Monograf-Result Based Financing To Support Public Health

RESULT BASED FINANCING
TO SUPPORT PUBLIC
HEALTH INTERVENTION:
A LESSON FROM COMMUNITY-BASED
HEALTH AND NUTRITION TO REDUCE
STUNTING PROJECT
Mardiati Nadjib
Hendri Hartati
Dini Dachlia
RESULT BASED FINANCING TO SUPPORT PUBLIC HEALTH
INTERVENTION: A LESSON FROM COMMUNITY-BASED
HEALTH AND NUTRITION TO REDUCE STUNTING PROJECT
Mardiati Nadjib
Hendri Hartati
Dini Dachlia
Faculty of Public Health

Universitas Indonesia
ii
RESULT BASED FINANCING TO SUPPORT PUBLIC HEALTH
INTERVENTION: A LESSON FROM
COMMUNITY-BASED HEALTH AND NUTRITION
TO REDUCE STUNTING PROJECT
Authors:
Mardiati Nadjib
Lecturer in Departement of Health Administration and Policy,
Faculty of Public Health, Universitas Indonesia
Hendri Hartati,
Researcher in Center for Health Research,
Dini Dachlia,
Researcher in Center for Health Research,
ISBN : 978-979-9394-64-4
Publisher :
Universitas Indonesia
Redaction :
Kampus UI Depok, 16424
Tel +6221 7864975
Fax +6221 7863472
Email fkmui@ui.ac.id
www.fkm.ui.ac.id
1st Edition, January 2017
All Rights Reserved. May not be copied, scanned, or duplicated,

in whole or in part.
iii
ACKNOWLEDGEMENT
This study was done with support from the World

Bank. The author would like to thank to the World Bank, the
Ministry of Health and Bappenas for all input and support
during the process of the study. Thank you to all resource
persons from relevant institutions i.e health centers, District
Health Office in selected samples in West Java, West Nusa
Tenggara and East Nusa Tenggara for all support during data
collection and finalizing process of the study.
This study would not be successfully done without
support from Center for Health Research, Universitas
Indonesia. Sincere gratitude for Mr Darren Dorkin from the
World Bank who believe that this study can be done and
implemented., and his support to make this study happened
and successfully reported to the Ministry of Health and
Bappenas.
iv
FOREWORD
Result Based Financing is not a new approach for

provider payment in developing countries. We also have
experiences based on Indonesian context. However, its
sustainability remain challenge, The Millennium Challenge
Corporation Community-Based Health and Nutrition to Reduce
Stunting Project was developed and involved reserachers to
develop a potential approach for implementing “pay for
performance” in the project.
As implementation of a “Result-Based Financing” for
public health intervention has not been that popular in
Indonesia and considered as something not easy to explore, we
considered this study as a unique and challenging to undertake.
Lesson learned from other countries and experiences from the
field gave us such a rich learning process and we believe that it
could be further developed for public health interventions in
our real world.
This study was done during preliminary phase of our
Social health Insurance Scheme or Jaminan Kesehatan Nasional
(JKN) implementation. During its process BPJS, the insurance
company/ payer initiated provider payment scheme for health
providers, including a kind of “pay for performance” for
curative care. On the other hand, little attention was given to
any performance-based approach to incentifize the public
health providers. One relevant situation with health policy was
v
on stunting or nutrition area, which was explored in this study.
Even the current context of policy implementation under busy
assigment in health facilities doing the public health
interventions and JKN impementation i.e provides service
treatment, this study could be refferred as a lesson learned for
RBF implementation. Hence, this study could be further
developed to meet the need for the current context and to
harmonize public health and treatment with regard to “fair”
result-based financing.
Depok, January 2017
Authors
vi
TABLE OF CONTENT
ACKNOWLEDGEMENT............................................................................... iv
FOREWORD ......................................................................................................v
TABLE OF CONTENT ................................................................................. vii
LIST OF TABLES............................................................................................ ix
LIST OF ABBREVIATIONS ...........................................................................x
PART 1 ............................................................................................................... 1
INTRODUCTION ............................................................................................. 1
1.1 Background ......................................................................................... 1
1.2 Objective of the Study .................................................................... 5
PART 2 ............................................................................................................... 6
METHOD ........................................................................................................... 6
PART 3 .............................................................................................................10
BASIC CONCEPTS FOR MODEL DEVELOPMENT............................10
3.1 Basic concepts ..................................................................................10
3.2 Indicators ...........................................................................................15
3.3 Setting targets ..................................................................................17
3.4 Setting incentives ...........................................................................18
3.5 Performance verification.............................................................19
3.6 Contracting ........................................................................................19
3.7 WB-MCC Plan for RBF Pilot .......................................................19
PART 4 .............................................................................................................22
EVIDENCE FROM THE FIELD ................................................................22
4.1 PNPM Generasi District Facilitator, Subang district ........22
4.2 Midwives in Puskesmas, Subang District, West Java .......23
4.3 Puskesmas Banjaran Kab. Bandung (PONED), West Java
................................................................................................................23
4.4 DHO Ngada, West Nusa Tenggara ............................................24
4.5 Desa Pengenjek, West Nusa Tenggara ...................................24
PART 5 .............................................................................................................26
RESULT............................................................................................................26
THE MODELS: PREVIOUS, EXISTING AND PROPOSED SCHEMES
............................................................................................................................26
5.1 LESSON FROM CORDAID PROJECT IN NTT .........................30
5.1.1 Legal Feasibility .....................................................................30
5.1.2 Organizational Feasibility ..................................................32
5.1.3 Verification, Monitoring and Evaluation .....................34
vii
5.1.4 Payment Scheme ...................................................................36
5.1.5 Proposed model based on Cordaid experience ........38
5.1.6 Challenge ..................................................................................40
5.2 LESSON FROM THE ADD (ALOKASI DANA DESA) SCHEME
................................................................................................................40
5.2.3 Monitoring and Evaluation................................................43
5.2.4 Payment Scheme ...................................................................44
5.2.5 Proposed Model Using ADD Approach .........................44
5.2.6 Challenges ................................................................................46
5.3 LESSON FROM THE NICE PROJECT ........................................47
5.3.4 Payment Scheme ...................................................................55
5.3.5 Sustainability ..........................................................................58
5.3.6 Proposed Model Using NICE Approach ........................59
5.3.7 Indicators..................................................................................65
5.4 LESSON FROM THE EXISTING TPP (TUNJANGAN
PENINGKATAN/ PENAMBAH PENGHASILAN).....................66
5.4.4 Payment Scheme ...................................................................70
5.4.5 Proposed Model Using TPP (Tunjangan
Peningkatan/ Penambah Penghasilan) ....................................72
5.5 PROPOSED RBF MODIFIED/ COMBINED MODEL.............75
5.5.1 Proposed Model at the District Level ............................77
5.5.2 Proposed Model at the Village Level .............................81
5.5.3 Challenges to Implement the Model at District and
Village Levels.......................................................................................83
PART 6 .............................................................................................................86
CONCLUSION AND RECOMMENDATION ..........................................86
6.1 Conclusion .........................................................................................86
6.2 Recommendation............................................................................88
REFERENCES ................................................................................................90
BIODATA.........................................................................................................94
viii
LIST OF TABLES
Table 1. Nutritional and Health Indicators Related to the First

1000 Days of Life .........................................................................................28
Table 2. List of Indicators from Cordaid Project in West Nusa
Tenggara .........................................................................................................35
Table 3. Unit Cost Used as the Basis for Payment in Cordaid
Project in West Nusa Tenggara .............................................................36
Table 4. Example of List of Indicators for Proposed Model
Using NICE Approach ................................................................................65
Table 5. List of Indicators for Proposed Model Using TPP
Approach ........................................................................................................74
ix
LIST OF ABBREVIATIONS
ADD : Alokasi Dana Desa

AIP-HSS : Australia Indonesia Partnership for Health
Systems Strengthening
APBD : Anggaran Pendapatan dan Belanja Daerah
BDD : Bidan Di Desa
BOK : Biaya Operasional Kesehatan
BOS : Bantuan Operasional Sekolah
BPJS : Badan Penyelenggara Jaminan Sosial
CHC : Community Health Center
CORDAID : Catholic Organization for Relief and
Development
DAK : Dana Alokasi Khusus
DHO : District Health Office
DIPA : Daftar Isian Pelaksanaan Anggaran
FP : Family Planning
GOI : Government of Indonesia
GSC : Generasi Sehat Cerdas
IBI : Ikatan Bidan Indonesia
Jamkesmas : Jaminan Kesehatan Masyarakat
KGM : Kelompok Gizi Masyarakat
MCC : Millennium Challenge Corporation
MCH : Mother and Child Health
MCI : Millennium Challenge Indonesia
MOH : Ministry of Health
x
NICE : Nutrition Improvement through Community
Empowerment
P4P : Pay-for-Performance
PBF : Performance Based Financing
PGM : Paket Gizi Masyarakat
PKH : Program Keluarga Harapan
PMT : Pemberian Makanan Tambahan
PNC : Postnatal Care
PNPM : Program Nasional Pemberdayaan Masyarakat
PONED : Pelayanan Obstetri Neonatus Essensial Dasar
PTT : Pegawai Tidak Tetap
RBF : Result Based Financing
SKN : Sistem Kesehatan Nasional
SPM : Standar Pelayanan Minimal
TBA : Traditional Birth Attendance
TPC : Targeted Performance-Based Contract
TPG : Tenaga Pelaksana Gizi
TPP : Tunjangan Peningkatan/ Penambah
Penghasilan
UKM : Upaya Kesehatan Masyarakat
UKP : Upaya Kesehatan Perorangan
UP4B : Unit Percepatan Pembangunan Papua dan
Papua Barat
WB : World Bank
xi
PART 1
INTRODUCTION
1.1 Background
Result Based Financing (RBF) is one approach to
finance or pay the provider using performance as the basis of
setting up the amount of payment. This approach, or known in
a more generic term as ”pay for performance” has been
developed for many years, followed by various pilot to learn its
success and failure. The implementation in many countries
were reported, including in Indonesia.
There has been a need to develop the RBF approach for
public health program intervention for couple reasons. The
first reason is is little attention to “appreciate” achievement by
public health staffs, especially in health center, while under our
universal health coverage scheme or JKN (Jaminan Kesehatan
Nasional) the insurer incentifize the providers with a
reasonable consideration on performance. The second reason
is achieving target for public health program need to be
acknowledged and appreciated. Can payment incluence
behaviour of the staffs to achieve better performance? For
these reasons Ministry of Health and Bappenas assigned
Center for Health Research to conduct a study on developing an
RBF model and assessing whether it would be potentially
implemented in the context of Indonesia.
1
The Community-Based Health and Nutrition to Reduce
Stunting Project (CHNRS Project) was developed to reduce and
prevent low birth weight, childhood stunting, and
malnourishment of children in project areas.
The GOI designed the project that covered demand and
supply interventions and to achieve reductions in rural
stunting for children 0-2 years old, based on the community
development experience gained under the PNPM Generasi
program.
As part of the PNPM GSC project, communities received
assistance from trained facilitators to diagnose problems and
identify ways to use funding provided by village-level block
grants to achieve 12 health and education indicators(PNPM,
n.d).
Those indicators aimed at improving community health
outcomes include:
• Four prenatal care visits for pregnant women
• Taking iron tablets during pregnancy
• Delivery assisted by a trained professional
• Two postnatal care visits
• Complete childhood immunizations
• Ensuring monthly weight increases for infants
• Monthly weighing for children under three and
biannually for under-fives
• Vitamin A twice a year for under-fives
2
Malnutrition reduction was the strongest impacts of the
PNPM Generasi program in Nusa Tenggara Timur (NTT)
Province, rates of underweight children were reduced by 8.8
percentage points, a 20 percent decline compared to control
areas; and severe stunting was reduced by 6.6 percentage
points, a 21 percent decline compared to control areas.
The proposed PNPM Generasi Plus initiative would seek
to build on the achievements of previous rounds of PNPM
Generasi (1) by seeking specific improvements in the following
areas:
• Improve maternal nutrition and decreased incidence of
children born less than 2500 grams
• Increase rates of exclusive breastfeeding among
children 0-6 months old
• Improve understanding and application of weaning and
complementary feeding practices among lactating and
mothers of children 7-24 months old
• Improve sanitation conditions and household hygiene
behaviors
• Increase provider attendance, accuracy in monitoring
and reporting and coverage of basic health services for
the treatment and prevention of childhood stunting
• Empower communities to reward performances of
health service providers, especially those that provide
services to geographically marginalized populations
3
• Improve provincial and district engagement in
improving health and nutrition services to reduce
stunting
Result Based Financing (RBF) is defined as: any
program that rewards the delivery of one or more outputs or
outcomes by one or more incentives, financial or otherwise,
upon verification that the agreed-upon result has actually been
delivered. Pearson defines it as a mechanism through which a
funder is willing to make payments to an agent who assumes
responsibility for achieving pre-defined results (Pearson,
2011).
It may be reminded that all aid provided in the form of
cash or services is seeking results, be it through a results based
financing modality, be it through general budget support to a
recipient government, or through technical assistance via a
NGO project. Results based financing can take various forms,
use different actors, and apply classic or innovative
approaches.
PNPM GSC seek to design and field-test a PBF pilot to
effectively reduce stunting by rewarding health service
providers and connecting these efforts to demand side efforts
that have thus far proven to be effective. Results-based
financing (RBF)/ performance-based Financing (PBF)
principles combined with social accountability mechanisms,
contribute to better health outcomes. From health system
perspective, RBF will improve motivation of the staffs to work
4
more productive and effectively, to achieve targeted output
and outcome.
1.2 Objective of the Study

The study is aiming at developing the model of
implementing Result Based Financing for the public health
program, in this regard is nutrition project
Specific objectives are:

