Summary of Terminal Evaluation Findings
1.

Outline of the ProjectCountry: Republic of Indonesia

Project Title：Project for Improvement of District Health Management
Capacity in South Sulawesi Province (PRIMA Kesehatan) Phase 2
Issues/Sector: Health
Cooperation scheme：：Technical Cooperation Project
Division in charge：JICA Indonesia Total cost: JPY 290 million equivalent
OfficePeriodof (R/D): Nov. 2010~ Counterpart Agencies：
Cooperation Mar. 2014
South Sulawesi Provincial Government: Regional Development Planning
Board (BAPPEDA), Health Office (DINKES), Community
Empowerment and Local Governance of Villages and Wards (BPMPDK)
District Governments of Barru, Bulukumba and Wajo: Health Office,Community Development and Village and Ward Development (BPMD),
Regional Development Planning Board (BAPPEDA), District Financial
Management Office (DPKD)
Supporting Organisations in Japan: N/A

1-1

Background of the ProjectIn the Republic of Indonesia (hereinafter referred to as Indonesia), while the overall quality of life is showing
an improvement, regional gaps in development are widening. Compared to the official poverty rates in Java andBali (12.5%) and Sumatra (14.4%), those in the Eastern region such as Sulawesi (17.6%), Maluku (20.5%), Nusa
Tenggara (24.8%) and Papua (36.1%) are much higher, indicating a need for appropriate development
interventions in the Eastern regions, if the regional imbalances are to be corrected.
Decentralisation of the governance system was instituted in 2001 and ever since various powers and functions,
including those related to development planning, human and financial resources and health care delivery, havebeen decentralised to the regional governments. However, due to differences in local capacities and not-so-clear
demarcations between the central and regional governments, the decentralisation also has been contributing to
the widening regional gaps, causing such problems as delayed disbursement of budget and deterioration inquality of the public services. Establishing effective and efficient local governance systems is still an issue inIndonesia.
Indonesia has in recent years seen great improvement in terms of health but still lagging behind many ASEAN
countries. Infant mortality rate in Indonesia was 31 per every 1000 live births (Malaysia: 6, Philippines: 26,
Thailand: 13) and maternal mortality rate 420 per 100,000 deliveries (Malaysia: 62, Philippines: 230, Thailand:110), while access to improved sources of water was 80% (Malaysia: 99%, Philippines 93%, Thailand: 93%).
JICA implemented from Feb. 2007 to Feb. 2010 a Project for Improvement of District Health Management
Capacity in South Sulawesi Province (PRIMA Kesehatan) in Barru, Bulukumba and Wajo districts in the South
Sulawesi Province and developed and implemented a mechanism in which communities and governments work
together to improve community health. This model was proven to be effective in strengthening community
health but faced issues of sustainability in terms of finance, policies and regulations. This Phase 2 cooperationof the above-mentioned project aims to overcome those remaining challenges by modifying the model developed
during the Phase 1 period so that it fits in the existing system of planning and budgeting and also by integrating
into the “Desa dan Kelurahan Siaga Aktif” programme (the national health promotion programme by the
Ministry of Health) of the national government.

1-2

Project Overview

This project aims to strengthen sustainability of the mechanism developed under the project in the Phase 1stage, in which communities and governments work together for primary health care. The mechanism is to beinstituted and implemented in the same target districts involved in the Phase 1, namely Barru, Bulukumba andWajo. The governments of the three districts and the South Sulawesi province as well as all the communities inxithe three target districts will receive technical assistance to set up and operate the mechanism (“Prima-K
mechanism”) so that community-initiated health interventions (“PHCI activities”) are planned and implemented
as a part of regular development interventions without relying on external resources.
(1)

Overall Goal

①
②
③

(2)

Quality of Primary Health Care in the target district is improved
The mechanism of Primary Health Care in which community and government work together isdisseminated.
Regional Development Mechanism in which community and government work together isstrengthened.
Project Purpose

The mechanism of Primary Health Care in which community and government work together is establishedand operated in the target districts
(3)
①
②
③
④
(4)

