Selanjutnya
A.I.D. PROJECT NO. 497-0253
LOAN NO. 497-U-057
LOAN NO. 497-U-057A
c
AMENDMENT NO. 2 TO
LOAN AGREEMENT
BETWEEN THE
REPUBLIC OF INDONESIA
AND THE
UNITED STATES OF AMERICA
FOR
(;:_
'-
.
AN EXPANDED PROGRAM ON IMMUNIZATION (EPI)
PROJECT
DATED: August 7, 1987
Dated: Augu st 7, 1987
This AMENDMENT NO. 2, is entered into between the REPUBLIC OF
INDONESIA ("Borrower") and the UNITED STATES OF AMERICA, acting
through the AGENCY FOR INTERNATIONAL DEVELOPMENT ("A. I. D. ").
WHEREAS, the Borrower and A.I.D. entered into an Expanded
Program on Immunization Project Loan Agreement on August 15, 1979,
which was amended on September 21, 1984 ("Loan Agreement"), whereby
A.I.D. agreed to loan to the Borrower up to Nine Million Five
Hundred Thousand United States ("U.S.") Dollars ($9,500,000)
("Loan"); and
WHEREAS, the Borrower and A.I.D. desire to further amend the
Loan Agreement to add an additional $2,000,000 to the Loan and to
make other related changes;
NOW THEREFORE, the Borrower and A.I.D. hereby agree as follows:
1.
A new Section 2.2.
Incremental Nature of Project, is added
as follows:
"Section 2.2.
Incremental Nature of Project
(a) A.I.D. 's further contributions to the Project will be
provided in increments, the first one being made available in
accordance with Section 3.1 of the Agreement.
Subsequent
increment(s) will be subject to the availability of funds to A.I.D.
for this purpose, and to the mutual agreement of the parties, at the
time of a subsequent increment, to proceed.
- 2 -
2.
The first sentence of Section 3.1. of the Loan Agreement is
revised to read as follows:
"Section 3.1.
The Loan.
To assist the Borrower to meet the
costs of carrying out the Project, A.I.D., pursuant to the Foreign
Assistance Act of 1961, as amended, agrees to lend the Borrower
under the terms of this Agreement not to exceed Eleven Million Five
Hundred Thousand United States Dollars ("U.S.") Dollars
($11,500,000) ("Loan").
3.
Section 3.2 (b) of the Loan Agreement is revised to read as
follows:
"(b)
The resources provided by the Borrower for the total
project (both grant and loan) will be not less than the equivalent
of U.S. $17,956,000, including costs borne on an "in-kind" basis."
4.
The Project Assistance Completion Date (PACD) set forth in
Section 3.3.(a) of the Loan Agreement is revised to read
"September 30, 1990."
5.
A Revised Annex 1, Amplified Project Description, and
Attachment 1, Financial Plan, are attached to this Amendment as
Annex 1.
6.
Except as expressly amended herein, the Loan Agreement
remains in full force and effect.
IN WITNESS WHEREOF, the Borrower and the United States of
America, each acting through its respective duly authorized
- 3 -
representative, have caused this Amendment No. 2 to be signed in
their names and delivered as of the date and year first above
written.
REPUBLIC OF INDONESIA
UNITED STATES OF AMERICA
Signed
Signed
Rusli Noor
Director General
for Foreign Economic Relations
Department of Foreign Affairs
ｾｶｩ､＠
N.' Merri 111
Director
USAID/Indonesia
Annex I
(Revision 1)
EXPANDED ffiOffiAM ON IMMUNIZATION (EPI)
The amendment to the EPI introduces the design of more cost
effective immunization delivery systems, expansion of the role of
curative facilities, both private and public in EPI, and the use of
improved communication technologies in program strategy. The amendment
also strengthens the research and development capacities of the Ministry
of Health (MOH) by supporting activities which seek to clarify problem
definitions and which identify and test potential solutions to these
problems. Successful demonstrations of innovative approaches will be
linked to policy discussions with the MOH and other decision making
bodies within the Government of Indonesia ((l)I) with the expectation of
appropriate modifications in the national EPI program.
The objective of these activities is to assist the MOH in designing
improved management and delivery systems that can be institutionalized to
enable the EPI to sustain 65% full immunization coverage levels. Through
activities proposed in this amendment, the EPI will have reached a
sustainable status and will be positioned to play a lead role in the
future assault upon infant child mortality which will be embodied in the
upcoming USAID supported Child Survival project.
