R-300-TLP sRETURN TO REPORTS XA2tL~X RES RICTED CIRCULATIING C'PY ONE WL Rep,ort No. PP-8a TO BE RETURNED TO REPORTS DESK . *1 This report is for official use only I the Bank Group and specifically authorized organizations or persons. It may not be publisheu, quoted or cited without Bank Group authocization. The Bank Group does not accept responsibility for the accuracy or completeness of the report. INTERNATIONAL BANTK FOR RECONSTRUCTION AND DEVELOPMENT INTERNATIONAL DEVELOPMENT ASSOCIATION APPRAISAL REPORT OF A A JOINT IDA-UNFPA POPULATION PROJECT INDONESIA 44 February 29, 1972 Population Projects Department CURRENCY EQUIVALENT U.S.$ 1.00 = Rp 41. Rp 1 = U.S.$ 0.0024 Rp 1 million= U.S.$ 2,400 Indonesia Fiscal Year - April 1 to March 31 GLO I S S A R Y Abbreviations ABRI = Armed Forces A.KRI = Police ANK = Auxiliary Nurse-Midwife BAPPENAS = National Economic Planning Agency BPP = Office of Educational Development DIP = Authority for Expenditure of Government Budget Funds DKD = Voluntary Village Worker FP = Faxnily Planning GDP = Gross Domestic Product IPH = Institu1le of Public Health IPPA = Indonesian Planned Parenthood Association IPPF = International Planned Parenthood Federation IUD = Intra Uterine Device KAP = Knowledge, Attitude, and Practice LEKNAS = Indonesian Institute of Sciences LKBN = National Family Planning Institute MCH = Maternal and Child Health NFPCB = National Family Planning Coordinating Board NTB = National Training Board NTC Nat:ional Training Center PCC = Project Coordinating Committee PIU = Project Implementation Unit PKC = Assistanau Nurse PKE = Assistant l9iidwife PSC = PopnuJation Study Center PTC = Provincial Training Center RSU = General Hospital Ad1ministered by the Ministry of Health STC = Subtraining Center SURURI = Survey & Business Research Indonesia TCPS = Yaws Examiner UN United Nations UNESCO = United Nations Education, Scientific and Cultural Organization UNFPA = United Nations Fund for Population Activities UNICEF = United Nations Childrexn's Fund USAID = Unit,ed States Agency for International Developmen-t WHO World Health Organization Indonesian 'erms DUKUN = Indigenous Mid-wife KABUP,ATEN = Regency KAWEDANAN = District KETJAMATAN = Subdistrict MANTRI = Male Nurse BUPATI = Regent INDONESIA: BASIC DATA 1970 (Except where indicated) Area ........................................ . ....... 1,904,345 km2 Population ............................ ........... 121 million Density: Indonesia ..................................... r64/1km2 Java and Madura .................................... 590/km2 Birth Rate ................ ............................. 8/1i0,O Death Rate ....................... .................... .. 2/1,000 Rate of' Population Growth ................................ 2.6% per annum General Fertility Rate .................................. 207/1,000 Population By Age Groups (1961 Census): UnderrsS..e.r.....................................2.% TUA er 15 74ea-sveev*ves***000***v"esc*"o@@@@Xs**@ 42.1% 15 - 64 Years ......................................S5.1% 65 Years and Over ................................ 2.5% Population by Religion: Muslim .............................. 90% Christian .................................. . ..-.......... . % Hindu ............................................ ...... 3% Buddhist .................................. .. * .. 3% Literacy (1961) - 10 Years of Age and Over ................ 43% Labor Force (1961) - 10 Years of Age and Over ............... 34.5 million Gross Domestic Product (GDP) ........... U.S.$75 per capita INDONESIA : A JOINT IDA-UNFPA POPULATION PROJECT TABLE OF CONTENTS Paae No. SUMMARY AND CONCLUSIONS .................... - iii I. INTRODUCTION o... o s....... *ee@*se*es* ....... o........... ..e .o.... .o... 1 II. IEMOGRAPHICJ SOCIAL, AND ECONOMIC BACKGROUND ................ 1 III. FAMILY PLANNING SERVICES AND PROGRAM .e . ....e........ 2 A. Background ............ .................. . . . . . . . . . . . . . 2 B. Famdly Planning Organization and Administration ........... 3 C. Attitudes Toward F,aily Planning Acceptance .............. 4 D. Family Plannimg Services.. .......................... . . ... 4 E. Family Planning Program Performance ..................... 7 F. Training ...............................................DO o 7 G. Infoin ation and Conmu.nications e............................. 8 H. Service Statistics, Eviluation, and Research ............. 9 I. ForeigL Aid ,...................... .. .......DD...DDD. DD ..DDe .DDDD 9 J. NFPCB Budget ................................................... ...... 10 IV. THE PROJECT ..............................**...................... 10 A. Paramedical Education ........ ............................. 12 B. Renewal of MCH/FP Centers e............. e .... 14 A C. Family Planming Training .................................D 15 D. Nonmedical Field Workers Program ......................... 16 -E. Evaluation and Research Do- .............. ............. 16 F. Family Planming Administration Centers .... . ........ 17 G. Other Transport Fequirenments ............................. 18 H. Hospital Postpartum Program .................. *..... ...*..O. 18 I. Information and Comnunications .....*..................... 19 T. Popul.ation Education ............. .. . .. .......... 19 K. Advisory Team ..............................e.g. O 19 L. Project Implementation Unit ............................. D , 20 V. OSTS, F ING AND CGROXJCT IMPLEXENTATION ......................... 20 A.Costs ................ Dow 20 B. Proposed Financing .......................................... 22 C. Implementation .................. *.. * 23 VI. SOCIO-ECONONIC ANALYSIS . . ........................... .... .. 26 VII. RECO*MENDATIONS ..... eo g... ... . . . .......* * **g* * 27 ANNEXES MAPS This report is based on the findings of a mission in June 1971 to Indonesia comprising Mr. G. Zaidan (Chief of Mission), Messrs. H. M. Jones, J. R. Burfield, and K. V. Ranganathan from the Bank, as well as Miss C. Walsh (Nursing) and Messrs. R. Trengove (Architecture) and J. Ratcliffe (Evaluation) as consultants. The mission was joined by Mr. H. Gille, Associate Director of the United Nations Fund for Population Activities (UNFPA) and Mr. C. R. de Silva of the BankIs East Asia & P&cific Department. This report was prepared by Mr. H. M. Jones, with the cooperation of Miss I. Z. Husain and Mr. J. R. Burfield in particular sections. TABE OF CONTNTS -2- ANNEX NO. Ii Demographic Backgr-ound 2 Selected Economic T^rends 3 CentraL Organization of the National Family Planning Coordinating Board 14 Provincial Structure of the National Family Planning Coordinatiing Board 5 Central Organization of the Ministry of Health 6 Provincial Health Stracture 7 Indonesian Planned Parenthood Association Organization Chart 8 Reorganization of the NFPCB 9 Family Planning Field Worker Program 10 Present Staffing Pattern of Typical Health Center at District Level In East Java 11 Health Services and Facilities in East Java, Bali, and Djakarta 12 Data on Midwifery Schools, 1970 13 Family Planning Sorvices and Performance 14 Total Number Trained in Family Planning Up to June 1971 15 Estimated Traini-ng Load for In-Service Training in Family Planning for All Training Institutions in Java and Bali, 1971-76 16 Standing Committee on Family Planning Training 17 Foreign Assistance to Indonesia in Family Planning, 1968-71 18 Foreign Assistance to Indonesia in Family Plannir.'g, 1969-70 19 Paramedical Education 20 Training Requirements for the Auxiliary Nurse-Nidwife 21 Recommended Integrated NCH/FP Staffing Patterm for East Java, Bali, and Djakarta at Regency Level and Below 22 Sites for MCH/FP Center Construction 23 Requirements for In-Service Training Centers 24 Family Planning Functions of Personnel at Regency Level and Below 25 Recommended Curricula for In-Service Training' of Family Planning Workers 26 Evaluation and PRsearch 27 Project Vehicle Requirmenta 28 Hospital Postpartu Family Planning Program 29 Information and Conunications 30 Development of Population Education 31 Summary of Project Costs 32 Summary of Civil Works Cost Estimates 33 Schedule of Accommodation 34 Project Imlementation Unit 35 Outline of Agreements on Assistance with Implementation by Other Agencies 36 Schedule of Impleaentation for Civil Works 37 Schedule of Diibursements 38 Demographic Impact of the Project 39 Economic Impact of the Project MAPS 1 Java and Bali 2 East Java and Bali Provinces ., , .. 4..; INDONESIA: A JOINT IDA-UNFPA POPULATION PROJECT SUMARY AND CONCILUSIONS i. This report appraises a popluat"Jon project in Indonesia for which an IDA credit of U.S.$13.2 million is proposed. The project has been deve- loped jointly with representatives of the Unf`ied Nations Fund for Popul.ation Activities (UNFPA) from which will be provided foreign exchange for the project in the same amount as the IDA credit. IDA will act as Executing Agent for the UNFPA Thnrds, with responJi.bilityy for project supervision and for disbursement of the UNFPA grant. ii. Indonesia is a country of 121 million people with a low per capita income and with a high population growth rate (2.6%). Nearly two-thirds of this population live on the islands of' Jaava and Bali, two of the most heavily populated regions in the world. This combination of facts makes it unlikely that living standards can be significantly raised unless the rate of population growth can eventually be slowed. The Government is aware of this problem. and has given strong policy support to a national family planning program. In 1970 it established a National Famn-ly Planning Coordinating Board (NFPCB) to take over and expand a program which had been initiated by a voluntary orga- nization. Progress to date has been encouraging, but much higher numbers of continuing acceptors are necessary before any significant effect on the birth rate can be expected. iii. The project consists of a widely dispersed construction program, involving over 300 separate structures, plus an integrated set of noncon- struction activities necessary to increase the effectiveness of the national program. The construction activities will be mainly in East Java, Bali, and the city of Djakarta (in West Java). The project, costing U.S.$33.0 million, over a 5-year period, will account for substantially, all of the national program's physical expansion in East Java, Bali and Djak:arta, and"for the major part of program expansion, in such fields as motivation, training and evaluation, throughout the country. The institution building and technical assistance components of the project will benefit the entire national program. iv. In functional terms, the project will: a. oe motivation services by 1. providing sWport for a ten-fold increase in the number of nonmedical field workers, who are the only full-time field workers in family planning; 2. providing training schools for all categories of staff in the national family planning program; 3. strengthening the capability of the NFPCB to coordinate and direct an effective information program; 4. providing mobile infomation units to take family planning information to village level; and 5. introducing population education into in-school and out-of- school education. b. ipove family plarning Services by 1 renewing present:Ly inadequate buildings which are the foci of the delivery syrstem 2. building trainng fac-ilities to increase the number of para- medical tlaff -ho are responsible for providing the intra- uteri'ne device (IUTD) and coon aceptive pill used by 90% of new acceptors; and 3. supporting the improvement and expansion of the hospital postpartum program. c. strengthen NFPCB'a capacity to coordinate the national program by 1. providing an advisory team covering overall program management, training and comminications; 2. providing technical advisers and foreign fellowships to improve specific program functions and skills; 3. expanding the evaluation and research capability of the NFPCB at central and provincial levels, and enhancing Indonesian institutional research capability to provide es,-3ntial contract research; 4. supporting a&n organizational restructuring to provide the strong managerial capability which the prograr. requires; and 5. building administrative centers needed to house staff, foreign ad.visers, and equipment. v. Total project costs are estimated at U.S.$33.0 million (Rp 13,695 million). The Association, UNFPA, and the Goverment will share these costs on a 40-40-20 basis. The Government's contribution of U.S.$6.6 million will go entirely to its share of the additional operating costs required by the project (IDA and UNFPA will also finance a portion of these costs, on a declining share basis). The total foreign exchange cost is estimated at U.S.$12.8 million. Total government expenditures for family planning are estimated to be about UJ.S.$58 million equivalent between 1972 and 1977. vi The NFPCB would be responsible for the administration and coordina- tion of project activities, and would establish a-Project Implementation Unit (PIU) for this purpose as part of its control organization. The PIU would have twe sections -- one responsible for construction and the other for nonconstruct- ion compoxients. A consulting firm would be retained to advise and assist the PIU on all matters concerning project realization. During negotiations, assurances will be sought from the Government that it will associate other agencies with the implementation of specific project components. These agencies and components are: WHO - hospital postpartum program; UNESCO - communications and population education; UNICEF - vehicle procurement; UN Population Division - two of the evaluation and research components covering the Institute of Demo- graphy and the Populationi Study Center; and the' Population Council of New York - demonstration field postpartum program. Should the Government fail to reach agreement with these agencies, other agencies of similar competence acceptable to IDA willl be associated with these project components. vii. With the exception of the central NFPCB headquarters buildings in Djakarta, the buildings to be constructed are small and scattered and a-re not suitable for international tendering, and will be built by prequalified local contractors on a competitive basis. A contract for the NFPCB headquarters will be awarded on the basis of international tenders. Nonconstruction equip- ment will also be procured on the basis of international competitive bidding except for the hospital equipment (valued at less than U.S.$25,o0o) to be procured by UNICEF to standardize with existing equipment. Vehicles will be procured by UNICEF on the basis of international competitive bidding except when the use of UNICEF's existing long-tenm negotiated fleet contracts is indicated in the interests of fleet standardization and economy. viii. As a result of the project, it is estimated that the number of new acceptors of family planning would increase to a level more than three times higher than would be reached without the project. In 1970-71, about 180,000 new acceptors were reached. Without the project, this might rise to around 5XO,000 per year by 1975; with the project, a figure of 1.6 million is pro- bable. The figures needed to measure with confidence the economic impact of the project do not exist. The use of arbitrary, but conservative assumptions, however, indicates that, in the long run, the project will contribute to an increase in per capita income and a reduction in unemployment. Project costs will be very low compared iith project benefits. INDONESIA: A JOINT IDA-UNFPA POPULATION PRJECT I. INTRODUCTION 101 Since 1966, the Indonesian Government has become increasingly aware of the acute problems which a rapidly growing population pose for its efforts at economic development. With over 120 million people, the fifth largest population in the world,, Indonesia has a current growth rate of 2. , giving an annual increm3nt of some 3 million persons. In his 1971 National Day address, President Suharto said that "the success or failure of /the7 planned parenthood drive is a challenge to the future of the Indonesian nation." 1.02 On assuming responsibility for family planning work, the Indonesian Government invited the Bank Group and the UNDP in JuLly 1969 to help in developing a comprehensive program. A mission, jointly spon- sored by the UN, WHO, and IBRD, visited Indonesia from September to Novem- ber 1969. Its report, outlining a 5-year program to reach 6 million new acceptors in Java and Bali in that period, was presented to the President of Indonesia in July 1970, and formed the basis for the 5-year program subsequently adopted by the Goverment. 1.03 In response to a request from the Government to develop a project within the framework of this program, a preapprai5al mis3ion visited Indanesia in November and December 1970. 1.0L The Government also approached the United Nations Fund for Population Activities (UNFPA) independently in 1970 to fund specific projects within the 5-year program. To coordinate assistance to the Indonesian program, the Bank Group invited the UNFPA to join an appraisal mission which would aim to deve- lop a joint project. The appraisal mission visited Indonesia in June 1971. As a result of this mission, and of subsequent discussions at headquarters, a joint IBRD-UNFPA project was developed. II. DEMOGRAPHIC, SOCIAL, AND ECONCOIC BACKGROUND 2.01 In 1970,, Indonesia had a population estimated at 121.2 million living on five large and some 3,000 smaller islands. Two-thirds of the population are concentrated on the islands of Java and Bali (Fnly 7% of the land area) where population densities approach 550 per km , considerably greater than those of industrialized countries of western, Europe, such as Belgium and The Netherlands. This contrasts with other islands, such as West Irian which accounts for almost 25% of the land area but has a density of only 2 per km2. The population comprises a variety of ethnic groups, but the majority are of Malay origin. Diverse languages and dialects, culture, and social organizations distinguish the groups, the most important being the Javanese. Muslims comprise 90% of the population, the remainder being Christians (L%), Hindus (3%), and Buddhists (3%). Those who can read and write constituted 42% of the population of 10 years and over in 1961. Details -2- of the population are given in Annex 1. 2.02 Between the censuses of 1930 and 1960, the population of Indonesia grew from 60.7 million to 97.1 million. The rate of growth of the population ave. aged 1% per annum between 1931 and 1961, but fluctuated markedly. Vital rates underwent abrupt changes as a result of the World War, and subsequent War of Independence. Mortality dropped in the thirties, rose during the wars, and subsequently declined to an estimated level of 22 per 1,000 persons by 1970 in association with the control of malaria, yaws, smallpox, and other diseases. The birth rate appears to have remained almost constant and was estimated to be 48 per 1,000 persons in 1970. The result has been a rapid acceleration in the rate of growth of the population from 2% per annum in the fifties to an estimated 2.6% per annum in 1970. 2.03 According to the 1961 census data, 42.1% of the population was under 15 years and 2.5% was over 65 years. They indicated a high dependency burdera/ of 88, which must hare increased during the sixties due to constant high fer- tility levels and a decline in infant mortality. 2.04 The rapid growth of the Indonesian population has serious economic and social implications (see Annex 2), the obvious effects of -which are rising unemployment and underemployment, and the severely restricted growth of per capita income. Estimates are unreliable, but there is clearly serious unemployment awd underemployment throughout the country. 2.05 Unless population growth can be curbed, there is a serious question as to whether Indonesia can sustain even a moderate increase in the living standards of its population. The rate of growth of per capita income during the early sixties was scarcely perceptible in spite of an average growth rate of the GDP of 2.6% during the period. III. FAMILY PLANNING SERVICES AND PROGRAM A. Background 3.01 Family planning work in Indonesia was initiated by a voluntary organization, the Indonesian Plamned Parenthood Association (IPPA), in 1957. Its woric was restricted at first by an unfavorable political climate to an information program, directed mainly at women' s organizations. Increasing awareness by the Govermnent of the country's population problem and the need for family planning became evident in 1967, and a modest ser-vice pro- gramr using facilities provided by the Ministry of Health was developed by IP,PA. Its activities then expanded considerably from 8 branches and 52 clinics to 92 branches and 396 clinics by December 1969. 3.02 Govermnent involvement in family planning started with the creation of the National Family Plarming Institute (LKBN) in October 1968. The first 5-year plan (1969-74) included a family planning program designed to reach 3 million acceptors in Java and Bali by the end of the plan period. In spite of this activity, however, there was no effective national program. In July 1/ The dependency burden is calculated as the number of peo le in the age groups 14s and under, and 65 and over per 100 persons in The age group 15-64 years. -3- 1069, the Government asked IBRD and UNDP to help develop a comprehensive government program. At the same time, it assumed responsibility for the IPPA clinical facilities in Java and Bali. A UN-WHO-IBRD mission visited Indonesia in October and November 1969. Following the submission of its report, the President of Indonesia directed that an operational plan be prepared to implement acceptable recommendations. For this purpose, a task force was appointed which produced a 5-year plan; it was based main- ly on the recommendations of the UN-WHO-IBRD Report and d4optad a target of 6 mill-ion new acceptors to be achieved by I976. B. Family Planning Organization and Administration 3.03 The organizational structure of the family planning program derives from Presidential Decision No. 8 of 1970. rne President is responsible for the national family planning program with the Minister of State for Peoples' Welfare responsible for its immediate implementation. The National Council for Guidance of Family Planning was established at ministerial level to advise the President on the "guidance and contrfl of all operations in the field of family planning." To achieve the "coordination, integration, and synchronization of efforts in realizing the national program of family plan- ning carried out by the implementing units,," the semi-autonomous LKBN was replaced by the National Family Planning Coordinating Board (NFPCB). In addition to its main coordinating function, the NFPCB is responsible for generating policy, drawing up implementation guidelines, and coordinating foreign aid. The structural pattern of the NFPCB, which started work in July 1970, is shown in Annexes 3 and 4. 3.04 NFPCB staff are seconded, and draw their basic salary, from other government departments, primarily the Ministry of Health, retaining such rights as those of promotion and transfer. Many senior NFPCB posts, parti- cularly at the central level, are filled on a full-time basis. Most, however, are part-time appointments, adcditional to other official posts. All posts a tract salary supplementsi, and related financial payments include compen- sation to Ministry of Health staff for family planning work, and inducements to those who refer new acceptors. 3.05 Responsibility for translating policies and plans into action lies with the implementing units. The main burden of providing family planning services in Java and Bali falls on the Ministry of Health. Within the Ministry, a directorate is responsible for maternal and child health (MCH) and family planning work. In common with other directorates, its functions are mainly consultative, coordinative, supervisory, and legislative. Execu- tion of the Ministry's plan is primarily the responsibility of the provincial health departments which, because they fund most of their1lctivities, have considerable autonomy. Administration of health services including MCH and family planning, progresses from the Ministry of Health in Djakarta, through the health department in each province down to regency, district, sub-district, and village levels. Its structure at central level is shown in Anex 5, and at provincial level and regency level in Annex 6. Supplementary support is provided by those medical facilities (hospitals and clinics) of the Armed Forces (ABRI) and Police (AKRI) which are open to the general public. The (Christian) Council of Churches and the Muslim Mohammedijah also have faci- lities providing family planning services. 1/ The structure of the national health services is based on a long-term development program prepared by the Government with the assistance of WHO and UNICEF, and described in the Master Plan of Operatiois dated Januar 1969. -4- 3.06 The IPPA is the most important voluntary organization and, since the Government took over the national program, its activities cover training, information, and services outside Java and Bali. The changing role of the IPPA foreshadowed organizational changes in 1970. A staff of full-time, salaried workers has replaced the group of experienced volunteers, with a clear separation of policymakers from executive officials. The organization is indicated in Annex 7. Although no final decisions have been made, thiere is general, informal agreement between the IPPA and the Government that, in Java and Bali, IPPA will play an important part in developing training, research, and information work. In the outer islands, the IPPA will still be responsible for almost every aspect of family planning activities. 3.07 The main orgarnzational problem is the ineffective relationship between the NFPCB and the implementing units, in spite of the recent creation of an ad hoc working committee designed to improve coordination. This is due to the weak administrative component of the NFPCB's organization. To imprve those functions essential to the development of its coordinating role, a modification of the organizational structure is proposed to secure a more effective focus on planning, budgeting, and supervision. This will be a condition of effectiveness. The proposed reorganization is outlined in Annex 8. C. Attitudes Toward Family Planning Acceptance 3.08 The only Knowledge, Attitude and Practice (KAP) study of consequence to measure knowledge of attitudes toward and acceptance of family planning methods was sponsored by IPPA and the Ford Foundation in 1968 and limited to a sample population in Djakarta. The principal impressions were that knowledge of family planning methods is limited, that contraception is practiced by a small fraction of the population and the methods used are generally ineffective, and that despite the paucity of knowledge, there is a high level of interest in learning about family planning. Religious support for the program is increasing and is helped by the Minister of State for Peoples' Welfare, who is a respected Moslem leader. There is little overt opposition to the government family plan- ning program. D. 3.09 In the national family planning program, the facilities and staff of the Ministry of Health's MCH program are used to deliver 80% of the services. Services are also delivered through MCH centers run by the Armed Forces, voluntary organizations, agricultural and industrial3 estates, and doctors and midwives in private practice. Because the program is still in ani early stage of development, most women first hear about family planning through the M.CH staff. Of a sample of new acceptors in the first quarter of 1971, 58% were referred by health workers, 10% by friends who were using contraceptive methods, and 17% by field workers. Of the government health workers, the midwife is an important figure and presently the principal contact with potential acceptors. In 1969, there were about 1,900 midwives working in government MCH services. Midwives and nurses are trained in separate courses for 3 years, after 9 years of general education. In some schools, the sepa"ate courses are being replaced by a 4-year course training nurse-midwives. The first 3 years cover general nursing and the fourth year provides specialist training, one of the options being midwifery. Midwives assist in deliveries, run baby clinics, provide family planning services, and also have associated administrative responsibilities. At lower levels, the two most important categories are the assistant nurse (PKC) and the assistant midwife (PKE); each has 2 years of training following 6 years of general education. In East Java, there are no PKE training facilities; their functions are carried out mostly by untrained assistants to midwives. 3.10 Other important motivators in the field include traditional midwives (dukuns) who are responsible for about 80% of deliveries in rural areas. They are gradually being trained, with UNICEF assistance, in delivery procedures by government midwives. Successful trainees are provided with free de3ivery kits which are renewed each time a delivery is reported to the nearest government midwife. Their training includes a fmuily planning element, and indigenous midwives are playing an increasingly important role in family planning motiva- tion. In East Java, 6,700 of the 14,000 dukuns practicing in the province had been trained by August 1970. In addition to other health workers, and staff from other ministries with extension field staff who also try to recruit acceptors, the full-time nonmedical field workers are being recruited on an increasing scale and beginning to play an important part in the motivation of potential acceptors. to- date, however, only 400 nonmedical field workers have been recruited in Java and Bali, and there are still important questions of organization, training and supervision to be resolved. Annex 9 describes the present state of the field worker program. 3.11 Potential acceptors are referred to family planning clinics, i.e., those MCH centers at which contraceptive methods are offered, either at special sessions or as a routine part of the MCH program. The program is female-oriented, with about 90% of new acceptors using either the IUD or contraceptive pill. In East Java, nearly 90% of the MCH centers are the responsibility of the provinces' health services and of these, 92% are in rural areas. Facilities at village level are rudimentary; for an average village of 2,800 people, there is usually a simple MCH center built by the community and visited perhaps twice a month by a midwife and more rarely by a doctor. At the sub-district (ketjamatan) level, with a typical popu- lation of 44,000 people, there is a permanently manned MCH center with a trained government midwife in charge; some have more than one MCH center. The district (kawedanan), a grouping of five sub-districts, is the main provincial sub-unit for health purposes, headed by a medical officer, with primarily administrative functions, and supporting 3taff as shown in Annex 10. 3.12 In the large cities, the ratio of government MCH centers to the population is lower than in rural areas, but they are supported by a much larger number of private facilities. In the city of Surabaja, for example, the ratio is 1:85,000 for government centers,but 1:35,000 when private centers are taken into account. In the smaller provincial towns, which also act as the headquarters of adjacent sub-districts, the ratio is still better -- in East Java, it is 1 b25,000. Hospital and maternity services are centered in urban areas. In Djakarta, in 1969, 50% of the 160,000 deliveries were reported from maternity instit-utions. 3.13 The provision of MCH facilities and staff in East Java, Bali, and Djakarta, as examples of tha services provided by provincial health authori- ties, is detailed in Annex 11. Because acceptors now use mainly those con- traceptive methods which require the attention of trained medical and para- medical staff in health facilities, an improvement in the basic services -6- provided through the MCH progran is of critical importance to the success of the family planning program. There are three serious constraints to development: a. Shortage of Staff The number of midwifery schools in Java anld Bali is variably reported but best estimates are 6 in Djakarta, 15 in East Java, 1 in Bali, and 22 in the rest of Java, giving a total of 44 for the two islands. Details of the main midwifery schools in the provinces of East Java, Bali and Djakarta are in Annex 12. Provincial medical officers have roughly estimated that for existing MCH, maternity hospital, and administrative purposes, there is, for example, a shortage of 500 midwives in East Java and 700 in I)jakarta. In East Java, the number of midwives gives a ratio of 1:33,000 people (compared with a ratio of 1:4,750 people in West Malaysia). In Bali., the ratio is one midwife for 12, 00 people. The ratio of goverment midwives worxking in MCH centers and, therefore, available for the delivery of family planning services, is about 1:45,000 people. This is extremely low and indicates a need for at least twice as many midwives as presently employed and the improvement and expansion of training facilities. b. Inadequate Buildings There is a shortage of centers and many use inadequate buildings. In East Java, each rural center serves at average of 25,600 persons. In addition to the fact that not all are staffed, their irregular distribution means that wide areas of the country are inadequately serviced. Many of the existing centers are locally built of poor materials and others occupy rented accommodation. The village MCH center is often a room in a house rsnted for two afternoons a month and used as a dwelling for the rest of the time. In a survey made by the Bank in May 1971 of family planning clinics using MCH centers in East Java, nearly 90% needed new buildings or extensive renovations to bring them to standard in terms of space and facili- ties. c. Inadequate Maternity Facilities Maternity facilities in the larger cities such as Djakarta and Surabaja provide for only 50% of deliveries in urban areas. Al- though at the end of 1970 the average number of deliveries per bed in Djakarta in all facilities was 38, the rate of over 80 per bed for public maternity f acilities is well above an acceptable rate of 60 deliveries per bed annually. The decentralization of maternity facilities to smaller 20-bed units in tfhe suburbs of Djakarta and Surabaja is proceeding, but in Surabaja, for example, only 3 out of 16 MCH centers have been provided with such units. They have, however, proved successful in providing better coverage of maternity services and greatlY expanded opportunities for f-mily planning motivation by providing information and services to the recently-delivered mothers. For mall urban, and rural areas, only some 20 beds are provided for maternity cases in each district (kawedanan). -7- E. Family Planing Program Performance 3.14 Of the 1,686 centers which reported family planing activity in September 1971, 86% are operated by government agencies and the remainder by private agencies (5%) and others, including the military forces (9%). Table 2 of Annex 13 shows the distribution of family planning clinics by agency and province. The target of family planning acceptors per clinic!/ month set by the Ministry of Health is 8..0 for the 1971-72 plan year. The actual rate has risen for all clinics fi 8.7 for, 1970 to 15.7 in the first quarter of 1971 and 25.6 in the second quarter of FY1972. Table 3 of Annex 13 shows the rates of acceptors per clinic/month by province. It illustrates an increase in the number of acceptors which is not entirely due to the opening of additional facilities. Data indicate that the centers are now devoting more time to providing family plarming services. 3.15 From 1967 to 1970, the number of acceptors increased over 11 times from 11,363 to 132,307. In FY1970-71, the number of new acceptors totalled 183,442, exceeding the target by 58,442 acceptors. This increase continued in the first half of FY1972, when the full target for this year was exceeded by 35%. Whilst this is encouraging, the total number of women practicing family planning represents only 1.3% oL the women in the fertile 15-44 years age group (compared, for example, with 24% in Taiwan). Details of new acceptors for Java and Bali are shown in Annex 13, which indicate that family planning acceptance is strongest in urban Djakarta and Bali. Female acceptors are generally young (over half are between 20 and 29 years) and have already had four children. The trend has been towards the contraceptive pill as the most frequently accepted method, but, as Annex 13 shows, there are interprovincial variations in contraceptive use. Throughout Indonesia, a vasectomy is not acceptable for cultural reasons; there is, however, a growing awareness among government planners of its potential importance to a family plan- ning program. Abortion is illegal; no information is available on its prevalence in Indonesian society. F. Training 3.16 To date, most family planning training has been done through the IPPA. Between 1963 and 1968, 44 doctors, 20 midwives and nurses, and 23 others were trained at the International Planned Parenthood Federation Regional Training Institute in Singapore. In September 1968, a national training center (NTC) was established by IPPA in Djakarta. It is designed to train and upgrade family planning workers and provincial training center (PTC) teachers, technically supervise PTC work, as well as guide and assist other family planning training programs. The faculty is employed part-time only. With the assistance of the Netherlands Government, a permanent center is being built. Six provincial training centers (PTC) were established by IPPA in mid-1969. They have no permanent buildings, and equipment and books are inadequate. Each PTO is a major unit for training field workars, and is able to train between 275 and 400 annually. The total IPPA training capacity is rated at 2,000 workers per armnum. Details of personnel trained to June 1971 are shown i:< Annex 14. Some family planning training, but only as part of routine refresher courses, has also been undertaken in provincial health training centers. 