Document of The World Bank Report No. 15118-IND STAFF APPRAISAL REPORT INDONESIA HIV/AIDS AND STDs PREVENTION AND MANAGEMENT PROJECT January 31, 1996 East Asia and Pacific Regional Office Country Department III Population and Human Resources Division CURRENCY EQUIVALENTS (as of November 1995) Currency Unit = Rupiah (Rp) US$1.00 = Rp 2,246 Rp I million = US$445 FISCAL YEAR ABBREVIATIONS, ACRONYMS AND DEFINITIONS AIDS Acquired Immune Deficiency Syndrome AusAID Australian Agency for International Development AZT Azidothymidine (also known as zidovudine), an antiretroviral drug used to slow progression of AIDS Bappenas National Development Planning Board Bupati Chief district administrator CAS Country Assistance Strategy CDC/EH Communicable Disease Control and Environmental Health DG Director General Dinas Provincial Health Service DIP Development budget ELISA Enzyme-linked Immunosorbet Assay GOI Government of Indonesia GPA Global Program on AIDS HAPP HIV/AIDS Prevention Project HIV Human Immunodeficiency Virus ICB International Competitive Bidding iwg-AIDS model Epidemiological projection model Kakanwil Head of the Provincial Office of Ministry of Health KEPRI Kepulauan Riau district in Riau province KfW Kreditanstalt fur Wiederaufban Lokalisasi Regulated brothel complex MOH Ministry of Health NAC National AIDS Commission NCB National Competitive Bidding NGO Non-governmental organization O&M Operations and maintenance PAC Provincial AIDS Commission PIU Project implementation unit STDs Sexually transmitted diseases USAID United States Agency for International Development Wali kota Mayor WHO World Health Organization WTP Willingness to pay INDONESIA HIV/AIDS AND STDS PREVENTION AND MANAGEMENT PROJECT LOAN AND PROJECT SUMMARY Borrower: Republic of Indonesia Implementing Agency: Ministry of Health Poverty Category: Not applicable Amount: US$24.8 million Terms: Standard amortization term, grace period and interest rate for fixed rate US dollar, single currency loans with an expected disbursement period of 3-6 years. Commitment Fee: 0.75 percent of undisbursed loan balances, beginning 60 days after signing, less any waiver. Financing Plan: The proposed Bank loan, US$24.8 million, would cover about 70 percent of the total cost, US$35.2 million equivalent; the Government would finance the remaining cost, US$10.4 million equivalent. Economic Rate of Return: Net present value calculated for major component Staff Appraisal Report: No. 15118-IND Project Identification No.: ID-PE-39643  - 1i - CONTENTS 1. BACKGROUND, ISSUES AND STRATEGY .........................................................1 Sexually Transmitted Diseases in Indonesia. ....................I The Advent of HIV in Indonesia............................2 Some Regional Dimensions ...................................3 Economic and Welfare Implications ..........................5 The Government's Strategy and Key Design Issues ...... .........9 2. PAST AND PROSPECTIVE BANK INVOLVEMENT.....................................15 Lessons from World Bank Projects and Other Initiatives...................... 15 Bank Strategy and Rationale for Involvement ....... ...........16 3. THE PROJECT ....................................................................................................... 19 Project Objectives ..................9..... .............19 Project Components ...................................22 Project Description....................................23 Project Management and Implementation. ............. ........27 4. PROJECT COSTS AND FINANCING ...............................................................31 Costs .......................... ...................31 Financing..........................................34 Procurement ................................ ............35 Procurement Review ...................................37 Disbursement .........................................40 Accounts, Audits and Reports...............................41 5. PROJECT BENEFITS AND RISKS ...................................................................43 Program Goals and Potential Benefits.......................43 Risks.............................................44 Sensitivity Analysis ...................... .............45 Environmental Impact.................... ..............45 Implications for Women .................................45 Poverty Impact.......................................46 Sustainability .................................46 6. AGREEMENTS REACHED AND RECOMMENDATION...............................47 BIBLIOGRAPHY .................................................................................................. 49 This project is based on the findings of a July, 1995 pre-appraisal mission comprised of S. Lieberman (Task Manager) and F. Saadah, and an October, 1995 appraisal mission made up of S. Lieberman, F. Saadah, N. Mattson and E. Iswandi. F. Saadah led the October, 1994 identification mission, while S. Lieberman and F. Saadah visited Indonesia in February 1995 for project preparation. During the project development, significant assistance was provided by the following JGF-funded consultants -- K. Parker, L. Gelmon, N. Constantine, M. Moore, C. Campbell, M. Linnan, and J. Moran -- who worked closely with the Ministry of Health preparation team. Tracee Williams handled the processing and production of this report in every respect. This project has been endorsed by Marianne Haug (Director). - Iii - A NN EXES ........................................................................................................................ 51 1: Treatment Costs.................. ..................... .....53 2: The Syndromic Approach to STD Diagnosis and Treatment. ...............55 3: Donors Funding AIDS-Related Activities, 1996-2000 ...................57 4: Monitoring and Evaluation.....................................58 5: Project Implementation Plan ..............................66 6: Proposed Technical Assistance .......................... .........79 7: Supervision Plan.......................................83 8: Cost Tables........................ ................ 84 9: Estimated Schedule of Disbursements .......................86 10: Procurement Plan: Contracting and Review Responsibilities ..............87 11: Economic Analysis of AIDS Expenditures...........................88 TABLES IN TEXT Table 3.1: Designated Performance Indicators ....................... ......20 Table 4.1a: Summary of Project Costs by Component by Province (US$ million) .........31 Table 4.lb: Project Cost Summary .......................................32 Table 4.2a: Summary of Project Costs by Category of Expenditures by Province (US$ million)....................................................33 Table 4.2b: Project Cost Summary ........................... .........33 Table 4.3: Financing Plan (US$ million) ................................36 Table 4.4: Procurement Arrangements (US$ million)......... ................39 MAP .................................................. IBRD 27707 -1- 1. BACKGROUND, ISSUES AND STRATEGY Sexually Transmitted Diseases in Indonesia 1.1 Sexually transmitted diseases (STDs) were a major public health concern in Indonesia in the late colonial period and in the first several decades following Independence. The increasing number of cases led to the establishment in Surabaya of a special institute within the Ministry of Health (MOH) to address STD-related issues. This institute carried out prevention, control and research activities, including provision of weekly penicillin injections to prostitutes working in recognized brothel complexes.2 Thanks to improved antibiotics and persistent efforts, including the mass prevention and treatment program for brothel workers, the incidence of syphilis fell in the 1970s. 1.2 Along with the decline in incidence rates for syphilis came a lessening of interest in and support for STD services. The central MOH budget for STD-related activities fell sharply. Central support for the mass treatment of syphilis was terminated in 1987, and during the 1987/88-1989/90 interval, no funds were allocated for the subdirectorate covering STDs within the overall communicable diseases directorate. Budgetary restrictions and shifting priorities took their toll on different aspects of the STDs program. For example, STD surveillance and efforts eroded; there was a reduction in research on epidemiological and clinical issues including antibiotic sensitivity and resistance patterns; health workers' awareness of and ability to diagnose and treat STDs were suspect; and laboratories were unprepared to test for and identify STD cases. 1.3 This situation has persisted despite growing indications that STDs are present in high rates within large segments of the Indonesian population. Such evidence is not comprehensive and systematic, due to the limited coverage and reliability of the existing passive surveillance mechanism which relies on routine reports from government hospitals, laboratories and clinics. Among other things, this system refers only to syphilis and gonorrhea and fails to cover numerous other STDs which may be present. The passive system is also unable to document the very large share of STD cases seen by One study estimated that 1.5% of the population of Surabaya suffered from infectious syphilis; other studies pointed to very high STD prevalence rates among pregnant women, soldiers and the urban population overall. 2 Beginning in 1957, a weekly injection of 2 ml of penicillin aluminium monostearate was given to brothel workers in Surabaya. In 1967, the amount given was increased to 3 ml since many workers were skipping injections and not maintaining the required blood level. This program created a public impression that regular injections were a guarantee of the good health of prostitutes (Jones, et. al., 1994) -2- private practitioners and diagnosed and tested through private laboratories, or which are self-treated, sometimes with antibiotics purchased in pharmacies. 1.4 Indonesia's sentinel surveillance mechanisms for STDs, which ideally would include a range of special surveys, longitudinal studies and other active reporting arrangements are also inadequate. Nevertheless, available information suggests ample grounds for concern. The most reliable findings, based on information collected in Surabaya in 1992 and 1993, relates to sex workers and their clients, as well as several occupations thought to make extensive use of sex industry services and a sample of antenatal clinic clients (Linnan and Surabaya STD Study Group, 1995). STD infection rates were high in all of the groups surveyed. For instance, 39 percent of the 1925 sex workers who were tested had at least one STD, and 28 percent had two or more infections; 22 percent of the clients of sex workers had an STD; and 18 percent of the sample (599 women) of antenatal clinic visitors had an STD. The high rates for sex workers were consistent with findings from small surveys of prostitutes and transvestites carried out in the same period in Jakarta and Batam. What is of special note are the high infection rates found among groups, e.g., pregnant women visiting antenatal clinics, truckers, sailors and construction workers, drawn from and arguably representative of the general population not only in Surabaya but elsewhere in urban Java. Based on such findings, the study concludes that prevalence rates for any one STD vary between two and five percent within the sexually active population (ages 15-60). The Advent of HIV in Indonesia 1.5 The low priority attached to STDs as public health concerns has begun to change, largely because of the arrival in Indonesia of the human immunodeficiency virus (HIV) which is the causative agent for the deadly Acquired Immune Deficiency Syndrome (AIDS). HIV can be transmitted through blood transfusion, intravenous needle sharing, vertical (mother-fetus and mother-child) channels, and through other means. However, the main transmission route, accounting for over 95 percent of known cases in Indonesia and similar proportions in most other countries, is through unprotected sexual activity. HIV is a new, complex and dangerous STD, and as such, interactions between HIV and other STDs are of special concern since the presence of a conventional STD can facilitate transmission of HIV, and hasten the onset and increase the severity of the symptoms and complications experienced by those who are HIV seropositive (Wasserheit,1991). This link is clearest between HIV and those STDs that cause genital ulcers, e.g., chancroid and syphilis. Other STDs such as chlamydia, gonorrhea and trichomoniasis can increase the risk of HIV transmission as well through genital inflammation (which raises the white blood cell count and causes microscopic cuts). On the other hand, infection with HIV is conducive to the acquisition of other STDs, prolongs their infectiousness and makes them more resistant to standard treatment. 1.6 HIV was first diagnosed in Indonesia in 1987, though the arrival and initial transmission of the virus may have occurred as early as 1984. As of December 1995, 364 HIV cases had been documented through MOH's passive reporting system. Over a -3- third of these individuals lived in Jakarta and adjacent urban areas with another 23 percent of the cases located elsewhere in Java and Bali. So far, HIV victims have been identified in fifteen of the country's 27 provinces and in all of the major islands except for Sulawesi. 1.7 However, these figures have many questionable features. For instance, the high ratios of males to females among individuals with HIV and of AIDS victims to all HIV cases are uncharacteristic of the epidemic in other countries and point to a significant undercount. Similarly, the median white blood cell count for those with HIV is at the low level typical of those who have had the disease for five or more years, while the average age of reported HIV cases, 30.2 years, is high compared to other countries. In the HIV epidemic elsewhere, transmission has hit mainly those in the 15-25 age interval. The exclusion from the regular reporting system of vulnerable groups such as the military needs be noted as well. 1.8 Also pointing to underenumeration of HIV cases are various features of the Indonesian social and economic scene. As in neighboring countries, rapid economic growth has brought changing employment patterns and increased migration to urban areas and to special economic zones. Employment shifts and geographic and social mobility have raised demand for commercial sexual services and increased exposure to STDs and HIV. The commercial sex industry appears to be expanding, in part because of rising tourism, but also due to heightened demand from local clients. A second risk factor is the increased number of Indonesians who have been visiting neighboring countries such as Thailand and Australia which are further advanced in the HIV epidemic. A third factor may be transmission of HIV through drug use by injection. There appears to be less intravenous drug use in Indonesia than in Thailand or Australia. Nevertheless, such behavior may spread HIV in some subgroups which are not covered by existing reporting arrangements. 1.9 In short, it appears that most HIV cases are not being enumerated by existing routine and still limited active surveillance mechanisms. Accordingly, the actual number of Indonesians who are HIV seropositive is probably far higher than the reported figure, though the size of the undercount cannot be determined with precision. Some Regional Dimensions 1.10 Jakarta. The scale and imminence of the HIV epidemic very likely vary by region. As mentioned, Jakarta accounts for a third of Indonesia's reported HIV cases. This is not surprising since the country's capital has characteristics that heighten the population's exposure to HIV. Jakarta's vulnerability to HIV derives from the large inflows to the area of temporary visitors, e.g., tourists, businessmen, truckers, sailors, and so forth; students and migrant workers; the large formal and informal industry and A 1994 study of high risk behavior in metropolitan Surabaya concluded there were at least 2500 intravenous drug users in that metropolitan area alone (Linnan, et. al., 1995). -4- service sectors that have developed; and from the extensive and flourishing commercial sex industry that serves the metropolitan region. 1.11 Greater Jaka, with an estimated population of 9 million in 1990, includes Jakarta itself (1990 population, 8.2 million) and the contiguous cities of Bogor, Bekasi and Tangerang (combined 1990 population 800,000). The sexually active population in this urban region was an estimated 5.4 million in 1990. Although exact data do not exist, recent studies suggest there may be 20,000-40,000 individuals in this region earning income as sex workers (Jones, et. al. 1994). The commercial sex industry caters to a wide range of lower, middle and upper income customers, and includes a range of service locations and considerable diversity among service providers. For instance, there are recognized and regulated brothel complexes (lokalisasi) such as Kramat Tunggak in Tanjung Priok in North Jakarta which are typically visited by lower and middle income clients . In addition, there are other places where sexual transactions and activities occur including smaller brothel complexes, massage parlors, and single unit brothel houses. There are also numerous sites--nightclubs, discotheques, bars, hotel lobbies, beauty salons-- which provide a venue for sexual transactions. Finally, there are many call girls and streetwalkers working as independent operators. Sex workers vary in their provincial origins, educational and media characteristics, access to health information and facilities and in their bargaining position vis a vis clients. 1.12 As discussed, surveys point to very high STD infection rates among commercial sex workers. Rapid assessments conducted as part of project preparation suggest that some of these individuals, particularly those working in lokalisasi, are informed to some extent about conventional STDs as an occupational hazard, and believe they know how to prevent infections and respond to symptoms. However, the health remedies sought are typically delayed and suboptimal, while condom use is not widely practiced by such commercial sex workers. Awareness of STD risks and counteracting behavior were less evident outside the lokalisasi complexes. 1.13 The high STD infection rates in Jakarta are of concern because of the associated risks of acquiring and transmitting HIV. As with the national level total, the reported, cumulative HIV figure for Jakarta, 118 through October 1995, appears to underestimate substantially the actual count. The iwg-AIDS projection model was used to estimate current and future numbers of HIV and AIDS cases in Jakarta through the year 2010.4 The realistic standard scenario explored through this model puts the number of HIV seropositives at 2500 in 1993 and 8500 in 1995, and anticipates an increase to 42,500 in 2000, 75,500 in 2005 and 140,000 in 2010. In this projection, the number of individuals with AIDS rises from 3800 in 2000 to 8,500 in 2005 and 17,500 in 2010. The iwg-AIDS model determines the number infected within key subgroups and then aggregates these to obtain population-level estimates. Needed parameters were drawn from available surveys of commercial sex workers and through a Delphian process with a panel of Indonesian experts (see Kosen and Linnan, 1994, and Annex II on Economic Analysis of AIDS Expenditures). The estimates reported here were derived by Dr. M. Linnan, Centers for Disease Control, Atlanta. -5- 1.14 Riau province. Another area of concern comprises Batam, Tanjung Pinang and several other sites in Riau province. Batam, Tanjung Pinang, the capital city of Kepulauan Riau (KEPRI) district, and adjacent areas in this district are part of a policy- stimulated growth triangle which also includes Singapore and Johore in Malaysia. Batam's population grew from 6000 in 1973 to 168,000 in 1995 and is expected to continue to rise at a rapid pace. KEPRI district has grown more slowly--its population increased from 422,712 in 1980 to 477,700 in 1995, but is expected to expand at a quickening pace as a result of close ties to Batam and Singapore. Pekanbaru city and Bengkalis, Kampar and other districts have grown less rapidly, but are still vulnerable to the epidemic. 1.15 Batam has emerged as an industrial, tourist and entertainment center. Nearly 64 percent of the labor force is employed in the different manufacturing firms which have been attracted to the island by tax, tariff and other incentives. Women account for over 60 percent of the industrial workforce and roughly 44 percent of island's working population. Anther part of Batam's growth is due to its hotel and tourist services. Nearly 900,000 people, many tourists from nearby Singapore, visited the island in 1994, as compared to 60,000 in 1985 and 579,000 in 1990. During the late 1980s and early 1990s, the sex industry expanded rapidly at Batam, thanks to restrictions in Singapore and Malaysia and a growing inflow of relatively foreign and Indonesian businessmen, industrial workers, sailors, and others. Currently, there are an estimated 3000 or more women working in Batam's highly differentiated commercial sex sector. 1.16 There is a comparable concentration of entertainment services and commercial sex workers in KEPRI district adjacent to Batam and in reach of Singapore, Malaysia and even Thailand. In particular, there are nine subdistricts in this district, including East and West Tanjung Pinang, North and East Bintan. Singkep, Siantan, Moro, Karimum and Kundur, with entertainment establishments catering to tourists, soldiers and sailors, Thai fishermen and businessmen. There are an estimated 1500- 2000 commercial sex workers in these areas. 1.17 The above factors have made Batam and KEPRI very susceptible to STDs and the HIV epidemic. Local health authorities reported six HIV infected persons in Batam and eight in KEPRI, and 29 for Riau province overall in December 1995. Of special concern are the high turnover rates of those employed as commercial sex workers in the two areas and as laborers in Batam's industrial estates and the large number of transient tourists, sailors, truckers, and so forth--the region may become a site which transmits HIV to other parts of Indonesia and Southeast Asia. Economic and Welfare Implications 1.18 Conventional STDs can cause serious complications, and can result in chronic ill- health and death. Typically, infections in men cause mild to severe genital and/or urinary tract problems. Complications may include incapacitating urethral stricture, epididymitis, infertility, neurological sequelae, cardiovascular infections, chronic liver diseases and -6- cancer. The consequences for women include spontaneous abortion, ectopic pregnancy, tubal occlusion and other adverse reproductive outcomes; crippling pelvic inflammatory disease; infections in infants; and hepatitic and cervical cancer. Particularly in women, morbidity and mortality from STDs are not well defined. There may be a long latent period before acute problems appear. 1.19 The health consequences of STDs have not been treated as high priority public health problems in most developing countries. (As discussed, government attention to these diseases decreased in Indonesia in the 1970s and 1980s.) However, recent work has reexamined the health impacts of STDs (Over and Piot, 1991). These studies suggest that the burden, measured in terms of healthy days lost per capita, can be significant in high prevalence settings, e.g., urban centers and industrial and tourist areas. Because of these health consequences, treatment of STDs can yield significant economic benefits, since most of those affected are of working age and also have responsibilities towards children and aged relatives. 1.20 Moreover, establishing effective control over STDs is likely to have further beneficial impacts by slowing transmission of HIV (please see para. 1.5). Indeed, the benefits of averting an HIV case usually dominate those associated with reducing the prevalence of conventional STDs. This is because HIV is far more expensive to treat than other STDs. HIV and AIDS often entail protracted illness and numerous opportunistic infections and other symptoms and complications which require costly clinical or palliative interventions. In addition, the economic effects of HIV are more serious because AIDS leads to eventual (as opposed to periodic) withdrawal from the labor force, growing debilitation and death. All in all, the life days lost due to HIV place this disease in the forefront of the list of incapacitating health problems. Even in low prevalence urban centers, HIV and conventional STDs ranked eleventh among major causes of health loss, ahead of tuberculosis, adult pneumonia and neonatal tetanus (Over and Piot, 1991). In high prevalence urban areas, STDs including HIV account for a substantial fraction of the entire disease burden of the population-- by itself HIV ranked fourth in one study and moved up to third when days lost were weighted by relative productivities. 1.21 These findings point to the potential advantages of reducing the rate and extent of HIV transmission. These benefits may be defined in terms of the HIV-related costs to individuals and the society which can be averted through public policy. Here, the dominant approach in the literature distinguishes between direct and indirect costs associated with the epidemic. The former involve various costs of treatment including those for HIV and other tests, drugs, consultations and hospital stays. Treatment costs are based on assumptions about the typical patterns of symptoms and complications associated with HIV/AIDS and standard treatment protocols.5 Such cost figures are often AIDS is usually diagnosed when a patient experiences severe weight loss, chronic diarrhea and persistent fever, as well as some combination of recurrent coughing, dermatitis, herpes, zoster, candidiasis (in the mouth, respiratory tract or vagina), herpes simplex infection and/or enlarged lymph glands. -7- underestimated because patients may consult several providers simultaneously. In addition, there may be specific symptoms or medicines and therapies not included in the "standard" treatment package. For example, treatments costs were estimated at US$17,000 per HIV/AIDS patient in Brazil in 1992. This high cost reflected extensive use of AZT to delay the onset of AIDS.6 In India where AZT and other antiretrovirals were not generally used, the costs per AIDS patient were estimated at US$738 in 1991 (Bloom and Glied, 1992). 