The proposed components of the amendment are designed to assist the
MOH in overcoming major program constraints, as identified through
independent evaluations, by:
(1)
supporting research to better understand the problems relating
to missed opportunities (eligible persons in a health care
facility who fail to receive needed immunizations), testing
potential solutions, and demonstrating improved program
procedures.
- 2 -
(2)
supporting research, development and testing of new strategies
that could lead to practical solutions to the problem of high
drop-out rates (the percent of individuals who begin the
process of receiving immunizations but fail to receive full
protection).
(3)
initiating steps to decentralize EPI management (shifting
appropriate responsibilities of EPI leadership to lower
administrative levels).
(4)
creating the policy environment necessary to obtain increased
budgetary and political commitment to the EPI.
Research into missed opportunities will concentrate upon
inappropriate as well as poorly understood technical procedures and the
lack of involvement of EPI in curative facilities. One research topic
will be provider behavior to describe and analyze the implementation of
current program procedures at facilities already participating in the EPI
program. Another research topic will be health-seeking behavior to
target efforts to expand the participation of curative facilities in the
EPI.
The problem of high drop-out rates is well documented but the
causes of these problems are little understood. This amendment will
assess new approaches and identify different community groups which can
play the most active and effective roles in EPI development as a means of
reducing the number of drop-outs. Pilot tests will be conducted and
demonstrations of social mobilization will be carried out. These
community resources, such as local chapters of the National Family
Welfare Movement, can be organized for screening the EPI target
population and educating mothers to continue with immunizations until
completion. This amendment will also support market research, pilot
testing of social marketing demand generation activities, and social
marketing demonstration programs as another means of reducing the number
- 3 -
of drop-outs. Social marketing, using modern communication technologies,
will be investigated as a potential vehicle for increasing the knowledge
of mothers, particularly those living in urban areas where strong
conununity organizations do not exist.
To alter the current centrally managed EPI system, the amendment
will investigate and refine a new area specific planning approach that
has already been conceptualized and approved by the MOH. Under this
approach the EPI delivery system will be adapted to the unique
socio-cultural and epidemiology characteristics of aggregates of
provinces or municipalities. Elements of the EPI delivery and demand
generation strategy will be tailored to the conditions in each area and
specific interventions will be introduced in areas where conditions allow
for maximum impact. The amendment will also develop local area
monitoring systems to decentralize EPI management. These systems are
designed to monitor important epidemiologic and program indicators at the
district and subdistrict levels as input for making operational decisions
outside of Jakarta. Sentinel health centers will support local area
monitoring by providing local health leaders with epidemiologic and
program profiles based upon case finding and follow-up. Finally, the
amendment will support manpower development activities for the purpose of
providing province and district level physician epidemiologists who are
able to analyze and interpret monitoring data and district level nurses
who can supervise the collection of data and the implementation of local
operational plans.
The amendment will attempt to create policy environments to improve
budgetary commitment to the EPI by supporting studies to demonstrate the
cost benefit and cost effectiveness of the EPI. Information will be
disseminated to MOH planners and decision makers and efforts will be made
to educate and motivate persons who make resource allocation decisions
regarding the importance of full commitment to preventive health
measures. Also, new financial support systems will be investigated as a
means to make the EPI more sustainable. The possibility of establishing
a vaccine endowment fund will be explored in which both private and
- 4 -
public contributions would be accepted. 'Ibe purpose of such a fund would
be to ensure availability of monies for vaccine procurement on an annual
basis.
'Ibe Directorate General for Communicable Disease Control and
Environmental Health will be responsible for implementation of the
amendment and for coordination with the Integrated Task Force. A Project
Steering Committee, whose membership will represent a broad range of
national and international technical expertise, will provide policy and
operational guidance. Overall responsibility for project monitoring and
evaluation lies with this Project Steering Committee. Indicators of
progress arrl progress benchmarks for each project component are described
and illustrated in tabular f onnat in the amendment. A Project Technical
Review Group, under the direction of the Chief of the EPI Directorate,
will monitor the progress and findings of assessments and demonstrations
approved and funded under the amendment. Two nation-wide evaluations
will be conducted during the course of the amendment.
The MOH and AID are confident that through the activities of the
amendment the following accomplishments will be realized:
(1)
Management and delivery systems will have been improved to
reduce missed opportunities and drop-out rates, decentralize
management according to designated regions, and provide
monitoring activities which reflect regional characteristics.