3.17 The NFPCB has calculated training loads for the current fiscal year and broad estimates for the next 4 years (see Annex 15). There is, however, no clearly defined national training policy and plans to achieves the training -8- of more than 4,000 personnel annually are inadequate. Training responsibi- lities are confused and the present organization and utilization of availa- ble training centers are, therefore, unsatisfactory. None has eitier an adequate number of trained faculty of the correct type needed as trainers or sufficient equipment or accommodation for effective functioning. Their management lacks uniformity and purpose and, in consequence, the relevance of their training function to the national family plarnning program is often marginal. In the PTCs established by the IPPA, the training program has not been fully utilized. Trainees are drawn primarily from among employees of provincial health departments and selection for training is thus the res- ponsibility of health officials. Many PTC facilities and staff are in fact made available to the IPPA by the Ministry of Health. With the lack of central direction, there is considerable overlapping of authority. Curri- culum development lacks the necessary coordination. There is no uniform:ity of salary scales. Standards of training vary considerably, in the absence of firm decisions as to the training load, irn both type and number of trainees, for each center. There is a need for the establishment of a national training committee, an immediate review of training piiroblems and requirements, a clear statement of responsibility and policy, and detailed plans 'for its implemen- tation (see Annex 16). The Government has given assurances that it will establish a standing comnittee on family planning training to be responsible .for recommending to the Chairman of the NFPCB training policies and priorities, the appointment of training responsibilities, and the use for training purposes of the facilities for wbich the project provides. G. Information and Communications 3.18 The NFPCB has information bureaus at central, provincial and regency levels. The information component of the budget was substantially increased from Rp 63 million in FY1971 to Rp 357 million in FY1972. It covers mass communications items such as radio programs, bill board, posters, films, and press releases. The IPPA has accepted an increasingly important role in the dissemination of family planring information by preparing posters and leaflets, and organizing seminars for opinion leaders. It will continue to use mass media such as radi.o and the national press. With the assistance of USAID, the Ministry of Health is developing a program to develop personal-contact motivation to practice family plamning. 3,19 Thius far, the most intensive information program is being carried out in Djakarta. Here, mass media can be used to reach a dense urban popula- tion, the field worker program is more developed than elsewhere in ,Java and a variety of information materials is used in motivation work . The national program's main problems in this field are the successful development of mass media techniques to cover the whole of Java and Bali, the development of information materials suitable for use by field workers, and the means to spread information on family planning to the mass of the rural population. Successful solutions to these problems are essential in maintaining increases in the number of newi acceptors using the daveloping and expanding delivery system. Strengthenirng the Information and Motivation Bureau of the NFPCB to enable greater coordination of' the two main implementing units (Ministry of Information and IPPA), and stimulat,ion of research into improved motivation techniques is needed. Thm provision of mobile units for information work at village level is required and, with more and better trained field workers, will lead to improved knowledge of family planning methods and services. -9- H. Service Statistics, Valuation, and Research 3.20 The NFPCB has established two bureaus in this field, one for report- ing aad recording, and the other for research and evaluation. The links betwee3n research, evaluation, and program operations, however, are unclear and ill-defined,, a problem compounded by the fact that the two bureaus are under separate direction. The NFPCB hlas assumed the responsibility, as if it, wag; an implementing unit for reporting and recording. Until now the seve- ril implementing units have evolved various systems which generally produce i;ucomplete data. To mid-1969, the IPPA collected reports from its clinics, but often achieved only 70% coverage with most reports being submitted up to ) monthls late. An improved and simplified reporting and recording system has been ci'troduced recently. As a result of a better working relationship with the im?lmnting units, and with the assistance of USAID, current performance data htve improved considerably, being more comprehensive and up-to-date than data provided hitherto. 3.21 Because the Bureau of Evaluation and Research has been established for one year only, little evaluation has been accomplished. Some research activities have been initiated by the implementing agencies, such as IPPA and the Ministry of Health, but the lack of sound research techniques and methodology has inhibited progress. Assisted by the Ford Foundation, the IPPA carr-ied out a KAP study in 1968. The Institute of Public Health in Surabaja has carried out useful operational studies of MCH services. Re- search attention should be focused on studies wich have the maximum opera- tional significance. As reliable data are produced, subsequent studies should include contraceptive oontinuanco surveys and KAP studies to provide baseline data against which performance can be matched. They require effi- cient coordination by the NFPCB. I. Foreign Aid 3.22 Financial and comodity foreign assistance, detailed in Annex 17 and Annex 18,has grown from U.S.$2.0 million in FY1969 to U.S.$3.32 million in FYi1971. In the past, asaistance has been channeled through the Ministry of Health and IPPA. The NFPCB is now charged with coordinating all foreign aid for family planning activities. USAID has been the most important donor, directly through the Ministry of Health or indirectly through support to the International Planned Parenthood Federation (IPPF) which is the source of 80% of IPPA finance. Its aid has included oral contraceptives, vehicles, audio- visual and teaching aida as well as medical equipment. USAID will provide assistance for an expansion of health education. Sweden and Japan have also provided contraceptives. UNICEF has committed U.S.$6.0 million between 1971 and 1974 to help the Ministry of Health to upgrade its service structure and provide essential commodities. With UNFPA funds, UNICEF is financing the construction and equipment of one and the upgrading of two more midwifery teachers' schools in addition to providing transport for family planning services. WHO has provided consultancy services and sponsored studies in the fields of training and education; with projected UNFPA support amounting to almost U.S.$1.5 million in 1971-73, WHO will also support medical training in family planning, the extension of cytology services, and other health- related activities. IPPF support is provided through the IPPA. With the assistance qf U.S.$0.2 million from the Netherlands Government, IPIA is building a national training center. - 10 - The Population Council has supplied IUDs and supported postpartum work in 26 hospitals in Java and Bali. The Ford Foundation has provided two con- sultants to work with IPPA, one in overall planning and the other in com- munications, as well as grants for surveys and studies. Aid is currently adequate to meet the needs for contraceptives and existing commitments will be increased to meet the demands of an expaoding program. Should present sources fail or be unable to meet demands, tU,.e Governent would provide contraceptives as required by the program. J. NFPCB Budget 3.23 Budget allocations for the government family planning program have risen substantially from U.S.$75,000 in FY1969 to U.S.$300,000 in FY1970, to U.S.$1,323,000 in FY1971, and in FY1972 to U.S.$3,968,250. Because of the late establishment of the NFPCB in FY1971, only 30% of the budgetary allocation was disbursed. According to the final revised DIP (authority for budget xpeniditure), the carry-over into FY1972 totalled U.S. $837,000, mainly under the items for infrastructure and administration. 3.24 In the NFPIB's budget for FY1972, provision for information and motivation services is nearly 25% of the total, representing twice the previous year's allocation. A further 25% of the budget is provided for the rehabilitation of offices, training schools, MCH/AP centers and equip- ment. Salary supplements, incentives and financial compensation to staff of health services account for 13% of the budget allocation. Administrative overheads are estimated at 17% of the total budget. IV. THE PROJECT Introduction 4.01 As the preceding account makes clear, population activities in Indonesia are going through a critical transition stage. Having accepted the necessity of making population control a major goal of government policyy, and having established an organization and a program to provide the neces- sary services, the Government must now strengthen, broaden and greatly expand the scale of its efforts. This "scaling up" will require a sizeable program of construction, an expansion of health service personnel, a major training effort, the building up of demographic research, the further improve- ment of the statistical reporting system., and, to these ends, large increases in budgetary allocations, and considerable help from abroad in the fonms of both capital and technical assistance. No country has unlimited absorptive capacity, and it would be unwise for Indonesia to attempt to do, through- out the country, everything that now needs to be done. Consequently, the construction and service elements of the project have been limited to three high-prio.rity areas, the provinces of Djakarta, East Java and Bali. The technical assistance provided to the NFPCB and the research institutions will of course affect the development of the total system, not merely deve- lopments within the project areas. However, program expansion outside the project areas during the next 4-5 year period will be at a much slower rate than inside those areas. 4.02 The project has boen developed with the UNFPA which has agreed to IDA acting as Etxecuting Agent, thus being responsible for supervision and disbursement for the joint funds of the IDA credit and UNFPA grant. 4.03 toe comnponents inclutde assistance./for: a. Paramedical Education S.$4.51 million),, constructing 10 new schools to graduate 490 auxiliary nurse-midwives annually, together with vehicles2/ and equipment; b. CHF?P Centers (U.S.$3.77 million), rebuilding 277 MCHtTP centers 226 in East Java, 34 in Bali, and 17 in Djakarta; c. Famil Plannin Trainin U.S. .07 million), constructing 6 new provincial training centers and 10 new sub- training centers for the training of medical and nonmedicae. staff of the national family planning program, together with vehicles, equipment, and training fellowships; d. Nomedical Field Workers Frogrkm (U.S.$4.04 million), covering salary support8tfor 7,000 nonmedical field workers, 1,533 supervisory staff, 129 drivers, and vehicles; e. Evaluation and Research (m.S.$1.7 million), / providing 7 foreign advisers for a total of 20 man-years, 30 man- months for foreign short-tem consultants, fellowships totalling 34 man-years, salary support for additional staff funds for esserntial operational research studies and seminars, and the establishment of a demonstration field postpartum program; f. Family Planning Administration Centers (U.s$0.89 million)-, providing 1 new center in Djakarta for NFPCB headquarters, and 6 new provincial centers at Surabaja, Semarang, Djogjakarta, Derpasar, Djakarta, and Bandung, as well as vehicles and equipment; g. Other TransporttReQuirements (U.S.11.24 million), providing vehicles for health services staff involved in MCLI and family planning activities, 2 foreign advisers for a total of 6 man-years, spares and freight for all project vehicles, and support for a study of the utilization of health service vehicles; -/ Whiere appropriate, provision is made for maintenance and operating costs on a declining basis for the first 4 years of the project -- 80% in the first year, 60% in the second year, 40% in the third year, and 20% in the fourth year. 2/ A sumuary of project vehicle requirements is in Table 1 of Annex 27. /All salary support is provided on a declining basis for the first 4 years of the project -- 80% in the first year, 60% in the second year, 40% in the third year, and 20% in the fourth year. - 12 - h. Hospital Post artum Progran (U.S.$1.87 miLlioi , providing 1 foreign adviser for 2 years, salary support and equipment; i. Information and Counications (U.S. $2.07 million), providing 115 mobile information units, salary support for 237 additional staff, equipment, 36 man-months of short-term foreign consultant services, fellowahipo for 9½! man-years, and studies and seminars; d . Population Education S0 8 llion , providing 1 foreign r or 5 years, funds for seminars and research studies, fellowships for 24 man-years, teaching materials and equipment, and vehicles; k. Advisory Team (U.S.$0.45 million), providing 3 foreign advisers for 2 years in management., training, and communications, in addition to the technical expertise provided in othe,r components, vehicles and office equipment; and 1. Projecst Iplementation Unit (U.S.$0.54 million), providing salary suport for additional staff, fellowships for 4 man-years, and assistance from a firm of consultants in project management. A. Paramedical Education 4.04 This component provides facilities for graduating 50 nurse-midwives and 490 auxiliary nurse-midwives arzually. This training flow takes into account existing shortages and the capacity of the provincial governments to absorb new staff; in East Java, for example, it will only reduce the ratio of midwives to the population to 1:31,000. The Government has given assurances that it will establish and maintain the additional new posts needed to employ staff trained in the schools provided in the project. 4.05 The shortage of paramedical staff for use in the delivery of para- medical services has been indicated above in para 3.13 (a). With the adoption of a 4-year course for nurse-midwivess the demand for additional staff cannot be met until 1979 at the earlient, taking into account the time required to build schools and enlarge classes. A cadre of professional staff requiring on.ry 2 years training has to be developed to meet the shortage as soon as possible. They are auxiliary nurse-midwives (ANiMs) -- multipurpose health workers remponsible for community health care with emphasis on MCH and family planing. An outline of their proposed functions is in Annex 19, and of their training requirements 4n A1nex 20. To reduce economic hard- ship, one of the major causes of student midwife attrition, and to provide for direction of trained staff to essential positions, the project provides for training stipends (see Annex 19) which should be linked to service agreements. The Goverment has given assurances that it will train students to graduate as auxiliary nurse-midwives after a 2-year course under service contracts providing for stipends. 13 - East Java 4.06 The staffing and service pattern outlined in Annex 21 has been accepted as suitable and realistic by the halth authorities of East Java. On this basis, the family planing program would require an additional 176 nurse-midwives -- 139 for supervisory duties at district level and 37 for duty in the maternity sections of regency hospitals. For this purpose, the proJect would graduate 50 nurse-midwives annually, which entails providing claarsoom and hostel accommodation for 240 students in a new school to be attached to the Dr. Soetomo Hospital in Surabaja. Teaching facilities for general nursing and midwifery are adequate at this hospital. The Government has given assurances that it will restrict the new school at Surabaja to the training of nurse-midwives. 4.07 To start ANM training in East Java, the project provides for two new sc.ools, each to graduate 100 ANMs, attached to the hospitals at Malaang and Blitar respectively, and two new schools, each to graduate 50 ANMs, attached to the hospitals at Tuban and Magetan respectively. The former will have accommodation for 2140 pupils each and the latter for 115 pupils each. To provide the necessary rural health experience for student ANMs, provision is made for the renewal of the MCH/FP facilities in 16 district centers, with small dormitory accommodation for students on field visits. These centers are listed in Annex 22. Bali 4.08 The project provides classroom and hostel accommodation for train- ing 70 ANM students at the existing midwifery school in Denpasar. Bali will require 72 supervisory midwives, 151 nurse-midwives, and 186 ANKs according to the model staffing pattern. The island now has 115 midwives working in MCH/FP centers, leaving 32 centers without adequate staff. To meet the current deficit of staff and promote the training of ANMs, the project will provide 30 graduates annually. Adequate MCH/FP centers for rural practice are located close to the hospital. Djakarta 14.09 The capacity of the city to satisfy the shortf'all of some 750 mid- wives is limited because it is impossible to expand existing inadequate training schools. To promote ANM training and provide ANMs as essential supplementary staff to the existing midwives, the project provides for 100 AM graduates annually, trained in two new schools attached to the Sumber Waras and Husada hospitals respectively. To this end, classroom and hostel accommodation for 1 5 students will be built at each location. Adequate facilities for field practice are readily available. West and Central Java 4.10 To initiate ANM training as a pilot school for the subsequent expan- sion of the service components of the project to the rest of Java, it is pro- posed to provide one ANM school each in West and Central Java, each graduating 30 ANlMs annually. The West Java school will be situated at Rangkasbitung, and the Central Java school will be at Kebumen. Both locations provide adequate training facilities. 14 - Supplementary Training 4.11 To upgrade the qualJ.ty of existing staff, the project provides stipends required to attract staff for retraining for which existing faci.lities will be used. The Government has given assurances that sup- plemental training will be provided to upgrade the existing qualifications of existing nurees and midwives, and assistant nurses and assistant mid- wives, to nurse-midwives and auxiliary nurse-midwives respectively. B. Building of MCH/FP Centers Rural 4.12 The project provides for the building of 199 rural, govermnent MCH/FP centers in East Java to replace existing centers. Of these centers, 15 are at district level, with provision for a doctor and supporting staff,, and 188 at sub-district level with a resident midwife and staff. Anl additional 16 district centers will be built with new dormitory accommoda- tion for four trainees in each to facilitate the rural training practice of ANMs. In Bali, 34 sub.-district centers, the focal supervisory centers in the island's health structure, will be built. The total number of exist- ing MCH/FP centers will not be increased by this project component. New facilities are needed to replace existing centers, already inadequate for MCH purposes and unable to meet the demands of an expanding family planning program. 4.13 The program centers on the sub-district MCH/FP center, which is the headquarters of the midwife. This is the lowest level at which a full range of family planning services is regularly delivered; it accom- modates staff essential for the support and supervision of workers engaged in the motivation and information aspects of the program. The sub-district level center is the key local facility for IUD insertions and for ensuring the proper euxamination of women both for precontraceptive assessment and postcontraceptive follow-up care. The centers selected for renewal are now located in dilapidated buildings, many in rented village houses without proper sanitation, privacy, or adequate space. Adequate buildings for the delivery of MCH/FP services are essential to ensure proper asepsis during examinations. The new ouildings (35% of existing centers at district level and 38% of existing centers at sub-district level) will provide the adequate. h-se from which staff can operate family planning services and give pa:rticular attention to women recently delivered at home. Sites are listed in Annex 22. Urban 4.14 The project provides for the building of 11 MCH/FP centers in Sura- baja and 17 in Djakarta, the two largest cities in Java. Of the 16 sub- district supervisory MCH/FP centers in Surabaja, 3 have adequate buildings and local budgetary provision has been made for 2 more, leaving 11 without adequate accommodation. The project ensures that all the city's sub-districts will have adequate MCH/FP facilities with a 10-bed maternity ward. At present, 12 of the 16 centers have resident doctors, in addition to supervisory mid- wives, midwives, and supporting staff. The projecti will facilitate the - 15 - expansion of the urban family planning program by providing adequate accom- modation and allowing for an expansion of the family planning maternity- centered approach, which is working well in three of the city's centers. Of the 15 MCH/FP centers to be built in Djakarta, 9 will be centrally located and have 20-bed maternity wards, while 8 will cover peripheral areas and have 10-bed maternity wards. There are aboiu.t 160,000 deliveries in Djakarta each year, of which about half are in maternrity hospitals and clinics. Assuming a bed utilization rate of 60 per annum, the additional maternity facilities will provide for 15,600 deliveries annually, reducing the current capacity deficit for institutional deliveries by about 20%. The provi3ion of mlall neighborhood maternity units instead of large hospital facilities is designed to achieve wider geographic coverage, thie promotion of local interest and prestige to overcome the latent suspicion of institutional facilities, and the promotion of interest in family planning work among staff where doctors would be otherwise confined to outpatient work. Sites are listed in Annex 22. C. Family Planning Training 4.15 This component covers the construction and equipping of 6 provincial training centers (PTCs) and 10 subtraining centers (STCs). Details of the necessary staff and equipment are described in Annex 23 and details of accom- modation are in Annex 33. The PTCs will be used for the in-service training of medical officers, supervisory midwives, MCH/FP midwives, and ANMs. They will also deal with the training of mass communication personnel, statistical staff, and administrators. PTC staff will also carry out training evaluation, provide supervisory support to lower-level training activities, provide re- training, and prepare teachers for population education work. Each PTC should train 300-500 persons annually and facilities will be provided for instructional and dormitory accommodation for 50 trainees and staff. To improve the teaching standards of the training staff, the project provides for 20 man-years of fellowships for overseas training. 4.16 To provide for the training of supportive workers at village level (nonmedical field workers, group leaders, information officers, and social workers, etc.), 10 subtraining centers (STCs) will be established. They will have accommodation for 30 trainees and staff. The STCs must be accessible to village-level workers and their locations have been selected at regency headquarters. Decentralization will provide training as close to field conditions as possible and help to ensure closer support after training. 4.17 The training bureau of the NFPCB must assist the standing com- mittee (see para 3..7) in detennining priorities and in contracting train- ing centers to implement training programs based on standard curricula. The several centers must concentrate on the training of specific types of per- sonnel; to establish schools catering to all categories will involve wastage of resources and urnnecessary dilution of training potential. Training levels .and loads are shown in Annex 15. A clear definition of the job functions of each type of potential trainee is needed; an outline is provided in Annex 24 but a detailed study of the job functions of primary and supportive workers must be undertaken as soon as possible. Recommendations for training curri- cula are described in Annex 25. 16 - 4.18 To be fully effective, the ongoing training of dukuns and extensive family planning orientation for community leaders must be given by people well known to the conmiunity and must be provided at village level. These are continuing functions of midwives and field workers; they require transport and communications equipment, for which the project provides. D. Nonmedical Field Workers Program 4.19 The project provides salary support, on a declining basis, for 7,000 nomedical field workers and 1,400 additional group leaders, as well as a new supervisory structure of the fielc' rkers program. The latter comprises i15 supervisory staff at sub-dis.,_t level, 12 at provincial level, and 6 at central level. Provision is also made for vehicles to ensure mobi- lity necessary for effective guidance and supervision. 4.20 Nonmedical field workers are the only field staff involved full time in family planning. Government efforts to train more nonmedical field workers will be helped by the fMily planning training component of this project. The contin-aous recruitment of increasingly large numbers of new acceptors can be ensured only by the effective use of nonmedical field workers in face-to- face education and information work. Supervision is essential to control and direct the planmed expansion of the number of field workers. Even with only some 400 field workers, the program is facing serious difficulties caused by lack of interdepartmental communication at field level, varied interpretations of the role of the field worker, and lack of adequate administrative direction from the center. A sound supervisory structure is required to introduce and maintain cohesion and direction. Anmex 9 outlines the background to the family planning nonmedical field worker program as initially conceived, con- siders its problems, and makes recommendations on decisions urgently required to ensure the effectiveness of its contribution to the national family plan- ning program. The Government has given assurances that, the effectiveness of the noimedical field workers program will be ensured by the implementa- tion of financial and administrative measures to be agreed to by the Association. E. Evaluation and Research 4.21 This project component is designed to: a. strengthen the evaluation and research capability of the NFPCB at central and provincial levels; b. enhance Indonesian institutional research capability in providing essential contract research as required and coordinated by the NFPCB; and c. develop a specific research program based on a maternity-centered approach to family planning to provide inforxmtion essential to the development of the national program. 4.22 In its present form, the NFPCB's evaluation and management inform- ation system will be unable to realize its potential importance to program success. To be fully effective, the bureau of reporting and recording and the bureau of evaluation and research must come under one technical director. The Government has given assurances that the bureau of reporting and recording and the bureau of evaluation and research will be brought under - 17 - the direction of one technically competent director. Their capabilities will bJe enhanced by providing a foreign adviser for 2 years with additional short- term consultation, fellowships for overseas training, as well as salary support for additional staff including a demographer, social scientist, arid economist, funding for short-term studies, and for in-country seminars, equipment, and vehicles. This assurance will enable the NFPCB to take a positive lead in directing family planning research and provide an essential forum through which positive, fully documented aspects of the national family planning pro- gram can be publicized. 4.23 The NFPCB's provincial offices have neither the staff nor the equipment needed to carry out primary processing of provincial data. Colla- tion, checking, and basic analysis must be done at this level where referral is easy and checked data are immediately available for operational staff. Salary support for the additional posts of one health controller/statistician and one clerical assistant, and a anall provision for essential equipment is included for each of the six NFPCB provincial offices. The Government has given assurances that it will establish and maintain the additional posts required for the NFPCB's evaluation functions. 4.24 In order to take the leadership in guiding family planning research, the NFPCB should be able to use the best resources available in Indonesia for contract research. The project provides technLical assistance, training sup- port, and equipment inputs for institutions to carry out essential research projects wich are operationally oriented. These institutions are the Institute of Demography and the Population Study Center of the Institute for Social and Economic Research. Annex 26 includes an outline of the studies which require urgent consideration, the techn-ical assistance required, and details of the institutions which would be involved in contract research. 4.25 The project also makes provision for a specific research project based on the Taylor-Berelson proposals for an intermational study of the feasibility of providing comprehensive family planning services based on MCH services. The proposals consider that the use of staff and facilities for service delivery can be maximized by using a maternity-centered approach to farily planning motivation. The project provides for a demonstration of this approach in one regency in East Java with one control regency in West Java. It will be developed in association with the Population Council as part of the international study. Beyond the purpose of testing the effect- iveness of the approach in producing a steady increment in the numbers of family planning acceptors, the demonstration field postpartum program will detennine quantitatively the optimum level of maternity care needed to pro- duce the desired effects with regard to family planning as well as health. Annex 26 details the requirements of the demonstration field postpartum program which include two foreign advisers for 3 years, salary support on a declining basis over 4 years for additional staff, the construction of additional MCH/FP centers, vehicles, equipment and provision for surveys and studies to evaluate the demonstration field postpartum program. The Government has given assurances that it will establish and maintain the additional posts required for the demonstration field postpartum program. F. Family Planning Administration Centers 4.26 lhe project provides for a central family planning administration center in Djakarta and for provincial offices in Surabaja, Semarang, - 18 - Djogjakarta, Djakarta, Denpasar and Bandung. The central NFPCB headquarters in Djakarta provide insufficient working accommodation and staff are unable to function efficiently. There are no offices available in the building for the advisory team, technical advisers, or planned staff expansion in the fields of evaluation and communications. The proposed building includes office space for the NFPCB and advisers, as well as space for evaluation equipment; it will constitute an effective center from which the national family planning program will be administered. Details of the office accom- modation and warehouse space are described in Annex 33. The provincial NFPCB offices are similarly inadequately accommodated and provision is made for new family planning centers now accommodated in buildings owned by provincial health departments. The proiect also provides vehicles and office equipment for the NFPCB's central and provincial administrative services. G. Other Transport Requirements 4.27 This component provides for 115 cars, 1,L400 motorcyclesn, 2 foreign advisers, and survey funds, as well as spares and freight costs for all pro- ject transport requirements. Provision for vehicles has been included under each component. This component provides for 115 cars and 1,400 motorcycles which cannot be appropriately linked elsewhere. The cars and motorcycles are urgently needed for use by regency doctors and midwives respectively. The regency doctor is also the head of the NFPCB regency organization and is required to make regular visits to family planning and health units. Without reliable transport, this is impossible; many of the vehicles pro- vided by UNICEF are obsolete or nearing the end of their economic life. The component provides for one vehicle for each regency. With the addition of family planning, the workload of midwives has increased con- siderably. To increase the.rate of home visits, light motorized vehicle is required. UNICEF is providing 1 ,600 motorized bicycles for this purpose, but an additional 1 ,400 will be needed to cope with the expanding family planning program. 4.28 The organization established in cooperation with UNICEF by the Ministry of Health for the management, servicing, and repair of the health service fleet is in need of considerable strengthening. The project provides for two foreign aLdvisers for 3 years -- one a fleet manager, and the other a maintenance organization manager to assist in the direction and maintenance of a fleet expanded by the demands of the family planning program. To im- prove fleet management and utilization, it also provides for a survey of current transport utilization. A summary of the project vehicle requirements is shown in Table 1 of Annex 27. H. Hospital Postpartum Program 4.29 The Population Council established the International Postpartumi Family Planning Program in 1966 as a demonstration of the value of such an approach in presenting family planning information, education, and services to women during pregnancy and after delivery. Indonesia was among the countries represented in the successful demonstration. This component pro- vides for a foreign adviser for 2 years, salary support on a declining basis -19 - over 4 years for additional staff, equipment and vehicles, in order to allow the Goverent to take over and expand the current program. To the 26 hos- pitals supported up to now by the Population Council, 30 hospitals will be added in the first year of the project and 30 in the next year. Details of the current and expanded programs and inputs needed for the latter are shown in Annex 28. I. Information and Comnunications 4.30 To help with the development of a local capability in this new field, provision is made for essential audiovisual and office equipment, and the necessary transporta-tion., as well as 36 man-months of foreign con- sultancy services, for fellowships and study tours, and for training semi- nars and workshops. In addition, salary support is provided on a declining basis over 4 years for essential, additional staff to strengthen the NFPCB'S Information and Motivation Bureau. The project also provides for the test- ing and trial production al' experimental documents and materials using mass communications media. Detailo are in Annex 29. 4.31 There is also an urgent need to develop the provision of fanily planning information at the peripheral service level. The project makes provision for 115 suitably equipped mobile family planning information units, details of which are at Annex 29. They would form part of the Ministry of Infoxmation's information unit in each regency. Each unit, in.addition to using various media such as tapes, films, etc., would be able to reproduce, on a limited scale, material with local color for distribution down to vil- lage level. The Govermnent has given assurances that it will establish and maintain the additional posts required to strengthen the information and communications program. J. Population Education 4.32 This component is designed to lhelp the Goverrment in introducing the subject of population education into school curri.cula at the most suitable points and into out-of-school education. It provides for one foreign adviser for 5 years, short-term consultants, fellowships for train- ing, equipment needed to develop texts and teaching aids, and support for seminars and workshops to train those who will be involved in furthering the subject of population education as well as community leaders whose influence on its introduction will be critical. Details are in Annex 30. Commui-nication needs in the field of population education are presently both urgent and sensitive. Plarns are needed for the design of curricula and materials, for children and youth, as well as adult community groups of differing ethnic and religious background. The direct, primarily clinical approach to family planning education will not be sufficient to change customs and attitudes wihich must be influenced by long-range education plans conceived quite differently from the strategy employed in urgent- ly communicating information about the national family planning program. K. Advisory Team 4.33 Besides the technical assistance provided where necessary for each component (a total of 11 advisers for 31 man-years), the project also pro- vides for three foreign advisers Lor 2 years to stirengthen the senior manage- ment capability of the NFPCB. The UNFPA has already made available U. S. - 20 $400,000 as preproject financing and the advisers are in the process of recruitment by the Association. The advisers will be seconded to the Government of Indonesia and will be directly responsible to the Chairman of the NFPCB. One adviser will be responsible for program management, a second for family planning training, and a third for family planning communications. Thei4r advice would be directed at the overall national program and not restricted to the scope of this project. The Goverrment has given assurances that it will employ such advisers to the Association's satisfaction. L. Project Implementation Unit 4L3 The project will be implemented by the NFPCB. This demands the effective development of those functions essential to the effective dis- charge of its coordinating role. It will be achieved by a modification of its organizational structure to secure mra effective planming, budgeting, and supervision. A spund managerial element is needed to comaplement the present emphasis on the technical aspects of program development. To this end, the project provides salary support on a declining basis over 4 years to cover the essential additional posts of Deputy Chairman (Program Manage- ment) and two executive assistants. Four fellowship years are aso pro- vided for foreign training in administration and logistics. The proposed restructuring of the NFPCB is in Annex 8 and provides the basis for attaching an effecttve project implementation unit (PIU) (para 5.09 and Annex 34) to the NFPB. To asBist the PIU in the management of the project, provision is made for a firm of consultants to be retained, the functions of which would include the preparation of procedural and design guidelines, assistance with tendering procedures, and the establishment of an effective accounting system. The restructuring of the NFPCB and the appointment of a Deputy Chairman (Program Management) on a full time basis, after views on the qualifications and experience of candidates have been exchanged with the Asscciation, are conditions of credit effectiveness. V. COSTS 3 FINANCING2 AND PROJECT IMPLMENTLTION A. Costs 5.01 The total project cost is estimated at Rp 13,695 million. Of this, Rp 4,524 million (33%) would bet for civil works, Rp 1,079 million (8%) for vehicles, Rp 1,992 million (14%) for technical assistance, Rp 498 million (4%) for equipment not related to civil works, and Rp 3,112 million (23%) for operating costs. Project costs are shown in Annex 31 and summarized in the following table: - 21 - Breakdown by Disbursement Cateagor Foreign Exchange RP (In millions) U.S.