1.22 In Indonesia, the costs of treating AIDS were estimated for patients in Jakarta in 1995 (Annex 1, Tables 1-2). These costs were higher for those in private (US$1213-6235 per case) as compared to public (US$489-2899 per case) facilities. These estimates were based on the costs of the drug therapies prescribed for a "typical" set of opportunistic infections associated with AIDS. AZT and other antiretrovirals are not included in the standard treatment regimen. Accordingly, costs per AIDS patient are well below those in Brazil, the USA, and Europe (Scitovsky and Over, 1988), and closer to outlays in India. Nevertheless, these costs, at roughly US$2700 per patient, are not inconsiderable. Jakarta residents, like most urban Indonesians, have access to government and private providers. But fewer than 10 percent of the population are covered through prepaid health insurance arrangements including Health Maintenance Organizations (HMOs). For this reason, the costs of the HIV epidemic will not be shared through insurance-based mechanisms but will be absorbed largely by affected households and the government budget. Higher income patients will likely turn to private providers and hospitals while middle and lower income patients will rely on public facilities for treatment of AIDS-related infections and symptoms. 1.23 Several concerns need be noted here. First, as has occurred in Thailand, an increasing number of AIDS cases may put significant pressures on the health budget and delivery system in Jakarta. This can be seen first by considering the impact of a rising patient load on hospital capacity. Currently, there are about 14,400 beds in Jakarta's 60 general and 33 special (including maternity) hospitals; the bed occupancy ratio is approximately 60 percent. Using the standard projection scenario, and assuming no increases in bed capacity, AIDS patients would account for six percent of all hospital beds in 2005 and 13 percent in 2010. Government spending on health in Jakarta in the early 1990s was roughly US$63 million in 1994 (US$7.5 per capita). At an assumed cost of US$2700 per case (per year), outlays for the 8500 AIDS patients projected to be receiving treatment in 2005 (please see para. 1.13) would account for nearly 36 percent of current health expenditures. The fiscal burden of the epidemic would be even larger if costs per patient were to rise, as they are likely to do if and when AZT and other antiretrovirals are included in the standard treatment protocol. 6 In Thailand, only ten percent of new AIDS patients were reported to be using antiretrovirals in 1994. Nevertheless, the amount spent on these drugs already accounted for thirteen percent of the AIDS budget (Prescott, 1995) -8- 1.24 Secondly, significant expenses will still have to be met by affected individuals and families, even if the government budget finances a large share of possible rising per patient treatment costs. Cash payments in advance are normally requested for most drugs and procedures, in public as well as private facilities. There will also be outlays for transportation, other hospital expenses including food, over-the-counter drug purchases, test and consultation fees and so forth. These charges will have to be covered largely from savings, loans and/or liquidation of assets. This will be very difficult for poorer households who as in other Asian countries likely account for a disproportionate share of AIDS patients. AIDS may threaten the viability of such units, resulting in a lasting impairment of poorer households' earning capacity and engendering widening income inequality 1.25 The financial viability of affected households would be further weakened by various output or income reductions associated with AIDS-related morbidity and mortality. These income losses comprise the indirect costs of the epidemic. Again using Jakarta as an illustration, these costs were calculated by assuming that individuals infected with HIV forgo earnings equal to gross provincial product per adult, $3400 in 1995, from the age of onset of AIDS (assumed to be 35) to the average retirement age (assumed to be 60). Two adjustments were made to this projected income stream. First, per adult product in Jakarta was reduced by 20% to $2720 to reflect the likely disproportionate representation of lower income individuals amongst AIDS patients. On the other hand, calculations allowed for future income gains through a yearly growth factor of 4%. No account was taken of income reductions that occur due to STD or HIV, temporary absences from the labor market before full blown AIDS sets in, or of the losses incurred by other family members who reduce their labor force involvement to care for a sick relative. Finally, the flows of lost income were discounted at a rate of 8 percent. The resulting estimate of income loss per AIDS case, $29,132, is more than ten times larger than the estimated direct medical costs, roughly US$2700, of treating AIDS patients. 1.26 These direct and indirect costs of AIDS are substantial on a per patient basis, and foreshadow high aggregate costs if large numbers become infected. But these estimates may capture only a fraction of the losses potentially associated with this disease. Mention has already been made of a possible rise in treatment costs per patient (which may have to be absorbed in large part by the government health system), income losses incurred by other family members, STD and HIV-related treatment costs and income reductions, and possible adverse implications for equity. 1.27 Moreover, the potential impact of the HIV looms even larger once account is taken of individuals' willingness to pay (WTP) to avoid pain, discomfort, and restrictions on non-working activities. WTP is usually estimated by using wage premiums linked to increased mortality risks to estimate the value of a statistical life, i.e., what the society or market are willing to pay to reduce each member's risk. In the absence of appropriate wage or direct survey data, one approach derived rough estimates of WTP in Indonesia by postulating a linkage with per capita, based in turn on findings for the U.S.A. (World -9- Bank, 1994). This study concluded that the implied value of a statistical life in Indonesia fell in the US$ 75,000-175,000 interval. This range of values is 2.5-5 times the direct and indirect costs of AIDS per case presented above. The Government's Strategy and Key Design Issues 1.28 Overview. The Government of Indonesia (GOI) has acknowledged Indonesia's vulnerability to HIV and the negative economic effects of a possible epidemic. In the last two years, GOI has taken a number of decisive steps to reduce the pace and extent of HIV transmission in the country.7 A May 30, 1994 Presidential decree created a National AIDS Commission (NAC) headed by the Coordinating Minister for People's Welfare, with the Ministers of Health, Religious Affairs, Social Affairs and Population serving as vice chairmen and heads of designated working groups. With support from a small secretariat and various working groups, the NAC is expected to coordinate national policy and program development as regards AIDS. Three specific functions for the NAC were cited in the accompanying June 1994 Ministerial decree 8: to promote or provide technical and social services essential to the national program and which are beyond the capacity of communities; to develop guidelines for high quality case management; and to support the responsible involvement of community groups and NGOs in AIDS activities. The Presidential decree also established a commission in each province, chaired by the Governor, and involving appropriate staff from various government departments as well as community leaders and other local stakeholders. 1.29 The June 1994 Ministerial decree identified HIV and AIDS as health problems with significant political, economic, social, ethical and legal consequences. For that reason, the approach taken in this decree differs from that adopted towards other health goals, e.g., control of conventional infant diseases. First, public policy concerns extend beyond improving service access and quality particularly for the poor, which is a rationale for current government health interventions. Here the justification for public involvement lies in the recognition that individuals involved in risky behavior are not aware of the health implications of unprotected sex and drug use, and do not bear the full costs of their actions since some consequences are shifted via infection to others and to the health system. The goal is to urgently educate the public about the risks of unprotected sex, to reinforce behavior which does not involve possible HIV transmission and to change high risk behavior. 1.30 Secondly, government leadership is expected to result in a strategy involving numerous actors and sectors, including private providers and NGOs. The potential for such a comprehensive approach is seen in the case of Jakarta which has a large and As early as 1987, MOH established an AIDS Control Committtee which drew up short and medium term plans for HIV/AIDS prevention and control. A further Ministerial decree, issued in February 1995, provides guidelines for public and private institutions in carrying out HIV/AIDS prevention and control programs. - 10 - diverse health services sector. In 1993, there were almost 4000 doctors and over 14,000 nurses working in the city's 93 hospitals and 317 health centers, and in numerous private clinics and residential practices. Jakarta is also well endowed with public and private health laboratories and pharmacies whose staff and facilities can be mobilized as part of an STDs/HIV initiative. In addition, a very high share of Jakarta's population are reached by television, newspapers and other mass media, and also are accessible in the workplace and in schools. Thanks to this media involvement, there is already greater awareness of AIDS in Jakarta than elsewhere in the country. For instance, in 1994 the Indonesian Demographic Health Survey found that 87 percent of women ever married had heard of AIDS in Jakarta as compared to 69 percent for those living in urban Java and 38 percent for Indonesia overall. Third, there are many NGOs active in health in Jakarta. Several of these, including Yayasan Mitra and Yayasan Kusuma Buana have initiated small scale, HIV-related efforts which can be fine-tuned and replicated on a wider scale. 1.31 There are opportunities for a multisectoral approach in Riau as well. For instance, Batam has the health facilities (twelve hospitals and clinics) and staff (over 50 doctors and 90 nurses) needed to develop a strong STD program. Another advantage for policy development purposes is the accessibility of those who work in Batam or visit the island. Most Batam residents are employed in relative large establishments--this applies not only to industrial laborers but also to sex workers who are either concentrated in virtual lokalisasis or operate in well demarcated entertainment complexes. Tourists and commercial visitors would also be relatively easy to reach, for example with carefully designed health education messages and other behavioral change measures that would form part of an HIV program. 1.32 Key design features. The Ministerial decree and subsequent policy statements embody a commitment to a number of program guidelines. The first of these is to strengthen surveillance. The decree acknowledged that HIV prevalence exceeds the documented number of cases, posing problems for the design of prevention efforts and the evaluation of pilot initiatives. This will require capacity building, and improved coordination between the epidemiology subdirectorate within the directorate of communicable diseases which handles routine reporting of STDs and HIV/AIDS cases, and the communicable disease subdirectorate which is responsible for sentinel surveillance. Another design principle is the importance accorded to targeting those who engage in risky behavior. The decree recognized the need to reach out not only to the general public, health care providers, and women and adolescents, but also those individuals whose work or lifestyle put them at higher risk of being infected with HIV or transmitting the infection. The decree also signaled an intention to rely on and empower local bodies. The leadership, management and coordination of HIV activities were entrusted to broadly based provincial, district and municipal AIDS Commissions. It was felt that such entities had the potential to mobilize and utilize various community resources (including NGOs) effectively, and to identify and reach groups with high risk behavior. In this regard, the decree designated NGOs as full partners in the national program. Here, reference was made to the ability of NGO staff to reach those with special needs and interests, such as religious leaders, youth, professionals and so forth. -11- The decree also cited the credibility of NGOs amongst those, such as sex workers and drug users, who were not easily reached by government employees. 1.33 The final design imperative enumerated in the Ministerial decree was the need to improve STD and HIV diagnosis and treatment, including preparing laboratories and blood banks to deal with STDs and HIV. Currently, most facilities and providers are not -prepared to deal effectively with STD patients-- rapid assessments in Jakarta and Batam revealed low levels of knowledge among health workers about STDs with few providers aware of the syndromic approach (please see Annex 2) or other promising diagnosis and treatment methods. Moreover, these assessments suggested that the accessibility and quality of STD services can be improved. Provincial health laboratories appear capable of testing for HIV and some but not all STDs, while some private laboratories also have adequate testing capacities. Similarly, the Red Cross has excellent testing facilities at the central and provincial levels, and the blood supply screened there is probably free of HIV, HBV and syphilis. But testing capacity and actual activities are uncertain in many district laboratories and blood units. For this reason, the screening of blood units needs to be expanded using HIV rapid testing techniques, and STD testing capacity needs to be augmented as well. Also, the accuracy of HIV and STD tests needs to be safeguarded. The quality of current tests is in question because of the absence of proficiency testing and other quality assurance mechanisms. 1.34 Operationalizing the national AIDS strategy. The Presidential and Ministerial decrees have opened the door to significant policy initiatives regarding STDs and AIDS. Affordable and effective interventions now need to be designed and implemented. Several challenges must be addressed in regard to operationalizing the national AIDS strategy. First, careful and intensive pilot testing is required of alternative ways of reaching those with STDs and delivering services to them, and of the messages and commmunications channels that can have an impact on the behavior of targeted groups. 1.35 In addition, pilot activities need include not only trials directed at specific target groups or service delivery mechanisms but efforts to determine how to assemble cost effective, mutually reinforcing packages of interventions appropriate to particular locations. What is required, in short, are pilot programs in provinces known to have significant STD infection rates, indications of high risk behavior and a growing number of reported HIV cases. The aim would be to bring together simultaneously and in a unified framework all of the interventions, i.e., behavior change and service delivery initiatives, laboratory improvements and upgraded surveillance, thought to be indispensable in managing and preventing STDs and HIV. These comprehensive local pilots would provide experience for program design and replication in other areas of the country, if and when the epidemic continued. 1.36 The comprehensive local pilots would also provide a vehicle for working out coordination and planning mechanisms and organizational arrangements governing the different public and private stakeholders concerned with AIDS at the provincial level. Matters to be addressed include how the local AIDS Commissions would function, the -12- best way to involve NGOs, and different ways of channeling funds. It would be essential as well to use the pilot provincial programs to institute effective monitoring and evaluation procedures and activities-- it would be pointless to invest in numerous, possibly expensive trial initiatives if proper assessments could not be conducted. The Ministerial decree indicates that staff and resources need to be allocated to this important function. To this end, appropriate performance indicators need to be developed and derived from existing or newly collected information, and a monitoring and evaluation capacity and mindset will need to be established within all implementing units. 1.37 The role of MOH. Coordination of MOH's various AIDS-related activities constitutes a second issue with a significant bearing on the operationalization of the national AIDS strategy. The Presidential decree designated the Minister of Health as the First Vice Chairman of the NAC, with MOH expected to play a strong technical role in program development. To date, MOH's AIDS-related activities have been centered in the Directorate General for Communicable Disease Control and Environmental Health (CDC/EH) under the leadership of the Director General (DG). Within CDC/EH, the directorates of Directly Transmitted Diseases, Epidemiology and Immunization and the Program and Reporting Division in the DG's office have been involved. However, the latter units are also concerned with other diseases and issues and may lack the critical mass of skills and focus required for a timely response to STDs and HIV. In addition, other MOH units will need to be involved in a coordinated response to the epidemic. The Center for Health Laboratories is crucial for surveillance and STD control, while the Center for Health Education can contribute to the design of behavior change strategies. The DGs for Medical Services and Public Health, who administer the country's 337 publicly owned general hospitals and 7000 health centers, will need to endorse changes in diagnosis and treatment protocols. 1.38 Making the best use of donor assistance. The third operational issue relates to program financing and focus. AIDS-related interventions can be costly and of long- duration. Indonesia is fortunate that several donors have assisted the planning, policy development and organizational activities which have taken place thus far. In particular, WHO and USAID have supported policy work on AIDS in Indonesia since the late 1980s. In addition, USAID has made available grant money to initiate program design and delivery in several locations. WHO has funded program development, technical assistance and related activities relying in part on resources provided by the Global Program on AIDS(GPA) which, however, was terminated in December 1995. In 1994/95, WHO assistance, including long term consultants within MOH, amounted to over US$650,000. 1.39 Looking ahead, USAID and several other donors are supporting initiatives which are larger than past AIDS-related activities in Indonesia (Annex 3). For example, USAID's five year HIV/AIDS Prevention Project (HAPP), which began in late 1995, will provide US$20 million in grant funds to support social marketing of condoms, behavioral change trials and diagnosis and treatment of STDs, primarily through demonstration activities in North Jakarta and Surabaya and a third location to be - 13 - determined later. AusAID's five year grant of US$14.5 million equivalent will fund AIDS-related activities, primarily in Bali, NTT and Ujung Pandang. AusAID's assistance is directed for the most part at strengthening the NAC, and supporting PACs and some NGO activities in the three provinces. KfW's grant of US$13.1 million equivalent will finance private sector condom promotion and improvements in blood safety in Surabaya, Bali and Jakarta. 1.40 Donors have been the mainstay of the limited program developed to date, and will continue to provide a major part of AIDS funding during the next three to five years. Still, the government has recognized that grant resources in the form made available thus far need to be supplemented with more flexible funding, and must be programmed and managed carefully. For example, all of the donor-funded initiatives due to start in late 1995 or 1996 incorporate a stated preference to focus on specific geographical areas and or activities. AusAID indicated a strong interest in working in Eastern Indonesia and operating through the NAC and PACs, USAID has insisted on channeling nearly all of its funds through NGOs, and KfW has emphasized blood safety. Because of such strong donor priorities, grant money has not been made available to fund a variety of training, capacity building, institutional development and outreach activities. Yet the latter are indispensable building blocks for a sustainable program. Second, none of the donors has contributed a broad approach or framework through which to prioritize and coordinate various grant-funded trials and demonstration efforts. GOI expects that comprehensive local pilot projects in different provinces, supported by Central-level technical assistance, will provide the missing program design and organizational framework. Third, the introduction of funds from different sources has added to the complexity of developing and managing a program which involves numerous units within MOH as well as many ministries, NGOs, private parties and other stakeholders. These various considerations relating to the involvement of different donors, each with specific priorities and objectives, have been reflected in the design of this project (see Section 3), and are an important element of the rationale for Bank involvement (see para. 2.7). - 14 - - 15- 2. PAST AND PROSPECTIVE BANK INVOLVEMENT Lessons from World Bank Projects and Other Initiatives 2.1 Health Projects in Indonesia. The Bank has funded 13 health and population projects in Indonesia since 1977. Five of these operations are still under implementation. The ongoing and eight completed lending operations together point to lessons that should be incorporated in HIV/AIDS policy development in Indonesia. These include: (1) vertical interventions with blanket approaches have only limited impact given the diversity in health status and determinants across the country; (2) community participation and political and religious support are indispensable in such programs; (3) the ability of government programs to reach minority and/or hard-to-reach groups has been limited and better collaboration with NGOs and the private sector is needed to deliver services to such groups; (4) addressing institutional issues and building capacity at all level is needed to ensure sustainability; (5) phased implementation can be effective if a comprehensive package of services is provided and areas are selected to maximize program impact; (6) monitoring and evaluation should be an integral part of each project component; and (7) projects can be an effective tool for policy development. 2.2 HIV/AIDS Projects and Components. There are at least 40 ongoing Bank projects with AIDS and STD components. In addition, Bank-funded AIDS operations are underway in Zaire, India, Brazil, Zimbabwe, Uganda and Kenya. One review of early project results called on Country Departments to focus increased attention on countries, notably those with high levels of STDs but low incidence of HIV, which still have an opportunity to slow the epidemic (Lamboray and Elmendorf, 1992). There are other emerging findings: (1) government programs are often unprioritized and spread too thin; (2) the private sector and NGOs are better equipped typically than governments to reach many communities; (3) understanding determinants of behavioral change in different settings is crucial for prevention; (4) mass media are more effective if linked with community and interpersonal initiatives ; (5) STD prevention and management should be an integral part of HIV/AIDS programs; (6) operational research is often needed to identify effective approaches; (7) good monitoring and evaluation systems should be developed within HIV/AIDS programs; and (8) such programs usually help to strengthen overall health policy and disease control efforts. 2.3 Yet despite these broad findings and growing experience around the world with HIV interventions, Bank projects as well as other STD and AIDS initiatives have provided little concrete guidance on how to design cost effective interventions of appropriate scope. This absence of transferable lessons is surprising at first sight since -16- the literature on AIDS refers to many "success" stories, including documented reductions in risky sexual and drug-related behavior and in STD and HIV prevalence. For example, a Thai government program has brought increased condom use and a reduction in the number of STD cases being treated in public clinics (Brown, et.al., 1994). Promising reductions in risky behavior by injecting drug users and young men in general in Thailand have also been cited (Sittirai and Brown, 1994). Another recent illustration is the reported 42 percent reduction in HIV incidence in Tanzania as a result of improved case management of conventional STDs in primary care facilities in rural areas (Grosskurth, et.al., 1995). 