(2)
The MOH will be in a better budgetary position to provide
recurrent costs for vaccines, equipment and supplies,
training, and supervision to the EPI infrastructure.
(3)
'Ibe foundation will have been laid for a wider and more
pluralistic participation in the EPI.
(4)
A full 65% of target populations will be fully immunized.
- 5 -
At the conclusion of this amendment, on September 30, 1990, these
basic achievements should contribute to the GO! goal of reducing inf ant
and child mortality from 90.3/1000 to 70/1000 and reducing the mortality
rate of children ages 1 to 4 from 17.8/ 1000 to 14/ 1000.
A.I.D. will provide both loan and grant funding in support of the
amended GO! EPI program. A total of up to $19,700,000 shall be available
of which $12,500,000 shall be loan funded and $7,200,000 shall be grant
funded. 1he GO! contribution as set forth in the attached table shall
amount to no less than $17,956,000 in cash or "in kind". Written changes
may be made to line item amounts by the authorized representatives set
forth in Section 9.2. of the Loan Agreement or Section 8.2 of the Grant
Agreement without formal amendment of this Agreement, provided that the
total A.I.D. contribution is not increased or the Borrower's total
contribution is not decreased.
Attachment 1
FINANCIAL PLAN
EXPANDED PROGRAM ON IMMUNIZATION
PROJECT 497-0253
(US$OOO)
FY 87
OBLIGATION
GRANT
LOAN
A.I.D.
TOTAL OBLIGATION
TO DATE
GRANT
LOAN
2,500
-
5,006
2. Vaccines
-
-
-
3. Commodities
-
-
-
5,043
1. Technical Assistance
PROPOSED
LOP
GRANT
LOAN
-
I
1,200
5,506
I
I
-
G0 I
TOTAL LOP
AID & GO!
-
5,506
-
I 1,200
9,001
10,201
-
5,043
4,391
9,895
4. Program Monitoring
25
1,500
266
2,254
291
3,054
3, 720
7,332
5. Manpower Development
25
400
478
2,903
503
3,103
844
3,722
450
100
450
100
900
100
-
1,000
3,000
2,000
6,200
11,500
7,200
12,500
17,956
37,656
- - - --
--- --
======
======
6. Program Development
T 0 T AL
-----
\I..
-----
=====
-----------
\ .
LOAN NO. 497-U-057
LOAN NO. 497-U-057A
c
AMENDMENT NO. 2 TO
LOAN AGREEMENT
BETWEEN THE
REPUBLIC OF INDONESIA
AND THE
UNITED STATES OF AMERICA
FOR
(;:_
'-
.
AN EXPANDED PROGRAM ON IMMUNIZATION (EPI)
PROJECT
DATED: August 7, 1987
Dated: Augu st 7, 1987
This AMENDMENT NO. 2, is entered into between the REPUBLIC OF
INDONESIA ("Borrower") and the UNITED STATES OF AMERICA, acting
through the AGENCY FOR INTERNATIONAL DEVELOPMENT ("A. I. D. ").
WHEREAS, the Borrower and A.I.D. entered into an Expanded
Program on Immunization Project Loan Agreement on August 15, 1979,
which was amended on September 21, 1984 ("Loan Agreement"), whereby
A.I.D. agreed to loan to the Borrower up to Nine Million Five
Hundred Thousand United States ("U.S.") Dollars ($9,500,000)
("Loan"); and
WHEREAS, the Borrower and A.I.D. desire to further amend the
Loan Agreement to add an additional $2,000,000 to the Loan and to
make other related changes;
NOW THEREFORE, the Borrower and A.I.D. hereby agree as follows:
1.
A new Section 2.2.
Incremental Nature of Project, is added
as follows:
"Section 2.2.
Incremental Nature of Project
(a) A.I.D. 's further contributions to the Project will be
provided in increments, the first one being made available in
accordance with Section 3.1 of the Agreement.
Subsequent
increment(s) will be subject to the availability of funds to A.I.D.
for this purpose, and to the mutual agreement of the parties, at the
time of a subsequent increment, to proceed.
- 2 -
2.
The first sentence of Section 3.1. of the Loan Agreement is
revised to read as follows:
"Section 3.1.
The Loan.
To assist the Borrower to meet the
costs of carrying out the Project, A.I.D., pursuant to the Foreign
Assistance Act of 1961, as amended, agrees to lend the Borrower
under the terms of this Agreement not to exceed Eleven Million Five
Hundred Thousand United States Dollars ("U.S.") Dollars
($11,500,000) ("Loan").