• to carry out a study to identify options on project
design of the results-based financing approach in
country context.
• to describe the experience on RBF/ (and related
mechanisms, eg, fee-for-service) in Indonesia
(including the Cordaid PBF Pilot in Flores); identify the
challenges facing the implementation of RBF and what
can be done to overcome those difficulties; and cover
issues: operational feasibility, technical feasibility, legal
feasibility, organizational feasibility, and monitoring
and verification feasibility.
5
PART 2
METHOD
To accomplish this assignment, method or specific tasks used

include:
(i) Review and document the experience with RBF (and
related mechanisms) in Indonesia, and lessons learned.
(ii) Carry out consultations with concerned Project
stakeholders including Government representatives from
MOH, Bappenas and Millennium Challenge Indonesia
(MCI).
(iii) Identify the challenges facing the implementation of RBF
Lesson Learned from other country as well as from
implemented PBF in the country is summarized in this
report and later being used as the basis for new model
with carefully considered its strentgh and weakness.
There are some RBF projects implemented in other
countries that we could learned, in this report we are only
focusing on Vietnam RBF model as we learned this model
might have similarities in terms of culture and experience
with service provision (Anon, 2011).
Lesson learned from incountry PBF (or similar to PBF)
was also assessed in this report. Poverty alleviation programs
other than PNPM were also reviewed as inputs for model
deelopment. Furthermore, based on these experiences we
6
developed options for “new RBF design”. The implemented
models we learned include:
• Cordaid project in Nusa Tenggara Timur (Haryoko,
2011; Soeters, 2008)
• ADD model in desa Pengenjek Nusa Tenggara Barat
• NICE project in Nusa Tenggara Barat (Solikin, Kristiani
and Gunawan, 2016)
• TPP model implemented in kabupaten Bandung
In addition to the lesson learned, current and upcoming
policies were also reviewed to understand better about the
feasibility of the model. Current issues and relevant policies
such as universal health coverage and implementation of BPJS
(single payer) in January 2014 will influence the provider
payment scheme in the District health Office and health center.
MOH set up two different scheme for health care
provision as stated in the National Health System (Sistem
Kesehatan Nasional or SKN), namely UKP (upaya Kesehatan
Perorangan or Personal Care/ curative care) and UKM (Upaya
Kesehatan Masyarakat or public health program). These
provision models will influence our proposed RBF design, since
payment for UKP and UKM is received from different sources
and using different scheme. UKP in the health center is
financed by the government, partly from central government
(eg. vaccine and drug procurement, and even capitation
payment for Jamkesmas) and partly from local government (eg
subsidy for equipment, fee for providers, Jamkesda). UKM is
7
financed by both central and local government, including for
transportation / outreach program (using BOK fund), specific
intervention (using DAK or deconcentration fund or local
budget) such as nutrition program, HIV and AIDS, TB, Malaria,
Filariasis programs etc. Some interventions even considered as
“cross-cutting” program, partly UKP and partly UKM. For
example, immunization program in health center is supported
by central government (vaccine procurement), BPJS (fee for
provider under capitation) and local government (handling
cost). Coordination is critical to ensure program run smoothly
and achieve its target.
The proposed model needs a careful consideration: is it
a team work? At what level or institution (Puskesmas level? Or
village level?) and what would be the role of District health
Office? Who is the staff/ personnel we choose for this RBF
model, is it Bidan or petugas gizi (nutritionist) or other staffs?
If we choose or involve Bidan, at the moment IBI (Midwives
Association is proposing a certain payment scheme under BPJS
for maternal care (top-up separate from capitation, similar to
Jampersal, but unclear whether is it accepted by decision
makers), would our proposed model be integrated to the
capitation or top-up? There is also some other initiatives
supported by other donors such as AIP-HSS with intention to
support piloting health center converted to “autonomous body”
with flexibility to perform UKP and UKM in good quality. This
would include strengthening health center to implement
8
universal coverage as “gate keeper” and at the same time
ensuring achievement of minimum service standard (SPM) by
carrying out public health programs. There is an idea to allow
DHO “purchase” performance-based output of the health
centers in its authority area.
9
PART 3
BASIC CONCEPTS FOR MODEL DEVELOPMENT
3.1 Basic concepts

There are many lesson learned from other countries
implemented RBF. The description on the basic concept below
is cited from some references, including the World Bank’s
experience on “using financal incentive to improve primary
care in Vietnam”, experiences in Rwanda and Burundi and
some examples from Indonesia (Anon, 2011; Glassman, Todd
and Gaarder, 2007; Vergeer et al., 2011; Vergeer, Manshande
and Johnston, 2011; Soeters, Habineza and Peerenboom, 2006;
Vergeer, Manshande and al, 2011).
Currently health system in Indonesia relies on input-
based financing such as payment for salaries, or fee-for-service
payments for service used by patients. Salaries are paid
regardless the employee/ staff performs productively or not,
regardless of whether the desired health outcomes is achieved
or not. Social Health Insurance with single payer scheme is
implemented started in January 2014, and payment for
hospital and primary care will be done using capitation or
diagnosis-related group scheme. Payment for salaries and
incentives will be adjusted accordingly, remuneration system is
expected to be developed by the institutions. In many
provinces, payment for staffs under Local Government’s
authority using local governmnent’s budget (APBD) has been
10
set up as “top-up” of the basic salary to improve staff’s
performance, however how the payment has made according
to the performance is unclear. We learned from field visit to
some provinces (West Java, NTT and NTB) that at present
actually no formal performance-based payment is
implemented, except in some pilots such as Cordaid project in
NTT or voucher-system to improve maternal care outcome
(Haryoko, 2011; Soeters, 2008).
Performance-based financing (PBF) or Pay-for-
Performance (P4P) or Results based financing (RBF), linked
payments with performance. It is a supply-side incentive
payments to facilities, teams of health workers conditional on
increasing processes, health outputs or outcomes or demand-
side incentive payments to individuals, households or
communities, conditional on engaging in pre-agreed healthy
behaviors or utilization of health services (Pearson, 2011;
Glassman, Todd and Gaarder, 2007; Hecht, Batson and Brenzel,
2004).
Key elements of results-based financing include:
• Clear identification of a set of priority health outcomes
to be achieved,
• Interventions to be implemented,
• Measurable and verifiable indicators,
• Monitoring systems to measure performance,
• Meaningful size payments that reward good
performance.
11
Interventions are often applied to obtain very specific
objectives such as improvements in nutrition program,
maternal health, TB, HIV, malaria, or chronic disease care such
as cardiovascular diseases, or even improvement in quality of
PHC, coverage of care, reduced out-of-pocket spending
(Vergeer et al., 2011; Mohr et al., 2005; Manshande, Vergeer
and Fritsche, 2010; Meessen, Kashala and Musango, 2007;
Dupas, 2005). In some cases payments have been made linked
with processes indicator such as data reporting, use of
protocols, disease management, for mistake prevention such as
control of adverse events, at hospitals to encourage
accreditation, to improve patient satisfaction etc.
Complex and fragmented system often make
performance-based scheme do not work well in reality. There
was an initiative to introduce a performance-based scheme in
Indonesia. Targeted Performance-Based Contract or TPC, a
World Bank initiative, involved a change in the type of contract
used by DHO to remunerate BDD (Tan, 2005). The system
substituted a salary-based PTT contract (as an option when
they renewed contracts) with a fixed monthly when they
renewed contracts) with a fixed monthly honorarium for
assisting with HC village-level program and for helping out at
the HC a few days per month. Otherwise, BDD-TPC is expected
to function as private providers. For the poor, the vouchers
can be used to “purchase” basic package of MCH and FP
services from BDD-TPC. Coupons presented by BDD to DHO on
12
a monthly basis for reimbursement. For the non coupon
holders, they use “user charge”. The result revealed that
behavior of poor women had changed dramatically increased
delivery with midwives. However, they continue PNC to the
TBA. Why it was not sustained? Conflicts between overlapping
systems (TPC and health Card to receive free care) reduced
midwives motivation. The project failed in its intent to move
toward privatization– conflicted with Government policy to
sustain PTT contract and increased salary. The voucher system,
if implemented well, can help midwifery services reach the
poor better than the health card program (strong motivation to
seek out poor clients), little room for fraud. The new insurance
program presents an opportunity to build on the success of the
voucher pilot in reaching poor pregnant women.
Another experience is Detasering program in Mimika, a
program part of the tasks assigned by UP4B (Unit Percepatan
Pembangunan Papua dan Papua Barat), concerning the need of
acceleration of program achievement in remote area. It was
noted that 29 out of 86 villages in Mimika district categorized
as remote and very remote area. Some villages even located in
highland and transportation is difficult, hired airplane or even
folowed by chartered boat Despite PTT bidan (midwives) has
been implemented and midwives are assigned in this remote
area, maternal care provision and delivery assisted by skilled
birth attendance remain challenge.
13
The DHO initiated so called “midwife detasering
program” in 2012 as local initiative has tried cover the absence
of health services by contracting 30 private midwives for 3
months to work in the remote and very remote villages using
DHO budget (Depkes, 2012). DHO allocated budget to cover
fee, food and other supplies for each midwife much higher than
budget for contracted midwife from MOH. This program
required midwives to reach the target of services (i.e 10
pregnant women/village and at least provide health services to
80% birth and postnatal care) and head of the village to
provide housing, transportation to hamlets and security of the
midwives. How the assignmnet and verification worked? DHO
determine location for each midwife based on Save Papua
program finding on maternal health care demand in each
village and assign midwife to certain village, equipped with
necessary facilities. Midwife provides services as scheduled
and fills the time sheet and signed by head of village on
monthly basis. At the end of contract, DHO will pick-up all
midwife and collect time sheet. What was the result? Is there
any improvement on target achieved? It is revelaed that
coverage of pre and postnatal services by health worker in the
village increased substantially. However, whether this program
is suit for longer term, needs to be assessed. As an option to
attract midwives to work in remote area more productive and
improve access of the unreached mother (even under this new
financing scheme on universal coverage), this program looks
14
promising. Local context, skill of the staffs, sufficient funding
are three main critical components to ensure the success of the
intervention.
Currently, health care (Puskesmas) has different
assignments as primary care for the Social Health Insurance
scheme (JKN) to provide curative care services and at the same
time has to ensure public health programs provision.
Overlapping between services covered and paid by different
source of fund add confusion.
3.2 Indicators
Indicators can be defined as a set of key measures as
the basis to define and track progress towards objectives.
Indicators used to reward performance should be quantitative
variables that needs verification, can be categorized into
efficiency indicators, quality indicators and administrative
indicators, or alternatively process and outcome indicators
(Pearson, 2011; Haryoko, 2011; Glassman, Todd and Gaarder,
2007; Eichler and Levine, 2009).
Efficiency indicators: often expressed in terms of
percentage of target population covered, or number of health
services provided per capita or proportion of patients having
good health outcomes. Examples include proportion of children
immunized, proportion of cardiovascular and diabetes patients
with normal blood pressure.
15
Quality indicators were not as widely used; usually
reflect patient satisfaction, medical record and treatment
guideline compliance, reduced waiting time or whether or not
the facility met accreditation standards.
Administrative indicators are dealing with procedures
of contracting, reporting, or service availability. These
included, for example, whether planned and actual drug stocks
matched, or whether supervision systems with specific criteria
were in place. These also included such items as unreported
activities or data entry errors.
Performance indicators could also include process
indicators, such as implementation of a certain proportion of
planned activities, or timeliness and completion of health
information reports, or even output indicators such as number
of children correctly treated for fever, diarrhea.
We learned from Vietnam and other countries’ RBF
experiences, they advice to be careful in choosing performance
indicators (Anon, 2011; Glassman, Todd and Gaarder, 2007;
Vergeer, Manshande and Johnston, 2011; Manshande, Vergeer
and Fritsche, 2010; Meessen, Kashala and Musango, 2007;
Dupas, 2005). First, indicators must relate to priorities and
objectives of interventions. Second, indicators should be
chosen to measure actions or outcomes over which health care
providers have direct influence, and not broad outcomes that
are influenced by many other factors; thus “reduction in child
mortality rates” would not be appropriate because it is
16
determined by many social factors over which providers have
little influence. Third, indicators should be measurable and
verifiable. Fourth, the number of indicators needs to be well
balanced among areas of interest since focusing attention on
one area may result in neglect to other areas while too many
indicators will make verification complicated. And fifth,
focusing on efficacy indicators only may compromise quality
care. Both quantity and quality should be included in the set of
indicators. It is not easy to decide the optimal number of
indicators is sufficient. Some literatures recommended that
output indicators should not exceed 25 for easy verification of
payments that were made every month without too
complicated administrative procedure. Especially for
developing countries with weak information systems, paper-
based systems, a small number of indicators (less than 10)
should be considered at the onset of RBF intervention. As the
RBF evolves, more complicated indicators can be introduced.
3.3 Setting targets

Performance targets are the link between performance
indicators and payment mechanisms. Example from RBF
schemes targets were set as proportion of the population
served, increases in services provided or outcomes achieved,
or even yes/no that some feature was implemented. In some
cases, targets involved different degrees of achievement. Some
targets were set for measurement on an annual basis, and for
17
others on a quarterly or monthly basis. It is recommended that
targets should not be too easy to achieve, but also should not
be too difficult to achieve with moderate effort. In addition, it
was recommended that targets should be set for improvement
in relation to each facility’s own baseline. Failures were seen
when common targets were set or when only top ranking
performers were rewarded.
3.4 Setting incentives

