Indonesia COVID Additional Financing Technical Assessment (P175759) Introduction 1. This addendum to the technical assessment evaluates the adequacy of the proposed Program- for-Results (PforR) Additional Financing (AF) to scale up and expand activities of the Indonesia Emergency Response to COVID-19 parent PforR (P173843). The total IBRD financing for the parent PforR is US$250 million and was approved on May 22, 2020 as part of the COVID-19 Strategic Preparedness and Response Plan (SPRP) using the Multiphase Programmatic Approach (MPA), which itself was approved by the Board of Directors of the Bank on April 2, 2020. Its program development objective (PDO) is to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness in Indonesia. It includes three results areas: (i) address hospital and health system readiness and systemic improvements in the quality of care; (ii) strengthen the Government of Indonesia’s (GOI) public health laboratory and surveillance systems; and (iii) facilitate communication and coordination for better pandemic response and preparedness. As Indonesia continues to experience increasing and widespread community transmission, the number of confirmed cases and deaths has risen to 1,718,575 confirmed cases and 47,218 deaths from COVID-19 as of May 8, 2021, - the highest in the East Asia Pacific Region. The GOI has requested an additional loan of US$500 million to support the GOI’s plan for scaling up its response to COVID-19 and to support the COVID-19 vaccination plan as one of the national economic recovery strategies. 2. The scope of this document acts as an addendum on new or incremental aspects of the parent PforR rather than a repetition or update of the original assessment. It will be organized in four sections (i) assessing the strategic relevance and technical soundness of the AF; (ii) updating the Program expenditure framework based on the performance of the original PforR and new elements covered by the AF; (iii) updating the results framework and assessing the performance of monitoring and evaluation (M&E) arrangements; and (iv) providing an economic justification for the new activities described in the AF. Strategic Relevance and Technical Soundness Strategic Relevance 3. Given the importance of limiting the spread of COVID-19 for both health and for economic recovery, providing access to COVID-19 vaccines will be critical to accelerate economic and social recovery. By one estimate, delaying access to vaccination by just six months will cost the economy US$44 billion or 4.1% of GDP1. While global vaccine production plans are already underway, production capacity 1 https://theconversation.com/delaying-a-covid-19-vaccination-program-may-cost-indonesia-us-44-billion-147446 depends on the successful vaccine candidates and the expected demand, among other factors. High- income countries, representing 13 percent of global population, have already reserved 51 percent of the initial supply of COVID-19 vaccines. 4. The GOI has included COVID-19 vaccination as one of the key interventions under the national strategy for economic recovery. A Presidential Decree appointed the Ministry of Health (MOH) as the main implementer of the national COVID-19 vaccination program (Presidential Decree 99, 2020 on ‘Procurement and Implementation of COVID-19 Vaccines’). The decree delineates MOH’s roles as the main agency to procure, price, and implement COVID-19 vaccination. It also clarifies the roles of other government ministries and agencies to support the MOH2. The GOI has also taken measures to secure vaccines from several sources. Indonesia has already signed an agreement on COVID-19 vaccine procurement under the Gavi-led COVID-19 Vaccines Global Access Facility (COVAX Facility) – which aims to accelerate the development and manufacture of COVID-19 vaccines and to promote equitable access to COVID-19 vaccines. The COVAX facility initially assures vaccines for 20 percent of the country’s population and has delivered 6.4 million doses as of May 8th, 2021. The Government has, in addition, undertaken bilateral agreements with vaccine suppliers from China, United States, and United Kingdom. 5. With a population of 268 million, Indonesia’s financing needs to secure vaccines for its entire population will be substantial. Although considerable uncertainty about final vaccine prices3 remains, cost estimates of US$4 per dose in low-and lower-middle income countries (LMICs) and US$6.5 in upper- and high-income countries have been used. Incremental costs for deployment are further estimated at US$1 per dose, bringing the estimated cost for each vaccine dose, including delivery, to US$5 in LMICs and US$7.5 in upper-middle income countries. Indonesia is expected to secure favorable pricing that should not exceed estimates for the LMICs. It is also expected that a two-dose vaccine regimen may be required for most vaccine candidates. This would bring Indonesia’s total financing needs to more than US$1.8 billion, were it to vaccinate 68 percent of its population – enough to reach herd immunity, assuming a cost of US$10 per person. Prioritizing front line workers, people with co-morbidities and other groups who stand to benefit the most – or ~20 percent of its population – would cost over US$ 535 million. 6. This AF plays a critical role in strengthening the GOI readiness for vaccine deployment system as well as support the health service delivery system for an effective rollout of COVID-19 vaccines. The GOI program to acquire, deploy, and deliver COVID-19 vaccines for all the targeted beneficiaries require an increase in the overall expenditure envelope of the Government budget. The budget commitment for the vaccine program has increased in early 2021 and is now estimated between US$4.7 to US$5.2 billion, of which US$1.5 billion is for vaccine procurement in 2021, resulting from the GOI’s decision in December 2 For instance, the National Agency for Food and Drug will be the main partner for pharmacovigilance and state- owned pharmaceutical companies will act as vaccine procurement agents. 3 One frontrunner vaccine is already priced at below US$3 to US$5 per dose in high-income countries. This vaccine candidate and another prominent one are both priced at up to US$3 per dose in low-income countries. The manufacturer of another leading candidate has agreed to US$10 per dose in the US (for what is hoped to be a single- dose regiment); their price for developing country purchase is not yet confirmed. Vaccines using innovative technologies such as mRNA vaccines may cost US$20-40 per dose. 2020 to provide free vaccines for all adults in the country. The GOI is mobilizing various sources of financing and has already allocated an estimated US$240 million in 2020 for the upfront payment to secure vaccines. The GOI is leading donor coordination in close consultation with the World Bank (Table 1). The World Bank proposed AF, along with co financing from other partners is projected to provide significant share of total funding for the COVID-19 response in the health sector. Therefore, continuing Bank engagement is essential to enabling the expansion of a sustained and comprehensive pandemic response in Indonesia. Table 1: Financial and in-kind development partner support Financing amount (if Development Partners known) WHO In-kind support with Providing technical leadership for vaccine introduction, and assessment of country a US$22 million readiness (along with UNICEF); contribution from the Korea Providing technical support to the GoI on the vaccination policy objectives, strategy, International Cooperation targets and vaccine safety issue in the country’s roadmap; Agency - KOICA, Japan - Supporting the Indonesian Technical Advisory Group on Immunization (ITAGI) (along JICA, Germany - KfW, The with UNICEF); Australian Gov – DFAT, and Supporting the development of guidelines and training on adverse events following USAID6 immunization (AEFI) surveillance, vaccine pharmacovigilance Organizing and leading development partner coordination for support to the Country’s COVID-19 response including the vaccine roll out UNICEF Financing amount In-kind support Providing technical support for the vaccine introduction readiness assessment and Cold Chain Equipment (CCE) assessment Supporting the development of a COVID-19 vaccine deployment roadmap, including the quantification and forecasting of needed supplies for service delivery (e.g. CCE); Advising on the integration of COVID-19 vaccine roll-out within the expanded programme of immunization and other primary health care (PHC) services Enabling the procurement of vaccines, CCEs, and other supplies for the vaccine roll- out; Supporting monitoring and evaluation functions related to vaccine deployment as well as the continuity of essential health services (along with WHO, WB) Providing support to monitor the vaccine hesitancy and continuity of essential health services (along with WHO, WB) UNDP Financing amount Providing technical support for the vaccine introduction readiness assessment and In-kind support Cold Chain Equipment (CCE) assessment in collaboration with UNICEF Expanding the use of technological solution to strengthen the immunization supply chain system through SMILE (electronic logistic monitoring information system) Gavi/COVAX Financing