Annex C: Timeline of events for the HIV/AIDS and STDs prevention and management project.

Annex C: Timeline of Events for the HIV/AIDS and STDs Prevention and
Management Project

Year    Events in Indonesia              World Bank Events

1985    AIDS study group formed by
        University of Indonesia and
        National Institute for Health
        Research (MOH).

1987    First AIDS case identified, in
        foreign homosexual in Bali.

1987    National AIDS Committee
        established by MOH, chaired by
        Director General of
        Communicable Disease Control
        and Environmental Health (DG
        CDC-EH).

1988    * AIDS becomes a notifiable
        disease under MOH guidelines.
        MOH appoints Working Group on
        HIV/AIDS prevention,
        reorganized and expanded in
        1989 by bringing in
        multisectoral and NGO
        representatives.

        * HIV sentinel surveillance
        begins among sex workers in
        Jakarta and Surabaya. No
        HIV-positive cases found in
        either site.

1989    The first AIDS Service
        Organization--the NGO Yayasan
        Pelita llmu--is established.

1992    Mandatory HIV testing for        AIDS enters WB policy dialogue
        transfused blood is              with GOI authorities (SAR, pg.
        introduced. By 1998, about 95    91)
        percent of transfused blood is
        screened for HIV. CDC
        Epidemiologist Dr. Michael
        Linnan, resident in Indoneisa,
        is lead author on the paper
        "HIV/AIDS in Indonesia: The
        Coming Storm." The paper
        states that all HIV epidemics
        inevitably follow the same
        course; it concludes that the
        Indonesian epidemic will
        follow the course of the HIV
        epidemic in Thailand.

1992/   First HIV positive blood
1993    samples identified among blood
        donors. 8/533,865 blood bags
        HIV positive (0.0015 percent).

1993                                     Box in a WB country economic
                                         study on Indonesia suggests
                                         that Indonesia has entered the
                                         AIDS epidemic's exponential
                                         growth phase, with the
                                         doubling time for the case
                                         load reaching less than one
                                         year and threatening to fall
                                         further.

1993/   First HIV positive sample
94      reported in sentinel
        surveillance; 3/52,870 sex
        workers tested positive for
        HIV (0.0057 percent).

1994    * Presidential decree creates
        a National AIDS Prevention and
        I Coordination Commission
        (NAC), including 14 Ministers,
        chaired by the Coordinating
        Minister for People's Welfare
        (May. The Commission does not
        meet)

        * Comprehensive, multisectoral   ** WB project identification
        national AIDS strategy           mission; 3 staff from US CDC
        adopted, modeled on              participate (October).
        Indonesia's successful
        population control program       ** Initial Executive Project
        BKKBN. The strategy espouses     Summary (IEPS) for WB HIV-
        broad principles rather than     AIDS Prevention and Management
        specific programs, does not      Project. IEPS states that the
        include focus on high risk       number of HIV cases is
        groups among its basic           projected to rise steeply to
        principles, and is not           roughly 500,000 in 2000 and
        financed (July)                  700,000 in 2005, assuming
                                         effective prevention efforts
        * Bappenas and US CDC staff      are launched in the mid-
        publish a paper (in a            1990s; if prevention programs
        supplement--Vol. 8--to the       are less successful in
        journal AIDS) predicting a       reducing infection risk, the
        "most likely" scenario of half   IEPS projects a far steeper
        a million HIV infections in      rise to 700,000 in 2000 and
        Indonesia within 4 years. The    1.2 million in 2005. Benefits
        paper states, based on           of an early start on
        personal communications with     prevention cited in the IEPS
        US CDC and WHO staff, that       include 200,000 fewer HIV
        there were up to 50,000 HIV      cases by 2000 and 500,000
        infections in Indonesia at       fewer AIDS cases by 2005. IEPS
        end-1993 (July)                  reports that "during the past
                                         few years, the Bank has drawn
                                         attention in discussions with
                                         planning and finance
                                         officials, to the adverse
                                         development impacts of an AIDS
                                         epidemic, and recommended
                                         decisive action." Project
                                         risks cited in IEPS are (a)
                                         spread of HIV so rapidly that
                                         public and private response
                                         mechanisms prove inadequate;
                                         (b) HIV initiatives will
                                         overwhelm GOI policies towards
                                         other health problems; and (c)
                                         possible difficulties in
                                         persuading different audiences
                                         to modify private behavior
                                         (December).