The level of the incentive, proportion of total payments
that were performance-based, the trigger for receiving
incentives (individual components of performance or total
package), timing of incentive payments, the actual recipient of
incentives (individuals or facilities), the “carrot versus stick”
nature of incentives varied across RBF schemes, while most
schemes allowed the recipients of the incentive payments
complete freedom over how they could use the funds received.
Some evidence indicated that if too small incentives did not
influence behavior to improve performance. Positive
incentives, i.e. additional remuneration, worked better than
threats of reduced payments. In addition, ensuring adequate
resources and knowledge for implementing the interventions
was also essential for RBFs to be successful.
18
3.5 Performance verification
Verification and payment are key features of RBFs.
Verification process include ensuring accuracy and consistency
of self-reported data on number and/or quality of services,
ensuring reliable reporting. We also need support from direct
observations of the conditions of service delivery and actual
care through use of medical record reviews, external audits,
household surveys, regular monitoring by fund holders, pre
and post-evaluation and meetings with stakeholders. Aside
from that, counter verification by a third-party was also found
to be useful, to ensure that payments were made, that quality
assessments were objective, that consistency checks between
reports and actual services reported were actually performed.
A good IT system is required, as well as other factors such as
involving the community, sustainability, involving research
institutes to support the RBF.
3.6 Contracting
Contracts must clearly established targets, describe
how performance will be measured, and determine the award
fee associated with attainment of each target.
3.7 WB-MCC Plan for RBF Pilot

The proposed scheme will consider factors mentioned
above. Key elements should be included, such as (Millennium
19
Challenge Corporation, 2013a; Millennium Challenge
Corporation, 2013b):
• Clear identification of a set of priority health outcomes
to be achieved: stunting or more specific nutrition
status achievement or “the first 1000 days of life”
• Interventions to be implemented: related to nutrition,
some other MCC targets will be covered under
capitation Ina CBGs, payment’s scheme under single
payer of the SHI or BPJS
• Measurable and verifiable indicators: will be developed
further for next step, based on nutrition program
indicators selected
• Monitoring systems to measure performance: we could
learn from Cordaid experience
performance: we could also learn from Cordaid
experience and proposed size of payment need to be
discussed further prior to the pilot. Need to be decided
how the MCC support will be used, how the fund
chanelling would be (would it be through existing
system/ government scheme, or would it be through
different/ special scheme?). Literatures said that the
success of the RBF implementation is depending on
whether payment to award attained performance can
be easily done. External funding to pay civil servant (i.e
health center staffs) might not be accepted or need
20
special MoU/ contract through Local government, such
as what has been done by Cordaid in NTT (District
Health Office of Ngada and Cordaid, 2012; Schoffelen,
Haryoko and Tacoy, 2011). To ensure sustainability,
“buy-in” from beginning of the process has to be set up.
Local government’s committment is not only limited to
legalizing the incentive but also providing money to
pay the incentives. In this regard, fiscal capacity of the
chosen district is really matter. Otherwise, central
government is the source of the fund. There are some
implemented project funded by local government
cencerning the “additional/ extra salary or incentive for
civil servant” that could be combined with RBF scheme,
such as TPP (will be discussed later). In addition to this
plan on the supply side, we could also combine it with
the demand-side approach, in this regard is the PNPM
Generasi Sehat Cerdas (PNPM GSC).
21
PART 4
EVIDENCE FROM THE FIELD
This section describes some lesson learned from our

field visit to some provinces such as West Java, NTB and NTT.
4.1 PNPM Generasi District Facilitator, Subang district

PNPM Generasi is an innovative project introduced by
the Government of Indonesia to address certain lagging human
development outcomes and accelerate attainment of the
Millennium Development Goals. PNPM Generasi adapts the
PNPM-Rural program delivery model to achieve improvements
in maternal and infant mortality, universal primary education,
and poverty reduction. Communities work with facilitators and
health and education service to allocate block grant funds to
target 12 health and education indicators. Communities can
use funds to effectively target local problems, addressing issues
effecting individuals and the community as a whole. PNPM
make sure that there is no overlapping fund for same activities
supported by PNPM Generasi, BOK, and BOS. PNPM health
activities focused to “non-user” group such as: pregnant
women who did seek ANC to the trained health professionals,
severe or under-nutrition children, and under-5 children who
did not come to posyandu. Despite substantial proportion of
the fund was allocated for PMT (food supplement) program,
nutrition problem remains high, not only food issues but also
22
parenting issues. PNPM GSC provides incentive for cadres, and
it is assumed that activities to perform targeted program have
already been listed as health center’s routine program.
Therefore, informant suggested that no need to provide
incentive for village midwife, PNPM GSC is actually supports
midwives to accomplish their tasks in the village. Whether in
reality midwives and other service providers/ health
personnels received insufficient incentives, it is not PNPM’s
authority to discuss and decide. The demand side approach to
increase demand for health care services through Conditional
Cash Transfer program (i.e PKH) and PNPM GSC might be good
if combined with supply side approach such as incentivize
health personnels.
4.2 Midwives in Puskesmas, Subang District, West Java

There was no special incentive for midwives, mainly
from APBD and Jampersal fund. Usually fund received is
distributed for all staffs, not only for those who work directly
for service provision. Workload is not considered as
adjustment factor for incentive under government system.
4.3 Puskesmas Banjaran Kab. Bandung (PONED), West

Java
TPP or Tunjangan Penambah Penghasilan, a program
funded by local government to provide additional salary on top
of basic salary. It is aiming at improving motivation of the staffs
23
and productivity. In fact, incentives were given without any
relationship with workload and performance. With regard to
nutrition program, no calculation on achieved target to
determine the amount of incentives. Complaints were also
raised when the health (nutrition program) personnels felt
transporation costs was not adequate. It was suggested to
improve cadres capacity to monitor the growth and
development of child. TPP might be combined with PNPM GSC
and initiative to incentivize providers to increase motivation.
4.4 DHO Ngada, West Nusa Tenggara

Cordaid project was the most recent (perhaps the only)
example found in the country that directly related to
performance-based financing or “pay-for-performance”. The
pilot suggested the flexibility of the system to ensure incentive
for personnels timely received, so that it is meaningful to link
performance and payment. The project systematically
developed the payment scheme, indicators to achieve,
verification and monitoring process. Leadership, support from
local stakeholders and willingness of the staffs to comply with
agreement were factors affected the success of this PBF
scheme. Unfortunately the project was not sustain.
4.5 Desa Pengenjek, West Nusa Tenggara

ADD or Alokasi Dana Desa is local budget allocated for
village and can be used to support activities at village level,
24
depending on priority set up by the village. Head of Pengejek
village stated that incentives should be given to cadres since
they work so hard to help the community, the ADD fund in
Pengenjek was used to pay monthy incentive for 65 cadres. At
the moment PNPM GSC also provide incentive for cadre.
Nutrition program activities was done by TPG and cadres,
including to identify severe-malnutrition children, to refer
children with infection disease to puskesmas/hospital.
Leadership and motivated cadres were factors behind the
success of the use ADD to improve access of the people. Village
people could seek care to health center for free, paid by village
authority using ADD fund. Innovative activities were proposed ,
such as using ADD fund to support program to improve
nutrition status of the people, especially children. In the case of
malnutrition, TPG and cadres would choose nearest shop
(warung) to supply the mother with healthy foods (vegetables
and fish) every day, instead of giving money to the mother. TPG
monitored the weight of the sick child regularly. It was
suggested to increase fairness in fund allocation by using
better factor for adjustment such as number of population,
fiscal capacity etc.
25
PART 5
RESULT
THE MODELS: PREVIOUS, EXISTING AND PROPOSED
SCHEMES
There are some initiatives on innovative projects

related to nutrition or performance based financing in
Indonesia. We reviewed how the projects work, how they
managed the fund from external support, whether they use
performance-based indicators for payment, what are the
challenges etc.
The first project we learned was Cordaid, an initiative
to improve provider performance in NTT, and proposed a
modified approach to support MCC focused-program: stunting
(Haryoko, 2011; Soeters, 2008; District Health Office of Ngada
and Cordaid, 2012). The second project we learned was ADD or
Alokasi Dana Desa scheme that has been used partly to ensure
access of the village people. The third project we learned was
NICE (Nutrition Improvement through Community
Empowerment), a 5 year (2008-2012) project funded by the
ADB, implemented in 6 provinces (Solikin, Kristiani and
Gunawan, 2016; Bappenas, 2007; District Health Office of
Lombok Barat, 2009). We learned from the implementation in
NTB and further assess how we could propose a new model
based on the NICE model and combine it with PNPM GSC’s role
and function to support nutrition program with particular
26
focus on the performance based financing. The fourth scheme
we learned was TPP (Tunjangan Peningkatan/Penambah
Penghasilan) or Additional incentives to increase staffs’
performance. The source of the fund was the local government
budget. Although it is meant to be used as a “tool” to increase
performance, however only limited performance measurement
involved as the basis for incentives. The most common
indicator was number of patient treated (MOH, 2010b; MOH,
2003; MOH, 2010a; MOH, 2009).
Based on the lesson learned from the four initiatives,
two approaches are proposed to introduce a result based
financing to support targets achievement under MCC project.
The two schemes were developed in regard to the level of
implementation: village/ subdistrict (health center staffs) or
district (DHO and HC staffs). MCC support can be planned to
initiate the pilot, starting from developing the detail guideline
and plan of action. A buy-in process involving stakeholders in
the selected district(s) should be conducted prior to the pilot. A
strong committment from the local government is required to
ensure that the model will be sustained and even be used as the
basis to achieve the SPM (Standar Pelayanan Minimal) or
Obligatory Function of the local government, to monitor
achievement of the targeted performance. Funding to support
the incentives can be proposed from either central or local
government, or even both. For example, BOK, which is funded
by the central government is potentially used to support
27
“outreach” program activities, while ADD or TPP that funded by
the local government can be proposed to finance provider
incentives at the village, health center and DHO level. To avoid
duplication with other payment i.e. for curative care provision
(will surely obtained capitation payment for primary care
under Universal Health Coverage or Jaminan Kesehatan
Nasional/ JKN scheme), the MCC RBF initiative should focus on
certain intervention(s), in this regard is nutrition program. We
could use indocators or some of the indicators as the MCC
target using RBF’s scheme. The following indicators are cited
from the MOH program on “Seribu hari pertama dalam
kehidupan” or “the first 1000 days of Life” (Bappenas, 2012;
MOH, n.d).
Table 1. Nutritional and Health Indicators Related to the First 1000

Days of Life
PHASE INDICATORS NUTRITION PROGRAM OTHER HEALTH

IN PNPM (POTENTIAL PAID BY MCC) PROGRAM (ALREADY
PAID BY BPJS OR BOK)
Pregnancy/ • Antenatal/ • % of pregnant women who • % of antenatal care visits
prenatal Prenatal care consume <70% RDA • % of pregnant women
visits for − Percentage of received malaria
pregnant underweight pregnant treatment
women women who received − % Netting and Drugs
• Taking iron treatment • % of pregnant women
tablets • % of anemia in pregnant who detected of
during women hypertension in
pregnancy • % of pregnant women who pregnancy
received calcium − % coverage of
supplementation hypertension women
• % of pregnant women who who received
received counselling of early Treatment
initiation of breastfeeding
and exclusive breastfeeding
28
PHASE INDICATORS NUTRITION PROGRAM OTHER HEALTH
IN PNPM (POTENTIAL PAID BY MCC) PROGRAM (ALREADY
PAID BY BPJS OR BOK)
• % of pregnant mothers who
living in household using
adequately iodized salt
Natal/ • Delivery • % of infants less than 24 • % of delivery by a trained
delivery assisted by a months breastfed within 1 professional
trained hour of birth • % of delivery women
professional • % of women postnatal who who are delaying cutting
took iron tablets the umbilical cord
• % of women postnatal who • % of neonatal visit
received a vitamin A dose in
the first two months
Postnatal & • Postnatal • % of women who recived
newborn care visits individuals or groups
(0-28 days) promotion on breastfeeding
and IEC nutrition
Neonatal • Complete • % of infants less than 6 • % of children who living
(0-24 childhood months breastfed in household using
months immunizatio • % of infants 6-10 months adequately iodized salt
old) ns fed complementary foods • % of children who
• Ensuring • % of children who recieved received complete
monthly vitamin A supplementation immunization
weight • % of eligible children in • % of children who living
increases for growth monitoring / in household using
infants promotion mosquito nets-drug
• Vitamin A • % of children three years • % of children who
twice a year who classified as detected worm infection
for under- undernourished according • % of children who
fives to 3 antropometric indices received deworming
• Monthly of nutritional status (height drugs
weighing for for age, weight for age,
children weight for height)
under three • % of children in growth
and promotion program gaining
biannually weight in past 3 months
for under- • % of underweight children
fives who received food
supplementation
• % of children aged < 3 years
who consumed sprinkle
29
The chosen targets will be incorporated in the
proposed models. The four potential “model” are discussed as
follow.
5.1 LESSON FROM CORDAID PROJECT IN NTT

This schematic illustrates how the intergovernmental
RBF scheme transferred funds between different level of
government (Haryoko, 2011; Schoffelen, Haryoko and Tacoy,
2011). There were numbers of principles we can learn from
this model as described below.
5.1.1 Legal Feasibility