Outputs
Capacity of community to conduct community-centred Primary Health Care Improvement (PHCI)
activities in line with the local governance system is strengthened
Capacity of Health Centres and Sub-District Offices to facilitate and support community-centred PHCI
activities is strengthened
Capacity of District to manage community-centred PHCI activities is strengthened.
Capacity of Province to supervise and disseminate community-centred PHCI activities is strengthened
Inputs（as of November 2013）

Japanese side: A total of JPY 290 million equivalent
Project personnel: 6 persons (Long-term: 3, Short-term: 3), for a total of 58.16 man/month
Provision of equipment: IDR 123,440,000
Local operational expenses: IDR 16,255,414,000 （equivalent of JPY 141,861,000）
Trainees received: 53 persons
Indonesian side:
Counterpart personnel: A total of 77 persons
Land, buildings and facilities: Project offices in Makassar, Barru, Bulukumba and Wajo with some officefurniture and utilities such as water and electricity
Operational expenses: IDR 361,567,000 (equivalent of JPY 3,155,000) for seminars and workshops, inaddition to expenses related to duty travels of related personnel

2.

Evaluation TeamJapanese
LeaderRegional Development

Mr. Shinichi Tanaka Senior Representative, JICA Indonesia OfficeDr. Makoto Inaba
Regional Development Program Manager, JICA

Cooperation Planning 1 Ms. Tomoko Enoki

Project Formulation Advisor, JICA Indonesia Office

Cooperation Planning 2 Ms. Ida Gosal

Program Officer, JICA Indonesia OfficeEvaluation Analysis
Indonesian

Ms. Naomi Imani

Consultant, Global Link Management, Inc.

drg. Rarit Gempari,

Head of Division of Community

Health Promotion Center, Ministry of

MARS

Empowerment and Partnership

Healthdr. Marti Rahuyu Diah

Staff of Division of Community

Health Promotion Center, Ministry of

KusumaEmpowerment and Participation

Healthxii

Drs. A. Irawan

Head of Division of Organizational andBintang, MT

Human Resources Development

M. Ilyas

Acting Section Head of Human Resource

BAPPEDA, South Sulawesi Province
BAPPEDA, South Sulawesi Province

Development
dr. H.A. Mappatoba,

Head Division of Community Health

Health Office, South Sulawesi Province

Drs. Haryamin, APT,Head Section of Health Promotion and

Health Office, South Sulawesi Province

M.Kes

Community Empowerment

Ir. H. Muhammad

Head

BPMPDK, South Sulawesi Province

Head of Sub-Division of Programme

BPMPDK, South Sulawesi Province

DTAS, MBA

Kasim Alwi
Ir. Musran A.
Muchsin, M.Si
Mission Period

24 Nov. ~ 20 Dec. 2013

Type of Evaluation：：Terminal Evaluation

3. Results of the Evaluation
3-1. Project Performance(1) Project Purpose
The project purpose is considered to be achieved with the current status of the assigned indicators as follows:(i) 97.8% of the communities in the target districts, as against the target of 80%, successfully complete all theactivities of the Prima-K mechanism for the 2nd cycle (2012) and that a similar result is expected for the 3rd
cycle (2013); and (ii) the “Implementation Guidelines for the Prima-K Mechanism (also known as“Supplement”)” developed by the project was officially issued by the District Governments concerned, thus
could be considered as one of the official documents that institute the Prima-K mechanism as an official system.
The completion rate above is likely to decline after the project ends, however, as it was achieved with
substantial interventions by JICA project staff, who will be withdrawn once the project is over.
(2)

Outputs
Output 1: Capacity of community to conduct community-centred Primary Health Care Improvement(PHCI) activities in line with the local governance system is strengthened