2.4 Some cautionary principles need to be kept in view when reviewing such findings. First, outcomes may be taken out of context or not evaluated with sufficient rigor. For example, the study just cited noted that it was difficult to determine how much of the reported drop in STD cases was due to shifts from government to private treatment centers. Moreover, results often refer to limited trial initiatives--replication on a larger scale usually introduces major complications. Here Thailand is again a good reference point. The country's well publicized successes at the pilot stage including those just reported do not seem to have materially altered an overall government effort which recent observers have found to be "grossly inadequate" (Ungphakorn and Sittirai, 1994). More generally, findings and lessons appear to be context specific and culture-bound. For example, a recurrent observation is that behavior change messages need to be provided by credible sources and reinforced by locally reputable community figures. An implication is that to achieve success, initiatives directed at groups practicing risky behavior in Indonesia will have to be articulated and pursued in culturally acceptable terms. Bank Strategy and Rationale for Involvement 2.5 The proposed project is fully consistent with the Country Assistance Strategy (CAS) which was presented to the Board in February 1995. As indicated in that document, the Bank's assistance supports the main features of Indonesia's development strategy including enhanced human resource development, poverty reduction through greater access of the poor to basic services and assignment of increased responsibility to local governments in the provision of health and other services. The CAS notes that considerable scope exists to improve the quality of health services through better resource use. Bank-supported lending and sector work in Indonesia have addressed health service quality by tailoring interventions to local epidemiological patterns; involving provincial and district authorities and community members in the design and implementation of health programs; improving availability and use of appropriate skills, drugs and materials at the facility level; and enabling central units to concentrate on providing technical support. 2.6 The proposed project extends this approach to the specific health circumstances now emerging in a metropolitan region (Jakarta) and special economic zones (Batam municipality, KEPRI district and other localities in Riau). These areas may provide a preview of Indonesia's future. By virtue of rapid urbanization and economic growth, - 17 - nearly half of the population may be living in such settings within a decade. Health priorities in Jakarta, as well as Batan and Tanjung Pinang in Riau province now include reducing the risk of transmission of HIV and STDs. This public health agenda needs to be addressed with cost-effective interventions. 2.7 In this regard, the rationale for Bank involvement is to provide the flexible resources and planning and coordination framework needed for the emergence of locally grounded responses to a possible HIV epidemic. As discussed above (para. 1.40), Bank funds, unlike most other donor resources, will be available to finance indispensable training, capacity building, institutional development and outreach activities. In addition, this Bank-supported initiative will introduce a broad framework, based on comprehensive local pilot programs, and other mechanisms which will allow local and central level activities, including those funded by different donors, to be differentiated, prioritized and coordinated. Besides supporting comprehensive provincial projects in Jakarta and Riau and complementary central level activities, Bank funds will assist in establishing an HIV/AIDS and STDs Management Unit within MOH. This Central level unit will be responsible for managing not only the Bank-supported project but all other donor assisted AIDS interventions which involve MOH. - 18 - - 19- 3. THE PROJECT Project Objectives 3.1 The project is intended to help operationalize and implement the AIDS strategy presented in the 1994 Presidential and Ministerial decrees. These policy pronouncements are aimed at achieving lower STD and HIV incidence and fewer deaths from AIDS in Indonesia, and the aim of this "first phase" project is to use intensive pilot efforts to develop institutional mechanisms and interventions capable of reducing transmission of STDs and HIV in Indonesia. A core program for STD and HIV prevention in two pilot areas would be designed and implemented in partnership with local NGOs; extensive monitoring and evaluation would identify which trial interventions were promising and worth continuing. 3.2 Proximate objectives and corresponding performance indicators. Due to various measurement challenges, progress towards the ultimate goal of reducing HIV transmission may not be discernible within the three year duration of the project. STD and HIV incidence will be monitored through the surveillance system (see Table 3.1: Designated performance Indicators). However, at least initially the reported number of STD and HIV cases would be expected to rise, as an indication that a strengthened surveillance system was functioning. For this reason, the project is designed to attain a number of proximate objectives. These include enhancing awareness about HIV and STD transmission and prevention strategies in specific groups; promoting behavior change among those participating in risky sexual activities; increasing the knowldege and skills of health providers who deal with STDs and HIV; improving the capabilities of the health laboratory system as regards STDs and HIV; and establishing effective surveillance mechanisms for STDs and HIV and monitoring and evaluation systems to gauge the impact of various interventions. The corresponding performance measures will include the proportion of sex workers in designated sites who report ever and recent condom use; the proportion of persons in particular target groups able to describe correct use of condoms, and where and how they most recently obtained condoms; the proportion of trained health providers who use the syndromic approach correctly; the proportion of STD patients who sought care with 24 hours of noticing symptoms; reported condom use and HIV and STD incidence and the scores achieved by different laboratories in competency reviews and proficiency panels. Baseline values for these indicators will be estimated during the first six months of implementation, and reasonable achievement levels for years two and three of project execution will be agreed with the government and then reviewed by Bank supervision missions. Various process and output indicators will be used to assess the effectiveness of each of the many trials included in the project (para. 3.27 and Annex 4). - 20 - Table 3.1: Designated Performance Indicators Indicators Data Source Level of Collection Frequency I. Goal: Improved Awareness and Behavioral Change in Key Groups 1. Percent of CSWs seen by providers for STDs who: Exit Interviews Sentinel Surveillance Quarterly Sites - can describe correct use of a condom according to standard guidelines - can explain where and how they most recently obtained condoms - have a positive attitude toward consistent, correct condom use 2. Percent of CSWs in "localisasis" Survey NGOs and province/ Yearly and other complexes reached by district staff project who report ever use of condom and use in last sexual act. 3. Percent of persons by target Exit Interviews NGOs and other Quarterly group leaving group education implementation agencies sessions who: - can cite at least 2 means of STD prevention - state that HIV is a special type of STD - state that a person can remain healthy for several years but still transmit the virus - express the importance of positive family attitudes toward a member with AIDS 4. Percent of STD patients Clinic/patient record Providers at Sentinel Sites One day per month reportedly seeking care within 24 hours of noting symptoms II. Goal: Improved Knowledge and Skills of Health Providers 5. Percent of health workers trained Surveys of Health center - conducted Every six months, in syndromic approach who, 6 observations of by province & center beginning six months months after training can: randomly selected personnel after first training -21- Indicators Data Source Level of Collection Frequency health workers workshops - demonstrate appropriate use of flow chart - demonstrate how to use a condom - explain the importance of treating STDs as a way of preventing AIDS III. Goal: Establish Effective Surveillance Mechanisms 6. Reported condom use with non- Periodic surveys Population-based Twice yearly regular sex partners (conducted by center staff or contracted out) - # people aged 15-49 who reported condom use in most recent act of sex intercourse with a non-regular partner - # of people aged 15-49 reporting sexual intercourse with a non- regular sex partner in the past month 7. Reported STD incidence - (MEN) Periodic surveys Sentinel Surveillance Monthly Sites (reported episodes of Syphilis in men aged 15-49 - past month) (men aged 15-49, surveyed) 8. STD incidence - (WOMEN) Periodic surveys Sentinel Surveillance Monthly Sites (reported women aged 15-24, positive for syphilis) (pregnant women aged 15-24) IV. Goal: Enhance Capabilities and Proficiency of Health Laboratory System 9. Performance on bi-annual Competency Laboratory Every six months proficiency panel (Competency Reports Report) - 22 - 3.3 Strategic alternatives. The approach developed in this project was selected over several potential alternatives, based on criteria such as the possible dynamics of disease transmission, the availability of grant funds to support specified activities, and the likely efficacy of government staff and services. One of these alternative options was not to introduce, at least in the near term, specific measures which respond to STDs and the onset of a possible HIV epidemic. Instead, existing public and private facilities would be expected to handle STD and AIDS patients as they presented themselves for treatment. This alternative was rejected because there is clear evidence that the HIV infection is spreading within Indonesia and because of the long lead time required to change the course of an HIV epidemic. A second option was to concentrate on specific trial interventions and tasks, e.g., mass media messages, outreach to sex workers particular settings, or blood safety improvements. This alternative was rejected because of Indonesia has access to donor grant funding which is earmarked for such demonstration activities. What has not been made available are flexible resources which can be used to assemble and evaluate packages of pilot interventions in individual localities. Another option would be to strengthen and rely exclusively on public sector providers and facilities. This alternative was found to be insufficient since it is unlikely that government workers will have the commitment and empathy required to convey persuasive messages to those evidencing high risk behavior. 3.4 A participatory approach. During project preparation, different beneficiary groups, e.g., commercial sex workers, truckers and doctors, were consulted through the interviews and focus group discussions that formed part of the needs assessments undertaken in Jakarta and Riau. This high level of interaction with target beneficiaries and other stakeholders will continue during the implementation thanks to several project features. NGOs with credibility among different target groups will play a large role in planning, carrying out and evaluating different behavior change interventions. In this respect, training and deploying peer educators and counselors, drawn from different target groups, will be an important initiative. Finally, beneficiaries will be consulted periodically on different aspects of implementation via focus group discussions and other mechanisms. Project Components 3.5 The project consists of provincial level components and complementary central level activities. Provincial (including district and municipality-managed) interventions would introduce simultaneously and in the same localities various behavior change and service delivery measures thought likely to achieve significant outcomes. These steps would be accompanied by intensified surveillance, monitoring and evaluation efforts and backed by appropriate coordination, management and funding arrangements. These comprehensive pilot initiatives are intended to put in place packages which are cost effective and replicable elsewhere in Indonesia. Behavioral trials and other interventions to reduce or prevent risk would typically be carried out by NGOs and would include peer and workplace education, counseling and other measures targeted at different groups. Service delivery efforts, which would also draw on NGO providers, would involve - 23 - improvements in STD case diagnosis and management, antenatal syphilis and other STD screening, condom marketing, blood screening, and infection control practices. The relative weight and focus of the various elements in the pilot behavior change and service delivery packages would be specified and approved by the provincial AIDS commissions. 3.6 The project will also fund various central level activities which assist in the implementation of provincial AIDS programs. Resources will be provided to MOH for the development of guidelines, standards and materials needed at the provincial level; various forms of technical support to the pilot projects; strengthening surveillance and health laboratories in preparation for the extension of the pilot initiatives to new areas; and monitoring and evaluation and research to improve interventions and to gauge program impacts. The project will also support needs assessments, baseline surveys and related preparatory activities in several provinces which could be covered in a follow-up operation. Relevant review and coordination activities of the National AIDS Commission will be financed as well. Project Description 3.7 Provincial Pilot Programs. Project activities and outlays in the two pilot provinces are described below. The amounts in parentheses are base costs (see Table 4.1 a for a detailed breakdown). 3.8 Jakarta (US$8.8 million equivalent). The project will support behavior change, STD service delivery, STD and HIV surveillance, laboratory strengthening, NGO capacity building, monitoring and evaluation and management activities in the province of Jakarta. As regards behavior change, the project will i) increase knowledge of HIV risks within the population, while reinforcing traditional values and norms for positive behavior, ii) enhance skills in risk reduction for those engaged in high risk behavior, and iii) promote use of accessible, confidential and high quality STD services. Behavioral interventions will be directed at various groups engaging in high risk behavior, health providers and technicians, workplace and school audiences, and community organizations. NGOs will play a key role in designing and carrying out behavioral interventions in respect of the above groups. For the various audiences, the project will support training of district and local trainers, counselors and peer group educators; baseline surveys and needs assessments, focus group discussions and other forms of message design and formative research; production (including printing) and distribution of written educational and informational materials; and purchase and distribution of condoms. NGOs and other entities will be contracted to develop and implement various outreach activities including telephone "hotlines" and confidential HIV testing and counseling services. Finally, projected pilot behavioral initiatives in North Jakarta to be financed through the USAID-assisted HAPP project as well as possible European Community-supported interventions will be accommodated within the above program, once specific activities are clarified. 3.9 The project will also strengthen delivery of STD services in Jakarta by supporting training of staff in the syndromic approach and infection control procedures. Due to the - 24 - particular features of the syndromic approach (please see para. 3.16 and Annex 2) not all providers can be made proficient in STD case management in the first instance. Initially, a relatively limited number of health workers will be targeted, comprising those most likely to provide services to those engaging in risky sexual behavior. Funds will be provided for skills need assessments; staff training; production of educational materials; dissemination of guidelines and techniques to public and private doctors, nurses and laboratory staff; purchase of laboratory equipment, test kits, drugs, condoms and reagents; and dissemination of infection control and waste disposal techniques. Jakarta's health laboratory system will be upgraded as regards STDs and HIV primarily through purchase of equipment and materials needed to perform tests. Some retraining of public and private laboratory staff will also be funded. Support to the blood banking and transfusion system in Jakarta will not be included in this component as it is expected that such activities would be financed by KfW (Annex 3). 3.10 In addition, the project will finance stepped up surveillance of HIV and STDs and extensive monitoring and evaluation activities. The project will support collection, testing and analysis of blood samples for a wide range of sentinel surveillance groups and sites, as well as baseline and follow-up surveys of those providing STD services, and women attending antenatal clinics. This will involve funding computers and other equipment, reagents and other operating costs including supervision activities. 3.11 Finally, the project will support (i) establishment and operation of a province- level management unit and (ii) review and coordination functions to be carried out by the Provincial AIDS Commission. 3.12 Riau Province (US$7.3 million equivalent). The project will finance behavioral and service delivery initiatives and associated surveillance, monitoring and evaluation, and management activities initially in Batam and KEPRI, and later in other places in Riau province. Behavioral interventions will be directed at health staff whose work makes them susceptible to HIV, and at commercial sex workers, the clientele for the sex industry, and others at risk. Comparable efforts will be made to reach secondary audiences, e.g., employers and employees, educators and so forth. The activities to be supported include production and distribution of educational materials; formative research to develop effective media messages; counseling by telephone and on a person to person basis; purchase of radio and television spots; procurement of condoms; and training of district and local level trainers, peer group educators and counselors. An NGO in Batam will be asked to develop and implement many of the outreach activities directed at sex workers. In addition, Jakarta-based NGOs will be invited to initiate activities in Batam, with proposals to be reviewed in a competitive process according to announced criteria. For the secondary audience, the project will finance preparation and dissemination of messages through different media workshops, needs assessments and training of counselors, health education equipment and vehicles and so forth. 3.13 STD services will be strengthened through project support for skill needs assessments; staff training including discussion of guidelines as regards patient confidentiality and notification; dissemination of educational materials, standard -25- procedures and new techniques to doctors and other health care and laboratory staff; and purchase of equipment, reagents, drugs, syringes and condoms. Guidelines and procedures for those with AIDS will be tested and made available to doctors and nurses. In existing blood transfusion units, blood banking and screening will be improved through support for training of laboratory and blood bank staff, and through purchase of equipment and reagents. In addition, the project would support renovation and equipping of five transfusion centers together with purchase of reagents and staff training. 3.14 As in Jakarta, the project will fund intensified surveillance of STDs and HIV and various monitoring and evaluation activities, including surveys of those providing STD services. Sentinel surveillance will cover several categories of sex workers, their clients, women attending antenatal clinics, and other relevant groups. The project will support needed training as well as collection and analysis of blood samples, supervision, and purchase of computers and other equipment, reagents and test kits. 3.15 Central activities (US$15.0 million equivalent).9 The project will support coordination, technical assistance, media development, monitoring and education, research and other activities carried out by central MOH units as well as review and related functions performed by the NAC. Activity categories and outlays are described below. The amounts in parentheses are base costs (see table 4.1 a for a detailed breakdown). 3.16 STD service delivery (USS 1.5 million equivalent). Reducing the incidence of STDs is the main medical strategy used in this project to prevent HIV. The syndromic approach has been chosen as the basis for strengthening the STD program. Successful implementation of this strategy requires careful provider training that engenders changes in practices regarding patients, the availability and proper use of recommended drugs and materials, effective patient counseling and follow-up and a functioning laboratory and referral system to back up the syndromic provider. The project will finance development and testing of procedures relating to (i) the syndromic approach to STD case management at the clinical level (including co-infection with tuberculosis) and though antenatal service delivery, (ii) infection control techniques, and (iii) appropriate disposal of infected blood products and other materials. Support will be provided for preparation and production of training modules, research, fellowships, technical assistance, training of trainers, and procurement of supplies, equipment and drugs. Project-funded activities including technical assistance will be coordinated with the work program of a WHO- financed expert on syndromic methods who will be assigned to MOH during 1996-97. 3.17 Surveillance (US$2.9 million equivalent). The phased strengthening of STD services will need to be based on an effective local surveillance system. The project will focus initially on STD and HIV/AIDS surveillance activities in Jakarta and Riau, and then in the second and third years of the project on strengthening surveillance in 65-70 other districts. Current STD surveillance will be changed to reflect the syndromic Includes project management expenditures of US$1.5 million equivalent. - 26 - approach and a sentinel surveillance system will be established which focuses initially on STD and HIV prevalence as well as behavior in high risk groups. The introduction of this system will benefit from technical assistance during the first year; a WHO-funded resident expert will also contribute to the design to be supported through this project. Based on an assessment of experience during the first year, including a review of the design and implementation of the system, the pace of expansion to other districts will be determined. This expansion to other districts will also be based on epidemiological considerations and on demonstrated regency-level capacity. The project will provide resources for the identification of sub-populations and sentinel groups of interest and for the development of objectives, key indicators and standard methods for each type, e.g., active case detection in hospitals, linked and unlinked serosurveys, and special surveillance in selected sites, of surveillance activity. Through this sub-component, technical support will be provided for surveillance in the pilot provinces, and also in other provinces. Tasks and items to be funded include development of guidelines and manuals regarding group/site selection and testing, and notification for those found to have STDs and/or HIV; training of staff at different levels; technical assistance; study tours and fellowships; development of a database; purchase of supplies and equipment; and meetings and workshops. Surveillance activities will involve several sub-directorates within the directorates for Directly Transmitted Diseases and Epidemiology as well as the Program Planning Unit. During appraisal, agreement was reached on a program of coordinated planning and implementation of sentinel and routine surveillance activities within MOH and at the provincial level. 3.18 The laboratory system (US$6.0 million equivalent). The project will strengthen Indonesia's health laboratories as regards HIV and STDs by increasing capabilities for testing and diagnosis at different levels of the system and establishing tiered arrangements for monitoring and training. Centers of Excellence would be established in Jakarta, Medan, Surabaya and Ujung Pandang to serve as anchors in a system of quality assurance. Improvements at these four sites would prepare staff and facilities to carry out training, proficiency testing, trouble shooting and guidance roles as regards provincial laboratories and other centers in their "catchment" areas. Provincial laboratories throughout the country would be provided increased capacity to handle: HIV ELISA and rapid assay tests, alternative HIV coinfirmatory approaches, culture and sensitivity testing for gonorrhea, large scale surveillance testing and chlamydia testing. The project would assist the national reference laboratory at Cipto Mangunkusomo hospital in establishing the capacity to detect early HIV infections and laboratory diagnosis of AIDS. The project would also increase accuracy and quality in most laboratories through training, provision of educational materials, monitoring through visits and proficiency panels, and development of standard procedures. In Jakarta (para. 3.8) and Riau (para. 3.12), as well as in selected sites in Irian Jaya, the project would improve testing and diagnosis capabilities not only in provincial level laboratories but in district level facilities. The project would also make available retraining without cost and inclusion in quality assurance programs to private laboratory staff. To accomplish the above, the items and activities to be funded will include training and related costs; technical assistance; purchase of reagents and equipment; and workshop and seminars. -27- 3.19 Behavior change (US$3.1 million equivalent). The project would fund various activities needed to support provincial level behavior change interventions. These would include design of prototypes for needs assessments, preparation and pretesting of health education materials, training of trainers and other forms of training, technical assistance, research, NGO capacity building, fellowships and a wide range of monitoring and evaluation activities. 