CORDAID, a Dutch NGO, started PBF in 2009 with its
Indonesian partner, PT Bahana, in the remote districts Ngada
and Nagekeo on the island of Flores in eastern Indonesia. These
30
two districts were selected after visits to several districts and
in close consultation with the provincial health office. Criteria
for selecting these districts included the absence of other
donor assistance, high poverty indicators, low health status of
the population and poor condition of health care providers. At
the beginning of the project, the MoU at the central level is
done by the Ministry of Social Affairs since communication
problem. Furthermore, the central government is fully hand
over to the cooperation mechanism in NTT Province. Activities
adapted to the situation and condition of health centers or
district, neutral of religion, and transparent between the
stakeholders.
MoU between Cordaid and NTT province, as well as
Nagakeo and Ngada districts were developed. In fact, Local
Government assigned Steering Committee (SC) for this project.
SC team consisted of Bappeda, DHO, and Chief Head of the
Health Center, private BP, Perdhaki (Catholic Organization),
and community representatives. There was no local budget
alloctaed for this project.
For Ngada district, the agreement was signed on April
4th, 2011 by Ernest Schoffelen representing Cordaid
Netherland, and Marianus Sae, as Executive Head of Ngada,
consists of 6 articles concerning the objective of the PBF, how
the implementation is structured, duration, and how to solve
any problem related to the agreement.
31
Initially Cordaid Project was planned to be
implemented over 7 years, but in the 2nd year the project was
terminated due to the EU crisis. The project was not sustained.
Despite “buy-in” process was carefully initiated before the
project was implemented, no comittment from Local
Government to continue the project after Cordaid fund was
terminated.
5.1.2 Organizational Feasibility

A basic principle of the PBF system is the separation of
the function of purchaser and provider (“purchaser-provider
split”) using contracts that define payments for each unit of
services delivered. There must be a functioning monitoring
system in place for the independent verification of results. If
payment is (at least in part) dependent on the number of
services and their quality (performance), health managers will
be encouraged to attract more patients and give them a good
service. This system will lead to more efficiency in the
allocation of resources, because there is an incentive to
maximize output with the least possible consumption of inputs.
It requires another principle: the health provider is given
autonomy on deciding how to use revenue from budget
allocation and user fees.
The basis for how this pilot organized as written in the
agreement. An institutional structure at the District level that
separates the following functions:
32
a. Regulation. (Dinkes Provinsi). Its principal role in the
health system of the Province is to assure quality, enforce
fulfilment of standard procedures based on national health
policy and licensing of private care providers.
b. Fund Disbursement. The responsibility for the distribution
of funds (from public sources as well as health insurance
premiums) is implemented best by an organisation that
has no responsibility for regulations. International
experience demonstrates that mixing the function of
regulation and administration is associated with
inefficiency, mismanagement and corruption.
Nevertheless, the autonomous Fund Holder operates
under the control of the Regulator that has the authority to
revoke the contract with the Fund Holder in case of
problems.
c. Provision of Health Care Service. The Health Service
Providers will be encouraged to organise their activities in
an autonomous manner to reinforce their responsibility to
offer the Minimum Services Package and Complementary
Packages.
d. Client Satisfaction. Increase the voice of users through
surveys that measure user/patient satisfaction, thus
encouraging health centres to provide quality care or risk
to lose patients to better performing providers. Currently
a patient satisfaction survey is conducted and analized.
33
The objective of this separation of functions is to
ensure transparency and encourage building local
responsibility and accountability for delivering quality health
services. The representatives of the four different functions
have their own autonomy from one side, but also work
together with the objective to make available health services of
high quality to the population. Cordaid project experienced
that during the pilot separation of the functions worked, and
leadership was one of the factor contributed to
implementation.
5.1.3 Verification, Monitoring and Evaluation

In the beginning PT Bahana did not have any standard
guideline for this PBF implementation. The guideline was
developed later and has been refined to respond local situation
and condition. The guideline covered various things such as
how to make a business plan, payment mechanism, amount of
payment, and type of services and its performance as the basis
for payment.
There was an agreement between the Fund Holder (PT
Bahana) and Providers (hospitals and health centers) and
regulator (Department of Health). The agreement was used as
a reference for business plan and the basis for the Fund Holder
in conducting routine monitoring and evaluation.
Verification was done by Cordaid (PT Bahana). Bahana
recruited one person per district to verify data. This project
34
involved community representatives, who were volunteers
from local church. They helped to check the accuracy of the
data and monitored satisfaction of patients. They visited the
sampled household to verify the visit, service and whether they
were satisfied with services provided. The project granted
transport allowance.
The project evaluation was done quarterly to see
achievement of the target as set up in the bussiness plan.
Cordaid submitted the Midterm Evaluation Project to the
Ministry of Health. Unfortunately the midterm report become
the final evaluation because the project was terminated.
A total of 15 performance indicators for health facilities
were selected carefully in a consultative process with
provincial, district- and local health authorities. For the district
hospital a set of 11 indicators were selected (Table 2).
Table 2. List of Indicators from Cordaid Project in West Nusa Tenggara
Puskesmas (Health Center) Hospital

New consultations In-patient days
In-patient days (max 6) Feedback to Puskesmas following
Referrals (general including delivery) to hospital referral
Referrals (tubectomy and vasectomy) to hospital Major surgical procedure
Complete immunization (excluding caesarian)
New TB case findings Minor surgical procedure
Confirmed TB cases cured Tubectomy and vasectomy
Old and new family planning visits Delivery with complications (incl.
Insertions of IUD or implant caesarian) Delivery with
Complete four (4) prenatal visits complications (excl. caesarian)
Pregnant women immunisation (TT2) Curretage
Delivery in appropriate Health Facility (Puskesmas) Blood bags stored (for
Delivery in less than appropriate HF (Pustus, Polindes) transfusion)
Complete neonatal visits (KN2) Treatment of low birth weight
Detection and management of sexually transmitted Treatment of new born with
diseases complications
35
As discussed earlier, decision on the number of
indicator is important for RBF. In district with poor/ weal
information system, too many indicator will bring to the
difficult process to verify, monitor and even too ambitious to
achieve. This project has started with a list indicator for health
center and hospital, and during the pilot it was closely
discussed with local authorities.
5.1.4 Payment Scheme

Unit cost as the basis for payment was structured with
consideration on the level of difficulty and level of coverage.
This unit cost was determined jointly by the project and the
DHO, ranging from IDR 1,000-50,000. Average incentive for
health center staff was IDR 1,000/patient, but for difficult cases
such as TB it could reached IDR 50,000. For hospital staff,
incentive for outpatient service reached IDR 75,000, but for
inpatient care with complication such as C-section incentive
was much higher.
Table 3. Unit Cost Used as the Basis for Payment in Cordaid Project in
West Nusa Tenggara
Unit cost Unit cost

No Health Facilities District Hospital
(IDR) (IDR)
1. New consultations 2,000 In-patient days 1,000/day
2. In-patient days (max 6) 1,400 Feedback to Puskesmas 3,000
following referral
3. Referrals (general including 8,000 Major surgical procedure (excl. 100,000
delivery) to hospital caesarian)
4. Referrals (tubectomy and 8,000 Minor surgical procedure 5,000
36
Unit cost Unit cost
No Health Facilities District Hospital
(IDR) (IDR)
vasectomy) to hospital
5. Complete immunisation 10,000 Tubectomy and vasectomy 100,000
6. New TB case findings 40,000 Delivery with complications 40,000
(incl. caesarian)
7. Confirmed TB cases cured 75,000 Delivery with complications 75,000
(excl. caesarian)
8. Old and new family planning 10,000 Curretage 50,000
visits
9. Insertions of IUD or implant 25,000 Blood bags stored (for 5,000
transfusion)
10. Complete (4) prenatal visits 8,000 Treatment of low birth weight 30,000
11. Pregnant women immunisation 4,000 Treatment of new born with 30,000
(TT2) complications
12. Delivery in appropriate Health 20,000
Facility (Puskesmas)
13. Delivery in less than appropriate 10,000
HF (Pustu, Polindes)
14. Complete neonatal visits (KN2) 6,000
15. Detection and management of 4,000
sexually transmitted diseases
The unit cost was modified as needed. For example if

there was any tendency of increased number of Csection
without any “medical indication”, incentive was reduced. To
respond fairness issue, for staffs who work in remote area, in
addition to this unit cost, a multiplier factor for special bonuses
was used for adjustment (additional 10-15%). Range of
payments for health center staffs reached between IDR 700
thousand-6 million, while for hospital staffs reached around
IDR 15 million.
37
For accountability purpose, funds from Cordaid
Netherlands was not directly transferred to the PT Bahana, but
through Perdhaki, and later was transferred to PT Bahana.
5.1.5 Proposed model based on Cordaid experience
Proposed Combined
model of Ex-Cordaid Nutrition Section DHO:
and PNPM GSC - Making contract
Regulator - Desiging mechanism
DHO/PNPM :
- Managing MCC’s grant
- Advocacy for APBD
Provider Fund holder fund to sustain
program
Nutrition Team in CHC:
Nutrition issues or indicator:
- Village midwife - % of pregnant who Independent verificator
- TPG received iron folate - Validating data
- % Exclusive BF
- % monitored chlidren by
- Paid by MCC
monthly weighing, etc
Voluntary community verificator

Community - Cadre from PNPM GSC
(mother, baby, and - PNPM Team in sub-disctrict
children)
To meet the RBF related to nutrition program

intervention, this proposed model is focusing on nutrition
components and performance of personnels who are dealing
with the targets. In general we propose similar approach with
Cordaid with modification (this need to be explored after the
pilot area is decided). There are three important functions in
the model: fund holders, regulators, and providers. Cordaid
38
project in NTT has shown success initiative in separation of
functions and this could be continued (if we choose NTT as
pilot area).
Midwife at the village level and TPG personnel in health
centers are personnels who engaged with the scheme. We
could also consider involvement of community, in this regard
cadre is incentivized under PNPM GSC. Verification process is
done by cadre(s) from posyandu or PNPM. His/ her function is
to ensure that the program is working on the right track.
Independent verificator(s) can be people from outside
institution hired by the scheme or from nutrition section of
DHO. If they are DHO staff(s), they need permission from head
of DHO, so there no jealous from another program. In the
proposed model, the verificator is an independent health
personnel who paid by DHO. If the budget limited, nutrition
team can be as verificator personnel.
Payment for personnels is in this model is calculated
based on target indicator to be achieved. Recording and
reporting become critical as the basis for the payments. There
are two type cohort books: cohort for baby and for mother,
informations includes all relevant characteristics of the baby
and mother. Both books are managed by the village midwife.In
this proposed model, direct payment to bank account at village
level might be difficult, it could be easier if payment is made by
DHO to health center(s), under an agreement between funder
(MCC) and local authority.
39
5.1.6 Challenge
Cordaid model requires flow of fund outside

government’s system. If we propose this for the RBF using MCC
fund, it will need clear procedure, how it works and collaborate
with province and district, what the roles and functions of each
entity.
5.2 LESSON FROM THE ADD (ALOKASI DANA DESA)

SCHEME
ADD or Alokasi Dana Desa can be considered as a
potential source to support the efforts to achieve health
program targets (Minister of Home Affairs, 2007). In many
districts we can find various initiatives of the Head of the
Village to use the money, and many of them have already
aware that improving “spending quality” is really matter, it can
shows how the leadership at the village level has a strategic
role to ensure access of the village people.
40
Lesson Learned 2:
Existing ADD Model
District Government Musrembangcam DHO
Sub-district Authority Musrembangcam CHC
Village → ADD Musrembangdes Village midwife

PP No.37/2007 → ADD as
resource of fund
Permen No.37/2007
70% of funding for Community
community
empowerment, including
for health .
We learned from our field visit to Pengenjek village in

West Nusa Tenggara, the Head of the Village used the funds to
support health care provision for the people. They can easily
come to the health center for free. For pregnant mothers and
malnutrition cases, cadres are expected to help to seek ANC to
the Midwife services and improve nutrition status of the Baby
and toddlers. The existing system do not involve such a
initiative to give incentives to the providers to improve
performances.However, it can be modified to integrate the
performance-based incentives to the existing ADD scheme.
41
Under decentralization reform, more specific as written
in the law (UU No.32 Tahun 2004) the role and function of the
central government is given to the local government. According
to PP No.37/2007 village level obtain fund to implement
activities to fulfil its role. Fund allocation addressed to
community empowerment, health issues.
Source of fund is Local budget or APBD. There are some
relevant regulations such as PP No.27/2005 about Village
Government Affairs, SK Menteri dalam Negeri No.
140/640SJ/2005 about Guidance of Village Funding Allocation,
and Permendagri No. 37 Tahun 2007 about Guidance to village
funding management.
Local government sometimes regulate details and
amount of ADD in their local regulation. Proposed activities for
ADD proposed by village meeting (Musyawarah Perencanaan
dan Pembangunan Desa) that proposed each fiscal year.
Musrembangdes followed by village officials and community
representative. It means proposed activities depend on ideas of
the meeting.
Community representative can contribute to proposed
activities for ADD by musrenbangdes or village level planning
process involving stakeholders including village leaders/
representatives.
42
ADD allocated annualy for each fiscal year (March or
April) which precede by Musrembangdes in the beginning of
year.

According to the regulations principles of management
of ADD is transparant, accountable, partisipative, folow the
rules, dicipline, effective allocation and controlled.
ADD allocates around 30% for personnels (or “belanja
aparatur”) and around 70% for community empowerment
(including for building, investment, education, socio culture,
and health. Funding of ADD very sustain because of the strong
support of the policy. The amount depends on the ability of
central and local government.
5.2.3 Monitoring and Evaluation

ADD is a government scheme, regulated and structured
as government’s support to implement program at the village
level. Monitoring and evaluation follow the regular
government’s procedure(s). Monitoring of the health center
nutrition program (and other health program) achievement is
done by the health center and DHO, separate from the ADD
system.
Reporting and accountability of ADD integrated with
reporting and accountability APBDes (Village level local
budget). Supervision of the implementation of ADD according
43
to scheduled supervision from government according to the
regulation.

