The PNPM-Generasi Project One-Year Impact Evaluation Preliminary Findings Presented by: Susan Wong, EASER, The World Bank Ben Olken, M.I.T. Department of Economics November 5, 2009

Structure of Today’s Presentation Indonesian context Description of PNPM-Generasi project design PNPM-Generasi implementation update Impact evaluation design and analysis Preliminary findings of one-year PNPM-Generasi implementation Impact on health indicators Impact on education indicators Effect of community incentives Heterogeneity Conclusion, Further Analysis, and Next Steps

Indonesian Context Remarkable progress in poverty reduction and key human development indicators over past few decades. Economic growth, increased access to education and health services, expanded anti-poverty programs, and improvements in infrastructure have all helped to reduce poverty. Poverty headcount is 14.1% in 2009. However, 32.5 m Indonesians still live below poverty line & one-half of all HHs remain clustered around national poverty line. High vulnerability. Regional disparities with Eastern Indonesia lagging behind other parts of country, esp. Java. Human development areas require more attention: child malnutrition, infant and maternal mortality, primary to secondary school transition, access to safe water and sanitation. Quality of services also a major concern.

Two Pilot Projects In 2007, GoI started two pilot projects: Household CCT – the traditional model Quarterly tranches of cash transfers Statistically identified 633,000 poor households with children Currently in 13 provinces, 70 districts, 629 municipalities Annual budget of IDR 1.2 trillion (@USD 120 m) PNPM-Generasi Community Block Grants Addresses the same health and education indicators, but at the community level 5 provinces, 21 districts, 178 subdistricts Covering approx. 3.1 million beneficiaries Total budget from 2007-2009 of @USD 107 m

WB Support Role Collaboration between PREM, HD, and Social Development Units in Indonesia Provide TA for design, implementation and evaluations of two pilots. Portion of KDP/PNPM WB loan funds support the PNPM Generasi pilot in 5 provinces.

The PNPM-Generasi Project Objectives: Accelerate the achievement of MDGs Reduce child mortality Reduce maternal mortality, and Ensure universal coverage of basic education Conditionalities: Places incentives on communities to identify problems and seek solutions to improving 12 health and education indicators

The PNPM-Generasi Project Community incentives: Version A: 20% of year 2 allocation depends on previous year’s village performance Version B: Village performance not linked to fund allocation. Otherwise identical to Version A. Implemented through KDP/PNPM-Rural with: Same management structures at the national, provincial, and district levels as PNPM-Rural Facilitated by 2 subdistrict facilitators 7

PNPM-Generasi Project Design 12 indicators: communities are required to work on the same indicators as HH-CCT (Program Keluarga Harapan) Health: Four prenatal care visits during pregnancy Taking iron 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 (7-12 year olds) Regular primary school attendance >85% Junior secondary school enrolment (13-15 year olds) Regular secondary school attendance >85%

PNPM-Generasi Design

PNPM-Generasi Project Implementation Geographical coverage: 178 subdistricts in 21 districts, five provinces Approx 3.1 million beneficiaries Block grant amounts: 2007 average per village amount USD 8,400 2008 average per village amount USD 11,600 2009 average expected per village amount USD 14,400 Timeframe: First block grant disbursed to villages in Oct-Dec 2007 Second year disbursement to villages in Oct-Dec 2008 Third year disbursement to villages in Oct-Dec 2009

Village Fund Allocation in 2007 56% of block grants on education: School materials, equipment and uniforms (59%) Financial assistance and school fees (31%) Infrastructure (satellite classrooms and access roads) (5%) Financial incentives for honorarium teachers (4%) Training and behavior change communication (1%) 44% of block grants on health activities: Supplementary feeding activities (40%) Financial assistance for pregnant mothers to use services (30%) Infrastructure (13%) Facilities and equipment (11%) Training and behavior change communication (3%) Incentives for health workers (3%)

Impact Evaluation Design Uses a randomized evaluation Subdistricts allocated by lottery into three groups: with performance incentives, without performance incentives, and controls Subdistrict level randomization addresses spillovers and crowding out

Impact Evaluation Design Three rounds of surveys: - Baseline/Wave I (2007): PNPM-Generasi & PKH (HH CCT) Wave II (2008): PNPM-Generasi only Wave III (scheduled to begin Nov 2009): PNPM-Generasi & PKH Survey design: 12,000 households per wave spread over 300 subdistricts including Anthropometric measurements of children <3 Math and Indonesian tests administered to school-aged children (Baseline and Wave III) School and health provider interviews to track supply-side effects Qualitative studies to understand bottlenecks in use and provision of services (Baseline and Wave III)

Impact Evaluation Design Sample size per survey for PNPM-Generasi: 33,000 total respondents - 12,000 households 10,800 married women in reproductive age 4,850 pregnancies (2 years prior to the survey) 9,500 school-aged children (7-15 years old) 4,750 children under-three 2,313 villages 300 subdistrict health centers (puskesmas) 1,157 midwives 2,391 village health posts (posyandu) (Waves II & III only) 847 junior secondary schools 1,065 primary schools (Waves II & III only)