Almost all (98.9%) the 367 communities in the target districts are currently implementing PHCI activities
financed by the regular budget of the respective communities. In 2012, 97.2% of the planned activities were
implemented, indicating that the overwhelming majority of the communities involved in this project are able toaccomplish the activities under the Prima-K mechanism with the technical and moral support provided by the
project. As to the real capacity of the communities, however, the Terminal Evaluation (TE) found that majorityof the communities still require substantial facilitation if they are to continue with the Prima-K mechanism, andin this sense, the capacities of the facilitators from Health Centres (HC) and Sub-district offices (SDO) to
provide technical support and monitor developments are extremely important as there will be no more
project-employed Field Facilitators (FF) to help them once the project is over.
Output 2: Capacity of Health Centres and Sub-District Offices to facilitate and support
community-centred PHCI activities is strengthened.
The capacities of HCs and SDOs were strengthened through developing a pool of facilitators in every
sub-district to assist Health Working Groups (HWGs) by training some of their staff in technical mattersrelated to Prima-K mechanism. The TE found, however, due to an absence of a system to fill gaps created bytrained facilitators transferred to other duty stations, the pools of facilitators set up by the project arediminishing to the extent that some of them may not be able to adequately respond to the needs of thecommunities. In view of the importance of the HC/SDO facilitators in sustaining the Prima-K mechanism, theproject may need to officially establish a system, which not only takes care of vacancies created by inevitablestaff rotations but also keeps their motivation and technical capacities through official recognition, fairxiii

incentives and appropriate organisation.
Output 3: Capacity of District to manage community-centred PHCI activities is strengthened.
In each of the target districts, a district team was established drawing its members from the four relevant
agencies (DINKES, BAPPEDA, BPMD and DPKD), which then together with the JICA project team created asystem through which the PHCI activities of the HWGs are financed by the regular budget of the communities.
The capacities of the district teams have been strengthened through (i) training on technical issues of thePrima-K Mechanism so that they can function as trainers (of HC/SDO facilitators), and (ii) financial resources
provided from the regular budget of the district governments to implement routine activities under the
Mechanism. While their technical and financial capacities are considered quite sufficient, there remain somemanagerial issues including (i) lack of an appropriate monitoring system to see how well and to what extent thePrima-K Mechanism is utilised by the communities and (ii) weak coordination within the district teams, inaddition to the need for instituting (iii) a system to ensure availability of HC/SDO facilitators as identified in theprevious section. These weaknesses appear to impinge upon implementation of the exit plans establishedfollowing the recommendation by the Mid-Term Review, of which implementation was found to be somewhat
lagging.
Output 4: Capacity of Province to supervise and disseminate community-centred PHCI activities isstrengthened.
This output is yet to see substantial development. With regard to the province’s supervising PHCI activities inthe target districts, most of the activities designed to be implemented by the provincial team were carriedout/organised by the JICA team, perhaps as a reflection of the limited function of the provincial government insupervising now autonomous districts.
With the “learning by doing” methodology of capacity building employed by this project, it is rather
unrealistic to expect development of capacity in dissemination of the Prima-K Mechanism within the project
period, as dissemination could only take place after the effectiveness of the model is reasonably established.
The provincial team is planning to assist several districts that expressed interest in adopting the mechanism
starting 2014. It is a new initiative for the province and they are not clear about how and to what extent theprovincial team, which does not have the first-hand experiences in developing the mechanism (as it was done by
the districts), would assist the autonomous districts in implementing their own projects. As the provincial teamrepeatedly expressed their needs for technical assistance in this matter, these issues must be sorted out to apracticable extent before the project ends.
3-2.

Summary of Evaluation Results(1) RelevanceThe project has high relevance in terms of local policies and needs. Health is one of the 11 strategic
priorities in Indonesia’s medium-term development plan and its priority status is also reflected in similar plansof South Sulawesi province and the three target districts. At the same time, strengthening of local governancecontinues to be an agenda after more than 10 years of decentralisation, and effective and transparent systems for
local governments to efficiently utilise financial resources are very much wanted especially in view of theincreasing trend of the amount of the village allocation fund (ADD). Development of the Prima-K Mechanism,
which utilises the standardised planning system of Musrenbang, is highly relevant in this context as it
contributes both to health and local governance. On the other hand, the project’s relevance to the Japanese
official development assistance policy to Indonesia has somewhat declined when the policy was modified in2012 to give more emphasis to economic growth.
(2) EffectivenessThe effectiveness of the project appears to be high in view of the achievement of the project purpose.