ADD derived from APBD which sourced form central
and local financial received by 10%. Distribution and
disbursement mechanisms ADD implemented using financial
assistance expenditure. The existing ADD scheme do not relate
with any “performance-based financing” related to health
scheme. Payment cycle follows government’s planning and
budgeting process and fiscal year period.
5.2.5 Proposed Model Using ADD Approach

The ADD scheme is potential to be used as the basis for
the MCC-RBF. The implementation will at the village level,
combined with the PNPM GSC program that has been
implemented in many provinces. In PNPM GSC area(s),
nutrition program has already been the focus of the
intervention. If we decide ADD scheme as the basis for RBF (e.g
selecting Pengenjek village as thepilot area), a combined model
of PNPM GSC and ADD scheme would be one option with less
complicated legal framework ince these two government’s
program are already in place. Inserting RBF to improve
performance of providers is a possible plan to consider.
44
We propose to incorporate
• Quantitative target to monitor ADD performance. This
would need specific RBF indicators in hand before the
pilot
• Specific health/ nutrition program targets as part of the
intervention supported by ADD in selected pilot area
• Since ADD is implemented at the village level, for
supervision and support by DHO staffs will be financed by
APBD district/ municipality funds
• PNPM GSC will support nutrition program with particular
focus on cadres, while health center could get funding
from ADD and DHO
The schematic below show how the interaction
between District authority, subdistrict and village level will
sinchronize the use of resources from different level to support
nutrition program, using RBF approach. Challenges for
payment scheme is low flexibility to use the government fund
to respond the good performance, it will need local
government’s commitment as well as head of the village
innovation to support the RBF. The strenght of the ADD
approach to be used for RBF is the “close distance” in terms of
cooperation between cadres, health center staffs/ midwife, and
PNPM GSC, while head of the village could closely monitor the
progress and even motivate all assigned staffs and cadres to
work together hand-in-hand to achieve the targets.
45
Proposed Combined ADD
and PNPM GSC
District Government Musrembangcam DHO
Sub-district Government Musrembangcam CHC
Village → ADD Musrembangdes Village midwife
Community
Independent person inserted in PNPM to advocate issues and

activities related to nutrition in village level: Nutrition issues or indicators:
- To empower community - Monitoring child health ,monthly
- To assist village to create nutrition activities weighing at posyandu
- To coordinate program with health sector - Treatment underweight chlidren,
supplementary feeding program, etc
5.2.6 Challenges
Reffering to ADD’s regulation, it might be difficut for
MCC to incorporate the RBF scheme at the village level. Our
proposal could be consider to develop RBF under MCC pilot
such as to:
a. Encourage and empower the community to bring the
health issues or activities as part of the ADD funded
program.
b. Provide “stimulant” fund (top-up or even additional)
including insentive for cadre to improve nutrition
status of the community, or even incentive for health
personnel.
46
c. Combine this approach at village level with PNPM GSC
and RBF with district level model.
5.3 LESSON FROM THE NICE PROJECT

Nutrition Improvement Project Implementation
through Community Empowerment -NICE (Nutrition
Improvement Through Community Empowerment – NICE
Project) is a project financed through loans from the Asian
Development Bank (Asian Development Bank) carried out for 5
years starting in 2008 until 2012 which was held in 6 elected
Provincial namely West Kalimantan, South Sulawesi, North
Sumatra, West and East Nusa Tenggara (Solikin, Kristiani and
Gunawan, 2016; District Health Office of Lombok Barat, 2009).
We visited on of the NICE project area in NTB. There were
positive responses from local authorities, informants we
interviewed expressed their appreciation. Concerns were
addressed related to the sustainability and need for
improvement in coordination with other institutions such as
PNPM GSC, and the need to provide incentive for provider
(such as midwives).
47
PREVIOUS the Coordinator (Head of Provincial Nutrition Bappenas
NICE Bappeda ) :
Directorate MoH:
SYSTEM - dev. Regulation
- Coordinating the project - dev. programs i.e
-Managing the project (Taburia package) MoF : fund
Project Manager (Head of PHO) disbursement
Fund holder
(PHO): - the User Authorization
Regulator
budget
District Project Implementation

Team Unit DPIU (Head of District
District: Bappeda)& Head of DHO
- Overal Technical
Community official
facilitators Nutrition Team in
contracted by DHO to CHC:
assist KGM in - Village midwife
nutrtion project & - TPG
coordinate Provider
Beneficiery
Community Nutrition Group :(mother, baby,
(Kelompok Gizi Masyarakat KGM): and children)
-Plan specific nutrition project
-Innovate & run community program Beneficiery

Concept adopted in the NICE project is community
development or the development of public awareness, building
character of the community to be aware with their duties and
responsibilities in maintaining health and nutritional status of
their families. Project was tailored to the community context in
all project areas. In the implementation of this project, local
staffs and communities were encouraged to make the "Bottom
up Planning" to pursue indicators related to nutrition (output
and outcome) specified by the project. Further planning of the
activities arranged in a proposal to obtain funding through the
Community Nutrition Package (Paket Gizi Masyarakat: PGM).
48
This project had strong support from Central and Local
Goverment. NICE project implementation activities based on
ADB Loan agreement, dated October 5, 2007 between the
Government of Indonesia and Asian Development Bank, the
Loan No. 2348 INO (SF) on the Nutrition Improvement through
Community Empowerment Project (NICE Project). 1 This
project was also supported by several decrees:
1) Decree of the Minister of Health of Indonesia, Number:
534/Menkes/SK/2007, on Appointment of Project
Director, Center for Management Unit, the Provincial
Project Coordination Unit, Project Implementation Unit at
District level or the NICE project
2) Decree of the National Development Planning Board/
Head of Bappenas No.364/ M.PPN/10/207, October 25,
2007 on the establishment of the Steering Committee and
Technical Team Project of NICE Project, year 2007-2012
3) Decree of the Director General of the Ministry of Finance
No. Pembendaharaan: PER/23/PB/2008 June 12, 2008 on
Guidelines and Disbursement Disbursement of ADB Loan
No.2348-INO (SF) Project NICE.
In addition, MOH also launched “taburia” program that
has also been actively promoted and distributed in the project
areas.
1 Nutrition Improvement Trough Community Empowerment Project, posted

on 13 Maret 2011 by Ppcunicesumsel, NICE Project ADB Loan 2348 (Sf)
South Sumatra Province, 2010
49
Activity of all program activities of the NICE project
was incorporated in DIPA (Daftar Isian Pelaksanaan Anggaran)
NICE Project, a government’s financial procedure (this is a loan,
not a grant, by regulation is treated as government budget and
must follow government procedure/ code of conduct). The
POA (Plan of Action), technical guidelines and type of activity
and the amount of funds in the DIPA were decided based on
proposed tasks of each District/ Municipality.

Stakeholders at local level showed their interest untill
the end of project. Skill of the staffs varied and influenced the
result. Most of all project management officers were
determined by local authority (high and middle manager
positions were given to the local goverment staffs). For
example, decision on position for the Coordinator and Project
Manager was written in the Governor Decree (Project
Coordinator for each province was Head of Provincial Bappeda
and Project Manager was Head of the Provincial Health Office),
Routine activities of PPCU (Planning, Programming and
Coordinating Unit) Secretariat in carrying out all project
activities stated in the terms of reference activity (TOR) and
DIPA each year. There was a Project Implementation Unit at
the District level (District Project Implementation Unit: DPIU),
Project Coordinator: Head of Bappeda Kab / City, Project
Manager: Chief Medical Officer of Regency / Municipality.
50
There were also Technical Team District (District Technical
Team). This organization structure was legalized in the decree.
Community facilitators were selected by District
Selection Committee Facilitator who were appointed and
legalized by a decree of the DHO.
The project was carried out for 5 years starting in 2008
until 2012. The Project considered implemented only in short
time and in some provinces, impact of the intervention can not
be seen yet.
Community nutrition group (Kelompok Gizi
Masyarakat: KGM) formed and selected by the community
through the Rural Community Council (MMD). They carried out
early observations called Self Survey (Survey Mawas Diri: SMD)
which was implemented by the village people through their
representatives in the Nutrition group. They tried to find and
discover health and nutrition problems in the village and then
formulated in the form of Community Nutrition Group action
plan that aims to solve and address the health and nutrition
problems, set up priorities and implement local specific
activities. Further planning of the activities arranged in a
proposal to obtain funding.
KGM members and cadres using PGM funds to create
innovative businesses (Innovative here is defined as a better
ability with dynamic personality to be able to adapt to various
situations and conditions as well as to learn from the
experience to develop better self-direction).
51
Since no incentive payment introduced in this project,

there was no verification process as the basis for incentive
payment. The achievement of the program was evaluated and
verified in the project evaluation. The project team (local)
worked on managing and controling the project
implementation. No incentive for special achievement was paid
to health provider or volunteers. There was no independent
facilitator to verify any achievement of this project.
Project staff KGM was not equipped with standard
guidelines for project implementation and evaluation, no
technical guideline to harmonize all resources related to
nutrion improvement. Sinergy of resources/fund from APBD
from Province and district level in 2011, Jamkesmas, BOK and
NICE to increase nutrion status was really depending on the
community and midwive decision.
The indicators were given by the project. The
development of indicators did not involve local government
and community. However the activities for achieving the target
indicators were develop by community together with local
goverment.
The evaluation of the project was considered
fragmented since the focus of each province program relatively
different. The result (outcome) was considered not obviously
achieved although the output (posyandu activity) is proven to
be succeeded.
52
Taburia as one of project component was positively
reduce anemia but did not directly improve nutrition status. In
general, activity and performance of the posyandu were
increased and malnutrition was reduced but remained
uncertain whether nutritional status of children under five
increased. KGM determined their own activities to increase
nutrition status of the community. The central government also
launched a food supplement program of Taburia. Taburia
product was considered as a breakthrough to meet the need for
12 vitamins and 4 minerals among toddlers. Poor families
could take Taburia to add nutrients in foods they cook at
home. Indicators were listed as follow.
Outcome indicators:
• Coverage of integrated health post (posyandu) at least
80%
• Coverage of exclusive breastfeeding up to 6 months
40%
• Coverage of pregnant women received iron tablets
increase to 80%
Output indicators:
• Component 1. Development of policy and surveillance
program;
• Component 2. Strengthening nutrition program
planning and management;
• Component 3. Integrated nutrition services;
53
• Component 4. Empowerment of community.
Component 1. Development of Policies and Surveillance:

• Establishment of six strategic policy on community
nutrition program
• Number of Health Workers trained increased by 50%
compared to the baseline
• District Food and Nutrition Action Plan Year 20 10 -
2014.
• Integrated Inter-sectoral program at the village level
Component 2. Integrated Nutrition Services:
• A half of Trained staf in Puskesmas are women
• 90% health centers equipped with Nutrition Services
• At least 80% of integrated health post open every
month and achieve D/S 80%;
• At least 90% Posyandu have 2 trained cadres;
• Coverage of Fe 90 tablets in pregnant women at least
90%
• Existence of referral system to improve community
nutrition;
Component 3: Community Empowerment on Nutrition:
• Establishment of 524 Community Nutrition Group in 4
District, 524 villages and 60% of its members are
women
• At least 70% of Community Nutrition Package is
approved in 2011.
54
• At least 242 trained Community Facilitators and 50% of
them women
• Proportion of Primary Schools / Madrasah in 524
villages have clean water and basic sanitation facilities
increased by 50%
Component 4: Fortification and Nutrition Communication
• TABURIA is available in the market in at least 2
Districts/ municipalities
• All regional laboratories have trained personnel on
flour and salt fortification;
• Registered family with low Nutrition status increase at
least 50%
Component 5: Strengthening Program, Planning and
Management Nutrition
• All Implementation unit has schedule on activities and
detailed plan on project monitoring;
• The implementation of the Monitoring and Evaluation
of Technical and Financial Planning Project;
• Dissemination of Information

This project focused and commited more on demand
side rather than supply side particularly to improve the ability
of communities to make a plan and implement nutrition
program related to families and to Expand Food Fortification
Program. It was meant to support community empowerment,
55
develope capacity of institutions in developing policies and
surveillance nutrition programs; strenghtening the capacity of
institutions in developing policies and surveillance nutrition
programs; increasing quality of integrated nutrition services
especially for vulnerable groups. There was no comittment on
incentive for District Health officer (nutrition officer) and
provider. They did not receive any insentive for the
performance achieved. No incentives forhealth providers who
work on program intervention to cope stunting (civil servant,
non permanent staff (central and local)/PTT pusat and PTT
daerah, sukarelawan/ volunteer (supportive staff have no
medical and management background working at health
centers) and cadres.
There was no incentive for community volunter (cadre,
others) and KGM. They dedicated they work for their
community without any incentive for any targeted indicator
achieved. They were commited to undertake inovative
activities, such as Fishery in backyard pond, running small
scale food industries, running chicken and ducks farm, running
oyster mushrooms and other mushrooms farm or other
community initiatives that can be developed by them selves.
There was no unit cost determination, since there was
no incentive payment for provider or community.
NICE was financed through loan from the Asian
Development Bank (ADB) carried out for 5 years starting in
2008 until 2012. All program activities was stipulated in the
56
NICE project in DIPA NICE Project. Stated in DIPA (ths budget
is sharing between Loans and goverment budget so that there
should be regulations as “umbrella”).
Fund chanelling was quite complex, and the fund
mangement was regulated by at least 9 regulation as follow :
1. Government Regulation No.2 Year 2006, concerning
the Procedures for Procurement of loans and / or
Revenue Grants And Loan and / or Grants
2. Presidential Regulation No.7 Year 2004 on
RPJMN/Long Term Strategic Plan 2004-2009 which
stated that the Nutrition Improvement Program is
intended to enhance community nutritional status of
families, especially pregnant women, infants and
toddlers
3. Decree of National Development Planning Board
No.005/M.PPN/06/2006 on the Procedures for
Planning and Proposal Submission and Reviewing
Activities financed by loans and / or Foreign Grants
4. Kepmenkes No: 331/Menkes/SK/V/2006 concerning
MoH Strategic Plan 2006-2009
5. Minister of Health Decree
No.1457/Menkes/SK/X/2003 concerning Minimum
Service Standard
6. Loan agreement dated October 5, 2007 between the
Government of Indonesia and Asian Development Bank,
the Loan No. 2348 INO (SF) on the Nutrition
57
Improvement through Community Empowerment
Project (NICE Project)
7. Decree of the Minister of Health of Indonesia,
No.534/Menkes/SK/2007, on Appointment of Project
Director, Center for Management Unit, the Provincial
Project Coordination Unit, Project Implementation Unit
District Project Nutrition Improvement Through
Community Empowerment (NICE Project)
8. Decree of National Development Planning Board or
Bappenas No.364/M.PPN/10/207, October 25, 2007 on
the establishment of the Steering Committee and
Technical Team Project Center for NICE Project 2007-
2012
9. Decree of the Director General of the Ministry of
Finance Decree No. Pembendaharaan:
PER/23/PB/2008 June 12, 2008 on the Guidelines and
Disbursement of ADB Loan No.2348-INO (SF) Project
NICE.
5.3.5 Sustainability
Although the project was designed to be sustained,
typically projects funded by donorswas not or less sustain. The
conditions that might cause NICE projects less sustain were:
• The areas selected were considered as poor rural areas
and the need of building infrastructure was still high.
• The project was implemented in a relatively short time.
58
• The project activities were not integrated with other
intervention to empower community.
• Poor atention on “maintaining” what has been initiated.
• Full time nutrition facilitators who assist community
has been transferred after project was terminated
• Exit strategy such as ADD, PKH (the Conditional Cash
Transfer program) and other funds have been
identified, but unfortunately it was not properly
followed up.
5.3.6 Proposed Model Using NICE Approach