amount Through COVAX Facility: the Providing vaccines to cover the first prioritized 20 % of the population value of vaccines for 20% of Providing access to COVAX Facility vaccine pricing beyond the fully subsidized 20% the population or 108 vaccines million doses. Estimated at Providing technical assistance through supporting the ITAGI US$ 400 million. Financing amount (if Development Partners known) DFAT Financing amount COVID Emergency Response AUD 1,5 billion (~USD 1.15 billion); Regional COVID-19 Vaccine Access and Health Security Initiative (VAHSI) ~AUD 100m, a part of which also flows through this AF AIIB Financing amount Co-financing with the World Bank in the COVID-19 Emergency Response PforR and USD 250 m + this Additional Financing USD 500 m ADB – supporting BioFarma in purchase and deployment of vaccines US$ 450 m Support Indonesia’s Fight Against COVID-19 grants USD 3 million COVID-19 Emergency Response and Vaccine (TBD) KfW Financing amount COVID-19 Emergency Response 200 million Euro JICA Financial and Technical support, in-kind Financial support: TBD + In-kind support USAID and US-CDC Technical support, in-kind In-kind support EIB Financial support (budget support) against purchase of vaccines Euro 300 million 7. The AF will also support crucial non-vaccine immunization costs needed to expand immunization capacity. Even with considerable doses of an effective and safe vaccine in hand, Indonesia will face major challenges deploying those vaccines at scale. Indonesia (and most countries) are used to vaccinating successive cohorts of infants – and not vaccinating a large proportion of all adults (>65 percent of their population) all at once, though this is what would be required to reach ‘herd’ immunity. Using routine childhood immunization as a proxy for potential COVID-19 vaccine delivery, Indonesia does not compare favorably to its peers. Vaccinating adults is much more complex, especially when it may involve multiple doses – adding the complexities of targeting and monitoring. The latest Indonesian Basic Health Survey reported that the proportion of fully immunized children was 58 percent, and 63 percent of all unvaccinated children were living in rural areas4. As much as a three-fold difference in immunization coverage rates exist across provinces, and sizeable inequalities by economic status exist as well. 8. In Indonesia, several weaknesses from local production capacity to service delivery hinder the achievement of higher immunization coverage rates. a. Local production and procurement. Most domestic manufacturers of program pharmaceuticals are not able or willing to make costly investments in system and equipment upgrades needed to meet the quality standards of stringent regulators or the World Health Organization (WHO) Prequalification of Medicines Program (PQP). As a result, only PT. Bio Farma (an Indonesian state- owned enterprise) is prequalified by the WHO for vaccines. The procurement procedure of 4 https://www.litbang.kemkes.go.id/laporan-riset-kesehatan-dasar-riskesdas/ program pharmaceuticals and supplies is also complex resulting in long lead times and drugs that are close to expiry. Routine vaccines are procured using the national budget Anggaran Pendapatan dan Belanja Negara funds (ABPN)5. All procurement that uses APBN must use the Indonesian Government Procurement System (IGPS)6. b. Supply chain management. The selection, planning, procurement, and distribution of APBN- funded program pharmaceuticals and supplies falls under the MOH’s One Gate Policy (“Tata Kelola Obat-Vaksin Secara Terpadu�); they are distributed via a network of central, provincial, and district medicine warehouses (Instalasi Farmasi) before reaching facilities’ medicine warehouse. Upon leaving PT. Bio Farma, routine immunization vaccines are sent to Provincial Health Office Medicines Warehouses to be distributed to District Health Office Medicines Warehouses and health facilities, while maintaining cold chain throughout the distribution process. The availability of functioning cold-chain equipment at public health facilities has improved with the increased financing from the Central level over the past five years, while the maintenance costs rely on the local government’s budget and commitment. The UNICEF’s assessment of Effective Vaccine Management completed in May 2020 identified temperature monitoring and storage capacity were among the main gaps in vaccine supply chains. The enhanced storage and supply chain needed for COVID vaccination, therefore, may require exploring private sector capacity, while also providing an opportunity to upgrade the supply chain and strengthen temperature monitoring systems. c. Decentralized service delivery. Although the central government procures and distributes vaccines, provincial and district governments manage the operations of public health facilities and services. Management capacity and commitment to immunization is extremely variable across different provinces/districts, leading to varying immunization coverage rates. Still, routine immunization services are available at virtually all public health center (puskesmas). Two-thirds (67 percent) of puskesmas offer daily or weekly immunization services, and 92 percent provide outreach services on at least a monthly basis. However, the lack of a distribution budget is a last- mile-availability barrier. To date, the cost for distributing program pharmaceuticals is financed by the central government through BOK channels or covered by local government on an ad-hoc basis. This is a significant barrier given that almost three-fourths of all vaccinated children in Indonesia receive their immunization at a sub-village level health post (posyandus), followed by 10 percent at puskesmas, 10 percent at private clinics and hospitals (although this can be as high as 50 percent in some provinces), and the remainder at a delivery village post (polindes) and other 5 The main source of pharmaceutical financing is the national budget (APBN), whereby ABPN funds are transferred to local governments, using the Specific Allocation Fund or Dana Alokasi Khusus (DAK). Fiscal transfers for pharmaceuticals via DAK for health could occur through two mechanisms: DAK Fisik, for public pharmaceuticals, and DAK Non-Fisik (i.e. Bantuan Operational Kesehatan, BOK), for distribution costs. However, local governments, both provincial and district, also utilize local budgets (Anggaran Pendapatan dan Belanja Daerah , APBD) to pay for pharmaceuticals. The third source of financing is capitation payments from Badan Penyelenggara Jaminan Sosial (BPJS), the administrative and implementing body for JKN. MOH Regulation No. 19/2014 specifies that 40% of capitation payment can be utilized to support operational expenses, which includes pharmaceuticals, medical devices and medical supplies. 6 Despite being eligible to procure vaccines internationally through low-cost platforms such as those of UNICEF, Indonesia prefers to use BioFarma under its domestic preference policy, though vaccine prices are much higher. places (including midwives’ homes). Routine immunization is also provided for school children via the school based Bulan Imunisasi Anak Sekolah (BIAS) program. d. Monitoring and evaluation. The quality of administrative data on immunization is poor and there is often a 30-40 percentage points difference between administrative data and survey data. There are also inconsistencies between survey data from different sources. Among the main reasons for poor data quality hindering accurate monitoring and evaluation are: 1) the existence of a patient is not known or different target populations are used as denominators at different reporting levels contributing to widely varying coverage rates; 2) data is distorted in transmission. The immunization program relies on facility reporting starting from the community level, posyandu. Data is manually transcribed between documents six times and subject to manual calculations and one electronic calculation as it makes its way up from point of care all to the national level; 3) the fragmented nature of the MOH information system contributes to a high reporting burden on the front lines of the public health system, variable/inconsistent reporting rates and data of questionable quality; 4) finally, there is poor data storage/handover that adds to the challenge (Figure 1). Figure 1: Immunization data collection and reporting flows Source: Findings from a 2017 World Bank Health Data Tracing study in South Sumatra, Maluku and East Nusa Tenggara 9. The MOH has also recently undertaken a vaccine readiness assessment using the integrated VIRAT (Vaccine Introduction Readiness Assessment Tool) and VRAF (Vaccine Readiness Assessment Framework) Tool 2.0 with the support of World Bank, WHO, and UNICEF; its findings are summarized in Table 2 below. Table 2: Vaccination readiness findings from the VIRAT/VRAF 2.0 assessment Core Activity Assessment Readiness and Measures to Address Key Gaps Areas Area A. Planning A1. • Readiness. Priority target population group has been identified, and Vaccination estimated/calculated, and mapped. The National Deployment and Management objectives and Vaccination Plan (NDVP) is being revised, but the implementation guideline targets has been issued (January 2, 