xivHowever, production of the outputs, which are the building blocks for achievement of the project purpose, arecuriously less than optimal as observed earlier, indicating some problems in the project implementation. While
the modality of capacity building of this project was “learning by doing”, the JICA project team carried out
some of the tasks to be taken on by the counterparts (CPs). In this way, the project was able to keep up with theschedule but as a consequence some of the capacity building opportunities for CPs were lost. The absence ofclear definitions of the capacities to be built at each level in the project design also affected effectiveness of theinterventions, as indicated in the oversight on the needs to strengthen management system apparent from theremaining weaknesses of the district and provincial teams identified in the earlier sections.
(3) Efficiency
The project boosts high efficiency in terms of (i) setting up a mechanism through which community-initiatedhealth interventions are financed by the regular budget of the local governments and (ii) getting
community-driven health interventions implemented through this mechanism in most of the 367 communities
involved in 3 years. Major contributing factors are (i) meticulous project planning process involving district-,provincial- and central-level stakeholders, which resulted in a shared vision on the mechanism to be establishedas well as in good sense of ownership especially amongst the district-level CPs, (ii) JICA team’s taking oversome of the tasks designed to be carried out by CPs for the sake of keeping up with the government planning
cycle, and (iii) a large number of local project staff deployed, who are in general much more efficient in termsof costs and communication than Japanese experts. Concerning the factors (ii) and (iii), however, there was atrade off between the efficiency and output production as observed in the previous section.
(4) Impact(a) Prospect of achieving Overall Goals
With regard to the Overall Goal 1, it is rather unlikely that impact of this project is reflected in themacro-level health indicators assigned, as the health interventions undertaken under this project are of small
scale and diverse. However, it would be reasonable to expect some positive contributions for community healthimprovements, as the project has generated communities’ interest in health-related issues, reportedly resulting inincreased utilisation of health facilities as well as increased participation in community-level activities
organised by HCs. With regard to the replication of the Prima-K Mechanism in other districts (Overall Goal 2),
it appears quite promising given the current level of interest expressed in adopting the mechanism. Adoption of
the mechanism in other sectors (Overall Goal 3) may benefit from more vigorous advocacy and dissemination,
as currently the mechanism is not well known outside of the district/provincial teams. Nonetheless, there is an
initiative in Barru district in which other sectors are involved in community-level Musrenbang and this may
show positive results in line with this Overall Goal 3.
(b) Other positive impact
The project has been reportedly effective in (i) generating communities’ awareness and interest in health, insanitation in particular, which has resulted in substantial increase in voluntary contributions by individuals to
the community-initiated health interventions. The project has also been instrumental in availing ADD-like funds
to wards and also in demonstrating possibility of utilising ADD for non-construction projects throughMusrenbang, to the extent Barru district started a pilot project with 10 villages to use the model involving othersectors.
(c) Negative impact
Some HC facilitators reported increased workload as a negative impact of the project. This was more of agrievance rather than a negative impact, stemming from the current uneven distribution of workload among HC
staff and the absence of official recognition and fair incentives/rewards for the extra tasks they shoulder.
These issues should be addressed when the districts consider appropriate organisation/ officialise of the
HC/SDO facilitators as discussed under the Output 2.

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(5) Sustainability
The financial sustainability is very promising. So long as health remains a priority in the development
agenda, and so long as political leaders are committed to address priorities identified by their constituents, it isreasonable to assume that both the community-centred PHCI activities and supporting activities by the district
governments shall have some funds allocated from their regular budget. The reported plan of the central
government to increase the ADD amount also contributes to the Prima-K Mechanism’s financial sustainability.
The organisational sustainability, on the other hand, is less solid without appropriate management systems tomonitor implementation of the Prima-K Mechanism and to coordinate efforts of the involved agencies. Lack ofthese systems is affecting the implementation of the exit plans established after the Mid-term Review. Theseissues must be addressed in the currently on-going efforts to design a post-project management system of thePrima-K Mechanism in each target district.
Other issues that may impinge on sustainability include motivation of the HWGs, complexity of thepaperwork in the Prima-K Mechanism and the forthcoming election of the village chiefs in 2014. Districts needs
to be vigilant to the circumstances and needs of the communities so that appropriate measures are taken intimely manner to mitigate these challenges. JICA could also play a role by fielding monitoring missions fromtime to time to sustain the motivation of the stakeholders as well as the effects of the project.
3-3.

