interest in large loans their Indonesian counterparts, were often in the field, and in the economic sectors. helped the BKKBN to develop its changing operational Nevertheless, this potential comparative advantage of program. The USAID team worked closely with the BKK- the Bank has not been realized in many countries where BN in developing the important shift from clinic-based to there is disinterest in or opposition to population policy. village-based contraceptive supply, information, and moti- Several reviews of the Bank's work in population have re- vation in 1975-76.42 The USAID mission had flexible funds ported that Bank economists in such countries are reluctant which could be committed on short notice without refer- to advocate or even discuss this issue. ence to Washington. In 1976, the BKKBN director for a ma- In Indonesia, however, the Bank officials have worked jor province with a successful program told an interviewer with leaders who saw population issues as important for for the Berelson Committee that the Bank could not give development policy from the early days of the New Order. him the kind of flexible and timely support for new initia- After the announcement of a national family planning pol- tives that he got from USAID staff who knew his province icy in 1968 and even before the creation of the BKKBN in well. 1970, the Bank had a series of missions and officers discuss- By contrast, for most of the period since the first Bank ing family planning in the context of health with the Indo- population loan, there was no resident Bank field represen- nesians and with other donors. A joint initial mission with tative for population. There were such residents for two WHO and UNFPA occurred in November 1969. In May limited periods, but neither spoke Indonesian and neither 1970, President Suharto, already a warm advocate of family had supporting technical staff. Almost all of the Bank's planning, had further discussion with Robert McNamara, work in population was done by staff based in Washington President of the Bank, about a mission to develop a project who came to Indonesia for visits of 2-4 weeks a few times a with support from the Bank and other donors. In the course year, supplemented by occasional missions for planning of seven Bank missions between 1969 and 1971, the first new loans, reviewing loan completion, and other special project, eventually a joint one with UNFPA, was formulat- purposes. ed. Several Bank officials successfully encouraged a sub- Half a dozen international and bilateral donor represen- stantial expansion of the scale and geographical coverage tatives in Indonesia, interviewed in 1976 and 1978, were of the family planning program. Also, the Bank staff collab- unanimous in the view that the Bank's influence on the na- orated closely with government officials in selecting, bud- geting, and coordinating specific project components for 42. T. Reese, a USAID population officer, and Dr. Haryono Suyono, long- the First Project. Dr. Widjojo Nitisastro, an economist and time Chairman of the BKKBN, were co-authors of reports on this important leader of BAPPENAS and Coordinating Minister for Eco- phenomenon. The reports acknowledge the role in preparation of the reports nomic, Financial, and Industrial Affairs, at that time had a of the field notes of another USAID officer. This kind of immediate participa- tion in program policy development is inconsistent with the Bank's operat- strong interest in this issue. He was an important figure in ing style. It can well be argued that the Bank should not be so involved, but, these developments. absent such participation, the Bank is less likely to play an important, inno- The Bank, indeed, has had frequent interaction with key vative role in the development of program policy. The relevant reports are: H. Suyon, S. H. Pandi, I. B. Astawa, Moeljono, and T. Reese, "Village Family Indonesian officials, a by-product of the almost US$ 15 bil- Planning-The Indonesia Model, Institutionalizing Contraceptive Practi- lion in financing of 221 loans to Indonesia from 1968 ce,"National Family Planning Coordinating Board, Technical Report Series, through 1989. Such special leverage probably was not re- Monograph No. 13, Jakarta, July 1976; and H. Suyono and T. Reese, "Inte- grating Village Family Planning and Primary Health Services-The Indone- quired to discuss population issues with the Indonesian sian Perspective,"Jakarta: BKKBN, 1976. 146 ANNEX 2 ture of the program was limited by its failure to have a res- periods. Traveling Bank missions from Washington, how- ident staff with some authority to change projects. While ever qualified, could not have the knowledge of Indonesia the BKKBN staff, interviewed at that time, were naturally or the relations with BKKBN staff necessary for coopera- restrained in any criticism, the project completion report for tively developing and testing ideas in a very dynamic pro- the second population loan indicates that the BKKBN had gram. USAID, for example, in addition to a resident staff of suggested that Bank projects would go more smoothly if three population officers, has had many resident expatriate there were such representation. and Indonesian consultants working day-to-day with the When this issue was raised with the director of the BKKBN in operations research and in other ways. The Bank Bank's Indonesia office by a Berelson Committee member has done this only in a very limited way. in the rnid-1970s, he indicated that the kind of detailed The Bank has been less flexible than other donors, partly work done by USAID's mission staff was technical assis- because its typically infrastructure components did not re- tance which was not appropriate for the Bank. He indicated quire the flexibility needed for software components. Its that, if such assistance were needed, it should be provided projects, designed for five-year periods, have taken two by creating a special agency for this purpose as part of a years or more to develop. Once developed, the project com- loan project. ponents have been difficult to change, largely because such While part of the explanation for the Bank's emphasis on decisions were referred to Washington. In addition, be- hardware is the fact that they worked through loans rather cause the projects were financed as loans rather than grants, than grants and their extensive experience with hardware, time-consuming approvals were required from the Indone- it was also a result of the BKKBN perception that the Bank's sian government. By contrast, USAID reviewed and re- operating style did not permit the year-to-year flexibility vised its program annually and had the capacity to desirable for many software activities. authorize new expenditures locally on short notice. An In- Since a good case can be made for a division of labor donesian official who has observed the whole human re- among donor agencies, it can be argued that little would source field for many years said in an interview, "We say have been gained if the Bank had replicated USAID's resi- that, if you want to develop ideas for a new social institu- dent staff and done more on programmatic software. How- tion, don't go to the Bank." ever, this means accepting the fact that, without a resident The net result was that the Bank has been perceived by staff the Bank had much less influence on program deci- the Indonesians and other donors primarily as well-quali- sions than it might have had. Since the important macro- fied to provide essential hardware infrastructure and to level political decisions about population policy were made support the large-scale extension of ideas first tested and relatively early, it is the policy decisions at the changing developed by others. The Bank is not perceived as having program level which determined its course for most of the provided intellectual leadership. Bank staff have not period under review. played an important role in helping the BKKBN to develop the major ideas guiding the program since the first project. Support for the Family Planning Program Such a view of the Bank's role in population is in sharp con- trast to its acknowledged important intellectual leadership Most of the Bank's effort in population has been in direct role in Indonesia's general development program and in support of the family planning program. macro-economic policy for Indonesia. The Bank has popu- With respect to specific project components, the distinc- lation staff capable of exercising such leadership, but, at tive characteristics of the Bank's population work in Indo- least in Indonesia, the implicit or explicit choice was to let nesia has resulted in a de facto division of labor with such other donors who had competent resident staff lead the other donors as USAID, UNFPA, and UNICEF. This has de- way in policy for software operations. termined the balance among the specific components of the While these perceptions about the Bank's role in popula- Bank's projects. The Bank has specialized in providing tion appear to be generally correct, the Bank deserves credit hardware: infrastructure, buildings and their furnishings, for its support - in a more limited way - of such specific equipment, and vehicles. New ideas for the program gener- program components as training, population education, ally were developed and tested by BKKBN in collaboration and IEC activities. with other donors who concentrated on the software of pro- It is not possible to assess in any precise way the effect of gram design and implementation. The Bank sometimes the Bank's loans and activities in the population field on the provided the resources for large-scale extension of already- rise of contraceptive prevalence and the decline of fertility, tested program initiatives, but did not lead in software which are the ultimate marks of program success, because components. the program is large and complex. It involves multiple In- Unlike the other major donors, the Bank has not had a donesian agencies. There are multiple donors with overlap- significant resident staff for population, except for limited ping agendas and activities. The program is dynamic, 147 ANNEX 2 changing in many respects over the years. Such change and capitals. This was supplemented by a network of important flexibility have contributed to its success. For this changing, training facilities. An extensive building program during complex situation, it is not feasible (especially after the fact) the third project provided infrastructure for decentraliza- to establish direct links, for example, between the Bank's tion of program management. loans for building training schools and contraceptive prev- While there were delays and shortfalls on quality, the alence. building programs were reasonably well executed. An In- Nevertheless, the Bank can reasonably be credited with a donesian official with extensive experience with building significant role in BKKBN's success insofar as: programs indicated recently that Bank standards and pro- It is plausible that these elements have contributed to cedures resulted in buildings substantially better than oth- program success in changing reproductive behavior and er government buildings, especially outside of Jakarta. norms. Buildings are in use and in general, funds are available Unfortunately, the evidence that can be cited from sys- for their maintenance. Buildings have been used for signif- tematic evaluation of specific project components is rather icant program purposes: training that appears to be impor- thin. Project completion reports rarely provide evidence of tant for the program went on in the training centers built; systematic evaluation in terms of the component's continu- the program has been administered from BKKBN offices in ing operation and impact. Most of the evidence provided 27 provinces and 301 district population and family plan- has to do with pro forma completion of project components ning centers; warehouses have been used for storage of during the project period. Evaluation, according to prede- contraceptives and supplies; inpatient annexes to health termined criteria, was called for in various audits and centers were being utilized. project reports. However, this was not done systematically It is plausible that having buildings, furniture, and over the years. equipment to carry on such activities helped the program. Beyond that, BKKBN officials believe that the buildings Assessing Specific Components of have had an important value in symbolizing the impor- the Bank's Projects tance the Government and important international agen- cies attach to family planning/MCH goals. Hardware Vehicles In terms of civil works, furniture, equipment, and vehi- cles account for about two-thirds of the expenditure of This major component of all the projects provided the Bank loans in the first four projects.43 Even during the first mobility essential for field services, supplies, training, IEC project, when there was more emphasis than later on soft- work, and administration. It facilitated reaching the popu- ware and program operations, 53 percent of the credit went lation at the grass roots, especially in less accessible and less for buildings, vehicles, and equipment. Part of the explana- densely-settled areas. There is some evidence of higher ac- tion for the Bank's emphasis on hardware was that the In- ceptance rates associated with mobile clinic services and donesians (like other borrowers) preferred grants rather with increasing the mobility of field workers by providing than loans for software components. Loans were more ac- them with motorcycles. ceptable for capital costs and other hardware. These are types of assistance with which the Bank has long experi- Training ence in many sectors and countries. A number of Bank au- dits and reviews indicate that these were relatively easy for Training of large numbers of family planning officials the Bank as compared with software elements. Further, and various kinds of workers at various levels presumably hardware project components can absorb relatively large contributed to the effectiveness of BKKBN's thousands of investments which fit nicely with established Bank proce- workers at every level. Sixteen training centers were built dures. Approximately 40 percent of all expenditures during in Java-Bali during the first project period with Bank sup- the four population projects was for buildings and 26 per- port, and were provided with vehicles and other equip- cent was for equipment, furniture, and vehicles. The build- ment. In these centers, a yearly average of 8,100 officials ings provided the physical base for the program as it were trained in 1970-76, 10,000 in 1976-79, and 15,000 expanded throughout the islands. The Bank provided during 1978-83. Under the second project, 10 provincial headquarters and supply warehouses not only in Jakarta training centers were built in the Outer Islands-I area. and the 27 provincial capitals, but also in the 301 district These trained over 42,000 participants between 1979 and 1986-a shortfall from the 75,000 targeted in the project 43. Actual expenditures for projects one through three, plus appraisal es- esign. Under the Third Project, additional training centers timates for project four. were built in the Outer Islands-II area, and there was sup- 148 ANNEX 2 port for a wide range of training activities throughout the to create population centers at 10 or more provincial uni- country. The reported numbers trained included: versities exceeds the supply of trained and capable leaders. The new BKKBN research centers supported by the Teachers in population education 24,020 Bank, while doing some useful work, are not yet operating Supervisors of family planning workers 2,529 at a very high level, according to both Indonesian and for- dctr h 274 eign observers. They are handicapped by a shortage of ex- Subditinand hth tentseried 2,44 peri enced staff for a very ambitious program that is not Traditional birth attendants (retrained) 21,500 sufficiently focussed. The 1987 KAP survey (NICPS) has Primary health care nurses 1,186 been very useful and another is planned for 1991. Continu- Nursing school teachers 790 ation-rate studies are under way. Paramedical personnel (for IUD insertion) 6,613 Such micro-studies as those being done at Gadja Mada Such a volume and range of training, indicative of the University provide insights into the changing Indonesian complexity of the program, was made possible by the de- family structures and reproductive behavior. However, velopment of the training infrastructure in all three of the there apparently is no provision in Indonesia for surveys on initial Bank projects. the family to provide national and regional parameters on such issues as changing authority and dependency rela- Population Education tions between the younger adults and their parents and how these are related to changing reproductive behavior. Support for large-scale population education programs This is an important research challenge in Indonesia, rele- has produced materials and curricula and trained trainers, vant to population policy because of the inter-action of so- as well as thousands of teachers. An evaluation of this com- cial and economic change, vigorous development and ponent indicated that large numbers were exposed to it, population programs, and regional cultural variations. The learned a reasonable amount of the material taught, and re- Bank should have special interest and expertise in such tained it at least until an examination. It is plausible-but studies because of its involvement in both the population by no means certain-that this contributed to ideational and broad development programs. changes in the younger population about the desirability of As previously indicated, the BKKBN system for estimat- lower fertility, smaller families, and family planning. ing contraceptive prevalence, initiated with strong USAID The Bank support for population education included support early in the program, served the program very well buildings and their furnishings, audio-visual equipment, for a time in quickly providing data at every level down to consultants, training materials, fellowships, vehicles, and the village. and it was not far discrepant from the 1976 IFS. staff support. During the third project period, 117,000 cop- However, in the last decade, that system produced large ies of population-education instructional materials were overestimates of prevalence, with serious consequences for produced and were being used in primary and secondary planning and policy The recent revision of the system still schools throughout the country. The materials were again produced a probable overestimate of prevalence of approx- reproduced and circulated under the fourth project. imately 10 percent in 1989. So far, the program has done quite well without the ben- Research and Evaluation efit of many sound research studies on the relationship be- tween specific program inputs, socioeconomic The Bank (and, for that matter, the BKKBN and other do- development, and reproductive behavior. Research on nors) has not been very successful in helping to improve what does and does not work in program operations has the indigenous infrastructure for research and evaluation not yielded the kinds of reports that should be possible, activity. As recently as the current Fourth Project, important given the level of program success. In April 1985 the ap- goals in this area were the creation of three research centers praisal report for the fourth Bank project indicated that the in the BKKBN, a regular series of KAP and continuation- BKKBN still had only limited capacity for undertaking op- rate studies every two years, and the strengthening of 10 erational research. There has been only modest improve- provincial university centers. ment since then. The Demographic Institute at the University of Indone- However, the successful expansions of the program from sia and the Population Studies Center at Gadja Mada clinic basis to outreach by field workers, and then to large- University are the premier national Indonesian academic scale use of village volunteers were based on experimental centers in the population field. The latter is well-known for pilot projects by BKKBN with the collaboration of USAID. its sociological-anthropological micro-studies. Qualified In- These trials did not result in scientific reports. However, donesian and foreign observers are agreed that the attempt because of their supervision by program managers, the large-scale expansion following testing did not face the 149 ANNEX 2 problems associated with pilot projects external to the op- The Ministry of Population and Environment erating program.44 The Bank's undoubted capacity for analytical sector The Bank has supported several kinds of activity in train- studies was not much utilized in population in Indonesia ing, research, population policy development, and other ac- during the Bank's early projects. Even when such reports tivities of the Ministry of Population and Environment. were later done, they do not appear to have affected the de- This Ministry is charged with encouraging and coordinat- sign of the Bank's four loan projects very much. In the two ing a broad range of population activities in various minis- instances in which Bank projects included potentially im- tries. While the mandate of the Ministry is important, for a portant operations research projects to test new ideas, the variety of reasons, the achievements are still mainly poten- results were not very useful, in part because of inadequate tials for the future. A recent Bank sector report45 character- collaboration with Indonesians in the initial design. How- izes the population section of the Ministry as "... a small ever, two recent reports are highly relevant to program office supported by consultants, and it has a limited capac- needs and are likely to influence the fifth population loan ity to fulfill its functions." now being negotiated. One deals with the prospects for the Other donors have always recognized the Bank's special program in the 1990s. The other is a much-needed econom- contribution in hardware infrastructure. However, for ic analysis of the program. many years, other donors as well as some Bank staff saw the Bank as being at a disadvantage in software compo- Support for Field Staff nents. Uneasiness about the software components was ex- pressed as follows in the audit of the second Bank project: The Bank helped to finance field staff salaries during the "Some concern has been expressed by certain donor first project and later, for the special outreach effort for agencies that the Bank is expanding into areas such as trans-migration resettlement areas. With these exceptions, research and evaluation in Indonesia, where the other the Bank generally has left the direct support of the largely agencies have already spent considerable resources recurrent costs of field staff to the Indonesian Government. and in which they are better equipped to monitor, giv- The Bank's initial support of field staff salaries was recently en their representation in the field. Given resource cited by BKKBN officials as especially helpful at a crucial constraints, countries may be better off obtaining stage of the program. resources for certain software elements from else- where, especially when these can be financed from grants and/or when these software components re- quire close supervision which the Bank is not The Bank has provided support in several projects for equipped to provide." ThCequieBn ha nsltats , oertranin evea poecs for However, in recent years, this evaluation has been mod- IEC equipment, consultants, other training costs, field pro- ified to some extent. For example, appreciation of the role duction costs, operating costs for media centers, and vehi- of the Bank in implementing on a large scale projects devel- cles for IEC work. While there are qualitative reports of oped by others is illustrated in a recent UNFPA evaluation wide-spread exposure to posters, films, pamphlets, and report.4 UNFPA supported the development of six media other IEC activities, there are few data on the sizes of audi- projection centers in Java-Bali. The Bank then responded ences and none on possible effects on reproductive behav- favorably to a BKKBN request to replicate them in all other ior or values. provinces. The UNFPA initiated an IEC project covering the cost of developing training materials and of educating mas- Hospital Postpartum Program ter trainers, with the understanding that the costs of train- ing the supervisors and field workers would be covered by This component helped to increase the number of hospi- the Bank. The UNFPA also reported cooperative large-scale tals providing postpartum family planning services as part assistance from the Bank in supporting the institutionaliza- of the international programs coordinated by the Popula- tion of population education in both the formal and infor- tion Council. A Bank mission reported in 1977 that 25 per- mal sectors. cent of abortion and obstetric cases became new family planning acceptors. 45. World Bank, Indonesia: Family Planning Perspectives in the 1990s (Wash- 44. This aspect of the program is given particular emphasis as an impor- ington, D.C.: World Bank, 1990). tant basis for its success by Samuel Paul in Managing Development Programs: 46. United Nations Population Fund, Report on the Evaluation of Indonesia The Lessons of Success, (Boulder, Colorado: Westview Press, 1982). Country Programme, New York: United Nations, November 1988. 150 ANNEX 2 Similarly, UNICEF staff recently reported47 that their point given exceptional stress during its briefing on work in developing the program for Posyandu posts was Indonesia in 1976. greatly facilitated by the Bank's support to BKKBN for rap- This litany of complaints about management occurred id early expansion of these posts to the 25,000 mark before just when the BKKBN was having great success in provid- its subsequent expansion to 225,000 in over 60,000 villages. ing services and information to rapidly growing numbers In summary, the preceding review indicates reasonable of contraceptive users. Was the Bank failing to understand but variable achievement in implementing specific project what was, apparently, a very successful indigenous man- components, which plausibly could contribute to program agement style because it had a preconceived, non- success. Given the considerable success of the program, it is Indonesian view of what management should be? In docu- likely that the specific Bank inputs, taken together, made a ments covering the third and fourth loan periods, there is a significant contribution to program success. The major greater readiness to acknowledge management strengths at Bank investment in buildings and vehicles, providing es- BKKBN, and indeed, to claim credit for them. sential program infrastructure, could not have been provid- Understandably, the BKKBN has had many management ed by other donors. Most of the software components were problems. Initially, the inexperienced BKKBN staff had to useful, although in this area the Bank was a follower rather deal with the politics and arcane procedures of multiple In- than a leader. While its software functions could have been donesian agencies, as well as those of international foreign carried out by other donors, it is unlikely that they could donors. The fact that the Bank provided loans rather than have absorbed the costs of doing that. Besides, the Bank's grants increased the problem, because loans required spe- important role in hardware components and policy dia- cial procedures with BAPPENAS and the Ministry of Fi- logue might have had less credibility without some in- nance. Significant recurrent problems for the Bank and volvement in funding the program's actual operations. BKKBN were delays by the GOI in releasing required coun- terpart funds. The Bank itself was also initially inexperi- Developing Management Capacity enced in dealing with the multiple Indonesian agencies and the other donors. During the first Bank project, the Bank's The Bank staff have frequently claimed in their reports resident population officer was reported to have spent most that it has helped to develop BKKBN's management capac- of his time on relations with multiple agencies, dealing not ity, presumably through its very methodical appraisal, re- with substantive issues, but with internal Bank and GOI porting, supervision, and review procedures. procedures and paperwork. BKKBN not infrequently suf- A number of knowledgeable observers, interviewed in fered from the inconsistencies between the Bank's proce- the 1970s and more recently, claim that the Bank's require- dures and those of the rest of the Indonesian government. ments are onerous in terms of reporting and planning and During the third Bank project, the Bank staff spent 140- related documents, together with the time required from 150 weeks for supervision.48 BKKBN apparently could not BKKBN staff to work with numerous supervisory missions remedy an exceedingly slow rate of disbursement of project and to correspond with Washington. funds. It was necessary for Bank missions to persuade BAP- Another major donor also has reporting requirements PENAS and the Ministry of Finance to release the necessary that are no less time-consuming and detailed than those of counterpart budget allocations. An able staff member in the Bank. However, BKKBN's ability to deal with these are residence might have been more effective and, in the end, facilitated by the resident staff of the other agency. less expensive than so many missions from Washington. A very knowledgeable Indonesian government official BKKBN's management problems, as described in Bank indicated in an interview that administrative rigidities reports, seem to have occurred much less with the agencies were as often those of the Indonesian Government as of the and personnel it was supervising and coordinating to carry Bank. He indicated further that the administrative prob- out the program than with the Indonesian and donor agen- lems of working with the Bank arose mainly from having to cies from which it obtained its resources. correspond with Washington rather than working with a The Bank's audit of the second project stated that, "Over- resident representative for population. all the BKKBN was a well-managed organization and, in During the First Project, the Bank was constantly con- general, it implemented the project well. However, its effec- cerned about the failures of BKKBN and GOI management. tiveness has, in the audit's view, been impaired from time The audit report for Project One cites 12 of 13 supervision to time by extensive reorganizations, and this continues to reports as indicating that BKKBN management was an im- be a cause of concern."Similar concerns with the changes in plementation problem. The Berelson Committee heard this 48. This included some time spent in supervising several other Bank projects and in preparing for a later project - time which could not be sepa- 47. In interviews in Jakarta, February 1990. rated out. 251 ANNEX 2 BKKBN organization appear in later Bank reports. There to spend out their annual budgets, BKKBN does so regular- does not appear to have been adequate recognition by the ly because its data-based MIS system provides accurate Bank that changes are to be expected-indeed, may be de- month-by-month accounts of its financial status in relation sirable-in a program whose character necessarily changes to its detailed forward plans. Several donor representatives with rapid technical, social, and economic change and with also regarded it as better managed than family planning changes in the public's knowledge and acceptance of the programs in other Southeast and South Asian countries. program's basic ideas. No doubt, the interaction over many years on many The Bank often has tried to micro-manage and micro-su- projects of the BKKBN with the Bank and other donors has pervise from a distance. The Appraisal Report on Project contributed to the development of better management Four has an astonishing list of "agreements and recommen- structures and skills. But the Indonesians themselves de- dations"on which assurances were obtained as part of loan serve major credit in the managerial area on the basis of negotiations. These involve requirements for detailed ac- successful program results from the early years, the adap- tions and reports with specified early deadlines. Some of tation of the program to the Indonesian environment on a these seem clearly unattainable in the time specified and, regional basis, and such specific administrative indicators indeed, this has proved to be the case. After 20 years of suc- as its ability to spend out its budget according to plan. cessful experience, the BKKBN might well regard such re- BKKBN now faces new managerial challenges. It is seri- quirements as unnecessary and condescending. ously trying to shift as much of the program as possible to The contributions of the Bank and of other donors to de- the private sector (K-B-Mandiri) and to increase cost recov- veloping management skills should be evaluated in the ery in the public sector to contain the mounting costs of the perspective of the primary role of the Indonesian govern- increasing number of acceptors. Such a transition will re- ment and leadership. The BKKBN has been imaginative quire both experimentation and substantial reorganization. and effective in molding the program to fit Indonesian in- USAID, which is heavily involved in the privatization pro- stitutions. The considerable financial, technical, and intel- gram, has indicated that it intends to radically reduce its lectual resources provided by international and bilateral general participation in the program after 1995. The Bank donors, no doubt, have been important. However, the may have to decide whether Indonesia will need assistance Indonesian leadership has been unusually successful in ne- with the new management problems and whether the Bank gotiating for and utilizing these resources in the Indonesian is capable of providing it. context. Some other Asian countries which have had simi- Is Indonesia ready to make its own decisions and man- lar resources available to them have not had similar suc- age its own program? The Bank and other donors have cess. P is indicative of the BKKBN's attention to managing been making grants and loans for almost 20 years and the donor relations that it has prepared manuals for its staff, three principal donors all claim to have helped to build pm- laying out the operating style and the detailed require- gram management infrastructure. And, after all, the pro- ments of each donor. gram is eminently successful. If, as is likely, continuing The independent role of the Indonesians in managing financial assistance is needed, especially in foreign ex- their own program may be indicated by the rising share of change, perhaps such loans could be made with less super- program spending financed by the Government of Indone- vision, but with final accountability according to broad sia during the first three completed projects: guidelines. This could be done by allowing more flexibility * Repelita 1 (1969-70 - 1973-74) 40 % on project loans or by providing sector or program loans. * Repelita 11 (1974-75 - 1978-79) 52 % * Repelita III (1979-80 - 1982-83) 72 % A Bank audit suggested that the major Indonesian con- When the Bank was developing its first project, many tribution to program funding reduced its need "to accom- other donors were already active in Indonesia (USAID, modate to widely divergent views of population experts or UNICEF, WHO, IPPF, the Population Council, the Ford to the substantial political sensitivities of donors."Such Foundation, and the Swedish and Japanese Governments). problems were reported as occurring in another Asian The entry of the Bank and the UNFPA onto the scene, with country where the Bank and other donors provided a large major funding for a joint project, involved a readjustment share of the program funding. which was described in the first project completion report The BKKBN is regarded by knowledgeable Indonesian as "... long and somewhat contentious, with each agency and foreign observers as being much more effectively man- attempting to strengthen its own institutional position, aged than other Indonesian human resource agencies and while simultaneously expecting co-operation from the oth- departments. While other Indonesian agencies are unable ers."Resentments resulted from the perception that the 152 ANNEX 2 Bank saw itself as the coordinating agency. Indeed, the Possible Bank Influence on Fertility through Bank did become the executing agency for the joint Bank/ Assistance in Non-population Sectors UNFPA project, with several of the other agencies imple- menting specific aspects of the work. Discussions of the Bank's role in population almost always Resentments developed during this initial period per- call attention to the potential leverage from the Bank's invest- sisted for many years, exacerbated by the fact that the ments in other social and economic sectors. While the idea of Bank usually had no resident representative who could linking population and other sectors is plausible, there is little develop informal personal ties with the resident repre- evidence that this is done very often, either in Indonesia or sentatives of the other donor agencies. Representatives elsewhere. For example, while the Ministry of Health (MOH) of the other donor agencies told a member of the Berel- provides a substantial portion of the family planning services son Committee in 1976 that the Bank was "standoff-is- in Indonesia, neither the Bank loans for health nor those for h"and "arrogant."They complained that they often were population provide direct support of family planning activi- interviewed by visiting Bank mission staff who didn't ties by the MOH. Similarly, while the Bank projects have pro- know Indonesia well, but that they almost never got vided support for the population education program, this has feedback on the Bank's reports, ideas, or intentions until been done through the BKKBN without direct support to the after decisions were made that often affected them. An Ministry of Education. While such direct linkages with other outside mission evaluating USAID in 1979 reported that sectors are probably desirable, they would be unlikely to have as powerful effects on reproductive motivation and behavior "There is little contact with the World Bank, because it as general progress in the social and economic sectors. does not have a resident technical staff for population. The World Bank's loans and projects in such other sectors as The experts it brings in for specific loan arrangements education, agriculture, health, transportation and communi- do consult with USAID staff, but there is little opportu- cation, and, more generally, for economic development have nity for sustained contact once they depart." contributed to the major social and economic changes of the In recent years, relations with other donors have been last 20 years in Indonesia. As previously indicated, these in very much improved because of a determined effort by a turn could have played a role in the decrease in the number of relevant Bank staff member to keep other major donors children wanted, the increased use of contraception, and the informed about what happens during and following vis- fertility decline. iting missions. Donor representatives with many years The Bank's spending for the Indonesian development pro- of experience reported a cooperative change for the gram has been substantial for a broad range of development better in relations with the Bank. There has been cooper- programs. The scope of the Bank's loan program is indicated ation in funding specific projects. There have been help- by the following distribution of Bank commitments to Indone- ful exchanges of information and cooperation in sia for fiscal years 1968-89, by sector: evaluation of program components of mutual interest. Also, in recent years, Bank sector reports in population Sectors US$ millions and in such related fields as health have won the respect Agriculture and rural development 3,794 of staff of other donor agencies, both in Indonesia and in Education 1,536 the central offices of the agencies. References to such Health and nutrition 156 reports have recently appeared in publications of other Industry 540 agencies. Population 119 These recent developments indicate that, with suffi- Power/energy 3,305 cient sustained effort by a motivated staff member, do- Small-scale enterprise 798 nor relations can be improved even without a resident Telecommunications 27 population representative. Tourism 16 Transportation 2,016 More formal and comprehensive joint planning and Urban development 960 budgeting by the donors, even if it were feasible, would Water supply and sewerage 147 not necessarily be desirable. An integrated program de- Other economica 1,372 sign in this sensitive area by a consortium of outsiders Total 14,786 would be resented and probably rejected by the aDevelopment finance companies, trade policy, private sector development. Indonesians, who take justifiable pride in the successful program they have designed and executed. The BKKBN These data provide concrete evidence of the Bank's major coordinates the donors to suit Indonesian needs and support for a wide array of crucial development sectors. sensibilities. Most population specialists would agree that substantial progress in these sectors taken together should facilitate 153 ANNEX 2 social and familial changes generally associated with fertility central government expenditures on health fell by more than decline. Chapter 2 indicates that substantial social and eco- 40 percent between 1982-83 and 1987-88. These were far nomic changes have indeed occurred. There is little doubt greater than the declines for the family planning program. that the Bank has contributed to the Government's efforts in The Ministry of Health recognizes the difficult problems in these sectors. the health system and is attempting to address them. The fact that the population sector accounts for less than The rather poor status of the health system suggests that 1 percent of the Bank's total lending program suggests that, the mortality declines in Indonesia may have been associated if a larger population lending program were deemed desir- with rising standards of living as much as with improvement able, it could be done with little increase in the total of de- in health services. As previously indicated, the family plan- velopment lending to Indonesia. ning program's success in reducing fertility probably has fa- Specific comments may be useful on the education and cilitated the decline in infant and child mortality. health sectors - the two generally believed to have the The health system is important for fertility decline, both closest connection to changes in reproductive behavior. because lower infant mortality affects reproductive intentions The Bank has made 29 education loans since 1965. The and because the health system provides much of the essential proportion of Bank lending for education has been larger family planning services. A recent internal Bank report found for Indonesia than for any other country. (The substantial that BKKBN bears about half of family planning delivery progress in education has been described in Chapter 2.) Ed- costs: the Ministry of Health, 40 percent: and the community, ucation is the social factor with the clearest evidence of ef- the remaining 10 percent. The massive Posyandu system de- fects on reproductive behavior, both in general and for pends to a considerable extent on the system of health clinics Indonesia specifically. While much of the Bank's education for the medical aspects of its monthly services in several hun- lending has been for higher education, the lending for pri- dred thousand hamlets. Further, there is general agreement mary education (US$61 million), secondary education by BKKBN and the donors that the future success of the pro- (US$293 million), and teacher training for primary and sec- gram will depend to a considerable extent on a shift toward ondary schools (US$275 million) was not inconsiderable. such more permanent contraceptive methods as Norplant, re- Emphasis on textbook production and teacher training quiring more clinical medical services. More clinical services aimed to improve the quality of education. Emphasis on would also be required if there was an increase in voluntary technical education was especially relevant to elevating sterilization, which is the most used method in the United economic aspirations of young people and their parents. States. There is similarly a requirement of better health servic- The Bank's strong support for higher education (US$596 es for the goal of improving the quality of family planning million) gave Indonesia greater latitude to invest its own services, especially with reference to side effects. funds in primary and secondary education. All of this suggests that the Bank might usefully have con- The Bank's efforts in health are more recent than in other sidered both a more integrated approach to population and sectors. In general, Bank health projects have not yet dealt health and more substantial strategic assistance to upgrading with the central problems in Indonesia's health system. Ac- the health system as a whole. This would have served both cording to a recent internal health sector report by the Bank, health and population objectives. It is pertinent that in cur- Indonesia's health programs do not compare favorably with rent negotiations for the fifth population project, a major ma- those of other countries in Southeast Asia and, in some re- ternal and child health component is contemplated involving spects, to those of even poorer countries elsewhere. Indonesia a large loan element going directly to the Ministry of Health, spends much less of its GNP or of its budget on health than with expectation of a major additional component in the next other countries in the region. It spends 2.5 percent of its bud- health loan. get on health as compared to an average of 5 percent in the re- More generally, since population trends are influenced by gion. In comparative terms, there is a low density of health intersectoral forces, the Bank could exercise greater leader- services and low utilization of both the inpatient and outpa- ship in developing an explicit intersectoral strategy for the tient services available, perhaps in part because of the low population field. density. The density of services and their utilization is lower The benefits flow not only from the other development sec- in poorer areas, raising substantial questions of equity. Skilled tors to population, but in the reverse direction as well. A Bank personnel are disproportionately in better-off places and at staff member has recently estimated49 a rate of return of 12 leading hospitals located there. There is a stress on curative percent per annum for expenditures on family planning, services as compared with preventive and child-centered ser- based on savings in the health and education sector resulting vices. Hospital beds per capita are an extremely low 0.6 per from births averted. thousand, compared with 0.9 in low-income countries and 1.3 in the lower middle-income countries with which Indone- 49. World Bank, Indonesia: Family Planning Perspectices in the 1990s (Wash- sia should be compared. During; the fiscal crisis of the 1980s, ington, D.C.: World Bank, 1990). 154 ANNEX 2 The Role of the Bank in the Next Decade adopt innovative strategies and targeting for these groups. Strong public program efforts should be maintained at the The Indonesian population and development programs same time that the private sector is encouraged to become still face a formidable task in further reducing fertility and a more significant partner in family planning." bringing population growth rates to the desired zero- To achieve the targeted reduction of total fertility rates growth level. Despite the considerable success in reducing from 3.41 in 1988 to 2.88 in 1994 is estimated to require an fertility through increased use of contraception, the annual increase in the number of contraceptive users from 14.2 to rate of increase of the population only fell from 2.35 percent 19.4 millions-a 27 percent increase. The Bank report esti- in 1965--70 to about 2.00 in 1985-88.50 The rate of popula- mates that, to achieve the contraceptive prevalence rates for tion growth did not decrease more rapidly, mainly because 1994, the BKKBN budget would have to grow by 13 to 16 the decline in fertility was offset to a considerable extent by percent per annum. Projections for longer periods into the a decline in mortality Despite its effect on retarding the future, with much larger increases in numbers of contra- growth rate decline, the mortality decline is, of course, val- ceptive users, involve very large budget increases, if it is as- ued not only for the intrinsic value of saving lives, but also sumed that most services will continue in the public sector because lower child mortality facilitates further fertility de- with little cost reimbursement. For this reason, the BKKBN cline. has launched a major long-term drive to increase the pro- Indonesia still has a very young population, a result of portion of services provided by the private sector (the K-B- formerly high (and presently still moderately high) fertility. Mandiri program) and for greater cost reimbursement in This young age structure is partly responsible for the con- the public sector. USAID is devoting a major share of its tinued relatively high crude birth rate and rate of natural current Indonesia budget funds to this purpose, but intends increase. Even when total fertility rates reach the replace- to phase out most of its program support by 1995. The Bank ment level, the population will continue to grow for de- is supporting this privatization initiative, although it is less cades because of the large number of couples of sanguine than USAID about how rapidly privatization can childbearing age produced by earlier high fertility rates. take place. Further, while the decrease in total fertility rates to 3.3 is a Estimates of probable trends in contraceptive practice considerable achievement, reaching replacement-level fer- depend on estimates of demand as they appear in different tility of about 2.1 will take considerable time, even assum- strata of the population whose composition is changing. ing continued good progress. The demand, in turn, depends not only on the program, but Therefore, large increases in population are almost inev- also on the extent to which continuing social and economic itable. The size of projected population increases depends development will affect the demand for children and con- on the assumptions made about fertility and mortality, but traception. However, given the central importance the GOI all credible projections indicate large population increases. attaches to reducing population growth, it is likely that it For example, recent projections by the United Nations Pop- will continue to support the program strongly, until it is as- ulation Division5 indicate a population of 216 to 253 mil- sured that autonomous actions by individuals will meet the lion by 2010 and 228 to 305 million by 2025, depending on need. Presumably the Bank ought to take a similar ap- the assumptions made. Actual zero population growth may proach while holding a watching brief on the development not be attained before the end of the twenty-first century, of strongly internalized small, planned family norms and even if replacement-level fertility is reached by 2010. the availability of services in the private sector. For the immediate future, a recent Bank sector report52 If USAID does radically reduce its participation, the presents an excellent but sobering picture of the challenge Bank may need to consider larger loans, unless privatiza- for Indonesia in the population field in the 1990's: "Further tion is much more rapid than expected or other major do- declines in fertility and in the population growth rate will nors appear on the scene. Large building programs are no take considerably more effort, because the program will longer needed, although there is a major need to replace ob- need to reach unprecedented numbers of contraceptive solescent vehicles. As USAID phases out its program, there acceptors and motivate couples with high-fertility will be major unmet needs in the software areas it has been attitudes, less likely to know about family planning and to covering. Programs to develop structures appropriate for seek services (e.g., remote areas, urban poor). The detailed the transition to privatization and self-motivation require programming of family planning operations will need to considerable software elements. As already indicated, the Bank is not presently well-equipped to field such software projects effectively, if they require the kind of in-country 50. United Nations, Department of International Economic and Social Af- continuing technical assistance USAID has given, with its fairs, World Population Prospects, 1988, Population Studies No. 106, (New considerable staff and consultant group. If the Bank does York: United Nations, 1989). 51. Ibid. decide to move into such software areas, it should consider 52. World Bank, Indonesia; Family Planning Perspectives in the 1990s (Wash- having field staff resident in Indonesia and giving them ington, D.C.: World Bank, 1990). some latitude for changing projects and re-allocating funds. 155 ANNEX 2 6. Lessons from the Bank's Indonesian Experience In current negotiations for a fifth loan, a major expan- in the field were not sympathetic to the idea of reducing re- sion in software areas is being discussed. It is significant sources in such areas. They insisted that, even where the that this comes with a plan to make the Bank's relations rates were at such high levels, the staff needed to work to with BKKBN "more flexible" by having an annual review maintain the motivation for practice and also to work in of BKKBN-prepared plans for the next year, with the other aspects of family welfare defined as part of BKKBN's Bank's supervisory missions having authority to make general mission. reasonable changes in the field including budgetary real- Eventually, in the life of any family planning program, locations within broad categories. If this innovation devel- there should be a time when the program can function in- ops, it will be important to know whether such flexible dependently, at first in terms of program design and imple- annual reviews are feasible without a resident representa- mentation, and eventually, in financial terms as well. The tive and with the present very limited authorized time for strength of the BKKBN suggests that the Indonesian pro- supervisory missions. gram may be one the Bank should study closely from this However, a different course of action is possible, on the point of view. assumption that after 20 years BKKBN is competent to de- What factors account for the success of the Indonesian vise and manage its own programs without detailed over- program? To what extent are these factors ones to which the sight and consultation. On that assumption, a sector loan Bank made a contribution? To what extent is that experi- would be appropriate, involving design and implementa- ence relevant elsewhere? What could the Bank have done tion of the program by the Indonesians within broad guide- better or differently which might have made its contribu- lines and with provision for accountability for expenditures tion greater? and program results. Consider first the favorable factors: In interviews in Indonesia in February 1990, it appeared Strong, continuing, and reliable political support for the family that BKKBN was ready for something like a sector loan, but planning program. that BAPPENAS preferred the discipline and checks of * The Bank's influence through policy dialogue was sig- something closer to present procedures. nificant, especially in the early years, but also later in In several provinces of Indonesia, where prevalence lev- providing continuing legitimation for a program has al- els are at about 70 percent, there are many subdistricts in ways been somewhat controversial. which contraceptive prevalence is virtually at saturation * Providing such support was not difficult, because the levels. These provide an opportunity to experiment with Indonesian leadership was always favorable. changes in the deployment of staff and resources in such * The Bank has the potential for such broad policy sup- maturing programs. A recent internal economic analysis of port everywhere it functions, but its influence is condi- the program suggests that In areas in which the program is tioned by the extent of indigenous leadership support. well-established and not too dependent on outreach activi- * However, the Bank had relatively little influence in ty, as in Yogyakarta, savings may occur by reducing the working with the BKKBN to develop specific BKKBN's field staff and limiting their activity to IEC. In in- operational policies through which the broad policies terviews in 1990, BKKBN staff at central headquarters and were implemented. 156 ANNEX 2 Skillful, charismatic, and stable leadership. development program alone. Population should be seen While the Bank's financial support and appreciation as an integral part of a general development effort, with strengthened the hands of the BKKBN leaders, the Bank reciprocal effects involving relatively small direct costs probably had little influence on their selection and suc- for the population sector. cessful career advancement. The leadership knew how A pervasive network of community-based volunteer groups and to develop and implement a program suitable for the In- workers providing information, services, and most important, so- donesian social environment. cial support and pressure for the legitimacy and desirability of * This was a fortunate given indigenous asset. small, planned families. * It is not transferable. Advice to choose and support good * The BKKBN has been exceptionally successful in build- leadership is gratuitous. ing this network. A good general administrative structure with the capacity for * The Bank and other donors have supported this effort in communication to and from the local community level and for various ways. mobilizing local community involvement. * However, the success of this massive effort rests mainly * The BKKBN used and skillfully adapted the general ad- on the consensus-building meetings and group activi- ministrative-political system to its special needs. ties, the central Government's ability to mobilize action * This important institutional asset was not developed by at the village base effectively, and on the BKKBN's high- the Bank or any other donor. priority effort toward building this important network * It is basically a result of Indonesia's distinctive social, and maintaining its vitality over many years. political, and cultural history. * Within Indonesia, the BKKBN is a leading model for de- * It is not easily transferable or created de novo elsewhere. velopment efforts utilizing this community-based, vol- A strong and successful development program which produces untary-effort approach. both social and economic changes favorable to fertility decline and * The basic idea of using voluntary groups in community- an infrastructure which facilitates family planning program based service and social support networks is relevant for operations. almost all countries. Each country must build such net- * Indonesia has had such a successful development pro- works to fit its own situation, but it may require social gram and its leaders appreciate its links to the popula- innovations. It will be difficult where governments do tion program. not have strong capacities for communication inter- * The Bank has contributed substantially to the broad de- changes with the villages and for mobilizing community velopment program in a range of sectors