2021). Stakeholders are actively involved — including ITAGI. • Key gaps and measures to address them. A detailed national deployment and vaccination plan7, including subpopulation targeting, is developed. An integrated target population database is being developed that includes health personnel database, the Dukcapil (Civil Registration and Vital Statistics) data under the Ministry of Home Affairs, the National Health Insurance Agency (Badan Penyelenggara Jaminan Sosial - Kesehatan, BPJS-K) membership and facility databases, and various civil service databases under the coordination of the Ministry of Communication and Information registry. The GOI has added a bottom-up listing and registration process to ensure the comprehensiveness of Program coverage. A bottom-up approach to add any missing beneficiaries is being undertaken. The PforR includes DLIs, as well as PAP requirements, to support the GOI in addressing these issues. A2. Regulation • Readiness. The national regulatory authorization path has been established and Standards and communicated to the WHO. The waiver mechanism for expediting import and local lot testing release based on summary protocol are in place. Regulatory approvals for vaccines procurement will be using the national procedures. • Key gaps and measures to address them. Policy to expedite the procurement and import of COVID-19 related goods is already in place. BPOM has already authorized two vaccines, Sinovac and AstraZeneca, based on review of the data submitted. The WHO and UNICEF are also providing technical assistance in this process. 7 Technical Guidelines for COVID-19 Vaccination Plan are developed and issued, and will be updated from time to time; The document fits the description of a national deployment and vaccination plan as recommended by the WHO; The MOH issued the plan in technical guidelines format as it is more adaptive to the dynamic of the COVID-19 vaccination. The guidelines contain overall strategy and plan for the acquisition, prioritization, deployment, and monitoring of the COVID-19 vaccine implementation; a technical guideline document provides operational guidance and technical steps for the field managers, and vaccinators. Core Activity Assessment Readiness and Measures to Address Key Gaps Areas Area A3. • Readiness. The GOI has assured privacy protection of the database of the Performance vaccine beneficiaries; personal data protection has been incorporated in the management database with the support from the National Cyber and Crypto Agency and M&E (Badan Siber dan Sandi Negara, BSSN). • Key gaps and measures to address them. The quality of health reporting continues to be a major concern. A supervision system is in place and to ensure the effectiveness of this system. The GOI has developed a One Data for Vaccination information system to ensure the reporting quality of the program. The PAP for the original financing includes requirements on data privacy which will continue to be applicable to the AF and will help mitigate this risk. A4. Budgeting • Readiness.: The GOI has committed budget allocation for the vaccine program, wherein the financial management will be in accordance with the national regulations. These have been reflected in an MOF decree. • Key gaps and measures to address them. The GOI has decided to fully finance vaccines for all adults in the country—estimated at 181.5 million persons (around 67% of the total population). The GOI has mobilized financing both internally (for example, revised budgetary allocation for this increased need will be reflected in the MOH budget), as well as from external sources. B. Supply and B1. Vaccines, • Readiness. The GOI has identified sources of vaccines, estimated amount, Distribution PPEs and other and procurement mechanisms that will be used. The GOI has allocated medical and budget for the provision of vaccines and supplies including PPE. non-medical • Key gaps and measures to address them. The GOI has secured about 80% of supplies the country’s projected vaccine needs, including commitments for free vaccines from the COVAX Facility. The GOI has expressed its intention to acquire further doses through the COVAX Facility on self-payment basis. Exact additional paid allocation from COVAX is not yet known and will be clearer in the coming months, once decisions on allocations from this paid allocation are made by COVAX. However, the Government also has the provision to further increase its orders from bilateral suppliers to meet its requirements. B2. Logistics • Readiness. Distribution and logistics strategy for the vaccines and ancillary and cold chain products has been developed to include the public and private sectors. The CCE assessment is being finalized, which will be followed by the plan to address the CCE capacity gaps. The use of technology to monitor temperature up to points of service has been included in the technical guidelines. • Key gaps and measures to address them. The logistics and cold chain for such a large number of vaccines will require careful management of available storage and logistics solutions. The cold chain action plan is one of the DLIs under this PforR, and several other areas for strengthening cold chain and logistics are also incorporated in the PforR design. Core Activity Assessment Readiness and Measures to Address Key Gaps Areas Area B3. Waste • Readiness. Waste management is already included in the recently published management Vaccination Technical Guideline8. • Key gaps and measures to address them. A wide range of health facilities/local government capacity, and whether the most appropriate waste management is available in certain locations, needs to be ensured. A guideline for waste management has been developed and disseminated. Coordination with the national authority (Ministry of Environment and Forestry [MOEF]) is ongoing. C. Program C1. • Readiness. An initial assessment on vaccine hesitancy has been conducted, Delivery Community and a public communication strategy and messages are being developed. engagement The communication strategy needs to be continuously updated. and advocacy • Key gaps and measures to address them. The MOH team has been conducting data collection to monitor for misinformation, while regular assessment of social behavior still needs to be developed. The development support may include a population-based survey that monitors government programs implementation and social behavior due to and toward COVID-19 to inform the vaccine rollout. Development partners, such as UNICEF and the World Bank, are planning to conduct regular monitoring on community response toward the GOI COVID-19-related programs. C2. Points of • Readiness. The facility database has been developed, operational standards delivery have been developed, and a mechanism exists to identify points of service/vaccination facilities including those from the private sector. Monitoring tools have been developed and outlined in the vaccination implementation technical guideline. This will include the private sector. The training for health personnel involved in the vaccination rollout has been developed, and virtual training has been initiated. • Key gaps and measures to address them. Supervision and monitoring to ensure the quality of service, reported data, and the training. UNDP is providing support to expand the availability of the logistics and remote temperature monitoring system. C3. Vaccine • Readiness. The guideline for KIPI (Adverse Events Following Immunization) is safety being finalized, and institutional arrangements have been clarified in an surveillance MOH decree. An active surveillance guideline is being finalized, and the information system has been functioning and has the ability to track the type of vaccine given. The KIPI committee has been established at the central and subnational levels and is to be provided with training. The KIPI monitoring will be based on the existing surveillance system. • Key gaps and measures to address them. Training for KIPI surveillance is being designed. Compensation scheme for KIPI has been designed and announced. 8 Technical Guideline, see footnote 7 (above) Core Activity Assessment Readiness and Measures to Address Key Gaps Areas Area D. Supporting D1. Data • Readiness. An integrated database and information system for recording Systems and quality and reporting (Sistem Informasi Satu Data Vaksinasi C19 – C-19 Vaccination Infrastructure One Data Information System) is to be developed for COVID-19 vaccine implementation, as stated in the technical guideline. • Key gaps and measures to address them. The integrated database and information system continue to evolve. The Phase 1 implementation for health personnel has been used as a ‘field test’ of the information system, and the system improvement is ongoing. The GOI also mobilized experts from communication companies and technology-based companies to provide technical support to improve the information system, especially to address data quality issues. D2. • Readiness. Mapping and assessment of facility capacity have been partially Infrastructure completed; for energy and IT, it is still at an early stage. • Key gaps and measures to address them. Existing infrastructure readiness is variable across the country. • Possible solutions. The involvement of the private sector, and expediting the strengthening of the national immunization program, and health service delivery in general, for instance, the expansion of remote temperature monitoring system to cover all provinces and more districts and health facilities. 