NICE project was focusing on increasing community
empowerment, increasing the capacity of institutions to
develop policies and surveillance nutrition programs;
strenghtening the capacity of institutions in developing
policies and surveillance nutrition programs without incentive
scheme for result achieved. It is obvious that NICE project has
shown us lesson on how to manage nutrition as selected
program intervention, linking the indicator/ project goals with
local context.
Contribution on increasing nutrition performance:
• NICE encourage Bottom up planning, output based
project and enhance program management to work
more efective and efficient
• NICE project strengthened Posyandu
59
• All nutritional indicator from output to outcome were
listed and targeted
• There were supportive factors such as human
resources, participation of various sectors, villages and
community/religious leaders and integration with
other programs (PNPM-Mandiri, GSC, local budget)
• Funds were awarded to the village
• Increased planning and management capacity of the
DHO and the health centers
• Managers learn how to choose activity based on the
targeted indicators with consideration on local context
and available resources.
Specific characteristic could be adapted:
• Involvement of the local stakeholders and local
managers to run the project that increase sense of
belonging and willingness to work hard to achieve their
own targeted result
• Flexibility to choose project activies related to the
indicators
• Inclusion of sub district and village as project areas.
If NICE project is taken as the proposed model, ideally
ex-NICE areas could be considered as pilot area, and financial
incentive could be incorporated. NTB might be the good
example; it has several villages that already adopted NICE
“culture” (community empowerment/development) in their
current business. Some practices on innovative health
60
management at village level such as in Pangenjek Village were
also evident. They also aware about the importance of
nutrition program interventions for children under five, and
the need to link it up with a kind of performance-based
payment scheme.
The proposed model includes functions; regulator, fund
holder, project manager, provider, verificator and beneficiary.
The position of MCC is as Funder and coordinating the project.
The Government trhough Bappenas and MoH (Nutrition
Directorate) regulate and coordinate program activities with
MCC.
The most important thing in this proposed model in ex
NICE Project is to include verification function. The old model
did not cover verification function since that was no incentive
for providers. Ideally, verification is divided in two part, first,
under DHO direction (contract independent verificator) and
secondly, is the community (KGM) which proven to have
significant role in old model and the function is proposed to be
upgraded in this new model not only as facilitator but also
verificator.
The achievement of the program is not only evaluated
and verified in project evaluation (usually at the end of project
time) but also during the implementation to estimate the
amount of incentive awarded.
61
In this proposed model, local staff and communities are
still encouraged to do "Bottom up Planning" to pursue
indicators (output and outcome). Ideally, the indicators are
specified by them selves and not project given. After indicators
are set up, the community representatives will list nutrition
problems, propose intervention and its indicators.
This project should have strong support from Central
and Local Goverment. Need more work on deciding howt the
fund from MCC can flow to the district level for project
purpose. Commitmen/ agreement between MCC and national
goverment as “umbrella” of the project intervention activities
is a required. This project should also be supported by several
62
decrees; for example Decree of the Minister of Health
concerning on the project implementation, Decree of National
Development Planning Board/ Head of Bappenas and
Regulation of the Director General of the Ministry of Finance as
guidance for fund disbursement. The Head of Nutrition Health
Unit also become a facilitator for coordination with BPJS who
manage National Health Insurance to avoid overlapping with
the benefit package.
In addition, this program should also inline with other
Government policies (nutrition directorate, as Directorate
General of MCH Nutrition-Health Ministry). For example, MOH
launched nutrition project namely SUN (Scale Up Nutrition) or
“1000 Hari Pertama Kehidupan” or the first 1000 days of life.
All program activities are stipulated in DIPA of MCC Project
(based on NICE experience, need more work on this), however
MCC fund is considered as grant, not loan.
KGM will determine their own activities to empower
community, and at the same time they have to follow the
central government’s programs/ directions. Similarly, the local
stakeholders have to be committed to the model and
government’s policy, it is proposed that the project officers/
management will be determined and legalized by local
regulation. As in the old model, determination of position for
the Coordinator and Project Manager can be legalized with
Governor Decree and the Project Coordinator for each province
can be ex-officio Head of Provincial Bappeda and Project
63
Manager was Head of the Provincial Health Office, while for the
Technical Coordinator, Finance and Administration can be
Head of District Health Office as Project Manager.
Assignment of community facilitators will be based on
the selection process, coordinated by District Selection
Committee Facilitator (CFs District Selection Committee)
appointed by decree of the head of DHO. Full time nutrition
facilitators will be hired by the project, one possibility is ex-
NICE official can be re-hired to assist community. The
beneficiary would be communities, especially pregnant
women, infants and toddlers. Progress on nutrition status can
be monitored (observed) by the community verificator.
KGM members and cadres IHC (Integrated Health
center; Posyandu) verified the output or outcome of nutrition
project and noted some various situations and conditions that
related with output and verification process and then reported
to independent facilitator as input. The independent facilitator
itself does the verification based on project tools. To maintain
and achieved results, beside the incentive for provider, the
incentive for verificators should be considered.
In the old model, there was no incentive for providers.
In the proposed model the incentive will be given to
provider(s) who work in nutrition area which are bidan and
TPG. Unit cost for incentive payment can be determined
through assesment lead by DHO, agreed by providers and
approved by MCC.
64
All project components should be equipped with
sufficient standard/ technical guidelines for implemention and
use as the benchmark for project evaluation. It would also
useful to harmonize all resources related to intervention(s) on
nutrition improvement such as PNPM projects.
5.3.7 Indicators
Some indicators of the old model should be changed if
not applicable or could be modified based on local situation.
The modified indicators should be discussed and agreed again
by DHO, MCC and providers. The selected indicators should not
be difficult to evaluate and can be in the area of process,
output, and outcome or even impact indicators, such as:
Table 4. Example of List of Indicators for Proposed Model Using NICE

Approach
Proposed Indicator
Input/ Process Number of nutrition campaign activity
Indicators Training/Workshop
Facilities (equipment and others nutition improvement tools)
Nutrition improvement plan
Posyandu activity
Coordination meeting
Output Indicators Coverage of Fe in pregnancy
Ekslusive breast feeding
Coverage of Posyandu
Outcome Malnutrion prevalens
Indicators Number of underweight children
Prevalence of anemia among pregnant mother
65
5.4 LESSON FROM THE EXISTING TPP (TUNJANGAN
PENINGKATAN/ PENAMBAH PENGHASILAN)
TPP or additional incentives or extra income to
improve performance, is a government’s program to improve
civil servant’s motivation to work more productive by
providing additional incentive (theoretically can be cash or
inkind or other benefits) (MOH, 2009; MOH, 2010a). In
Bandung, the local goverment provides TPP in the form of
additional salary to the basic salary based on level /position
and function in the services. Staffs who work related to “direct
services” obtain more incentives then managerial staffs. TPP is
given to all sectors including DHO. Puskesmas staffs obtain
relatively higher incentives than those who work in DHOs.
66
TPP DHO Local
MODEL Local Gov:
- Socialization the -the User Representatives
scheme Authorization
- Monitoring the budget Bappeda
incentive scheme --Diburse
budget
-regulate
Treasury of DHO:
Disburse to CHC Regulator
The Head of
CHC treasury: CHC : Report
distribute the the
incentive Performance
-Midwife
-TPG
-Others

The TPP program (Allowances for Additional or Extra
Income), is implemented based on Regulation of Minister of
Home Affairs Republik Indonesia Number 37 Year 2012
concerning “Guideline to develop Local Budget for Fiscal Year
2013”. One of the attachment stated that "Budget for Extra
Income of the civil servant at local/ village level”, both its
policy and criteria used should be established in advance under
local regulations. It should consider fiscal capacity as mandated
by Article 63 paragraph (2) of Government Regulation No. 58,
2005 and Article 39 of the Regulation of the Minister of Home
Affairs Number 13, 2006 concerning “Guidelines to manage
local government’s funds”. The regulation has been revised and
67
the latest was the Regulation of the Minister of Home Affairs
Number 21 Year 2011.
TPP is an incentive scheme funded by the local
government (APBD) and it is not necessarily implemented at
national level. Currently, many districts have started to
implement incentive scheme for government officials despite
no national support or guideline.

This Incentive scheme is a General Policy from local
goverment to all sectors. Performance measurement is only
related to “general” or common performance (applied to all
goverment employee/civil servant) and do not have any
association with specific program performance such as
nutrition. This additional income or “Income Supplement” For
Civil Servants (PNS: Pegawai Negeri Sipil) in Bandung was set
up and defined by local goverment stipulated in the decree
(Peraturan Daerah Kabupaten Bandung or Perda Kabupaten
Bandung), Regulation No. 21 of 2009 which later been refined.
It is also refers to the legal basis Permendagri No.13/2006 on
Regional Financial Management article 39, paragraph stated
that the local government can provide additional income to the
civil servant depending on the objective of the incentive, and
considering the financial capacity and should be approved by
Parliament. The Decree (Perda) is a strong legal committment
of the local government, showing that TPP is highly supported
68
politically and financially. Once the Perda is enacted, it would
be difficult to change or re-new. The advocacy process to
obtain committment is a long process and need large
resources. Organization of the progam is a typical
government’s program that must follow all formal code of
conduct, the strength is the secured budget from APBD, and the
challenge is the process is rigid, less flexible.

To monitor and verify the performance, the report
(evidence) of performance managed and kept in the
administration unit or TU (tata usaha) of the “puskesmas
management”. All staffs sign the attendance form and cannot
be delegated, followed by checking the authenticity of the
signature and final verification in puskemas is done by the
head of puskesmas.
It is not clear how the DHO did the verification/
monitoring of the puskesmas performance. Recording and
reporting of performance is available in puskesmas and seems
not being used for evaluation by DHO or to relate health center
staffs’ performance with output or outcome. Based on the
interview with DHO and health centers in Bandung, no specific
measurement on performance and its implication to incentives
using RBF scheme. Complaints from those who work more on
administrative assignments with much less incentives. This
TPP was informally critized by some staffs and being discussed
69
to be evaluated since many staff unsatisfied with the
differences of the incentives received.

The TPP implemented in Bandung do not involve any
specific nutrition indicator as the basis for additional income/
incentive given to the DHO or puskesmas staffs. There is a brief
guideline in Peraturan Bupati Bandung from the legislation
Number 21 year 2009 that being use as referrence untill now,
but it is not clear how this guideline has been used or how the
institutions comply with the guideline. Performance
measurement was made based on level/position of the staff
and role/ function of the staffs (as multiplier factor). Staffs who
directly serve patient (as providers) or community will get big
multiplier factor and consequently will receive more incentive,
while employees working in managerial or hold administrative
position will get smaller multiplier factors. Head of Puskesmas
will monitor and report his staf performance to DHO. The
incentives will be transferred to Puskesmas staff as individual
incentive based on the performance appraisal.
This model is relatively sustained since the Legal aspect
as the basis is local regulation (perda) and the sources of fund
is local government budget (APBD).
Interview with DHO and health center staffs revealed
that TPP as “incentive” is “ok”, or “satisfy enough” but no
indicator related with health outcome or output.
70
Implementation of this model is considered as not succeeded
as expected in terms of improving performance particularly
nutrition indicators. Only limited effect/impact of TPP on
increasing the performance, productivity and discipline. For
example, Bihbul health center staffs said that they felt “nothing
change in performance, or output or “outcome achieved”
during TPP implementation, “all work are done as usual”. They
also addressed concern that Civil servants attitude can not
simply changed by TPP model. TPP is only spur civil servants
come on time to puskesmas and remain in the office during
office hours.
TPP has been provided for all government agencies
including public health staff and health workers in health
centers and its network. However, TPP is only given to the civil
servants. Volunteers and contract staffs (PTT) do not entitle to
receive TPP incentive. In fact, many volunters and PTT have
shown better performance than those who are civil servants.
In addition to that, different individuals with same type
of assignment could receive substantial different incentive,
showing unclear measurement of the “performance”. TPP
implementation also raises issues on unfairness between
structural/ managerial staffs and staffs who assigned as service
provider. Calculation the “additional salary” is not based on
performance or work load but based on duration of work and
position. For example incentives for midwives can vary
substantially depending on their position in their duties. A
71
senior midwife or a midwife coordinator may receive lower
TPP than others. This may reduce motivation. There were
various internal policies in Puskesmas to solve “jealousy
problem”, however it seems that not all of Puskesmas could do
such thing.
Some other reason why TPP is considered as “not
succeeded” are: first, there is no incentive for management and
secondly there is no authority/ flexibility for health center to
distribute this “additional incentive” for other dedicated staffs
who are not civil servant.
5.4.5 Proposed Model Using TPP (Tunjangan

