Executive Summary
This case study assesses the impact of the World Bank’s assistance on Indonesia’s national response to HIV/AIDS, and derives lessons from that experience, as one of four case studies for the larger OED evaluation of the Bank’s HIV/AIDS assistance. It reflects events through early 2004, at the time of the team’s field mission to Indonesia. The HIV/AIDS epidemic, until recently, was at very low levels in Indonesia. The first case of HIV was identified in a foreign homosexual tourist in Bali in 1987. Systematic sentinel surveillance of sex workers in Jakarta and Surabaya began in 1988. In 1993/1994, sentinel surveillance reported the first positive sample among sex workers and the first positive blood samples were identified among blood donors. Prevalence was still sufficiently low in 1997 that Ministry of Health (MOH) statistics refer specifically to a small number of cases in Irian Jaya as “Thai fishermen, who have since left the country,” and this relatively small adjustment accounted for a significant share of all AIDS cases in the country at the time.
Projections of the possible course of the HIV/AIDS epidemic were generated by expatriate consultants and researchers beginning in the early 1990s. They did not take existing surveillance data as their starting point, were largely based on the sub-Saharan African and Thai experiences of the late 1980s and early 1990s, and showed rapid acceleration of the epidemic. In hindsight, the projection models were ill suited to the purpose to which they were put in Indonesia. Apparently based on these projections, the Bank staff reported that HIV appeared to be spreading at an increasing rate, and that HIV cases were projected to rise to roughly 500,000 in 2000 and to 700,000 in 2005, assuming that effective prevention efforts were launched during the mid-1990s. If prevention efforts were less successful, the model used by the Bank predicted that the number of cases would increase to an estimated 700,000 in 2000 and 1.2 million in 2005. This turned out to be dramatically wrong, as HIV prevalence barely increased through most of the 1990s. Since 1999, the HIV epidemic has emerged concurrently with an epidemic of intravenous drug use (IDU). IDU was rare prior to 1997, and has made a significant contribution to the HIV/AIDS epidemic. Without its contribution, more current projection models show virtually no epidemic taking place in Indonesia.
Prior to the AIDS epidemic and since its advent, the World Bank has had a long, active, and largely successful engagement in health in Indonesia. Starting with a population project in 1972, the Bank financed 13 health, nutrition and population projects previous to its engagement on HIV/AIDS in the country in 1996. Nonetheless, much remains to be done to improve health services and outcomes. Compared to neighboring countries, Indonesia shows high infant and maternal mortality levels throughout the 1990s (including the period prior to the financial crisis), and UNDP data suggest that health indicators in Indonesia improved at a slower rate than would be consistent with Indonesia’s per capita economic growth.