10. Therefore, it is essential that the national COVID-19 vaccine effort also strengthens the underlying immunization infrastructure. This includes: (i) functional, end-to-end supply chain and logistics management systems for effective vaccine storage, handling, and stock management; (ii) rigorous cold chain control; (iv) robust service and coverage tracking systems; (v) well trained, motivated and supervised vaccinators, tailored large-scale communication and outreach campaigns at household, community and national level; (vi) people centered service delivery models that reach different target populations effectively; and (vii) effective governance and any additional institutional frameworks for the safe and effective deployment of vaccines, regulatory standards for vaccine quality, guidelines for acceptable minimum standards for vaccine management, and policies to ensure robust governance, accountability, pharmacovigilance, and citizen engagement mechanisms. Technical Soundness 11. There is strong technical rationale for vaccination consistent with the strategies recommended globally to slow down the transmission of COVID-19 and prevent associated illness and death. While the efficacy of the various vaccines under production remains a clinical unknown, we know from global experience that vaccines significantly reduce or even eliminate the threat of morbidity and mortality from disease. Following a surge of cases during the New Year holiday, many hospitals are on the verge of being overwhelmed, with intensive care units and isolation rooms at more than 70 percent capacity. 12. The GOI’s national COVID-19 vaccination implementation roadmap proposes a phased approach based on. Indonesia’s vaccine strategy is to vaccinate the entire adult population (18 years old and above) with the exception of those pregnant, currently COVID-19 positive, and with uncontrolled co-morbidities, who may be at high risk of adverse effects from vaccination. Frontline health workers were the first priority group to receive the vaccines, and this has been completed in February 2021. The next phase, ongoing now, comprises of the elderly and the frontline public service workers. The national regulatory authority (the Indonesian Food and Drug Agency, or BPOM) has approved the use of the available vaccines for the elderly, as well as those with co-morbidities, with strict screening (Table 3). Table 3: Indonesia’s vaccination plan for target populations Number of target % Population group beneficiaries (million) of total population First Wave Vaccination Period January – May 2021 Phase 1 Health Personnel: Vaccination will be conducted for health 1.5 0.65% personnel in 34 provinces. This includes health assistants, support/administrative personnel, and students who are currently in professional training who also work in health service facilities Phase 2 a Public service workers: military and police forces, other 17.3 6.44% uniformed officers judicial officers, and strategic public service officers those working at ports of entry, transportation stations, banks, utilities electric/power companies, and clean water companies, as well as other officers involved directly provide services to the community Phase 2 b Senior citizens: 60 years old (y.o) and above* 21.5 8.0% Second Wave Vaccination Period June 2021 - March 2022 Phase 3 Vulnerable population based on geographical location, social, 63.9 23.66% and economic aspects Phase 4 Wider population; Economic actors using a cluster approach 77.4 28.66% according to the availability of vaccines 13. The overall risk to achieving the PDO will be revised from Substantial to High, given the risks associated with support for the implementation of a national vaccination campaign. Safe and effective deployment of a COVID-19 vaccine to a large share of the population is an unprecedented endeavor and entail additional risks that were not anticipated under the original Program. These include risks related to: (a) overall macroeconomic outlook, (b) political and governance; (c) the technical design of the Program, (d) the institutional capacity for implementation, and (e) stakeholders. a. Overall macroeconomic risk. While the pandemic has dealt a significant blow to public finances – increasing the deficit to 7.1 percent in 2020 – the shortfall is expected to narrow to narrow to 6.1 percent in 2021 and further thereafter as it is unlikely that the government will enact further lockdowns. The government’s reluctance to repeat the more large-scale restrictive measures it introduced in 2020 will mean less economic disruption. However, in the immediate future, Indonesia is experiencing severe fiscal pressures and faces the risk of not having sufficient additional fiscal space for the purchase of vaccines at scale and other COVID-related response interventions. The proposed AF specifically aims to mitigate this risk by providing financing for vaccine purchase and promoting prioritized deployment to vulnerable groups. Residual macroeconomic risk to the AF and parent PDO is limited to risks that cannot be readily mitigated (e.g., risks related to significant counterpart financing, other specific macroeconomic risks that may hinder the operation from achieving its intended results). b. Political and governance risks will be revised from Moderate to Substantial . This is mainly due to two reasons. First, COVID-19 vaccines’ integrated deployment will be carried out at an unprecedented scale and in a relatively short period of time, which would mean an additional political pressure on the government to acquire and deploy the vaccines which may affect the quality of implementation. This risk will be mitigated by the fact that all readiness and deployment support under this Program will be for the VAC-compliant vaccines, accompanied by system strengthening measures and linked to a program of technical assistance, to support strengthening and resilience of the overall health system. Another potential risk is associated with ensuring appropriate targeting of the population to be vaccinated given the initial vaccine supply constraints as well as limitations of existing population databases, which could result in the vaccines not reaching the priority populations, based on objective public health criteria. Current identification of target and prioritized populations is relying on multiple existing population databases; however, data inconsistencies and discrepancies exist. This risk will be mitigated by development and implementation of a mechanisms to complement the top-down data, to ensure inclusion of the target population. c. Technical design of the AF: The large-scale acquisition and deployment of COVID-19 vaccines entails certain risks. There are several unknowns with regards to vaccine efficacy, durability of immunity, and potential adverse reactions. The first vaccines certified through the SRA mechanism may not be the most effective, nor purchased in a timely manner. A mass vaccination effort also stretches capacity, entailing risks. This is mitigated to some extent by using the COVAX Facility as a source of vaccines, which invests in a diverse and actively managed portfolio of candidate vaccines, thereby maximizing the probability of success. COVID-19 vaccine deployment will also be an unprecedented effort in terms of population coverage. The PforR will also focus on expanding immunization capacity, supporting the health system to implement a comprehensive (and sustainable) COVID-19 vaccine deployment strategy. The Bank and its partners will work with the country to consider trade-offs and to determine the appropriate approach and risk balance. The remaining risk must be considered against the risk of not deploying COVID-19 vaccines, or less timely and effective deployment of vaccines, potentially exacerbating development gaps and eroding past development gains. d. Institutional capacity for implementation: the magnitude of the pandemic; the uncertainty around vaccine efficacy, safety and availability; the challenges in providing technical assistance amidst limited mobility (both international and within the country); the need for contextual and technical expertise to support the development of necessary institutional frameworks to ensure the safe delivery of vaccines, are among the challenges that further stretch an already constrained immunization program. The PforR instrument will mitigate these risks by coordinating with other partners to organize appropriate technical assistance to support the development of policies, plans, and strategies for the safe and effective deployment of vaccines. Competition for vaccine purchasing will only increase once approved production commences and access to limited supplies may be difficult. However, the PforR supports financing of the payments to the COVAX Facility, allowing the Government to ensure equitable and affordable access to cost-effective vaccines for priority populations. e. Stakeholders: The main concern is that the GOI’s response does not meet the need of particular