N/A

New/Continuing Activity: New Activity

Continuing Activity:

Program Budget Code: 18 - OHSS Health Systems Strengthening

Total Planned Funding for Program Budget Code: $360,000

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Indonesia has mounted a comprehensive response to the HIV epidemic with the primary goal of slowing new infections. While

growing, it is still nascent in comparison to the more mature responses of other Asian countries. The role of the National AIDS

Commission (KPA) was revitalized by Presidential Regulation 75/2006 which strengthened the role of the KPA and identified

provincial and district leadership as key actors. The National HIV and AIDS Costed Action Plan 2007-2010 provides a framework

for government priorities and development partner support, emphasizing collaboration and avoidance of duplication. The plan

assures services throughout Indonesia linking GOI, development partners (including GFATM) and the private sector services.

Operating under the principles of the Three Ones, the KPA has defined targets for the achievement of universal access to HIV

prevention, care, support, and treatment as required by the UNGASS HIV/AIDS Declaration. Essential HIV/AIDS policies are in

place; however, it is necessary for work to continue to assure compliance with updated global technical standards and guidelines.

Government planning for the next phase of the HIV/AIDS Strategy (2010-2014) has already begun. With the rapidly growing need

for care and treatment services a move to an increased level of synergy will be critical.

Until recently, the KPA, the MOH, and other key GOI organizations have demonstrated limited institutional capacity to plan,

implement and monitor responses to the HIV/AIDS epidemic. NGO capacity is also relatively limited. There is high staff turnover

both within the GOI structure and NGOs as well as a lack of human capacity and knowledge of comprehensive HIV programming.

Within the uniformed services, challenges include rivalries among services, suspicion of working with foreigners, and lack of

command level commitment. Decentralization has further complicated program implementation, as KPAD and District Health

Offices (DHO) lack trained personnel and systems to manage the response and the KPA and the KPA/District are now charged

with guiding the HIV/AIDS response in locally appropriate ways. With new leadership over the last 2 years, the KPA is now

developing a solid framework for HIV/AIDS programs and providing the national leadership to ensure program success and

coordination.

Various program reviews have identified numerous weaknesses in the overall health care system. These include the limited

capacity of health sector personnel at provincial and district level to implement programs; weak capacity of civil society

organizations and community-based organizations; difficult environment and resistance to new strategies and interventions; and

poor coordination of AIDS programs among various sectors at district level. Although many improvements have been instituted

since 2007, challenges remain, particularly in the area of coordination and partnership at national, provincial and district level.

A weak community health system is inadequate to cover the health care needs of all community members. The national health

system performance varies widely across the 33 provinces and 440 districts. Most of the target populations are poor - they

depend on public health care and often do not receive enough support and counselling from health care personnel. The national

supply and procurement system is quite weak; without a dependable supply distribution system, prevention, care and treatment

services continue to be extremely challenged. One of the major causes of patient drop-out and non-adherence to ART is the

frequent occurrence of stock-out of essential medicines.

With a limited budget the USG's approach to HSS has been to leverage other partners and initiatives such as GFATM. Of the six

recognized building blocks in the WHO framework, the USG has been most involved with leadership and governance, the delivery

of quality services and referral networks (especially for MARPs), and has also had a major role in surveillance and information

management. Little has been done with commodities systems and human resources. A USAID core-funded situational

assessment of the commodities management system in Tanah Papua was conducted by SCMS in October 2007. The resulting

report stated that any strategic design for a supply chain management system must be constructed so that it meets the needs of

the local hospital and community health center level.

While donor coordination is a KPA priority, donor and financing harmonization is a key issue and one that has not yet received

attention. It is an area where targeted and effective technical assistance could yield tremendous impact. The community of

development partners is small and cohesive and all recognize the value of synergizing HIV/AIDS work. At the root of

harmonization and policy reform, it is important to work closely with GFATM and UNAIDS; AusAID, World Bank and WHO are

currently engaged in HSS.

At the national (and increasingly the provincial) level, the USG focus has been to create an enabling environment for effective

interventions at the community level, and on generating quality surveillance data informing evidence-based programming. District

level emphasis has been to build local NGO capacity providing critical outreach and targeted referral networks to disenfranchised

MARPs; in Papua limited HSS is also taking place in 10 districts. The USG bilateral program has achieved a strong impact in

targeted technical and geographical areas, but interventions have been constrained by funding and the expense of maintaining

activities throughout the archipelago

The USG has supported NGO capacity-building to manage programs and achieve expected results. The key sustainability

strategy is to build capacity and skills in indigenous NGOs, including evidence-based program design, proposal writing, strategic

assessment, target setting, supervision, quality assurance (QA), monitoring and evaluation (M&E), budgeting and financial

tracking and reporting. In FY08 this is implemented through the USG funded FHI/ASA Program. In FY09 a new procurement will

be let for the continued management of NGO capacity building.