3.20 Research. As noted, the project would provide funds under different components to support research on topics such as health provider attitudes and behavior; infection control practices; infection patterns and health seeking behavior of those with STDs and/or AIDS; guidelines and practices with respect to removal and disposal of contaminated waste; the costs and cost effectiveness of behavioral and service delivery interventions; modeling disease trends; quality of care in different facilities; the commercial sex industry; and resistance to antibiotics used in treating STDs and the opportunistic infections which attack those with AIDS. Prior to negotiations, agreement was reached on the terms of reference and level of support required for research activities to be carried out in the first year of project execution, and on the mechanisms through which research proposals will be reviewed and funded. 3.21 Preparation areas (US$162.500 equivalent). The project would support needs assessments, baseline surveys and other preparatory activities in areas designated for possible follow-up STD and HIV interventions. Project Management and Implementation 3.22 Project management. provincial level and below. The project would be executed by local government authorities in Jakarta and Riau. In each province, the project would be directed by the Assistant III for Social Welfare in the Regional Secretariat in his capacity as Secretary to the Provincial AIDS Commission (PAC). The Project Manager would be the head of the provincial office of MOH (Kakanwil). The Project Director and Manager would be appointed by the Governor. Implementation of activities within the health sector would be the responsibility of the head of the provincial health service (Dinas), with technical support in health the responsibility of the Kakanwil. A key role would be played by the PAC. This body is chaired by the Governor with members drawn from government departments and NGOs. The PAC would set program priorities and directions, coordinate interventions and management review results. The Project Director and Manager and the PAC would be supported by an implementation unit (PIU) located in the Dinas, tasked with carrying out program priorities agreed to by the PAC, tracking activities and expenditures, and monitoring and evaluating various behavior change and service delivery initiatives. The PIU would be headed by a unit Chief, and supported by an Executive Secretary and other staff. At the district level, the bupati (chief district official) or wali kota (mayor) will have overall responsibility for implementation. District level health activities would be delegated to the head of the district or municipal health office, while activities outside the health sector would be the responsibility of the District (or Municipal) AIDS Coordinator. A PIU at the district level in Riau province - 28 - would be staffed by a full-time Secretary. During negotiations, assurances were obtained that the governments ofJakarta and Riau provinces will maintain provincial Project Directors and Managers and district Project Directors until the project is completed Detailed terms of reference covering the roles, functions and staffing of provincial and district project implementing units were also agreed at negotiations. 3.23 Project management, central level. At the center, the project would be headed by the Director General (DG) of Communicable Disease Control and Environmental Health (CDC/EH). The Project Director would be advised by a Steering Committe chaired by MOH's Secretary General, with members drawn from MOH, Bappenas, Ministry of Finance and the Ministry of Human Affairs (Annex 5). In light of the new challenges posed by HIV/AIDS to MOH, the project would support the establishment within CDC/EH of a special unit, called the HIV/AIDS and STDs Program Management Unit (PMU, see Annex 5). The head of this unit would report directly to the DG for CDC/EH. The unit would be responsible for planning, coordinating and monitoring and evaluating all HIV/AIDS and STD-related work within MOH, for providing technical support to provinces and districts, and for facilitating MOH's links with and support for the NAC. In addition to the Bank-supported project, the unit would also be responsible for all other donor assisted activities in MOH related to STDs and HIV/AIDS. This unit would consist of technical support, planning, monitoring and evaluation, and administration subunits. Staff in the unit would be appointed, hired or seconded from other units in MOH, and would include individuals with expertise on surveillance, NGOs, monitoring and evaluation, and information and communications. During negotiations, assurances were obtained that the government will maintain within MOH a Project Director who shall be the Director General of Communicable Diseases and Environmental Health, a Project Manager who shall be responsible for day-to-day implementation of the Project, and an HIVIAIDS and STDs Program Management Unit ofagreed size and skill mix. The role, functions and terms of reference of the Program Management Unit were also agreed at negotiations. 3.24 NGQs. A defining feature of the project is the role of NGOs in different aspects of implementation. NGOs are expected to be actively involved in the deliberations and decisions of the PACs. In addition, individual NGOs will be contracted to carry out various behavior change, service delivery, training and monitoring and evaluation activities as well as operational studies. For specified tasks, NGOs with known expertise will be asked by provincial authorities to submit proposals. Funds are earmarked in the project to procure training services and instructional materials supplied by NGOs. NGOs will have a further option of submitting unsolicited proposals to carry out STD and HIV/AIDS related activities including studies. An NGO grant fund of US$566,300 is included for that purpose within the Jakarta component. Proposals will be evaluated according to technical, management and financial criteria, with submissions to be assessed by review panels established and managed by the PIU; these panels would include NGO representatives. At the request of such panels, the PIU could assist in refining promising proposals, including strengthening the monitoring and evaluation components. In addition, the project will finance other capacity building measures - 29 - directed at smaller NGOs some of which have strong ties to particular groups of interest. These typically recently established NGOs may not have the experience and financial resources needed to submit full-dress proposals and bids, and/or may not have complied with all registration steps and procedures. Capacity building measures may include needs assessments, financial and organizational audits, orientation and training opportunities, quarterly review meetings between NGOs and MOH officials, technical assistance, joint NGO-MOH training activities and workshops, seconding MOH staff to NGOs, pairing or mentoring arrangements linking established and emerging organizations, and endowing a larger NGO with limited grant making authority and resources. At negotiations, assurances were obtained that the process of selecting and coniracting with NGOs under different project components, including but not limited to the NGO fund, will be on terms and conditions acceptable to the Bank Also at negotiations, GOIpresented guidelines and supporting legal documents defining the mechanisms to be used within the project to ensure the fullest possible use ofNGO. 3.25 Channeling of funds. Loan funds would be channeled through development budget (DIP) allocations at the central, provincial and district levels. The central level health DIP would be employed for various MOH units involved in the project. Money for project activities within the health sector in Jakarta and Riau would flow through the provincial and district health department DIPs. Funds for activities normally outside the purview of the health department would initially be transferred through a provincial health department DIP which would be assigned to support activities carried out by other departments and NGOs. During the course of project implementation it is expected that the latter arrangements will be superceded by decisions creating new mechanisms for channeling funds to local governments. 3.26 Technical assistance. The project would support modest amounts of international and local technical assistance, concentrated in the first eighteen months of implementation (Annex 6). International technical expertise, estimated at 37 person months, would be directed at the development of the syndromic diagnosis/treatment and surveillance components, design of evaluation and research activities, and preparation of training and quality assurance materials. Local technical assistance of 112 person months would be used to elaborate training modules and supervise and assess training programs, develop testing procedures, improve planning and management capacity in NGOs, and carry out needs assessments and other tasks. 3.27 Performance evaluation and supervision strategy. Monitoring and evaluation have a central place in this pilot project-- the aim of the project is to test and assess a range of behavioral and service delivery interventions. Accordingly, monitoring and evaluation steps were built into each activity and budget, and various input and process indicators will be used to monitor implementation of different components (Annex 4). Moreover, agreement was reached at negotiations on the indicators which would be used to assess project performance (para. 3.2 and Table 3.1: Designated Performance Indicators). Annual performance reviews and plans for the project's behavior change, service delivery and surveillance interventions will be the key vehicles for project evaluation and supervision. Preparation of reviews will be the responsibility of each province's PIU, -30- using monitoring and evaluation data collected routinely as part of each intervention and focusing in particular on the agreed performance indicators. The central HIV/AIDS and STDs Program Management Unit will employ a full-time evaluation specialist, supported by technical assistance. The evaluation specialist will be expected to develop and disseminate a monitoring and evaluation plan, covering measurement of indicators, generation of data and feedback for use of findings by project managers, and feeding into the annual performance plan and midterm review. This specialist will liaise with evaluation staff at NAC and take responsibility for overseeing evaluation of all activities within the central component. The central specialist will also work closely, in a technical oversight role, with evaluation staff assigned to provincial and district management units. Evaluation personnel at those levels will develop evaluation plans for project activities taken up in each local component. The project will also fund visits by technical specialists with expertise in behavior change, service delivery and surveillance. 3.28 The Bank will conduct periodic reviews of project implementation and impact whose timing will be linked to specific activities, the preparation of annual plans and the availability of key indicators and findings. A detailed supervision plan is presented in Annex 7. -31 - 4. PROJECT COSTS AND FINANCING Costs 4.1 The total cost of the project is estimated at US$35.2 million equivalent (Rp. 79.1 billion), including contingencies and identifiable taxes and duties. Tables 4.1 and 4.2 summarize the estimated costs by provincial and central components, and project activity and expenditure category. Detailed project costs by year, purpose and components are given in Annex 8. Table 4.1a: Summary of Project Costs by Component by Province (USS million) Component Jakarta Riau Center Total IEC & Behavioral Interventions High Risk Groups 1.0 0.3 0.4 1.7 Workplace 0.2 0.3 0.4 0.9 School/University 0.6 0.5 0.4 1.5 Community & General Public 0.5 0.6 0.3 1.4 Health Providers 1.8 0.5 0.4 2.7 Other Support Activities 0.2 0.4 1.2 1.8 Subtotal 4.3 2.6 3.1 10.0 Biomedical Services Protection of Blood Supply 0.5 0.5 STD and HIV/AIDS Services 3.0 2.6 1.5 7.1 STD and HIV/AIDS Surveillance 0.7 0.4 2.9 4.0 Laboratory Services 0.1 0.5 6.0 6.6 Subtotal 3.8 4.0 10.4 18.2 Management & Support STD/AIDS Management 0.2 0.6 0.8 Future Project Preparation 0.2 0.2 Project Management 0.8 0.5 0.7 2.0 Subtotal 0.8 0.7 1.5 3.0 Total Base Costs 8.9 7.3 15.0 31.2 Physical Contingencies 0.4 0.4 0.8 1.6 Price Contingencies 0.8 0.6 1.0 2.4 Total Project Costslo 10.1 83 16.8 35.2 % of Total Project Costs 29% 23% 48% 100% 10Includes identifiable duties and taxes of USSl.5 million equivalent. - 32 - Table 4.1b: Project Cost Summary % % Tetal (Rps. '000) (USS '000) Foreign Base Local Foreign Total Local Foreign Total Eichange Casfs A. Jakarta 1. IEC & Behavioral Interventions High Risk Groups 1,975,152.4 344,251.6 2,319,404.0 879.4 153.3 1,032.7 15 3 Workplace 352,095.0 53,805.0 405,900.0 156.8 24.0 180.7 13 1 School/University 1,156,762.0 180,458.0 1,337,220.0 515.0 80.3 595.4 13 2 Community & General Public 961,046.4 122,505.6 1,083,552.0 427.9 54.5 482.4 11 2 Health Providers 3,404,986.8 593,137.2 3,998,124.0 1,516.0 264.1 1,780.1 15 6 Other Support Activities 474,687.5 9,687.5 484,375.0 211.3 4.3 215.7 2 1 Subtotal IEC & Behavioral Interventions 8,324,730.1 1,303,844.9 9,628,575.0 3,706.5 580.5 4,287.0 14 14 2. Biomedical Services STD and HIV/AIDS Services 6,241,777.0 574,290.0 6,816,067.0 2,779.1 255.7 3,034.8 8 10 Surveillance 612,803.1 837,374.9 1,450,178.0 272.8 372.8 645.7 58 2 Laboratory Services 89,480.1 268,520.0 358,000.2 39.8 119.6 159.4 75 1 Subtotal Biomedical Services 6,944,060.2 1,680,184.9 8,624,245.2 3,091.7 748.1 3,839.8 19 12 3. Management & Support Project Management 1,490,250.0 132,250.0 1,622,500.0 663.5 58.9 722.4 8 2 Subtotal Jakarta 16,759,040. 3,116,279.8 19,875,320.2 7,461.7 1,387.5 8,849.2 16 28 B. Rian 1. IEC and Behavioral Interventions High Risk Groups 670,584.0 106,176.0 776,760.0 298.6 47.3 345.8 14 1 Workplace 602,313.6 83,590.4 685,904.0 268.2 37.2 305.4 12 1 School/University 835,020.0 167,780.0 1,002,800.0 371.8 74.7 446.5 17 1 Community & General Public 969,111.2 324,904.8 1,294,016.0 431.5 144.7 576.1 25 2 Health Providers 1,043,820.0 155,980.0 1,199,800.0 464.7 69.4 534.2 13 2 Other Support Activities 706,400.0 211,100.0 917,500.0 314.5 94.0 408.5 23 1 Subtotal IEC and Behavioral Interventions 4,827,248.8 1,049,531.2 5,876,780.0 2,149.3 467.3 2,616.6 18 8 2. Biomedical Services Protection of the Blood Supply 556,720.0 594,460.0 1,151,180.0 247.9 264.7 512.5 52 2 STD and HIV/AIDS Services 5,264,100.0 644,300.0 5,908,400.0 2,343.8 286.9 2,630.6 II 8 Surveillance 562,500.0 318,300.0 880,800.0 250.4 141.7 392.2 36 I Laboratory Services 254,250.0 935,650.0 1,189,900.0 113.2 416.6 529.8 79 2 Subtotal Biomedical Services 6,637,570.0 2,492,710.0 9,130,280.0 2,955.3 1,109.8 4,065.1 27 13 3. Management & Support STD/AIDS Management 249,438.0 39,382.0 288,820.0 111.1 17.5 128.6 14 - Project Management 994,350.0 146,150.0 1,140,500.0 442.7 65.1 507.8 13 2 Subtotal Management & Support 1,243,788.0 185,532.0 1,429,320.0 553.8 82.6 636.4 13 2 Subtotal Riau 12,708,606. 3,727,773.2 16,436,380.0 5,658.3 1,659.7 7,318.1 23 23 C. Center 1. IEC & Behavioral Interventions High Risk Groups 711,681.9 259,578.0 971,259.9 316.9 115.6 432.4 27 1 Workplace 609,581.9 246,678.0 856,259.9 271.4 109.8 381.2 29 I School/University 609,581.9 246,678.0 856,259.9 271.4 109.8 381.2 29 I Community & General Public 609,581.9 246,678.0 856,259.9 271.4 109.8 381.2 29 1 Health Providers 586,631.9 244,128.0 830,759.9 261.2 108.7 369.9 29 1 Other Support Activities 1,393,640.0 1,251,960.0 2,645,600.0 620.5 557.4 1,177.9 47 4 Subtotal lEC & Behavioral Interventions 4,520,699.7 2,495,699.9 7,016,399.5 2,012.8 1,111.2 3,124.0 36 10 2. Biomedical Services STD and HIV/AlDS Services 2,084,060.8 1,287,203.2 3,371,264.0 927.9 573.1 1,501.0 38 5 Surveillance 4,254,399.0 2,342,018.0 6,596,417.0 1,894.2 1,042.8 2,937.0 36 9 Laboratory Services 3,350,820.0 10,129,555.0 13,480,375.0 1,491.9 4,510.0 6,001.9 75 19 Subtotal Biomedical Services 9,689,279.8 13,758,776.2 23,448,056.0 4,314.0 6,125.9 10,439.9 59 ? 3. Management and Support STD/AIDS Management 1,159,500.0 195,500.0 1,355,000.0 516.3 87.0 603.3 14 2 Future Project Preparation 308,500.0 56,500.0 365,000.0 137.4 25.2 162.5 15 1 Project Management 1,371,300.0 164,700.0 1,536,000.0 610.6 73.3 683.9 11 2 Subtotal Management and Support 2,839,300.0 416,700.0 3,256,000.0 1,264.2 185.5 1,449.7 13 5 Subtotal Center 17,049,279. 16,671,176.1 33,720,455.5 7,591.0 7,422.6 15,013.6 49 48 Total BASELINE COSTS 46,516,926. 23,515,229.1 70,032,155.7 20,711.0 10,469.8 31,180.8 34 100 Physical Contingencies 2,325,846.3 1,175,761.5 3,501,607.8 1,035.6 523.5 1,559.0 34 5 Price Contingencies 4,588,069.1 950,472.3 5,538,541.4 2,042.8 423.2 2,466.0 17 8 Total PROJECT COSTS 53,430,842. 25,641,462.8 79,072,304.8 23,789.3 11,416.5 35,205.8 32 113 -33- Table 4.2a: Summary of Project Costs by Category of Expenditures by Province (US$ million) Category of Expenditures Jakarta Riau Center Total Equipment 0.4 0.6 2.1 3.1 Vehicles 0.1 0.1 Technical Assistance & Studies 0.2 0.2 2.7 3.1 IEC Materials 0.8 0.7 2.0 3.5 Reagents (Center) 3.9 3.9 Fellowships 0.1 1.0 1.1 Training & Workshops 5.0 2.8 1.6 9.4 Grants 0.6 0.6 Administrative Costs 0.4 0.6 0.9 1.9 Recurrent Costs 1.5 2.2 0.8 4.5 Total Base Costs 8.9 7.3 15.0 31.2 Physical Contingencies 0.4 0.4 0.8 1.6 Price Contingencies 0.8 0.6 1.0 2.4 Total Project Costs 10.1 8.3 16.8 35.2 % of Total Project Costs 29% 23% 48% 100% Table 4.2b: Project Cost Summary % % Total (Rps.'000) (USS '000) Foreign Base Local Foreign Total Local Foreign Total Exchange Costs 1. Investment Costs A. Equipment 1,417,110.6 5,668,442.4 7,085,553.0 630.9 2,523.8 3.154.7 s0 10 B. Vehicles 20,000.0 180,000.0 200,000.0 8.9 80.1 89.0 90 - C. Technical Assistance & Studies Foreign Consultants 264,480.0 1,057,920.0 1,322,400.0 117.8 471.0 588.3 80 2 Local Consultants 950,108.3 50,005.7 1,000,114.0 423.0 22.3 445.3 5 1 Studies & Research 3,647,140.0 911,785.0 4,558,925.0 1,623.8 406.0 2,029.8 20 7 Subtotal Technical Assistance & 4,061,720.3 2,019,710.7 6,881,439.0 2,164.6 099.2 3,063.9 29 10 Studies D. Instructional Materials 5,443,460.8 2,332,911.8 7,776,372.5 2,423.6 1,038.7 3,462.3 30 11 E. Reagents (Center) 1,733,700.0 6,934,000.0 8,660,500.0 771.9 3,087.6 3,859.5 80 12 F. Fellowships Overseas - 2,445,000.0 2.445,000.0 - 1,088.6 1,088.6 100 3 Domestic 162,000.0 18,000.0 180,000.0 72.1 8.0 80.1 10 - Subtotal Fellowships 162,000.0 2,463,000.0 2,625,000.0 72.1 1,096.6 1,168.7 94 4 G. Training & Workshops 18,918,379.9 2,102,042.2 21,020,422.2 8,423.1 935.9 9,359.0 10 30 H. Grants 1,272,000.0 - 1,272,000.0 566.3 - 566.3 - 2 I. Administrative Costs 3,831,138.0 425,682.0 4,256,820.0 1,705.8 139.5 1,895.3 10 6 Total Investment Costs 37,659,517.6 22,126,589.1 59,786,106.7 16,767.4 9,351.6 26,613.9 37 85 II. Recurrent Costs A. Operations & Maintenance 1,138,002.0 - 1,138,002.0 506.7 506.7 - 2 B. Supervision & Travel 3,199,480.0 - 3,199,480.0 1,424.5 - 1,424.5 - 5 C. Supplies & Condoms 4,172,767.0 - 4,172,767.0 1,857.9 - 1,357.9 - 6 D. Reagents (Provinces) 347,160.0 1,38,640.0 1,735,800.0 154.6 618.3 772.8 30 2 Total Recurrent Costs 8,857,409.0 1,388,640.0 10.246,049.0 3,943.6 618.3 4,561.9 14 15 Total BASELINE COSTS 46,516,926.6 23,515,229.1 70,032,155.7 20,711.0 10,469.8 31,180.8 34 100 Physical Contingencies 2,325,846.3 1,175,761.5 3,501,607.0 1,035.6 523.5 1,559.0 34 5 Price Contingencies 4,588,069.1 950,472.3 5,538,541.4 2,042.0 423.2 2,466.0 17 8 Total PROJECT COSTS 53,430,342.0 25,641,462.8 79,072,304.8 23,739.3 11,416.5 35,205.8 32 113 -34- 4.2 Base of Costs Estimates. Baseline costs are estimated at October 1995 prices. Medical and office equipment, and vehicle costs are based on current prices for similar imported or locally available items. Costs for international and domestic consultants are in line with recent health projects for appropriately qualified experts. Operational costs are consistent with current government practices and recent health projects. Costs for short-term, in-country training vary depending on the type of training being given and location. Recurrent costs are based on standard government allowances for travel, per diem, O&M and consumable materials. 4.3 Contingency Allowances. Physical contingencies represent 5 percent and price contingencies 8 percent of total baseline costs. Physical contingencies have been allowed for all categories, as actual expenditures for all project components are expected to differ from current estimates. 4.4 Foreign Exchange Costs. Foreign exchange costs are estimated at US$11.4 million (representing about 32 percent of total project costs) based on the following percentages: (a) equipment--80 percent, (b) vehicles--90 percent, (c) instructional materials-- 30 percent, (d) research and studies-- 20 percent; (e) drugs and reagents-- 80 percent, (f) international technical assistance-- 80 percent, (g) overseas fellowships-- 100 percent, (h) domestic consultants -- 5 percent; and (i) training, domestic studies, program development expenditures, project management costs-- 10 percent. 4.5 Taxes and Duties. Identifiable taxes and duties are estimated at US$1.5 million (Rp. 3.5 billion). These would be financed entirely by the Government of Indonesia. Financing 4.6 The total project cost of US$35.2 million would be financed by a proposed loan of US$24.8 million equivalent, covering 70 percent of total project costs. The Government would finance the remaining costs of US$10.4 million equivalent from annual budget allocations. Government outlays would amount to 26 percent of total project costs excluding taxes (Table 4.3). 4.7 Incremental Recurrent Costs (US$ 4.6 million equivalent). Incremental recurrent costs are for office operating costs, travel and supervision and for consumables, including reagents for Jakarta and Riau. These account for 15 percent of total base costs and 13% of total project costs. 4.8 Indonesia is eligible for a single currency fixed rate loan. Total borrowing by Indonesia under the single currency loan program including this loan, is projected to amount to at most 50 percent of the expected FY96 Bank lending program for the country. 4.9 The Borrower has selected a single currency loan in US dollars in order to better manage its external liabilities, in view of i) the weight of US dollars in Indonesia's foreign exchange receipts, and ii) the current high exposure to the Japanese yen. The -35- choice of a fixed interest rate reflects the Borrower's preference to manage its interest rate risk in view of its current exposure to floating rate loans. Procurement 4.10 The loan proceeds would be used to finance procurement of goods and services under all project components (see Table 4.4): (a) Equipment totaling US$3.4 million equivalent including contingencies. Equipment will be handled by central, provincial and district levels depending on where the goods are being delivered. Equipment contract packages valued at or above US$200,000 equivalent would be awarded under International Competitive Bidding (ICB) procedures, using the Bank Procurement Guidelines under IBRD Loans and IDA Credits, January 1995. Locally manufactured goods would be granted a 15 percent domestic margin of preference. Contract packages valued at less than US$200,000 equivalent and up to an aggregate amount of US$1.7 million equivalent including taxes would be awarded through National Competitive Bidding (NCB) procedures acceptable to the Bank. Contract packages valued at less than US$50,000 equivalent, up to an aggregate limit of US$1.0 million equivalent including taxes, may be purchased through national shopping on the basis of a minimum of three price quotations. (b) Reagents for Central laboratories totaling US$4.3 million equivalent, including contingencies. These materials would be purchased under International Competitive Bidding (ICB) procedures. (c) Vehicle costs totaling US$0.1 million equivalent. The government of Indonesia considers the procurement of vehicles as reserved procurement and therefore Bank financing would not be used to purchased vehicles. During negotiations, assurances were received that required vehicles will be provided by the Government in accordance with an agreed upon schedule. (d) Instructional materials totaling US$3.9 million equivalent including contingencies. This would include printed manuals, guidelines, books, teaching materials, standard medical forms, and video and media packages procured and produced locally. Printing and other production services would be procured through National Competitive Bidding (NCB) from private printing firms by each provincial project managers and by the central project managers. Already printed materials, up to an aggregate limit of US$1.0 million equivalent, could be procured through national shopping on the basis of a minimum of at least three competitive price quotations, directly from publishers or distributors. -36- (e) Consultant services, studies and research totaling about US$3.4 million equivalent including contingencies, would be selected and contracted in accordance with Bank Guidelines for the Use of Consultants. (f) Grants for NGOs totaling about US$0.7 million equivalent including contingencies. Grants from this fund will be awarded by a Review Panel that includes NGO representatives based on technical and other considerations. Funding would be by Competitive Selection based on invitation and submitted proposals, and National Shopping (with at least three quotations). At negotiations, agreement was reached on the criteria to be used in reviewing proposals and awarding grants and on contracting procedures. (g) Overseas and in-country fellowships totaling US$1.3 million equivalent, including contingencies. Placement of candidates in foreign institutions would be made on the basis of relevance and quality of programs offered, cost, and prior experience, according to government procedures acceptable to the Bank. At negotiations, assurances were obtained that plans for use offellowship funds will be presented annually for Bank review. Table 4.3: Financing Plan (US$ million) Expenditure Categories GOI IBRD Total % IBRD Equipment 1.1 2.2 3.3 70% Vehicles 0.1 0.0 0.1 0% Instructional