segments of the population, particularly poor, vulnerable, and remote populations. Mitigation measures will be proposed in the program action plan as well as DLIs aimed at improving communications. A critical intervention would be to identify and prioritize critical populations for the different phases of vaccine availability in a transparent way consistent with the WHO’s Fair Allocation Framework. In addition, 87.2 percent of the population identify as Muslim and reassurance that vaccines are classified as halal will prove crucial to the success of the vaccination effort and mitigation of vaccine hesitancy. The Indonesian Ulema Council – the country’s top clerical body – has also already declared the coronavirus vaccine halal. f. Other risks are rated High. Digitization of the immunization database and vaccine certification, while important from an implementation perspective, also carries risks related to data privacy. The GOI has assured the privacy protection of the database of the vaccine beneficiaries; provisions for personal data protection have been incorporated in the database with support from BSSN. The PAP for the original financing includes requirements on data privacy which will continue to be applicable to the AF and will help mitigate this risk. Further, there are integrated risks associated with the implementation of a large-scale national vaccination campaign with newly developed vaccines entails certain global risks which individual countries are not well-placed to mitigate. A mass vaccination effort in the context of this global pandemic may exacerbate the already stretched capacity. Further spread of the disease and the new variants may result in less effective deployment of the vaccine, potentially further enhancing development gaps and eroding past development gains. This risk will be mitigated through the implementation of the government’s vaccination strategy with clearly defined targeting measures and communication efforts. Expenditure Framework 14. The program boundary has increased at mid-term review, fueled by the rising number of COVID-19 cases and rising budget needs for detection and treatment. The AF expenditure framework will support: 15. Results Area 1: Improve hospital and health system readiness for COVID-19 response and vaccination and maintaining essential non-COVID-19 health services (IBRD AF US$245 million) Results Area 1 supports further strengthened health system readiness for COVID-19 response, including vaccination. This will include: • Specific additional measures to support and compensate health professionals for added COVID- 19-related workload and risk are implemented (Scaled up parent Program indicator); • Health facilities’ readiness for emergency response: 2,000 additional high care beds in existing medical facilities outside Jakarta are equipped to manage severe respiratory illnesses pursuant to the National Protocol (of which at least 50 percent are equipped with ventilators) (Scaled up parent Program indicator); • Use of public and private hospital capacity for free treatment of COVID-19 patients and improved timeliness of hospital claims payment; and • Maintaining unintended impact of COVID response on essential non-COVID health services: (i) Developed a deployment/mobilization plan for ongoing COVID-19 response and mass vaccination in a manner that preserves a share of staffing to maintain Essential Non-COVID Health and Nutrition Services; (ii) Essential Non-COVID Health and Nutrition Services are utilized at more than 90% of pre-COVID utilization. 16. Results Area 2: Strengthening public health laboratory, surveillance and supply chain capacity (IBRD AF US$136 million) With vaccine cold chain requirements, the need for temperature monitoring, and also pharmacovigilance systems needed in place, the scope of this expanded results area will include: • Assessing and planning actions to address gaps in supply chain and logistics for maintaining the cold chain for storage and distribution of vaccines: (i) Developing an action plan to address identified gaps in supply chain and logistics for maintaining the cold chain from points of entry to points of service for COVID-19 vaccines; (ii) Installing temperature monitoring devices in vaccine storage locations (not including Jakarta) and specifically: (a) Remote temperature monitoring is installed and functioning at the Province and district level; (b) Remote temperature monitoring is installed and functioning at the Puskesmas level; (c) End-to-end supply chain management and logistics information system is functional (at least for COVID-19 vaccines) and regularly in use; • Improving installed capacity of quality-assured COVID-19 confirmatory tests per day tested 1 person per 1000 population per week (including polymerase chain reaction (PCR), rapid molecular and rapid antigen tests) in the Additional Provinces; • Introducing Rapid Antigen Testing in all Provinces; • Undertaking regular genomic surveillance for variants of the COVID-19 virus; and • A pharmacovigilance system is in place to report adverse events in a timely manner: Developed and implemented a pharmacovigilance system to monitor any adverse events related to the COVID-19 vaccine. 17. Results Area 3: Enabling communication and coordination for emergency response and vaccine delivery (IBRD AF US$119 million) • Upgrade the public communication/information services for COVID-19 response and on vaccine deployment; • Develop an HR plan for the vaccination delivery. The plan should include capacity building/training plan, and training modules for HR for vaccine delivery; • Monitor the training of relevant HR for health engaged in the vaccine implementation including those at the subnational level (MOH received confirmation of training completion from districts. The vaccine prioritization plan for the first 20 percent of population includes health workers and elderly persons and generally follows WHO Strategic Advisory Group of Experts on Immunization (SAGE) and other guidance. It considers priority for vulnerable adult population with co- morbidities; it also includes a fair allocation for remote provinces with community transmission. The vaccine allocation plan across all provinces is done through a consultative and transparent process; • Ensure a communications strategy is in place, based on an assessment of vaccine hesitancy and mitigation measures planned to improve uptake, with appropriate cultural sensitivity and a focus on inclusion.  Results Framework and Monitoring and Evaluation Capacity 18. The Program’s progress toward achievement of the PDO and overall implementation progress were rated Satisfactory in the last Implementation Status and Results Report (ISR) of March 3, 2021, and the Program continues to display good progress, as was also assessed at the midterm review (MTR) conducted in October 2020. As of May 5, 2021, disbursements amounted to US$212.5 million or 85 percent of the IBRD financing (and an equal amount was disbursed from the AIIB’s co-financing as well). Overall, the PforR has made remarkable progress in the achievement of its DLIs at the midterm. The three prior results DLIs were reported as achieved by the end of July 2020. Of the remaining seven DLIs, DLIs 4–6 were verified as fully achieved, while DLI 7 is partially achieved. Even for the remaining DLIs 8–10, which are due in 2021, significant progress has been made already, and these are expected to be reported, verified, and disbursed by June 2021 (details of these DLIs are provided in the DLI matrix included in section IX on Results Framework and Monitoring). Achievement of DLIs are summarized in Table 4. 19. The PDO will remain largely unchanged; However, since the AF will finance the scale-up of program activities and new activities around COVID vaccine roll-out the results framework, theory of change, and disbursement linked indicators will be modified accordingly. The existing PDO level indicators will have one additional PDO indicator to reflect improved immunity at the population level measured by number of persons who have received free vaccination in accordance to the prioritization group. The target values of the PDO and intermediate results will be updated to account for the current achievements and extended duration of the program. (highlighted in blue in Figure 2 and Table 5). Table 4: Results achieved under parent project by DLI Disbursement DLI As per Notification As Confirmed by Task Team in USD DLI#1: Specific additional measures to DLR#1.1: Guidelines to provide support for health DLR#1.1 is achieved. 50,000,000 support and compensate health professionals in response to COVID-19 have been issued professionals for added COVID-19 related and benefits have started to be paid out. workload and risk are implemented DLI#2: MOH works closely in coordination DLR#2.1: The Government of Indonesia has: (i) set up a DLR#2.1 is achieved. 