Factors promoting better sustainability and impact(1) Factors related to the project design
In order to find a right way to improve financial sustainability of the model created by the Phase 1, JICA in
designing this project had numerous sessions with stakeholders at all levels. This by clarifying the issues andpossible solutions enabled the project to start implementation of the activities at once when the project design
was finalised. In this way the district-level stakeholders also developed high sense of ownership and goodunderstanding of the mechanism to be developed, which contributed to efficiency as well as high financial
sustainability.
While the established mechanism could be used in any sectors, the project managed to win favours of thelocal governments and politicians by choosing health sector, which enjoys high priority in the official
development policies and also often is a public commitment of political leaders at the time of elections.
(2) Factors related to the implementation processes
The multi-agency teams organised, especially those at the district level, were identified by the CPs as one of
the major contributing factors, through which issues could be addressed much more efficiently than otherwise.
Another contributing factor would be a large number of the experienced local project personnel, without whom
the project would not have been able to cover so many communities.
3-4.

Factors inhibiting better sustainability and impact(1) Factors related to the project design
The project by design is ambiguous about the details of the capacity building and no capacity assessment or
analysis was undertaken before or during the project period to determine the scope. This resulted in overlooking
appropriate management systems as a part of the capacity, compromising the outputs as well as thesustainability of the project.
Another issue was the lack of exit strategies in the project design when such a large number of project staff
was involved. Though there was a plan for a gradual reduction of the project personnel, as it was not stipulated
in the official reference documents (i.e. Record of Discussion (R/D), Project Design Matrix (PDM) and Plan ofOperation), the plan was somehow forgotten and never implemented.
(2) Factors related to the implementation processes
A Japanese project leader was absent for the first three months of the project and also for almost 1 year in the
middle of the project. Although the project managed to implement most of the planned activities on the PDM,

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other activities such as setting up PDM indicators, following up on the recommendations left by Japaneseexperts, supervision of the local project personnel and devising/implementing exit strategies did not receive
sufficient attention.
The local project staff, or rather mishandling of them, was arguably a major inhibiting factor in terms of theoutput production. Most of them were well experienced in facilitation but not in capacity building ofgovernment institutions. Without appropriate guidance and supervision by a Japanese project leader, they
worked in a way to fill the capacity gaps of the CPs rather than building them for the sake of timely
implementation of the project.
3-5.

Conclusion

Based on the model produced by the previous phase, the project was successful in establishing a mechanism
through which community-driven health interventions are financed by local regular resources by utilising theofficial planning system of Musrenbang. The project purpose was achieved with higher than expected
implementation rates of the Prima-K Mechanism, indicating high effectiveness and efficiency of the project.
The project, addressing issues related to community health and local governance, is also highly relevant to the
local policies and needs.
On the other hand, the capacities of the district and provincial administrations were not fully developed to thelevel desired. The project needs to do some more work to set up an appropriate administration/management
system for the Prima-K Mechanism in each of the district and provincial governments, instituting some kind ofmonitoring and coordination functions so that the Prima-K Mechanism is systematically managed after the
JICA team is withdrawn. The financial sustainability is promising with the increasing trend of ADD, provided
the communities and local governments continue to see health as a priority.
The health impact of this project is unlikely to be reflected in the assigned macro indicators but iscomplementing HCs’ interventions in community health improvement. With the interest expressed by some
districts in adopting the Prima-K Mechanism and with the provincial team’s aspiration to help the process ofadoption, there is a good possibility that the mechanism will be replicated in other parts of the province, perhaps
also in other sectors than health, in near future.
3-6. Recommendations(1) To the PRIMA-K Project Team (by 31st March, 2014)
In view of the limited time available, the Team recommends the following two tasks be treated as priorities,
to be completed before the end of the project period.
To provide technical support to the district teams in developing an appropriate management system forthe operation of Prima-K Mechanism in each district, which should be included in appropriate
authoritative documents such as Bupati’s (Governor’s) regulation and decree.
To compile the tools developed during the project period into a “Prima-K Tool Package” to serve as a
guiding reference for possible replications by interested parties. The production of this package be ideallycompleted by the planned national seminar before the conclusion of the project so that it could be widely
disseminated.
(2) To the District Teams of Barru, Bulkumba and Wajo
As a matter of priority, an appropriate management system for operation of the Prima-K Mechanism bedesigned and instituted. The system should include, among others,
process and procedures for inter-agency collaboration and coordination;
monitoring system with clear indicators (data/information to be periodically collected), sources of theinformation, responsible parties and frequency of data collection, compilation and analysis, as well as
flow of the information for appropriate and timely decision makings; anda system to retain a pool of trained facilitators at every HC and SDO and to ensure supportive
environment for them to function effectively and efficiently with good motivation in each sub-district.
This may include (a) official appointment of facilitators at HCs and SDOs through decrees (SK), (b)organising them into sub-district teams with appointed team leaders or coordinators and (c) ensuringxvii