materials 1.2 2.5 3.7 70% Consultant services Central consultants 0.1 0.4 0.5 80% Provincial consultants 0.0 0.4 0.4 100% Studies and Research 0.0 2.4 2.4 100% Grants 0.0 0.6 0.6 100% Fellowships 0.0 1.2 1.2 100% Training/workshops NGO 0.0 5.6 5.6 100% Others 3.2 1.4 4.6 30% Project management 0.0 2.1 2.1 100% Reagents 0.0 4.3 4.3 100% Recurrent costs 4.7 0.0 4.7 0% Unallocated 0.0 1.7 1.7 Total 10.4 24.8 35.2 70% - 37 - (h) Training and workshops totaling US$10.7 million equivalent, including contingencies, would be procured on the basis of relevance and quality of the programs offered by government, private institutions and NGOs according to government administrative procedures acceptable to the Bank. (i) Project management totaling US$2.2 million equivalent, including contingencies. Project management will include expenditures directly related to the management of the project, such as travel, consumable materials, honoraria, meetings, office supplies and operational costs, but excludes salaries. The expenditures would follow government procedures acceptable to the Bank. (j) Recurrent costs totaling about US$5.2 million equivalent including contingencies. This would cover operations and maintenance, supervision and travel expenses, and purchase of other supplies, including reagents and condoms for provincial centers. The recurrent costs would be financed by the government. Procurement Review 4.11 Review by the Bank would be as follows (see Annex 10): (a) On receipt from the borrower, the Bank will review (i) bidding documents (SBD, January, 1995) for goods to be awarded under ICB procedures, (ii) letters of invitation, terms of reference and other relevant information for consultants, to ascertain their conformity with the Bank guidelines and standard form of contract published in June 1995, (iii) standard bidding documents for national competitive bidding (NCB) procurement for goods. Approved documents would be used for all future bidding. Roughly 59 percent of goods purchased through the project will be subject to prior review. The relatively low proportion covered by prior review is due to the large number of contracts expected to cover small amounts; many of these contracts will be the responsibility of district implementation units. (b) All contracts for goods valued at or over US$200,000 equivalent and the first two contracts for goods in each of the two Project provinces estimated to cost less than the equivalent of US$200,000 would be subject to prior review by the Bank, whereas all other contracts for goods would be subject to post review, and the resident mission (RSI) and supervision missions would carry out the review. (c) All individual consultant contracts including those for NGOs valued at or over US$50,000 equivalent and contracts for consulting firms valued at over US$100,000 equivalent would be subject to prior review by the Bank. - 38 - All other consultant contracts would be subject to random post review. The terms of reference and single source selection would be subject to prior review. (d) Overseas fellowships would be subject to random post review by the Bank Beginning in 1996, the plans for each year would be submitted to the Bank for review and approval. (e) Beginning in 1996, central and provincial training and workshop plans for each year would be submitted to the Bank for review and approval by December 31 for the forthcoming year. -39- Table 4.4: Procurement Arrangements (US$ million) Category of Expenditure Procurement Procedures ICB NCB Other/a N.B.F./b Total Cost (including cont.) Equipment 0.7 1.7 1.0 3.4 (0.7) (1.7) (0.6) (3.0) Reagents (Center) 4.3 4.3 (4.3) (4.3) Vehicles 0.1 0.1 (0.0) (0.0) Consultants Services & Studies Consultants 1.0 1.0 (0.9) (0.9) Studies 2.4 2.4 (2.4) (2.4) Instructional Materials 2.9 1.0 3.9 (2.0) (0.7) (2.7) Grants 0.2 0.5 0.7 (0.2) (0.5) (0.7) Fellowships 1.3 1.3 (1.3) (1.3) Training & Workshops NGOs 5.8 5.8 (5.8) (5.8) Others 4.9 4.9 (1.5) (1.5) Project Management 2.2 2.2 (2.2) (2.2) Recurrent Costs 5.2 5.2 (0.0) (0.0) Total 5.0 4.8 20.1 5.3 35.2 (5.0) (3.9) (15.9) (0.0) (24.8) Note: Figures in parentheses are the respective amounts financed by the Bank. a/ Includes national shopping and hiring of consultants. b/ Not Bank financed. -40- Disbursement 4.12 The proposed loan of US$24.8 million equivalent would be disbursed over a period of three years (Annex 9). The project's closing date is September 30, 1999. 4.13 Disbursements would be made as follows: Amount % of Expenditures (USS million) To Be Financed Equipment 2.2 100% of foreign expenditures (excluding vehicles) 100% of local (ex-factory) 65% of local expenditures for other items procured locally Reagents 4.3 100% of foreign expenditures 100% of local (ex-factory) 65% of local expenditures for other items procured locally Instructional Materials 2.5 70% of total expenditures Fellowships 1.2 100% of total expenditures Training & Workshops NGOs 5.6 100% of total expenditures Other 1.4 30% of total expenditures Grants 0.6 100% of grant amount disbursed Project Management 2.1 100% of total expenditures Consultant's Services Consultants Central 0.4 80% Provincial 0.4 100% Studies, Research 2.4 100% of total expenditures Unallocated 1.7 Total 24.8 -41- 4.14 Disbursements from the loan for the following contracts would be against full documentation: (a) goods contracts valued at or more than US$200,000 equivalent; and (b) consultant services (for firms) contracts valued at or more than US$100,000 equivalent; and (c) individual contracts valued at or more than $50,000 equivalent. All other disbursements would be against statements of expenditure (SOE) for which relevant documents would be retained by responsible agencies and made available for review as requested by visiting Bank missions. To facilitate disbursement, a Special Account in an amount of US$2.4 million would be established at Bank Indonesia. This Special Account would be held in the name of the Director General of Budget, Ministry of Finance, following established procedures. The Special Account would be used for all eligible foreign and local expenditures. Replenishment to the Special Account would be made on the monthly basis or when 20 percent of the initial deposit has been used, whichever occurs first. Accounts, Audits and Reports 4.15 MOH would establish project accounts for all project expenditures at both the provincial and central levels, to be maintained in accordance with sound accounting practices. Accounts for the SOEs and Special Account would be maintained separately for annual audits. Each provincial PIU would send financial statements for all project expenditures for each fiscal year to the Central Management Unit. The Central Management Unit would consolidate the two provincial financial statements with the central level financial statement and prepare a consolidated financial report. The financial statements and consolidated financial reports would be audited by independent auditors acceptable to the Bank, including a separate audit opinion on SOE expenditures. Certified copies of the financial report on the project for each Government fiscal year, together with the auditors' statements, would be furnished to the Bank as soon as available, but not later than six months after the end of each government fiscal year starting September 30, 1997. MOH would also monitor progress in project implementation and report to the Bank each semester on this progress. Within six months after the completion of disbursement, the Ministry would submit an implementation completion report (ICR) to the Bank. -42- - 43 - 5. PROJECT BENEFITS AND RISKS Program Goals and Potential Benefits 5.1 HIV is spreading in Indonesia, and the disease will be part of the country's health picture for many years. However, the development and replication of effective interventions can slow the rate of transmission and lessen significantly the cumulative impact of HIV/AIDS and related health problems. An early, effective effort to prevent HIV transmission would save many lives. As an illustration, the iwg-AIDS projection model predicts 8500 new AIDS cases (deaths) in Jakarta in 2005 and 17,500 in 2010, and cumulative figures for AIDS of 55,000 by 2005 and 123,000 by 2010 (Annex 11). New and cumulative figures for HIV infections are even larger. Jakarta province would spend US$8.8 million under the present project to slow the transmission of HIV and reduce the number of deaths attributable to AIDS. At issue is whether the likely impact of the project in terms of deaths averted justifies the proposed level of spending. 5.2 Like other health system interventions, this operation can be assessed, with some modifications, according to accepted principles of project analysis. Modifications are needed because this initiative will not finance interventions, such as a dam or a bridge, of known design specifications and inputs and predictable costs, construction and start-up phases, and whose consequences can be estimated with some confidence. Instead, this project will sponsor, fund and direct an entire "portfolio" of experimental measures in the two provinces. Many of these trial activities have not been fully identified, and there will be quite a few which fail or need to be modified extensively. Due to these features, project analysis must take account of (i) the ultimate impacts on behavior change in key respects and on whether there is a reduction in the number of new STD and HIV cases (incidence) which is reported, and also (ii) how long it takes to determine which approaches seem most promising and to assemble these into coherent, sustainable provincial programs. Taking into account these two dimensions of efficiency, i.e., ultimate impacts on behavior and timely and efficient trialing and related processing steps, various outcome scenarios can be used to identify different levels of project achievement and associated benefits and costs. 5.3 This approach can be illustrated again using Jakarta as an example. As mentioned, the baseline projection developed using the iwg-AIDS model predicts a cumulative total of 55,000 AIDS cases in Jakarta by 2005 and 123,000 by 2010. The second scenario (Annex 11, Tables 1, 2 and 5 and Figures 1-2) depicts the course of the In addition, an estimated outlay of US$2 million under the central component would support activities in Jakarta. - 44 - epidemic assuming that interventions begin in January 1997 and achieve full impact within three years. This scenario, which results in 5000 fewer AIDS cases by 2005 and 22,500 fewer cases by 2010, is based on conservative assumptions about the impact of the project on risky behavior. Specifically, the project is expected to result in a 25 percent reduction in the incidence of STDs and in risky sexual behavior, and a 25 percent increase in the use of condoms. In this scenario, the present value of cumulative project- related savings in direct treatment costs in Jakarta would amount to US$6.3 million for 2005 and US$19.2 million for 2010. There would also be substantial, cumulative indirect economic benefits by 2005 and 2010. The net present value of the overall outlays and benefits in this illustrative calculation amounts to US$140 million for 2005 and US$551 million for 2010. In short, the project as depicted in scenario two appears to be economically justified. Moreover, the calculations exclude such project benefits as reduced morbidity and death from a long neglected category of health problems, STDs. Risks 5.4 Several risks arise in designing public policy in response to an unprecedented health challenge like AIDS. First, the disease is complex and difficult to detect and react to. On the one hand, the current extent and potential for rapid transmission of HIV may have been exaggerated. For this reason, the government is well advised to invest initially in improving surveillance and laboratory testing facilities, and in pilot projects in areas of known incidence. On the other hand, HIV could spread so rapidly that public and private response mechanisms prove inadequate. Here, the government's proposed steps through the current project are also appropriate since surveillance, laboratory testing and locally tailored, pilot initiatives will be key elements in an eventual Indonesian response, as they have been in other settings, e.g., Australia and the USA, where some success has been recorded in limiting transmission. A second risk relates to possible difficulties in reaching and persuading different audiences, including groups which are not part of the social mainstream, to modify what has hitherto been a very private aspect of behavior. This risk includes a potentially reluctant or even critical reception from mainstream religious leaders, and an inability to communicate with and extend program activities to groups practicing risky behavior. This eventuality which is anticipated in GOI's broad approach towards AIDS (and reflected in the Presidential Decree on AIDS), will be addressed in the current project through unobtrusive coalition building, quiet persuasion and involvement of key opinion leaders, and reliance on NGOs in reaching out to target groups. This points to a third risk, that of overburdening small, recently formed NGOs. This latter risk will be overcome through use of pilot initiatives, capacity building steps, careful monitoring and evaluation and phased expansion in light of demonstrated NGO capabilities. A fourth risk is that HIV initiatives will overwhelm GOI's policies towards other health problems--this contingency can and should be avoided by integrating HIV/AIDS diagnosis and treatment with high priority reproductive health and child survival activities and with ongoing efforts to upgrade service quality in health centers and hospitals. Moreover, this risk is more likely to eventuate if program efforts are delayed. - 45 - Sensitivity Analysis 5.5 The implications of several of the risk factors just discussed were assessed through sensitivity analysis. Specifically, scenarios were developed in which the project takes longer, possibly because of different risk factors cited above, to become fully effective, and in which project impact is not only delayed but of lower magnitude (Annex 11, Tables 1,2, and 5 and Figures 1-2). Scenario three, in which the project takes five years to become fully effective, results in 3500 averted AIDS cases by 2005 and 13,000 by 2010; taking account of direct and indirect savings (benefits, excluding those relating to STD treatment) and outlays, the net present value of the project in this scenario is US$96 million and US$314 million in the two years respectively. Scenario four, which involves delayed and lessened effectiveness, results in 1000 averted AIDS cases by 2005 and 5000 averted cases by 2010. The net present value of the project in the latter case is US$20 million by 2005 and US$114 million by 2010. In short, estimated benefits far exceed expenditures even under assumptions of delayed and reduced project effectiveness. The net present value of the project is also very high even when highly conservative assumptions are made about the present extent and likely spread of HIV in Jakarta; this eventuality corresponds to the first risk discussed above. Specifically, this latter set of scenarios (Annex 11, Tables 3,4 and 6) builds in considerably lower rates of sexual activity and casual sex. Despite such stringent and unrealistic premises, the project appears to be economically justifiable, even when the impact of interventions is phased in over five years and at reduced effectiveness, and when a higher (ten percent) discount rate is used. Moreover, the project retains its economic rationale even when direct and indirect benefits per case are reduced by 50 percent (Annex 11, Table 6). Environmental Impact 5.6 Safe disposal of waste materials, including contaminated blood, bandages and needles, generated in different facilities is always an issue in communicable disease efforts, and of special concern as regards HIV. Accordingly, appropriate guidelines and practices with respect to protecting patients and health workers, removing and disposing of hazardous materials will be fostered during project implementation. Included in this project is a study of waste disposal procedures and practices in government health facilities. Current WHO guidelines will provide a point of departure for this study. Implications for Women 5.7 This project addresses important health risks and problems for a vulnerable group in Indonesian society which is largely female, commercial sex workers. The project will also draw attention to the underreporting of HIV and STD prevalence, especially among women, and will include initiatives to reduce transmission of HIV and STDs from brothel clients to their wives and to improve diagnosis and treatment for infected women. - 46 - Poverty Impact 5.8 The project promises to have a small but favorable impact on the incidence of poverty by reducing transmission of HIV to low income individuals. The poor are especially exposed because they have less access to accurate information on the nature of this disease, behavior which is risky, and ways of avoiding infection. Not only are low income individuals more susceptible to HIV, their families are usually less able to absorb the losses of income and treatment costs associated with AIDS. Indeed, poorer households may have to liquidate assets and adopt other coping strategies, resulting in a permanent reduction in income earning potential and a threat to the economic viability of the unit. Sustainability 5.9 The raison d'etre of this project is to identify cost effective and sustainable interventions to slow transmission of HIV and STDs in Indonesia. This objective is addressed through a number of features of project design. These include: the emphasis on monitoring and evaluation in all components and activities; the delegation of planning, institutional development and operational decision making in the pilot provinces to local government officials; the assignment of responsibilities for priority setting, review of results and coordination to local AIDS Commissions with wide representation; extensive involvement of NGOs in all dimensions of the project; and the large share of project expenditures allocated to one-time outlays, e.g., training, laboratory upgrading, and mass media campaigns, which will not need to be funded at similar levels in later years. The above aspects are conducive to the emergence by the end of the project of locally owned, pilot-tested interventions which are affordable and sustainable. -47- 6. AGREEMENTS REACHED AND RECOMMENDATION 6.1 Prior to negotiations, agreement was reached on: (a) a program of coordinated planning and implementation of sentinel and passive (routine) surveillance activities within MOH (para. 3.17); (b) the terms of reference and level of support required for research activities to be carried out in the first year of project execution, and on the mechanisms through which research proposals will be reviewed and funded (para. 3.20); and (c) the indicators to be used to measure performance in respect of the project's proximate objectives (para. 3.2). 6.2 During negotiations, GOI provided assurances that: (a) the governments of Jakarta and Riau provinces will maintain the provincial Project Directors and Managers and district Project Directors until the project is completed. Detailed terms of reference covering the roles, functions and staffing of the Project Implementing Units were also agreed at negotiations (para. 3.22). (b) the government will maintain within MOH a Project Director who shall be the Director General of Communicable Diseases and Environmental Health, a Project Manager who shall be responsible for day-to-day implementation of the Project, and a HIV/AIDS and STDs Program Management Unit of agi,ed size and skill mix. The role, functions and terms of reference of the Program Management Unit were also agreed at negotiations (para. 3.23). (c) the process of selecting and contracting with NGOs, including but not limited to the NGO grant fund, will be on terms and conditions acceptable to the Bank. Regarding the NGO grant fund, agreement was reached during negotiations on the criteria to be used in reviewing proposals and making grants and on contracting procedures (para. 4.10). Also during negotiations, GOI presented guidelines and supporting legal documents defining the mechanisms to be used within the project to ensure the fullest possible use of NGOs (para. 3.24). -48- (d) the vehicles required for the project will be supplied according to an agreed schedule (para. 4.10). (e) beginning in 1996, central and provincial plans for training activities, workshops and use of fellowship funds will be presented annually to the Bank by December 31 in each year for review and approval (para. 4.11). (f) agreed indicators would be used to assess project performance (para. 3.2 and Table 3.1). 6.3 Subject to the above agreements, the proposed project is suitable for a Bank loan of US$24.8 million to the Republic of Indonesia under the standard amortization term, grace period and interest rate for fixed rate US dollar, single currency loans with an expected disbursement period of three to six years. - 49 - BIBLIOGRAPHY Bloom, David E. and Sherry Glied. 1992. "Who Is Bearing the Cost of the AIDS Epidemic in Asia." Blowfield, Michael. 1992. "The Commercial Sex Industry in Surabaya, Indonesia: An Ethnographic Study." Edited by Michael Linnan and Tom Reis. Chen, Lincoln C., Jaime Sepulveda Amor and Sheldon J. Segal, eds. 1991a. "Epidemiological Synergy: Interrelationships Between HIV Infection and Other STDs." In Judith N. Wasserheit, eds., AIDS and Women's Reproductive Health New York: Plenum Press. ------. 1991b. "The Public Health Significance of Sexually Transmitted Diseases for HIV Infection in Africa." In Seth Berkley, eds., AIDS and Women's Reproductive Health New York: Plenum Press. Grosskurth, Heiner, Frank Mosha, James Todd, Ezra Mwijarubi, Arnoud Klokke, Kesheni Senkoro, Philippe Mayaud, John Changalucha, Angus Nicoll, Gina ka- Gina, James Newell, Kokugonza Mugeye, David Mabey and Richard Hayes. 1995. "Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania: randomized controlled trial." The Lance 346:530- 536. Indonesia, Minister of People's Welfare and Chair of the Indonesian National AIDS Commission. 1994. Indonesia National AIDS Strategy. Ministry of People's Welfare and Indonesian National AIDS Commission, Indonesia. Indonesia, Minister of People's Welfare. 1994. The President of the Republic ot Indonesia Presidential Decree on AIDS Prevention and Control Commission. Ministry of People's Welfare, Indonesia. Jones, Gavin W., Endang Sulistyaningsih and Terence H. Hull. 1994. "Prostitution in Indonesia." Kosen, Soewarta and Michael Linnan. 1994. "Projection of HIV/AIDS in Indonesia (1990-2005)." Paper presented at the 7th International Congress of the World Federation of Public Health Associations, December 4-8. Bali, Indonesia. -50- Lamboray, Jean-Louis and A. Edward Elmendorf. 1992. "Combatting AIDS and Other Sexually Transmitted Diseases in Africa - A Review of the World Bank's Agenda for Action." Discussion Paper 181. World Bank, Africa Technical Department, Washington, D.C. Linnan, M., M. Kestari and A. Kambodji. 1995. "Adult Sexual Behavior and Other Risk Behaviors in East Java - Behavioral surveys from urban, periurban and rural areas of East Java. Yayasan Prospectiv, Surabaya. Linnan, Michael and The Surabaya STD Study Group. 1995. "Summary Report of the STD Studies in Surabaya, East Java." Over, Mead and Peter Piot. 1991. "Health Sector Priorities Review: HIV Infection and Sexually Transmitted Diseases." Health Sector Priorities Review 26. World Bank, Population and Human Resources Department, Washington, D.C. Prescott, Nicholas. 1995. "Economic Analysis of Antiretroviral Policy Options in Thailand." Paper presented at the Third International Conference on AIDS in Asia and the Pacific Satellite Session on Rational Use of Antiretrovirals, September 21. Chiang Mai, Thailand. Scitovsky, Anne A. and Mead Over. 1988. "AIDS: costs of care in the developed and the developing world." AIDS 2(suppl 1):S71-S81. Sittitrai, Werasit and Tim Brown. 1994. "Risk factors for HIV infection in Thailand." A1DS 8(suppl 2):Sl43-S153. Ungphakorn, Jon and Werasit Sittitrai. 1994. "The Thai response to the HIV/AIDS epidemic." ADS 8(suppl 2):Sl55-S163. World Bank. 1994. Indonesia Environment and Development. Washington, D.C. -51 - ANNEXES -52- -53- ANNEX I INDONESIA IIV/AIDS AND STDs PREVENTION AND MANAGEMENT PROJECT Table 1: Components of the Costs of Diagnosing and Treating IIIV/AIDS in Indonesia Services provided User as a Full cost Number of Full cost (units) percentage per unit units per per case of fun cost (1995, in case (1995, in USD) USD) PUBIC HEALTH CARE SYSTEM Tests: ELISA 100 6-9 1 6-9 Western Blot 100 36.7-40 1 36.7-40 Consultation/visit 30 0.4-2 15-25 6-50 Drugs 50 20-67 15-25 300-1,675 Hospital (day) 35 7-45 20-25 140-1,125 PUBIC HEALTH CARE SYSTEM Tests: ELISA 100 8-10 1 8-10 Western Blot 100 40-42.5 1 40-42.5 Consultation/visit 100 11-15 15-20 165-300 Drugs 100 40-133.5 15-20 600-2,670 Hospital (day) 100 20-128.5 20-25 400-3,212.5 Note: Data obtained from consultation with Cipto Mangunkusomo Hospital. -54- ANNEX 1 Table 2: The Cost of Drug Therapies to Treat Opportunistic Infections Associated with AIDS in Indonesia Proportion of Number of Total drug cost Infection AIDS patients Drug Episodes per course/ month affected (%) (USD) Oral candidiasis 83 Fluconazole or 3 63.00 Ketoconazole or 14.70 Itraconazole 18.00 Esophagus 80 Fluconazole or 3 135.00 candidiasis Ketoconazole or 29.40 Itraconazole 36.00 Brain 25 Pyrimethamine & 1 7.10 toxoplamosis Sulfadiazine 11.30 Retinitis 33 Acyclovir 2 35.55 cytomegalovirus Pneumonia 50 Co-trimoxazole or 1 22.60 Amoxicillin 40.90 Broncho- 19 Co-trimoxazole or 2 22.60 pneumonia Amoxicillin 48.00 Tuberculosis, 58 INH 1 0.74 lung Ethambutol 12.90 Rifampicin 31.50 Tuberculosis, 44 INH 1 0.74 lymphadentitis Ethambutol 12.90 Rifampicin 31.50 Tuberculosis, 3 INH 1 0.74 meningitis Streptomycin 10.90 Kaposi Sarcoma 8 symptomatic I treatement Scabies 3 Lindan 1% 3 usnic acid 1% or 0.40 Pemethrin 3.00 Aspergillosis, 3 Corticisteriods 1 0.68 lung Amphotericin B 68.50 Mycosis, 3 Chlorambucil or 1 54.00 lung Cyclophosphamide 45.00 Hepatitis A,B,C 11 Methisoprinol 1 116.25 Herpes 3 Acyclovir 1 49.50 Cryptosporidiosis 3 Ampicillin 1 40.90 Amoxicillin 48.00 Efusion of 8 Co-trimoxazole 1 22.60 cardial/pericardial Source: Cases administered in Cipto Mangunkusomo Hospital, Jakarta, 1990-1995. -55- ANNEX 2 INDONESIA HIV/AIDS AND STDs PREVENTION AND MANAGEMENT PROJECT THE SYNDROMIC APPROACH TO STD DIAGNOSIS AND TREATMENT 1. The syndromic approach to STD diagnosis and treatment is designed to provide STD treatment services where laboratory confirmation is neither possible nor available. It is premised on the assumption that certain symptoms associated with STDs are the result of a limited number of conditions, and the appropriate medications to treat those conditions are known for a certain geographic locale. Combined with a system of partner referral and treatment, the syndromic approach can increase access to treatment for both symptomatic and asymptomatic STDs, reduce the duration of infectiousness and result in a reduced prevalence of STDs in the general population. 