10,000,000 with the country's multi-sectoral National National Taskforce to accelerate emergency response to Task Force to Accelerate the Response to COVID-19 with a member of the MOH staff as Vice the COVID-19 Emergency Leader; and (ii) completed and issued a national plan in response to COVID-19 DLI#3: Increased capacity for patient DLR#3.1 and DLR#3.2 are isolation and medical care achieved. DLR #3.1: 1500 beds belonging to non- DLR#3.1: As of June 8, 2020, there are 2,391 inpatient 7,500,000 medical establishment(s) have been rooms with total of 6,011 beds in Tower 4, 6, and 7 at converted and suitably adapted to serve as RSD Kemayoran. temporary, low-intensity medical facilities DLR#3.2: The Ministry of Health has issued KMK 7,500,000 DLR #3.2: regarding Technical Guidelines for Claims for MOH has issued the MOH Guidelines on Reimbursement of Patient Care Costs for Certain Claims Reimbursement for different levels Emerging Infectious Diseases for Hospitals Organizing of severity of COVID-19 patients managed COVID-19 Services. in health facilities. DLI#4: Health facilities’ readiness for Based on data from RS Online as of September 28 and DLR #4.1 is achieved. 75,000,000 emergency response 29, 2020, there are currently 3,974 ICU beds with 708 beds equipped with ventilators. Meanwhile there are DLR #4.1: At least 3000 high care beds in 41,338 existing medical facilities are equipped to beds for COVID-19 isolation with 1,426 beds equipped manage severe respiratory illnesses with ventilators. pursuant to the National Protocol (of which at least 50% are equipped with ventilators) DLI#5: Strengthen the implementation of As of September 30, 2020: The number of PPE purchased DLR #5.1 is achieved. 20,000,000 optimal infection and control measures in consists of covers all of 4,712,400 pcs and N95 masks healthcare settings. totaling 1,0276,152 pcs. Of these, 4,366,039 pieces of DLR #5.1: At least 1,000,000 sets of cover all have been distributed and 863,780 pcs of N95 Personal Protective Equipment (PPE) have masks have been distributed. been procured and distributed by the Borrower. Reported achieved as of 07 May 2021 DLR 5.2 As of January 1, 2021 or later, at DLR 5.2 reported achieved 10,000,000 least 100,000 sets of Personal Protective Equipment (PPE) are available as reserves for future emergency needs. DLI#6: Protocols for infection prevention The Ministry of Health has published several protocols DLR #6.1 is achieved. 10,000,000 and clinical management of patients with related to COVID-19 that have been disseminated and respiratory symptoms. can be accessed by the public, including: - Protocol for the Prevention and Control of COVID-19 DLR #6.1: MOH has developed protocols for - Technical Guidelines for the Use of PPE in managing the infection prevention and clinical COVID-19 outbreak management of patients with respiratory - Waste management protocols in various types of symptoms and disseminated them to all medical facilities Non-Referral Facilities DLI#7: Installed capacity of quality-assured DLR #7.1: The Ministry of Health has established the 5th DLR #7.1 requires further Not achieved COVID-19 confirmatory tests per day revision of the Guidelines for Prevention and Control of discussion and evidence to COVID-19 (Chapter IV) which has mentioned the steps confirm that the external quality DLR #7.1: The Borrower has established taken in the context of Consolidating Laboratory Quality, assurance system was and maintained an external quality which includes mentioning that the laboratory should operational for the full lab assurance system for the entire installed conduct External Quality Consolidation (PME) or quality network. We propose to process capacity of COVID-19 confirmatory assurance according to the provisions stipulated. this separately for a timely Polymerase Chain Reaction (PCR) tests – determined by the Litbangkes Agency. confirmation of the remaining including MOH and non-MOH hospitals The Ministry of Health has issued a Decree of the achievements. authorized to carry out COVID-19 testing. Minister of Health (KMK) regarding the Establishment of a COVID-19 Examination Laboratory, which is DLR #7.2: The Borrower has made 350 updated with KMK regarding the COVID-19 Examination quality-assured rapid molecular testing Laboratory Network. machines regularly functional for DLR#7.2 is partially achieved, for 3,920,000 undertaking COVID-19 confirmatory tests. DLR #7.2: As of September 30, 2020, there are 98 28% of the scalable target. quality-assured rapid molecular testing machines regularly functional for undertaking COVID-19 confirmatory tests. Total 193,920,000 Authorized for Payment 183,920,000 Figure 2: Theory of change of the Additional Financing Table 5. Intermediate and PDO indicators, by results area (new AF indicators in blue) Results Areas   Intermediate Indicators  PDO Indicators  Improve hospital and health • Concrete measures to support and • Increased population system readiness for COVID compensate health professionals for added COVID- immunity to COVID-19, as response and vaccination, 19-related workload and risk are implemented  measured by number of and maintaining essential • Number of beds temporarily converted for persons who have non-COVID health services patient isolation and/or low-intensity medical care   received free vaccination in • Number of COVID-19 cases successfully accordance to the treated, disaggregated by sex   prioritization group  • Infection prevention and clinical • Reduced service management protocols developed and readiness gap in treating disseminated to all non-referral facilities   serious respiratory • Maintaining essential non- illness patients   COVID services – Number of completed fourth ANC services delivered in the previous quarter as a proportion to the corresponding quarter in 2019 Strengthening public health • Number of functional locations with remote • Strengthened laboratory, temperature monitoring system.  laboratory capacity   surveillance, and supply • Cumulative number of COVID-19 suspects • Improved chain systems  tested by PCR or rapid molecular testing, reporting and surveillance disaggregated by sex. system  • A surveillance mechanism for community- based reporting of outbreaks and new illnesses among humans and animals is functional  • Cumulative number of cases reported in the pharmacovigilance system Enable communication and • MOH supports the creation of a multisectoral • Enhanced coordination for emergency coordination mechanism for COVID-19 response  community engagement response and vaccine • MOH counters COVID-19 related and communication  delivery misinformation and posts on its website  • Cumulative number of cases MOH counters COVID-19 vaccine related misinformation and posts on its website  • Cumulative number of website visitors to the COVID-19 communication portal set up by the Government of Indonesia. 20. The Disbursement Linked Indicators for the AF reflect the Program’s results areas and involves the similar implementing units responsible for the Parent Program. DLIs related to the scale up of the COVID responses will continue to include the Director General (DG) of Health Services, the Board for Human Resource for Health. While for those related to the vaccine and surveillance, including pharmacovigilance, highlights the roles of the DG of Disease Control, especially the Surveillance Directorate, as well as the Center for Biomedics under the Institute of Health Research and Development. The Disbursement linked results to ensure the continuity of essential non-COVID services such as maternal health services, child immunization and nutrition outreach, and tuberculosis (TB) case detection and treatment, require multiple units coordination. This would include not only the respective programs but also health personnel deployment plan and monitoring. 21. The Program Implementation Unit was established under the parent project and is coordinating effectively. The program management structure and coordination mechanism were established with a Ministerial decree; this unit sits under the MOH’s Bureau of Planning. The management structure brings together various units responsible for DLI achievements and Program Action Plan (PAP) implementation. The same implementation arrangements will continue under the AF. 22. However, the parent project will have to be restructured to incorporate changes related to the AF. First, representation on the program implementation unit needs to expand to include the MOH’s immunization sub-directorate. MOH units responsible for the achievement of AF DLIs are listed in Table 6. Second, the PforR’s closing date needs to be extended to December 31, 2022 to reflect the GOI’s vaccine deployment schedule. Third, changes to target changes on the DLI/Rs related to strengthening health laboratory due to rapid expansion of the PCR diagnostic laboratory network, from 12 laboratories to more than 500 laboratories in the 12-month period (March 2020 – March 2021), and to introduce a new DLR (10.2) to accommodate the GOI expansion on testing and tracing as a key element of Surveillance. The DLIs will be updated to account for the current achievements and extended duration of the program as described above. Table 6. New DLIs under the AF Disbursement Linked Target including Disbursement Linked Results Baseline Notes/Formula Indicators Updated Target (1) DLI #1: Specific additional DLR #1.2: The Implementation Guidelines for 0 The policy to provide Value: US$ 40 million measures to support and Health Professionals’ Support for COVID-19 incentives and death Scalable/monthly payment: Unit Price: compensate health response remain in place and the payment of compensation is $3,333,333 per Calendar month in 2021 professionals for added COVID- benefits has been continued in FY 2021. continued for all that the Guidelines for Health 19 related workload and risk calendar quarters in Professionals’ Support remain in place and are implemented 2021. the payment of benefits has been continued. Responsible MOH units: The National Board for Human Resource for Health Empowerment and Use (Badan PPSDM) (3) DLI #3: Increased capacity DLR #3.3: At least 90% of hospital claim 0 More than 90% for Value US$ 10 million (Unit Price: for patient isolation and payments received by the hospital within 10 each quarter $2,500,000 for every calendar quarter of medical care working days after receiving the verified claims 2021 that the Target is met. for treating COVID-19 cases in each calendar quarter of 2021. Target: at least 90% of hospitals treating COVID-19 patients have received claim payment within 10 working days of submitting claims MOH Unit: DG Health Services (Referral Unit) Value US$ 60 million. Scalable. Unit Price: DLR # 3.4: Number of COVID-19 patients with 200,000 $300 for each claim paid for COVID-19 moderate to severe illnesses that receive 0 patients receiving free hospital treatment, hospitalization and have their claims paid for up to the Target. by the MOH, on or after the date of signature of this Agreement. Disbursement Linked Target including Disbursement Linked Results Baseline Notes/Formula Indicators Updated Target MOH Unit: DG Health Services (Referral Unit) (4) DLI #4: Health facilities’ DLR #4.2: 2000 additional high care beds in 0 in May 2020 2,000 new beds over Scalable; Value: U$ 50 million readiness for emergency existing medical facilities outside Jakarta are and above the current Current value is Unit Price: $25,000 per high care bed fully response equipped to manage severe respiratory achievement. 2,355 equipped pursuant to the National illnesses pursuant to the National Protocol (of Protocol, up to which at least 50% are equipped with ventilators) 2,000 new beds over and above the Baseline. Current value: 2,355 is the # of high care beds outside of Jakarta 2020 MOH Unit: DG Health Services (Referral Unit) (7) DLI #7: Installed capacity of DLR 7.3 Borrower has tested 1 person per 1000 5 Provinces 20 Provinces Total value: US$ 45 million quality-assured COVID-19 population per week (including polymerase Scalable, Unit Price: confirmatory tests per day chain reaction (PCR), rapid molecular and rapid antigen tests) in the Additional Provinces. $3,000,000 per Additional Province beyond the baseline where 1 person per 1000 population per week is tested up to the Target. Target: 15 Additional Provinces Note: The five provinces as the baseline; DKI Jakarta, Daerah Istimewa (DI) Yogyakarta, Kalimantan Timur, Kalimantan Selatan, Kalimantan Utara. MOH Units: DG Disease Control and the National Institute for Health Research Disbursement Linked Target including Disbursement Linked Results Baseline Notes/Formula Indicators Updated Target DLR 7.4 The Borrower has introduced Rapid 0 provinces 34 provinces Value US$ 51 million; Scalable. Antigen Testing in all Provinces. Unit Price: $1,500,000 per Province that has completed the first 10,000 Rapid Antigen Testing up to the Target. MOH Unit: DG Disease Control (Directorate Surveillance and Health Quarantine) DLR 7.5 The Borrower is undertaking regular 0 At least 300 samples Value US$ 15 million; Scalable: genomic surveillance for variants of the COVID- for every calendar Unit Price: $5,000,000 per calendar 19 virus. semester from January semester in which at least 300 samples are 2021 to June 2022. tested for genomic variants of the COVID- 19 virus during the Target period. Target: January 2021 to June 2022 MOH Unit: The National Institute for Health Research (9) DLI # 9 Communications DLR # 9.2 By no later than September 30, 2021, 0 COVID-19 vaccine- Value: US$ 10 million. strategy on COVID-19 based on MOH has updated the communication strategy related update to the MOH Unit : DG Community Health experience and lessons-learned for information on COVID-19 vaccines, their MOH communication (Directorate Health Promotion) rollout, eligibility, and grievance redress as well strategy is available as adverse event information (11) DLI # 11 Assess and plan DLR 11.1 By no later than July 30, 2021, the 0 Cold chain action plan Value: US$ 10 million actions to address gaps in Borrower has developed an action plan to is developed and MOH Unit: DG Disease Control (Directorate supply chain and logistics for address identified gaps in supply chain and under Surveillance and Health Quarantine) maintaining the cold chain for logistics for maintaining the cold chain from implementation. storage and distribution of points of entry to points of service for COVID- COVID-19 vaccines 19 vaccines. Disbursement Linked Target including Disbursement Linked Results Baseline Notes/Formula Indicators Updated Target DLR 11.2 The Borrower has deployed remote 0 a) Remote DLR #11.2 Value: US$ 45 million. temperature monitoring devices in vaccine temperature storage locations (not including Jakarta) and monitoring is specifically: installed and DLR #11.2 (a) Unit Price: functioning at (i) the (a) remote temperature monitoring is installed provincial and district $150,000 for each percentage point of and functioning at the Province and district level for all identified Identified Districts where remote level; temperature monitoring is installed and districts; functioning at the Province and district level; (b) remote temperature monitoring is installed b) Remote and functioning at the Puskesmas level; temperature monitoring is DLR #11.2(b): $15,000,000 installed and (c) end to end supply chain management and Unit Price: $150,000 for each percentage functioning at the logistics information system is functional point of Identified Districts where remote Puskesmas level in all (at least for COVID-19 vaccines) and temperature monitoring is installed and identified districts. regularly in use in 2000 Puskesmas up to functioning at the Puskesmas up to the March 31, 2022. Target. c) End-to-end Target: all Identified Districts supply chain management and logistics information DLR #11.2(c): $15,000,000 system is functional (at least for COVID-19 Unit Price: $7,500 per puskesmas where vaccines) and end-to-end supply chain management and regularly in use in up logistics information system is functional (at to 2,000 Puskesmas least for COVID-19 vaccines) and regularly locations as of 31st in use, as of March 31, 2022. March 2022. Disbursement Linked Target including Disbursement Linked Results Baseline Notes/Formula Indicators Updated Target MOH Unit: DG Disease Control (Directorate Surveillance and Health Quarantine) (12) DLI #12 Human Resource DLR 12.1 By no later than July 30, 2021, the 0 HR Mobilization plan Value: US$ 10 million. Capacity Building and Managing Borrower has developed a that preserves MOH Unit: DG Disease Control (Directorate unintended impact of COVID deployment/mobilization plan for ongoing essential services, is Surveillance and Health Quarantine) and response on essential non- COVID-19 response and mass vaccination in a developed and other relevant units within MOH COVID health services manner that preserves a share of staffing to implemented maintain Essential Non-COVID Health and Nutrition Services. DLR 12.2 The Borrower has confirmed that No MOH has received Value: US$ 20 million; Scalable. appropriate capacity building/ training of confirmation of Unit Price: $40,000 per district that has human resources for COVID-19 vaccine delivery training completion confirmed that appropriate capacity has been carried out. for all districts building/training of human resources for implementing COVID- COVID-19 vaccine delivery has been carried 19 vaccination. out up to the Target. Target: 500 districts MOH Unit: The Board for Human Resource Planning and Use (Badan PPSDM), The Center for Health Workforce Training, and relevant units responsible for the essential health service) DLR 12.3 Essential Non-COVID Health and 0 Targets for each Value: US$ 69 million Nutrition Services are utilized at more than program will be based Scalable; Unit Price: $3,000,000 per 90% of pre-COVID utilization. on individual program calendar quarter for each program performance in 2019. achieving the Target in each quarter between April 2021 and June 2022. Disbursement Linked Target including Disbursement Linked Results Baseline Notes/Formula Indicators Updated Target (2019 Target: program is utilized at more than performance) 90% of pre-COVID utilization, with the exception of the treatment coverage of TB Programs & program (=> 82% than 2019, or not lower Indicators** than 55%) Programs & Indicators Maternal Maternal - K4 visits MOH Units: DG Community Health (Dit 84.6% - K4 complete visits Family Health and Dit Nutrition); DG (KOMDAT/ - Facility based Communicable Diseases (Dit Surveillance Program delivery and Health Quarantine, and Dit Directly reporting) Nutrition Transmissible Diseases – the National TB - Facility Program); Under the coordination of Monthly Growth based delivery Secretary General Ministry of Health Monitoring of Children 83.15% Under 5 (KOMDAT, Program) TB Nutrition Case Notification Under 5s Immunization monthly Pentavalent (3rd