1995    Yayasan Spirita, an              ** Project preparation mission
        organization of people living    on a "first, trial phase of a
        with HIV, is formed.             continuing program." Bank
                                         staff report "ownership of the
                                         project is very strong within
                                         the MOH," with "unequivocal
                                         endorsement" of the project
                                         concept and processing
                                         schedule (January).

                                         ** Appraisal of HIV/AIDS and
                                         STDs Management Project
                                         (October)

1996    * Behavioral surveillance        ** Approval of IBRD project
        among female sex workers, male   (February).
        and female factory workers and
        high-risk male groups (sailors   ** Effectiveness of IBRD loan
        and truck drivers) initiated     for HIV and STDs Prevention
        in Jakarta, Surabaya and         and Management Project (May).
        Manado. Factory workers are
        dropped from surveillance        ** Initial WB supervision
        because reported risk behavior   mission finds the project to
        is so low, but surveillance      be "starting in a
        among high-risk groups is        disappointing fashion"
        repeated annually.               (September)

        * Over 300 NGOs working or
        interested in the area of AIDS
        form an NGO Communication
        Forum (FKLOPA), chaired by Dr.
        Adhyatma, a former Minister of
        Health.

        * Director General of CDC-EH
        issues a circular to
        provincial health Departments
        to promote 100 percent condom
        use in all prostitution
        localization areas.

1997                                     ** Second supervision mission
                                         reports PMU not in a position
                                         effectively to manage the
                                         project (January).

                                         ** PSR rates implementation
                                         progress and development
                                         objectives as satisfactory,
                                         project management as
                                         unsatisfactory (February).
        ** Financial crisis in
        Thailand spills over into        ** 3rd supervision mission
        Indonesia (July)                 rates project satisfactory on
                                         development objectives because
                                         of progress on some
                                         components. PMU still not
                                         staffed with specialists on
                                         surveillance, STDs, IEC and
                                         M&E. Follow-up letter sees
                                         failure to establish a
                                         functional PMU as main reason
                                         for unsatisfactory
                                         performance. If in a further
                                         six months rating remains
                                         satisfactory, Bank will seek
                                         to discuss possible
                                         restructuring or, if
                                         necessary, closure of the
                                         project (September).

        ** Indonesia seeks IMF
        assistance to confront
        financial crisis (October).

1997/   Survey of HIV among 13,656
1998    military recruits in 5
        provinces. No HIV-positive
        cases found.

1998    ** Resignation of President      ** Meeting among
        Suharto (May)                    USAID-financed HAPP Project
                                         staff, IBRD project staff and
                                         RSI staff on HIV/AIDS
                                         coordination. Meeting
                                         recognized a large number of
                                         areas of overlap, seemingly
                                         for the first time in a donor
                                         coordination meeting, and
                                         recommended follow-up actions
                                         (March).

                                         ** Supervision mission finds
                                         performance on action plan
                                         agreed in September 1997 to
                                         have been late and partial.
                                         Economic crisis has required
                                         decision makers to focus on
                                         the drug emergency and other
                                         immediate matters. Project
                                         still has no effective
                                         management structure and
                                         implementation arrangements.
                                         Staff concludes that
                                         BAPPENAS/MOH have decided to
                                         cancel $19.8 million from the
                                         HIV project and another $60
                                         million or so from other
                                         Bank-funded health projects.
                                         PMU written comments on the
                                         draft of the mission's aide
                                         memoire state findings reflect
                                         a discontinuity and
                                         inconsistency on prior
                                         understandings. Comments
                                         continue that coordination
                                         with other donors is rejected,
                                         leaving PMU to manage only WB
                                         project and coordinate with
                                         HAPP project in N. Jakarta.
                                         Basic burden seen by PMU is
                                         short project life, planning
                                         assumption of an epidemic that
                                         does not happen, and contracts
                                         involving poor skill and
                                         management capacity of small
                                         NGOs (June-July).

                                         ** PSR concludes that the
                                         project's development
                                         objectives will not be
                                         achieved, and GOI and Bank
                                         have agreed on the
                                         cancellation of all or nearly
                                         all undisbursed funds. MOU
                                         between GOI and IBRD on
                                         portfolio restructuring in the
                                         face of economic crisis and
                                         tripling of problem projects
                                         from October 1997 CPPR to July
                                         1 1998. Total cancellations of
                                         undisbursed loans amount to $1
                                         billion, or 23 percent of
                                         loans outstanding and
                                         undisbursed. Of HNP
                                         operations, cancellations
                                         (including AIDS/STD loan)
                                         amount to $78.9 M, or 8
                                         percent of total
                                         cancellations. Two of 8
                                         projects in the sector were
                                         problem projects--Safe
                                         Motherhood (subsequently
                                         upgraded) and HIV/AIDS
                                         (August).