2. For example, urethritis in males is usually accompanied by a discharge, and in many developing countries, the vast majority of discharges are due to gonorrhoea or chlamydia. Therefore, if a male presents to a clinic with a urethral discharge, he is given drugs for both gonorrhoea and chlamydia, and told to return in a week if his symptoms do not improve. If he does return with no improvement, he is given either second-line drugs, or referred to a specialist who will then institute a laboratory test. 3. Through the use of procedural flow charts (algorithms), personnel at primary health care centres are trained to recognise a small number of syndromes -- urethritis, vaginitis, cervicitis, pelvic inflammatory disease (PID) and genital ulcer, and dispense appropriate medication. It has been shown that this approach results in the successful treatment of most of the symptomatic STDs that present at PHC centres, with only a minority of cases requiring referral to specialist and laboratory services. 4. However, the syndromic approach involves more than diagnosis. Ideally, clients who have been diagnosed with STDs should receive treatment at the same time, and there are arguments that in order to achieve a high rate of compliance, drugs should be available at the clinic. One dose of a drug taken under supervision at the clinic would ensure 100% compliance, but some conditions require seven-fourteen days of antibiotics. However, receiving at least the first dose of medication at the clinic would improve compliance as compared to giving the client a prescription. 5. Secondly, clients should be counselled on the importance of informing their contacts, many of whom may be asymptomatic, and trying to convince them to come for treatment. Besides the importance of partner referral and strategies for assisting in this, counselling should also include messages and information about how STDs are contracted and how to prevent them, including information on condoms and how to use them. -56- ANNEX 2 6. Therefore, the syndromic approach is more than simply a tool for diagnosis and treatment in the absence of a laboratory, but a co-ordinated programme for diagnosis, treatment and counselling towards partner referral and prevention. As such, it is based on several assumptions and preconditions which complicate its implementation and add to its expense: 7. Knowledge about the relative prevalence of STDs in an area, the anti-microbial sensitivity patterns, and the recommendations for first and second-line drugs. This requires baseline research before the commencement of the programme, and also periodic monitoring and surveillance to determine changes in anti-microbial sensitivity. It also requires both the availability and the affordability of the recommended drugs, either at the clinics or through local pharmacists. 8. Health workers trained in the syndroic approach. Health workers who are seeing clients with STDs need to be trained in the syndromic approach. A properly designed training programme will involve training not only in the use of the flow charts or algorithms, but also training in counselling and communication skills in order to help health workers to transmit the desired messages and to break down their own prejudices about people with STDs. Ideally, training should also include practical supervision at an STD clinic, and it has been found that a four-five day training course is the necessary minimum. Training courses must be designed to include all health workers who may see STD clients -- doctors, nurses, medical assistants, and pharmacists (in those countries where people tend to self-medicate and go directly to chemists when symptoms appear). Special training courses have also been designed for supervisors in clinics where a large volume of STDs are seen. 9. Sufficient personnel to deal with the workload. It will be seen that a properly implemented syndromic approach will require more time than is usually allotted to PHC clients -- besides the time required for diagnosis and treatment (a physical examination including an internal speculum exam for women is necessary), time is needed for counselling. Some clinics may assign a separate person for the counselling, who may be the same person who provides counselling messages in other areas such as family planning and nutrition, but the introduction of the syndromic approach at a clinic that sees a large number of STD patients will likely necessitate a change in staffing requirements. 10. Adequate supplies and materials. Clinics where the syndromic approach is used will need flow charts for the staff to refer to, educational posters and materials to use with clients, condoms for distribution and demonstration purposes, medications (if the policy is to dispense medications directly), etc. 11. A referral system. If an STD patient has been given both the first-line and second-line treatment with no improvement in symptoms, he/she needs to be referred to a specialist for further examination and laboratory diagnosis of what is probably a drug- resistant STD or another condition. PHC's or clinics should have access to these services, either in the nearest urban centre, the district hospital, a private clinic, and so on. INDONESIA HI/AIDS AND STDs PREVENTION AND MANAGEMENT PROJECT Donors Funding AIDS-Related Activities, 1996-2000 Grant Program Area Donor Amount Behavior Change STD Services Blood Safety/ Administrative Support/ Duration Geographical Area Comments (US) Laboratories Policy/Research UNAIDS 275,700 Promote general awareness Assist NAC in developing 1996-1997 Not focused on Much reduced through NAC-run activities refining national strategy and specific provinces support following in coordinating, supporting termination of PACs GPA WHO 540,000 Development of surveillance; 1996-1997 Pays for full-time introduction of syndromic senior consultant approach to STDs and related activities AusAID 14,500,00 Develop packages and train Train staff in STD management, Assistance to NAC and PACs, 1995-2000 Bali, NTT and S. MOU signed 0 staff in 3 provinces infection control, provide funding for National AIDS Sulawesi 10/30/95; main equipment in 3 provinces; Conference; NGO focus on assure condom quality strengthening and behavioral NAC/PACs studies in 3 provinces USAID 20,000,00 Workplace education; condom STD/HIV curricula for medical Improving laboratory Upgrade NGO capacity; 1995-2000 Surabaya, N. Jakarta 80% of funds 0 marketing; youth leaders; schools; training for service capacity for diagnosis develop framework for policy and a third area to channeled through counseling activities providers; epidemiologicall assessments; research on be designated as an NGO and private microbiological surveillance; knowledge( attitudes additional sector contracts develop drug management regarding sexual behavior, demonstration area and logistic system; STDs, drug resistance; improved access to evaluate mass treatment diagnostics KfW' 13,100,00 Use NGO to handle social Assist in developing counseling Improve Red Cross blood 1995-1998 Surabaya, Bali, Emphasis on 0 marketing of condoms; programs; support/care for banking and screening; Jakarta blood system and improve IEC capacity in people with HIV and AIDS model tissue banking condom social MOH train health workers programs; pre/post marketing counseling of blood donors UNFPA 1,400,000 Create AIDS awareness among Strengthen institutional capacity 1995-2000 E. Java, W. Focus on families leaders and in general public and commitment of BKKBN Kalimantan, rather than high through mass media to family-centered approach Yogyakarta, Irian risk groups; work campaign in 4 provinces Jaya with BKKBN European 852,395 Develop materials based on Strengthen STD counseling in Assess incidencet prevalence of 1995-1996 Jakarta, Bandung, Mainly funds Community I research findings target areas STDs among sex workers Surabaya research work . Kreditanstalt fur Wiederaufban M:\uEBERMA\STD\ANNEX3.DOC -58- ANNEX 4 INDONESIA HIV/AIDS AND STDs PREVENTION AND MANAGEMENT PROJECT MONITORING AND EVALUATION Introduction 1. The basic goal of this project is to prevent the explosive, exponential growth of the HIV/AIDS epidemic that has occurred in other countries. The primary strategy to achieve this goal is to strengthen and expand the prevention and control of other sexually transmitted diseases (STDs) in two geographic areas of the country with large populations at risk. Studies have demonstrated the "synergistic" relationship between STDs and HIV. Thus, the planned interventions against the first must include consideration of the other, and improve control of "traditional" STDs may have a noticeable impact on the spread of HIV. It is apparent that an approach to HIV/STD control must involve both multidisciplinary and multisectoral approaches, including clinical, laboratory and educational services. 2. As part of a three-year comprehensive pilot effort designed in the above framework, the monitoring and evaluation component of this project is one of its most important activities. Numerous activities will be planned and implemented in a short time frame with multiple groups of people by numerous agencies and individuals in different locations. The challenge to the monitoring and evaluation component will be to quickly detect and respond to problems of implementation as well to be able to say something about "what works" in Indonesia in STD/HIV prevention among different groups of people and why, so that "scaling up" of activities can occur in the future. Monitoring and evaluation should be carried out by managers at all levels of this project (see below), at intervals sufficiently frequent to permit feedback and continuous improvement of programs. 3. Presented in the following paragraphs is an overview of the project's monitoring and evaluation strategy, including designated performance indicators, how and when they will be measured and by whom, for each of the principal components of the project. Definitions 4. Monitoring tracks the process of carrying out activities necessary for program implementation. This can be accomplished through routine recording and reporting from service delivery sites, supervisory visits, and periodic program reviews. Monitoring is an integral part of evaluation; it is used to measure process objectives, that is, to determine if and to what extent activities are being implemented as planned. -59- ANNEX 4 5. Evaluation measures the progress of the program toward two types of objectives: (1) outcome objectives which specify changes in behavior or services as a result of project activities; and (2) impact objectives which describe expected changes in STD incidence and prevalence, HIV incidence and so forth. Measurement, particularly of outcome objectives, can involve clinic-based surveys of STD service providers, pre/post- tests of participants in training courses, long-term follow-up surveys of training participants, exit interviews of STD patients, disease and behavioral surveillance, and cohort studies. 6. The term evaluation also includes operational research designed to answer questions related to interventions and services of the program; for example, the relative effectiveness of using a peer group approach compared to a mass media-oriented approach to reach senior secondary school students or the effectiveness of two different approaches to work place education in two similar kinds of work places. 7. indicators are quantified measurements that can be repeated over time to track progress toward the achievement of objectives. They are normally expressed as numbers, proportions, percentages or rates. Impact indicators appear at first glance to have advantages over outcome indicators because they measure directly the reductions in STD incidence and prevalence that are the ultimate objectives of the program. However, the utility of impact indicators in this project is limited, for example, by the short time frame. Outcome indicators, on the other hand, are based on more reliable data (e.g., the performance of health workers or laboratory technicians) and measure variables whose improvement should lead to a decrease in the negative impact of STDs. For this reason, outcome indicators appear preferable to impact indicators for the evaluation and management of this project. Overview of Monitoring and Evaluation Strategy 8. Monitoring and evaluation activities will be the responsibility of all three levels of the project: Lel1: The central HIV/AIDS and STD Program Management Unit will have a full-time evaluation specialist, supported by technical assistance as well as an institutional contractor. The evaluation specialist will be responsible for overseeing the development and dissemination of a monitoring and evaluation plan by the contractor that will: define overall program objectives; formulate appropriate evaluation criteria and indicators; identify appropriate data sources and determine how often indicators will be measured; and -60- ANNEX 4 describe a strategy for feedback and use of the data for ongoing project management. 9. The evaluation specialist will be responsible for explaining and developing a commitment to the evaluation among those participating in project implementation. Close coordination with evaluation experts at the National AIDS Commission will be essential. 10. The central evaluation specialist will have primary responsibility for overseeing monitoring and evaluation of all central components of the project, including feedback and data use. 11. The central evaluation specialist will work closely with evaluation specialists from Jakarta and Riau to ensure consistency between central and provincial level evaluation plans. He/she will also help the provincial evaluation specialists by providing guidance to evaluation planning and implementation by local implementing groups. Level II: Each provincial project implementation unit will hire an evaluation specialist who will serve as the key link between central project staff and implementing agencies as concerns implementation of the monitoring and evaluation component. She/he will be responsible for coordinating monitoring and evaluation activities among similar groups or similar interventions involving more than a single front-line implementing unit. Level III: Pursuant to the pilot nature of this project and consistent with the Ministerial decree which states that "because of the importance of monitoring and evaluation in the strategy [for HIV/AIDS prevention] all plans of all organizations/groups should include time, budget and staff for this purpose", all implementing agencies will be required to undertake monitoring and evaluation activities as part of their terms of reference for implementation of project- supported activities. NGOs and other groups will be assisted in this task by the provincial evaluation specialist, technical assistance consultants and appropriate technical staff from management units. Evaluation Contractor 12. The comprehensive and pilot nature of this project presents important challenges for evaluation. For this reason, the central HIV/AIDS and STDs Management Unit will seek proposals from institutions and organizations in Indonesia with the expertise and management capacity to provide all evaluation services require by the project. Services would be provided by the resident experts of the institution; in some cases, specific components of the evaluation, e.g., KABP surveys, or health provider surveys or focus group discussions of CSWs participating in project activities, could be subcontracted to other groups or individual consultants. -61- ANNEX 4 13. The evaluation contract would be managed by the evaluation specialist in the Program Management Unit. -62- ANNEX 4 Table 1: Designated Performance Indicators Indicators Data Source Level of Collection Frequency I. Goal: Improved Awareness and Behavioral Change in Key Groups 1. Percent of CSWs seen by providers for STDs who: Exit Interviews Sentinel Surveillance Quarterly Sites - can describe correct use of a condom according to standard guidelines - can explain where and how they most recently obtained condoms - have a positive attitude toward consistent, correct condom use 2. Percent of CSWs in Survey NGOs and province/ Yearly "localisasis" reached by project district staff who report ever use of condom and use in last sexual act. 3. Percent of persons by target Exit Interviews NGOs and other Quarterly group leaving group education implementation agencies sessions who: - can cite at least 2 means of STD prevention - state that HIV is a special type of STD - state that a person can remain healthy for several years but still transmit the virus - express the importance of positive family attitudes toward a member with AIDS 4. Percent of STD patients Clinic/patient Providers at Sentinel One day per month reportedly seeking care within 24 record Sites hours of noting symptoms H. Goal: Improved Knowledge and Skills of Health Providers 5. Percent of health workers Surveys of Health center - Every six months, trained in syndromic approach observations of conducted by province beginning six months who, 6 months after training can: randomly selected & center personnel after first training health workers workshops -63- ANNEX 4 Indicators Data Source Level of Collection Frequency - demonstrate appropriate use of flow chart - demonstrate how to use a condom - explain the importance of treating STDs as a way of preventing AIDS III. Goal: Establish Effective Surveillance Mechanisms 6. Reported condom use with Periodic surveys Population-based Twice yearly non-regular sex partners (conducted by center staff or contracted out) - #people aged 15-49 who reported condom use in most recent act of sex intercourse with a non-regular partner - # of people aged 15-49 reporting sexual intercourse with a non- regular sex partner in the past month 7. Reported STD incidence - Periodic surveys Sentinel Surveillance Monthly (MEN) Sites (reported episodes of Syphilis in men aged 15-49 - past month) (men aged 15-49, surveyed) 8. STD incidence - (WOMEN) Periodic surveys Sentinel Surveillance Monthly Sites (reported women aged 15-24, positive for syphilis) (pregnant women aged 15-24) IV. Goal: Enhance Capabilities and Proficiency of Health Laboratory System 9. Performance on bi-annual Competency Laboratory Every six months proficiency panel (Competency Reports Report) 1 -64- ANNEX 4 Table 2: Process Indicators - IEC/Behavioral Change Indicators Data Source Level Of Collection Frequency - Number of group education Activity reports from Province Monthly sessions (packages) conducted by agencies each province - Number of peer group education Agency reports Province Monthly sessions conducted by each province - Percent of health providers having Agency reports Province Monthly received basic training in AIDS awareness and infection control by province - Number of educational materials M.I.S. Province Quarterly printed and distributed by province by target group - Percent of factories/companies who Survey Province Yearly have participated in educational programs (CEOs, managers, supervisors) who develop formal policies related to HIV/AIDS in the workplace - Percent of registered CSWs who Survey Province Annual have participated in at least one peer group education session within the past 3 months - Number of NGOs involved in M.I.S. Province Annual implementing IEC activities - Percent of schools reached by M.I.S. Province Annual project that have organized peer group programs - Number of condoms distributed by M.I.S. Center & provinces Annual each project management unit to NGOs providing IEC services - Number of implementing agencies Reports Province Annual that have conducted focus group discussions or other activities to solicit feedback from those served by the NGOs - Percent of implementing agencies Supervision reports Implementing agency Bi-annual who report at least I supervisory visit and/or activity by PMU staff during past 6 months reports -65- ANNEX 4 Indicators Data Source Level Of CoHection Frequency BIOMEDICAL SERVICES 1. # of syndromic training workshops Activity report Province Monthly conducted by province 2. # of condoms distributed by Activity report Province Monthly central province health dept. 3. # of condoms distributed health Surveys of selected Clinic province Quarterly centers/clinics as a numerator of # health centers received SURVEILLANCE 1. # of health workers trained in new Activity report Province Monthly surveillance methods 2. # of supervisory visits made by Activity report Center/province Monthly central and provincial level staff surveillance HEALTH LABORATORIES Equipping Individual Facilities 1. Completion of Materials Checklist Routine Laboratory First year by each laboratory 2. Completion of Readiness Report Reports Laboratory First year by each laboratory Assessment of Testing Capabilities 1. Completion of Knowledge Readiness/inspection Laboratory First year Assessment (written) reports 2. Performance on Proficiency Panel Of Sera: a) ability to determine CD3/4/8 Proficiency panel Laboratory Twice yearly levels by flow cytometry Laboratory Twice yearly b) ability to determine p24 levels Proficiency panel Laboratory Twice yearly c) ability to perform Chlymadia Proficiency panel Final Assessment OfPreparedness 1. Visitation and completion of the Reports Laboratory Every year Inspection Report Monitoring 1. Second year visitation and Inspection reports Laboratory Second year Inspection Report -66- ANNEX 5 INDONESIA HIV/AIDS AND STDs PREVENTION AND MANAGEMENT PROJECT PROJECT IMPLEMENTATION PLAN Project Management 1. The worldwide AIDS epidemic has only developed during the last decade. Indonesia itself is in the early stages of the epidemic and no one is certain how fast the epidemic will spread. Nonetheless, the potentially devastating impact of HIV/AIDS demands an early mobilization on resources to prevent the outbreak of a large epidemic in Indonesia. Institutional structures normally evolve over time and are not easily able to respond sudden changes, such as the AIDS epidemic. Therefore, it is necessary to establish functional arrangement to ensure that the MOH is able to meet the increased demands for responsibilities and tasks involved with the HIV/AIDS. Thus, the project will support the establishment of management arrangements which will support overall activities of the MOH in the area of AIDS prevention and relief, as well as the activities of the World Bank-supported project itself. 2. Another consideration in establishing management arrangements is the National AIDS Commission, recently established by a Presidential Degree. This commission is under the Coordinating Ministry for People's Welfare and is responsible for coordinating the work of all department, agencies and community organization in HIV/AIDS related activities. This intersectoral group also has similar commissions at the provincial and district level which are directly under local governments. The project will support the work of these commissions and establish linkages with the health sector at all levels. Central Level 3. A management unit, called the Management Unit for the HIV/AIDS and STDs Prevention and Management Program (PMU) will be established in the Ministry of Health to guide the planning and technical support for implementing all activities related to HIV/AIDS and STDs within the MOH. STDs has been included in this unit since the major medical strategy to prevent HIV/AIDS in Indonesia is to reduce the incidence of STDs. All work within the MOH will be coordinated by this unit and it will serve as the major gateway to the other sector, by way of the National Aids Commission. The head of this unit reports directly to the Director General of Communicable Disease Control and Environmental Health (CDC/EH) in the ministry. The Unit has subunits for technical support planning, monitoring and evaluation and administration. 4. The Unit will be responsible for planning all MOH activities related to STDs and HIV/AIDS and providing technical support for their implementation. This will include the activities in the World Bank-supported project. However, policy and formal decision- -67- ANNEX 5 making (such as budget authorizations) will be made by officials in the formal MOH structure. Depending on the decisions of the Director General of CDC/EH, staff within the Directorate General may be seconded to work in this unit and report directly to the head of the Unit. Whenever necessary, the Director General may consult with other Directors General or the Secretary General to second staff from outside the Directorate General for Communicable Diseases Control and Environmental Health. 5. The Unit will also have responsibilities to other donor-assisted activities related to STDs and HIV/AIDS which will be implemented by the MOH. The Planning, Monitoring and Evaluation subunit will be responsible for monitoring the implementation of various donor-assisted projects and to guide the scheduling of all activities related to these. The Technical Support subunit will work closely with all projects to ensure the development of appropriate technical materials and to disseminate these materials to other projects and regions which might use them. Donor agencies other than the World Bank will be encouraged to assign staff or consultants to work in this subunit if this is beneficial. However, all donor-supported staff and consultants assigned to this subunit will be directly responsible to the Unit Head, who will in turn be accountable to the donor agencies as needed. 