dose) weighing 73.6% (Program reporting) TB Case notification 67% (Program reporting) Immunization Disbursement Linked Target including Disbursement Linked Results Baseline Notes/Formula Indicators Updated Target Pentavalent (3rd dose) coverage (Program reporting) (13) DLI #13 Vaccine DLR 13.1. The Borrower has developed fair and 0. Vaccine prioritization Value: US$ 25 million prioritization and distribution is equitable criteria for prioritization and and distribution based on pre-determined, fair distribution of COVID-19 vaccines across its criteria are developed, and objective criteria. geographical areas through a consultative and made publicly DLR 13.1 Criteria developed and made transparent process. available, and COVID- publicly available: US$5 million 19 vaccines deployment and DLR 13.2 As of September 30, 2021, the distribution has COVID-19 vaccines distribution has DLR 13.2 As of September 30, 2021, the conformed to the conformed to the above criteria: US$10 prioritization, deployment and distribution of criteria million COVID-19 vaccines has conformed to the fair and equitable criteria referred to in DLR #13.1. DLR 13.3 As of December 31, 2021, the COVID-19 vaccines distribution has conformed to the above criteria: US$ 10 DLR 13.3 As of December 31, 2021, the million prioritization, deployment and distribution of MOH Unit: DG Disease Control (Directorate COVID-19 vaccines has conformed to the fair Surveillance and Health Quarantine) and equitable criteria referred to in DLR #13.1 (14) DLI #14 A DLR #14.1 The Borrower has developed and 0 Value: US$ 10 million pharmacovigilance system is in implemented a pharmacovigilance system to The system has the ability to track the exact place to report adverse events monitor any adverse events related to the batch of COVID-19 vaccine in a timely manner COVID-19 vaccine(s). Pharmacovigilance system is developed Disbursement Linked Target including Disbursement Linked Results Baseline Notes/Formula Indicators Updated Target The pharmacovigilance Value: US$ 15 million system is developed DLR #14.2 As of September 30, 2021, the and is providing As of September 30, 2021, the system is pharmacovigilance system has been regular reports. functioning and able to track exact batch of 0 implemented and is functioning in accordance COVID-19 vaccines given to beneficiaries with the ITAGI Guidance, to monitor any adverse events related to the Program COVID- 19 vaccine. Value: US$ 15 million DLR# 14.3 As of March 30, 2022, the As of March 30, 2022, the system is pharmacovigilance system has been functioning and able to track exact batch of implemented and is functioning in accordance COVID-19 vaccines given to beneficiaries with the ITAGI Guidance, to monitor any adverse events related to the COVID-19 MOH Unit: DG Disease Control (Directorate vaccine. Surveillance and Health Quarantine) Economic Justification 23. The economic rationale for investment in a COVID-19 vaccine is strong, considering the massive economic losses due to the pandemic. The Indonesian economy is expected to shrink by 1.5 percent in 20219. The COVID-19 crisis is also expected to result in a sharp increase in poverty. Preliminary projections indicate an additional 8 million individuals will either be unemployed or impoverished in Indonesia. Unemployment in Indonesia is expected to rise to 7.5 percent in 2020, up from 5.3 percent in 2019 – implying an additional 3 million projected to be unemployed. In addition, declining economic growth is projected to push an additional 5 million below the poverty line. However, the successful development, production, and delivery of a vaccine has the best potential to reverse these trends, generating benefits that will far exceed vaccine-related costs. A rapid and well-targeted deployment of a COVID-19 vaccine can help reduce the increases in poverty and accelerate economic recovery – even at levels of imperfect effectiveness. By one estimate, delaying access to vaccination by just six months will cost the economy US$44 billion or 4.1% of GDP. 24. There are also traditional economic arguments for investment in vaccines to contain communicable diseases. First, they are generally considered merit goods that have positive externalities that extend beyond the select group who can afford to pay for them. Second, the risk and uncertainty of falling ill to COVID-19, a partial and/or lengthy recovery, or death exposes individuals to potentially ruinous medical expenditures and loss of earnings during extended sick days. 25. Beyond the economic arguments, vaccinations will also significantly reduce morbidity and mortality from COVID-19. As of May 8, 2021, Indonesia confirmed 1,718,575 confirmed cases and cases and 47,218 deaths from COVID-19 – the largest burden of COVID-19 in the East Asia Pacific region. While the efficacy of the various vaccines under production remains a clinical unknown, global experience shows that vaccines significantly reduce or even eliminate the threat of morbidity and mortality from disease. Using conservative estimates of COVID prevalence between 5-10 percent, a case fatality rate of 3 percent, and a vaccine efficacy rate of 75 percent, between 300-600 thousand deaths could be averted – more if the prevalence rate for the Indonesia is determined to be higher. 26. A simplified cost-benefit analysis suggests that a COVID-19 vaccination programs will generate a positive cost to benefit ratio making the support provided by this PforR a good investment. Assuming the value of a statistical life saved is  approximated to be three times Indonesia’s GDP per capita – US$4,136 in 2019 – and that individuals saved have 10 years of remaining working life, the total benefit from vaccinating  the target populations (~68 percent of population) is roughly estimated to be over US$270 billion. Using an estimated cost of vaccination of US$10 per person, this yields a benefit to cost ratio of 149. This is also a gross underestimate as it only considers the benefits from deaths averted – not the benefits from the cost of illness, nor the economic impact of sustained 9 These estimates are based on the latest data from the IMF’s World Economic Outlook update. closures. Global experience with immunization against diseases shows that by avoiding these and other health cost, vaccines are one of the best buys in public health. Program Boundaries DLI/ IDR US$ DLR PROGRAM MANAGEMENT SUPPORT 001 Dissemination of DLI Information for 9/DLR Health 20,237,743 1,432,534 9.2 Development Policy 002 Public Communication DLI SECRETARIAT Strategy and 9/DLR GENERAL 2,622,080 185,605 Public Opinion 9.2 Management 003 Information DLI Services and 9/DLR Contact Centre 1,365,660 96,669 9.2 'Halo Kemenkes' 004 Development of Public DLI Communication 9/DLR 809,090 57,272 and Information 9.2 Management DLI Community 12/DLR Nutrition Program 750,231,553 53,105,354 12.1; 12.3 DIRECTORATE DLI GENERAL Family Health 12/DLR COMMUNITY Program 350,655,991 24,821,284 12.1; HEALTH 12.3 Health DLI Promotion and 12/DLR Community 256,614,892 18,164,558 12.1; Empowerment 12.3 DIRECTORATE GENERAL Health Service DLI 3; HEALTH Delivery DLI SERVICES Facilities 671,416,495 47,526,408 4/DLR 3.3; 3.4; DLR 4.2 Referral Health Servvices Norms, DLI 3; Standards, and DLI Criteria for Health 4/DLR 1,021,361 72,297 Service Delivery 3.3; 3.4; and Management DLR 4.2 DLI 3; Support for DLI Vertical 31,059,551,3 2,198,559,1 4/DLR Health 75 92 3.3; 3.4; Facilities DLR 4.2 Management Support for DLI 11; Disease DLI 12; Control and 979,413,102 69,328,035 DLI 13; Prevention DLI 14 Programs Surveillance and Health Quarantine Standards and Management of DLI 11; Prevention and DLI 12; 2,703,247,63 Control of 191,350,154 DLI 13; DIRECTORATE 7 Outbreak DLI 14 GENERAL Potential Diseases DISEASE PREVENTION Standards and DLI 11; AND CONTROL Management of DLI 12; New Emerging 622,942 44,095 DLI 13; Diseases DLI 14 AEFI Surveillance DLI 11; (Adverse Events DLI 12; Following 2,017,312 142,796 DLI 13; Immunization) DLI 14 Surveillance and DLI 11; Early Detection of DLI 12; New Emerging 408,134 28,890 DLI 13; Diseases DLI 14 Prention and Control of Directly Tranmissible Diseases Coordination and DLI Implementation 12/DLR of TB Prevention 3,686,444 260,946 12.3 and Control Improvement of Supervision for Medical DevIces and Medical Supplies Additional essential DIRECTORATE pharmaceuticals GENERAL (essential drugs, PHARMACEUTIC vaccines, AL SERVICES 772,546,032 54,684,891 supplies) AND MEDICAL including buffer DEVICES during COVID-19 pandemic Distribution of DLI 11; 3,102,299,24 Vaccine 219,597,136 DLI 14 1 COVID-19 Vaccine 10,355,668,9 733,028,978 Acquisition 62 Research and Development of Laboratories and NATIONAL Biotechnology INSTITUTE FOR DLI 001 Laboratory HEALTH 7/DLR Infrastructure and RESEARCH AND 13,139,530 930,085 7.3; 7.4; Equipment DEVELOPMENT 7.5 DLI 002 Laboratory 7/DLR 4,720,384,58 Supplies 334,133,768 7.3; 7.4; 8 7.5 BOARD FOR Management DLI PLANNING AND Support for 7,266,554,86 1/DLR EMPOWERMEN Human 514,365,156 T OF HUMAN 7 1.2 Resource for RESOURCE FOR Health HEALTH Development, Planning, and Empowermen t Human Resource for Health Training Development of Capacity Building Standards (Norms, DLI 2 28,324,324 2,004,945 Standards, Protocol, and Criteria) 038 Training for DLI 2 COVID-19 4,484,613 317,445