Peningkatan/ Penambah Penghasilan)
The proposed TPP model will cover nutrition
issue/indicators to incentivize the providers. Since some
district actually committed to provide more to improve
performance and productivity of the staffs, this model may not
be difficult to adopt. Some pre-condition should be well-
prepared id advance, such as reviewing the availability, size
and allocation of TPP fund, developing a local regulation or
commitment as “umbrella” for allocating incentive for nutrition
and aggreement about the flexibility of DHO to add or modify
performance indicators particularly nutrition indicators.
Health center is also expected to receive authority to involve
non civil servant such as volunteer and contract staffs (PTT)
and entitle to receive TPP incentive.
72
TPP: DHO Local Gov: Local
PROPOSED - Socialization the scheme -the User Representatives
MODEL - Monitoring the scheme Authorization
Project Manager budget
MCC --disbursement
-Give Fund & -regulate Bappeda
other Support
Treasury of DHO: Regulator
Disburse to CHC
Project Support
Verification Team
CHC treasury:
(The Head of CHC and administration
distribute the
staf, Midwife Coordinator):
incentive
Verified the achievement of Midwife &
TPG
-Midwife, -TPG, -Others Verificator
Provider
Beneficiery :(mother, baby, &children)

Beneficiery
TPP is local government initiative, so that Bappeda,

local government and local representatives are involved as
regulator, policy maker, ensure budget allocation (authorize
the budget), disbursement and monitoring the use of the fund.
This model may have potential sustainability since the scheme
is rely upon the local goverment commitment, as long as the
government has the resources. This model may not be
attractive for district with low fiscal capacity.
MCC could provide “extra fund” to initiate the pilot and
support technical assistance. Fund from MCC might also used
to help local government to set up the RBF scheme, assist the
implementation and develop monitoring scheme, including
73
indicator as the basis for incentive calculation. MCC may also
support advocacy to local government to gain committment to
support nutrition program.
Similar with NICE project, performance appraisal will
be based on level/position and role/function/ responsibility
(as multiplier factor) as well as nutrition service performances.
Staffs who will be involved and receive incentives are Midwife
and TPG. The appraisal of the performance will be done at the
health center (Puskesmas) level, Head of Puskesmas and TU
(tata usaha) will verify and report Midwife and TPG (and
others) performances to DHO. Monitoring will be done by DHO.
Head of Puskesmas and Head of TU Puskesmas will be
the key persons who responsible for the approval. The
performance report as the basis for incentive calculation will
be sent to Bendahara (treasury) of the DHO and Puskesmas
every month after verification is approved. The preventive
service may have higher weight then curative one since the
curative may already covered by BPJS. Payment will be based
on administrative and service indicators:
Table 5. List of Indicators for Proposed Model Using TPP Approach

Proposed TPP Indicator
Input/ process Indicators:
Indicators Administrative and reporting:
• Provider attendance / services involvement
• Skill and experience of provider
• Reporting skill and responsibility
Output Indicators Service indicators:
• Pregnant women whose Hb are monitored
• Pregnant mother who get anemia are treated
74
Proposed TPP Indicator
• KEK (Kurang energi protein) mother who get the treatment
• Pregnant mother who get risk (TBC, cardiac problems) are
treated
• Post natal mother with KN3
• Number of Infant who get HB 0-7 days
• Low birth weight infant are treated
• Sick infant who get treated
• Low nutrion infant who get treated
• Complete immunization
• Children who get MP-ASI (Makanan Pendamping Air Susu
Ibu)
• Children who get Vitamin A 1 /year
• Children who get Vitamin A for 2 times/year
• Children with a weight increase or stabil every month
• Children who visited if not come to Posyandu every month
• Children whose weight not increase whose parent are got
nutrion conselling
• Under weight children who are treated
Challenge:
• TPP is designed for all staffs in certain institution. A pilot
to cover only some staffs and some indicators will raise
complaints from other staffs.
• TPP is only one of some sources of fund to incentivize
staffs. Other sources are: capitation (From BPJS and
Jamkesda), APBN such as BOK, this would need a good
coordination since integration of the fund received by
health center can not be easily decided and different
source has its own accountability procedure.
5.5 PROPOSED RBF MODIFIED/ COMBINED MODEL

After reviewing models 4 models that have been
implemenred in the country and tried to assess potential
implementation of each model with specific modification, two
75
combined models are proposed. The first one is a model set up
for district level and the second one is meant to be
implemented at the village level. “Combined” means a
combination (and of course modification) of models such as
ADD, TPP, lesson from Cordaid and NICE projects, and PNPM
GSC. “Combined” would also mean a proposal to combine both
village/ subdistrict and district/ DHO level. Or, the two models
could be tried-out concurrently with careful consideration to
ensure that they are related and support each other.
76
5.5.1 Proposed Model at the District Level
Tingkat Kabupaten
MCC
BPJS
DHO as
manager the TPP
project
7. Quarterly
report on
quality
Nutrition unit
at DHO 8. CF and
10. Quarterly
PNPM selects
report on
11. CF and samples of 50
verified
PNPM HH per
3. Nutrition quantities
determines posyandu
6. Quarterly team TPG 1. Nutrition Team and HH
quarterly each quarter
report on submit togteher with KGM satisfaction
payment
peer montly submit “business based on
reviewed invoice plan” on contracted quantity,
quality nutrition PH services quality,
4. DHO quarterly provided (each 3 counter Community Facilitator
evaluates quality of months). verification (contracted by MCC)
nutrition PH and HH and PNPM
services provided 2. KGM and PNPM satisfaction
verifies consistency
5. DHO quarterly quality between business
9. CF and PNPM for 50 HH:
of nutrition PH services plan and the records
- Cointerverfication: trace HH to verify
assessment by peer on number nutrition
their existence and reality of services
review team PH services
on quarterly basisi
- Assesses the HH satisfations of
nutrition PH services
Nutrition team in CHC
(midwife and TPG)
Beneficiery:
Verification/supervision mother, baby, children
Request submission
Fund transfer
BOK
Document/report transfer
Coordination
PKH
This model assessing the performance of nutrition

health center personnel. Actually at the health center or CHC,
the services are provided by a team (midwives and nutrition),
but since partly will be funded by BPJS and BOK funds and can
be used to incentivize midwife, integration of the model and
coordination of the payment need to be assessed and later
distributed using RBF approach, while for nutrition staffs the
RBF scheme could be developed separately. The schematic
above shows different sources will provide resources for
77
health program activities (UKM and UKP) including for
nutrition program.
In this model the basic payment of performance based
on indicators of nutrition. Other indicators are considered as
part of other sources accountability. Or, for integrated planning
and budgeting, MOH need to develop special tool to help
subnational level use resources efficiently and productive, this
would include RBF principles. If it is related with the first day
of the 1000 nutrition indicators are in the health center level
(not RS) includes:
• During pregnancy (Tablet Fe, counseling pregnant
women and PMT KEK),
• Postpartum (Vitamin A Capsules, Tablets Fe),
• Neonatal and infant (IMD and exclusive breastfeeding)
• Baby/ Under two or Baduta (vitamin A capsules,
monitoring weight gain, PMT counseling, and PMT
recovery for undernourished children.
This model uses an existing government financial
system such as TPP in Bandung district. Ideally, we’d better
find areas for pilot projects that have developed model such as
the TPP model or similar. This means that MCC funds will be
deposited through the budget or if it is not allowed, it will be
used to develop RBF model as “top-up” fund or for project
preparation etc, with the buy-in process from the beginning to
gain support from local government to incentivize providers.
When outside fund channeling is chosen, special treatment
78
need to be proposed to ensure the plan to incentivize could
work well as planned (refere to Cordaid experience) or leave it
through government’s system such as NICE experience
(however, NICE is a loan and MCC fund is a grant and cannot be
easility inserted to the government system).
This proposed model includes two level approaches:
district-sub district/village. The model refers to the existing
system in Indonesia, such as in TPP (renumeration
mechanism). The model is proposed to adopt some ex-Cordaid
principles. Four roles will be employed: fund holder role,
provider role, verifikator, and supervisor.
At the distict-sub district level, the fund holder is DHO
(financial and nutrition unit). The fund holder pays claim that
proposed periodically by the CHC. Prior to this, provider
(puskesmas) submit contract or “business plan” to the DHO.
The claim will be verified by independent verificator
(community facilitator who paid by DHO or PNPM). Supervisor
from DHO will monitor services provided by puskesmas on
regular basis.
Explanation of the chart according to the order number:
1. Nutrition team with KGM develop “business plan”
proposed to a Nutrition Section of DHO
2. KGM and PNPM check whether proposed activities are
inline with program of Nutrition section
3. Every month the nutrition team submit claims
according to the activities have done.
79
4. DHO evaluate the services including availability of IEC
material, cold chain vaccine and program of PMT.
5. Quality of services is evaluated by peer review.
6. Result of peer review is discussed in DHO.
7. Result of peer review also sent to Nutrition Section of
DHO
8. Every month the Community Facilitator and PNPM
select some households as benefiaicties of the targeted
intervention.
9. Selected households will be visited by Community
Facilitator or PNPM cadres to verify whether they
receive the services and satisfied.
10. Result of verification reported to Nutrition section of
DHO.
11. Community Facilitator and PNPM give input whether
the claims approved or not, based on the verification
report.
80
5.5.2 Proposed Model at the Village Level
Tingkat Desa
BPJS MCC
BOK DHO
CHC 7. Quarterly PNPM (kec

report on and village
quality VM-
level)
VHW ADD, Head of 8. PNPM
Village selects 10. Quarterly
samples of 20 report on
11. PNPM
HH per verified
determines
3. VM-VHW posyandu quantities
quarterly
6. Quarterly submit 1. VM-VHW submit each quarter and HH
payment
report on montly “business plan” on satisfaction
based on
peer invoice contracted PH quantity,
reviewed services provided quality,
quality of (each 3 months) and counter
4. CHC quarterly VM-VHW copying to PNPM and verification
CHC PNPM
evaluates quality of and HH
PH services provided satisfaction
by VM-VHW 2. PNPM verifies
consistency
5. DHO quarterly quality between business
9. CO (contracted by PNPM) for 20 HH:
PH services assessment plan and VM-VHW’s
- Cointerverfication: trace HH to verify
of VM-VHW by peer records on number
their existence and reality of services
review team PH services
on quarterly basisi
- Assesses the HH satisfations of PH
services
Village midwife and Cadres (VM-VHW)
Beneficiery:
Verification/supervision mother, baby, children
Request submission
Fund transfer
Document/report transfer
Coordination
PKH
At the village level, fund holder is the PNPM. Fund

holder pays the claims periodically. Prior to that, health
providers (village midwife and cadre) proposed contract
“business plan” to Fund holder. The claim will be verified by
PNPM or cadre. CHC monitor the quality of services provided
by a village midwife or cadre.
ADD support a community empowerment programs
that are funded by PKH, BOK, or BPJS. ADD will purchase
81
performance of village midwife and cadre, e.g. sweeping
program, home visit, counselling to house, and preparing food
for the malnutrition children.
Explanation of the chart according to the order number:
1. Village Midwife and Voluntary Health Worker team
(VM-VHM) make “business plan” proposed to a CHC
2. PNPM check whether proposed activities are inline
with VM-VHM program
3. Every month the VM-VHM team submit claims for
activities have been done
4. CHC evaluate services provided by village midwife
including availability of IEC material, cold chain and
program of PMT
5. Quality of services evaluated by peer review
6. Result of peer review is discussed in DHO
7. Result is also sent to Nutrition section in DHO
8. Result of peer review is send to PNPM in sub district
and village level
9. Eevery month PNPM select households who received
services from VM-VHM Team
10. Selected household will be visited by PNPM cadres.
They will verify whether beneficiaries received the
services and satisfied
11. Result of verification is reported to village team
(ADD/fund holder)
82
12. Regularly verification result will be reported to the
village head (ADD team)
13. PNPM give input whether the claims approved or not,
based on the verification report.
5.5.3 Challenges to Implement the Model at District and

Village Levels
There are some challenges to implement the proposed
designs, related to the gvernment’s regulation, local context,
current policy on financing scheme such as:
• The model only accomodate a TPP to pay for
performance Team Nutrition (midwife and TPG). It is
better if for another health personnel accomodate the
same mechanism with source of funding from BPJS or
BOK.
• Nutrition section in DHO is small part of DHO. Probably,
this section meets difficult to manage CHC or cadre than
head of DHO.
• It is unclear whether ADD fund can be used to pay health
provider(s).
• “Buy-in” with selected province and district(s) is crusial.
MCC funds would only cover part of the RBF scheme or
even only covers budget for model development and plan
of action, while local government’s support is required
not only to support the implementation but also to
finance the RBF scheme
83
• Local specific situation and condition might influence the
success of the implementation. MCC need to select pilot
area carefully considering the local culture, political
committment, fiscal capacity, leadership and health
institutions characteristics
• As discussed earlier, performance-based financing or
result-based financing can potentially success if
implemented in the area with poor/ low health status
and weak health care providers. However, areas with
mentioned conditions are usually areas with low fiscal
capacity and the local government do not have adequate
resource to fulfil the need of additional budget to support
program activities and incentivize providers. In this
regard, the central government should play a role to
ensure program can be implemented without any
resource shortage and encourage efforts to improve
productivity, including provide incentives for providers
using RBF approach. This would need more work on
advocacy, equipped with a comprehensive assessment
on the pilot according the amount of the fund needed.
• Started in January 2014, the single payer (or BPJS) of the
Social Health Insurance scheme is started and part of the
payment scheme for health center will be covered by the
BPJS. Some targeted program such as maternal care,
immunization, will be overlapping between ‘public
health program (under UKM)” and “curative program
84
(under UKP)”. Source of incentive for health center staffs
could be from the BPJS (part of the capitation for primary
care) or DHO (part of the APBD to support public health
program) or even from central government (part of the
BOK, Deconcentration funds).
• Currently “one gate policy” to incorporate all grant and
loan in the central government’s budget is being
discussed and will be decided. For example, the Global
Fund support started in 2013 is classified as
government’s source or noted under MOH (Foreign
Cooperation or Kerja Sama Luar negeri). For special
intervention it might be treated differently or not, need
to be confirmed.
• Realistically, it will be a big challenges for MCC to
promote incentive for nutrition only, although other
program might get additional fee/honorarium/ incentive
from APBD or capitation payment from BPJS.
85
PART 6
CONCLUSION AND RECOMMENDATION
6.1 Conclusion
1. There were very limited experience with result-based-
financing in Indonesia. More than ten years ago the
World Bank iniciated the Targeted Performance-Based
Contract (TPC) using voucher system for maternal care,
but it was not sustain. The reasons were: conflicts
between overlapping systems (TPC and health Card to
receive free care) reduced midwives motivation. The
project failed in its intent to move toward
privatization– conflicted with Government policy to
sustain PTT contract and increased salary. Cordaid
project was implemented in NTT but it was not sustain.
2. There were four model that we learned and use as the
basis for model development:
• Cordaid model
• NICE project
• TPP
• ADD
Each model has its strength and challenges, local
context and national policy need to be considered when
we propose one of this model or combine it.
3. Key elements of the RBF should include:
86
• Clear identification of a set of priority health
outcomes to be achieved: stunting or more specific
nutrition status achievement or “the first 1000
days of life”
• Interventions to be implemented: related to
nutrition, some other MCC targets will be covered
under capitation Ina CBGs, payment’s scheme
under single payer of the SHI or BPJS
• Measurable and verifiable indicators: will be
developed further for next step, based on nutrition
program indicators selected
• Monitoring systems to measure performance: we
could learn from Cordaid experience
performance: we could also learn from Cordaid
experience and proposed size of payment need to
be discussed further prior to the pilot. Need to be
decided how the MCC support will be used, how
the fund chanelling would be. To ensure
sustainability, “buy-in” from beginning of the
process has to be set up. Local government’s
committment is not only limited to legalizing the
incentive but also providing money to pay the
incentives. In this regard, fiscal capacity of the
chosen district is really matter. Otherwise, central
government is the source of the fund. There are
87
some implemented project funded by local
government cencerning the “additional/ extra
salary or incentive for civil servant” that could be
combined with RBF scheme, such as TPP (will be
discussed later). In addition to this plan on the
supply side, we could also combine it with the
demand-side approach, in this regard is the PNPM
Generasi Sehat Cerdas (PNPM GSC).
6.2 Recommendation
This study has assessed potential models to be used by
MCC to implement the RBF pilot. More work are needed to
develop the detail of:
1. Legal framework for the pilot
2. Pilot areas (province, districts)
3. Design of the pilot
• Staff will be involved, who does what
• Interventions to be implemented
• Measureable indicators
• Monitoring and evaluation system
• Fund chanelling
• Payment scheme
• Contract
4. Cost implication of the pilot in selected districts
5. “Buy-in” process with central and local government
6. Guideline for the pilot project
88
7. To evaluate the improved result of the RBF or outcome,
MCC need to prepare the baseline as part of the project
steps.
89
REFERENCES
Anon (2011) Using Financial Incentives to Improve Primary

Care in Vietnam: A Results Based Financing Pilot Study.
Decree of National Development Board
Planning/Bappenas No.364/M.PPN/10/207, October 25,
2007 on the establishment of the Central Steering
Committee and Technical Team Project Center for
Nutrition Improvement Through Community
Empowerment (NICE Project) years 2007-2012.
Kerangka Kebijakan Gerakan Sadar Gizi dalam Rangka Seribu
Hari Pertama Kehidupan (1000 HPK).
Depkes (2012) Profil Kesehatan Mimika 2012.
District Health Office of Lombok Barat (2009) Final Report for
NICE Project Implementation 2009-2012.
District Health Office of Ngada and Cordaid (2012)
Management of Performance Based Financing.
Dupas, P. 2005. The Impact of Conditional In-Kind Subsidies on
Preventive Health Behaviors: Evidence from
Western Kenya.
Eichler, R. and Levine, R. (2009) Performance incentives for
global health: potential and pitfalls. CGD Books.
Glassman, A., Todd, J. and Gaarder, M. (2007) 'Performance-
based incentives for health: CCT programs in Latin
America and the Caribbean', Centre for Global
Development Working Paper No. 120.
90
Haryoko, F. R. (2011) Policy Paper The Performance Based
Financing (PBF), The Implementation Of PBF in Ngada
and Nagekeo Districts, Flores, Indonesia, 2009-2011.
Hecht, R., Batson, A. and Brenzel, L. (2004) 'Making health care
accountable: why performance-based funding of health
services in developing countries is getting more
attention', Finance and Development, 41(1), pp. 16-19.
Manshande, J., Vergeer, P. and Fritsche, G. (2010) 'Rwanda:
Performance-Based Financing in Schematics', RBF
Health.
Meessen, B., Kashala, J. P. and Musango, L. (2007) 'Output-
based payment to boost staff productivity in public
health centres: contracting in Kabutare district,
Rwanda', Bull World Health Organ, 85(2), pp. 108-15.
Millennium Challenge Corporation (2013a) MCC Desk Review
and Discussion Summary for RBF Design – Indonesia.
Millennium Challenge Corporation (2013b) MCC Quarterly
Status Report – Indonesia Compact: As of March 2013.
MOH (2007) Regulation of the Minister of Home Affairs Republik
Indonesia No.37 Year 2007 on Guidance to village
funding management.
MOH (2003) Decree of the Minister of Health
No.1457/Menkes/SK/X/2003 on Standard Minimum
Area Health Services in the District.
91
MOH (2009) Keputusan Menteri Kesehatan Republik Indonesia
No.857/Menkes/SK/IX/2009 tentang pedoman penilaian
kinerja sumber daya manusia kesehatan di puskesmas.
MOH (2010) Decree of Minister of Health
No.156/Menkes/SK/I/2010 on Giving Incentives For
Health Workers as a Special Assignment in Remote Area
Health Center, Country Border and Islands.
MOH (2010) Decree of Minister of Health
No.1307/Menkes/SK/IX/2010 on Main Income and
Special Incentives for Doctors and Midwives (Temporary
Staff).
MOH (n.d) 1000 Hari Pertumbuhan yang Menentukan.
Mohr, T., Rajobov, O., Maksumova, Z. and Northrup, R. (2005)
'Using incentives to improve tuberculosis treatment
results: lesson from Tajikistan'.
Pearson, M. (2011) 'Results based aid and results based
financing: What are they? Have they delivered results',
London: HLSP Institute.
PNPM (n.d) A Healthy and Bright Generation (PNPM Generasi).
Available at: http://pnpm-support.org/pnpm-generasi
(Accessed: April 16, 2013).
Schoffelen, E., Haryoko and Tacoy, J. (2011) 'Performance
Based Financing Can Help to Increase Coverage in
Remote Areas'.
Soeters, R. (2008) 'Feasibility Study for A Performance Based
Financing Intervention in Indonesia Indonesian Context
92
, Exploratory Visit to Sikka, Ende and Nagekeo Districts
Problem Analysis and Recommendations Step-By-Step
Approach for Introducing of PBF'.
Soeters, R., Habineza, C. and Peerenboom, P. B. (2006)
'Performance-based financing and changing the district
health system: experience from Rwanda', Bull World
Health Organ, 84(11), pp. 884-9.
Solikin, S., Kristiani, K. and Gunawan, I. M. A. (2016)
'Pemberian paket gizi masyarakat proyek NICE
berpengaruh terhadap kinerja posyandu, tetapi tidak
meningkatkan status gizi balita di Provinsi NTB', Jurnal
Gizi dan Dietetik Indonesia (Indonesian Journal of
Nutrition and Dietetics), 2(1), pp. 1-13.
Tan, E. (2005) Making Services for the Poor in Indonesia, Case
Study 2: Vouchers for Midwife Services in Pemalang
Districts, Central Java Province.
Vergeer, P., Manshande, J. and al, e. (2011) 'In Schematics:
Burundi Performance-Based Financing through a
Private Puchaser', RBF Helath.
Vergeer, P., Manshande, J. and Johnston, T. (2011) 'In
Schematics: Cambodia Performance-Based Contracting
of Non-Government Organizations', RBF Health.
Vergeer, P., Manshande, J., Romero, D. and Cortez, R. (2011) 'In
Schematics: Argentina Performance Based Financing
Plan Nacer', RBF Helath.
93
BIODATA
Mardiati Nadjib is a Lecturer and senior researcher, in

Department of Health Policy and Administration, Faculty of
Public Health, Universitas Indonesia
She received her degree in DDS, master degree in
public health and Doctor in Public Health from Universitas
Indonesia with sandwich program in University of California
Los Angeles in 1999. Her focus area is public health and health
economics. She is interested in economic evaluation and
support assessment on benefit package for Social Insurance
Scheme, as well as economics of public health including AIDS,
TB, malaria, immunization. Her research projects include study
on result based financing which aiming at insentivising health
provider staffs to improve performance.
Currently she is also member of Heatlth Technology
Assessment Ministry of Health, Indonesia and member of
NITAG Indonesia (Indonesian Technical Advisory Group for
Immunization or ITAGI) . She is also member of core team
National Health Account Indonesia.
94
BIODATA
Hendri Hartati is a researcher from Center for Health

Research, Faculty of Public Health, Universitas Indonesia. She
received her bachelor degree in 2001 and Master degree in
2007 in Faculty of Public Health, Universitas Indonesia. She
also received another master degree in School of Population
and Health, University of Melbourne, majoring in health
program evaluation and economic evaluation.
Hendri has been involved in various research projects
with support from donors in the area of health economics,
maternal care, nutrition. Her back ground and experiences in
health economics and nutrition has supported her work in the
area of result-based financing with the lead author.
Dini Dachlia is a researcher from Center for Health
Research, Faculty of Public Health, Universitas Indonesia. She
graduated from Faculty of Public Health, Universitas Indonesia
in 1996 bachelor degree majoring in nutrition. Her master
degree was received in year 2000 from Faculty of Public
Health, Universitas Indonesia, majoring in reproductive health.
Dini has been working in research projects focusing on
maternal care, gender issues, family planning, nutrition and
reproductive health. Her interest in nutrition and experience in
previous study in nutrition helped this work successfully
completed.
95

Monograf-Result Based Financing To Support Public Health

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Monograf-Result Based Financing To Support Public Health

Uploaded by

Copyright:

Available Formats

RESULT BASED FINANCING

Faculty of Public Health

1st Edition, January 2017

All Rights Reserved. May not be copied, scanned, or duplicated,

This study was done with support from the World

Result Based Financing is not a new approach for

Depok, January 2017

Table 1. Nutritional and Health Indicators Related to the First

ADD : Alokasi Dana Desa

1.2 Objective of the Study

Specific objectives are:

To accomplish this assignment, method or specific tasks used

3.1 Basic concepts

3.3 Setting targets

3.4 Setting incentives

3.7 WB-MCC Plan for RBF Pilot

This section describes some lesson learned from our

4.1 PNPM Generasi District Facilitator, Subang district

4.2 Midwives in Puskesmas, Subang District, West Java

4.3 Puskesmas Banjaran Kab. Bandung (PONED), West

4.4 DHO Ngada, West Nusa Tenggara

4.5 Desa Pengenjek, West Nusa Tenggara

There are some initiatives on innovative projects

Table 1. Nutritional and Health Indicators Related to the First 1000

PHASE INDICATORS NUTRITION PROGRAM OTHER HEALTH

5.1 LESSON FROM CORDAID PROJECT IN NTT

5.1.1 Legal Feasibility

5.1.2 Organizational Feasibility

5.1.3 Verification, Monitoring and Evaluation

Table 2. List of Indicators from Cordaid Project in West Nusa Tenggara

Puskesmas (Health Center) Hospital

5.1.4 Payment Scheme

Unit cost Unit cost

The unit cost was modified as needed. For example if

5.1.5 Proposed model based on Cordaid experience

Voluntary community verificator

To meet the RBF related to nutrition program

Cordaid model requires flow of fund outside

5.2 LESSON FROM THE ADD (ALOKASI DANA DESA)

District Government Musrembangcam DHO

Sub-district Authority Musrembangcam CHC

Village → ADD Musrembangdes Village midwife

We learned from our field visit to Pengenjek village in

5.2.2 Organizational Feasibility

5.2.3 Monitoring and Evaluation

5.2.4 Payment Scheme

5.2.5 Proposed Model Using ADD Approach

District Government Musrembangcam DHO

Sub-district Government Musrembangcam CHC

Village → ADD Musrembangdes Village midwife

Independent person inserted in PNPM to advocate issues and

5.3 LESSON FROM THE NICE PROJECT

District Project Implementation

5.3.1 Legal Feasibility

1 Nutrition Improvement Trough Community Empowerment Project, posted

5.3.2 Organizational Feasibility

Since no incentive payment introduced in this project,

Component 1. Development of Policies and Surveillance:

5.3.4 Payment Scheme

5.3.6 Proposed Model Using NICE Approach

Table 4. Example of List of Indicators for Proposed Model Using NICE

5.4.1 Legal Feasibility

5.4.2 Organizational Feasibility