Incentivizing Communities and Providers to Improve Health and Education Outcomes: PNPM Generasi

1. Incentivizing Communities and Providers to Improve Health and Education Outcomes:PNPM Generasi August 19th, 2011

2. Structure of Presentation • Two forms of “incentives” in the existing program model • Performance-based incentives for communities • Communities provide operational support to front-line providers • Evidence of Impacts • The next frontier: community-based monitoring of service provision through PNPM Generasi?

3. Incentivizing Communities 12 indicators that communities aim to improve Health: • Four prenatal care visits during pregnancy • Taking iron folate tablets during pregnancy • Delivery assisted by trained professional • Two postnatal care visits • Complete childhood immunization • Ensuring monthly weight increases for infants • Regular weighing for under-fives • Taking Vitamin A twice a year for under-fives Education: • Primary school enrolment • Regular primary school attendance • Junior secondary school enrolment • Regular secondary school attendance

4. Incentivizing Communities Financial incentives = inter-village yardstick competition • Fixed amounts of block grants to subdistricts • Year 1 block grants: distributed to villages according to population in target age groups • Year 2 block grants: • 80% according to population of target age groups • 20% according to year 1 performance on the 12 indicators

5. Communities Incentivize Providers—Rationale • Communities can use Generasi support to overcome small-scale supply constraints, such as • Lack of personnel at health and education facilities (midwives, teachers) • Shortages in operational funds for providers and community members that play a role in service delivery (e.g. health caders) • Infrastructure

6. Communities Incentivize Providers—Operations • Communities establish three sub-district working groups (Pokja Pendidikan, Kesehatan, and Dukungan Layanan) to oversee activities that address supply constraints • Members chosen from village facilitators, school committees, village health volunteers, village elders, dll • Each Pokja maintains a separate collective account at the UPK • Village implementation teams (TPK) oversee and record payments from Pokja funds

7. Types of Support for Providers • From 2007-2009, communities invested US$835 per village on incentives for providers, including • Honorarium for contract teachers (GTT) • Transportation subsidies for midwives and health cadres • Training and behavior change communication activities (delivered by midwives and health cadres)

8. Impacts of Incentives for Communities and Providers • Increased community effort at accessing, providing, and monitoring services • Large increase in community uptake of Posyandu services • More health caders at Posyandu • Higher participation in SMP school committee meetings • Increased provider effort • Midwives work longer hours providing services • Increase in some provider quantities • More contract teachers at SMP • Source: PNPM Generasi Impact Evaluation Report (World Bank, 2011)

9. Community-Based Monitoring in PNPM Generasi? • Communities that successfully manage PNPM Rural and Generasi take on more responsibilities for monitoring service provision • With support from 3rd party facilitators • Community Score Cards for health and education services • Scoring process promotes routine dialogue between communities and providers over score card results • Communities use Generasi funds to reward providers based on performance • Feedback on community and provider performance is communicated to LG: SKPD and DPRD