6. The PMU will facilitate MOH support for and communications with the National AIDS Commission. For example, if the National AIDS Commission requests support from the MOH to work with other sectors or to provide technical information or reports, the unit will identify who should provide this support and to follow-up with its implementation. If the MOH requires the involvement of other sectors or departments, the Unit will be responsible for bringing this need to the attention of the National Aids Commission. (a) Technical Support Subunit - This subunit will be responsible for developing national STD and HIV/AIDS program protocols and materials, as well as to provide technical support to provincial staff involved with these programs. This will include biomedical aspects such as the case management of STDs and HIV/AIDS patients, surveillance activities for HIV/AIDS, diagnostic services for these diseases and universal precautions for health workers and STDs. Because of the importance of behavioral change in combating STDs and HIV/AIDS, the subunit will include IEC (Information, Education and Communications) and evaluation specialists. They will concentrate on interventions to reduce high-risk behavior related to the spread of STDs and HIV/AIDS activities. This will involve development of IEC materials and training materials, such as modules and IEC materials and training materials, such as modules for training STD counselors. Some development work will be carried out by subunit staff, while other will be assigned to research units and universities. This subunit will be responsible for evaluating the effectiveness of such protocols and materials, either through consultant services or studies. The division would be responsible for drawing up -68- ANNEX 5 terms of reference (TOR) for consultants and studies, as well as to monitor performance in these assignments. Subunit staff will also be responsible for providing technical support for provincial staff involved with STDs and HIV/AIDS activities. Materials and protocols will be sent to these staff, training will be provided as needed and there will be periodic visits to the provinces to assess progress and assisting in solving problems with implementation of program activities. (b) Planning, Monitoring and Evaluation Subunit - The main responsibilities of this subunit are to plan the smooth execution of all activities involved with STDs and HIV/AIDS. This will start with activities related to the national budget and activities supported by the World Bank project. Eventually, this subunit will also be responsible for activities supported by other donor agencies. In order to make appropriate plans, the subunit will also monitor the implementation of existing activities being carried out at the central level, and to compile monitoring reports received from all provinces. If possible, this will also include performance indicators, although formal evaluations will be carried out by the Technical Division. This should provide a clear picture of the implementation of overall activities related to STD and HIV/AIDS. Each year, the subunit will be responsible for preparing the draft plan and budget for the following year's activities at the central level, and to compile provincial plans and budgets. As new national and donor assisted projects are being prepared, this subunit will plan an active role in identifying special needs and drawing up plans for the period of the proposed project. Monitoring of activities in the province will be the responsibility of the Provincial Health Office. However, this subunit will prepare monitoring protocols and guidelines, help train provincial staff and undertake periodic visits to support provincial activities. (c) Administrative Subunit - This section will be responsible for providing administrative support to all staff in the PMU. This will involve the normal administrative procedures needed to release, use and account for expenditures by the PMU. It will also include financial monitoring to track current expenditures and compare these to budgets. Contracts for consultant services and studies would be drawn up and implemented by this section. Especially for the World Bank project, the subunit would be responsible for administrative issues involving the Bank, including procurement, communications with the Bank and the monitoring of loan disbursements. Some of these activities would also be allocated to provincial and district staff, under the guidance of this subunit. Steering Committee 7. A Steering Committee will be established composed as follows: -69- ANNEX 5 Chairperson : Secretary General of MOH Vice-chairperson I : Director General of CDC/EH Vice-chairperson II : Chairperson of the NAC's Working Group Secretary : Chief of the Planning Bureau, Ministry of Health Members : 1. Bureau Chief for Social Welfare, Health and Nutrition, Bappenas 2. Director II of Budget, Ministry of Finance 3. Director of Budget Administration, Ministry of Finance 4. Director of Regional Development, MOHA 5. Head of the Secretariat of Directorate General of CDC/EH 6. Project Manager Roles of the National AIDS Commission 8. The National AIDS Commission, under the Coordinating Ministry of People's Welfare or Menko Kesra, plays three key roles in supporting activities for HIV/AIDS under the project: (a) Establishment of national policies regarding AIDS - As the AIDS epidemic develops, there will be many issues which must be decided at the highest levels. For example, what will happen if HIV victims are fired from their jobs or released from health insurance coverage? Should children with HIV be allowed to attend school? Issues such as these involve many sectors and may require the drafting and implementation of new laws and regulation. Decisions should only be made after investigation of all sides of the issues and consideration of all interests. (b) Central coordination of various ministries and agencies involved with HIV/AIDS - The activities of all departments and agencies should be in line with national priorities and agreed targets. The commission should be responsible for communicating with each sector to ensure that all work is -70- ANNEX 5 being done, to prevent duplication of programs and to avoid conflicting messages or programs. (c) Support the effective coordination of local AIDS Commissions - Actual coordination of the implementation of HIV/AIDS related activities will be done at the local levels under the local government. Local AIDS commissions have been established to support this work and to encourage various actors to work and plan together. The National AIDS Commission should support the work of the Provincial AIDS Commissions by providing effective training and materials (such as guidelines for preparing provincial AIDS plans or for monitoring the work of various sectors), and to make periodic visits to AIDS Commissions to explain national policies and to help solve local problems related to coordination and planning. 9. The project will strengthen the capacity of Menko Kesra in these roles and provide funds for implementing activities involving these during the course of the project. District or Municipal Level 10. The implementation of interventions related to STDs and HIV/AIDS will be the responsibility of the district or municipal level. Furthermore, since conditions and capacities vary from region to region, the district or municipality will be responsible for determining the specific mix of interventions in the region and to decide which institution and individuals are responsible for implementing them. 11. At this level, the bupati (chief district official) or wali kota (mayor) are responsible for the overall implementation of AIDS related activities, as described in the Presidential Decree. The mechanism for doing this is the District or Municipal AIDS Commission headed by the bupati or wali kota. Membership of this commission consists of all local units or agencies involved in AIDS work, along with representatives from local NGOs. 12. Under this project, the bupati or wali kota will have the overall responsibility for implementation. However, in practice, he or she will delegate this authority to other local officials. In the project, there will be two centers of delegation. First, activities fully under the implementation of the health departments will be delegated to the Head of the District/Municipal Health Office (Dinas Kesehatan Tingkat II or DinKes II). Funds will be budgeted for this work through the APBN DIP in the health sector, usually through the integrated health DIP, which has a sub-project manager at the district or municipal level. 13. Responsibility for implementing activities conducted by other government units, joint activities between health and other sectors and work performed by NGOs will be delegated to a local government official, at the discretion of the bupati or wali kota. This person, called the District/Municipal AIDS Coordinator, will consult with key -71- ANNEX 5 government or NGO officials and ensure that they have adequate funds for agreed activities and are accountable for their performance. This official will also be responsible for ensuring that World Bank procedures and agreement are being followed. In addition, the District/Municipal AIDS Coordinator will use the forum of the local AIDS Commission to report on AIDS-related activities and to promote an exchange of views between various government agencies and NGOs. 14. Activities will be carried out by various structural staff within the departments or sections responsible for assigned work. During the course of the project, the District/Municipal AID Coordinator and the Head of the District/Municipal Health Office will hire one full-time professional and two full-time administrative staff to assist with the functions of coordination, implementation, monitoring and evaluation. These staff may be seconded from government units or hired on a contract basis from local NGOs. Provincial Level 15. The overall role of the provincial level is to facilitate implementation of district and municipal activities in the province. This involves planning functions (determining where activities will be implemented and ensuring that budgets are prepared), providing technical support to district and municipal units (training, assessment and problem solving) and holding local units accountable for their performance (including monitoring and supervision). 16. The overall responsibility of the HIV/AIDS and STDs Prevention and Management Program is with the Governor who is also the responsible official of the Provincial AIDS Commission. The Project Director, as the responsible official of the HIV/AIDS and STDs Prevention and Management Project at the provincial level is the Assistant III (Peoples' Welfare) of the Regional Secretary, in his capacity as Chairperson/Secretary of the Provincial AIDS Commission. The Project Manager will be the responsible executing official of the Project in Region Level I is the Kakanwil for MOH. 17. The Project Implementation Unit (PIU) will be a unit within the Provincial Health Service (Dinas Kesehatan I) which is responsible for the implementation activities of the project. This unit will be established by the Local Government and is directly responsible to the Project Manager. The main function of the PIU is to cause expeditious execution of activities at the Region Level II or equivalent, primarily in terms of: (i) coordination of planning and budgeting; (ii) coordination of cross-sectoral IEC implementation; (iii) provision of technical support, such as training; and (iv) to conduct guidance/supervision and monitoring and evaluation. -72- ANNEX 5 18. The responsible official in the planning and budgeting of HIV/AIDS and STDs Prevention and Management Program at Regional Level I is the Chairperson of the provincial planning body (Bappeda). Through the AIDS Commission, a special communication forum will be formed consisting of relevant Kanwil/Dinas officials, including Social Affairs, Manpower, Education, Family Planning, with the Head of the Program Formulation and Monitoring (Kepala Bidang P2TK) with Kakanwil acting as the Secretary. 19. The PIU will include a Unit Chief supported by full time secretariat which will be responsible for the day-to-day activities. The secretariat will be headed by an Executive Secretary. The PIU will also be supported by a number of professionals (technical team). The main function of the technical team is to support biomedical activities including surveillance to be carried out under the project, behavioral interventions as well as monitoring and evaluation activities. The main functions of the Executive Secretary are as follows: (i) coordinate the cross-sectoral IEC, involving NGOs; (ii) execute and coordinate the World Bank assisted project in the province; and (iii) coordinate World Bank funded project activities with those of other donor supported projects to ensure most effective use of fund resources. INDONESIA HIV/AIDS and STDs Prevention and Management Project Summary Tasks and Three-Year Implementation Schedule 1996 3 1997 0 1998 ID Task Name 01 02 03 Q4 Q1 02 03 Q4 0Q1 02 Q3 04 01 02 1 LCENTER 2 A. IEC & Behavioral Interventions 3 1. Start-up 9 2. Needs Analysls/Program Design (5) 16 3. Develop Train-of-Trainers Modules (6) 23 4. Develop IEC Materials Packages (5) 29 5. Training of Trainers (6 groups of 30) 34 7. Ongoing Project Support 36 Annual national workshops 43 IEC research 47 Communication research 53 B. Biomedical - STDs & HIV/AIDS Services 54 1. Syndromic Approach-Various Activities 61 Supervision visits 68 2. Counsellingicondoms-Various Activities 75 Supervision visits 82 3. Universal precautions-various activities 89 Supervision visits 95 4. AIDS Awareness-Various Activities 102 Supervision visits 108 5. Treatment AIDS Patients-Activities 115 Supervision visits 115V INDONESIA HIVIAIDS and STDIs Prevention and Management Project Summary Tasks and Three-Year Implementation Schedule 1996 1997 1998 ID Task Name Q1 Q2 Q3 04 Q1 02 Q3 04 01 Q2 Q3 4 01 2 120 6. Treatment TBIAIDS Patients Activities 127 Supervision visits 132 7. Annual M&E Meeting 136 8. Research Projects (2/year) 140 9. Annual Report Preparation 145 C. Biomedical-STDs & HIVIAIDS Surveillance 147 2. Antimicrobial Sensitivity-Various Activitle 153 3. Routine Syndromic-Various Activities 159 4. Sentinel Sites-Various Activities 165 5. AIDS Cases-Various Activities 171 6. Health Providers-Various Activities 177 7. Risk Groups-Various Activities 183 8. Infection Control-Various Activities 189 9. HIV and TB-Various Activities 196 10. Monitoring & Evaluation Studies 199 11. Special Studies 203 12. Computer Training 207 13. Annual M&E Meeting 211 14. Annual Report Preparation 216 D. Biomedical - Laboratory Services 217 1. Planning Phase 220 Plan workshops INDONESIA HIV/AIDS and STDs Prevention and Management Project Summary Tasks and Three-Year Implementation Schedule 1996 1997 1998 ID Task Name Q1 02 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 224 2. Implementation Phase 225 Conduct workshops 232 3. Assessment Phase 234 Assess lab capibilities 237 Proficiency panels 246 II. JAKARTA 247 A. IEC & Behavioral Interventions 248 1. Start-up 254 2. Needs Analysis & Program Design 260 3. IEC materials 265 4. Training (301course) 266 Training-of-trainers - social workers 272 Training-of-trainers - schools 276 Training-of-trainers - community 280 Health providers 284 Workplace - doctors, paramedics) 288 Buddy training 292 5. STD/HIV Education Activities 293 Group education - high risk groups 297 Group education - workplace 301 Group education - schools 305 Peer group education - high risk INDONESIA HIVIAIDS and STDs Prevention and Management Project Summary Tasks and Three-Year Implementation Schedule 1996 1997 1998 1 ID Task Name Q1 02 Q3 Q4 Q1 Q2 Q3 04 Q1 Q2 Q3 04 01 Q2 309 Peer group education - workplace 313 Peer group education - schools 317 Follow-up activities - high risk ps 321 Follow-up activities - schools 325 Study Tours - workplace 328 6. Ongoing Project Support 335 B. Biomedical - STD & HIVIAIDs Services 337 2. Provincial seminar 341 3. IEC Meeting (blood doners) 345 4. Training - Syndromic Approach 349 5. Training - Infection Control 354 7. Provision of STD Services 358 8. Moriitoring & Evaluation 361 9. Preparation of Annual Report 366 C. Biomedical-STD & HIVIAIDs Surveillance 370 4. Purchase equipment 376 7. Monitoring & Evaluation 379 8. Preparation of Annual Report 384 D. Biomedical - Laboratory Services 385 1. Planning Phase 387 Plan Workshops 390 2. Implementation Phase INDONESIA HIV/AIDS and STDs Prevention and Management Project Summary Tasks and Three-Year Implementation Schedule 1996 1997 1998 ID Task Name Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 393 Deliver workshops 397 3. Assessment Phase 406 III. RIAU (BATAM & KEPRI) 407 A. IEC & Behavorial Interventions 408 1. Start-up 414 2. Needs Analysis & Program Design 420 3. IEC materials 425 4. Training-of-trainers (30/course in BatamlR 426 High risk groups 432 Health providers 436 5. Other Training (Batam/Riau) 438 Journalists 443 6. STD/HIV Education Activities 444 Group education - high risk groups 448 Group Education - workplace 452 Group Education - schools 456 Group Education - health providers 460 Peer Group Education - high risk group 464 Peer Group Education - workplace 468 Peer Group Education - schools 472 Follow-up Activities - high risk groups 476 Follow-up Activities - workplace INDONESIA HIV/AIDS and STDs Prevention and Management Project Summary Tasks and Three-Year Implementation Schedule 1996 1997 1998 1 ID Task Name Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 01 02 480 Follow-up Activities - schools 484 Workplace Special Occasions - CEOslR 488 Workplace Special Occasions - Health/ 493 Policyrmaker Seminar 497 Hotline Services 501 7. Ongoing Project Support 508 B. Biomedical - STD & HIV/AIDS Services 509 1. Provincial Intersectoral Meetings 513 2. District Intersectoral Meetings 517 3. Syndromic Approach Training oo 521 4. Infection Control Training 525 5. Evaluation & Planning Meetings 532 9. Preparation of Annual Report 537 C. Biomedical - STD & HIV/AIDs Surveillance 538 1. Workshops 542 2. Monitoring & Evaluation Meetings 552 D. Biomedical - Laboratory Services 553 1. Planning Phase 555 Plan Workshops 558 2. Implementation Phase 561 Deliver workshops 565 3. Assessment Phase INDONESIA HIV/AIDS AND STDs PREVENTION AND MANAGEMENT PROJECT Proposed Technical Assistance Standard TA Activity Purposel Objectives implementing Total Personl Status of TOR (DATE) Short List (DATE) Contract Responsibility for Agency (USS'000) Month Prepared (Y/N) Supetmsion Prepared Expected Prepared Expected RS1 HQ IMPLEMENTATION SUPPORT A. BEHAVIOR CHANGE Central Level International Experts Needs assessment Needs assessment/design MOH 18 1 11/6/95 TBD Y X Training Prep. TOT modules MOH 36 2 11/6/95 TBD Y X Local Experts Needs assessment Needs assessment/design MOH 12 6 11/6/95 TBD Y X Program Development Guidelines/workplace educ. MOH 12 6 11/6/95 TBD Y X NGO Capacity Development Program planninglevaluation MOH 12 6 11/6/95 TBD Y X Provincial Level International Experts NGO Capacity Development Program planning/evaluation MOH 54 3 11/6/95 TBD Y X Program Development Guidelines/schools MOH 72 4 11/6/95 TBD Y X Workplace implementation MOH 54 3 11/6/95 TBD Y X Local Experts NGO Capacity Development Program implementation/ MOH 8 4 11/6/95 TBD Y X management Needs assessment Rapid assessment/design/training MOH 16 8 11/6/95 TBD Y X Training TOT delivery MOH 16 8 11/6/95 TBD Y X Program design Workplace MOH 8 4 11/6/95 TBD Y X : Standard TA Activity Purpose Objecies Implementing Total Person/ Status ofTOR (DATE) Short List (DATE) Contract Responsibility fDr Agency (USS'000) Month Preo N) Superision Prepared Expected Prepared Expected RS1 HQ B. STD SERVICES International Experts Syndromic diagnosis and Develop training manual MOH 18 1 11/6/95 TBD Y X treatment Assist in training of trainers MOH 18 1 11/6/95 TBD Y X Assess training programs MOH 9 .5 11/6/95 TBD Y X Infection control methodologies MOH 18 1 11/6/95 TBD Y X Local Experts Syndromic diagnosis and Develop training manuals MOH 4 2 11/6/95 TBD Y X treatment Assist in training of trainers MOH 2 1 11/6/95 TBD Y X Supervise initial training MOH 16 4 11/6/95 TBD Y X Assess training programs MOH 2 1 11/6/95 TBD Y X 00 Infection control Assess/strengthen current MOH 2 1 11/6/95 TBD Y X 0 approaches Disposal of infected materials Assess/strengthen current MOH 4 2 11/6/95 TBD Y X approaches C. HEALTH LABORATORIES International Experts Initiation of Activitics Plan national workshop MOH 9 .5 11/6/95 TBD Y X Develop education materials Monitor purchase of supplies Develop registries of information Review TORs of players Advise on establishment of Centers of Excellence Assessment of needs Workshop Coordination Lead activities for preparation and MOH 18 1 11/6/95 TBD Y X (National) conduction of national workshop Workshop Coordination Lead activities for preparation and MOH 18 1 11/6/95 TBD Y X 0 (Regional) conduction of four regional workshops Monitoring of Activities and Review proficiency testing results MOH 18 1 11/6/95 TBD Y X Laboratory Performance Assess testing algorithm effective -ss Standard TA Activity Purpose/ Objectives Implementing Total Persont Status of TOR (DATE) Short List (DATE) Cn Responsibility for Agency (USS'000) Month Prepared (Y Suprvison Prepared Expected Prepared Expected RS1 HQ Assess specialized testing activities, Centers of Excellence capabilities, some prov. labs Final assessment of program and years 1-3 Local Experts Technical Advisor Monitor testing procedure and lab. MOH 24 12 11/6/95 TBD Y X operations Compile information and coordinate technical aspects of testing and troubleshooting Provide educational materials Quality Assurance Officer Prepare assessment materials MOH 24 12 11/6/95 TBD Y X Address variances Evaluate performance Coordinate educational endeavors D. SURVEILLANCE 00 International Experts Development of HIV/STD Recommend detailed approach MOH 36 2 11/6/95 TBD Y X Sury. AIDS Case Surveillance Advise on sample methodology MOH 18 1 11/6/95 TBD Y X Anti-microbial sensitivity Advise on technical design MOH 36 2 11/6/95 TBD Y X AIDS and Tuberculosis Advise on instrument MOH 18 1 11/6/95 TBD Y X Research and special studies Advise/comment on proposals MOH 18 1 11/6/95 TBD Y X Local Experts Development of HIV/STD surveillance MOH 12 6 11/6/95 TBD Y X Computers and data analysis MOH 6 3 11/6/95 TBD Y X Anti-microbial sensitivity MOH 8 4 11/6/95 TBD Y X Research and special studies MOH 8 4 11/6/95 TBD Y X E. MONITORING AND EVALUATION TA Activitq Purposet Objectives Implementng Total Person Stamus of TOR (DATE) Short List (DATE) Standard Responsibilkty for Agenc) (USVO0) Month Contract Supervision _____________________________________ Prepared (Y/N) _________ Prepared Expected Prepared Expected S1 HQ Central Level Interational Experts System design Advise on best approach MOH 54 3 11/6/95 TBD Y X Introduce behavioral surveillance MOH 36 2 11/6/95 TBD Y X Local Experts System design Join team on behavioral MOH 12 6 11/6/95 TBD Y X surveillance Provincial Level International Experts Behavioral surveillance Introduce agreed design MOH 108 6 11/6/95 TBD Y X Local Experts Behavioral surveillance Introduce agreed design MOH 24 12 11/6/95 TBD Y X 00 International Experts 684 37 Local Experts 232 112 ON -83- ANNEX 7 INDONESIA HIV/AIDS AND STDs PREVENTION AND MANAGEMENT PROJECT Supervision Plan Timing Duration Mission Purpose Team Composition (Weeks) (Staff weeks (SW)) 1. Apr. 1996 2 Review of plans for first year implementation including: Economist * needs analyses, research, program design, and training-of- trainer Health Specialist module for IEC and Behavioral Interventions; * plans for STD/HIV services and surveillance; SW=4 * plans for data collection, staff development, and training for laboratory services; and * plans for project management and NGO participation. Field visits in Riau and Jakarta; meet with NGOs 2. Oct. 1996 2 Review: Economist * procurement and processing of contracts; Implementation Specialist * availability and channeling of funds (especially for multi-sectoral activities and NGOs); SW=4 * IEC materials development; * training plans for STD/HIV health providers; * monitoring and evaluation plans (including results of initial baseline surveys); * equipment procurement for surveillance activities; and * equipment procurement for laboratories. Field visits in Riau and Jakarta; meet with NGOs 3. May 1997 2 Review and discuss the annual plans and report; carry out post review Economist of contracts. Review project expenditures, implementation progress, Health Specialist annual plans for the IEC workshops, surveillance activities, and results of laboratory proficiency activities. Update data on performance SW=4 indicators. Field visits in Riau and Jakarta; meet with NGOs 4. Oct. 1997 2 Review of procurement plans, processing of contracts, availability of Economist funds, project management; status of research projects, service delivery Implementation Specialist and surveillance activities (including review of the design of the surveillance system). SW=4 Evaluate the training of trainers. Update data on performance indicators. Field visits in Riau and Jakarta; meet with NGOs 5. May 1998 2 Review and discuss annual implementation plans; and review: Economist * project expenditures and disbursement; Health Specialist * lEC and training activities; * establishment of the testing capacity of laboratories (including SW=4 private laboratories); * status of surveillance activities; * results of the special studies; * monitoring and evaluation results. Update data on performance indicators. Prepare for ICR. Field visits 6. Oct. 1998 2 Final review of: Economist * procurement & project expenditures; Implementation Specialist * training activities for services; * implementation of service routines; SW4 * laboratory assessments, proficiency panels, and evaluation of test kits Field visits. Complete ICR -84- ANNEX 8 INDONESIA HIV/AIDS AND STDs PREVENTION AND MANAGEMENT PROJECT Project Components by Year (Rps. '000) Base Cost 1996 1997 1998 Total A. Jakarta 1. IEC & Behavioral Interventions High Risk Groups 633,641.0 859,077.0 826,686.0 2,319,404.0 Workplace 62,565.0 163,755.0 179,580.0 405,900.0 School/University 291,586.0 481,777.0 563,857.0 1,337,220.0 Community & General