$ (In millions) Per Item Local Foreign Total Local Foreign Total centage Civil Works: Construction 2,241 1,535 3,776 5.4 3.7 9.1 40 Furniture and Equipment 83 374 457 0.2 0.9 1.1 80 Professional Fees 249 42 291 o.6 0.1 0.7 10 Vehicles (including Spares aLid Freight) 208 871 1,079 0.5 2.1 2.6 80 Technical Assistance: Advisory Services 208 705 913 0.5 1.7 2.2 75 Fellowships 83 208 291 0.2 0.5 0.7 65 Research/Survey Funds 705 83 788 1.7 0.2 1.9 10 Equipment (Audio- visual, etc.) 42 456 498 0.1 1.1 1.2 90 Operating Costs: Personnel 2,614 - 2,614 6.3 - 6.3 - Maintenance 457 41 498 1 .1 0.1 1 .2 10 Contingencies 1 s494 996 2,490 3.6 2li 6.o 40 TOTAL 8,384 5,311 13,695 20.2 12.8 33.0 5.02 The distribution of expenditures according to the functional com- ponents presented in the project description is as follows: Breakdown by Functional Category U. S. $ (In millions) Tech- nical Opera- Civil Vehi- Assist- Equip- ting Per- Item 'Works cles ance ment costs Total centage Paramedical Education 3.90 0.06 - 0.02 0.53 4.51 16.7 MCH/FP Centers 3.77 - - - - 3.77 14.0 Family Planning Training 2.12 0.15 0.20 0.07 0.53 3.07 11.4 Nonmedical Field Workers - 0.74 - - 3.30 4.04 15.0 Evaluation/Research 0.28 0.04 2.46 0.15 0.64 3.57 13.2 Family Planning Adminis- tration Centers 0.81 0.03 - 0.04 0.01 0.89 3.3 Other Transport Require- ments - 0.97 0.21 0.05 0.01 1.24 4.6 Hospital Postpartum Program - 0.02 0.10 0.04 1.71 1.87 6.9 Infonmation and Communications - 0.59 0.23 0.72 0.53 2.07 7.7 Population Education - 0.01 0.73 o.o8 0.16 0.98 3.6 Advisory Team - 0.01 0.34 0.05 0.05 0.45 1.6 Project Inplementation Unit - - 0.46 0.01 0.07 0.54 2.0 TOTAL 10.88 2.62 4.73 1.23 7.54 27.00 100.0 Contingencies 6.00 TOTAL PROJECT COST 33.00 - 22 503 The budgeted costs for civil works, detailed in Annex 32, were based on current costs obtained from the Ministry of Public Works and Power, the provincial Directorates of Planning and Construction, the Building Information Center. and the National Building Research Instit-ute. In addi- tion, two of the five largest semi-nationalized building corporati ns were consulted. The unit cost rates employed vary from Rp 25,000 per m for simple small unit construction, to Rp 40,000 per m2 for multi-storey con- struction. Furniture and equipment costs are based on current market prices. Fees to cover the cost of architectural design and documentation, and adju- dication of bids have been taken as between 5% and 8% of the cost of the works, depending on the degree of repetition. Costs of imported items are net of any duties, from which the project will be exempted. The costs of site surveys and of building permit taxes have been excluded. Schedules of accommodation for facilities for which the budgeted costs have been estimated are in Annex 33. 5.04 The estimates include provisiorn of 10% for contingencies for unforeseen works and quantity changes. In addition, an allowance of .5% per annum is included for price escalation on all items. Inflation in Indonesia has recently been brought under control and an escalation rate of about 5% per annum is considered reasonable. Physical and escalation contingencies are the same for local and foreign expendi-tures. B. Proposed Financing 5.05 The projecb would be financed jointly by a proposed IDA credit and a UNFPA grant. The UNFPA has agreed to make an unconditional pledge of its full contribution towards the esti.mated expenditure of the first 2 years of the project (about U.S.$8.0 million) and 25% of the final 3 years (about U.S. $1.3 million) from existing resources. The balance of U.S.$3.9 million has been pledged subject to the availability of funds. As usual under an IDA credit agreement, the Government would have residual responsibility for pro- viding funds needed to complete the project. The financing plan prepared for the project is shown below: Rp U.S.$ Percentage of (In millions) (In Millions) Project Costs IDA Credit 5,478 13.2 40 UNFPA Grant 5,478 13.2 40 Government of Indonesia Contribution 2,739 6.6 20 TOTAL 13,695 33.0 100 - -:k - 5.o6 IDA and UNFPA would be jointly responsible for the total costs net of taxes of civil works, transport, technical assistance and equipment. Operating costs, which are incremental and additional to the present costs of the national program, would be funded on a declining basis with IDA and UNFPA sharing 80% of these costs in the first year, 60% in the second year, 40% in the third year, and 20% in the fourth year. The Government would con- tribute the balance and be responsible for all operating costs in the fifth year of the project. Prcovision is made for such assistance because of the burden created by the Governnent's proposal to spend about U.S.$58 million (excluding the IDA-UNFPA contribution to the project) in the period 1972-77, about 60% of which covers operating costs to maintain the momentum of the national program. 5.07 The proposed credit would contribute U.S.$13.2 million equivalent or about 40% of the total project costs. The credit and grant would together cover the whole of the foreign exchange component and about 70% of local cur- rency expenditures as well. The Government would contribute 20% of total project costs. The prior effectiveness of the UNFPA grant is a condition of credit effectiveness. C. Implementation 5.C8 To ensure the proper execution of the project, efficient coordination within the Government of Indonesia, and liaison with the Association, the NFPCB would be responsible for the administration and coordination of the project. In addition to its established mechanidss for coordination and cooperation, the NFPCB would establish a project implementation unit (PIU) as part of its central organisation. The PIU would be headed by the Deputy Chairman (Program Management) of the NFPCB and would consist of two major wings -- one dealing with the project's physical planning and construction, headed by a Construction Coordinator, the other dealing with project teclnical assistance, transportation and equipment, headed by a Program Input Coordinator. The functions of these two administrators and the structure of the PIU are described in Annex 34. The PIU would have appropriate supporting staff, including an accountant, procuremeInt officer, draftsmen and clerical staff. The Deputy Chairman (Program Management) would be assisted by a project implementation comnnittee (PIC) comprising represen- tatives of the Ministries of Health, Public Works, Information, Finance and Interior, and representatives of the international agencies and private foreign foundations involved in the implementation of the project. 5.09 The need to coordinate and establish overall building and operations procedures for the project and generally supervise all aspects of physical implementation, as well as the coordination of procurement of materials, vehicles, equipment and administration of fellowships and study tours, requires the employment of professional advisory manpower beyond the existing resources within t.he Government. It is proposed, therefore, to retain a firm of management consultants, on terms and conditions acceptable to the Association, to advise and support the PIU on all matters concerning the realization of the project. The establishment and staffing of the PIU, and the conclusion of contracts with the consulting firm are conditions of credit effectiveness. 5.10 Pruper environmental and constructional standards for the physical components of the project, as well as general supervision of the implementa- tion of construction, will be the responsibility of an architectural team. It is proposed that these functions should be performed by the Hospital Design Workshop of the School of Architecture of the Institute of Technology at Bandung, heacded by the Deputy Head of the school. This team, augmented as required, and referred to as the Appointed Architect, will be retained by the Government of Indonesia, by a form of agreement on terms and conditions acceptable to the Association. The signing of this agreemen t is a condition of credit effectiveness. The Appointed Architect will work in close coopera- tion with the Construction Coordinator in the PIU, the Ministry of Health, the Minis-try of Works, and its provincial directorates, as well as the Regional Housing Center of the Ministry of Works in Bandung. The Ministry of Works will be responsible for complete surveys and description of all sites, as well as detailed supervision of the execution of the works. The duties and functions to be performed by the Appointed Arcehitect and the Ministry of Works are detailed in Appendix C of Annex 34&. The Government has given assurances that it will acquire not later than 15 months from the signing of the Credit Agreement all land and rights in land required for the construction and operation of the facilities included in the project, and that it will provide to the boundary of each site, as necessary, connecting roads, sewerage, power, water and other supporting facilities. Fees for the professional services of the Appointed Architect will be determined on a fixed fee basis. Projects will be packaged for tendering according to recommendations agreed between the Appointed Architect and the Construction Coordinator and submitted to the NFPCB. A schedule showing the timing of the implementation of the construction components is in Annex 36. Implementation of Nonconstruction Components 5.11 Nonconstruction components would be implemented through the appro- priate bureaus of the NFPCB and the implementing units of the national family planning program. In order to ensure adequate support for the NFPCB in its implementation of specific components in which Indonesian technical expertise is presently inadequate, the Goverment has given ass-urances that it will make appropriate and effective arrangements satisfactory to the Association with WHO, UNESCO, UNICEF, other United Nations bodies, the Population Council, or other sources of expertise acceptable to the Association, for assistance in carrying out, respectively, the hospital postpartum prograa, the information and education activities, the vehicle and transportation components, the assistance to the Institute of Demography and of Economic and Social Research, and the demonstration field postpartum program. Contracts and Procurement 5.12 Contracts for the construction of the family planning administration center in Djakarta, estimated to cost U.S.$316,000 equivalent, would be awarded on the basis of international competitive bidding. The rest of the civil works contracts, will be packaged by the Appointed Architect with the cooperation of the Construction Coordinator and the Ministry of Works. Since they comprise small units scattered at 310 sites in Java and Bali, they would not be suita- ble for international bidding and would be awarded on a competitive basis after bidding by prequalified local contractors. Some furniture contracts are likely to be awarded to local firms. Domestic manufacturers qf furniture and equipment would be accorded a preferential margin equal to 15% of the CIF costs of competing imorts or to the existing rate of duty, whichever is the lower. 5.13 Small amounts of hospital equipment (estimated at less than U.S. $25,000 equivalent) would be procured direct from UNICEF stocks to standardize with equipment previously supplied by UNICEF; other equipment (such as office, data processing and audiovisual equipment) would be either packaged for inter- national bidding, or as is more likely, obtained by domestic tendering in Indonesia where a large number of overseas suppliers are represented. 5.14 Vehicles and spares would be procured by UNICEF for the Government on the basis of international competitive bidding except when the use of UNICEF's existing long-term negotiated contracts and preferential freight rates is indicated in the interests of (a) the standardization of vehicles supplied by the project with the existing fleet of over 600 vehicles already supplied by UNICEF for the health services; (b) economy in quality and variety of spares required; and (c) economy in maintenance because vehicles would be maintained together with the fleet under existing arrangements with the Ministry of IHealth. Disbursements 5-15 Disbursements will be administered by the Association on behalf of UNFPA, who will deposit funds quarterly in advance in accordance with estimates of disbursements. IDA and UN'PA funds will be used jointly in equal proportions to finance the total cost of civil works, vehicles, technical assistance and equipment (about U.S.$19.5 million); 80% of the operating costs in the first year, 60% in the second year, 40% in the third year, and 20% in the fourth year of the project, representing approximately 32% of the total operating costs (about U.S.$24 million); about U.S.$4.5 million remains for contingencies. Disbursement requests against civil works, vehicles, technical assistance and equipment will be supported by the Association's usual requirements of contracts, invoices, statements of work performed and evidence of payment and shipment where applicable. For the operation and maintenance costs, claims will be supported by a state- ment of expenditures, certified by the Deputy Chairman (Program Management). The Government has given assurances that the accounts and financial statements of the NFPCB related to the project will be audited at least annua2llY by independent auditors acceptable to the Association. The UNFPA has already provided funds to finance the advisory team which is expected to be appointed shortly; it is intended that IDA funds be used, after effectiveness, to finance 50% of all expenditures already incurred to that date. UNFPA has no objection to guaranteeing 50% of all "agreements to reimburse" entered into by the Asso- ciation; it will not, however, collect colrmaitment fees for 'cheir portion of any irrevocable commitment. 5.16 In order to take into account the fact that the Bank Group and the United Nations do not have identical memberships, and that the availability of the additional final amount of the UNFPA grant remains subject to confirm- ation by the UNFPA, the arrangements for disbursement described in para 5.15 would not be followed when: - 26 a. withdrawal of the proceeds of the credit in respect of the cost of goods and services is precluded by the fact that they were obtained from countries which are not members of the Bank (other than Switzerland); and b. the UNFPA notified the Association that (i) any disbursement from the UNFPA grant would be in violation of rules applicable to the use of the UNFPA grant, or (ii) there were insufficient grant funds available for which to disburse. In the case of (a), the Association, upon instruction from UNFPA, would dis- burse against such costs entirely out of the UNFPA grant as specified in such instructions. Provided it involves a Bank member or Switzerland, in the case cf (b), the Association would disburse such UNFPA funds as are available, if any, and pursuant to the Development Credit Agreement, proceeds of its credit only. In the event of any non-shared disbursement of this kind, the UNFPA, and the Association would consult on the making of adjustments to future dis- bursements which may be appropriate cr desirable in order that total disburse- ments from the UNFPA grant and from the credit remain, as nearly as practicable, equal. 5.17 Project expenditures are estimated to be approximately as follows: U.S.$ (In millions) 1972-73 1973-74 1074-75 1 1976-77 Total IDA Credit 2.5 5.5 3.2 1.5 0$5 13.2 UNFPA Grant 2.5 5.5 3.2 1.5 G.5 13.2 Goverrment of Indonesia Contribution 0.3 0.8 1.3 1.8 2.4 6.6 TOTAL 5.3 11.8 7.7 4.8 3.4 33.0 A schedule of estimated disbursements is shown in Annex 37. VI. SOCIO-ECONOMIC ANALYSIS 6.o0 The conflict between the high rate of population growth and the objective of raising the living standards, and the elimination of unemploy- ment for the large numbers has been clearly realized by the Indonesian Government. The project will reinforce and expand the Government's efforts to reduce fertility, thereby creating consideirable social and economic bene- fits. It wilL contribute towards an increase i.n per capita income, an improvenent in the balance of paments, ande a reduction in unemployment. Improvement in matermal health through less frequent child bearing and the provision of better MCH services wil1 reduce maternal mortality. Infant mortality will also decline due to better nutrition and care resulting from smaller families. In addition, it will also contribute in (a) reducing tension and social problems associated with economic pressures and unemploy- ment, and (b) promoting social justice through equalization of opportunities by serving the poorer sections of the coommunity with usually larger families. ° 27 - 6.02 The (quantitative benefits estimated to be obtained from an addi- tional reduction in fertility with project inputs over that with ongoing program are only illustrative. In the absence of data for Indonesia, in some cases, assumptions are based on experience in other countries. 6.03 The number of acceptors of family planning is estimated to increase from about 270C,000 at present to approximately 1.6 million in 1975 with the project inputs instead of less than 500,000 without them. By 1980, it is estimated tiat about one-fifth of the females in reproductive ages in Java and Bali would accept family planning with the project inputs as against less than 10% without them. This proportion is estimated to increase to more than half by 20CO due to program improvement through the project, in- stead of less than one-fourth without it. 6.04 As a result of the above measures, the gross reproduction rate in Indonesia is estimated to decline from 3.2 at present to 1.7 (implying a birth rate of 27.4) by 2000 with the project inputs instead of 2.6 (implying a birth rate of 39) without them. This represents over twice as large a decline in fertility as a result of project inputs than would otherwise be the case. The population is estimated to be smaller by about 39% in 2000. With the ongoing program, the rate of growth of the population would be about 3% per annUm in 2000, but would be reduced to less than 2% per annum with the project inputs. (An analysis of the demographic impact of the project is given in Annex 38.) 6.05 The way in which the effect of reduced population growth is trans- lated into economic benefits is illustrated in Annex 39. The economic benefits of a reduction in population size, expressed in terms of an in- creased per capita income, are clear. The per capita gross domestic product (GDP) is estimated to be higher by 6% with the reduction in the populat,ion growth rate. The total cost of the project is in the order of 1% of the investment as necessary for an equivalent increase in per capita income. 6.06 A slowing of population growth would also have favorable balance- of-payment effects in an economy such as Indonesia's, which has required heavy food-grain imports in recent years. While these benefits would become substantial by 1980 if present food shortages and balance-of-payment tight- ness continued through the decade, expected developments in the agricultural and petrole-u sectors are expected to make these benefits less important than they now appear. 6.07 In the long run, the project will contribute to a slowdown in the growth of the labor force (assuming no significant change in the participation rate). In a country with serious problems of employment and underemployment, and with uncertain prospects of solving these problems through high econoLic growth rates above, any reduction in the growth of the labor force should be beneficial. With the project, the labor force is estimated to be lower by nearly 5 million in the year 2000, with consequent favorable effects on the employment situation. - 28 - VII. AGRI3EMENTS REACHED AND RECOMENDATION 7.01 During negotiations, assurances were obtained from the Government of Iridonesia on the following points: a. A standing commuittee on family planning training will be esta- blished to be responsible for recommending to the Chairman of the NFPCB training policies and priorities, the appointment of training responsibilities and the use for training facilities for which the project provides (para 3.17); b. Sufficient additional posts will be established and maintained to employ staff trained in the new paramedical schools provided in the project (para 4.04); c. Stiidents will be trained to graduate as auxiliary nurse-midwives after a 2-year course under service contracts providing for stipends (para 4I.05); d. The new school in Surabaja will be restricted to the training of nurse-midwives (para 4.06); e. Supplemental training will be provided to upgrade the existing qualifications of existing nurses, midwives, assistant nurses and assistant midwives to nurse-midwives and auxiliary nurse- midwives respectively (para 4,11); f. The effectiveness of the nonmedical field workers program will be ensured by the implementatiLon of such financial and adminis- trative measures as agreed to by the Association (para 4.20); g. The bureau of evaluation and research and the bureau of reporting and recording will be brought under the direction of one technically competent director (para 4.22); h. Additional posts required for the NFPCB's evaluation functions (para 4.23), and for the demonstration field postpartum program (para 4.29) will be established and maintained; i. Additional posts required to strengthen the information and communications program will be established and maintained (para 4.31); J. Not later than 15 months from the signing of the Credit Agreement, all land and rights in land required for the construction and operation of the facilities included in the project will be acquired by the Government, which will also provide, to the boundary of each site, as necessary, connecting roads, sewerage, power, water, and other supporting fa"ilities (para 5.10); 29 - k. Appropriate and effective arrangements satisfactory to the Association will be made with WHO, UNESCO, UNICEF, other United Nations bodies, the Population Council, or other sources of expertise acceptable to the Association for assistance in carrying out, respectively,, the hospital postpartum program, the information and education activities, the vehicle and transportation comuponents, the assistance to the Institutes of Damography and of Economic and Social Research, and the demonstra- tion field postpartum program (para 5.11); 1. The accounts and financial statements of the NFPCB related to the project will be audited at least annually by independent auditors acceptable to the Association (para 5.15); 7.02 As conditions of credit effectiveness: a. the NFPCB organization will have been restructured substantially as set out in Annex 8 and an appointment on a full-time basis made to the post of Deputy Chainman (Program Management) after views on the qualifications and experience of candidates have been exchanged with the Association (para 4.34); b. the PIU will have been established substantially as set out in Annex 34 and staffed to the satisfaction of the Association, and the management consultants employed (para 5.09); C. the UNlFPA's grant to the joint project will have become fully effective under its agreements with the Goverment and the Asso- eiation (para 5.07); and d. the agreement retaining the Appointed Architect will have been made by the Government on terms and conditions satisfac tory to the Association (para 5.10). 7.03 Subject to the assurances and fulfillment of conditions described above, the project provides a satisfactory basis for a development credit, of U.S.$13.2 million equivalent, to the Government of Indonesia, equal to 40% of total project costs. February 29, 1972 ANNEX 1 Page 1 of 10 DEMOGRAPHIC BACKGROUND Population Growth 1. According to the 1930 census, the population of Indonesia, covering Java, Madura, and the outer islands, was 60.7 million. It reached 97.1 million Ln the next census of 1961. The census was undertaken in September 1971 follow- ing an unsatisfactory preenumeration in 1970. The results of the census are not yet available. The population estimates are, therefore, tentative and may change on the basis of census data. Various estimates of population for 1970 indicate that the size of the population would be around 121 million. The rate of growth of population fluctuated during 1931-61. It was around 1.5% per annum in the thirties, with a birth rate of about 48 and a death rate of more than 33. The death rate declined later to 27.8. In the decade of the forties, vital rates underwent abrupt changes as a result of the Japanese occupation during World War II. While fertility might have declined during this period, mortality increased sharply to 35.1, resulting in lower rate of growth of population of 0.9%. During the fifties, the decline in mortality and probable increase in fertility, due to the reunion of couples separated during the war, contributed to a growth rate of around 2% per annum. In the 1960's, the rate of growth of population was estimated at 2.5% per annum (see Table 1). In recent years, it is estimated to have accelerated to 2.9% due to the fall in death rates to 19 and a constant birth rate of about 48. Regional Estimates 2. In 1961, about 65% of the population lived in Java and Madura, 16% in Sumatra, and 1.8% in Bali (see Table 2). East Java is the biggest province in Indonesia in terms of area and population. More than one-third of the population lives in East Java and Bali. 3. In area and population, East Java is the largest of Java's six provinces (see Table 3). With the island of Madura, it covers an area of 48,000 km2, and at the 1961 census had a population of 21.8 million. The 1970 population estimate is 24.8 million. Surabaja, the provincial capital, has a population of about 2.1 million; with seven other municipalities, the urban population totals 3.3.million, or about 13% of the total provincial population. 4. Bali, an island close to East Java, has a population estimated at 2.1 million and covers an area of 5,561 km2. Culturally, it is quite dif- ferent from East Java; the people speak Balinese, a Polynesian language, and 90% are Hindu. With about 375 persons per km2, Bali is one of the most densely populated islands. Fertility and Mortality 5. In the absence of reliable, vital statistics, fertility and mortality estimates are based on age-structure data from the 1961 census. They are sup- ported by some surveys in different parts of the country; so far, there has been no national survey, On these bases, the birth rate in 1961 was estimated ANNEX 1 Page 2 of 10 at 47.6 for the country as a whole. The corresponding general fertility rates1! and gross reproduction rates2/ were 207 and 3.1 respectively. The death rate was estimated at 22.4, while the expectation of life at birth worked out at 45 years. Since 1961, there seems to have been little change in these rates except for a slight fall in the death rate. It is difficult to say how much reliance can be placed on regional estimates of fertility and mortality. While mortality does not differ among different regions in Indonesia, fer- tility is highest in West Java and lowest in Djogjakarta (Table 4). The age-specific fertility rate reveals a curve with a plateau typical of high fertility countries. Fertility is high at ages 20-29 with a peak at ages 25-29 years. It contitues to be high at the later ages of 30-34 years (Table 5). Age and Sex Structure 6. According to the 1961 census, the age structure of the population revealed that 42% of the population was under 15 years of age and 2.5% over 65 years (Table 6). The sex ratio was 103 females to 100 males. The age structure indicated a dependency ratio of 88. Although the actual age and sex structure of population will not be available until after the 1971 census data are released, it seems that the dependency ratio has not improved because of the constant high level of fertility during the intercensal decade. Age at Marriage 7. The mean age at marriage is 25 years for males and 18 years for females. The proportion among single females has increased only slightly from 52% in 1930 to 56% in 1960. There has, therefore, been little increase in the mean age at marriage of females. Future Population Estimates 8. According to the UN population projections of constant fertility and sharply declining mortality, the population of Indonesia will double before 1995 and reach 329 million by the year 2001. The rate of growth of population would be more than 3% in 1986 and 3.7% by the year 2001. Even if fertility is reduced to half, the popuiation size will still be around 255 million and the rate of growth of population would remain at Education 9. The literates, or those who can read and write in Latin characters, constituted 42.9% of the population of 10 years and over in 1961. Out of some 15.9 million children of 7-13 years of age, 8.2 million or 54.27% were at school. Assuming that there will be no moderation of fertility, the number of children in similar age group is estimated to increase to 29 million by 1986 and 44 million by 2001. Children in the secondary schools (13-18 years) would numiber around 36 million by year 2001 without a decline in fertility (Table 7). 1/ The number of births per 1,000 women in the reproductive age groups (15-44 years). 2/ The average number of females born to a woman during the whole of her reproductive period. ANNEX 1 Page 3 of 10 Urbanization 10. Less than 15% of the population in Indonesia lives in urban areas. After World War II, there was a steady migration to the towns, but their over- all growth rate is estimated to be no greater than the national average; a lower than average increase in the natural growth rate has been supplemented by steady in-migration. The population of Djakarta has increased sharply from 533,000 in 1930 to around 1.8 million in 1955 and is now estimated to be about 4.2 million. It covers an area of 577 kmn; the 1970 density was estimated at some 7,300 per km2. Since 1947, migration to Djakarta from rural areas and small towns has proceeded continuously and since 1961 has exceeded 100,000 persons annually. With a relatively constant death rate and steadily rising birth rate, the natural rate of population increase. rose from about 2% before 1960 to about 3% in 1970. One-half of the popu- lation is under 20 years of age. The Governor declared Djakarta a closed city in 1970. The tangible results of this rapid increase are expressed in rising unemployment public health problems, inadequate public utilities, and congested housi.,g conditions. Ethnic Composition 11. The population comprises a variety of ethnic groups but the majority are of Malay origin. Diverse languages and dialects, culture, and social organizations distinguish the groups, the most important being the Javanese. Muslims comprise 90% of the population,-che remainder being Christians (4%), Hindus (3%), and Buddhists (3%). ANNEX I Page 4 of 10 Table 1 POPULATION TRENDS IN INDONESIA. 1930-70 (In thousands) Rate of Growth Java and Outer Java and Outer End of the Year Madura Provinces Indonesia Madura Provinces Indonesia Census 1930i= 41,718 19,000 60,727 - 2/ 1940 - 48,416 22,060 70,476 1.5 1.5 1.5 19501/ 50,456 26,751 77,207 0.4 2.0 0.9 19612/ 63,289 34,161 97,450 2.1 2.8 2.1 197032/ 77,224 43,875 121,199 2.2 2.9 2.6' Source: Statistical Pocket Book of Indonesia 1963. U.N. PFopulation Projections - Medium Variant. 1/ Government of Indonesia Census. 2/ Government of Indone\sia Estimates. 3/ UN Population Projections - Medium Variant. ANNEX 1 Table 2 Page 5 of 10 INDONESIA: POPULATION BY PROVINCE AND SEX, 1961 (In thousands) Province Males Females Total Djakarta 1,481 1,426 2,907 West Java 8,658 8,957 17,615 Central Java 8,968 9,440 18,408 Djogjakarta 1,092 1,149 2,241 East Java 10.602 11.220 1>822 Total: Java and Madura 30,801 32,192 62.993 D. I. Atjeh 822 807 1,629 North Sumatra 2,514 2,450 4,964 West Sumatra 1,118 1,201 2,319 Riau 637 598 1,235 Djambi 386 358 744 South Sumatra 2,466 2,382 4,848 Total: 5unatra 7,943 7,796 15,739 West Kalimantan 802 779 1,581 Central Kalimantan 251 245 496 South Kalimantan 726 747 1,473 East Kalimantan 287 264 551 Total: Kalimantan 2,066 2,035 4,101 North and Cent:ral Sulawesi 1,015 988 2,003 South and Southeast Sulawesi 2.475 2,601 5,076 Total: Sulawesi 3,490 3,589 7,079 Bali 884 899 1,783 West Nusatenggara 893 914 1,807 East Nusatenggara 984 983 1,967 Total: Bali and Nusatenggara 2,761 2,796 5,557 Maluku 403 387 790 West Irian 375 383 758 Total 778 770 1,548 TOTAL 47,839 49,178 97,017 Source: Central Bureau of Statistics. ANNEX 1 Page 6 of 10 Table 3 JAVA AND BALI: PROVINCIAL POPULATION ESTIMATES AND DENSITIES, 1970 Population 1/ 2/ Densit! Percent of Province (In millions) Area Km2 per Km Population Djakarta 4.23 577 7,331 5.5 West Java 20.97 46,300 452 27.7 Central Java 21.36 34,206 624 28.2 Djogjakarta 2.41 3,169 760 3.2 East Java 24.83 47,922 517 32.7 Bali 2.09 5,561 375 2.7 100.0 Java and Bali 75.89 137,735 550 I/ Government of Indonesia Estimates. 2/ Government of Indonesia Statistical Pocket Book 1963. ANNEX 1 Page 7 of 10 Table 4 ESTIMTES OF REGIONAL FERTILITY AND MORTALITY DIFFERENTIAL IN INDONESIA (1961) Gross General trude Crude Rate of Repro- Ferti- gitth Death Natural duction lity Region R ate Increase Rate Rate West Java 49.8 22.5 27.3 3.459 .2130 Central Java 46.8 22.3 24.5 3.161 .2076 Djogjakarta 399 22.3 17,6 2.508 .1681 East JavTa 42.7 22,2 20.5 2.771 .1830 Java 46.1 22.3 23.8 3.059 .2009 Sumatra 51.6 22.6 29.0 - .2240 Kalimantan 48.2 22.4 25.8 - .2089 Sulawesi 49.5 22.5 27.0 - .2185 Other Islands 49,6 22.5 27.1 - .2213 Outer Provinces 50.2 22.6 27.6 .2176 Indonesia 47.6 22.4 25.2 3.1 .2073 Source: Iskandar, S. Somie Monographic Studies on the Population in Indonesia; University of Indonesia, Djakarta. ANNEX 1 Page 8 of 10 Table 5 lmjLvIA: AGE-SPECIFIC FERTILITY RATES, 1965-70 (Births per 1,000 of Women) Age-Specific ASe Fertility Rates 15 - 20 years 0.119 20 - 24 years 0.324 25 - 29 years 0.334 30 - 34 years 0.257 35 - 39 years 0.175 40 - 44 years 0.078 45 - 49 years 0.022 Source: U.N. Estimates. ANNEX 1 Table 6 Page 9 of 10 INDONESIA: POPULATION BY SEX AND AGE, 19611/ (In thousands) Age Group Males Females Total % 0 - 4 8,462 8,580 17,042 17.7 5 - 9 7,684 7,639 15,323 15.9 10 - 14 4,319 3,861 8,179 .8.5 15 - 19 3,834 3,874 7,708 8.0 20 - 24 3,452 4,339 7,791 8.1 25 - 34 7,334 8,542 15,876 16.5 35 - 44 5,720 5,363 11,083 11.5 45 - 54 3,559 3,483 7,042 7.3 55 - 64 1,898 1,850 3,748 3.9 65 - 74 796 829 1,625 1.7 75 + 378 407 784 0.8 Unknown 60 57 117 0.1 TOTAL 47,494 48,825 96,319 100.0 1/ These figures do not include West Irian which had a population of 700,000 and which was under Dutch administration at the time. Source: Central Bureau of Statistics. ANNOEX1 Page 10 of 10. Table 7 PROJECTED SCHOOL AGE POPULATION, 1971-2001 Primary Secondary Year 7-12 Years 13-18 Years 1971 20,019 18,035 1976 22,399 19,506 1981 25,276 21,857 1986 28,843 24,679 1991 32,801 28,197 1996 37,523 32,108 2001 43,714 36,825 Source: Iskandar, S. Some Monographic Studies on Population in Indonesia, Djakarta. ANNEX 2 Page 1 of 3 SELECTED ECONOMIC TRENDS Labor Force 1. No reliable recent estimates of labor force or of employment are available for Indonesia. The census of 1961 provided an estimate of the incidence of unemployment. According to the definition used, unemployment included that part of the population 10 years and over who were unemployed for more than 2 months during the period of 6 months preceding the enumera- tion. For the country as a whole, the unemployment rate was 5.4% -- 7% for females and 4.8% for males. The total labor force in 1961 was estimated at 34.5 million, of which 1.9 million were supposed to be unemployed. This, however, does not reflect the extent of vast underemployment in the rural areas. The following table indicate the size of the labor force in rural and urban areas: Table 1 INDONESIA: LABOR FORCE IN RURAL AND URBAN AREAS, 1961 (In millions) Population 10 Years and Over Labor Force Area Male Female Male Female Total Rural 26.4 27.6 21.5 8.3 29.8 Urban 5.0 5.0 3.5 1.2 4.7 TOTAL 31.4 32.6 25.0 9.5 34.5 2. The results of the census in 1961 do not provide data from which estimates of underemployment can be made. The labor force sample survey in Java and Madura in 1950 collected information on the number of days in a year and the number of hours per day worked by the agricultural labor force. The total number of man-hours efiectively used in agricultural production per year was estimated at 22.353 million(i.e., the sum of 15.462 million man-hours in the peak season, and 6.891 million man-hours in the slack season). Assum- ing a total of 60 days off work per year (the total of Sundays and 8 national/ religious holidays), and an average work day of 7 hours, the total potential man-hours per year in Java should be 33,604 million man-hours. The under- employment rate per year in agriculture on this basis is estimated at 33.5%, or about one-third of the total labor force. 3. On the basis of these observations, it can be estimated that no less than 10 million out of 30 millior, persons in the labor force in rural areas were underemployed in 1961. They could rather be considered as unemployed, for during the slack season those who are working do not find work for more than 4 hours. Even in the peak season the maximum number of hours worked is only six. ANNEX 2 Page 2 of 3 Table 2 Mean Number of Hours Worked Mean Number of Season Per Day Days Worked Peak 6.16 154 Slack 3.8 162 4. The phenomenon of underemployment also exists in the urban areas of Java. On the basis of a survey made in 1958, it has been estimated that under- employed persons -- those aged 12 years and over, who are working for less than 30 hours per week but eager to work longer and seeking additional employment -- numbered 76,000 in urban areas. The underemployment rate in the urban areas was, therefore, estimated at 1.86% for males, 4.7% for females,.and 2.7% for both sexes. 5. The above analysis indicates that around 1961 a minimum of 2 million workers were reported to be unemployed and more than 10 million did not have adequate employment. 1/ 6. During 1961-71, the employment situation is unlikely to have improved substantially because of the slow growth of the economy, which could not have brought about any structural change. 7. Estimates of labor force without fertility control are also made by Iskandar. Assuming the same ratio of the rural labor force to total as obtained from the 1961 census, the estimates for 1971 are as follows: Table 3 Working Age Population 15 - 64 Years Labor Force Area Male Female Total Male Female Total Rural 27.1 28.5 55.6 27.0 10.5 37.5 Urban 5.2 5.2 10.4 4.4 1.5 5.9 TOTAL 32.3 33.7 66.0 31.4 12.0 43.4 Increase in Labor Force, 1961-71 Male Female Total Rural 5.5 2.2 7.7 Urban 0.9 0.3 1.2 TOTAL 6.4 2.5 8.9 8. According to the above table, the addition to the labor force during 1961-71 has been about 8 million in the rural areas and 1 million in urban areas. Job opportunities would have mainly reduced the existing un- employment and the addition of 9 millioa p6rsons w'ould have substantially added to unemployment. The incidence of unemployment may, therefore, be as 1! The analysis is based on estimat'e given in Iskandar, S. Some Monographic Studies on Population in Indonesia. . ANNEX 2 Page 3 of 3 large as one-fourth of the labor force. The elimination of unemployment of this magnitude without considering underemployment is extremely difficult. Per Capita Income and Consumption 9. The gross domestic product of Indonesia was estimated at Rp 347.5 billion in 1951. Population in that year was estimated at 77.2 million. The per capita GDP was only U.So$45 in that year. The annual increase in GDP has been negligible over the two decades starting in 1951. 10. More than half the increase in GDP at constant prices was offset by the more than 2% per annum growth rate of population during 1951-60. In 1961-67, a negligible incre'se of 0.2 was recorded in the per capita income as almost all the increase in GDP at 2.6% was eliminated by population growth of 2.4%. In 1967, there was an actual decline in the per capita income by 1.5%. Since 1968, the growth rate of GDP has been substantial. It, however, -fluctuated as in 1969 the growth rate was lower than in the earlier years. In 1970, it regained and reached a pea'k. The data are summarized in the following table: Table 4 Percentage Increase per Annum Year Population Total GDP Per Capita GDP 1951-60 2.1 3.8 1.7 1961-67 2.4 2.6 0.1 1967 2.5 1.0 -1.5 1968 2.5 6.9 4.3 1969 2.5 5.1 2.5 1970 2.5 7.9 5.3 11. Calorie-intake per capita per day was estimated at 1,980 in 1960. This, of course, is below acceptable standards. There was little improvement in the nutritional standards in Indonesia during the sixties. The per capita food availability declined by 1.17% during 1961-67 and 2.4% during 1967. An increase of 3.8% was recorded in 1968. Again a decline of 0.3% was experienced in 1969. Until recently, most of the increase in food production was absorbed by the accelerating growth rate of population as shown in the following table: Table 5 INCREASE IN AGRICULTURAL PRODUCTION (Percent per annum) Year Total Food Population Food Capita 1961-67 1,6 1.2 2.4 -1.1 1967 1.6 - 2.5 -2.4 1968 4.8 6.4 2.5 3.8 1969 3.1 2.3 2.6 -0.3 I N D O N E S I A CENTRAL ORGANMZA-ION OF THE NATIONAL FAMILY PLANNING COORDINATING BOARD THE PRESIDENT NATIONAL COUNCIL FOR GUIDANCE OF FAMILY PLANNING Minister of Peoples Welfarz (Chairman) Minister of Health (Vice-Chairman) STATE MINISTER Minister of Internal Affairs FOR PEOPLES WELFARE Minister of Finance Minister of Information Minister of Social Affairs . Minister of Education and Culture N ACHA RMANL FAMILY Minister of Armed Forces OF THE N F PCB PLANNING ADVISORY Chairman of Bappenas Chairman of I P PA REPRESENTATIVES OF CHIEFS OF SECRETARY NATIONAL PRIVATE RELATED GOVERNMENT ORGANIZATIONS DEPARTMENTS .DEPUTY CHAIRMAN I DEPUTY CHAIRMAN 11 INFORMATION AND EDUCATION AND RESEARCH AND MEDICAL SERVICES SUPPLY AND R EPORTING AND MOTIVATION BUREAU TRAINING BUREAU EVALUATION BUREAU BUREAU LOGISTICS BUREAU BDOCUENTATION z [ PROVINCIAL NF PCB Z IBRD-5590(3R) I N I INDONESIA PROVINCIAL STRUCTURE OF THE NATIONAL FAMILY PLANNING COORDINATING BOARD Provincial Level . PROVI NCIA L GOVERNOR PROVINCIAL CHAIRMAN ADVISORY CMOUNCIL EInspector of HDlth,CExE OjR RN A -wI EXECUTIVE CHAIRMAN SECRETARY MEDICALTSERVICETINNORMATION SECTIONI SECTIONATIO SETIO INFORMATION DIVISION | EDUCATION IVISION MEDICAL SERVICE RECORDING DIVISiON . - - - - - - - - - - - - - - =- - . . . . . . . . . . . . . . . . . . . . . . . . . . . . .- - - ,- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Kabupaten LevelI B UPATI |- - L SECRETARIAT MEIA SERIC TINX - I BRD-5588(3R) INDONESIA CENTRAL ORGANIZATION OF THE MINISTRY OF HEALTH MINISTER OF HEALTH ,|SECRETARY GNEA BUREAU 1 - Statistics and Evaluation BUREAU 2 - Organization and Construction BUREAU 3 - Personnel BUREAU 4 - Logistics BUREAU 5 - Education BUREAU 6 - Law and Legislation BUREAU 7 - Special Affairs (Foreign Relations) DIRECTOR GENERAL DIRECTOR GENERAL DIRECTOR GENERAL Health Promotion and Medical Care Communicable Disease Control Pharmacy DIRECTORATE OF.MEDICINE DIRECTORATE OF CONTROL,ERADICATION DIRECTORATE OF INVESTIGATION DIRECTORATE OF MENTAL HEALTH AND IMMUNIZATION ANG RESEARCH DIRECTORATE OF DENTAL HEALTH DIRECTORATE OF QUARANTINE DIRECTORATE OF PRODUCTION DIRECTORATE OF NUTRITION DIRECTORATE OF HYGIENE DIRECTORATE OF DISTRIBUTION DIRECTORATE OF REHABILITATION AND SANITATION AND HEALTH PROMOTION DIRECTORATE OF LABORATORY SERVICE DIRECTORATE OF MCH AND FAMILY PLANNING UNDER FIVE CLINICS HEALTH CENTERS SOCIAL OBSTETRICS > FAMILY PLANNING. Z z m x IBRD-5589(3R) un INDONESIA PROVINCIAL HEALTH STRUCTURE GOENR EXECUTIVE DIRECTOR INSPECTOR OF HEALTH ( Health Cabinet Member ) COMM()N ICAB LE DISEASES CONTROL PHARMACY HEALTH PROMOTiON Technical Responsibility AND FAMILY PLANNING Admi nistrative ResponsibilIi ty H EA LTH PROMOTIO0N BUAI CHIEF MEDICAL OFFICER --AND FAMILY PLANNING (KabupateXn Level) ( MCH ) MEDICAL CARE . ~COMMUNI CABLE DISEASE CONTROL KABUk ATEN | rM C H C ENTERS | HOSPITAL (K7Ad)an) !I I rI'-VE M CH CENTERS I( Ketiamatan Level) (B) Iz I> SATELLITE CLINlICS .Zx (KbCaenLve)(MH I BRD-5586 (3R) I I. INDONESIA ANNEX 7 INDONESIAN PLANNED PARENTHOOD ASSOCIATION NATIONAL CONGRESS National Level L MANAGING BOARD SECRETARY GENERAL DEPUTY SECRETARY GENERAL STAFF OF THE SECRETARY GENERAL 7T7 BUREAU FOR BUREAU BUREAU RESEARCH NATIONAL PROPGRAM FOR TRAINI G NFORMATION AND EVALUATION TRAINING CENTER DEVELOPMENT FO RIIG I ADMOTIVATION BUREAUL ProvinciaI Level - PLENARY BOARD OF THE PROVINCIAL CHAPTER MANAGING BOARD OF THE PROVINCIAL CHAPTER SECRETARY OF THE PROVINCIAL CHAPTER SECRETARY'S STAFF 1-7 OTHER INFORMATION PROVINCIAl POSSIBLE PROJECTS AND MOTIVATION MODEL CLINIC TRAINING CENTER * *- L - J - - I - I - - - - - Local Level I BOARD MEMBER 1 OF THE LOCAL BRANCH SECRETARY INFORMAT,ON FIELD PRACTICE AND MOTIVATION CLINIC IBRD-5587(4R) ANNEX 8 Page 1 of 1 REORGANIZATION OF THE NFPCB 1. The NFPCB will. be reorganized substantially on the following lines: a. The NFPCB will be res.ponsible for: i. advice on the formulation of national family planning policies; ii. formulation of a national family planning program which reflects the policies approved by the Borrower; iii. coordination anid supervision of the imiplementation of the national program; ancd iv. coordination and supervision of all assistance for family planning from foreign and domestic sources includling externally financed projects included therein. b. The 1FPCB will be headed by a Chairman who, in performing hls tasks, will be directly responsible to the President of Indonesia. The Chairman will be advised and assisted by the National Family Plan- ning Consultative Comittee comprised oL the Secretaries General of the Ministries involved in the implementation of the national pro- gram and other individuals called upon ay the Chairman. c. The NFPCB will have three Deputy Chairmen -- Deputy I will be responsible to the Chaimr.aa for overall program planring and bud- geting, supervision of program implementation, logistrics, imple- mentatiorn of special projects, and direction of the PIU. He will also act on behalf of the Chair-me-n duiring the latter's absence. Deputy II will be responsible to the Chair;man for the techni.cal direction and coordination during irmplementation of tuhat part of the national program dealing with .nformation and motivation, education and trainirng, and mrrif->a- senrices. Deputy III will be responsible to the Chairman for technical direction and coordina- tion of the part dealing witwh evaluation and research, and reporting and recording. The Chairman will also be assisted by an administrative secretary who rill be responsible for the administration of headquarters facilities anAd staff. d. The NFPCB will be provided with adequlate supporting staff for the execution of its tasks, including specifically staiff for: i. evaluation and research; ii. the field postpartum prograrm; and iii. information and communications. 2. A diagram outlining the proposed, new st.ructure is attached to this amnex. 3. A team of three advisers wrill be attached tio the central NFPCB for 2 years to strengthen its senior nmanagement capability. The proposed ANNEX Page 2 of 4 terms of reference for the adviser in family planing communications are in para 5 of Annex 29. The proposed terms of reference for the advisers in program management and family planning training are given below: a. Adviser in Program Management The function of the adviser in program management would be to assist the Chairman of the NFPCB in the formulation and execution of policies designed to develop the national family planning program. The specific responsibilities of the program adviser would include providing guidance on: i. the development of effective relationships in program plan- ning and execution between the NFPCB and the program's implementing units, particularly the Ministry of Health; ii. the provision of family planning services through the facilitJ.1es, particularly thru maternal and child health services, operated by the implementing units; iii. the use of service data, survey and research results, program evaluation data and the results of an effective supervisory system in expanding or modifying the use of human and financial resources available for the develop- ment of the national program; iv. the need to coordinate effectively all services of non- Indonesian assistance to achieve the national program's objectives; v. the aippropriate use of new family planniing techniques and methods in the development of the national program; and vi. the most effective balance, consistent with local circums- tances, between the provision of services and the stimula- tion of demand for family planning required to promote the national program's objectives. b. Adviser in Family Planning Training The functions of the training adviser would be to provide guidance to the Chairman of the NFPCB on the development of a program to meet the training needs of the National Family Planning Program. In this regard, he will mnake the fullest use of all expertise available i.n this field in the country as well as from interna- tional agencies. The specific responsibilities of the training adviser would include guidance on: i. development of an overall training policy in family planning; ii. development of a training strategy and train g system to meet t]ie training needs of the family planniaslg program; ANNEX 8 Page 3 of 4 iii. preparation, within the strategy, of an operational plan, including development of curricula based on expected job- functions for training of all categories of personnel involved in the implementation of the National Family Planning Program; iv. development of a system for coordination of all agencies implementing the training programs; V. working with governmental and non-governmental agencies to help in integrating family planning as a part of pre-service training, medical and nursing education, etc.; vi. development of training evaluation and feed-back for ensuring the relevance of specific training activities to meet program needs; vii. to stimulate needed research and innovative techiiques in training with particular reference to training methods, train- ing systems, etc.; and viii. development of programs for training of trainers. INDONESIA PROPOSED STRUCTURE OF THE NFPCB'S CENTRAL OFFICE PRESIDENT NATIONAL COUNCIL FOR J GUIDANCE OF FAMILY PLANNING MINISTER OF PEROPLE'S WELFARE CHAIRMAN NATIONAL IMPLEMENTATION COORDINATION I SECRETARIAT COMMITTEE IDEPUTY CHAIRMAN iI DEPUTY CHAIRMAN I DEPUTY CHAIRMAN 11 (Research and (Program (Program Evaluation) Management) Development) RESEARCH REPORTING PR SPEC INBoRMATION E MEDICAL & & PROGRAMG SPECIA EVALUATION RECORDING PLANNIGAPROECTSTOGISTCSNSUERVISONCES 0Z0 0 World Bank-6563 AMEX 9 Page 1 of 5 FAMLY PLANNING FIELD WORKER PROGRAM 1. The family planning field worker program was developed because the spread of family planning information through mass media was insufficient, and there was need for a more personal approach. The field workers were to be full-time nonmedical personnel who would be available to spread family planing knowledge in the commumity and, if necessary, remove resistAnce to the adoption of family planning and contraception. Ths program was started in October 1970, and until April 1971, it was organized by the Indonesian Planned Parenthood Association (IPPA); since then, the NFPCB has assumed responsibility. 2. The family planning field worker program comprises the selection and training of field workers, group leaders, supervisors, and inspectors. Field workers should have a junior high school education and be between 26 and 45 years old. They receive 3 weeks training and both PTCs and STCs have been used for this purpose. Field workers are- expected to recruit from 8 to 10 acceptors monthly. At present, they are unofficially attached to the clinics but they are administratively independent, being paid and directed from the central NFPCB headquarters. Some 400 field workers are employed by the NFPCB at present, together with a director and associated staff at central level. The field workers are concentrated in the provinces of Djakarta, West Java, Central Java, and Bali. 3. Tbe present disposition of field worker program staff is: Province Field Workers Djakarta "assigned to military clinics) 48 West Java - Bandung 89 Central Java - Semarang 76 Central Java - Karanganjan 35 Djogjakarta 53 Bali 49 East Java (assigned to Surabaja municipality) 35 TOTAL 3 The program targets by April, 1971, were to re-ruit 767 field workers, 85 group leaders, 15 supervisors, and 6 inspectors. The current NFPCB budget makes provision for Rp 147 million (U.S. $354,000) covering the recruitment and placement of about 2,500 field workers, 250 group leaders, other supervisory staff, and equipment for the six p-ovinces in Java and Bali. The program is lagging behind its implementat-on schedule. 4. This is the resalt of the current coiused position of the field worker program which is still nebulous. Th'e field workers trained in East Java, for example, are paid and adminis'-ered by the Surabaja municipality health services; their functional relationship, if any, to the NFPCB ANEX 9 Page 2 of 5 scheme is not clear. The NFRPCB has est is1..ed a committee to make recom- mendations to the chairman the best -.:-ay in which to implement the field worker project. Amo_ng- the principal difficulties fac-ng the project are: a. The fact that the NFPOB, a coordinatJ'rg agency, is trying to implement the project. Thus far, no decision has been r- ched on the program's sta.us or vcx_c.. agency or ministry will be responsible for imnplementatiDn. b. There is resistance, Darticularly at peripheral service levels, to the idea of fu1ll-time non-medical family planning.field workers. This is partly due to inadequate comnunication within the EFPCB organization so that even the nebulous instructions of the center have not ieen appreciated at lc--er levels. The field workers are also seen as a body of workers in direct competition with the paramedical staff of MCH/FP centers for the small rewards avail- able for successful motivators. This situation is aggravated by the fact that. particularly at peripheral levels, family planning is seen as the exclusive preserve of the health services. C. The program has not been organized in a systematic way so that some field workers are using concepts and work patterns which differ from those laid down centrally. There is considerable confusion regarding the payment of field workers salaries. Even for the small number of field workers in the field, the supplies of equipment and bicycles have not been effectively distributed. d. Salaries (Rp 2,500 per month per field worker) are inadequate, and field workers cannot be expected to work full-time. The field worker's job is regarded as complementary to other occu- pations; this is taken to justify the recruitment of paramedical staff as field workers. e. Although there is a curriculum for field worker training, it is not adequate because basic job functions hav not been fully developed and incorporated in the curriculum. There are dif- ficulties in training because some teachers do not have the essential practical experience required in field worker training. It is apparent that there is, in any case, little uniformity in training. f. With the lack of overall control, field workers are not assigned according to any predetermined plan. After training, they have no contracts and can leave their job easily with a consequent waste of training resources. There is little uniformity in the selection procedures. In Bali, nearly all the field workers who have been recruited are already employed as midwives and nurses, etc. The provision of supervisory staff, i.e., group leaders, etc., has not kept pace with even the slow recruitment of field workers, and there is, in consequence, a serious lack of guidance and AMEX 9 Page 3 of 5 supervision which is critical to the success of such a new pro- gram. There is, in most cases, no leadership at the local level. Supervisors and group leaders are, in most instances, themselves new to family planning and also require close guidance. 5. The NFPCB committee needs, therefore, to take urgent action in proposing recommendations which should be directed toward: a. systematic planning and organizatioyi; b. preparation of budget provision which will be based on the national family planning program targets. They are not now met by the general allocation of three field workers to a "complete clinic" which produces too intensive a ratio of 1:4,500 persons; c. an early decision on the agency responsible for implementatian; d. early resolution of administrative problems of salary and working conditions, including effective contracts; e. improving salaries for field workers and supervisory staff; and f. strengthening the supervisory structure. 6. To this end, the following recommendations are made: a. Provide field workers at a general ratio of 1:10,000 persons which will ensure a good motivational program. They should be paid an effective salary of Rp 3,S500 per month. b. The Ministry of Health, with provincial health authorities, must be closely associated.with field worker project implementation because of their extensive administrative network and major respon- sibility for the delivery of family planning services. c. The basic functions of the field workers should be clearly and specifically described and followed uniformly by all implementing units. These functions should include identification of eligible couples; family and community-centered family planning education; collaboration with the MCH/FP clinic personnel in providing MCH/FP services; distribution of conventional contraceptives themselves, as well as through nonmedical depot holders like village leaders; and responsibility for primary-level reporting and recording along with the MCH/FP clinic personnel; etc. d. Priority must be given to train the field workers and group leaders in local subtraining centers based on their specific job functions. Their training must be specifically oriented to prepare these workers to effectively carry out their job functions and should not be merely informational in nature. If efficiently used, present training facilities are adequate for training the 1971-72 recruitment targets. The family planning training component of the project develops an adequate training capability for subsequent years. ANNEX 9 Page 4 of 5 e. There must be adequate supervisory guidance of the field workers and an effective administrative, as well as supervisory, structure. These can be assured by: i. appointing one group leader to every five field workers, who would work directly under his control and supervision. Group leaders would be attached to the district level MCH/FP center. ii. appointing one full-time assistant supervisor to the NFPCB officer at regency level, who would be responsible for super- vising and giving technical guidance to the group leaders. iii. appointing an effective unit attached to the provincial office of the Inspector of Health to work with the Director of Health Promotion and Family Planing. It would consist of 1 super- visor, 1 assistant supervisor, and 3 supporting administrative staff. For the purposes of DIP (budget authority), the director would be the project officer. iv. appointing a coordinator to the provincial NFPCB offices to supervise all aspects of the family planning field worker pro- ject for the NFPCB and coordinate staff activities between the various agencies towham they have administrative and program responsibilities. v. appointing an effective unit at central NFPCB to coordinate all activities, which should consist of 1 director (of the rank of bureau chief), 2 senior coordinators to provide immediate super- vision of activity at provincial level, as well as supporting staff comprising 1 accountant, 1 clerk, and 1 typist. 7. In summary, the field worker program should aim to have the following staff in position in the next few years: Staff 1972-73 1973-7h 197h-75 197$-76 1976-77 Total Field Worker2l 1,500 1,500 1,500 1,500 1,000 7,000 Group Leader-/ 300 300 300 300 200 1,h00 Assistant Supervisor 40 40 35 - - 115 Provincial Unit Staff 6 - - - - 6 Provincial Coordinator 6 - - - - 6 Central Unit Staff 1 - - 1 Driver 2 32 30 30 35 129 1/ Based on a ratio of 1:10,000 and a Java/Bali population of 80 million, and allowing for 1,000 trained field workers before the project starts. 2/ Based on a ratio of 1:5 field workers, and allowing for 200 trained group leaders before the project starts. ANNEX 9 Page 5 of 5. 8. The costs of this component, excluding contingencies, are estimated as follows: Item 197273 1973-74 1974-75 197 -76 1976-77 Total U.S.$ U.S.$ U.S.$; UlS- U.S.$ U.S.$ Salariesl/ 219,000 430,000 639,000 838,000 971,000 3,097,000 2/ 26,000 108,000 185,000 260,000 166,000 7h5,000 Transport= 600 1800 1500 20-0 6,0 4,o Mainte mnce 10,000 20,000 38,000 000 76,000 2002000 TOTAL 255,000 558,000 862,000 1,15A,000 1,213,000 4,042,000 l/ Based on: 7,000 field workers at Rp 3,500 per month 1,1400 group leaders at Rp 5,000 per month 115 assistant supervisors at Rp 10,000 per month 6 provincial units staff, each comprising: 1 supervisor at Rp 15,000 per month 1 assistant supervisor 3 clerical staff 6 provincial coordinators at Rp 15,000 per month 1 central unit staff comprising: 1 director at Rp 20,000 per month 2 senior coordinators at Rp 15,000 per month administrative staff 129 drivers. 2/ Comprises: 129 cars at U.S. $2,000 each 1,600 120-cc motorcycles at U.S. $220 each 4,500 bicycles at U.S. $30 each. ANNEX 10 PRESENT STAFING PATERN OF TYPICAL HEALTH CENTER AT DISTRICT LEVEL IN EAST JAVA 1 Doctor 1 Health Controller 1 Midwife 1 Nurse 2-3 Assistant Nurses 1 Assistant to the Midwife 1 Assistant Sanitarian 1 Cleric 1 Laboratory Technician Auxdliary Staff includesl Malaria Workers (home visiting for mnear testing) Smallpox Vaccinator TCPS Worker (home visiting for yaws examinations) Voluntary Village Workers (DKDs) 1/ In a few cernters, the staff includes a dentist and a dental nurse. ANNEX 1 1 Page 1 of 7 HEALTH SERVICES AND FACILITIES IN EAST JAVA, BALI, AND DJAKARTA 1. This annex describes the structure and services of provincial health authorities by reference to the provinces of Eastl Java, Bali, and Djakarta. 2. The execution of health planning is primarily the responsibility of the provincial health departments. Because provinces and regencies in large part fund their own services, they have considerable autonomy. In each province, the Inspector of Health is responsible to the Governor. Under the Inspector, maternal and child health, and family planning services are the responsibility of a directorate. Administration iof health services, including maternal and child health, and family planning, progresses from the Ministry in Djakarta through the health department in each province down to regency, district, sub-district, and village levels. East Java Village Level 3. In any one of the 8,044 rural villages i.n East Java, medical facili- ties are rudimentary. The average village has a population of some 2,800 persons. Some, but not all, have a simple polyclinic, perhaps associated with a simple tQype of MCH center, usually built by the community and staffed by a male nurse (mantri). The polycinics provide first aid, aim at an early diagnosis of communicable disease, and are visited on occasion by a doctor and also by a midwife. Health services are not free; patients pay a fee of about Rp 10 (U.S. $0.026) used to buy medicines and stat:ionery, etc.; contraceptives are provided free of charge. 4. The majority of village deliveries are conducted at home by the traditional midwife (dukun). In cooperation with UNICEF, a major effort has been made to provide training in delivery procedures by government midwives; this takes up half a day weekly for 5 months. In recognition of this training, the dukun is provided with a free delivery kit, thei components of which are renewed each time she reports a delivery to the nearest government midwife. The provincial authorities estimate that there are over 14,000 dukuns in East Java, 6,758 of whom had been trained by August 1970. In addition to attending a delivery, the dukun assists in cooking,washing, and general h(ousehold duties for about 40 days after delivery and is, therefore, an important member of the community. Sub-District and District Levels 5. Villages are grouped for both civil and health administration into sub-districts. In East Java, there are 534 sub-districts, of which 507 are in rural areas and have a typical population of some 4,i,000 persons. At this level, there is an MCH/polyclinic center with a trai..ned government midwife in charge. For health purposes, about five sub-dis1tricts are grouped into a district. At district headquarters, a doctor coordinates activities in the ANM,X 1 1 Page 2 of 7 sub-divisions from one of the five health centers. Some sub-divisions have more than one MCH center and (less often) have a government doctor. There are 139 districts (six in urban areas) in East 2Java, grouped into 37 regencies. A typical regency has an area of some 1,700 km , and a population of about 800,000; for health purposes, it is the main provincial sub-unit. It has a chief medical officer with primarily administrative functions, usually a 100-bed hospital (including about 10 maternity beds) with a doctor in charge, and a third physician responsible for communicable disease control. Each regency has a supervisory midwife, who also has midwifery duties. 6. MCH facilities in East Java are detailed in Table 1. Of the 929 government centers, 92% are in rural areas; of 138 private centers, 59% are in rural areas. Taking only government centers, each serves about 25,600 persons. They are not fully staffed. Of the 750 midwives reported by the provincial authorities 494 are attached to rural government MCH centers - a ratio of one to 44,000 people. Municipal Areas 7. There are eight municipalities in East Java, subdivided into sub- districts and smaller municipal units. Surabaja, the provincial capital, has a population of about 2.1 million and has 16 sub-divisions. The municipalities are also the headquarters of administratively distinct but contiguous rural sub-districts. Health services are provided on a more intensive basis than in rural areas and there is an evident trend towards the hospitalization of obstetrical cases. The basic health pattern is similar but there are sub- stantial numbers of additioni. .'hospitals and health centers established by private agencies. Bali 8. The health service structure in Bali is similar to that of East Java but, as Table 2 shows, there is a more complete coverage. Bali is divided into eight regencies and 50 sub-districts; there are no districts or municipa- lities. There is one government MCH center for 10,500 people. Not all the centers are staffed, but there is one trained midwife for 12,500 people. Twenty-one MCH centers also have maternity facilities, but underut.>Xization is evident in the low utilization rate of 17.4 deliveries per bed during 1970.1/ Djakarta 9. Djakarta has provincial status and is divided into five municipa- lities, each subdivided into a total of 27 sub-districts. In each municipality, thexn is a general health center with a doctor in charge of health admiinistra- tion for the area., Each sub-district has a smaller center supplemented with satellite MCH centers - 77 in all - run by private agencies, the Armed Forces, and the university medical school. Djakarta has 16 general hospitals, one maternity hospital, and 86 maternity clinics (see Table 3). Government estimates place the total nunber of deliveries in Djakarta between 160,000 and 180,000, annually. In 1969, some 80,000 (or 50%) deliveries were reported from mate;rnity facilities; a further 40%uwe domiciliary deliveries attended by a doctor, 1/ Sixty deliveries per bed per annum is an acceptable rate. ANNEX 11 A Page 3 of 7 midwife, or dukun. At the end of 1970, there were 2,060 maternity beds in Djakarta. In 1970, the average number of deliveries per bed was 38. The detailed pattern of bed utilization is not available for 1970, but is similar to that of the previous year, which is shown in Table 3. This overall utilization rate conceals differernces associated with types of facility, agency, and location in Djakarta. Public maternity facilities are generally over- crowded, many with more than 80 deliveries per bed annually, whereas private facilities are mostly underutilized. ANNEX 11 Table 1 Page 4 of 7 EAST JAVA: MCH FACILITIES MCH Centers Doctors Midwives Sub--Dis-Populatic- RegenC Govt. PriVate Govt. Private Govt. Private trict (1968) URIBAN Surabaja 25 35 9 11 14 16 16 2,124,343 Modjokerto 4 3 3 3 4 3 1 60,327 Madiun 9 3 2 - 7 3 1 153,904 Kediri 10 - - - 4 - 3 181,380 Blitar 6 - 1 - 3 - 1 73,291 Malang 5 10 1 7 5 17 3 433,619 Probolinggo 5 1 - - 5 1 80,409 Pasuruan 3 4 1 3 1 - 1 - 6- Subtotal 67 56 17 24 43 39 27 3,181,919 RU-RAL Surabaja 18 3 4 2 2 10 19 596,639 Sidoardjo 19 10 3 5 18 6 18 626,911 Modjokerto 63 - 4 - 18 - 17 451,466 Djainbang 27 10 4 1 17 9 17 76:2,357 Bodjonegoro 41 2 4 - 9 1 20 765,875 Tuban I40- 1 5 1 14 1 19 740,332 Lamangan 14 - 1 - 10 - 22 848,678 Maldiun 52 - 4 - 26 - 13 560,507 Ngawi 18 2 - - 13 1 13 601,180 Magetan 16 1 - - 13 1 13 736,729 PoInorogo 18 6 - 1 18 6 19 719,149 Pat:jitan 28 - 3 - 12 - 12 453,231 Kediri 35 1 7 - 18 1 16 1,046,225 Bli-tar 40 - 6 - 18 - i7 897,033 Tulungagung 19 - 4 - 16 - 19 699,934 Tre.nggalek 24 - 2 - 15 - 13 301,376 Nga.ndjuk 26 - - - 17 - 20 708,947 Djember 34 15 14 3 48 8 25 1,781,926 Banjuwangi 37 13 6 1 19 - 14 1,203,949 Bon!doworo 32 3 - - 19 2 16 513,742 Panarukan 20 6 - - 13 - 14 518,546 Malang 45 3 7 3 33 3 29 1,620,248 Luiradjang 14 2 - - 14 2 13 733,392 Probolinggo 27 - 6 - 17 - 24 677,466 Pasuruan 26 2 7 2 22 2 23 861,1613 Bangkalan 29 - 5 - 16 - 18 593,320 Sampang 15 2 - - 11 - 12 505,404 Pamekasan 13 - - - 12 - 11 421,375 Sumenap 22 - 3 - 16 - 21 727 843 Subtotal 862 82 99 19 494 53 507 21,675.,393 TOTAL 929 138 116 43 537 92 534 24,857,312 ANNEX 11 Page 5 of 7 Table 2 BALI: MCH FACILITIES Popu- Assistant Sub-Dis- Vil- lation MCH Centers Midwives Midwives Regencies tricts lages (1970) G M P G M P G M P Badung 6 51 385,086 43 5 6 52 7 6 2 Djembran 4 48 165,196 9 - 3 11 - 3 - Bululeng 9 151 394,278 23 1 5 20 1 1 2 - 1 Gianjar 7 51 267,700 22 1 1 16 - 1 - - - Bangli 4 64 135,708 15 - - 10 - - 1 - I Kelungkung 4 55 135,175 24 - - 15 - - - Tabanan 8 95 324,840 38 - 3 27 - 2 2 - - Karangasem 8 43 260,357 23 - - 14 - - - - - TOTAL 50 558 2,068,340 197 7 18 165 8 13 7 - 1 G = Government M = Military P = Private ANNEX 11 Table 3 Page 6 of 7 DJAKARTA: MATERNITY FACILITIES AVERAGE DELIVERIES FOR BED BY AREA AND BY TYPE OF CLINIC 1968 AND 1969 1968 1969 Average Average Number Number Deli- Deli- Mater- veries Mater- veries Hosipi- nity Deli- Per Bed Hospi- nity Deli- Per Bed Area Type of Hospital tals Beds veries Per Year tals Beds veries Per Year Central Central Hospital, 1 136 2,696 20 1 136 2,491 18 Djakarta Provincial Govt. General Hospital, 3 167 7,138 43 .3 155 6,636 43 Private General Hospital, 1 94 3,111 33 2 121 5,116 42 Army Maternity Hospital, Private 1 133 5,919 45 1 138 6.216 45 Subtotal 6 530 18,864 36 7 550 20,459 37 East General Hospital, 1 34 590 17 1 34 686 20 Djakarta Central Govt. General Hospital, Army 1 20 587 29 2 40 506 13 Subtotal 2 54 1,177 22 3 74 1,192 16 West General Hospital, 2 39 1,170 30 2 32 887 28 Diakarta Private North General Hospital, 1 50 4,253 85 1 49 4,240 87 Djakarta Municipal Govt. General Hospital, 1 12 229 19 1 15 178 12 Central Govt. General Hospital, Army - 1 20 492 25 Subtotal 2 62 4,482 72 3 84 4,910 58 South General Hospital, Djakarta Private 2 73 513 7 2 75 868 12 TOTAL .14 758 26,206 35 17 815 28,316 35 Source: Djakarta Metropolitan Health Department. ANNEX 11 Table 3 Page 7 of 7. -2- DJAKARTA: MATERNITY FACILITIES AVERAGE DELIVERIES FOR BED BY AREA AND BY TYPE O.F CLINIC 1968 AND 1969 1968 1969 Average Average Number Number Deli- Deli- Mater- veries Mater- veries Cli- nity Deli- Per Bed Cli- nity Deli- Per Bed Area Type of Clinic nics Beds veries Per Year nics Beds veries Per Year Central Municipal Govt. 2 63 5,654 90 2 70 7,093 101 Djakarta Provincial Govt. 1 40 2,564 64 1 40 2,720 68 Army 2 36 1,872 52 3 76 3,135 41 Private 17 225 7,727 34 20 274 7,829 29 Subtotal 22 364 17,817 49 26 460 20,777 45 East Municipal Govt. 2 68 5, 360 79 3 77 5,944 77 Djakarta Army 2 22 1,871 85 2 22 1,950 89 Private 12 120 3,318 28 14 L59 3,983 25 Subtotal 16 210 10,549 50 19 258 11,877 46 West Army 2 55 1,325 24 2 53 1,446 27 Djakarta Private 6 76 5,352 70 10 108 5,853 54 Subtotal 8 131 6,677 51 12 161 7,299 45 North Municipal Govt. 1 10 90 9 1 9 201 22 Djakarta Army 1 7 176 25 1 7 178 25 Private 4 63 2.270 36 4 66 2,167 33 Subtotal 6 80 2,536 32 6 82 2,546 31 South Central Govt. 1 10 120 12 1 10 234 23 Djakarta Provincial Govt. 1 5 63 13 1 6 90 15 Army 1 20 598 30 1 20 647 32 Private 20 210 7,083 34 20 210 7,451 35 Subtotal 23 245 7,864 32 23 246 8,422 34 TOTAL 75 1,030 45,443 44 86 1,207 50,921 42 Source: Djakarta Metropolitan Health Department. ANNEX 12 DATA ON MIDWIFERY SCHOOLS, 1970 Students in Maternity Annual Applicants Residence G-aduates Beds Deliveries EAST JAVA Government RS Dr. Soetomo, Surabaja 237 343 31 50 3,000 RS Madiun 300 86 13 50 972 RSU Malang 200 163 29 50 2,885 RS Dr. Subandi, Djember 60 61 12 25 654 RS Gambiran, Kediri 50 64 11 12 722 RS Bangkalan - 1/ 41 8 10 163 RS Bodjonegoro 55 46 - 2/ 11 492 Subtotal 902 804 104 208 8,888 Military RSAL, Surabaja 297 76 353v/ 94 4,744 RSAL, Malang 20 127 30 50 2,400 Subtotal 317 203 65 144 7,144 Private RS Vincent A Paulo, 30 59 9 34 2,149 Surabaja Mardi Santoso, Surabaja 66 82 13 97 5,800 RS William Booth, Surabaja 62 47 13 41 1,680 RS Panti Waluja, Malang 30 43 8 NA NA Reksa Wanita, Modjoker:to 73 62 - 2/ 25 289 RS Sidi Chotidjah 4/ 71 - - NA NA Subtotal 332 293 43 197 9,918 TOTAL All Schools 1,551 1,300 212 549 25,950 DJAKARTA Government Budi Kemuliaan, Djakarta 196 36 138 6,216 Military RSAL Djakarta NA NA 27 1,680 Private Sint Josef of St. Carolus Hospital NA 26 79 4,031 RS Jajasan, Djakarta 82 15 51 1,309 RS Husada NA 6 63 1,510 Angkatan Darat, RS PAD NA 6 94 3,436 TOTAL All Schools 278 89 452 18,182 BALI Government RSU Denpasar 116 32 117 3, 000 1/ No admission in 1970 because of a staff shortage. 2/ Will begin to graduate students in 1971. 3/ Graduates estimated. 4/ Started 1971. ANNEX 13 Page 1 of 10 FAMILY PLANNIi SERVICES AND PERFORMANCE 1. The Goverrment of Indonesia Task Force which outained the 5-year national family planning program adopted the target of 6 million new acceptors which the UN-WHO-IBRD Report recommended, but rephased it as the table below indicates. Table 1 UN-WHO-IBRD Mission Calendar Year Annual Target Fiscal Year NFPCB Annual Target 1970 - 1970-71 125,000 1971 300,000 1971-72 200,000 1972 600,ooo 1972-73 550,000 1973 1 ,200,000 1973-74 1,.000°,000 1974 1,800,000 1974-75 1,700,000 1975 2,100,000 1975-76 2,500,000 TOTAL 66,000,,075, 000 2. Family planning services in the government program are provided through existing MCH facilities, frequently referred to as famly planning "clinics." Data for fami'.y planning facilities and performance for 1965 and earlier years were obtained by IPPA and covered the whole of Indonesia. In December 1969, shortly after the Government assumed responsibility, there were 310 family planning clinics. To that date, IPPA reported a small but steady growth in the number of acceptors per clinic/month -- from 4.6 in 1967 to 8.8 in 1968, and 10.8 in 1969. IPPA retains its res- ponsibility for the 99 clinics in the outer islands ihich have about 4(0 acceptors per month. As noted earlier, the program really got underway only in 1966 and full responsibility was not assumed by the Government until mid-1969. In the absence of a standard reporting system, family planning data are unreliable before 1968, and since then indicate con- sistency of coverage but about 15% of the centers fail to report each month. Sophisticated measurements, such as those used to indicate progress in large developed programs, are only now being developed. 3. In September 1971, the NFPCB reported that of the 1,804 family planning clinics, 1,686 family planning clinics reported new acceptors during the month (93.4%). Of these, 1,443 were operated by the Government, 79 by private agencies, and 164 by other institutions. There was an increase of 90 over the previous month, half of which were reported from East Java. The distribution of family planning clinics is shown in the following table: ANNEX 13 Page 2 of 10 Table 2 DISTRIBUTION OF FP C,LINICS BY PROVINCE. SEPTEMBER 1971 Average Hours of Total Listed Clinics Total Reporting Clinics Work per Govern- 1/ 2/ Govern- Clinic/ Province ment Private Ot:Ters Total ment Private Othars Total Month Djakarta 49 19 65 133 47 19 53 119 49 West Java 328 17 32 377 317 15 34 366 38 Central Java 30)4 17 13 334 302 16 17 335 45 Djogjakarta 82 5 4 91 81 4 3 88 26 East Java 656 24 54 734 583 17 49 649 68 Bali 119 8 8 135 113 8 8 129 67 TOTAL 1 ,538 90 17, T1 1,804 43 79 1 166 1/ Operated by medical and paramedical staff in their private capacity. f/ Includes clinics operated by the Armed Forces and voluntary organizations. Source: National Family Planning Coordinating Board. The target of acceptors per clinic/month set by the Ministry of Health is 8.0 for the 1971-72 plan year. For all clinics, the actual rate has risen from 8.7 for 1970 to 15.7 for January-March 1971 , and to 25.6 for July-September 1971. Table 3 shows the rate of acceptors per clinic/month by province: Table 3 JAVA AND BALI: ACCEPTORS PER CLINIC/MONTH Jan.-Dec. Jan.-Mlarch Apr.-June July-Sept. Provinces 1970 1971 1971 1971 Djakarta 17.7 23.2 22.4 24.6 West Java 6.7 15.8 17.7 2141 Central Java 6.1 9.3 18.9 23.6 Djogjakarta 10.1 9.8 16.3 17.9 East Java 10.4 20.0 17.2 31.9 Bali 7.2 15.0 17.5 17.4 Java and Bali 8.7 15.7 18.4 25.6 Source: National Family Planning Coordinating Board. The above table illustrates the general increase in the use of iacilities, indicating an increase in the number of acceptors not entirely due to the opening of more facilities. Data indicate that the time devoted to family planning services rose from 45 hours per clinic/month in May 1971, to 49 hours in June, and to 54 hours in September. ANNE)X 13 Page 3 of 10 4. Details of new acceptors for Java and Bali are summarized in the table below, and detailed in tables 5 to 12: Table 4 JAVA AND BALI: NEW ACCEPTORS BY METHOD, 1967-71 IUD Pill Others;/. Total Year Number Number , Number£ 1967 5,904 52.0 2,795 24.6 2,664 23.4 11,363 100.0 1968 15,871 60.3 5,199 19.8 5,221 19.9 26,291 100.0 1969 22,896 56.7 10,704 26.5 6,774 i6.8 40,374 100.0 1970 60,515 45.7 51 ,747 39.1 20,045 15.2 132,307 100.0 1971Z/ 113,635 420Q 138,771 51.2 18,535 6.8 270,941 100.0 TOTAL 218,821 45.5 43.5 53,239 11.0 4t1,276 100.0 1/ Includes condoms and vaginal foam tablets. T/ January-September 1971. From 1967 to 1970, the number of new acceptors has increased 11.6 times from 11,363 to 132,307. The biggest increase was experienced during the period 1969-70. In E71970-71, the number of new acceptors totalled 183,442, which exceeded the target set for that fiscal year by 58,442 acceptors. Of these, East Java accounted for 36%, followed by West Java with 23%, Central Java with 16%, Djakarta with 14%, Bali with 7%, and Djogjakarta with only 4%. Over one-third of the total number of new acceptors were recruited during the last quarter of FY1971. The number of acceptors for the first half of the FY1971-72 represents 33% more than the target set for that year. Whilst all provinces show a steady incraase in the number of new acceptors, East Java has nearly tripled the number of new acceptors and to September 1971 was responsible for over 40% of the national program's total. This increase is encouraging, but as yet only 1.3% of women in the fertile age group of 15-44 years practice family planning compared with 24% in Taiwan. 5. According to data derived from a random sample in West Java drawn from official service statistics of April 1971, 55.5% of the acceptors were between the ages of 20 and 29 years, and 74% between 20 and 34 years. The average number of children they had was 4.2. Of their level of education, 12.5% were illiterate and 47% had finished their elementary level. The acceptors' husbands were mainly farmers, government employees, and trades- men. Most of the new acceptors (97.5%) had not used any contraceptive method before going to the clinic. The main motivation for accepting fami- ly planning services was a desire not to have more children. Their princi- pal means of information on family planning had been received through the health personnel. 6. Throughout Java and Bali., the trend has been towards the adoption of the contraceptive pill as the most important method. Nevertheless, there are differences in contraceptive use between provinces (see Table 6). In Djakarta, during the first half of FY1971-72, 62.8% of the new acceptors used the IUD; in West Java, 76.1% preferred the contraceptive pill, whilst in Central Java, Djogjakarta, and Bali, the IUD was the most widely used method (55.9%, 56.6%, and 77.1% respectively). In East Java, there was an equal number of acceptors using the contraceptive pill and the IUD in 1970, although PAGE 1 3 Page 4 of 10 subsequent data show the preference of acceptors for the contraceptive pill (58.2%). To a great extent, the choice of a particular method may be accounted by staff preferences in the health facilities. According to the June 1971 returns (Table 12), government clinics have more contraceptive pill acceptors (51.1%) than others, as do other institutions (51.2%); private clinics, however, have more acceptors who prefer the IUD (55.8%) and this may reflect the fact that relatively more doctors are available for IUD insertion at private clinics than at government clinics. Social factors also have an influence; in many rural areas, for example, contraceptive pills are asso- ciated with sickness and not, therefore, very popular. Throughout Indonesia, a vasectomy is not acceptable for cultural reasons, and an abortion is legal only when the life of the mother is in danger. There is no information on the incidence of abortion in Indonesian society. ANYEX 1 3 PageT5 of 10 FAMILY PLANNING ACCEPTORS BY METHOD Table 5 DJAKARTA: NEW ACCEPTORS BY METHOD. 1967-71;/ I U D Pill Others Total Period No. % No. % No. % No. % 1967 Jan. - March - - - - - April - June 618 34.7 510 28.6 655 36.7 1,783 100.0 July - Sept. 1,106 36.6 924 30.6 992 372.8 3,022 100.0 Oct. - Dec. 0 37.4 1.055 36.2 771 26.4 2918 100.0 Total 2,816 36.5 2,489 32.2 2,418 31.3 7,723 100.0 1968 Jan. - March 1,108 67.5 263 16.0 271 16.5 1,642 100.0 April - June 1,417 68.9 292 14.2 349 16.9 2,058 100.0 July - SeptL. 1,682 68.8 384 15.7 377 15.4 2,443 100.0 Oct. - Dec. 1,891 68.1 473 17.1 411 14.8 2,775 100.0 Total 6,098 68.4 1,412 15.8 1,408 15.8 8,918 100.0 1969 Jan. - March 1,856 62.2 601 20.1 527 17.7 2,984 100.0 April - June 2,146 61.8 683 19.7 642 18.5 3,471 100.0 July - Sept. 1,835 52.8 808 23.2 833 24.0 3,476 100.0 Oct. - Dec. 2,335 57.2 887 21.7 862 21.1 4,084 100.0 Total 8,172 58.3 2,979 21.3 2,864 20.4 14,015 100.0 1970 Jan. - March 3,079 64.2 852 17.8 867 18.0 4,798 100.0 April - June 3,388 64.3 982 18.6 898 17.1 5,268 100.0 July - Sept. 3,857 66.0 1,053 18.1 925 15.9 5,835 100.0 Oct. - Dec. 4,004 62.8 1.348 21.2 1,021 16.0 6,373 100.0 Total 14,328 64.3 4,235 19.0 3,711 16.7 22,274 100.0 1971 Jan. - March 4,793 62.5 1,842 24.0 1,030 13.4 7,665 100.0 April - June 4,311 62.7 2,052 29.8 513 7.5 6,876 100.0 July - Sept,. 5548 63.1 2,693 30.7 547 6.2 8,788 100.0 Total 14,652 62.8 6,587 28.2 2,090 9.0 23,329 100.0 l/ January-September 1971. Source: National Family Planning Coordinating Board. ANNEX13 Page 6 of 10 Table 6 JAVA AND BALI: NEW ACCEPTORS BY PROVINCE AND METHOD, 19711/ I U D Pill Others Total Provinces No. % No. % No. % No. % Djakarta 14,652 62.8 6,587 28.2 2,090 9.0 23,329 100.0 West Java 10,425 17.8 44,649 76.1 3,582 6.1 58,656 100.0 Central Java 27,193 55.9 16,748 34.4 4,682 9.7 48,623 100.0 Djogjakarta 6,081 56.6 2,112 19.6 2,556 23.8 10,749 100.0 East Java 42,184 37.5 65,537 58.2 4,878 4.3 112,599 100.0 Bali J13,100 77.1 3,138 18.5 747 4.4 16,985 100.0 TOTAL 113,635 42.0 138,771 51.2 18,535 6.8 270,941 100.0 1/ January-September 1971. Table 7 JAVA AND BALI: NEW ACCEPTORS BY PROVINCE AND METHOD. 1970 I U D Pill Others Total Provinces No. % No. % No. % No. -- - Djakarta 14,328 64.3 4,235 19.0 3,711 16.7 22,274 100.0 West Java 7,248 25.6 16,850 59.4 4,262 15.0 28,360 100l 0 Central Java 10,339 46.1 8,639 38.5 3,448 15.4 22,426 100.0 Djogjakarta 2,128 43.8 1,349 27.8 1,384 28.4 4,861 100.0 East Javw' 19,250 42.8 19,160 42.6 6,555 14.6 44,965 100.0 Bali 7 222 76.7 1,514 16.1 685 7.3 9,421 100.0 TOTAL 60,515 45.7 51,747 39.1 20,045 15.2 132,307 100.0 ANNEX 13 Page 7 of 10 Table 8 JAVA AND BALI: NEW ACCEPTORS BY PROVINCE AND METHOD, 1969 I U D Pill Others Total Provrinces No. % No. % No. - % No. % Djakarta 8,172 58.3 2,979 21.3 2,864 20.4 14,015 100.0 West Java 1,736 45.8 1,482 39.1 574 15.1 3,792 100.0 Central Java 4,701 65.8 1,778 24.9 661 9.3 7,140 100.0 Djogjakarta 1,405 51.4 664 24.3 666 24.3 2,735 100.0 East Java 4,768 48.6 3,151 32.1 1,889 19.3 9,808 100.0 Bali 2a114 73.3 650 22.5 120 4.2 2,884 100.0 TOTAL 22,896 56.7 10,704 26.5 6,774 16.8 40,374 100.0 Source: National Family Planning Coordinating Board. Table 9 JAVA AND BALI: NEW ACCEPTORS BY PROVINCE AND METHOD, 1968 I U D Pill Others Total Provinces No. % No. % No. % No. % Djakarta 6,098 68.4 1,412 15.8 1,408 15.8 8,918 100.0 West Java 1,631 53.7 738 24.3 667 22.0 3,036 100.0 Central Java 3,127 41.7 1,559 20.8 2,820 37.6 7,506 100.0 Djogjakar a7 - - - - - - - - East Java 3,252 72.1 995 22.1 261 5.8 4,508 100.0 Bali 1,763 76.0 495 21.3 65 2.7 2,323 100.0 TOTAL 15,871 60.4 5,199 19.8 5,221 19.8 26,291 100.0 1/ Data for Djogjakarta were not providec separately. Source: Irdonesia Planned Parenthood Association. ANNEX 1 Page 5 Of 10 Table 10 JAVA AND BALI: NEW ACCEPTORS BY PROVINCE AND METHOD, 1967 I U D Pill Others Total Provinces No. ___ No. % No. % No. % Djakarta 2,816 36.5 2,489 32.2 2,418 31.3 7,723 100.0 West Java - - - - - Central Java 449 80.0 112 20.0 - - 561 100.0 Djogjakarta - - - - - - - - East Java 1,183 79.6 113 7.6 190 12.,8 1,486 100.0 Bali 1 91.4 81 5.1 56 3.5 .1593 100.0 TOTAL 5,904 52.0 2,795 24.6 2,664 23.4 11,363 100.0 Source: Natiortal Family Planning Coordinating Board. ANNEX 13 Table 11 Page 51 of 10 JAVA, MADURA. AND BALI: NEW ACCEPTORS BY PROVINCE PER 1,000 FERTILE WOMEN. APRIL 1970-MARCH 1971 Estimated Estimated Number of Acceptors Number of Total Women Aged Per 1,000 Clinics Population 15 - 44 Acceptors Fertile (March (In mil- (In mil- New Per 1,000 Women Aged Province 1971) lions) lions) Acceptors Population 15 - 44 Djakarta 110 4.23 0.76 25,141 5.9 33.1 West Java 384 20.97 3.77 42,321 2.0 11.2 Central Java 320 21.36 3.84 31,663 1.5 8.2 Djogjakarta. 86 2.41 0.44 6,637 2.7 15.0 East Java 463 24.83 4.47 64,,717 2.6 14.5 Bali 102 2.06 0.37 12,963 6.3 35.0 TOTAIL 1,465 75.86 13.65 183,442 2.4 13.4 Source: Naltional Family Planning Coordinating Board. ANNEX j Table 12 Page 10 of 10. NEW ACCEPTORS BY PROVINCE. METHOD, AND TYPE OF CLINIC, JUNE 1971 West Central Djc,- East Method Djakarta Java Java jakarta Java Bali Total Government Clini-cs Pill 313 4,162 1,865 285 5,331 432 12,38E8 51.1 IUD 867 1,127 3,362 773 3,130 1,214 10,473 43.2 Condom 24 225 250 192 182 76 949 3.9 Foaming Tablet 29 78 153 43 89 29 421 1.8 Subtotal 1,233 5,592 5,630 1,293 8,732 1,751 24,231 100.0 Private Clinics Pill 90 159 94 24 80 20 467 36.7 IUD 142 67 204 25 111 162 711] 55.8 Condom 10 5 16 19 9 - 59 4.6 Foaming Tablet 3 7 10 2 15 - 37 .2.9 Subtotal 245 238 324 70 215 182 1,274 100.0 Other Clinics Pill 289 332 13 35 372 38 1,079 51.2 IUD 391 108 67 44 254 22 886 42.0 Condom 47 19 7 4 9 1 87 4.2 Foaming Tablet t 28 1 - 1 23 1 54 2.C .Subtotal 755 460 87 84 658 62 2,106 100.0 TOTAL Pill 692 4,653 1,972 344 5,783 490 13,934 50.4 IUD 1,400 1,302 3,633 842 3,495 1,398 12,070 43.9 Condom 81 249 273 215 200 77 1,095 3.9 Foaming Tablet: 60 86 163 46 127 30 512 1.8 Grand Total 2,233 6,290 6,041 1,447 9,605 1,995 27,611. 100.0 Source: N F ional Family Planning Coordinating Board. ANNEX 14 TOTAL NUMBER TRAINED IN FAMILY PLANNING UP TO JUNE 1971 Inform- Reporting & Training Field ation Social Recording Institution Doctor Midwife Wori,PJ' Officer Worker Personnel Other National 75 97 70 ° 34 96 - 34 Training Center (IPPA) Provincial 142 94 50 - - 156 58 Training Center Djakarta 3, Provincial 7' 74 188 -3 Training Center Bandung Provincial 89 193 157 98 - - 124 Training Center Semarang Provincial 31 49 189 44 - 62 39 Training Center Djogjakarta Provincial 51 73 161 - - 97 Training Center Denpasar Provincial 128 149 36 559 - - Training Center Surabaja - - - - - - - TOTAL 592 729 851 735 96 315 256 1/ Includes both paramedical and nonmedical field workers. 2/ Includes 26 group leaders. 3/ Includes 30 group leaders. ANNEX 15 ESTIMATED TRAINING LOAD FOR IN-SERVICE TRAINING IN FAMTLY PLANNING FOR ALL TRAINING INSTITUTIONS IN JAVA AND BALI, -971-76 1/ Djogja- Semarang Bandung Surabaja Djakartafpjakarta karta Bali (C.Java) C.Java (W.java) W.Java (E.Java) E.Java N.T.C.- P.T,C. P.T.C. P.T.C. P.T.C. S.T,C, P.T.C, S,T.C. P.T.C. S.T.C. TOTAL Trainer 134 - - - - 134 Administrator 230 - - - 230 Regency Social Worker - 32 10 15 - 35 - 25 - 40 157 Regency Information Officer - 32 10 15 - 35 - 25 - 40 157 Regency Field Worker3/ - 425 240 210 - 2,140 - 2,100 - 2,500 7,615 Group Leader/ - 85 50 45 - 430 - 420 - 500 1,530 Field Worker 3 Supervisor - 5 5 8 - 35 - 26 - 37 116 Doctor - 116 58 87 473 - 439 - 527 - 1,700 Midwife, Auxiliary Nurse-Midwife, etc. - 300 152 228 1,212 - 1,128 - 1,355 - 4,375 Reporting and Recording Personnel - 12 5 8 34 - 26 - 37 - 122 TOTAL 364 1,007 530 616 1,719 2,675 1,593 2,596 1,919 3,117 16,136 1/ No re-training included. Targets subject to review by the National Training Board when established, and annually thereafter. 2/ The total training load for the National Training Board over the next 5-year period will be heavy (doctors-in charge of regency health services, medical officers in charge of MCH/FP at regency level -- for 1 month training program, seminars for administrators, special worlcshops, etc., in addition to the training of trainers for family planning training centers) but at this stage not definable in absolute numbers. 3/ Constitutes the nonmedical field worker personnel. ANNEX 16 STANING COiI4ITTEE ON FAMILY PLANNING TRAINIWa 1. To provide for adequate coordirnation of family plaaning training policies and requirements, a standing committee on family planning training should be established. It would be responsible for recommend- ing to the Chairman of the NFPCB training policies and priorities, the appointment of training responsibilities and the use for training purposes of the facilities included in the project. It must be fully representative of all the agencies involved in family planning training and might comprise the following: Chairman - NCPCB Chairman Secretary - Chief, NFPCB Bureau of Training & Education ]M'embers - Director, MCH/FP, IMinistry of Health IPPA Secretary General Chief, Edacation Bureau (5), Ministry of Health Representative of University of Indonesia (from I)emographic Center) Senior Professor of Obstetrics and Gynecologgy Representative of Armed Forces Family Planning Committee Representaltive of Ministry of Information. 2. The National Training Center (NTC) should come under the immediate review of the standing committee 1through a subcommittee or management board. The chairman should be the Secretary-General of the IPPA with the Director of the NTC as member.-secretary. The subcommittee would be responsible for overall management under the auspices of the IPPA, and for making decisions on programs, policies, and a budget, as well as supporting the Director in relating to the needs and expectations of the implementing agencies of the family planning program in Indonesia. The NTC must have full-time staff and be directed to training senior admiinistrative staff and medical staff and to the orientation of senior policyniakers. ANNEX 17 FOREIGN ASSISTANCE TO INDONESIA IN FAMILY PLANNING, 1968--71- (U.S.$ equivalent of aid amcunt) Donor 1268j9 170-71 Bilateral Governent Agencies Netherlands 166,000 - 250,000 Japan 9,000 4L6,O0 32,000 Sweden - 259,000 - USAID 1,o500,000 465,OO0 1,759 ,O00Q-/ Multilateral Agencies UNFFA - 4C',000 - UNESCO - 2,000 - IBRD 23, 000 - WHO - 236, 00o/ UNICEFY . 23,000 379,000 Private Organizations IPPF 180,800 427,000 402 ,,000 World Assembly of Youth - 9,000 19,000 Population Council 1,000 63,000 69,000 Pathfinder Fund 15,000 35,000 13,000 Ford Foundation 180,000 122,COO 160,()0 TOTAL 2,051,800 1 ,288,000 3,319,000 1/ Includes provision for family planning/health manpower development;. 2/ The total figure proposed by WHO for its country program. 3! In addition, UNICEF has made a long-term commitaenti to assist the Ministry of Health to upgrade general health services by contributing about U.S.$1 .5 million annually from 1969-744. ANNEX 18 FOREIGN ASSISTANCE TO INDONESIA IN FAMILY PLANNING, 1969-70 Recipient Donor Field Commodity Assistance NFPCB - WHO Services Technical advisers; studies Ministry Information Technical assistance of Realth Training Technical assistance Research and Evaluation Technical assistance; studies NFPCB - USAID Services Drugs; transport; medical kits Ministry office equipment of Health Logistics Technical assistance Training Equipment; teaching aids Research and Evaluation Equipment NFPCB - UNICEF Services Technical advisers; medical kits; Ministry equipment; t:ransport; dukun kits of Health Training Construction equipment Logistics Technical assi.stance NFPCB - Population Services IUDs Ministry Council of Health NFPCB - JAPAN Services Light t:ransport; office equip- Ministry ment:; condoms of Health Information Audiovisual aidls; printed materials NFPCB - SWEDEN Services Contraceptives,; drugs Ministry of Health NFPCB - FORD Training Technical overseas training Ministry of Health IPPA FORD Information Technical assistance Training Technical assistance; pilot project NFPCB - UNDP Research and Ministry Evaluation Studies and evaluation mission of Health IPPA IPPF Information Textbooks; equipment Training Construction; advisers IPPA NETHER- Training Construction; technical LANDS assistance ANNEX 15' Page 1 of 4 PARAMEDICAL EDUCATION Introduction * 1. The ability to meet the targets for family planning depends primarily on the ability to train the necessary paramedical personnel to help carry out the program. At present, the most important worker in this category is the midwife; the emphasis should be rapidly moved to nursenmidwives supported by auxiliary nurse-midwives (ANMi;). 2. On the average, some 15-20% of those who apply for admission to midwifery schools are admitted. There are high attrition rates during thie courses to which several considerations apply. In spite of 9 years of general education, the educa- tion level of candidates is low. More stringent selection procedures are required to obviate the additional test given to pupil midwives 3 months after entry. There are presently no stipends or grants for students; each student pays admission fees (of about Rp 1,500) and a monthly fee which ranges from school to school between Rp 750 and Rp 1,50O, together with 12 kilos of rice. There is no established common level of fees. Students are expected to do all the domestic work in the hospital to which they are attached for training, and also help in the hostels. The cost of training one midwifery student annually is Rp 360,000; of this the Government makes provision for Rp 36,00DO, the remainder being covered by fees and the labor of students as domestics and general nurses in the hospitals. In conse- quence, the status of the student is viery low and the extra duties leave little time for studying, with a consequently high failure rate in examinations. Parents are frequently unable to maintain fee payments. Many students become rapidly dis- enchanted with inadequate hostel accommodation, and in many cases, the need to live in cities in private accommodation heightens the adverse urban cultural im- pact. Attrition is also, in part, the result of a lack of qualified teachers, and also a high teacher-student ratio (of :!:80 or more) is not uncommon. 3. Classroom accommodatiton is frequently inadequate and equipment is in short supply. Anatomical charts, model.s, films, and posters, etc., are essential visual aids for training and teaching in midwifery and family planning. Models are needed to teach IUD insertioDn methods to midwifery students so that certain degrees of skill, manual dexterity, and confidence are achieved before actual in- sertions are performed. Library facilities are very poor, since there are few texts in the Indonesian language; consequently students have to rely upon lecture notes. 4e Dcrmitories are, in general, overcrowded and inadequate. Hostels are requir~ed for students which wciL be their nome dir-ng training; more amenities and recreational facilizies are neede-- to allow stuCentAs to relax after training and work duties, which are hard and tiring. 5. -The problem of attriziLon rates is complex and requires detailed study. It appears that it would be ameliorated, at 1G ast in part, by: a. abolishing fees and providing stipern.-.. to emove economic constraints with the introduction ol --rvLce agreements; b. providing adequate aomes-ic staff ir. sc;^. hostels, aria hospital wards to allow students more timie -L --ay -.d practice; ANNEX 15 Page 2 of 4 c. providing more clerical staff to relieve teaching staff and students in schools and hospitals, Df - -ie?vy ' oad of paper work; d. providing better physical facf.lities; and e. providing more and better oualified teachers. Staffing 6. The change of program commencng in 1971, from 3 years of midwifery training to 3 years of nurse training a':::. year of Ymidwifery training, will produce well-traine.d nurse-midwives. The curric-alum for their training has been developed to include an adequate component of family planning training. But the length of the new course will initially limit the number of graduate midwives trained. This would, therefore, be the ideal time to begin the training of auxiliary nurse-midwives, a cadre of which forms the backbone of the health services of many developing countries. 7. The ANM concept has already been accepted by the Government of Indonesia, but still has to be effected. The ANM should be an active multi- purpose worker, responsible for the health care of a given population, with emphasis on MCH and family planning. She would not replace the midwife, but would fall under her professional supervision and adninistrative control. To be fully effective, the ANM must live in the area to which she is assigned. Following 9 years of general education, the ANM program should consist of 2 years of basic training; it is described in Annex 20. ANM Functions 8. The functions of the ANM would include: a. Family Planning Direct responsibility for educating members of the community in family planning, in close cooperation with village leaders, other Government family planning workers, particularly field workers, and voluntary associations. Responsibility for providing contraceptive services, such as the distribution of contraceptive pills, condoms, etc. Responsibility for the follow-up care of contraceptive ac- ceptors of all kinds, and their referral if necessary. Assistance in the preparation of the necessary records and reports. b. Maternal Health Responsibility for the prenatal, intranatal, and postnatal care of all mothers known to her, and their referral where necessary. Health education of the mother in family care and family planning in the home and at the center. C. Child Health Responsibility for the care of newborn., infant, preschool, and school children -- general care, nutrition, prevention of deficiency and communicable diseases (vaccination, immunization, etc.). ANEX 19 Page 3 of ' d. Dukun Training and Supervision Responsibility for the training and supervision of the dukuns in her area, and their orientation to family planning. 9. To providea career possibilities, the ANM should have the opportunity of becoming a fully qualifieid nurse-midwife. After she has completed at least 5 years of field experience, further training for 1 year should be available to complete her qua:lifications. Supplementary Trainimg 10. In order to boost the number of paramedical staff available for MCH/FP work, supplementary training programs should be considered. Special attention should be paid to the requirements of the demonstration field paramedical program in East, Java. The most urgent areas are: a. Nurse-Midwives A 1-year post basic program in midwifery and family planning for existing qualified nurses has been accepted by the Government, and an acceptable curriculum has already been prepared. It could be implemented in existing schools, candidates being replaced at the rate of 100 per yeax in their present positions by new nurse graduates. Division E and the Division of Nlursing of the Ministry of Health should be responsible for: i. selecting suJitable midwifery schools; ii. selecting the best available students; iii. ensuring their replacement by new graduates; and iv. negotiating program implementation with the medical directors of the selected training schools. To attract candidates of the requisite calibre, stipends of Rp 5,000 pear month must be paid. In return, candidates should undertake to wor'k as directed by the Government for 3 years. b. Auxiliary lNurse-Midwives To meet thei urgent demands of the MCH/FP program, consideration should be given to planning and implementing supplementary training programs for existing assistant nurses (PKCs) and assistant mid- wives (PKEs). The former would require training in midwifery and family plarnning, and the latter would reqluire training in nursing and family plann:ng. No syllabus has been prepared by the Government, but bhe ANM syllabus (see Annex 20) could be adopted as appropriate for each staff category. Preparation should be, in either case, of L year's education. As an incentive to further training of staff already employed, and probably married, stipends of Rp 3,500 must be available. In return, candidates would have to undertake to work for 3 years in the MCH/FP program as directed by the Government. ANNEX 19 of 4. Tutor Training 11. A serious problem facing the expansion of paramedical education is the inadequate numlber and quality of teaching staff. With 11HO/UNICEF assistance, short courses (3 months) in methods of teaching are being con- ducted for qualified nurse-midwives or midwives, with at least 3 years of experience. In order to meet the problem mnore directly., a UNFPA-assisted UNICEF project is being developed to prepare nurses and midwives as nurse- teachers and midwife-teachers. it provides 1-year courses for which an adequate syllabus has been prepared. Three schools -- in Surabaja, Djakarta, and Macasser -- are being estabLished to admit 90 students annually. The school in Surabaja was to admit its first pupils in July, 1971. In Djakarta, the new school buildings will be ready by January, 1972. The graduates from these schools should be posted to the new schools established uncder this project, in addition to filling staff complements at existing schools. In addition, the Government of Indonesia nominates carldidates for a WHO/New Zealand Government program which enables nurses and nurse-midwives, ineligible for admission to post basic nursing programs in their own country, to obtain post basic preparation in teaching, public health, nursing services, adminis- tration, etc. Thei program lasts for 1 year and includes 3 months' intensive English language turaining. Candidates from Indonesia for the 1972 courses should be selected for preparation in teaching. If full use is made of the several opportunities, sufficient tutors will be available for the expanded paramedical education component of this project. Sanction for Posts 12. Development of the MCH/FP program depends on staff expansion which, in turn, depends on the provision of more and better training facilities. The objective will not be realized, however, until the Government sanctions more posts. There are no vacant posts in Djakarta for the midwives who will graduate in 1971; the 19 nurse-midwives who graduated from the Denpasar school in December, 1970, are employed only on an ad hoc daily basis. Where necessary, the central Government should underwrite the provincial Government's sanction for nurse-midwife and auxiliary nurse-midwife posts. ANNEX 20 Page 1 of 8 TRAINING REQUIREMENTS FOR THE AUXILIARY NURSE-MIDWIFE 1. A candidate for auxiliary nurse-midwife training should have reached the age of 17 years and have a minimum of 9 years education. The program should be of 2-year duration, 2. Its objectives should be to: a. produce a well-prepared family planning/family health worker; b. emphasize the far-reaching effects on family and community health of family planning and good maternal and child health (MC1I) practice; c. develop an appreciation of the significance of population growth and its impact on social change, national economic development, and health services; and d. develop in the student the ability to work as a member of a team in family planning and in family health. The Syllabus 3. Until such time as a Nurses and Midwives Council is established in Indonesia, requirements for training should be laid down and the syllabus planned by Bureau V (Education and Training) of the Ministry of Health and the Division of Nursing of the Ministry of Health. 4. To meet the objectives of the program and to enable the ANM to carry out her functions effectively, it is suggested that the program include family planning, nursing, midwifery, and public health with practical experience in each area and with family planning integrated throughout. Allowing for 4 weeks' vacation annually, training should include: a. 7 months - Nursing and Family Planning b. 12 months - Midwifery and Family Planning c. 3 months - MCH, Family Planning, Public Health in Rural Health Training Cx:ters, based on a rotation plan. 5e The syllabus should include the following subjects: a. Family Planning i. Philosophy Ef family planning -- introduction to the national family planning program; demographic, socio-economic, religious, cultural, and health aspects of family planning. ii. Human reproduction -- anatomy and functions of male and female reproductive organs; physiology of menstruation; contraception; methods of contraception -- traditional, modern; their use, effectiveness, contraindications,. complications, and side- effects; determination of referral cases; follow-up of acceptors; case finding and case holding. ANNEX 20 Page 2 of 8 iii. ]:nformation -- motivation methodology, communications, inter- viewing. iv. Health education -- aims and principles; melthods; follow-up; techniques for teaching individuals and groujps in family planning. v. Administration -- organization of MCH/FP clinics; preparation of the necessary equipment; maintenance of records and reports. vi. Integration of family planning into MCH and postpartum programs. Total hours 96 b. General Nursing i. General needs of the patient -- nu;,sing care in various conditions and diseases, e.g., bronchitis, pni ionia, rheumatic fever and heart failure; preoperative and posto>perative care of patients who have undergone surgery; family planning needs identified and referred. ii. Pediatrics .-- normal child growth and development; recognition of deviations from the normal -- physical or mental; child care and nutrition; prevention of infections -- vaccinations and immunization; nursing care of sick children; family planning advice to parents. iii. Communicable diseases -- communicable diseasets prevalent in the country, including diseases of the intestinal tract; their pre- vention and control --- vaccinations, immunization, and BCG; clean water supply; refuse disposal; nursing care of patients with infections or contagious diseases; problem of overcrowding; poor sanitation and exposure to infection in the large size, low-income families. iv. Ophthalmic conditions and diseases prevalent in the country - prevention and nursing care. v. Food and nutrition -- nutritional requirements of mother and child in relation to other members of the family; nutritional requirements of preschool and school child; essential food factors -- proteins, carbohydrates, fats, mirterals, and vita- mins; nutritional deficiencies and their prevention, e.g., anemia, blindness, beri-beri, etc.; balanced diets using the foods available in the country; nutrition in relation to family planning, size of family, food cost, and budgeting; improving family, nutrition through family planning. vi. Microbiology -- organisms causing diseases, e.g., venereal diseases; incidence of diseases; infection; asepsis and anti- sepsis; sterile techniques required for midwifery, insertion of IUDs, dressings, ete. vii. Pharmacology -- drugs and mixtures, including oral contraceptives; their usage, dosage, and administration. ANNEX 20 Page 3 of 8 viii. Personal and community health -- principles of hygiene and sanitation applied to person, home, and environment; pre- vention of infection; role of the ANM in health education. ix. Community nursing -- domiciliarv services; midwifery; maternal and child health; home visiting; home nursing; family planning; control of communicable diseases; envi- ronmental sanitation. c. Obstetrics i. General care of mother -- temperature, pulse, respiration, blood pressure, weight, and urine testing; palpation and auscul :ation. ii. Principles of hygiene -- sanitation and nutrition in relation to the mother. iii. Causes of infection in midwifery and their prevention; prin- ciples of asepsis and antisepsis applied to midwifery. iv. Anatomy and physiology of the female pelvis, reproductive organs, and the breasts. v. Physiology, diagnosis, and management of normal pregnancy. vi. Signs and symptoms suggesting deviation from normal pregnancy -- toxemia, antepartum hemmorrhage, and other obstetric compli- cations; their causes, prevention, and treatment. vii. Physlology, mechanisms, and management of normal labor. viii. Signs and symptoms suggesting departure from normal labor. ix. Physiology and management of the puerperium. x. Signs and symptoms suggesting departure from normal puerperium -- puerperal pyrexia, puerperal asepsis; causes, prevention, and managemrent. xi. Care of the breastrs under normal and pathological conditions. xii. Care of the newborn infant -- recognition of congenital abnor- malities; establishment of breast feeding and artificial feeding; recognition of disorders occurring during the first month of life with special reference to those in which skilled medical or surgical care may be needed. xiii. Resuscitation of the newborn infant as required; care of the premature infant. xiv. Ophthalmia neonatorum and other infections in the infant. xv. Venereal diseases -- their signs, symptoms and dangers, and ANNEX 20 Page 4 of 8 the risk of contagion; the midwives' responsibilities for advocating early and continued treatment. xvi. Postpartum contraception. xvii. Use of drugs and solutions as they may be required in midwifery practice; their dosage and' strength; mode of administration or application and the dangers involved. xviii. Maternal mortality, stillbirths, neonatal mortality, infant mortality -- the meaning of these terms; steps taken to pre- vent and reduce such mortalities; responsibilities of the midwife. xix. Records and reports -- prenatal, intranatal, and postnatal records; family planning records. d. Practical Midwifery Experience must include the following: i. Prenatal care of at least 20 pregnant women. ii. Responsibility for not less than 20 women during labor. If possible at least five of these should be delivered in their own homes. iii. Responsibility and care for not less than 20 postpartum women and their infants, five in their own homes if possible. iv. Active participation in the family planning program with particular emphasis on the postpartum program. e. Coumunity Nursing This experience should be planned during the 2 months rural health experience at which time the student iAN will participate, under supervision, in all activities, MCH/FP polyclinic, home-visiting, school health, and dukun training. Duration of program 2 years. Hours of duty : 8-hour day; 5-1/2-day week; 44 hours each week; 4 weeks annual leave; 834 hours theory and approximately 3,390 hours for practical experience in wards, maternity wards, labor rooms, MCH/FP clinics, and health centers. ANNEX 20 Page 5 of 8 Suggested Auxiliary Nurse-Midwife Curriculum Total Hours Subjects Theory Practical Basic Principles of Nursing Care 120 In demonstration room and wards. Anatomy and physiology 80 Family Planning (FP): Human Reproduction 6 Antenatal clinic. Introduction to the National Family Planning Program 2 Philosophy of Family Planning 2 Visits to MCH/FP clinics, health Demographic Aspects of FP 2 centers, wards. Home visiting Socio-Economic Aspects of EP 4 with a nurse, midwife, or field Cultural A.spects of FP 4 worker. Religious Aspects of FP 4 Health Aspects of FP 4 Micro-biology 20 Visit to laboratory, Personal and Community Health 30 Wards, MCH/FP clinics, health centers; home visiting with public health nurse. Medical Nursing 30 Medical wards. Surgical Nursing 30 Surgical wards. Gynecological Nursing 30 Family Planning: Gynecological wards, MCH/FP Structure and Functions of the centers, postpartum. wards. Generative Organs 16 Methods of Contraception Pediatric Nursing 40 Pediatric wards, MCH/FP clinics, health centers (polyclinics). Communicable Diseases: Nursing Care, Prevention, Infectious disease wards or and Control 40 hospitals, health centers; visits with public health nurse, malaria worker, smallpox vacci- nator, etc. Ophthalmology Nursing Care 15 Ophthalmology ward, pediatric ward, health centerc, MCH/FP center. First-Aid and Bandaging 10 Classroom. Food and Nutrition 30 Diet kitchen with nutritionist, MCH/FP center. Community Nursing 20 MCH/FP centers, health centers, home visiting. Phiarmacology: Drugs, Their Usage, Dosage, and Administration 10 Wards. Family Planning: Oral Contraceptives 6 Wards, MCH/FP clinics. Spermicidals Principles and Aims of Health Wards, 2ACH/FP centers, health Education 6 centers. ANNEX 20 Page 6 of 8 Total Hours Subjects Theory Practical Obstetrics: Obstetrical.Anatomy and Physiology 30 Nutrition Applied to Pregnancy 10 Micro-biology: Infection, Asepsis, and Antisepsis 10 Wards and delivery room. Management of Normal Pregnancy 40 Antenatal clinic, MClI/FP clinics. Signs and Symptoms of Departure from Normal Pregnancy 40 Antenatal clinic, MCH/FP clinics, antenatal wards. Mechanisms and Management of Normal Labor 20 Maternity wards and delivery rooms. Signs and Symptoms of Departure from Normal Labor 10 Maternity wards and delivery rooms. Puerperium: Management of Normal/Abnormal 10 Postnatal wards. Family Planning: Postpartum Contraception 16 Postnatal wards, MCH/FP centers. Child Care: Care of Newborn 1 20 Maternity wards and nursery. Care of Premature Infant J Family Planning: Information, Motivation 12 MCH/FP center. Obstetrical Complications 15 Maternity wards, delivery room. Pharmacology: Drugs Used in Midwifery 10 Wards and delivery room. Family Planning: Administration, Integration of FP into MCH, Postpartum Program 12 Maternity wards, MCH/FP clinics. Venereal Diseases 66 Venereal disease clinic. Records and Reports 66 Maternity wards, MCH/FP clinics. Vital Statistics: Maternal. Mortality Rate Stillbirths 6 Maternity wards, MCH/FP clinics. Neonatal Mortality Rate Infant Mortality Rate J TOTAL HOUJR,S THEORY 834 ANNEX 20 Page 7 of 8 Rural Health Experience for Student Auxiliary Nurse-Midwives 6. As the auxiliary nurse-midwife is being prepared to wcrk in rural areas, it is essential that part of her preparation takes plact at rural MCH/FP clinics and health centers. 7. To introduce her to the concept of MCH/FP and family health during the first year, arrangements should be made for visits of observation to these clinics, and to observe home visiting techniques with nurse-midwife or midwife, family planning field worker, vaccinators, sanitarians, malaria workers, etc. 8. During the second year, the program should be planned so t:hat each student has a minimum of 12 weeks' supervised practice in selected MCH/FP clinics and health centers. These selected centers will have living accom- modation attached to where the student will live. 9. The experience should be planned by the nurse-midwife tutor in consultation with the medical officer and nurse-midwife at the center, and to ensure adequate supervision of the students, if possible, not more than four should be sent to a center at any one time. 10. Before a student is sent to a rural center for practical experience, she must have been responsible for not less than five women during labor and delivery, and must have been responsible for the nursing care of five post- partum mothers and their infants. Practical Rural Health Experience a. Weeks 1-2 This should be a period of orientation to and further obgervation of all activities at the MCH/FP clinic and health center -- MCH/FP clinic including IUD insertions; infant and preschool clinics; polyclinic; vaccination and immunization clinics including BCG; dukun training classes; health _ducation -- family planning, indi- vidual and group teaching; home visits with the various MCH/FP and health center staff to observe the techniques of home visiting, follow-up of acceptors, and if possible a home delivery. b. Weeks 3-12 During this period, under supervision, the student ANM will participate, in rotation, in all the activities of the centers. If possible, she should be responsible, under supervision, for not less than five women during labor and delivery, and for the nursing care of five postpartum mothers and their infants in the home. (If home deliveries are not available, this experience could be arranged in the maternity ward of the MCH/FP clinic.) c. Prenatal Clinic Preparation of the clinic, interviewing and taking history of the mothers, weighing, urine testing, blood pressure, palpation and auscultat,on, advising on general health and family planning as required. ANNEX 20 Page 8 of 8. d. Family Planning Clinic Preparation of the clinic; sterilization of equipment required including IUDs; distribution of conventional contraceptives; keeping records and reports; individual and group teaching as required. e. Infant and Preschool Child Clinic Preparation of the clinic; interviewing mothers; weighing and measuring babies and children; assisting the doctor with examina- tions and treatment; advising on general care, nutrition, vacci- nations and immunizations, and family planning as required. f. Polyclinic Assisting the doctor and nurse in examinations, treatments, etc.; health teaching. g. Group Teaching Have the opportunity to plan and conduct at least two classes for mothers -- one on some aspectsof family planning. h. Administration of the Center Records, reports, and statistics; planning of home visits. i. Home Visiting The student ANM, having had a period of observation in home visiting with the health center personnel, should, be given a small area of about 50 families. In this area, she wil l be responsible, to the nurse-midwife, for the follow-up of all cases -- family planning, maternal and child health, and others - as required. ANNEX 21 Page 1 of 5 RECOMMENDED INTEGRATED MCH/FP STAFFING PATTERN FOR EAST JAVA. BALI, AND DJAKARTA AT REGENCY LEVEL AND BELOW 1. The annex outlines the present staf. of the MCH/FP structure at and below regency level and recommends additions (underlined) to ensure a more adequate family planning service coverage. A. East Java Regency: Population of about 800,000. Structure i. Offices of Administration and Records ii Small hospital, with about 10 maternity beds, but often without the equipment or medical skills for operative obstetrics iii. MCH/FP center. Staff i. Administrative medical officer ii. Doctor-in-charge of hospital iii. Medical officer for communicable disease control, Medical officer for health promo-lon (nutrition, sanitation, etc.), Medical officer for MCH/FP iv. Nurse-midwife assigned to maternity section of hospital v. One supervisory midwife to assist the family planning medical officer in supervising midwives and ANMs vi. Statistical assistant to ensure the adequate recording and reporting of family planning data from centers at regency level and below vii. One assistant supervisor for the nonmedical field worker program. District: (Comprised of about five sub-districts) Total population about 200,000. Staff i. Medical officer to supervise the work of the sub-district level health centers ii. Supervisory midwife to supervise the work of midwives in the sub-districts iii. Three group leaders for supervising the nonmedical field workers' program (one for every five nonmedical field workers). Sub-District: Population of about 44,000 Structure i. MCH center with family planning facilities at sub-district headquarters i NEX 21 Page 2 of 5 ii. Two MCH/FP centers elsewhere in the sub-district. Staff i. Onie nurse-midwife at the MCH/FP center ii. Two auxiliary nurse-midwives to work under the overall supervision of the midwife but responsible for all aspects of MCH and family planning work, resident at centers to be established at strategic sites in the sub-district, but outside headquarters iii. Four nonmedical field workers, one each for a population of about 10,000 for family planning education. Supgortive Workers 2. In addition to the staff listed above, who will be primarily res- ponsible for the integrated MCH and family planning program implementation, social workers and information officers, etc., at the sub-district and regency levels, other health workers such as health controller, malaria workers, yaws workers, and vaccinators, as well as the dukuns and D.K.D.s±/ at the village level, should be involved in bringing acceptors. B. Bali 3. For the eight regencies, with a total population of 2.1 million, a more intensive staffing pattern in accordance with existing plans for Bali is recommended. Regency: Average population 280,000. Staff i. Administrative medical officer for the regency ii. Doctor-in-charge of the hospital iii. Medical officer for communicaLble disease control, Medical officer for health promotion, Medical officer for MCH and family planning iv. One supervisory midwife to assist the medical officer in supervising the midwives and ANMs v. One nurse-midwife to work in the hospital vi. Another eight supervisory midwives to supervise the work of nurse-midwives and ANMs at and below the sub-district level, at the rate of one per five midwives or ANMsr- vii. One assistant supervisor for the nonmedical field workers' program viii. Five group leaders to supervise and support community education, at the rate of one for every five nonmedical field workers. Sub-District: Average population 45,000. Staff i. Oae nursej dwife at the sub-district health center ii. One niurs dwife or one auxiliary nurse-midwife for every two vi-l. es at an overall rate of one nurse-midwife to two ANMs s; 1/ Part-time health worke ', appointed and paid by village authorities. ANNEX 21 Page 3 of 5 iL One nonmedical field worker for every 10,000 population. Supportive Workers i. One social worker, one information officer, and one health controller for each regency ii. One social worker assistant and one information officer for each sub-district iii. About 25 dukuns for each sub-district iv. Other health workers such as malaria workers, yaws workers, vaccinatoirs, etc. C. Djakarta 4. For five municipalities and 27 sub-districts, each with a population of 200,000, the following staffing pattern is recommended: Municipality: Average population 1 million. Staff i. Administrative medical officer for the municipality ii. One doctor-in-charge of the hospital ii. Medical officer for communicable disease control, Medical officer for health promotion, Medical officer for MCH and family planning iv. One supervisory midwife to assist the medical officer in supervising the nurse-midwives and ANMs v. One assistant supervisor for the nonmedical field worker program. Sub-District: Average population 250,000. Staff i. One medical officer for the health center ii. One doctor-in-charge of the hospital iii. Four nurse-midwives for each health center iv. Four auxiliary nurse-midwives assignted to the health center and hospitals, and seventeen ANMs for community MCH and family planning work at the rate of one per 15,000 population v. Twenty-five nonmedical field workers, at the rate of one per 10,000 population vi. Five group leaders, at the rate of one per five nonmedical field workers. Supportive Workers 5. In addition to the staff listed above, the social workers and inform- ation officers, etc., at the sub-district and municipal levels, the other health workers such as health controller, malaria worker, yaws workers, and vaccinators, etc., as well as the dukuns, should be involved in bringing more acceptors. ANNEX 21 Page 4 of 5 Table 1 REC-1MENDED NUMBER OF STAFF FOR INTEGRATED MCH AND FAMILY PLANNING WORK IN EAST JAVA. BALI AND DJAKARTA Staff Cat>gory East Java Bali Djakarta Administrative Medical. Officers 37 8 5 Hospital Medical Officers 37 8 32 Medical Officers 250 24 42 Supervisory Midwives 176 72 5 Nurse-Midwives 571 151 108 Auxiliary Nurse-Midwives 1,068 186 297 Nonmedical Field Workers 2,136 200 675 Group Leaders 417 40 135 Assistant Supervisors 37 8 5 Supportive Workers 1,179 124 69 Dukuns 14,000 1,250 5,000 D. K. D.s 8,010 - Other Hea.lth Workers 2,553 224 i23 ANNEX 21 Page 5 of 5. Table 2 RECO1MENDED STAFFING PATTERN FOR INTEGRATED MCH AND FAMILY PLANNING SERVICES AT AND BELOW LEVEL OF REGENCY IN EAST JAVA Total MCH & FP Staff as per Recommnendations of Present MCH Staff UN-WHO-IBRD Report Appraisal Mission Sub-District 'District Regency Sub-District District Regency Sub-District District Regency Staff Categor Level Level Level Level Level Level Level Level Level I. Administrative Medical Officers - - 1 - - 1 Hospital Medical Officers - - 1 - - L Medical Officers - 1 2 - 1 3 - 3 Supervisory Midwives - - 1 - - 1 - - 2/ Nurse-Midwives a' 1 - - 2 - - 1 Auxiliary Nurse-Midwives 2 - 1 - 2 1 2 11. Nonmedical Field Workers - 2 - 4 - Gtoup Leaders - - - - 1 - - 3 4/ Assistant Supervisors - - - - - 1 III, Supportive Workers 2 - 3 2 - 3 2 5/ 3 Nurses (Mantris) 4 6/ - 4 - - 4 6/ Dukuns 25 - - - 25z- - - 25 - D.K.D.s 15 7/ - - 15 7' - - 15 7/ Other Health Workers 4 3 - 4 3 - 4 / 3 - 1/ Medical officers in charge of (a) healt)h promotion and (b) communicable disease control at the 'cegency le9Y-' 2/ Now only midwives. 3/ Now only assistants to midwives and, assistant midwives. 4/ In ratio of one group leader for five field workers. 5/ One social assistant and one information officer at sub-district level and one social worker, orne information officer, and one health controller at regency level. 6/ lNumber estimated. 7/ Number estimated. 8/ One malaria worker, one yaws worker, one smallpox vaccinator, and one assistant sanitarian at sub-district level and one malaria supervisor, one sanitarian, and one administrator at regency level. ANNEX 22 Page 1 of 10 SITES FOR MiCHASP CENTER CONS$TRU(ITION I. LK SCHOOLS 1. At district level with ANK dormitory accormnaon16 A. East Java Regency DistriOct TUBAN Tuban Rongol Djatir Tgo Parengr,mn MAGETAN Gorang - Gareng Pontjol. Karingredjo Sukomm,v~ BLITAR SrengaiN;> Lodojo Sanan ilJon Taluh 1/ SIDOARDJO Kwanjaji: B107ta Alasba,ja Sepulsa 1/ Clinics located in Bangkalan Regenoy ANNEX 22 Page 2 of 10 2. At district level (:l$) Regency District Location Modjokerto Sooko Sooko Gondang Gondang Godeg Gedeg BodJonegoro Kalitiduh Kalitiduh Madiun Saradan Saradan Wungu Wungu (desa Modj opurno) Ngawi. Ngrambe Ngrambe Tulungagung Tjampurdarat Tjampurdarat Trenggalek Karang n Karangan Malang Singosari Singosari Bululawang Bululawang Pasuruan Kedjajan Kedjajan Patjitan Tegalombo Tega2.ombo B}anjuwangi Bongoredjo Bongoredjo Paielcasan Galis Galis 3. At sub-district level (1841) Regency Sub-district Location Surabaja Gresik Manjar Tjerrne Dendjeng Duduk Sampejan Udjung Pangkah Drijoredjo Kedaxnean Menganti Wringin Anom Sedaju Dukun Bungah Tambak Tambak Sidoardjo Krijan Prambon Balongbendo Wonoaju Sidoardjo Tjandi Taman Sedati Waru Sukodomo Taman (desa Trosobo) Porong Tanggulangin Krembung ANNEX 22 Page 3 of 10 Regency Sub-district Location Modjokerto Modjosanr Kutoredjo Dlanggu Sumbersono Sooko Trowulan Bangsal Turi (desa Tangunian) Gedeg Djetis Djomnbang Djombang Diwek (desa Tjukir) Perak Tembelung (Puloredio) Plaso Kabuh Plandean Kudu Ngoro Wonosalam Bareng Gajam Modjoagung Kesamben (desa Blimbing) Kesamben Sumobito Bodjonegoro Bodjonegoro Kapas Dander Bautreno Kedung dalam Pandangan Purwosari Tambakredjo Ngraho Tuban Tuban Palang Bongol Plumpang Djatiroto Kenduran Bantjar Djemu Lamongan Lamorigan Kembang baku Karangbinangun Glagah Babat Modo Ngumbong Mantup Patjiran Brodong Dagangan Madiun Madiun Dagangan (desa Prambon) Baleredjo Baleredjo (desa Simo) Djiwan (desa Bakur) Hadiun (desa Nglames) Kebonsari ANNEX 22 Page 4 of 10 Regency Sub-district Location (Madiun) Saradan Pilangkentjeng Mediajan 'Wonoasu) Wungu Gemarang (desa Tawangredjo) Ngawi Padas Karangdjati Kwadunganlor Ngrambe Djogorogo Ngawi Paron Magetan Magetan Pontjol (desa parang) Panekan Gorang-Gareng Takeran Bendo Lambejan Maospati Karangredjo Tulungagung Tiilungagung Ngantru Bojolangu Kauman Karangredjo Tjampurdarat Besuki Trenggalek Keaka Gandusari Watulimo (desa Prigi) Karangan Pule Tugu Panggul Mudjungan Malang Pudjan Batu Tumpang Pontjokusumo Pakis Kepandjen Ngadjum Pag&k Donomuljo Singosari Karangploso Bululawang Wadjak Pasuruan Grato Redjoso Lekok Kraton (desa Ngempit) Pandaan Gempol Gondang Wetan Puspo (desa Tosari) Puspo ANNEX 22 Page5 o0f 10 Regency Sub-district Location Pur-woredJo Nongkodjadjar Purworedjo (desa Purwasan) Bangil Rembang Probolinggo Paitan Matikan (desa Pronodjiwo) Kraksaan Besuk Wangkal Krutjil Wonoasih Dring. Tongas Sumbezicareng LTmadJang Klakah Randuagung (desa Pronodjiwo) Pasirian Tjandipuro Josowilangun Kunir Kunir (desa Tukung) Lumedjang Sukodono Bondowoso Bondowoso Tegalazpel Tjurahdami Pradjekan Tjermee Tmanan Grudjukan Pudjer Panarulcan Asembagus Ardjoso Djangkar Besuki Djatibanteng Suboh Situbondo Pandji Ponorogo Ponorogo Djenangan Babatan Sambit Sawo Slakung (DiJebong) Pulung Sooka Sumoroto Sampung Sukoredjo Bandengan ANNEX 22 Page tof 10 Regency Sub-district Location (Ponorogo) Tamansari- laralc Djetis Patjitan Patjitan Ardlosari Kebonagung Punung Donorodjo Pringkuku Tegalombo Bandar Kebonadalam Igadiredjo Sudimoro Wonokerto Tulakan (desa Kotro) Kediri Modjo Modjo GmVengredjo Ganpengredjo (desa Ngasem) Ngadiluwih Wates Keras Kandat Purwosari Popar Pagu Pare Kepung Kandangan Ngandjuk Ngandjuk Sukomoro Bagor Kertosono Ngrenggot Lengkong Redjoso Ngluju B:Litar Lodojo Kanigoro Srengat Garun Wlingi Panaggungredjo Wates (desa Suruhwadang) Udanamn Ponggok Doko AN=E 22 Page 7 of 10 ;Sub-distrit Location Djember Wlhiuhan Karangdurend Ambulu (desa Sumberredjo) Ambulu DJember Ardjasa Ardjasa (desa Djelbuk) Majang Sempolan Majang Tanggul Sumberbaru Kalisat Susmberdjambe Rambipudji Magi Puger Guaukmas Kentjong (desa Wringintelu) Puger Banjuwangi Rogodjampi Singodjeruk (desa Sragi) Tegal (desa Kurwokardjo) Srono Ban juwangi Onagah' Genteng Glemaor Pamekcasan Pamekasan Propo Warn Batumamner (Temburu) Sampang Ketapang Banjuater Tardjun Djengerik Kedundung Sumenep Batang Batang Ambunten Pasorggsongan Amnbunten Bangkalan Bangkalaf Bumeh Kamal ANNEX 22 Page T of 10 B. Suraba a Sub-District Location Semampir Karang Tembok Peban Tjantian Peban Tjantian Bubutan Kalibutuh Simnokerto Simokerto Gubeng Gubeng Rungkut Rungkut Genteng Genteng Sawahan Mongojoso Tegalsari Pedigiling Wonotjolo Djemur Karang Pilang Karang Pilang C. DJakarta 1. At sub-district level with 10 beds Sungai Bambu Tamibora Pulo Gadung Pasar Minggu Mampang Prapatan Kampung Ambon Pondok Pinang Gandaria 2. At sub-district level with 20 beds Palmerah Bendungan Hilir Kelurahan Rawabangke Senen Sawah Besar Kramat Djati Kebajoran Lama Kodja Tandjung Priok AX 22 Page 9 of 10 D. Bali 1. At sub-district level Location Petang Pajangan Belahkiuh Tegallalang Kuta Gianjar Denpasar Blahbatuh BKIA Tabanan Sukawati Pupuan Dawan Penebel Klungkung Marga Tembuku Kediri Bangli Krambitan Rendang Sawan mlapura Kubutambahan Sidemen Sukasada Bebandem Bandjar Abang Buleleng Kubu Busungbiu Melaja Gerokgak Perung II. PARAMEDICAL SCHOOLS 1. Awduliary-Nurse Midwife Schools East Java Tuban Magetan Malang Blitar West Java Rangkasbitung Central Java Kebumen Djakarta Sumber Waras Husada Bali Denpasar 2. Nurse-Midwife School East Java Surabaja ANNEX 22 Page 10 of 10. III. TRAINING CENTERS 1. Provincial Family Planning Training Centers Djakarta Bandung Semarang Djogjakarta Surabk j a Denpasar 2. Famil y Planning Sub-Training Centers Djember Malang Madiun Tjirebon Sukabumi. Bogor Blitar Banjumas Temamggung Ambarawa ANNEX 23 REQUIREMENTS FOR IN-SERVICE TRAINING CENTERS Provincial Training Centers a. Staff - Director, medical officer, senior nurse- (Project additions midwife, information officer, statisticlan, underlined.) health educator, librarian, two teaching assistants for field training. b. Accommodation - Seo Annex 33 for schedule of accommodation. c. Transport - 1 bus to carry 35 persons. 2 cars, 3 minibuses d. Equipment - 1 film projector, 2 film strip projectors, 1 overhead projector, 1 set of silk screen equipment, 1 set of photographic equipment, 1 electric duplicator, 1 set of artists' equipment, 1 public speaking equipment, 1 tape recorder (regular), 1 tape recorder (battery-operated), 1 video tape recorder with tapes and accessories. Subtraining Centers a. Staff - Principal, senior nurse-midwife, information (Project additions officer, teacher, assistant librarian, two underlined.) teaching assistants. b. Accommodation - See Annex 33 for schedule of accommodation. c. Transport - 1 bus to carry 35 persons, 1 car, 3 minibuses d. Equipment - 1 generator (2 1/2 Hp.), 1 16-mm. film projector 2 film strip projectors, 1 overhead film projector, 1 tape recorder (regular), 1 duplicator, 1 video tape recorder with tapes and accessories. ANNEX 24 Page 1 of 4 FAMILY PLANN;[NG FUNCTIONS OF PERSONNEL AT REGENCY LEVEL AND BELOW A. Regency Level MCH/FP Medical Officer 1. The MCH/!FP medical officer should assist the administrative medical officer in charge of the regency health administration in the overall control and supervision of MCH/FP work, including administration. He would also be responsible for coordinating the MCH and family planning work of all imple- menting units in the regency. He would undertake regular tours to health centers to supervis.e and support the MCH and family planning work. He would ensure the regular flow of family planning supplies and services to MCH/FP centers, and promote and direct the field, as well as the hospital, post- partum program in the regency. - Supervisory Nurse-Midwife and Nurse-Midwife 2. In the existing health services pattern, there is already a super- visory midwife at tlhe regency level health administration. The supervisory midwife works in th/ hospital and supervises the MCH work of the midwives and their assistants. One nurse-midwife at this level should be added so that she can relieve the supervisory midwife of her hospital work. The supervisory midwife can then deirote attention to the supervisory guidance and support of the nurse-midwives and ANMs working at MCH/FP centers in the regency. Her functions should also include organizing and supporting postpartum programs, assisting the kabupztten MCH/FP medical officer, and giving support and guidance to voluntary agencies. Statistical Assistant 3. This person is responsible for collecting and compiling data from \the records and reports of the MCH/FP centers in the regency and transmitting t to the provincial and central NFPCB offices. He will also be responsible fo the routine evaluation of MCH/FP services in the regency and for providing the medical administrator with data for planning at this level. Assistant Supervisor 4. This worker could be chosen from the ranks of supervisory midwives, midwifery teachers, public health nurses, social workers, and information officers. The assistant supervisor is primarily responsible for the super- vision, support, and guidance of field workers in the regency. Her respon- sibilities should also include in-service training and orientation, as well as population education (consultancy for the school system), at the regency level. B. District MCH/FP Medical Officer 5. The medical officer at the district MCH/FP centers in East Java ANNEX 24 Page 2 of 4 supervises all family planning workers (both medical and nonmedical) in his area of jurisdiction, in addition to being responsible for general adminis- tr-ion, clinical referrals of contraceptive acceptors with complications, hospital beds in the health center, and general health administration. Through the services of the health controller, he would also guide and super- vise other health workers such as malaria workers, yaws workers, and vaccina- tors, etc., in their supportive role in family planning program implementation. Supervisory Midwife 6. The supervisory midwife at district level in East Java will be mainly concerned with supervisory support and guidance to nurse-midwives in her area for an integrated MC1H/FP program. This supervision is very important because of the large amount of clinical and educational responsibility of nurse-midwives at the sub-district MCH/FP centers and also because there are too many sub-districts (20) in a regency for one medical officer to manage. Group Leader 7. One group leader is required for every five nonmedical field workers. He would work under the overall control and supervision of the assistant supervisor at the regency level, even though he may cone under the administrative control of the medical officer at the health center to which he is assigned. 8. The group leader's primary function is family planning program implementation. His responsibilities include: a. Supervisory support and guidance to nonmedical field workers; b. Responsibility for organizing, promoting, and executing mass communication activities with the help and participation of the social work assistants, information officers, and other official and nonofficial personnel; and c. Responsibility for planning, organizing, and conducting village leader training sessions with the help of nurse-midwives, ANMs, nonmedical field workers, and other supportive workers at the sub-district level and below. C. Sub-District Nurse-Midwife 9. One nurse-midwife per 44,000 population (one per sub-district health center in the rural areas, and four per health center in Djakarta) is required. Primary functions include provision of contraceptive services such as the IUD insertion and distribution of contraceptive pills, and overall supervision of ANMs and all family planning activities. Her responsibilities comprise: a. Residence in the town or village where the sub-district-level health center is located; b. Direct responsibility for providing contraceptive services, such as IUD insertions and contraceptive pills; ANNEX 24 Page 3 of 4 c. Responsibility, with the help of administrative assistance, for reports and returns of program progress (number of acceptors in the sub-district area, and characteristics such as age, parity, period of adoption, discontinuance, etc.); d. Participation in community educational activities such as orientation for village leaders and taking the leadership in organizing training in cooperation with field workers, group leaders, and social workers; e. Visitation on a scheduled basis, to ANMs to provide on-the-job supervisory support and guidance; f. Responsibility for all MCH work (immunizations, school health work,,as well as antenatal, natal, and postnatal cases) in the immediate vicinity of the center; g. --esponsibility for training, supervising. and.gyding the dukuns in her area; and h. Collection and compilation of information on births from dukuns and community leaders. Auxiliary Nurse-Midwife 10. The auxiliary nurse-midwife (ARM) is not a complete replacement for the nurse-midwife who is more highly trained. The ANM would perform basic MCH and family planning functions under the overall supe-rvision of a rnurse- midwife. Phased continuing professional education is required to help ANMs qualify as full nurse-midwives over a period of time determined by the demands of the MCH and family planning program. Two ANMs should be added to the present staff of one midwife for each sub-district-level health center. They would be under the administrative control of the midwife, but assigned to a defined area and given responsibility for all MCH and family plannirg activities in that area. To be effective and efficient, the ANM must live in her juris- dictional area. The duties of an ANM, similar to those of the nurse-midwife, include: a. Direct responsibility for providing contraceptive services such as the storage and distribution of contraceptive pills; b. Responsibility for follow-up care of contraceptive acceptors and their referral, where necessary; c. Participation in family planning educ-tional activities such as orientation for village leaders; d. Assistance in the preparation of the necessary reports and records; e. Responsibility for MCH work such as immunizations, school health work, as well as antenatal, natal, and postnatal cases; and f. Assistance in training and supervising dukuns. ANIEX 24 Page 4 of 4. Non-medical Field Worker 11, One nonmedical field worker per 10,000 population (4-5 per sub- district) in rural areas, and about 25-30 per sub-district in Djakarta) is required. While the nonmedical field worker's primary function is educational, his responsibilities would include: a. Residence in his jurisdictional area, but administratively assigned to the sub-district-level health center; b. Responsibility for preparing and revising the list of "eligible couples" in villages in his area; this list should also be available at the sub-district-level health center for periodical evaluatory purposes c. Motivation of eligible couples through family-centered face-to- face education; d. Identification of interested influential leaders in the comrmunity and provision of education through individual contact, group techniques, and orientation training, and assistance through these leaders to help target couples recognize small family size as desirable and adopt contraception; e. Assistance in providing adequate follow-up sessions which include dispelling doubts about contraceptive methods, and recognizing complications and referring them to the nearest health center for proper treatment; f. Maintenance of simple records of eligible couples and acceptors including continuous and accurate information of births and deaths (especially infant deaths) collected from dukuns, village officials, and others; g. Assistance in other MCH activities such as immunization, mothers' classes, and antenatal education, etc.; h. In the field postpartum program, responsibility for reporting possible acceptors (antenatal cases) to the health centers, and educating acceptors for the postpartum program; and i. Assistance in distributing conventional contraceptives. Social Worker Assistant and Information Officer 12. While the social worker assistant and information officer are not primary workers in family planning, they do have, however, very important roles to play in the identification and orientation of village leaders. They should be involved in planning and executing mass communication activities such as dramas, puppet shows, and public meetings at the sub-district level and below. ANNEX 25 Page 1 of 6 RECOMMENDED CURRICULA FOR IN-SERVICE TRAINING OF FAMILY PLANNING WORKERS Introduction 1. In-service training is not an attempt at comprehensive professional preparation of workers, but is intended to train workers to develop knowledge and skills for the performance of critical functions needed to take the pro- gram towards predetermined goals. In family planning program implementation, this means: a. stating in clear terms the goals of the program; b. identifying and describing the critical functions that each category of worker is to perform in achieving the goal; c. preparing and pretesting a "job-oriented training curriculum" for each category of worker; d. using the curricula for in-service training; and e. revising them by a continuing process of feed-back. 2. The curricula for training family planning workers in Indonesia do not, at present, satisfy these requirements; the content is focused on providing information. It is recommended that a curriculum development and review com- mittee is established at the NTC to ensure that training is relevant to the functions of the various workers, which may change as the program progresses-. To be effective, instructors and representatives of the program implementing units should serve together to determine the curricula for in-service training. 3. It is also recommended that the NTCs and PTCs establish "field demonstration and study areas" in which an MCH/FP program could be demonstrated and used by: - a. training centers for "skill practice"; and b. instructors (just like the operation theater in teaching of surgery to the medical students), to improve the professional growth of the training faculty and give them the opportunity to make training program-oriented. These study areas would also be used to: a. demonstrate program effectiveness to administrators; b. try out new methodologies in program development as well as training; and also c. promote small program-oriented studies for program improvement. MNNEX 25 Page 2 of 6 Curricula for Non-Medical Field Workers and Group Leaders 4. The period of training would be 15 working days, and the curricula should iinclude the following: a. Introduction to family planning program in Indonesia -- its necessity, objectives, goals, and program implementation at various levels; b. The role of the field worker the family planning program including detailed job description; c. The knowledge and skills necessary for the field worker to satisfy his job function needs; d. Lectures and group discussions to help the field worker gain the required knowledge; this may be supplemented by using films and filmstrips. e. Skill practice in the clinic and demonstration area, as well as field practice to acquire sufficient skills required of a field worker, e.g., how to identify interested influential leaders, how to conduct a family interview for face-to-face education, and how and what records and reports to get, etc.; f. Emphasis on the most critical functions of a field worker; g. Field worker's role in an integrated MCH and family planning program, especially his workirg relationship with the ANM and midwife; h. Community profile of the village and general and health adminis- tration of village, sub-district, regency, province, and central governments in Indonesia; i. Religion and family planning; j. Field-oriented postpartum program; k. Methods of contraception, their use, effectiveness, and side- effects, etc.; and 1. Elementary human anatomy and physiology of the reproductive system. 5. Training for the field worker should also include sessions on super- vision (both knowledge and skill practice), use of mass media (dramas, puppet shows, etc.) at local level, organization, and conduct of short orientation sessions for village leaders, and the use of public speaking equipment, films, strip projectors, etc. 6. At least 50% of the training should be field-oriented -- that is, demonstration and skill practice, etc. ANNEX 25 Page 3 of 6 Auxiliary Nurse-Midwives, Nurse- Midwives, and Supervisory Midwives 7. Period of training required is 15 days, and the curriculum should include the following: a. Introduction to family planning program in Indonesia -- its necessity, objectives, goals, and program implementation at various levels; b. The roles of the ANM, nurse-midwife, and supervisory midwife in the family planning program, including detailed job description; c. The knowledge and skills necessary for the ANM or midwife to satisfy her job function needs; d. Lecture and group discussions to help the trainee gain the reiuire_dknow.edge;- e. Methods of contraception, their use, effectiveness, contra- indications, complications or side-effects and their treatment, if simple; f. Skill practice in clinic for IUD insertion, pill distribution, follow-up in the homes, treatment of simple side-effeLts, and determination of referral cases; g. Skills in interviewing patients in a clinic; h. Knowledge and skills for maintenance of records and reports relevant to MCH and family planning and their relevance to the program; (Sessions may include training in simple methods of evaluation of program -- continuation rates and pregnancy rates, etc.) i. Knowledge and skills on simple administrative methods and office management; j. Field-oriented programs as well as hospital postpartum programs including the skills and knowledge required of midwives; k. Community education in family planning; and 1. Elementary human anatomy and physiology of the reproductive system. 8. Training of midwives and supervisory midwives should, in addition, include knowledge and skill practice sessions on supervision, training methods, and curricula for training of dukuns; vital statistics and their relevance to family planning program; management of complications of various methods of contraception; office management in maintenance and transmission of reports and records; and relevance and. interpretation of the use of these data in the family planning program implementation. ANNEX 25 Page 4 of 6 Medical Workers (Working in Health Centers and Hospitals) 9. Period of training required is 15 working days, and the curriculum should include the following: a. Introduction to family planning program in Indonesia -- its necessity, objectives, goals, and program implementation at various levels; b. The role of the medical officer in the family planning program including details of job description; C. Administrative procedures in the family planning program, including office management, records and reports and their relevance to the program, supply requisitioning, and transport management, etc.; d. Plan of action for implementing the family planning program at local level, details of functions of each worker, and their role in family planning work; e. Evaluation of MCH and family planning program at local levels -- data needed, their compilation, interpretation, and utilization of such data for program improvement; f. Postpartum program -- both field-oriented and hospital-based; g. Family planning as an integral part of MCH services; h. Community education in family planning; i. Religion and family planning; j. Methods of contraception, their use, effectiveness, side-effects and complications, and their treatment; this area should include training and practice in the clinic for IUD insertion, and the physiology and pharmacology of contraceptive pills. k. Comprehensive revision of reproductive biology as a brief but intensive course; and 1. Supervision -- both theory and practice. 10. At least 25% of the training time must be spent in the clinic anid another 25% in field-oriented training. Administrative Medical Officers and Medical Officers in charge of MCH and Family Planning at the Regency Level 11. Period of training required is 30 working days. Cturriculum should include all areas suggested for the medical workers, plus the following: ANNEX 25 Page 5 of 6 a. Determination of targets and detailed program plan for integrated MCH and family planning program for a regency; b. Economics and demography of population control and their practical applications to program achievements at the regency, provincial and nat,ional levels; c. Principles of program management, including personnel management, budgeting, fiscal management, sociology of administration, systems approach, programming-budgeting, review and replanning techniques, and supervision in management, etc.; d. A full refresher course on up-to-date contraceptive technology; e. Basic principles of research methodology to enable trainee to under- stand the value of research in the various aspects of the family planning program; f. Multidisc4.plinary approach to family planning, why and how; and g. Nonclinical approach to population control. Supportive Workers (Social Workers, Information Officers, and Health Workers, etc. 12. Period of training required is 3 days, and the curriculum should include the following: a. Introduction to family planning program in Indonesia -- its justi- fication, objectives, goals, and the organizational structure of the integrated MCH/FP program at various levels; b. The role of social workers/information officers/health workers in family planning and how exactly they can support the program as a part of their regular duties and also the special functions they should perform to support the various components of family plan- ning program implementation; c. Elementary and very simple description of human reproductive anatomy and physiology; d. Elementary knowledge of the IUD and contraceptive pills; and e. Religion an family planning. Dukuns 13. Period of training required is 3 days, or 6 afternoon sessions. The curriculum should include the following: a. Family planning and its justification for socio-economic improvement of the Indonesian family; ANNEX 25 Page 6 of 6. b. Religion and family planning; c. Roles of ANM, field workers, and midwife in MCH and family planning activities at the village level; d. Elementary knowledge about human reproductive system, IUDL and contraceptive pills, possible side-effects due to contraception, and how to recognize and refer them; e. Role of dukuns in case referral for IUD, contraceptive pills, and conventional contraceptives; and f. Importance and procedure for notifying midwives and/or ANMs of births. Village Leaders 14.. The orientation program for village leaders is mainly intended to help them to: a. recognize the need for the FP program in their village; b. understand the components of the program at this level; and c. give their active support by their involvement in program implementation in the village. 15. They should also be given enough information to be able to support the education of eligible couples in the community to accept family planning. A one-day orientation program should be scheduled for a time and place agreed upon in advance by the leaders. In addition to family planning workers cind suppartive workers, formal leaders like the ulemas and village-level religious leaders, village officials, and village headmen should be invited toca----Forel-i - J l;gl- A. CLINICS 2/ 1. MCH/FP Type A: Bji-34 Site preparation 358,560 239,0o40 597,600 864 576 1)4 Construction 1,792,:385 1,194,370 2,986,755 4,319 2,878 7 ,l9 Professional fees- 145,665 16,185 161,850 351 39 390 Furniture and equipment 107,485 429,940 537,425 259 1,036 1,295 Fees for furniture and equ.ipmentW 24485 2_490 26,975 5 6 65 Subtotal 2428,58o 1¶74 0 5 , 4,1,0 2 '535 1 0, -,.- Total for 34 clinics: 82,571,'20 63,988,850 146,560,570 198,968 154,190 353,15' 2. MCH/FP Type Al: Central Djakarta - 9 Site preparation 1,638,420 1,092,280 2,730,700 3,948 2,632 6,580 Construction 8,201,645 5,467,210 13,668,855 19,763 13,174 32,937 Professional fees 617,935 68,475 686,410 1,489 165 1,654 Furniture and equipment 541,990 2,167,545 2,709,535 1,306 5,223 6,529 Fees for fur;Ature and equipment 122,010 13 280 135,290 294 32 326 Subtotal 11-,122,000 b,8o6,790 19,930,790 21,226 026 Total for 9 clinics: 100,098,000 79,279,110 179,377,110 241,200 191,034 432,234 3. MCH/FP Type A2.! Rural Djakarta - 8 Site preparation 1,180,260 786,840 1,967,100 2,844 1,896 4,740 Construction 7,082,805 4,718,550 11,801,355 17,,067 11,370 28,437 Professional fees 552,780 61,420 614,200 1,332 148 1,480 Furniture and equipment 353,995 1,415,980 1,769,975 853 3,412 4,265 Fees for furqi,ture and equipment WI 79,680 8715 88,395 192 21 213 Subtotal 9,249,520 6 , T1,025 221-6,241 T,0 7 39,135 Total for 8 clinics: 73,996,160 55,9329040 129,928,200 178,304 1134,776 313,080 4. MCH/FP Type A2: Surabaja - 11 Site preparation 1,180,260 786,840 1,967,000 2,844 1,896 4,740 Construction 7,082,805 4,718,550 11,801,355 17,067 11,370 28,437 Professional fees 552,780 61,420 614,200 1,332 148 1,480 Furniture and equipment 353,995 1,415,980 1,769,975 853 3,412 4,265 Fees for furpi ure and equipment 79,680 8 715 38,395 192 21 213 Subtotal 9,259,520 6,991505 T,2 22,2 16,847 39,135 Total for 11 clinics: 101,744,720 76,906,555 178,651,275 24.5,168 185,317 430,485 1/ These estimates naave been rounded in the suxwn,ary in $ection V of the Report. 2/ See Annex 33 (I) for type detaw.ls. ,, sight oercent of the total construction cost (5% for repetitive wo:'I<) includes 3iupervision and printing costs and expenses. &-te Jurveys, building permit taxes, ana transportation are not included. L/ Ten percent is included for design, selection, biddi: -, scheduling, supervising, and testing, etc., with 5% allowed for rapetitive worx. Page 2 of 5 ,sp- U.S.$ Items I.c 11 Foreign Total Local Foreign Total 5. MCH/FP Type A3: Rural East Java - 16 -.Site. preparation 687,240 458,160 1,145,400 1,656 1,104 2,760 Construction 3,435,785 2,289,970 5,725,755 8,279 5,518 13,797 Professional fees 3/ ' 279,710 30,710 310,420 674 74 748 Furniture and equipment 206,255 824,190 1,030,445 497 1,986 2,483 Fees for fuxniture and equipment 4/ 46 4.9-80 51.46 112 12 12 Subtotal 7 36554 7,608,010 8,263,480 11,218 B3 19,912 Total for 16 clinics: 74.487,520 57,728,160 132,215,680 179,488 139,104 318,592 6. MCH/F.P Type A4: Rural ELast Java - 15 Site preparation 622,500 415,000 1,037,500 1,500 1,000 2,500 Construction 2,863,500 1,909,000 4,772,500 6,900 4,600 11,500 Professional fees 3/ 242,775 26,975 269,750 585 65 650 Furniture and equipment 186,750 747,000 933,750 450 1,800 2,250 Fees for furniture and equipment4 41.o85 4 565 45.650 99 11 110 Subtotal 3, 102,540 7,059,150 3 7,47 17,010 Total for 15 clinics: 590349,150 46,538100Q 105,887,250 143,010 112,140 255,150 7. MCHP Type B: Rural East Java- Site preparation 249,000 166,000 415,000 600 400 1,000 Construction 1,515,165 1,010,110 ,2,525,275 3,651 2,434 6,085 Professional fees 3/ 117,860 12,865 130,725 284 31 315 Furniture and ecuipment 75,945 302,535 378,480 183 729 912 Fees for furniture and equipment 4 17,015 1,660 18 675 41 4 45 Subtotal 1,974,985 1,493,170 3,468,155 L4,759 3,9 8,37 Total for 184 clinics: 363,397,240 274,743,280 638,140,520 875,656 662,032 1537,688 B. NEPCB FACILITIES 1. NFPCB Headquarters Building -_Djakcarta Site preparation and services 10,487,880 6,991,920 17,479,800 25,272 16,848 42,120 Construction 52,439,400 34,959,600 87,399,000 126,360 84,240 210,600 Professional fees 3/ 8,781,400 975,665 9',757,065 21,160 2,351 23,511 Fumiture and equipment2,950x650 11,802,600 14,753,250 7,110 28,440 35,550 Fees for furpiture and equipment 4/ 1,328,000 147.325 1 75 3.200 - 355 35 Total 75,987 330 54P,77010 130,864,44 183,102 132,23 315,336 2. NFPCB Provincial, Offices Surabaja Site preparation and services 3,652,415 2,435s220 63,087,635 8,801 5,868 14,669 Construction 13,294,940 8,863,570 22,158,510 32,036 21.,358 53,394 Professional Fee&V 1,245,000 830,000 2,075,000 3,000 2,000 5,O00 Furnitt'.re and equipment2,639,400 1,759,600 4,399,000 6,360 4,240 iO,6§.r Fees for furture and equipm entif 263,940 175,960 1Q9.900 ___424 1,060 Total 21,*095,695 14,0&.,350 35v160,O45 50,833 33,890 84,723 ANNEX 32 Page 3 of 5 . .U. S.$ Item Local Fora&gn Total Local Forxeig4 Total 3. NFPCB Provincial Offices - Semarang as Dlakarta, Denpasar and Bandung Site preparation and services 3,652,415 2,435,220 6,087,635 8,801 5,868 14,669 Construction 13,294,940 8,863,570 22,158,510 32,036 21,358 53,394 Professional FeesY/ 622,500 415,000 1,037,5C)0 1,500 1,000 2,50X Fmuiture and equipment2,639,400 1 ,759.,600 4,399,0CI0 6,360 4,240 10,60o Feets for furniture and equipmentL4/ 82,170 780 136.950 198 132 330 Total 20,291,425 T3,1870 33,519,59.15 32,59 9 ,T493 C. A1$4 AN) NMW SCHOOLS 1. Blitar - 240 AMI Studenta Site preparation 24,236,000 16,156,780 40,392,780 58,400 38,932 97,332 Construction 108,730,415 72,486,805 181,217,220 262,001 174,667 436,668 Professional fees I/ 18,532,240 2,058,815 20,591,055 44,656 4,961 49,617 Furniture and equipment3,379,760 13,518,210 16,897,970 8,144 32,574 40,718 Fees for fu qiture and equipment 41520-560 168,90o5 16-9 689 65 3,664 407 4,071 Total 1563997 104,389,515 06,490 376,865 251,541 628i06 2. Surabaja - 240 NSi Students Site preparation and services 24,236,000 16,156,780 40,392,780 58,400 38,932 97,332 Construction 108,730,415 72,486,805 181,217,220 262,00i 174,667 436,668 Professional fees L/ 18,532,240 2,058,815 20,591,055 44,656 4,961 49,617 Furniture and equipment3,379,760 13,518,210 16,897,970 8,144 32,574 40,718 Fees for furp.;ture and equipment W 1,520.560 168.905 1,689,465 3 664 407 4j071 Total T1398,975 104,389,515 26078 490 3'T 251,5416 3. Malang - 240 ANM Students Site preparation 24,236,000 16,156,780 40,392,780 58,400 38,932 97,332 Construction 108,730,415 72,486,805 181,217,220 262,001 174,667 436,668 Professional fees 3i 11,582,235 1,286,915 12,869,150 27,909 3J!r 31,010 Fumriture and equipment3,379,760 13,518,210 16,897,970 8,144 32,3b. 40,718 Fees for furpiture and equipDment 4/ 608.390 67.230 675,620 ' 162 1,628 Total TZ48,536B 103515940 2529052,740 W 920 249,4 6073 4. Tuban - 11,5 Students Site preparation and se.,,,vices 11,787,660 7,857,610 19,645,270 28,404 18,934 47,338 Construction 58,998,475 39,332,040 98,330,515 142,165 94,776 236,941 Professional fees 9/ 9,878,660 1,097,260 10,975,920 23,,804 2,644 26,448 Furniture and equipment2,437,295 9,748,765 12,186,060 5,,873 23,491 29,364 Fees for furr4ture and equipment 1,096-845 M.595 1,218,440o 2,643 293 2,936 Total 6431'98s39 35 .-8573270 142,536,205 202,;89 140,138 343,027 ANNEX 32 Page 4 of 5 U.S.$ Item Local Foxeign Total Local Foreign Total 5. Maretan - llSAN( Students Site preparation 11,787,245 7,8581,025 19,645,270 28,403 18,935 47,338 Construction 58,998,475 39,332,040 98,330,515 142,165 94,776 236,941 Professional fees 3/ 6,173,955 685,995 6,859,950 14,877 1,653 16,590 Furniture and equipment2,437,295 9,748,765 12,1 6,060 5,873 23,491 29,3b4 Fees for frWture and 210 19235 13 7 1,37 Total 41 32 0 17 192. Ttl 79,835,625 ;303 - _137, 09,05 12375 138,972 3,37 6. Two additional schools at SUrber Waras and Husada similar to Magetan 159,671,250 115,346,760 275,018,010 384,750 277,944 6c2,694 7. Denpasar - 70 AM Students Site preparation 7,932,310 5,287,,930 13,220,240 19,114 12,742 31,856 Construction 39,661,550 26,440,480 66,102,030 95,570 63,712 159,282 Professional fees 31 6,6141,660 737,870 7,379,530 16,004 1,778 17,782 Furniture and equi4m.vnt1,703,575 6,813,470 8,517,045 4,105 16,418 20, 523 Fees for furniture and equipmentW 766505 85.075 851,580 1,847 205 2 052 Total 56-,705;6-oo 39g 64 136b,64 ,65 21 8. Two additional RSU facilities at Rangkasbitung and Kebumen similar to Derpasar 113,411,200 78,729,650 192,140,850 273,280 189,710 462,990 D. PROVINCIAL TRAINING CENTERS 1. Djakarta Site preparation 6,199,270 4,132,570 10,331,840 14,938 9,958 24,896 Construction 30,997,180 20,664,510 51,661,690 74,692 49,794 124,486 Professional fees 3/ 5,019,840 557,345 5,577,185 12,096 1,343 13,439 Furniture and equipmentl,779,105 6,783,175 8,562,280 4,287 16,345 20,632 Fees for fux4ture and equipment 4/ 770,655 85,8690 8 ,145 187 206 2,063 Total U4,766,050 32,223,090 761989,14B 1T07,70 77,646 185,51 ANNEX 32 Page 5 of 5e Ite-Rp U.S .$ Items Local Foreign Total Locel Foreign Total 2. S ;rabaj a Site preparation 6,199,270 4,132,570 10,331,840 14,938 9,958 24.,89/3 Construction 30,997,180 20,664,510 51,661,690 74,692 49,794 124,486 Professional fees 2/ 3,137,400 348,185 3,485,585 7,560 839 8,395 Furnituie and equipmentl,712,705 6,849,575 8,562,280 4,127 16,505 20,632 F(ees fo.r fu*i ture and equri4ent35 31030 342 375 743 82 825 Total. 42,54,900 32,026,8 743370 102,060 7T7iT7 179,238 3. F"our additional PTCs at Semarang, West Java, DiogJakarta, and Dlenpasar 169,419, 600 128,115,480 297,535, 080 408,240 308,712 716,952 E. SUBTRAINING CENTERS 1. D ber Site preparation 3,617,555 2,411,565 6,029,120 8,717 5,811 14,528 Constriuction 18,088,190 12,058,240 30,146,430 43,586 29,056 72,642 Professional fees 3/ 2,929,070 325,360 3,254,430 7,058 784 7,842 Furniture and equipment 955,745 3,821,735 4,777,480 2,303 9,209 11,512 Fees for furniture and e9quipment 4/ - 429,940 47725 665 1,036 115 1,151 Total 26, 020,00 1,664, 1685,125 62,700 44,97 107,675 2. M . Site preparation 3,617,555 2,411,565 6,029,120 8,717 5,811 1I4,528 Construction 18,088,190 12,058,240 30,146,430 43,586 29,056 72,642 Professional fees 3/ 1,830,565 203s,350 2,033,915 4,411 490 4,901 Furniture and equipment 955,745 3,821,735 4,,777,480 2,303 9,209 11,512 Fees for furnitur and equipment 4/ 171 810 19 090 190 900 414 46 460 Total 15 1 8,9 43077,8 59,431 44,612 0L4I3 3. Eiglt additional STCs at Madiun, Blitar, Temanggung, BanJumas, Sukabumi, Bogor, Tjirebong and 197,310,920 148,111,840 345,422,760 475,448 356,896 832,344 Ambawawa ANNEX 33 Page 1 of 5 SCHEDULE OF ACCONMODATION I. PROVINCIAL TRAINING CENTERS a. Location: DJakarta West Java Surabaja Denpasar Semarang Djogjakarta b. For 25 Male and 25 female students, a supervi.sor and staff. 2 c. Space : Hostel Accommodation 500 Common (Library, multi-purpose hall, kitchen, storage) 350 Adminiistration 25 TeachiLng and Conference 385 Staff IAccomoodation 236 TOTAL 1 ,496 II. SUBTRAINING CENTERS a. Location: Djember Bangumas Malang Sukabuni Bogor Blitar Bandung Temanggung b. For 10 Male and 20 female students, a supervisor and staff. M2 c. Space : Hostel Accomaodation 100 Common (Library, multi-purpose hall, kitchen, storage) 190 Administration 15 Teaching and Conference 240 Staff Acconmodation 192 TOTAL 737 III. AN4 SCHOOLS!/ a. Location: Tuban Sumber Waras Magetan Husada (Djakarta) b. For : 115 Female students, a supervisor and staff of 10. M2 c. Space s Hostel Accommodation (Double 828 bunks, sick bay, toilets, common romn) 1/ Each school to graduate 50 students annually. ANNEX 33 Page 2 of 5 III. AIM SCHOOLS (Cont'd.) Common (Library, multi-purpose ha:Ll,, kitchen, storage) 529 Administration 57 5 Teaching and Conference 1,403 Staff Acc:ommodation 1,100 TOTAL 3,91?.5 IV. ANM SCHOOLS1/ a. Location: Blitar and Malang b. For : 240 Femal.e students, a supervisor and staff of 20. M2 c. Space : Hostel Accommodation (Double 1,68o bunks, sick bay, toilets, common room) Common (Library, multi-purpose room, kitchen, storage) 624 Administration 120 Teaching and Conference 2,928 Staff Accommodation 942 TOTAL 6,292 V. AN! SCHOOLS2/ a. Location: Denpasar, Rangkasbitung, and Kebumen b. For : 70 Female students, a supervisor and staff of 6. '2 c. Space : Hostel Accommodation (Double 539 bunks, sick bay, toilets, common room) Common (Library, multi-purpose room, kitchen, storage) 420 Administration 60 Teaching and Conference 854 Staff Accommodation 324 TOTAL 2,197 1/ Each school to graduate 100 students annually. 2/ Each school to graduate 30 students annually. ANNEX 33 Page 3 of 5 VI. NURSE -MDWInE SCHOOLY a. Location: Surabaja lb. For : 240 Female students M2 c. Space : Hostel Accommodation (Double bunks, sick bay, toilets, comon room) 1,680 Common (Library, multi-purpose roma, kitchen, storage) 624 Administration 120 Teaching and Conference 2,928 TOTAL 5,52 VII. NlFPCB PROVINCIAL OFEICES a , Location: Surabaja amd Djogjaka;rta b. For : 40 Personniel c. Space : Administration and Meeting Room T General Office 90 Conference 32 Six Bureaus 216 Store and Warehouse 150 CirculatiLon, Toilets 218 TOTAL 861 VIII. NF?PCB HEADQUARTERS a. Location: Djakarta M' b. Space . Administration General Office 360 Six Bureaus 675 Common: Library 60 Lecture 120 Reception 60 Co!uittee 30 Canteen 240 Circulation, Toilets 288 Store and Warehouses 300 TOTAL 2,208 1/ To graduate 50 students anniually. IX. MCH/FP CLINICS a. Type : Type A Clinic (District) - 34 Bali b. For 1 Doctor, 1 supervisory midwife, 1 nurse-midwife, and 1 ANM. c. Space : Doctor's Office (1) Consulting Roam (1) Examination Rooms (2) Total Built Area Storage, Kitchen Circulation, Toilets 127 M2 Waiting Area (Verandah) X. MCH/FP CLINICS a. Type Type A.1 Clinic - Type A + 20 Maternity Bed Ward 9 Central Djakarta b. Space 4/4 Bed Rooms 2/2 Bed Rooms Nursing Labor and Delivery Rooms Total Built Area SS Store Kitchen, Laundry 127 M2 Toilets + 390 Circulation and Storage 517 M2 XI. MCH/FP CLINICS a. Type : rype A.2 Clinic - Type A + 10 Meternity Bed Ward - 8 Rural Djakarta, 11 Surabaja b. Space : 2/4 Bed Rooms 1 2/1 Bed l?ooms Total Built Area Labor and Delivery Rooms SS Store 127 M2 Kitchen, Laundry + 22 Toilets j 373 M Circulation and Storage XII. MCH/FP CLINICS a. )e : Type A.3 Clinic Type A + Accommodation for field staff and dormitory for 4 ANN trainees. - 16 Rural East Java 19. mEce 4-Bed Dornitory Total Built Area 2/3-Person Offices 2 Toilets, Storage, 127 M C(irculation + 100 227 M2 XIII. MCH/FP CLINICS a. Type : Type A.4 ClJlnic - Type A + Accommodation for field staff. - 15 Rural East Java b. Space : 2/3-Person COffices Total Built Area Toilets, Storage, 127 M2 Circulation +100 w;7 M2 XIX. MCH/FP CLINICS a. Type Type B Clinic- (Sub-District) - 199 Rural East Java - 38 Demon3tration Field Postpartum Progrkm. b. Space : Combined Consulting and Examination Room Office Total. Built Area Waiting Area (Vearandah) Storage, Toilets, 95 H2 Circulation Bed Sitting Room ANNEX 34 Page 1 of 23 PROJECT IMPIEMENTATION UNIT 1. This annex describes the structure and functions of the Project Implementation Unit (PIU) which will be attached to the NFPCB. 2. The unit will be directed by the Deputy Chainnan (Program Manage- ment) of the NFPCB. He will be assisted by a Project IAplementation Com- mittee (PIC) comprising representatives of the NFPCB and the Ministries of Health, Information, Finance and Interior, as well as representatives of the international agencies and private foreign foundations involved in the imple- mentation of the project. Its functions will be to provide inter-ministry coordination, to resolve implementation problems proving intractable by the construction and techniical assistance coordinators, and to provide effective liaison with non-Indonesian agencies assisting in project implementation. 3. In addition to providing administrative, accounting, and clerical services, the PIIJ will comprise two technical sections responsible respectively for the implementation of the civil works and program (nionconstruction) components of the project (the structure of the PItU is shown diagrammatically in Appiondix A). a. The civil works section will be in the charge of a Construction Co- ordinator, who will be provided with the technical personnel and facilities necessary to ensure its efficient functioning. The functions of this section are detailed in Appendix B, and the Con- struction Coordinator would be responsible, inter alia, for the technical aspects of the civil works componene; of the project and for liaison with the agencies concerned in its execution. The latter would include the Hospital Design Workshop of the School of Archi- tecture of the Institute of Technology, Bandung, led by the Ibputy Head of the School, who would be referred to as the Appointed Architect. The Appointed Architect, whose functions are shown in Appendix C, would be responsible, inter alia, for proper environ- mental and constructional standards, as well as general supervision of the implementation and the execution of thei project's con.struction component. Such components would be packaged for tendering according to recommendations agreed upon between the Construction Coordinator and the Appointed Architect. The detailed supervision of the con- struction sub-components would be the responsiLbility of the Ministry of Works and its provincial directorates. b. The program section of the PIU will be headed by a Program Input Coordinator, who will be responsible for the coordination of procurement arrangements for the program inputs of the project, including transport and equipment, and materias not connected with civil works. His funlcions are shown in Appendix Do He would also be responsible fo: the coordination of technical assistance arrangemeni-s. *C-e- administration of fellowships and study tours, both inside and outs-de Indonesia, in cooperation with the appropriate agency responsible for technical direction, and for the disbursements of the nonconstruction components of the project. ANE 34 Page 2 of 23 c. The two sections would have a jo.nt staff comprising an accountant, procurement officer, three surveyrors, three draftsmen, five cleri.cal staff, and drivers. 4. A team of management consultants will be retained to advise and support the Director of the PIU on all matters concerning the management and realization of the project. An outline of the functions the consultants wDuld be expected to perform is in Appendi:x E of this annex. 5. Provision is made under this component for the following costs: I tem 1972-73 1973-74 19L74-75 1975-76 1976-77 Total. U.S.$ U.S.$ U.S U.. W .SU.s. Technical Assistancs.i/ Fellows'hips 12.,000 12 ,000 - - 24,000 Management Consiltants 150,000 125,000 100,000 63,000 - 438,000 pEratting Costs Staff2!/ 8,000 8,000 83.00o 8,000 9,000 41 ,000 Maintenance 5,000 5,000 5,000 5,000 5,000 25,000 Ecquipmnt 8,000 2 ,000 - 10,000 TO1TAL 183.,000 152 ,000 113,000 76, 000 1 4,000 538 , 000 & Ti/ Provision for the consulting firm is made under the head (Df professional fees in the civil works estimates. 2/ Includes provision for 1 Deputy Chairman (Program Management), 2 executive assistants, construction coordinator, program input coord:inator, accountant, procurement officer, 3 surveyors, 3 drSftsmen, and 5 clerLcal staff. INDONESIA ORGANIZATION OF THE PROJECT IMPLEMENTATION UNIT (PIU) PROJECT IMPLEMENT-ATION COMMITTEE MINISTRY OF HEALTH MINISTRY OF INFORiMATION MINISTRY OF THE INTERIOR MINISTRY OF WORKS MINISTRY OF FINANCE MINISTRY OF EDUCATION INTERNATIONAL AGENCIES P IU _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ DIRECTOR I (DEPUTY / CHAI RMAN \ > Z ~P ROG RAM MANAGEMENT N FPCB) MINISTRY OF APPOINTED NFPCB WORKS ARCHITECT BUREAUS * _ | / / \ / PROGRAM \ CONSTRUCTION INPUT COORDINATOR COORDINATOR OTHER | s \ ] AND AGENCIES MANAGEMENT CONSULTANTS _I / _ ____/ ADMINISTRATIVE STAFF \IL NN IMPLEMENTING PROVINCIAL UNITS DI RECTORATES (MINISTRY OF OF THE CONTRACTORS HEALTH, MiNISTRY OF MINISTRY OF D WORKS EDUCATION, CDz m ETC.) M m W X X World Bank-6564 APPENDIX B to ANNEX 34 Page 4 of 23 CIVIL WORKS SECTICZ OF THE PIU 1. The Civil Works Section of the Project Implementation Unit will be in the charge of the Construction Coordinator, and will be provided with the technical personnel and facilities necessary to insure the efficient functioning of the section. 2. The Construction Coordinator will work under the general direction of the PIU Director, and will maintain close cooperation with the relevant units of the Government (Health, Family Planning, Works, Town. Planning ). With their assistance, the Construction Coordinator will act as technical and planning coordinator to the PIUf and make arrangements for briefing the Appointed Architect and ensuring that the project is carried out in accordance with that brief. The Construction Coordinator will assist the Appointed Architect in obtaining whatever background data are required and in producing user requirement schedules, outline and final schemes and estimates. 3. The Civil Works Section will be responsible for the following matters: A cninistrative a. preparation of a comprehensive implementation chart showing the planned timetable of coordinated activities and responsibilities, on the basis of which all aspects of the civil works will be carried out, and which will be prepared as the first step in implementing the project; and the planned timetable shall not be put into effect without the Bank being first given reasonable opportunity to comment on it; b. jointly with the Appointed Architect, for all matters concerning the establishment of standards, user requirements, equipment lists, space schedules and the preparation of schematic and final designs for construction components and their cost estimates; c. agreeing with the Appointed Architect and the appropriate agencies of the Borrower for the production of tender cocuments; contract documents and .upervision of the execution of the works; d. arrangements for the review and approval by appropriate authorities of architectural and engineering reports, plans, specifications., and other submitted material. 4. It will ensure continuity in the project by the following: a. arranging for the assembly of all information, relating to site and site condi.tions of the project institutions; b. maintaining liaison with the Ministry of Health, as well as the other user agencies involved in the project, representatives of the ultimate buildirng users and obtaining background data with regard to detail environmental requirements; APPENDIX B to ANNEX 34 Page 5 of 23 c. reviewing architectural drawings irn detail to ensure that space provisions and specifications have been interpreted so as .to mini- mize changes and alterations both during final design phase and construction, and to ensure the satisfactory interpretation of user requirements into proposals; d. liaising between the Appointed Architect and the user agency in all matters of adaptation and impleinmtation of materials and detailing which may require the production of rapid alternative detail designs; e. preparing tendering and bidding procedures, and obtaining and checking the lists of equipment and furniture for the project buildings, advise on packaging and grouping of bid components; f. advising on and observing the adjudication procedure performed by the Appointed Architect and making final recommendations on the award of contracts to the Deputy Chairman (Program Managenent) of NFPCB; g. taking all steps required to ensure that furniture and eq-uipment are designed and installed according to specifications, as well as insuriing timely procurement for use according to schedule,; h. processing and expediting all the Appointed Architect's cortificates for payment of contractors submitted from the local firms3, and forwarding to the accountant of the project unit when advised for payment, and to observe and implement the Association's prlocurement procedure; i. evaluating progress, receiving the Appointed Architect's weekly progress reports and submitting a monthly progress report to the PIU Director (Deputy Chairman (Program Manag nent) of the NFPCB). APPENDIX C to ANNEX 34 Page 6 of 23 PROFESSIONAL SERVICES TO BE PERFORMED BY THE APPOINTED ARCHITECT, AND SUPER- VISICN OF THE EXECUTICa OF THE WORKS BY THE MINISTRY OF WORKS A. Schematic and Master Plamnix; 1. Preliminary investigation and the preparation of studies of the project with recommendations and ecomomic and financial justification for the Physical requirements, to enable the NFPCB to agree with the Appointed Archi- tect on the general outline and form in which the civil works component of the project is to proceed, ensuring that it is feasible functionally, technically, and financially; includng in particular: 2. Taking the instructions of the NFPCB regarding: / a. Types of unit and functions. b. Numbers of staff and users (male/female). c. Target performance data of each facility. d. Methods,, sizes of units and kinds of spaces and volumes required. e. Preliminary :Lists of furniture and equipment required. f. Requirexnents for users' living and recreational faciliti.es and policies to be followed. g. Requirem.ents for staff and students' housing and policy to be followed. n. Supervision, administration, and organization. i. Policy for future expansion. j. Cost limits. k. Location of the sites, dates for legal possession and any limitations or special provisions of the FPCB's legal title. 3. Consulting with and advising the NFPCB and the Construction Coordinator, investigating the Board's requirements and preparing analyses, schedules and other data to enable,the Board to agree on general planning policy for the project, including:- 1/ The data which the NFPCB undertakes to furnish as instructions to the Architect and the times by which it shalL be made available shall be stated in their Agreement. 2/ The times at wihich the NFPCB and the Construction Coordinator undertake to be av-ailable for consultations and the time by which the general planning policy shall be decided'shall be stat+ed in the Agreement with the Architect. APPENDIX C to ANiEX 34 Page 7 of 23 a. Outlines of each facility when fully expanded with the main phases of proposed development and target dates. b. General policy as to: quality versus quantity; capital costs versus maintenance costs; compactness versus spread; fixity versus flexibility; designed life of buildings. c. Other major issues affecting the over-all planning of the project. 4. Consulting with the Construction Coordinator and advising the NFPCB, investigating the Board's requirements and preparing analyses, schedules and other data to enable the Board to agree, inter alia: 1t a. Economic room-loading and fixed medical equipment loading analyses based on the functions, sizes of tnits, methods, spaces and volumes requirel. b. Economic space standards. c. Schedules of areas of accommodation to be provided and their proposed uses. 5e Visiting all sites and investigating local conditions as they affect the project, including: at Local building traditions. b. Available standard designs, criteria, etc. c. Estimating and cost data. d. Building contracts and procedures for selecting contractors. e. Materials2 goods and equipment available locally and procurement procedures. f. Local contractors and labor. g. Town planning, building or other pertinent legislation, regulations codes of proctice, etc. h. Reporting to the Construction Coordinator and the NFPCB on the above. 6. Briefing the relevant section of the Ministry of Wobks to obtain the site surveys, including: 2/ I/ The times at which the NFPCB ar.d the Construction Coordinator untertake to be available and the times by which data shall be submitted to the NFPCB for approval shall be stated in the Agreement with the Appointed Architect. 2/ The surveys and investigat;ions wi-ch the NMnistr! of Works shall prepare and the times by which they shall be ccmpleted shall be stated in the Ageeement with the Architect. APPENDIX C to AiNEX 34 Pag of 23 a. Topographic survey with site boundaries, existing buildings, utility services, appropriate contours and principal surface vegetation. b. Climatic survey with available data on rainfall, winds, tem- perature, humidity, weather conditions and seismdc forces. c. Preliminary assessment of the sub-soil characteristics. d. Receiving and scrutinizing the surveys and reporting to the Construction Coordinator and the NFPCB. 7. Investigating sound and proved technical codes of practice applicable to the project and to local conditions and establishing basic design criteria as they effect: a. Daylight, sunlight and ventilation and orientation. b. Weather protection. c. Sound insulation. d. PrecauLtions against fire. e. Structural loadinge f. Acoustics0 g. Engineering and utility services. h. Heating and thermal insulation. i. Durability and maintenance of both fabric and equipment. j. Precautions against vermin and dirt. k. Precautions to withstand natural hazards (earthquakes, hurricanes, etc.). 8. Planning the overall site layouts of each project building and pre- paring a comparative analysis of the merits and costs of alternatives investi- gated, to enable the NFPCB and its Construction Coordinator to approve a plan which offers the maximum value while fulfilling the following prime conditions:l/ a. Units or departments shall be grouped whenever practicable to share c;ommon facilities, allow for accreted growth and encourage the maximum communication among the constituent parts of the institution. 1/ The time by which the Appointed Architect undertakes to submit the re- commended overall site layout plan with a comparative analysis of the alternatives investigated for the NFPCB's approval, shall be stated in the Agreement. APPENDIX C to ANNEX 3h Page 9 of 23 b. The grouped buildings shall be sited to take full advangage of the local climate and topography and, by prudent landscaping., improve the ambience and micro-climate of the site. 9. Consulting with the NFPCB and the Construction Coordinator about the implementation of the project and advising and agreeing on: a. The breakdoun of the project into the most practical and economical "bid packages" for procurement./ b. The phasing of the "bid packages" in order of priority. c. Documents required to be prepared and procedures to be followed fcr procuring construction (labor, materials and plant), medical equip- ment (fixed and loose), books and furniTte "bid packages"; including advance ordering as necessary../ d. Procedures to be followed for cost estinating and cost control. e. Staff required to implement procurement procedures and to provide constant on-site supervision of the project. 10. Preparing and agreeing with the NFPCB on an operational plan and timetable for the most efficient, way to design, prepare procurement documents, implement procurement prodecures, construct and sapervise the projact. 11. Preparing a Master Plan Report in a suitable form for submitting to tlhe NFPCB and the Association for approval, including:3 a. Introduction: The functions and purposes of the proposed facilities and swumary of the steps leading to the preparation of the Master Plan. b. Planning Policy: Statement of general over-all planning policies with a summary of the factors considered and justification for decisions reached. i ,aicards: Summary of prrposed economic space standards and other ..asic design criteria related to safety, comfort, health, engineering and lility services, local. climate, topography and social habits. 1/ By "bid package" is meant all the dra-wings and/or documer.ts needed to proci;re competitively a group of units of construction, or items of equipment or furniture. at one time and by means of a single contract. 2/ A-,y special conditions for procurement shall be stated in the Agreement. 3/ Lhe form arid content of the Miaster Plan Reoort; and drawings which the A-.ointed Architect undertakes uo p2repare and the number of copies to be firnished to the NFPCB and any other agency of the Goverrnment of Indonesia by the &ime specified, shall be stated in th.,e -jeeement. APPENDIX C to S2NEX 34 Page 10 of 23 d. Room-loading: Economic room-loading and fixed medical equipment- loading analyses with conclusions and recommendations. e. Schedules of Accommodation: Schedules of net and gross areas of accommodation required and their proposed uses, f. Planning Analysis: Suwmary of the steps leading to the selection of the overall site layout plans including references to surveys, NFPCBts instructions, decisions and approvals, critical planning factors, comparative analysis of the costs and merits of the princi- pal alternatives investigated and justification for the plan chosen. g. Specification Notes: Summary of available local resources of labor and materials with preliminary appraisal of appropriate specifica- tions which offer the most economic balance between availability, capital costs, maintenance and running costs, with justifications for the selections made. h. Site Development Services: Schedule of site development services sufficient for estimating purposes with the basic design criteria, methods used for couputing the requirements and justification for the proposals. i. Medical Equipment: Provisional lists of medical equipment and estiniated costs. j. Furniture: Provisional lists of loose furniture required and estimated cost. k. Capital Cost: Consisting of estimated i. Site development services and external site works generally; ii. Buildings and internal services; iii. Medical equipment - groups 1 and 2; iv. Furniture; ve Contingencies; vi. Professional services; vii. Foreign exchange component of items (i) and (vi) above. 1. Recurrent Cost: Consisting of the estimated runing and maintenance costs of the buildings, services, equipment and site. m Ulnit Costs: Consisting of the unit costs used for estimating. APPEINDI X C t ANNEL14 Page 11 of 23 n. Implementation: i. Proposed "bid packages" and procurement procedures; ii. Operation plan and timetable for the preparation of Sketch Schemes, Final Designs, preparabion of "bid packages&', pro- curement, construction and supervision of the project; iii. Quarterly forecast expendi.ures during the design and con- struction of the project. O. Drawings: i. Location maps showing position of the site in relation to the user catchment area, population densities, existing transport facilities and available utility services; ii. Explanatory diagrams or drawings to illustrate the "Planning Analysis" section of the report; iii. Site layout plans showing contours, existing buildings, orientation, latitude, altitude, prevailing winds; also showing proposals for siting nc.* buildings, site development services, roads, car parking, rec,.eation areas, landscaping, site perimeter security and external site works generally; iv. Sito topographic contour survey to same scale as site layout plan; v. Perspective or photographs of models when considered to be necessary to convey the overall layout. p. Annexes: i. Site climatic survey including sun-path diagram, comfort zone analysis charts and weather characteristics; ii. Assessment of the general nature of the subsc'l conditions (subject to more detailed investigation); iii. Further data as required to supplement the text of the report. B. Sketch Scheme 12. The preparation of preliminary calculations, drawings, estimates, outline specifications, schedules and other architectural and engirneering documents necessary with economic and financial justifucationi for the design to enable the proposals in the Master Plan for the construction of the works to be submitted for the NFPCB and the Association to approve the basic design, costs and program; including as may be necessary in the particular case: APPENDIX C to ANNNX 34 Page 12 of 23 13. Revisions (if any) to the Master Plan. 14. M4ayng arrangements for the Ministry of Works to prepare surveys, including: an Sub-soil investigation to determine the nature of the sub-soil, safe earth-bearing pressures and water characteristics of the site. b. Surveys of existing buildings with plans, sections, elevations and report on their structural condition, and general state of weather protection and mnaintenance. c. Other special investigations required. 1. Consulting with and advising the NFPCB and the Construction Co- ordinator,investigating the NFPCB's requirements and preparing analyses, schedules and other data to enable the Board to decide, inter alia: 2r a. Space priorities in terms of need and completion dates. b. Requirements for individual internal spaces: i. Finishes ii. Engineering and utility services iii. Fittings iv. Equipment (building, madica.L, educationatl) V. Furniture vi. Acoustics vii. Sound insulation c. Circulation requirements d. Internal and external security and its supervision and control. 16. Consulting with and advising the NFPCB and its representatives, investigating the NFPCB's 'requirements and preparing aqalyses, schedules and other data to enable the Board to agree, inter alia: 3/ 1/ The surveys and investigation.s which the Ministry will prepare and the times by wL-ich they shall be completed shall be stated in the Agreement. 2/ The times at which the NFPCB undertakesto be available for consultations and the times by which decisions shall be made shiall be stated in the Agreemnent. 3/ The times at which the NFPCB undertakes to be available and the times by which data shall be submitted to the Board for approval shall be stated in the Agreement. APPENDIX C to AMEX 34 Page 13 of 23 a. Principles of orientation to be followed. b. Thermal irnsulation, sun-screening, ventilation, etc. c. Means of escape and precautions against fire. de Building materials and techniques. eO Internal and external engineering and utility services. f. Roads and car parking. g. Site works, recreating areas and landscaping. h. Other special features of the buildings. 17. Designing the buildings and other features and preparing comparative analyses of the merits and costs of alternatives investigated, to enable the NFPCB to approve designs which offer the maximum value while fulfilling the following prime comditions: a. The basic deign criteria and requireants shall take full advantage of local climatic and sub-soil conditions to define the minilmum essentials required to permit sound practices to be followedl while at all times safeguarding the occupants from possible ill effects on heal-th, safety or general well-being. b. The materials and building techniques shall make the best use of resources to meet the design criteria and requirements in a manner which offers the most economic balance between capital costs, maintenance and operating costs. 18. Preparing a Sketch Scheme Report in a sr itable form for submitting to the NFPCB for approval, including: f a. Introduction: References to the Master Plan and to the "bid packages" to which the sketch scheme refers. b. Site Development Services: Summary of the developments in the design of the site development services since the Master Plan was approved, with justifications. c. Design Analysis: Summary of the steps leading to the choice of designs described in the Sketch Scheme, including references to surveys, Client's decisions and approva'ls, critical design factors, comparative analyses of the principal alternative solutions inves- tigated and justification for the solution finally chosen. 1/ The form and content of the Sketch Scheme Report which the Architect undertakes to prepare and the number of copies to be furnished to the NFPCB shall be stated in the Agreement. APPENDIX C to ANi'iEX 34 Page )14 of 23 d. Schedules of Acconmuodation: Detailed schedules of gross and net areas of accommodationi provided and their proposed uses, including all the requirements for each individual internal space, also recre- ation areas and vehicle parking. e. Outlinea Specification: Outline specification of the proposed basic designs with final appraisal aiid justification for selections made. (This outline specification shall not be subject to modification after the Sketch Scheme has been finally approved, except for reasons of technical necessity.) f. Provisional Schedules: Schedules of provisional design details, finishes, building and medical equipment, furniture, etc., mainly for estimating purposes, which may still be subject to modification in the final design. g. Costs: Schedules of approximate quantities, basic rates, assumptions made and estimated margins of error. h. Capital Costs: Estimates based on approximate quantities taken from the Sketch Scheme Report, to include: i. Site development serv-ices and external site works generally; ii. Buildings and internal services; iii. Medical equipment - groups 1 and 2; iv. Furniture; V. Contingencies; vi. Professional services; vii. Foreign exchange component of items (i) to (vi) above. i. Recurrent Cost: Consisting of the estimated annual running and maintenance costs of the buildings, services, equipment and site. j. Unit Costs: Consisting of the esti)iated net and gross cost Per user place and per unit of area or bed for each basic type of accommo- dation provided. k. Program: i. Operational plan and timetable for the final design, prcepa- ration of contracts, procurement, construction and supervision of this part of the project; ii. Quarterly forecast expenditures during the design and con- struction of this part of the project. APPBiDIX C to ANNEX 34 1. Drawings: i. Up-to-date Master Plan site layout plans; ii. Explanatory diagrams or drawings to illustrate the "lDesign Analysis" section of the report; iii Design drawings (plans, sections and elevations) for each building comrprising this part of the project;- iv. Perspectives or photographs of models when considered to be niecessary to convey the design. m. Annexes: i. Report on the sub-soil investigation; ii. Survey reports and drawings on existing buildings; iii. References to other special investigations or data required to supplement the text of the report. C. Final Design 19. The preparation of calculations, drawings, est:imates, draft speci- fications, draft schedules and other arohitectural and engineering documents necessary to enable the NFPCB to approave the final design and estimates of costs, which, once approved, shall not be changed except for reasons of tecA- nical necessity, including as may be necessary in the particular case: 20. Preparing architectural and engineering drawings, documents and estimates, and consulting with the Construction Coordinator, the NFPCB, and the Association to reach decisions and obtain approvals for: a. All design details not hitherto decided and agreed; b. Final schedules oil fixed equipment and furniture; c. Final estimates of costs; d. Final breakdown intol"bid packages" in order of priority with a timetable for their preparation, procurement, and implementation. 1/ The scale and type of design drawings shall be stated in the Agreement. - - -m APPENDIX C to ANNEX 3h Page 1c) of 23 21. Preparing a Final Design Addendum to the Sketch Scheme Re rt in a suitable form «or submitting to the NFPCB for approval, including: - a. Final Schedules: To replace the Provisional Schedules; b. Final Specifications: Changes (if any) to the outline specifications; c. Final Costs: Revised estimates of capital costs and recurrent costs; d. Final Program: i. Revised operational plan and timetable for the preparation, procurement and implementation of the "bid packages"; ii. Revised quarterly forecast expenditures. D. Contract Preparation 22. The preparation of drawings and other documents will be part of the duties of the Appointed Architect, possibly supplemented by local firms, chosen and recommended to the NF'PCB by the Construction Coordinator. In either case, the dr,ties to be performed are to be by agreement, and consist of the following: 23. Preparing architectural and engineering calculations, working drawings, specifications, schedutles, bills of quantities, conditions of tender, forms of contract and other necessary documents to describe, the Works, medical equipment groups 1 and 2, and furniture adequately for "bid packages" to ba tendered or otherwise ordered. 2h. Pricing one set of bills of quantities for comparison with tender prices and advising the NFPCB as to any material changes in the design, specifications, schedul.es or estimates, from those approved in the rinal Design. 25. Assisting the NFPCB to obtain all final statutory approvals. 2o. Advising the NFPCB together with the Construction Coordinator as to the desirability for pre-qualification of bidders; agreeing on procedures to be followed; preparing pre-qualification documents fcr the NFPCB to approve; undertaking pre-qualification procedures on the Board's behalf and in conjunction with the Construction Coordinator; analyzing the pre-quali- fication data submitted by potential bidders and recommending lists of selected contractors for approval. 27. Undertaking or initiating procurement of the Board's behalf, for those "bid packages" whicih need to be ordered in advance, and those for which sub-contractors or suppliers should be nominated ahead of main contracts - subject to placing acceptance orders, provided always that no order or nomination is made without the NFPCB's authorization in writing. 1/ The form and content of the Final Design Addendum to the Sketch Scheme Report which the Architect undertakes to prepare and the number of copies to be furnished to the Client, shall be stated in the Agreement. APPa'IDIX C to ANNEX 34 Page 17 of 23 E. Tender 28. Conducting approved tendering procedures for selecting contractors and advising the NFPCB and the Construction Coordinator on placing contracts, including as may be necessary in the particular case: 29. Pre-selecting and inviting selected contractors to tender. 30. Analyzing and adjudicating the tenders received and advising the Board as to tenders, contractors, prices and estimates for the carrying out of the Works, provided that no tender shall be accepted or order placed by the Architect except on behalf of the NFPCB and with its authority in writing. 31. Preparing tha contract dowuuments for signature. F. Contract Mobilization 32. The provision of the necessary additional information and instruc- tions to enable the Contractor., the Ministry of Works, the Construction Coordinator and all others concerned to make proper preparations before starting work on the site, including as may be necessary in the particular case: 33. Supplying the Contractor with .Anformation and instructions, including: a. Sufficient copies of drawings, specifications, schedules, bills of quantities and other architectural and engineering documents to enable him properly to fulfill his obligations under the con- ditions of contract. b. Full information about: Advance orders placed, sub-contractors and suppliers nominated, and the supply and installation of fixed - medical equipment and furniture. c. Instructions for placing acceptance F.'ters. 34., Advising the Contractor as to the preparation of a construction schedule based on the Gritic:al Path 4ethod (CPM), taking into accouint the work of all sub-contractors and the promised or anticipated delivery dates for materials, plant, fixed medical equipment and furniture. 35. Holding formal mobilization meetings jointly with the Ministry of Works' representatives and the Construction Coordinator and distributing the Minutes within 48 hours of the termination of the meeting - with the Contractor and all those concerned in the performance of the contract, including aLl sub-contractors and major suppliers, to ensure that: a. The conditions of contract are understood and apreciated. b. The ,;oligations of each towards the successful implementation of the co.'struction sch.edule are feasible, understood and agreed. c. Adequate instructions and information have been received, including access to site, way-leaves and basic setting out data and references. APPENDIX C to ANNEX 34 Pof 23 36. Authorizing site work to start when the NFPCB has stated in -writing that work may proceed and the Architect considers that cont-iact mobilization is sufficiently advanced. G. Construction 37. The provision of constant on-site supervision during construction to ensure that the architectural and engineering works are executed strictly in accordance with the conditions of contract will be undertaken by the Ministry of Works through its Regional Directorates in close liaison with the Architect and the Construction Coordinator. 38. The Ministry of Works' delegated inspectors will ensure that Contractors have all the information needed for the proper execution of the Works, including: a. Preparing and supplying further copies of the Appointed Architect's drawings, specifications, schedules and other details. b. Issuing written site instructions, which will be submitted to the Architect for confirmation. c. Issuing variation orders on behalf of the Client for minor alterations as may be necessary or expedient. Substantial changes of an emergency nature will be referred to the Appointed Architect for joint action. d. Examining and approving Contractors' details. 39. The delegated site inspectors will provide constant on-site super- vision to ensure that the conditions of the contract are strictly adhered to, including: a. Preparing weekly site reports on the day-to-day state of the Works, including progress of the Wbrks, labor, materials, plant, the weather, hours lost, drawings and other information received, and visitors to the site. b. Holding formal site meetings at least once per month and distributing the M4inutes within 48 hours of the termination of the meeting. c. Advising the Architect and the Construction Coordinator on the progress and quality of the Works and if the authorized expenditure is likely to be exceeded or the contract time likely to be varied. d. Inspecting and testing during manufacture such materials, machinery and plant as are usually inspected and tested by archicects and consulting engineers. e. Supervising all architectural and engineering tests on site. APPENDIX C to AITNNEX J Page 1Q oif 23 f. Checking Contractor's Day Work Sheets when such work has been authorized. g. Inspecting and measuring work done, materials and plant on site, and preparing interim valuations for accounting and certificate purposes. h. Taking prompt action to enforce the conditions of contracts and adherence to the agreed construction schedule. i. At the time of certifying practical completion, preparing a schedule of all contract items still to be finished, inspected and approved, before final completion can be certified. 40. The delegated site inspectors will assist the Architect in the exercise of his discretionary powers vested in him by virtue of the contract, including: a. Advising both the Architect and the Contractor as to the inter- pretation of the contract in relation to specific issues when in doubt. b. Assisting the Architect in adjudicating disputes. c. Assessing claims and advising the Architect. d. Assessing the quality of workmanship. e. Assessing whether materials and building methods conform to specifications. f. Authorizing Day Work when considered to be essential. g. Issuing certificates authorizing payment to Contractors, for authorizing by the Architect and honoring by the NFPCB3 h. Certifying the practical completion of all architectural and engineering work and enabling the Architect to officially hand over the Works, or portions of the Works., far the NFPCB to occupy. H. Cole 41. The Ministry of Works, through its Regional Directorates, will ensure the continued provision of on-site s-pervision during the defects liability peried, to ensure that defects in material and workmanship are put right after the buildings have settled down, and that details of design are adjusted whein the occupants have settiled in, including as may be necessary in the particular case: APPENDIX C to ANNEX 34 Page 20 of 23 42. Deciding technical issues and ensuring that contractors have all the information needed for the proper execution of the Works, including: a. Preparing a list and estimates of costs of minor design changes needed as a result of the experience of the occupants settling in during the defects liability period, to enable the NFPCB to approve and authorize a variation order for the work. 1 43. Providing site supervision to ensure that the conditions of contract are strictly adhered to, including: a. preparing site reports in accordance with G (39)(a) for the days that Contractors are actively engaged in performing contract architectural and enginrering work on the site. b. Holding formal site meetings in accordance with G (39)(b) as frequently as the Architect considers to be necessary over and above a minimum of 2 meetings. c. To (h) in accordance with G (32)(c) to (h). 44. Assisting the Architect in the exercise of the discretionary powers invested in hin by the contract, including: a. To (g) in accordance with G (4O)(a) to (g). h. Preparing a list of all defects of execution in architectural and engineering materials to be corrected and adjusted after the defects liability period according to the conditiorns of contract. i. Recommending the issuance of the final complet.1on certificate of all architectural and engineering work in the contract, to the Architect. j. Preparing and agreeing on the final account for certification by the Architect. 45. Preparing and providing the Architect with a complete set of as- built drawings to enable a schedule of routine maintenance to be prepared for instructing the NFPCB;s staff in the proper care and maintenance of the completed Works. l/ The probability that such minor design changes will prove to be necessary should be taken into account when estimating the contingency sum in the contract. APPENDIX D to ANEX4 Page 21 of 23 FUNCTIONS OF THE PROGRAM INPUT COORDINATOR 1. The Program Input Coordinator will be responsible to the Deputy Chair- man (Program Management) of the NFPCB for the coordination of the implementation of all non-constraction components of the project, in close collaboration with the relevant units of the Governent (such as the Ministry of Health, Mini-try of Information, Ministry of the Interior), and foreign agancies responisible for technical support as appropriate. His functions will include: a. coordina'tion of the procurement of all non-construction materials and equipment, and procurement when not assigned to an agency; b. preparation of a comprehensive planned timetable of activities and responsibilities for implementing the non-construction components of the project, which will not be put into effect before the Association has been given reasonable opportunity to comment on it; c. preparation,, with the assistance of the appropriate agencies, of the lists of materials, books, equipment and transport included in the non-construction components of the project, together with the speci- fications and the estimates of unit and total prices of each item; d. when appropriate, preparation of the bidding procedures, checking and finalizing lists cf materials and equipment, and packaging and grouping bid components; e. advising the Deputy Chairman (Program Management) of the NFPCB on the prequalifications of contractors and recommending to him the form of the packaging of components and execution of contracts; f. advising the Deputy Chairman (Program Management) on the adjudication and award of contracts; g. expediting, checking, and processing *ll contractors' bills of payment submitted; h. supervising the accounts of the non-construction components of the project; i. preparation of withdrawl applications; j. in cooperation with the appropriate agency, making preparations for fellowships, study tours, and local arrangements for advisors and short-term consultants; k. maintaining close liaison with the appropriate units of Government in the development of training facilities provided by the project; and 1. preparation of monthly reports to the Director of the PIJU (Deputy Cha.irman (Program Management) of the NFPCB). APPENDIX E to ANNEX 34 Page 22 of 23 FIICTIONS OF PROJECT IMPLE ATATION UNIT CONSULTANRTS 1. The Contract with the Consulting Firm to provide advisory services to the project Implementation Unit sho'ild include: a. The terms and conditions of emplolment. The terms of reference should include a draft plan of operations, with time schedules and set-out remuneration and reimbursable expenses. As far as practicable, fees and expenses should be firm figures. b. The Consultants would prepare a Procedures Guide reflecting the participation of the various central and regional government bodies, as well as other organizations in the overall project9 outlining the project and its implementation, together with guidelines on financial control. c. The Consultants would prepare a Design Guide in coliaboration with the Institute of Technology at Bandung, with additional recommen- dations based on experience gained and new conditions foreseen. T1here practi-cable, the Design Guide may be modified to give specific requirements and should give special regard to developing economies during the production of the project components. d. Standard architectural engineering plans and specifications and standard bills of quantities should be prepared for all buildings in the project by the Appointed Architect, with the guidance aaid collaboration of the Consultants. The PIU will incorporate these standard documients in the design and supervision of the project's civil works. e. The Consultants will advise on the examination, adjudication, and provision of comments and recommendations to the Government and the Association on draft contracts between the Government and finms of contractors and suppliers, and research institutions and orga- nizations, as well as any executive architects or engineers whose services may be retained. Each contract should incorporate a plan of operation, time schedule, estimates of fees, and reimbursable expenses. f. The Consultants' responsibilities would include: visiting and recommending approval of the project sites in liaison with the Appointed Architect and a representative of the government town planner; recommending any adjustments or modification to the schedule of accommodation due to local circumstances; assisting with furniture and equipment lists and estimates; establishing detailed cost plans for each project building; advising on the size of bid packages; and reviewing documents for bidding and contract. APPENDIX E to ANNEX Page 23 of 23. g. The Consultants would assist in regular progress reporting to the Director of the PIU and the Association, and in the preparation and up-dating of PERT or CPM charts, and withdrawal certificates. They would also assist the Appointed Architect in the overall supervision of the project. h. The Consultant would assist in the establishment of a project accounting system -which would ve the approval of the Association. ANE 35 Page 1 of 2 OUTLINE OF AGREEMENTS ON ASS]:STANCE WITH IMPEIMENTATION BY OTHER AiGENCIES 1. The role of other agencies is based on the premise that the project will be implemented by the Goverrment of Indonesia with the assistance of the other institutions. The Association will have the responsibility for clearing the necessary arrangements and supervising project implementation. 2. During negotiations, the Government has given assurances that appropriate and effective arrangements satisfactory to the Association will be made with WHO, UNESCO, UNICEF, other United Nations bodies, the Popvl ation Council, or other sources of expertise acceptable to the Association for assistance in carrying out, respectively, the hospital postpartum program, the infornation and education activities, the vehicle and transportation components, the assistance to the Institutes of Demography and of Economic and Social Research, and the demonstration field postpartum program. In certain cases, these agencies are already assisting with the implementation of activities related to the family planning program, such as paramedical education and family planning communications. In such cases, the Government would extend the cur-ent involvement of these agencies in those activities. 3. More particularly, specific assistance would be required from: a. WHO to assist in the implementation of the hospital postpartum program. The Government may ask WHO to provide the services of one adviser for 2 years for the functions outlined in Annex 28 and such other support, in the specification of medical equip- ment, for example, as the Goverieaent may require. b. The UN Population Division, through the UN Office of Technical Cooperation., to assist in the implementation of those parts of the evaluation and research components of the project relating to the Institute of Demography in the University of Indonesia, and the Population Studies Center in the National Institute for Economic and Social Research. The Government may ask the UN to provide the services of four advisers for the functions outlined in section G of Annex 26, and to assist, as required, with the development of a fellowship programn axnd adviser on the specifications and procurement of equipment. c. UNICEF to assist with the procurement of vehicles. The Govern- ment may ask UNICEF to provide the services of two advisers for 3 years for the functions outlined in Annex 2?, and to assist with the specification and procurement of vehicles and equipment. Pagte 2 of 2. d. The Population Council to assist in the implementation of the demonstration field postpartuz program. The Government may ask the Council to provide the services of two advisers for 3 years for the functions outlined in section F of Annex 26, and to provide for the analysis and evaluation of data and information derived from the demonstration. e. UNESCO to assist in the implementation of the information and communications, and population education components of the project. The Government may ask UNESCO to assist the communications adviser of the Goverrmient of Indonesia in helping with the provision of short-term cornsultants, and the development of a fellowship pro- gram. It may also ask UNESCO to provide the services of one adviser for the functions outlined in Annex 30, as well as short- term consultants, assistance with developing a fellowship program, and with resource personnel and material, as required, for the seminar and training program. ANNEX 36 SCHEDULE OF IMPLEMENTATION FOR CIVIL WORKS Credi t Effectiveness Pre-Credit Et.ectiveness First Year Second Year Rp U';$ Thousands Thousands JL-, 1.2 1 2 Clinics 1,713,535 4,129 1 a ,,,,,, ::: ***=. XXXX NFPCB Offices 329,925 795 s a ,,, ** *== Training Schools 1,586,960 3,824 s a ,,,:** ***.. XXXXXX KXXXXX PTCS 449,030 1,082 a 'a ,,,:::.*** XXX XXXxx STCS 433,260 1,044 a a ,,,:X::*** .XXX XXlX TOTAL 4,512,710 10,874 Third Year Fourth Year Fifth Year 1 2 1 2 . 1 2 Clinics + (+) NFPCB Offices xmOOOO XxOOOO XXX m + (+) Training Schools XX A (+) PTCS. + (+) STCS + (+ Legend: AL.. Selection and appointment of - Preparation of production in- architects and consultants formation and bid packages a - Selection and appointment of XXX - Construction specialist consultant = - Installation - Survey of sites, timetables, + - End defects liability period master plans for construction :: - Design (final) (+) - End defects liability period for furniture and equipment - Tender ANNEX 37 ESTIMATED DISBEUSE;NTE SCHEDUIE Cumulative Disbursement At End of Quarter CUOS.$- (IX thousands) IBRD Fiscal Year IDA UNFI'A 1 972-73 March 31, 1973 350 350 June 30, 1973 780 780 1973-74 September 30, 1973 1,44() 1,44o December 31, 1973 2,180 2,180 March 31, 1974 3,220 3,220 June 30, 1974 4,250 4,250 1974-75 September 30, 1974 5,990 5,990 December 31, 1974 7,720 7,720 larch 31, 1975 8,400 8,400 June .30, 1975 9 ,200 9,200 1975-76 September 30, 1975 10,010 10,010 December 31, 1975 10,820 10C,820 March 31, 1976 11,160 11i,160 June 30, 1976 11,520 111,520 1976-77 September 30, 1976 11,890 11,890 Dejember 31, 1976 12,255 12,255 March 31, 1977 12,380 12,380 Juie 30, 1977 12,505 12,505 1977-78 September 30, 1977 12,645 12,645 December 31, 1977 12,785 12,785 March 31, 1978 12,935 12,935 June 30, 1978 13,185 13,185 ANNEX 38 Page 1 of 6 DEMOGRAPHIC II4PACT OFs THE PROJECT 1. The project's demographic impact is estimated by initially assuming a reasonable desired decline in fertility levels and then seeing what this implies in terms of numbers of acceptors and the resulting number of prevented Airths. Overestimates of the number of new acceptors, of their continuation rates, or of the number of births averted will of course exaggerate the estimated decline in fertility. However3 once realistic and consistent values have been put on these parameters - based primarily on experience in other countries - it is possible to estimate the resulting crude birth rate and, by making assumptions about death rates and migration, to estimate the population growth rate. The overall results should not be taken as predictions of what will happen but as reasonable targets of what can happen with good project performance!. In addition, the identification of specific values used for the different parameters will pro- vide bases for comparison as future information is generated by the. program's evaluation and research activities. 2. No attempt has been made to analyze in quantitative tenus the relative contribution of different project components. Techniques of factoral analysis have not yet been applied to population programs in a way that prov:Ldes an ob- jective basis for allocating funds and energies among different progrram components. Thus while there has been an effort to "optimize" the composition of project ele- ments the analysis of results is based on treating all inputs as an integrated package which collectively produce the project's results. Target Decline in Fertility 3. About 182,000 new family planning acceptors were reported in FY1970, whicti exceeded the target set for that year. For FY1971, the number of accep- tors is again expected to exceed this year's targets. But despite such en- couraging returns, it seems unlikely that, with current family planning inputs as planned, it will be possible to achieve the target of 2.5 million acceptors set for FY1975 by the Government, the reasons being a) the inability of the present information and education system to reach 85% of the total population which is living in rural areas, b) inadequate physical facilities covering, on average, 18,000 women in reproductive ages per clinic, and c) a weak postpartum motivation program because of the low proportion of institutional deliveries and lack of trained staff. Until now, the impact of new acceptors on ferctility has been negligible. Without the project inputs and the consequent improvement in program performance, it is estimated that the gross reproduction rate would de- cline from 3.2 at present to 2.6 in 1995-2000. With program improvements result- ing from the project it is estimated that the GRR could be brought down to 1.7 by 1995-2000. This would represent over twice as large a decline in fertility over the next 28 years with the project inputs than without them. The gross re- production rates over the period in the two cases are given below: ANNEX 38 Page 2 of 6 Without Project With Project Year Inputs Inputs 1965-70 3.2 3.2 1970-75 3.2 3.1 1975-80 3.1 2.9 1980-85 3.0 2.6 1985-90 2.9 2.3 1990-95 2.8 1.9 1995-2000 2.6 1.7 Difference: 65/70-95/00 0.6 1.5 Required Number of Acceptors 4. The project's demographic impact will depend on two main effects, an increase in the number of acceptors and an improvement in the continuation rates of pill and IUD users. Achievement of the desired impact will also depend on the accuracy of the estimated number of births that are averted per woman-year of protection. 5. The assumed decline in fertility is checked against the possible number of new acceptors that the program would be capable of recruiting with, and without, the project inputs. The required number of acceptors is derived from the births that are to be averted to achieve the desired reduction in fertility. Births to be averted are taken to be the difference of the number of births wit-h constant fertility and the number resulting from the assumed reduction in fertility. For constant fertility, the number of births is calculated from United Nations pro- jections with constant fertilty. New projections have been made for the assumed declines in fertility with, and without, the project inputs. 6. Given the target number of births to be averted, acceptors of family planning are estimated by calculating the women years of protection required for averting a particular number of births. Given the current general fertility rate of about 220, about 4.5 women years of protection are assumed to avert one birth (1000 .4 220). The number of acceptors needed depends on botil the continuation rates of various contraceptive devices and on the contraceptive mix. For Indonesia, there has been no reliable nation-wide survey of continuation rates. Continuation rates for the IUD and the pill have, therefore, been taken from other countries in the region. They are similar to those which underlie the estimates of acceptors made in the 1970 UN-WHO-IBRD Report on the Indonesian program. The continuation rates are expected to improve over a period of time -- after 1985 by 50% because of an expected improvement in overall program performance. The continuation rates assumed initiatlly are as follows: Contraceptive I U D Pill Entering in first year 100 100 Remaining at beginning of the second year 65 45 Beginning of the third year 50 30 Beginning of the fourth year 30 20 Beginning of the fifth year 10 10 ANNJEX 38 Paae 3 of 6 7. The proportion of acceptors of contraceptive pills increased from less than 5% in 1967 to 50% in 1971. It is assumed that the acceptors of contraceptive pills will increase to 90% of all new acceptors in 2000. These assumptions are based on the supposition that there will be no major break-through in birth control technology by that date, 8. On the basis of the continuation rate assumptions, the number of women years of protection obtained for a cohort of 100 females during the 5 years was calcujlated. Applying these coefficients on the women years of protection, the number of acceptors required was estimated. They are as follows: With Project Inputs Without Project Inputs Women Percentage Women Percentage 15-44 Years in of Females 15-44 Years in of Females Year Acceptors Java and Bali 15-44 Years Acceptors Java and Bali 15-44 Years (In (In (In (In millions) millionis) millions) millions) 1975 1.6 18.9 8.4 0.5 18.9 2.6 1980 5.1 24.7 20.6 2.3 24.7 9.3 1985 8.4 25.1 33.5 25.1 18.3 1990 9.1 29.5 30.8 5.0 30.5 16.4 1995 13.4 34.1 39.3 6.5 36.6 17.7 2000 20.1 38.8 51.8 10.0 43.4 23.0 9. Since the Government program is now confined to Java and Bali - two-thirds of the population - the number of acceptori needed to reach the targeted decline in national fertility has been calculated from the eligible females in that area alone. Without the project the number of acceptors is expected to increase from less than 1% at present to more than 2% of women in the reproductive age groups in 1975. To achieve the desired reduction of fertility, the number of acceptors would have to increase to about 8% in 1975. Bv 2000, the number of acceptors would have to cover about 52% of the females in the reproductive age groups to achieve the tar- geted GRR of 1.7, if the program remains confined to Java and Bali. It is con- sidered possible that such targets can be reached. Population Size, Rate of Growth, and Birth Rate 10. Projections of population have been made for Indonesia as a whole on the basis of estimateu declines in fertility with and witnout the project. In both cases, mortality assumptions are the same as an increase in the expectation of life at birth from 48 years at present to 62.9 years in 2000. Totals of projected population are given in the following table, while the age and sex distributions are given at the end. ANNEX 38 Page 4 of 6 Program Improvement Program Improvement Year Without Project -nputs With Project Inputs (In millionis) (In millions) 1975 141 140 1980 164 162 1985 192 183 1990 224 209 1995 262 234 2000 306 258 11, If the ambitious targets for 2000 are met the population would be smaller by 48 million, or 39% of the 1971 population, with the project than without it. In addition to the reduction in absolute size of the population, the rate of growth of population would be lower. The vital rates and rate of growth of population with and without the project are given in the following table: Program Improvement Program Improvement Without Project Inputs With Project Inputs Crude Natural Expectation Crude Natural Expectation Firth Growth of Life Death Birth Growth of Life Death Year Rfate Rate at Birth Rate Rate Rate at Birth Rate 1970-75 47.5 30.0 48.1 17.2 46.3 29.0 48.1 17.4 1975-80 45.5 30.8 51.1 14.3 42.6 28.3 51.1 14,§ 1980-85 43.2 30.7 54.1 12,1 38.5 26,4 54.1 12.5 1985-90 41.7 30.9 57.1 10.4 35.6 25.2 57.1 10.7 1990-95 40.2 31.1 60.1 ;8.7 30.8 22.1 60.1 9.1 1990-2000 38.7 31.0 62.9 7.5 27.4 19.8 62.9 7.7 12. The birth rate would be 27.4 in 2000 with the project inputs, and about 39 without them. The rate of growth of population would remain at 3% per annum, or decline sllghtly to 2.7% in 2000 without the project inputs. With project inputs the population growth rate would fall nearly 50%. ANNEX 38 Page 5 of 6 Tabl. 1 AGE AND SEX STRUCTURE OF POPULATION (WITHOUT PROJECT INPUT) 1975 1980 1985 1990 1995 )00 Ages Hles Females Males Females Males Females Hales Females Males Females 0-4 13,415 12,861 15,359 14,689 17,446 16,645 20,110 19,117 23,113 21,934 26,406 25,C25 5-9 10,716 10,411 12,805 12,255 14,791 14,121 16,922 16,143 19,659 18,682 22,742 21,573 10-14 8,414 8,214 10,553 10,238 12,641 12,087 14,635 13,963 16,779 16,002 19,529 18,559 15-19 7,277 7,176 8,280 8.070 10,408 10,089 12,496 11,943 14,496 13,832 16,651 15,885 20-24 6,162 6,121 7,109 7,008 8,114 7,911 10,232 9,924 12,320 11,787 14,330 13,689 25-29 5,188 5,184 5,987 5,948 6,936 6,840 7,948 7,753 10,059 9,764 12,151 11,635 30-34 4,341 4,366 5,023 5,018 5,825 5,785 6,778 6,684 7,800 7,609 9,908 9,618 35-39 3,617 3,665 49180 4,209 4,864 *4,863 5,669 5,634 6,629 6,539 7,661 7,474 40-44 2,987 3,067 3,452 3.517 4,015 4,060 1,,700 4,715 5,510 5,489 6,475 6.398 45-49 2,427 2,547 2,815 2,925 3,277 3,371 3,837 3,912 4,521 4,564 5,330 5,338 50-54 1,924 2,076 2,245 2,398 2,624 2,769 3,078 3,209 3,631 3,745 4,307 4,392 55-59 1,477 1,653 1,730 1,913 2,036 2,225 2,401 2,587 2,840 3,0L9 3,377 3,545 60-64 1,079 1,268 1,271 1,470 1,504 1,717 1,789 2,014 2,131 2,363 2,544 2,780 65-69 734 916 869 1,065 1,037 1,250 1,243 1,476 1,497 1,752 1,804 2,077 70-74 451 596 535 703 644 830 780 988 949 1,184 1,159 1,424 75-79 166 241 282 397 341 477 418 573 516 694 640 847 80+ 73 116 58 87 100 146 122 177 152 215 190 264 70,447 70,476 82,552 42,476 96,602 95,183 113,156 110,810 132,600 129,173 155,20t 150,523 ANNEX 38 Page 6 of 6 Table 2 AGE AND SEX STRUCTURE OF POPULATION (WITH PROJECT INPUT) 1975 1980 1985 1990 - 1995 - 2000 A&es Mates Females Males Females Males Females Males Females Males Females Males Females 0-4 13,026 12,4.3 14,226 13,605 15,095 14,402 16,245 15,443 16,139 15,316 16,183 15,337 5-9 10,716 10.41L 12,434 11,900 13,700 13,079 14,642 13,968 15,881 15,092 15,879 15,063 10-14 8,414 8.214 10,553 10,238 12,275 11,736 13,555 12,933 14,518 l3,846 15,776 14,992 15-19 7,277 7.176 8,280 8,070 10,408 10,089 12,134 11,597 13,427 12,811 14,407 13,745 20-24 6,162 6.121 7,109 7,008 8,114 7,911 10,232 9,924 11,963 11,445 13,273 12,679 25-29 Sl18 5,184 5,987 5,948 6,936 6,840 7,948 7,753 10,059 9,764 11,798 11,298 30-34 4,341 4.366 5,023 5,018 5,825 5,785 6,778 6,684 7,800 7,609 9,908 9,618 35-39 3.617 3,665 4,180 4,209 4,864 4,863 5,669 5,634 6,629 6,539 7,661 7,474 40-44 2.987 3.,067 3,452 3,517 4,015 4,060 4,700 4,715 5,510 5,489 6,475 6,398 43-49 2,427 2,547 2,815 2,925 3,277 3,371 3,837 3,912 4,521 4,564 5,330 5,338 50-54 1,924 2.076 2,245 2,398 2,624 2,769 3,078 3,209 3,631 3,745 4,307 4,392 55-59 1,477 1.653 1,730 1,913 2,036 2,225 2,401 2,587 2,840 3,019 3,377 3,545 60-64 1,079 1,268 1,271 1,470 1,504 1,717 1,789 2,014 2,131 2,363 2,544 2,780 65-69 734 916 869 1,065 1,037 1,250 1,243 1,476 1,497 1,752 1,804 2,077 70-74 451 596 535 703 644 830 780 988 949 1,184 1,159 1,424 75-79 166 241 282 397 341 477 418 573 516 694 640 847 80+ 73 116 58 87 100 146 122 177 152 215 190 264 70,059 70,103 81,048 80,471 92,794 91,548 105,570 103,585 118,161 115,446 130,711 127,271 ANNEX 39 Page 1 of 3 ECONOMIC IMPACT OF THE PROJECT 1. The paucity of data on national accounts and the absence of a perspective plan or projected economic parameters do not allow measure- ment of the economic impact of the reduction in population growth resulting from the project inputs. This annex attempts, therefore, to show at a broad and simple level the economic consequences of reduced population size in terms of per capita income, investment requirements, and employ- ment. The effect of a unit decline in the rate of growth of population on demand for food, savings, and foreign resource gap is also demonstrated. Per Capita Income and Investment 2. The possible increase in gross domestic product (GDP) up to 1980 has been projected in the Bank's report on "Investment and Growth Perspectives in the 1970's" for Indonesia. The estimated increase itself, however, implies the effect of an assumed slower population growth. These estimates have, however, been used to calculate per capita income with and without project inputs. The additional GDP required to obtain the consequent increase in per capita income in the absence of decline in population increase with project inputs gives the idea of required investment. Assuming an incremental capital output ratio of 3:1, the additional investment needed to generate the additional GDP is also estimated. The results are given in the following table: Required Addition Population for Increase Required (In millions) in Population Additional Reduction GDP Per Capita WOPI (U.S.$- Inlvestment in Popu- GDP.! % In millions) as a lation (U.S.$ - In U.S.$ Increase Capital Proportion Year WOPI WPI WPI millions) WOPI WPI WPI GDP Stock of GDP 1970 121 121 - 8,746 72 72 - - - - 1975 141 140 1 12,359 88 88 - - - - 1980 164 161 3 18,378 112 114 1.8 326 978 5.0 1985 192 184 8 26,997 140 147 5.0 1,344 4,032 15.0 WOPI = Without project inputs. WPI = With project inputs. GDP = Grcss domestic product. 1/ Projections of GDP up to 1980 are taken from the Bank's report on "Invest- ment and Growth Perspectives in the 1970's" for Indonesia. From 1980 to 1985, a growth rate of 8% per annum in GDP is assumed. The growth rate in GDP assumed in the above mentioned report was 7.9% per annum for 1975-80. ANNEX 39 Page 2 of 3 3. As a result of the reduction in population attributable to the project, per capita income is estimated to increase by 1.8% in 1980 and by 5.0% in 1985. The project benefits (measured in terms of savings in re- sources required to increase GDP to achieve a comparable growth in per capita income without the project) are extremely large. For example, it is estimated that additional savings and investment equal to about 5% of 1980 GDP would be required to give everyone the 2% of additional income made possible by keeping population 3 million smaller than it would other- wise be. Project costs are insignificant in comparison with the savings in resources required to support the "births averted" population. Labor Force 4. Fertility reduction will affect the size of the labor force only after 15 years. It is estimated that the labor force would be smaller by 1.8 million in 1995 and 4.7 million in 2000 with reduced fertility. The figures are given in the following table: INDONESIA: ESTIMATED WORKING-AGE POPULATION AND LABOR FORCE 1975-2000 (In millions) Year Population 15-59 years Labor Force WOPI WPI WOPI WPI 1975 71.2 71.2 47.0 47.0 1980 81.8 81.8 54.0 54.0 1985 96.0 96.0 63.4 63.4 1990 113.5 112.8 74.9 74.4 1995 134.1 131.4 88.5 86.7 2000 158.2 151.0 104.4 99.7 5. Indonesia is at present a country with serious unemployment and under- employment. Overcoming these problems from the demand side alone, through the generation of very high growth levels over a period of several decades, does not seem a realistic expectation. Therefore any slowing in the growth of the labor force will contribute to a reduction in the country's chronic unemploy- ment; however, the extent of such a reduction cannot be predicted with confidence beyond stating that it would be significant. Food Consumption, Savings, and Resource Gap 6. As an aid to planning by both the Covernment of Indonesia and aid donors, long-range macro-eco.aomic projecticas of the possible growth of the Indonesian economy have been -made by the East Asia and Pacific Department of the Bank. The effects of alternative assumptions regarding exports, agri- cultural growth, the increase in population, tax rates, and private capital inflows are used. ANNEX 39 Page 3 of 3. 7. Differences in population growth rates have their main effects in the model through the demand for food. With a given rate of income growth and an income elasticity for food well below uniity, a higher population growth rate implies a lower growth of per capit:a income and larger increase in the demand for food. If the supply of food, and especially of food grains, is not elastic from domestic sources, the only recouree is additional imports from abroad which create a burden on the balance of payments. 8. Given certain assumptions on per capita food consumption and the growth of both population and domestic food supply, the model shows that by 1980 Indonesia could be saving as much as $30 million in foreign exchange if the population growth rate dropped a full percentage point during the decade. However, it is likely that domestic food suppliee will increase to a point where actual import savings will in fact be substantially less. BANGKA BELITUNG IIZE K A L I M A N T A N (BORNEO) 0Palembang S U M A T R A Bandiarmasin 41S J INDONESIA 4S- 0Menggala T JAVA AND BALI Bandardljo . Wcy Seputih RP RIVERS 0 f , --l11 AILWAYS G V G Gunungsugih °SukadCna Xc | * NATIONAL CAPITAL TeIukbetung n . PROVINCIAL CAPITALS --..--..................... PROVINCIAL BOUNDARIES S e a Merako DJAKARTA Se a JAKARTA Labuh, 5Indromaju E Serang R. RBogor f\ WEST JAVA Tjirebon Tuntang R. Tegal Pekalongan Teluk Pelabuhan Ratu0 MADURA Bumiaju ~ *, Wons bo o urabaj Indian Ocean Modjokerto Pameungpeuk° a.S uraka aS , e°S 108-E jABALI 8°SE .0 - ALAYA Tjilatjp -DJOGJAKARTA BALI . SABAH, PHILIPPINES ALAYA RUNEI 'MALAYSIA - Pacific Ocean BA L I SARAWAK SINGAPORE D. Denpasar @ KALIMANTAN S ' SULAWESI WEST 5!0 10,0 5I0 20 Java Seaa -. NEW MILES Indian Ocean I N D O N E S' I A 0 100 200 300 JAVA OR M KILOMETERS > - $ PORT, TIMOR AREA OF MAP TIMOR AUSTRALIA 112 E- MARCH 1971 IBRD 3360 r 1l!,- II!-EMAP 2 112'E I14E INDONESIA Imb ngEAST JAVA AND BAlI PROVINCES 0 25 50 75 100 MILE S E MA 5A 75 ( 05 K! LOMETERS Sangkalan /umene ~ a |~~~~~~ - - Pielp= KABUPATEN BOUNDARIES l NGKBUATE HADQARER wakarta SLZLAT MADU 7A PROVINCIAL BOUNDARIES i \/ \ EJ= : b >\>: ............. ..............O PROVINCIAL CAPITALS ( , / ~~~<,- golelt / t E ~~~AL SEWT0JtA B' V S -'-- a tu eNggane F L\ S . J A, \/ 4 Moget.n P. uuan lu otng/-/ X Bnaonruwang . :, {^ F^ , 7/ME < :>ANA n ""i\ > // / TA|BANAN I ) KARAGASEM |/ NDZSA N O CEZAN jBA1 K!^aAN(I I/t|> ; pQnm!I I BADUNG DENPASAR Trnp a k llZ'E fl4 E MARCH 1971 1BRD 3361 A- T A- V