1999    * HIV prevalence in IDU          ** Closing of IBRD loan and
        sentinel site (Jakarta drug      cancellation subsequently of
        treatment center) is 16          undisbursed balance
        percent, up from 0 percent in    (September).
        1996 and 1997.

        * MOH publishes Healthy          ** Completion of "External
        Indonesia 2010 perspective       HIV/AIDS Assessment' by John
        study with national health       Kaldor and Indonesian
        goals. The study is based on     colleagues, financed under WB
        four pillars: (a) a "healthy     loan and published with USAID
        paradigm" with emphasis on       support in 2000. Assessment
        health promotion; (b)            reported to be a valuable
        "professionalism," with          overview, with little, if any,
        emphasis on development of the   impact (November).
        country's health human
        resources; (c) a community
        managed health care program
        (JPKM); and (d)
        decentralization, with
        definition of boundaries,
        management guidelines and
        associated human resource
        policies.

1999/   Government budget for HIV set
2000    at approximately US$3.6
        million.

2000/   Government budgets for
2001    HIV/AIDS decreased to US$1.7
        million for fiscal year
        2000/2001.

2000    * HIV sentinel surveillance      * ** ICR review mission aide-
        among IDU records rise in HIV    memoire (draft) reports
        prevalence to 41 percent, from   absence of comprehensive
        16 percent a year earlier.       baseline data and final data
        Sentinel sites in Jakarta        collection makes objective
        prisons record HIV prevalence    evaluation of project outcome
        of between 12 and 18 percent,    hard.. On project management,
        up from zero a year earlier.     AM concludes PMU duplicated
                                         STD directorate and this was
                                         source of "endless conflicts"
                                         throughout the project life
                                         (April).

                                         ** Local consultant report on
                                         project mgt as input to ICR
                                         points out that during project
                                         prep Bank had noted possible
                                         conflicts in PMU roles. PMU
                                         did not have power to provide
                                         leadership to other donor
                                         projects. Steering Committee
                                         proved ineffective in giving
                                         leadership. Report finds
                                         project deserves credit for
                                         securing regulatory support
                                         for NGOs in the future but
                                         that the institutional
                                         mechanism of GOI-NGO
                                         collaboration has yet to be
                                         proven over time. Little
                                         coordination with other donor
                                         project indicated by parallel
                                         work on syndromic approach.
                                         M&E consultant to PMU did not
                                         produce workable outputs.
                                         Day-to-day mgt marked by
                                         "sporadic and reactive
                                         impulses rather than
                                         systematic programming."
                                         Project did not fully utilize
                                         TA expertise. For most
                                         domestic consultants,
                                         participating units could not
                                         state whether products were
                                         satisfactory. Unclear
                                         consultant outputs reflected
                                         unclear scopes of work and
                                         lack of quality control by
                                         users. Bank supervision
                                         programming failed to follow
                                         appraisal schedule. Bank
                                         focused on superficial
                                         symptoms rather than
                                         fundamental problems of
                                         ambitious expectations,
                                         unrealistic targeting,
                                         incompetent mgt, and lack of
                                         LT mgt Advisor for PMU. Tense
                                         communication between Bank and
                                         PMU could have been lessened
                                         by understanding of
                                         "bureaucratic culture
                                         preferring collective and
                                         participatory approaches other
                                         than instructive methods."
                                         Bank involvement in technical
                                         matters such as SOPs developed
                                         with international support was
                                         considered inappropriate by
                                         MOH without demonstrating that
                                         it had comparable technical
                                         expertise available (May).

                                         * ** Implementation Completion
                                         Report (ICR) on HIV.AIDS and
                                         STDs Prevention and Management
                                         Project prepared by WB EAP
                                         staff finds project outcome
                                         unsatisfactory, quality at
                                         entry into the Bank's
                                         portfolio at the time of
                                         approval in 1996 satisfactory
                                         (June).

2002    * President Megawati calls
        first cabinet meeting on
        HIV/AIDS, followed by a second
        one in December 2003. She is
        out of the country at the time
        of this cabinet meeting
        (March).

        * MOH leads national
        estimation process, in which
        estimates are made of the size
        of at-risk population and of
        HIV infection at the
        provincial level, with input
        from many sectors and NGOs. It
        is estimated that there are
        between 90,000 and 130,000
        people living with HIV in
        Indonesia, around a third of
        the IDU. The estimates process
        is declared an international
        best practice by UNAIDS/WHO
        (October).