Public 236,144.0 433,124.0 414,284.0 1,083,552.0 Health Providers 939,508.0 1,529,308.0 1,529,308.0 3,998,124.0 Other Support Activities 148,125.0 168,125.0 168,125.0 484,375.0 Subtotal IEC & Behavioral Interventions 2,311,569.0 3,635,166.0 3,681,840.0 9,628,575.0 2. Biomedical Services STD and HIV/AIDS Services 1,515,289.0 2,630,689.0 2,670,089.0 6,816,067.0 Surveillance 515,526.0 467,326.0 467,326.0 1,450,178.0 Laboratory Services 234,200.0 63,900.2 59,900.0 358,000.2 Subtotal Biomedical Services 2,265,015.0 3,161,915.2 3,197,315.0 8,624,245.2 3. Management & Support Project Management 577,500.0 522,500.0 522,500.0 1,622,500.0 Subtotal Jakarta 5,154,084.0 7,319.581.2 7,401,655.0 19,875,320.2 B. Riau 1. IEC and Behavioral Interventions High Risk Groups 229,752.0 243,504.0 303,504.0 776,760.0 Workplace 184,960.0 244,504.0 256,440.0 685,904.0 School/University 214,000.0 394,400.0 394,400.0 1,002,800.0 Community & General Public 310,432.0 495,292.0 488,292.0 1,294,016.0 Health Providers 232,600.0 483,600.0 483,600.0 1,199,800.0 Other Support Activities 437,500.0 240,500.0 239,500.0 917,500.0 Subtotal IEC and Behavioral Interventions 1,609,244.0 2,101,800.0 2,165,736.0 5,876,780.0 2. Biomedical Services Protection of the Blood Supply 848,410.0 166,385.0 136,385.0 1,151,180.0 STD and HIV/AIDS Services 1,276,400.0 2,325,000.0 2,307,000.0 5,908,400.0 Surveillance 313,600.0 283,600.0 283,600.0 880,800.0 Laboratory Services 583,600.0 306,150.0 300,150.0 1,189,900.0 Subtotal Biomedical Services 3,022,010.0 3,081,135.0 3,027,135.0 9,130,280.0 3. Management & Support STD/AIDS Management 117,140.0 92,140.0 79,540.0 288,820.0 Project Management 425,500.0 357,500.0 357,500.0 1,140,500.0 Subtotal Management & Support 542,640.0 449,640.0 437,040.0 1,429,320.0 Subtotal Riau 5,173,894.0 5,632,575.0 5,629,911.0 16,436,380.0 C. Center I. IEC & Behavioral Interventions High Risk Groups 320,353.3 325,453.3 325,453.3 971,259.9 Workplace 277,353.3 289,453.3 289,453.3 856,259.9 School/University 277,353.3 289,453.3 289,453.3 856,259.9 Community & General Public 302,853.3 263,953.3 289,453.3 856,259.9 Health Providers 277,353.3 289,453.3 263,953.3 830,759.9 Other Support Activities 882,200.0 851,700.0 911,700.0 2,645,600.0 Subtotal IEC & Behavioral Interventions 2,337,466.5 2,309,466.5 2,369,466.5 7,016,399.5 2. Biomedical Services ST) and HIVAID)S Services 1,454,932.0 1,216,432.0 699,900.0 3,371,264.0 -85- ANNEX 8 Base Cost 1996 1997 1998 Total Surveillance 3,122,757.0 1,772,130.0 1,701,530.0 6,596,417.0 Laboratory Services 4,163,675.0 4,489,300.0 4,827,400.0 13,480,375.0 Subtotal Biomedical Services 8,741,364.0 7,477,862.0 7,228,830.0 23,448,056.0 3. Management and Support STD/AIDS Management 565,000.0 565,000.0 225,000.0 1,355,000.0 Future Project Preparation - - 365,000.0 365,000.0 Project Management 534,000.0 501,000.0 501,000.0 1,536,000.0 Subtotal Management and Support 1,099,000.0 1,066,000.0 1,091,000.0 3,256,000.0 Subtotal Center 12,177,830.5 10,853,328.5 10,689,296.5 33,720,455.5 Total BASELINE COSTS 22,505,808.5 23,805,484.7 23,720,862.5 70,032,155.7 Physical Contingencies 1,125,290.4 1,190,274.2 1,186,043.1 3,501,607.8 Price Contingencies 544,067.5 1,857,706.0 3,136,767.9 5,538,541.4 Total PROJECT COSTS 24,175,166.5 26,853,464.9 28,043,673.5 79,072,304.8 Taxes 1,182,579.8 1,079,199.2 1,164,886.8 3,426,665.8 Foreign Exchange 9,085,753.6 8,055,390.1 8,500,319.1 25,641,462.8 Expenditure Accounts by Year (Rps. '000) Base Cost Foreign Exchange 1996 1997 1998 Total % Amount 1. Investment Costs A. Equipment 3,516,201.0 1,766,976.0 1,802,376.0 7,085,553.0 80.0 5,668,442.4 B. Vehicles 200,000.0 - - 200,000.0 90.0 180,000.0 C. Technical Assistance & Studies Foreign Consultants 480,800.0 430,800.0 410,800.0 1,322,400.0 80.0 1,057,920.0 Local Consultants 384,782.0 307,682.0 307,650.0 1,000,114.0 5.0 50,005.7 Studies & Research 2,128,165.0 1,113,180.0 1,317,580.0 4,558,925.0 20.0 911,785.0 Subtotal Technical Assistance & Studies 2,993,747.0 1,851,662.0 2,036,030.0 6,881,439.0 29.4 2,019,710.7 D. Instructional Materials 2,737,065.5 2,540,381.5 2,498,925.5 7,776,372.5 30.0 2,332,911.8 E. Reagents (Center) 2,462,500.0 2,889,500.0 3,316,500.0 8,668,500.0 80.0 6,934,800.0 F. Fellowships Overseas 815,000.0 875,000.0 755,000.0 2,445,000.0 100.0 2,445,000.0 Domestic 88,000.0 52,000.0 40,000.0 180,000.0 10.0 18,000.0 Subtotal Fellowships 903,000.0 927,000.0 795,000.0 2,625,000.0 93.8 2,463,000.0 G. Training & Workshops 5,089,654.0 8,225,801.2 7,704,967.0 21,020,422.2 10.0 2,102,042.2 H. Grants 220,000.0 526,000.0 526,000.0 1,272,000.0 - - I. Administrative Costs 1,328,140.0 1,458,140.0 1,470,540.0 4,256,820.0 10.0 425,682.0 Total Investment Costs 19,450,307.5 20,185,460.7 20,150,338.5 59,786,106.7 37.0 22,126,589.1 It. Recurrent Costs A. Operations & Maintenance 313,532.0 408,235.0 416,235.0 1,138,002.0 - B. Supervision & Travel 922,080.0 1,138,700.0 1,138,700.0 3,199,480.0 - - C. Supplies & Condoms 1,241,289.0 1,494,489.0 1,436,989.0 4,172,767.0 - - D. Reagents (Provinces) 578,600.0 578,600.0 578,600.0 1,735,800.0 80.0 1,388,640.0 Total Recurrent Costs 3,055,501.0 3,620,024.0 3,570,524.0 10,246,049.0 13.6 1,388,640.0 Total BASELINE COSTS 22,505,808.5 23,805,484.7 23,720,862.5 70,032,155.7 33.6 23,515,229.1 Physical Contingencies 1,125,290.4 1,190,274.2 1,186,043.1 3,501,607.8 33.6 1,175,761.5 Price Contingencies 544,067.5 1,857,706.0 3,136,767.9 5,538,541.4 17.2 950,472.3 Total PROJECT COSTS 24,175,166.5 26,853,464.9 28,043,673.5 79,072,304.8 32.4 25,641,462.8 Taxes 1,182,579.8 1,079,199.2 1,164,886.8 3,426,665.8 - - Foreign Exchange 9,085,753.6 8,055,390.1 8,500,319.1 25,641,462.8 - - -86- ANNEX 9 INDONESIA IHIV/AIDS AND STDs PREVENTION AND MANAGEMENT PROJECT Estimated Schedule of Disbursements Disbursements IBRD Fiscal Amount per Cumulative Disbursement Profile /a Year Semester Amount % % (US$ million) 1996 2 0.0 0.0 0 0 1997 1 4.0 4.0 16 3 2 4.5 8.5 34 6 1998 1 4.5 13.0 52 10 2 4.5 17.5 71 14 1999 1 4.5 22.0 89 26 2 2.8 24.8 100 38 Project Completion Date: March 30, 1999 Project Closing Date: September 30, 1999 a/ Latest standard disbursement profile for health projects in Indonesia (November 1995). -87- ANNEX 10 INDONESIA HIVIAIDS AND STDs PREVENTION AND MANAGEMENT PROJECT Procurement Plan: Contracting and Review Responsibilities Total Estimated Documnts Value Contract DIP Procurement Kind of Review Required for No. Category (US$ M) Quantity Allocation Method Review/a By/b Disbursemt I Equipment 3.4 Contract<$50,000 1.0 20 Province Shopping Random SPN SOE Post Contract<$200,000 1.7 10 Pro./Dist. NCB Random SPN SOE Post Contract>S200,000 0.7 3 Center ICB Prior TM Full 2 Reagents (Center) 4.3 N/A Center ICB Prior TM Full 3 Instructional Materials 3.9 Small <$50,000 1.0 10 Pro./Dist. Shopping Random SPN SOE Post Medium<$200,000 1.0 5 Province NCB Random SPN SOE Post Large>$200,000 1.9 8 Cen./Pro. NCB Prior RSI Full 4 Consultancy, Studies 3.4 Firm <$100,000 1.3 20 Cen./Pro. Short list Limited RSI SOE Prior Individual <$50,000 1.3 10 Cen./Pro. Short List Limited RSI SOE Prior Others/c 0.8 2 Central Short List Prior TM Full 5 NGO Grant 0.7 Contracts<$100,000 0.5 N/A /d Province Others Limited TM SOE Prior Contracts>$100,000 0.2 2 Province NCB Prior TM Full 6 Fellowships 1.3 N/A Cen./Pro. Others Limited RSI SOE Prior 7 Training/Workshops 10.7 N/A Pro./Dist. Others Random SPN SOE Post 8 Project Management 2.2 N/A Cen/Pro/ Others Random SPN SOE Dist Post al Prior review, random post review, and limited prior review (TOR, proposed program and draft contract). b/ Supervision missions, Resident staff Indonesia, task manager. c/ Firm>100,000; Individual>50,000. d/ Not applicable. -88- ANNEX 11 INDONESIA IIIV/AIDS AND STDs PREVENTION AND MANAGEMENT PROJECT ECONOMIC ANALYSIS OF AIDS EXPENDITURES 1. This annex explains how the project benefits discussed in Chapter 5 were calculated. This section also touches on other important dimensions of project economic analysis, following EAP's guidelines on this topic. 2. Estimating the number of AIDS cases: the iwg-AIDS model. Using Jakarta as an illustration, the number of AIDS cases 10-15 years from now was estimated using the iwg-AIDS, a deterministic model formulated by S.Seitz at the University of Illinois in 1989. The fourth revision of the iwg-AIDS model was used by M. Linnan, United States Centers for Disease Control, in developing the projections for Indonesia which are discussed below. Iwg-AIDS incorporates four interacting processes: demographic (births, deaths, migration); host/virus contact (infectivity per contact, susceptibility per contact, circumcision, and other factors bearing on risk of infection); sexual mixing factors (marriage, divorce, rate of sexual contacts and number of partners); and modes of infection (sexual, intravenous drug use, transfusion, and perinatal). Parameters relating to these processes were taken from available data, or were estimated by Indonesian experts. 3. Some of these parameters are as follows: * Demographics: Birth, death, and migration data were drawn from the 1980 and 1990 censuses. The population is assumed to be 9 million. * Host/virus contact: Virus specific parameters were based on the major strains being transmitted, which are related to those which predominate in Thailand. The HIV "seed" used was 1000 in 1990. Infectivity and susceptibility were based on the Thai strains. Circumcision rates were assumed to be 90%, and condom use rates were estimated at 10% for high risk groups and below 5 percent for other groups. STD rates were set according to risk groups. Inflammatory rates fell in the 0-12% range for sexually active adults, and ulcerative rates were in the 0-10 % range. * Sexual mixing: Marriage and divorce rates were taken from the 1990 census and cross checked with community surveys. Estimates for number of partners, sexual contact rates, and sexual behavior specific parameters were drawn from community surveys in urban Java and adjusted as needed by Indonesian experts. * Mode of infection: all modes were built into the model; however, sexual contact accounts for 95% of infections. 4. Projection results. Based on the above parameters, a baseline projection was run, which yielded the number of HIV-infected persons and number of persons with AIDS in -89- ANNEX 11 Jakarta at the mid-point of the year noted ( Annex 13, Tables 1 and 2, and Figure 1). The baseline case projection was also used to observe the impact of project-related interventions. Project impacts were introduced through various assumptions about the phasing in of interventions and their eventual effectiveness. For example, service interventions were assumed in scenario 2 (Annex 11, Tables 1 and 2) to be phased in over two years, begininning in 1997, and to have achieved a 25 percent reduction in STDs at the end of that two year span. Also in scenario two, the behavior change interventions were assumed to take two years of piloting before becoming fully effective and to result in a 25 percent decrease in specific risk behavior (casual sex, multiple partners, and so forth) and a 25 percent use rate for condoms. The final effectiveness figures were chosen in light of what has been achieved through comparable programs in other developing countries. Scenario three assumes a five year phasing in of the project but with the same ultimate effects as in scenario two (Annex 11, Tables 1 and 2), while scenario four assumes a five year phasing in of the project and ultimate impacts which are 50 percent of those in scenarios two and three. 5. Benefits--direct treatment costs. Treatment costs for AIDS patients were estimated from data collected at Cipto Mangunkusomo Hospital in Jakarta and from consultations with private hospitals (Annex 1). Costs included outlays on drugs, AIDS tests, outpatient visits and hospital stays. Patients are assumed to live one year after developing full blown AIDS. The estimated treatment cost in 1995, US$2700, represents the arithmetic mean of costs in public and private facilities. AZT was not included in the standard treatment regime and in the estimate of per patient costs, even though some patients in private hospitals are being given this antiretroviral (which is brought in from Singapore). At an 8 percent discount rate, the present value of these costs amounts to US$1251 per patient in 2005 and US$851 per patient in 2010; using a 10 percent discount factor these figures come to US$1041 in 2005 and US$646 in 2010. 6. Benefits--indirect costs. The indirect costs of AIDS are assumed to be the product lost to the economy due to the death of adults of working age. An average loss per AIDS death of 25 years is assumed, and the provincial product per adult in Jakarta, US$3400 in 1995, is used as the marginal product of labor. This figure is assumed to grow at an annual rate of four percent. The estimate of per adult product is reduced by 20 percent in light of the disproportionate representation of lower income, possibly unemployed individuals amongst those who get AIDS. Using an eight percent discount rate, the present value of income lost for each person with AIDS in 2005 is US$29,132; the estimate for individuals with AIDS in 2010 is US$24,118. Using a ten percent discount rate, these figures come to US$19,840 in 2005 and US$14,990 in 2010. 7. Project costs and benefits--net present value. The province of Jakarta will spend US$8.8 million through this project to prevent HIV transmission, and an additional US$2 million will be spent under the central MOH budget through this project on activities in Jakarta, resulting in overall project spending of roughly US$11 million. The overall benefits attributable to the project were derived for different scenarios and discount rates ( Annex 11, Table 5); a notional rate of return was calculated for each cost and benefit -90- ANNEX 11 stream (scenario). For each scenario, the cumulative number of deaths averted was multiplied by total direct and indirect benefits per person for 2005 and 2010. For the second scenario and using an 8 percent discount rate, total benefits, i.e. the direct and indirect costs which are saved, are US$327 million through 2005 and US$1.78 billion through 2010. The net present value of the combined benefits and outlays expected in this scenario is US$140 for 2005 and US$551 for 2010. In scenarios three and four, the net present value of the combined benefits and outlay stream is lower. For scenario three, these amount to US$96 for 2005 and US$314 for 2010. For scenario four, the figures are US$20 for 2005 and US$114 for 2010. Estimated net benefits, in present value terms, using a 10 percent discount rate are shown in Table 5. In sum and looking ahead only as far as 2005, the net present value of the project is quite substantial even when a 10 percent discount rate is applied. This is also the case when 2010 is taken as the cut-off point. Perhaps, an even stronger economic rationale for the project emerges when the number of HIV cases averted under the different scenarios, e.g., 90,000-12 1,000 in 2005, is brought into the analysis. The projected cost per averted HIV infection is approximately US$110, and if each HIV case causes a loss on average of at least ten discounted "disability adjusted life years," then the project is purchasing a year of healthy life for roughly US$11. Finally, taking account of individuals' willingness to pay (WTP) to avoid pain, discomfort, and restrictions on non-work activities provides further justification for the project. One recent study estimated that the implied value of a statistical life in Indonesia was in the US$75,000-175,000 interval (World Bank, 1994). This range of values is 2.5-5 times the estimated direct and indirect benefits per case discussed above. 8. More conservative premises. Scenarios were also developed based on more conservative but unrealistic assumptions about risky behavior (Tables 3,4 and 6). Specifically, couples were assumed to be monogamous and casual sex rates were reduced. Despite such strigent and highly optimistic premises, the net present value of the project remains very high under different scenarios, even when the impact of interventions is phased in over five years and at reduced effectiveness and when a higher discount rate is used. Moreover, the project retains its economic rationale even when direct and indirect benefits (costs) per case are reduced by 50 percent (Table 6). Checklist of Topics for Economic Analysis 9. Linkage to CAS and ESW. The rationale for Bank involvement in Indonesia's health sector is set out in the February 1995 CAS. That document identifies human resource development including health as one of the focal points for Bank assistance, and points to quality improvements through better resource use as an important challenge within the health sector. This project is consistent with the approach the Bank has taken towards quality improvement in other health projects: there is a focus on local epidemiological needs and priorities and an emphasis on involving local authorities and NGOs in designing and implementing interventions; efforts will be made to improve availability of skills, drugs, and other inputs and to enable central units to provide whatever technical assistance is needed. No formal ESW has been completed on HIV in -91- ANNEX 11 Indonesia, but the Bank has used boxes in recent Indonesia CEMs and informal notes to sustain a dialogue with GOI about AIDS. AIDS became part of the ongoing policy dialogue with GOI in 1992, with discussion turning increasingly to the details of program and policy design. 10. Analysis of alternatives. The alternatives which were reviewed and rejected included not responding with AIDS-related policies and interventions, at least in the near term, and relying exclusively on government staff and facilities to deliver HIV-related services. This topic is discussed further in the SAR, para.3.3. Also of relevance is the paucity of lessons learned from projects in other countries. Most reported successes are for limited trial initiatives which have been affected by various contextual factors. As a pilot effort, this project is intended to help identify and explore various alternative approaches, thereby generating Indonesia-specific examples which can help shape national policy. 11. Fiscal analysis and cost recovery. The fiscal impact of this small scale pilot project is negligible. Many of the STD-related services to be strengthened are in the private sector where cost recovery is extensive; fees and charges are also relatively high in public facilities. A large share of project expenditures are one-time outlays, e.g., on training, laboratory upgrading and health education campaigns, which will not need to be funded at similar levels later on. Sustainability is built into the project in other ways including the emphasis on monitoring and evaluation, and the extensive involvement of local governments and NGOs. 12. Benefit-cost analysis. Using a range of assumptions, project benefits under different scenarios were estimated and compared to estimated project expenditures (see above). Some sensitivity analysis was carried out in regard to different assumptions about sexual behavior and for different discount rates. 13. Institutional analysis. Institutional issues are paramount in this project. The role allocated to NGOs stems in part from concerns that government agencies and staff would be unable to communicate effectively with and deliver services to many of those engaging in high risk behavior. Similarly, the differentiation of roles at different levels of government that is a defining feature of the design reflects an assessment that central MOH can best play a technical support function. 14. Poverty analysis. The likely higher incidence of HIV amongst the poor is highlighted in Chapter 1 of the SAR. The prospective poverty impacts of the project are summarized in para. 5.8 of the SAR. 15. Environmental analysis. The project will support a study on current waste disposal practices and recommended alternatives. 16. Economic performance criteria. The indicators agreed with GOI for project peformance assessment are discussed in Chapter 3 of the SAR. -92- ANNEX 11 Table 1: Projections of Persons with AIDS, Jakarta Various Scenarios With and Without Project PWA(1) CPWA(1) PWA(2) CPWA(2) PWA(3) CPWA(3) PWA(4) CPWA(4) 1993 75 300 75 300 75 300 75 300 1995 375 3000 375 3000 375 3000 375 3000 2000 3800 23000 3750 21000 3775 22500 3775 21500 2005 8500 55000 7400 50000 7800 51500 8000 54000 2010 17500 123000 13500 100500 15000 110000 15700 118000 PWA= persons with AIDS CPWA= cumulative persons with AIDS Scenarios: (1) Baseline, no project. (2) Project begins in 1997, 3-year start-up, full impact (25%) by 2000. (3) Project begins in 1997, 5-year start-up, full impact (25%) by 2000. (4) Project begins in 1997, 5-year start-up, full impact (12.5%) by 2000. Table 2: Projections of Persons with HIV, Jakarta Various Scenarios With and Without Project PWH(1) CPWH(1) PWH(2) CPWH(2) PWH(3) CPWH(3) PWH(4) CPWH(4) 1993 2500 12500 2500 12500 2500 12500 2500 12500 1995 8500 35000 8500 35000 8500 35000 8500 33000 2000 42500 80500 41000 75000 41500 70500 42000 77000 2005 75500 260000 63500 139000 68500 155000 71500 170000 2010 140000 340500 99500 241000 115000 250000 126500 320000 PWH= persons with HIV CPWH= cumulative persons with HIV Scenarios: (1) Baseline, no project. (2) Project begins in 1997, 3-year start-up, full impact (25%) by 2000. (3) Project begins in 1997, 5-year start-up, full impact (25%) by 2000. (4) Project begins in 1997, 5-year start-up, full impact (12.5%) by 2000. -93- ANNEX 11 Figure 1: Projections of Persons with AIDS, Jakarta Various Scenarios With and Without Project 140000 120000 CMA(3) 100000 CPWA(l) CPWA(2) 80000 60000 40000 CPWA(4) 20000 0 1993 1995 2000 2005 2010 Figure 2: Projections of Persons with HIV, Jakarta Various Scenarios With and Without Project 350000 300000 CPWH(3) 250000 WHf(4) 200000 WH(1) 150000 CPWH(2) 100000 50000 0 1993 1995 2000 2005 2010 -94- ANNEX 11 Table 3: Projections of Persons with AIDS, Jakarta, Lower Sexual Activity Rates Various Scenarios With and Without Project PWA(1) CPWA(1) PWA(2) CPWA(2) PWA(3) CPWA(3) PWA(4) CPWA(4) 1993 24 100 24 100 24 100 24 100 1995 105 1050 105 1050 105 1050 105 1050 2000 1550 9300 1450 9000 1450 9150 1500 9200 2005 4600 29750 3500 27000 3750 28000 4000 28500 2010 9700 74500 6750 45000 7500 52500 9000 72500 PWA= persons with AIDS CPWA= cumulative persons with AIDS Scenarios: (1) Baseline, no project. (2) Project begins in 1997, 3-year start-up, full impact (25%) by 2000. (3) Project begins in 1997, 5-year start-up, full impact (25%) by 2000. (4) Project begins in 1997, 5-year start-up, full impact (12.5%) by 2000. Table 4: Projections of Persons with HIV, Jakarta, Lower Sexual Activity Rates Various Scenarios With and Without Project PWH(1) CPWH(1) PWH(2) CPWH(2) PWH(3) CPWH(3) PWH(4) CPWH(4) 1993 1450 7250 1450 7250 1450 7250 1450 7250 1995 3200 12800 3200 12800 3200 12800 3200 12800 2000 17500 34500 16500 33500 17000 31500 17500 29000 2005 52500 178500 35000 110000 18000 139000 52000 174500 2010 78500 191000 42000 150000 60000 168000 70000 187500 PWH= persons with HIV CPWH= cumulative persons with HIV Scenarios: (1) Baseline, no project. (2) Project begins in 1997, 3-year start-up, full impact (25%) by 2000. (3) Project begins in 1997, 5-year start-up, full impact (25%) by 2000. (4) Project begins in 1997, 5-year start-up, full impact (12.5%) by 2000. -95- ANNEX 11 Figure 3: Projections of Persons with AIDS, Jakarta, Lower Sexual Activity Rates Various Scenarios With and Without Project 80000 70000 Cp 60000 - 50000 40000 30000 CPWA(2) 20000 10000 0 1993 1995 2000 2005 2010 Figure 4: Projections of Persons with HIV, Jakarta, Lower Sexual Activity Rates Various Scenarios With and Without Project 200000 -_CPWA(l) 180000 160000 140000 120000 100000 CPWA(2) 80000 60000 40000 20000 0 1993 1995 2000 2005 2010 -96- ANNEX 11 Table 5: Estimated Economic Benefits Associated with Different Project Scenarios, Jakarta Discount rate 8% 10% 2005 2010 2005 2010 Direct medical costs 1251 851 1041 646 per case* Indirectcostsper 29132 24118 19840 14990 case* Total costs per case* 30383 24969 20881 15653 Number of cases (2) (3) (4) (2) (3) (4) (2) (3) (4) (2) (3) (4) averted by scenario 5 3.5 1 22.5 13 5 5 3.5 1 22.5 13 5 (in thousands) Net present value 140 96 20 551 314 114 94 62 10 341 192 67 (NPV) of project outlays and benefits* (US$ millions) Rate of return 41 36 20 40 35 27 38 33 17 39 34 25 * Present value Table 6: Estimated Economic Benefits Associated with Different Project Scenarios, Jakarta, Lower Rates of Sexual Activity Discount rate 8% 10% 2005 2010 2005 2010 Direct medical costs 1251 851 1041 646 per case* Indirect costs per 29132 24118 19840 14990 case* Total costs per case* 30383 24969 20881 15653 Number of cases (2) (3) (4) (2) (3) (4) (2) (3) (4) (2) (3) (4) averted by scenario 2.8 1.8 1.2 29.5 22 2 2.8 1.8 1.2 29.5 22 2 (in thousands) Net present value 84 54 36 696 538 48 57 37 25 496 370 34 (NPV) of project outlays and benefits* (US$ millions) Rateofreturn 32 27 22 43 40 19 30 24 19 41 38 18 NPV** 32 16 8 358 264 14 18 8 2 220 161 5 Rateofreturn 24 18 14 36 34 14 21 16 12 35 32 13 * Present value ** Assumes flow of benefits is reduced by 50%. BRD 27707 ----,THAILAND - INDONESIA PHanLIPPINES - HIV/AIDS AND STDs PREVENTION 13 PHILIP E AND MANAGEMENT PROJECT BRUNFJL -1 g"d" MALAYSIA MECAEA L PRONCE HEADQUARTERS NATIONAL CAPITAL ---- PRONCE BOUNDARES 12 MALAYSIA .'. INTERNAT1ONAL BOUNDARMES -1 7 MonadoO O cý,SINGAPORE 17.... _. P.konbaru -- 9 S U 9 T..Rk--- - HALMAHERA . '« e OU AT R Pahnk® 1 Samannda - .- -- -FhdangO l l N T A 10 15b 18 --- 1 D K LJRTA BANGKA l[ gkaray 25I 2 JAWA BART , n -k\ SULAWESI - 3 JAWATENGAH 7 \ ~ - 4 DI YOGYAKARTA - 20 CERAM - I R l A N 5 JAWAIMUR B l BEUITUNG BURU ---- 6 LAMPUNG TAnjormasn 21 Knari- AbonA 7 BENGKUIL 6 Bp-m's - 8 SUMATERA SELTAN B-d- 26 9 RIAU L'- aBan UiagSean-- 0 JAMBI Ug p 1l SUMATERA BRAT -d 12 SUMATERA UTARA 1 13 DI ACEH JAKARTA 14 KALIMANTAN ~ARAT - g nfdu- Ssmz I5 KALMANTAN TENGAH '-g-¯ 2 16 KALUMANTAN SELATAN Jw A 17 KALIANTAN TIMUR - ., 3 Surab-ya 18 SULAWESI TENGA1 5 19 SULAWESI UTA 20 SULAWESI SELATAN 22 21 SULAWESIITENGGARA TMG boundone , . D ¯ - 22 BALI den~m~~~n and nyD-npasr m- ..ýh - 23 NUSA TENGGARAAT .,her mf-mat .hon 23 - 24 24 NUSATENGGARATIMUR m 5, ImD d nE 2N3AN KA'a TIMOR 25 MALUKU Th WoAd B-nk Gu. -O27 26 1JRAN AA. 27 TIMOR iMUR -y .AUSTRALIA JANUARY 1996   IMAGING Report No: 15118 IND Type: SAR