generally be- involvement. However, since program success will be lieved to be relevant to lower fertility and mortality. difficult without such networks, how to implement * Among sectors believed most closely linked to popula- these ideas deserves close attention almost everywhere. tion, the Bank did much in education but considerably The BKKBN as an effective, free-standing coordinating agency. less in health. Such sectors as transportation and com- * The ability of the BKKBN to move regular ministries to munication, not generally thought of as population-rel- action has depended on its very strong political support. evant, may have had considerable effect indirectly, both * Its effectiveness has also depended on its capacity for di- on ideas and attitudes and in facilitating the program rect implementation when needed. operations. * The Bank and other donors supported the creation of the * Supporting development broadly is something the Bank BKKBN and contributed substantially to its develop- works at wherever it operates. How best to do this tran- ment. scends population issues. * Such an agency deserves serious consideration in other * By reducing the numbers of children to be served, the countries, as an alternative to placing this function with Indonesian family planning program is saving resources typically weak ministries of health. However, agencies in the education and health sectors, so there are recipro- on the BKKBN model will be unable to elicit action from cal benefits in the linkage of population and other devel- the agencies they are supposed to co-ordinate without opment sectors. Further, smaller planned families very strong political support. improve maternal and child health. Strong support for the BKKBN by both multilateral and bilateral * While the interdependence of population trends and de- donors. velopment usually gets nominal acceptance, citation of * While primary credit for program success belongs to the the Indonesian example may be useful in policy dia- BKKBN, the financial, technical, and intellectual support logue elsewhere. Specifically, it may be useful to empha- of the donors was considerable. size that relatively small marginal expenditures for the * The Bank's distinctive contribution was in hardware ele- population sector helped move Indonesia's fertility de- ments, where it has a comparative advantage: cline more rapidly than expected from the general 157 ANNEX 2 1. The network of buildings and equipment and the ve- However, in places like Sub-Saharan Africa, the Bank's hicles provided under Bank loans were essential in- role will be very limited if it does not have the capacity frastructure for the program. The Bank specialized in to assist in the software aspects of IEC, creation of effec- providing these elements successfully. tive demand, and service delivery. These are particularly 2. The Bank has long experience with hardware ele- important where the existing infrastructure is poor and ments in many sectors and countries. general development levels are low. 3. The hardware elements may seem prosaic, but they * The Bank could have been more sensitive and coopera- are important, providing other donors are support- tive in its relation to other donors. The benefits of a bet- ing the program software elements which the build- ter relationship have become evident in recent years. ings and vehicles must serve. More regular reporting of the division of labor and rela- 4. These are desirable and deliverable elements in most tionships with other donors would have been a helpful other countries, although the infrastructure neces- part of project completion reports, audits, and other doc- sary for good building and transportation compo- uments. This is still desirable. nents will vary considerably * The Bank could have taken earlier and stronger initia- The Bank's contribution in the software area consisted of tives in the health sector, which has both direct and indi- implementing ideas developed by others to a significant rect effects on the population sector. Emphasis on the extent. intersectoral linkage of health and population might 1. A de facto division of labor existed between the Bank have strengthened the case for improving the health and other donors, in which the Bank implicitly ac- system, especially in maternal and child health. This op- cepted their leadership in advising on program de- portunity still exists, since the Indonesians are well sign. aware of the linkage and of the inadequacies of their 2. Implicit recognition by the Bank of this division of health system. labor is to its credit. Especially in recent years, this * More generally, Indonesia is a place in which the Bank, has involved co-operation with other donors in eval- cooperatively with the Indonesians, might have devel- uation and implementation of software project ele- oped and tested strategies for intersectoral connections ments. between population and other sectors. The Bank is cer- 3. Such a division of labor was reasonable as long as tainly the best-qualified among donors to take a lead in the Bank did not wish to allocate the resident staff this direction. The BKKBN's efforts in linking income- and consultants needed to develop and test software generation and other development activities to the pop- ideas in the field. However, this meant that the Bank ulation program have not been systematically evaluat- did not exercise leadership or gain experience in pro- ed. The Community Incentive scheme under the second gram software areas which are of increasing impor- Bank project did not produce useful results for various tance. reasons. However, the Bank has not given this general 4. If such a division of labor is recognized and fostered, problem the sustained attention it merits, either in Indo- it is probably transferable to other countries, provid- nesia or elsewhere. ing other donors are available for the complementa- The Bank might have provided more intellectual leader- ry roles. ship in analyzing: What might the Bank have done better or differently that * The interconnections between development, the popula- could have increased its contribution to the population tion program, and the socio-cultural structure in Indone- program? sia. Indonesia is a good example of these inter-sectoral * Especially during the first decade, a resident Bank pres- and inter-institutional connections which are at the ence probably would have speeded and improved even heart of the Bank's general mission. the hardware components. A resident field representa- * The elements making for success in a program which is tive for population could have made the Bank's projects eminent in its ability to field a truly successful commu- more flexible and efficient by facilitating changes in nity-based program. There is enough variability be- project components as needed. Further, it might have tween areas in the country in program achievements to led the Bank to a larger and more innovative role in the make a study of determinants worthwhile. related software areas. However, substantial gain from a To carry out or to commission and monitor such studies resident staff would have required giving that staff lati- requires commitment of staff working on Indonesia and tude in making changes in projects and in reallocating other selected countries for some period of time. The PHN funds. That the Bank did not do more in the software ar- staff allocation is too small to add this to its other responsi- eas in Indonesia probably was not important for the In- bilities. The knowledge base in human resource areas is not donesian program, because other donors met that need. as well-developed as in areas with greater hardware 158 ANNEX2 components. Social and economic history is being made in is needed, investment in this area can be considered as rel- the human resource areas in places like Indonesia. The evant for the indirect population component of the general Bank should consider more than average allocation of ana- development programs. lytical staff time to the PHN area. If additional justification 159 4 称 The World Bank Headquarters European Office Tokyo Office 1818 H Street. N.W. 66 avenue d'I6na Kokusai Building Washington, D.C. 20433, U.S.A. 75116 Paris, France 1-1 Marunouchi 3-chome Chiyoda-ku, Tokyo 100, Japan Telephone: (202) 477-1234 Telephone: (1) 40.69.30.00 Facsimile: (202) 477-6391 Facsimile: (1) 40.69.3066 Telephone: (3) 3214-5001 Telex: WUI 64145 WORLDBANK Telex: 640651 Facsimile (3) 3214-3657 RCA 248423 WORLDBK Telex: 26838 Cable Address: INTBAFRAD WASHINGTONDC Cover illustration by Bill Fraser ISBN 0-8213-2081-5