3.
Section 3.2 (b) of the Loan Agreement is revised to read as
follows:
"(b)
The resources provided by the Borrower for the total
project (both grant and loan) will be not less than the equivalent
of U.S. $17,956,000, including costs borne on an "in-kind" basis."
4.
The Project Assistance Completion Date (PACD) set forth in
Section 3.3.(a) of the Loan Agreement is revised to read
"September 30, 1990."
5.
A Revised Annex 1, Amplified Project Description, and
Attachment 1, Financial Plan, are attached to this Amendment as
Annex 1.
6.
Except as expressly amended herein, the Loan Agreement
remains in full force and effect.
IN WITNESS WHEREOF, the Borrower and the United States of
America, each acting through its respective duly authorized
- 3 -
representative, have caused this Amendment No. 2 to be signed in
their names and delivered as of the date and year first above
written.
REPUBLIC OF INDONESIA
UNITED STATES OF AMERICA
Signed
Signed
Rusli Noor
Director General
for Foreign Economic Relations
Department of Foreign Affairs
ｾｶｩ､＠
N.' Merri 111
Director
USAID/Indonesia
Annex I
(Revision 1)
EXPANDED ffiOffiAM ON IMMUNIZATION (EPI)
The amendment to the EPI introduces the design of more cost
effective immunization delivery systems, expansion of the role of
curative facilities, both private and public in EPI, and the use of
improved communication technologies in program strategy. The amendment
also strengthens the research and development capacities of the Ministry
of Health (MOH) by supporting activities which seek to clarify problem
definitions and which identify and test potential solutions to these
problems. Successful demonstrations of innovative approaches will be
linked to policy discussions with the MOH and other decision making
bodies within the Government of Indonesia ((l)I) with the expectation of
appropriate modifications in the national EPI program.
The objective of these activities is to assist the MOH in designing
improved management and delivery systems that can be institutionalized to
enable the EPI to sustain 65% full immunization coverage levels. Through
activities proposed in this amendment, the EPI will have reached a
sustainable status and will be positioned to play a lead role in the
future assault upon infant child mortality which will be embodied in the
upcoming USAID supported Child Survival project.
The proposed components of the amendment are designed to assist the
MOH in overcoming major program constraints, as identified through
independent evaluations, by:
(1)
supporting research to better understand the problems relating
to missed opportunities (eligible persons in a health care
facility who fail to receive needed immunizations), testing
potential solutions, and demonstrating improved program
procedures.
- 2 -
(2)
supporting research, development and testing of new strategies
that could lead to practical solutions to the problem of high
drop-out rates (the percent of individuals who begin the
process of receiving immunizations but fail to receive full
protection).
(3)
initiating steps to decentralize EPI management (shifting
appropriate responsibilities of EPI leadership to lower
administrative levels).
(4)
creating the policy environment necessary to obtain increased
budgetary and political commitment to the EPI.
Research into missed opportunities will concentrate upon
inappropriate as well as poorly understood technical procedures and the
lack of involvement of EPI in curative facilities. One research topic
will be provider behavior to describe and analyze the implementation of
current program procedures at facilities already participating in the EPI
program. Another research topic will be health-seeking behavior to
target efforts to expand the participation of curative facilities in the
EPI.
The problem of high drop-out rates is well documented but the
causes of these problems are little understood. This amendment will
assess new approaches and identify different community groups which can
play the most active and effective roles in EPI development as a means of
reducing the number of drop-outs. Pilot tests will be conducted and
demonstrations of social mobilization will be carried out. These
community resources, such as local chapters of the National Family
Welfare Movement, can be organized for screening the EPI target
population and educating mothers to continue with immunizations until
completion. This amendment will also support market research, pilot
testing of social marketing demand generation activities, and social
marketing demonstration programs as another means of reducing the number
- 3 -
of drop-outs. Social marketing, using modern communication technologies,
will be investigated as a potential vehicle for increasing the knowledge
of mothers, particularly those living in urban areas where strong
conununity organizations do not exist.