supportive supervision provided by appropriate individuals/parties.
Have the devised management mechanism officially gazetted through appropriate authoritative
documents such as Bupati’s (Governor’s) regulations and decrees.
Consider possible application of the mechanism in other sectors than health.
(3) To the Provincial Team
Play facilitative roles for other districts in the province to adopt the Prima-K Mechanism as a team as
already started and also as individual agencies in line with the official mandate.
As it is a new and challenging task for the provincial government to orchestrate inter-sectoral efforts infacilitating autonomous districts in implementation of a programme without provision of funds, the team
may like to:i. consider drawing up an united vision on the goals and modalities of this initiative of dissemination
for the sake of effective inter-agency collaboration; andii. set up an effective mechanism of inter-agency collaboration/coordination for the purpose mentioned
above. This may include (a) identifying and assigning certain tasks to appropriate
entities/individuals and (b) setting up a monitoring and reporting system; andiii. document the above in appropriate media such as a Governor’s regulation/decree, which would also
legitimise actions/interventions for specific districts. .
(4) To the Central Governmenta) Center for Health Promotion, Ministry of Health
For the sake of synergising the effects of this project with the Desa dan Kelurahan Siaga Aktif
programme, the Promkes is encouraged to:
Examine the Prima-K Mechanism and the initiatives happening in the 3 districts to synergise the effectsof the Prima-K and Desa dan Kelurahan Siaga Aktif, and analyse the points which strengthen Desa dan
Kelurahan Siaga Aktif;
Disseminate the good practices in this project nationwide and encourage their replications as appropriate.
b)

Ministry of Home Affairs

In view of the accomplishment of this project in terms of (i) strengthening local governance including
democratic and transparent utilisation of ADD, and also for the sake of (ii) the community empowerment in
Desa dan Kelurahan Siaga Aktif, MoHA is invited to:
Examine the Prima-K Mechanism and the initiatives happening in the 3 districts to synergise the effectsof the Prima-K and Desa dan Kelurahan Siaga aktif, and analyse points which strengthen Desa dan
Kelurahan Siaga aktif;
Disseminate the good practices in this project nationwide and encourage their replications as appropriate.
(5) JICAJICA is to consider:instituting occasional monitoring visits to the three districts as well as to the province, to provide moral
support even after the project is concluded;
possible future technical assistance utilising the benefit and lessons learnt from this project
3-7. Lessons leant
A project could enjoy a smooth start of implementation when CP agencies were well involved indesigning of the project, with good sense of ownership and a shared vision on the project purposes.
A project should have a solid exit strategy built into its design from the beginning, especially when alarge number of project staff is involved. Such strategy must be clearly spelt out in an official documentsthat serve as the guiding documents for project implementation, namely R/D and PDM.

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In order for a capacity building project to be effective, capacities to be strengthened should be clearly
defined in relation to the tasks to be carried out. If such details are not clear from the R/D and/or PDM,
stakeholders should organise a session to clarify them at the beginning of the project to analyse, identify
and agree on the scope and methodologies of capacity building. A capacity assessment should also be
considered in this process.

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