Mid-Term Impact Analysis Regressions run for: PNPM-Generasi vs No PNPM-Generasi Incentivized (version A) vs Non-Incentivized (version B) Regression specifications: Uses baseline data as control variables Subdistrict average Individual baseline values for panel respondents (0 for non-panel) District fixed effects Province * previous KDP experience fixed effects HH sampling category dummies

Overview of Preliminary Findings Substantial improvements in health indicators No impact on education indicators Performance-based incentives lead to consistently better outcomes Substantial regional heterogeneity with strongest improvements in Sulawesi Provider effort, especially for midwives in incentivized locations, increased substantially. Greater community engagement particularly through service provision at the village health posts. 16

Preliminary Findings: Health Strongest improvements on health services coverage: Participation in growth monitoring Deliveries assisted by doctors or midwives, particularly in Java and Sulawesi Large increase in village health post participation Long-term health outcomes: Large reductions in neonatal and infant mortality (although some small differences noted at baseline) Some reductions in malnutrition (<2SD weight-for-age) among children under-three in NTT and Sulawesi

Notes on the figures Each bar represents the percentage change in the indicator in Generasi treatment areas compared to control areas Key messages of the figure Bars in patterns are not statistically significant Control avg. 7.52 visits 1.975 sachets 75% 2.91 visits 70% 2.18 times 1.62 Vit A 21% Control group averages Bars in solid colors are statistically significant Zero percent is the control group average. Bars to the right indicate increase while bars to the left indicate reduction. 18

Control avg. 7.52 visits 1.975 sachets 75% 2.91 visits 70% 2.18 times 1.62 Vit A 21%

Large increase in Village Health Post participation : Numbers of children weighed; receiving supplementary feeding; immunized; receiving Vit A Numbers of pregnant mothers receiving antenatal care; iron pills No increase in non-targeted village health post services Control avg. 41.21 children 34.99 children 11.85 children 4.54 mothers 4.79 mothers 44.61 children 2.83 mothers 20

Reduction in neonatal mortality and infant mortality (although some small differences noted at baseline) Similarly large infant mortality reductions found in other randomized community health programs in Uganda and Bangladesh Control avg. 5.9% 20.8% 34.3% 18 deaths per 1000 live births 8 deaths per 1000 live births

Preliminary Findings: Education No overall project impact on education Negative impact on enrollment and attendance of 13-15 year olds, primarily among those 13-15 year olds who would have been in primary No impact on primary or jr. secondary net enrollment Overall jr. secondary school enrollments increased in both treatment and control over this period

Control avg. 93.7% 89.1% 97.9% 90.7% 66.0% 24.8% 97.8% 23

Some Hypotheses on Education Findings Primary school enrollment already high at 95%. Jr. secondary gross enrollment increased overall in treatment and control areas. Great deal of fluctuation over last couple of years. Generasi targets only 13-15 years old for jr. secondary, so communities may have interpreted this age conditionality strictly. Program missed the school enrollment period of June-July. Communities seemed to be favoring more assistance towards children already in school vs. focusing on out-of-school children. “Help the greatest number vs. the few” mentality.

Preliminary Findings: Community Incentives Version A, incentivized version outperformed non-incentivized version in improving health service coverage Prenatal care Postnatal care Growth monitoring Version A had larger impact on long-term health outcomes: Acute morbidity (ARI or diarrhea) Malnutrition Version A was more effective in increasing midwives’ work efforts in: Outreach services Time spent seeing patients in their public capacity (reduced time for private practice)

Incentivized version outperformed non-incentivized in improving health service coverage Control avg. 7.52 visits 1.975 sachets 74.6% 2.91times 2.18 times 1.63 times 69.5% 20.8% 26

Incentivized version outperformed non-incentivized in improving health outcomes Control avg. 5.9% 20.8% 34.3% 18 deaths per 1000 live births 8 deaths per 1000 live births 27

Preliminary Findings: Heterogeneity Regional heterogeneity Sulawesi - strongest and consistent effects Java - some positive impacts NTT – smallest effects

Sulawesi - strongest and consistent effects Java - some positive impacts NTT – smallest effects All NTT Sulawesi Java

Incentivized version had larger impact on average health outcomes overall and in NTT 30

Negative impact on education largely seen in Sulawesi All NTT Sulawesi Java

Conclusions PNPM-Generasi has: Improved health service coverage mainly through increased village health post (posyandu) participation Reduced infant mortality, acute morbidity and malnutrition Increased number of hours midwives spend on outreach and services in their public capacity PNPM-Generasi has not yet improved formal education indicators Community incentives ensures better outcomes with the same project funds and design Certain heterogeneity in outcomes were observed: Regional: Sulawesi strongest, positive in Java, small in NTT Increased community participation and engagement, especially through service provision at village health posts. 32

Future Analysis Cost-benefit analysis Where/for whom PNPM-Generasi works best Spillovers Details of community incentives Changes in prices Targeting What communities spent their funds on 33

Next Steps PNPM-Generasi will likely expand in 2010 to an additional 1-2 provinces. Adjustment of some of the education indicators Conduct wave III survey in 660 kecamatan jointly with HH CCT (Nov 2009– Jan 2010) Finalize operations paper on lessons learned thus far 34