To alter the current centrally managed EPI system, the amendment
will investigate and refine a new area specific planning approach that
has already been conceptualized and approved by the MOH. Under this
approach the EPI delivery system will be adapted to the unique
socio-cultural and epidemiology characteristics of aggregates of
provinces or municipalities. Elements of the EPI delivery and demand
generation strategy will be tailored to the conditions in each area and
specific interventions will be introduced in areas where conditions allow
for maximum impact. The amendment will also develop local area
monitoring systems to decentralize EPI management. These systems are
designed to monitor important epidemiologic and program indicators at the
district and subdistrict levels as input for making operational decisions
outside of Jakarta. Sentinel health centers will support local area
monitoring by providing local health leaders with epidemiologic and
program profiles based upon case finding and follow-up. Finally, the
amendment will support manpower development activities for the purpose of
providing province and district level physician epidemiologists who are
able to analyze and interpret monitoring data and district level nurses
who can supervise the collection of data and the implementation of local
operational plans.
The amendment will attempt to create policy environments to improve
budgetary commitment to the EPI by supporting studies to demonstrate the
cost benefit and cost effectiveness of the EPI. Information will be
disseminated to MOH planners and decision makers and efforts will be made
to educate and motivate persons who make resource allocation decisions
regarding the importance of full commitment to preventive health
measures. Also, new financial support systems will be investigated as a
means to make the EPI more sustainable. The possibility of establishing
a vaccine endowment fund will be explored in which both private and
- 4 -
public contributions would be accepted. 'Ibe purpose of such a fund would
be to ensure availability of monies for vaccine procurement on an annual
basis.
'Ibe Directorate General for Communicable Disease Control and
Environmental Health will be responsible for implementation of the
amendment and for coordination with the Integrated Task Force. A Project
Steering Committee, whose membership will represent a broad range of
national and international technical expertise, will provide policy and
operational guidance. Overall responsibility for project monitoring and
evaluation lies with this Project Steering Committee. Indicators of
progress arrl progress benchmarks for each project component are described
and illustrated in tabular f onnat in the amendment. A Project Technical
Review Group, under the direction of the Chief of the EPI Directorate,
will monitor the progress and findings of assessments and demonstrations
approved and funded under the amendment. Two nation-wide evaluations
will be conducted during the course of the amendment.
The MOH and AID are confident that through the activities of the
amendment the following accomplishments will be realized:
(1)
Management and delivery systems will have been improved to
reduce missed opportunities and drop-out rates, decentralize
management according to designated regions, and provide
monitoring activities which reflect regional characteristics.
(2)
The MOH will be in a better budgetary position to provide
recurrent costs for vaccines, equipment and supplies,
training, and supervision to the EPI infrastructure.
(3)
'Ibe foundation will have been laid for a wider and more
pluralistic participation in the EPI.
(4)
A full 65% of target populations will be fully immunized.
- 5 -
At the conclusion of this amendment, on September 30, 1990, these
basic achievements should contribute to the GO! goal of reducing inf ant
and child mortality from 90.3/1000 to 70/1000 and reducing the mortality
rate of children ages 1 to 4 from 17.8/ 1000 to 14/ 1000.
A.I.D. will provide both loan and grant funding in support of the
amended GO! EPI program. A total of up to $19,700,000 shall be available
of which $12,500,000 shall be loan funded and $7,200,000 shall be grant
funded. 1he GO! contribution as set forth in the attached table shall
amount to no less than $17,956,000 in cash or "in kind". Written changes
may be made to line item amounts by the authorized representatives set
forth in Section 9.2. of the Loan Agreement or Section 8.2 of the Grant
Agreement without formal amendment of this Agreement, provided that the
total A.I.D. contribution is not increased or the Borrower's total
contribution is not decreased.
Attachment 1
FINANCIAL PLAN
EXPANDED PROGRAM ON IMMUNIZATION
PROJECT 497-0253
(US$OOO)
FY 87
OBLIGATION
GRANT
LOAN
A.I.D.
TOTAL OBLIGATION
TO DATE
GRANT
LOAN
2,500
-
5,006
2. Vaccines
-
-
-
3. Commodities
-
-
-
5,043
1. Technical Assistance
PROPOSED
LOP
GRANT
LOAN
-
I
1,200
5,506
I
I
-
G0 I
TOTAL LOP
AID & GO!
-
5,506
-
I 1,200
9,001
10,201
-
5,043
4,391
9,895
4. Program Monitoring
25
1,500
266
2,254
291
3,054
3, 720
7,332
5. Manpower Development
25
400
478
2,903
503
3,103
844
3,722
450
100
450
100
900
100
-
1,000
3,000
2,000
6,200
11,500
7,200
12,500
17,956
37,656
- - - --
--- --
======
======
6. Program Development
T 0 T AL
-----
\I..
-----
=====
-----------
\ .