Each NGO and government implementing partner is visited once a month by ASA Provincial Program Managers and at least per

quarter by relevant technical staff from either the Provincial or Country Office. Provincial and Country Office staff review

performance; provide program monitoring, as needed; and undertake QA checks during visits to NGOs. The KPADs are located in

all 80 target districts and 8 provinces where USG supports HIV/AIDS activities and all supported NGOs are required to attend

regular meetings with their district KPA to facilitate coordination and encourage accountability. Provincial Program Managers will

accompany them. NGOs bring their M&E data for review and discussion by the KPA and other local organizations.

In past years the USG has helped build GOI institutional capacity to plan and implement programs at the national, provincial and

district levels, within the national, regional and local prison systems; and in the uniformed services. The USG-supported Health

Policy Initiative (HPI) conducted a rapid audit of Indonesia's National HIV/AIDS Strategy and provided TA to the KPA to develop

the National HIV/AIDS Strategy for 2007-2010 and the costed action plan.

Other system strengthening initiatives have included: supporting the Department of Corrections in the development of National

Strategic Plan for introducing HIV/AIDS prevention, care and treatment services in prisons and planning for implementation in

prisons located in the 8 priority provinces covered by the USG; undertaking orientation and basic skill training for members of

KPADs from all 80 target districts; and providing the technical support to the KPA in the development of a national database and

program tracking system.

Previously, the USG supported the implementation of the Resource Needs Module (RNM) of the Goals Model to cost Indonesia's

2007-2010 Action Plan. Working closely with the University of Indonesia, HPI trained a core team of individuals from the national

level on the RNM data collection, and a draft training package was developed for use at the provincial level. Currently USG

funding is being used to build the capacity of national and community level leaders (for example, religious leaders, police) to

advocate for the implementation of policies; support KPA and KPAD to build capacity for evidence-base decision making and

resource allocation; and will provide technical assistance to KPA and involve ministry staff to revise the costed Action Plan.

In FY07 the USG program began assisting the provincial governments in Papua with their overall efforts at health systems

strengthening. The USG supported an operational analysis of the policies in Papua to identify opportunities for and barriers to

providing an integrated package of HIV, FP/HIV, malaria, and TB services in clinic settings. This was intended to identify policies

that need to be revised or updated, so that integrated support is provided in provincial healthcare systems, increasing access to

services and commodities for FP/RH, HIV, TB, and malaria and to enable policy makers to make informed choices about program

integration and investment needed to ensure integration from the policy to the program level.

In FY08 a significant decrease in other donor funding has dramatically affected the jointly funded USG program's ability to

effectively engage in HSS and this remains a component of the USG program limited to Papua. USG funds are being used to

address key HIV-related policy and advocacy issues and provide technical assistance to build KPA capacity for evidence-based

resource allocation. The FHI/ASA program supports 66 NGOs in program and financial management in the 80 target districts in 8

provinces. USG funds are also being used to provide technical assistance to GOI in program planning, monitoring and

coordination skills (e.g., training, mentoring, assisting in QA/QI, logistics, monitoring, reporting/recording systems) as part of the

overall health system strengthening in Papua and three COPC sites for MARPs. Through FY08 this will continue to be

implemented through the FHI/ASA program.

USG continues to work on Papua health systems strengthening by supporting efforts to engage local civil groups in promoting the

advantageous linkages between HIV, FP/RH, TB and malaria programs. HPI will continue to build the capacity of PLHA and civil

society leaders to develop advocacy strategies that promote support for integrated services in Papua, and encourage their use.

Activities will include support for meetings of relevant stakeholders, that include PLHA and other services users, to disseminate

findings from the analysis, and through advocacy trainings to provide stakeholders with the skills needed advocate for integration

of RH/FP, HIV, TB, and malaria services in Papua.

In moving forward strategically in FY09 and beyond, the decision regarding a Partnership Compact will dramatically affect the

focus and shape of the next phase of USG programming. At the current baseline $8 million level, programming must remain

committed to building local capacity of civil society and referral networks for MARPs at the district level. The GOI is keen for

continued USG support to NGOs - a recognized comparative advantage as well as a vital need to overcome nascent funding laws

and lingering uncertainties regarding civil society to emphasize best practice models for increased sustainability, and local

empowerment and leadership. Some limited HSS will take place in Tanah Papua but engagement will remain limited to bilateral

program level interventions and technical advice rather than policy engagement. With FY09 funds, a new procurement will be

tendered for the continued management of NGO capacity building for MARPs.

At the $13 million level, the USG creates an opportunity to impact systemically, engage policy reform at a strategic level, and

transition to a more balanced and harmonized assistance relationship.

Table 3.3.18: