Rapidly Expanding Access to Care for hiv in Tanah Papua (reach) 2012 2016

3. Implementation arrangements

3.1 Implementation plan

Implementation of REACH will benefit from the current CHAI Phase II program and operations. Some implementation costs will not be incurred by REACH, as they will be covered by CHAI Phase II transition activities. These include key staff recruitment and training and some operational costs. However, with the growth in the program and the staffing needed to implement REACH at multiple new sites, CHAI will need to make a significant investment of time for various start up activities for the first year of the program.

REACH implementation activities for the first 24 months of the program fall in two categories: start up activities and ongoing program implementation.

Start-up activities include:

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  Managerial activities: building and strengthening teams and supervisory systems; orientation for new managers; negotiating financial arrangements with GoI partners; and establishing provincial advisory committees.
  
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  Administrative activities: strengthening, promoting, and implementing fiscal, human resource, and administrative policies and systems; and hiring new CHAI and CoE staff.
  
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  Operational activities: setting up new CoE and CHAI sites and developing strong safety and security policies and procedures.
  
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  Programmatic activities: collecting baseline data; developing the program monitoring system; selecting and prioritising puskesmas for REACH assistance, promoting REACH; and developing relationships.
  

Ongoing program implementation that will continue through the life of the program includes:

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  Trainings: developing new curricula and revising existing ones and conducting training for CoE staff, hospitals and puskesmas.
  
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  Mentoring: partnering with CoE staff to implement ongoing mentoring for health services.
  
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  Technical assistance and support: developing job aides, systems, and tools to help sites with implementation.
  

The implementation plan in Annex 9 gives a broad level outline of activities REACH will undertake in the next 24 months and those targets already identified. Specific targets, key indicators, and means of verification will be developed in REACH’s first quarter as part of the monitoring framework. A detailed work plan for the first year will also be developed. Given the dynamic political and social situation in Tanah Papua, the plan is flexible and may vary if situations in each CoE area change. The Regional Program Manager will communicate regularly with staff at the CoE level (using the cascading issues matrix approach) to refine the program roll-out. This adaptive management approach will allow the pace of roll-out to align within any specific constraints encountered.

3.2 Budget

The total budget request for REACH is A$24,990,417 over the period July 2012 to June 2016. The majority of funding is allocated to the scale up of CST in the two Papuan provinces. In Phase II, CHAI directed 51 per cent of its program resources to CST in Papua Province. Under REACH, resource allocation to the Papuan provinces will increase to 78 per cent of the total budget. REACH has been designed in a way that other program components will contribute directly and indirectly to the outcomes in Tanah Papua. For example, national-level activities that support evidence-based policy decisions will help health facilities provide better services on the ground; and scaling up access to more treatment sites in the Papuan provinces will only succeed if SCM of ARVs and other HIV-related commodities at national and provincial levels are functioning properly. Details of the budget are in Annex 10.

3.3 Governance, coordination, management and structure

3.3.1 Governance

REACH will be a program component of AIPH, as is the current CHAI Phase II program. AusAID has indicated that the current Subsidiary Agreement between the Office of the Coordinating Minister for People’s Welfare and AusAID, which provides the foundation for AIPH, is sufficiently broad to cover the work of REACH and does not require amendment.

CHAI will be accountable to AusAID for the effective implementation of REACH. At the national level, CHAI’s key partner will be the MoH’s AIDS Sub-Directorate. The Clinton Foundation has a Memorandum of Understanding (MoU) with the MoH covering CHAI’s work in Indonesia. The MoU, which expires in January 2013, is sufficiently broad to cover REACH. CHAI has commenced discussions with the MoH to develop a new MoU and will consult with AusAID on key issues to be covered in this MoU.

Mechanisms that promote inputs by partners will be utilised to assist with governance. The governance mechanism for REACH at the national level will be the AIPH Partnership Coordinating Committee (PCC). Given the strong Papuan focus of REACH, a mechanism is needed that promotes provincial government leadership in the governance of REACH. Involvement of provincial government representatives in AIPH PCC meetings in Jakarta would be too costly and time consuming. A group that meets more frequently than the AIPH PCC, particularly in the early years of implementation, focussed on the roll-out of REACH at the provincial level is needed. The mechanism for achieving this at the provincial level will be two new AIPH Provincial Steering Committees (PSCs), one in Papua Province and the other in West Papua Province. Mechanisms to ensure the AIPH PCC and the PSCs operate in tandem are outlined below.

National level

To date, the AIPH PCC has primarily focussed on the work of HCPI. AusAID has identified that the significant scale up of its CST work in the Papuan provinces and the need for a more integrated programmatic approach by AIPH will require the PCC to strengthen its focus on REACH. This will include ensuring that synergies between the work of REACH and HCPI in the Papuan provinces are realised. A key finding of the 2011 AIPH IPR, which AusAID has accepted, was the need for a more integrated approach to the implementation of AIPH, particularly in regard to a continuum of prevention to care, support and treatment. AusAID has also identified the need for the PCC to have a stronger strategic and accountability focus in preference to information sharing. AusAID will be requesting the MoH to provide more senior level representation on the PCC. CHAI will also play a more significant role in PCC meetings.

National components of REACH’s annual work plan (primarily SCM and policy support to the MoH), will be approved by the PCC. The work plan for the CST component in the Papuan provinces will be approved by the AIPH Provincial Steering Committees, (see below).

Provincial level

Establishment of the AIPH PSCs will promote closer collaboration between the work of REACH and HCPI at the provincial level. The AIPH PSCs will be co-chaired by AusAID, the Provincial AIDS Commissions and the PHOs. However, in West Papua the PSC may be co-convened by the Regional Development Planning Agency (BAPPEDA) which is responsible for donor coordination in that province. Additional membership will include the Provincial Finance Office (PFO), the MoH’s AIDS Sub Directorate, CHAI, HCPI and AIPD. Secretariat functions will be provided by the government convening body, with support from CHAI and HCPI.

The two PSCs will hold a joint annual meeting to foster sharing of lessons learned between the provinces. This will be timed to coincide with one of the two annual Program Analysis meetings which are an integral part of REACH's monitoring structure (see section 3.4). This will allow the PSCs to be given a thorough overview of current progress and challenges faced by REACH in the field.

Linkage between the AIPH PCC and the two AIPH PSCs will be achieved by AusAID, CHAI and HCPI representatives reporting to the respective committees on the work of the PCC and the PSCs. Work plans for REACH in each province will be approved by the respective PSC. The PSCs will meet shortly before AIPH PCC meetings so that reports from the PSCs can be considered at the PCC meeting. Should there be differences in the strategic directions recommended by the AIPH PCC and the AIPH PSCs which cannot be resolved, the PCC and ultimately AusAID will be final arbiter.

In the Papuan provinces, CHAI’s key partners will be the PHOs, although there will also be substantive relationships with DHOs. As suggested by AIPD, REACH will enter into Technical Arrangements with appropriate government entities at the provincial and/or district level. These agreements will articulate roles and cost sharing responsibilities.

There was strong support for REACH from all levels of district government consulted during site assessments. CHAI will hold discussions with districts not visited during the proposal design phase in the coming months. All 21 district governments will be invited to participate in the provincial REACH launch ceremonies to further signify their commitment to the program.

3.3.2 Roles and responsibilities and reporting and communication channels of key parties

The key roles and responsibilities of AusAID, CHAI and partners are set out in Table 24 in Annex 11. Figure 7 in Annex 11 presents a key relationships flowchart between CHAI and all partners. The relationship flowchart should be read in conjunction with the description of CoE in section 2.5, governance arrangements in section 3.3.1, and mechanisms for coordination with other programs in section 3.3.3. There are large number of partners and stakeholders. CHAI will invest significant time in relationship management.

3.3.3 Mechanisms for coordination with other programs

AusAID is committed to strengthening integration of all its programming in the Papuan provinces and improved collaboration with the work other development partners. AusAID has decided to facilitate two joint meetings of all AIPH program components at the national level, including REACH and HCPI, every February and August to foster greater collaboration within AIPH. AusAID has indicated that it will strengthen management and supervision of AIPH’s work in the Papuan provinces, including more regular monitoring visits. This will include convening of two joint meetings each year between AusAID, and the Tanah Papua staff of REACH and HCPI to foster closer collaboration. AIPD will be invited to participate in these meetings.

AusAID and USAID have a strong level of commitment to improving donor coordination. In the absence of a GoI led forum to coordinate the work of health donors, AusAID and USAID, the two major bilateral health sector donors, have forged an informal partnership to achieve a greater level of harmonisation in their programs and cohesion in interactions with the GoI. At the national level, twice yearly meetings between AusAID, USAID and their health sector implementing agencies have commenced.

During meetings with the team that designed this proposal, the PHOs in both Papua and West Papua and BAPPEDA in West Papua strongly emphasised the need for improved coordination between donor implementing agencies and with provincial governments. This was also a key finding of the proposal design team. Effective coordination is particularly important for REACH as its success will, to a significant degree, be dependent on the work of other agencies in areas such as demand creation for HIV testing and treatment.

Although the current situation of poor donor coordination clearly needs to be addressed, this is a difficult task, with no easy solutions. We have outlined below a proposal for establishment of two Provincial Health Donor Implementing Agencies Coordinating Groups, one in each province. We recognise that this will, of itself, be insufficient to achieve the intended outcome. To achieve progress, a shift needs to take place in the importance donors and their implementing agencies place on coordination. Donors need to make it clear to their implementing agencies that effective coordination is a key accountability and that constructive and meaningful inputs to the proposed provincial Coordination Groups are expected. As the bulk of donor supported health programming in the Papuan provinces is supported by AusAID and USAID, both partners are well placed to provide leadership and require greater accountability by their implementing agencies. This can be reinforced by AusAID and USAID with the national offices of their implementing agencies and monitored against clearly articulated expectations by AusAID and USAID during field monitoring trips.

While CHAI will devote considerable energy to working with other donor implementing agencies on a one-to-one basis, the HIV response in the Papuan provinces would benefit considerably through a more comprehensive approach to harmonisation of the health programming of development partners. It is therefore recommended that AusAID propose the establishment of Provincial Health Donor Implementing Agencies Coordinating Groups. Separate Coordinating Group would be established in each province. The purpose of the Coordinating Groups will be to provide a forum for forward planning (not just information sharing) and improved coordination of all donor support to the health sector, not just HIV. There would be a strong emphasis on identification of synergies and leveraging off the work of other implementing agencies in support of the provincial health sector. The Coordination Groups would develop a results framework, a harmonised technical assistance plan for each province, and an agreed division of labour for training, using common curricula, to eliminate duplicative training.

The Coordinating Groups would be convened by the PHO in Papua Province and co-convened by BAPPEDA and the PHO in West Papua. The Provincial AIDS Commissions would also be represented. Given the operational focus and the difficulty in scheduling meetings when donors could be present, membership of the Coordinating Groups will be all donor implementing agencies. Health sector implementing agencies include the following:

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  For HIV-related programs:
  

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  AusAID: CHAI and HCPI
  
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  USAID: FHI (SUM I and TB Care), RTI (SUM II), Kinerja, Serasi (IRD)
  
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  UN: UNICEF (PMTCT and school education) and UNFPA– Papua only (sexual and reproductive health)
  

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  For other programs with broader health components:
  

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  AusAID: AIPD and AIPHSS if it extends its work to the Papuan provinces
  
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  USAID: RTI (Kinerja – health system strengthening)
  
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  UN: UNICEF (maternal, neonatal and child health – Papua only; nutrition – Papua only)
  
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  Netherlands Leprosy Relief – Papua only
  

Secretariat functions would be the responsibility of the PHOs and BAPPEDA. To assist with the foundation and development of the Coordinating Groups, the REACH government relations positions, (one in each province), would actively support the PHOs and BAPPEDA with secretariat functions for the first two years, with a plan for full transition of these functions to government.

3.3.4 Annual planning

CHAI will hold two annual planning meetings each year (in March and September). The first meeting is designed to ensure REACH’s annual plan aligns to AusAID’s fiscal year (July-June). The second meeting will be for alignment with the GoI’s fiscal cycle (January – December). The annual plan will be approved by AusAID as well as through the PCC and PSC processes. CHAI will utilize quarterly, bi-annual, and yearly mechanisms to monitor and modify ongoing program implementation. Monitoring data, for example, will be collected and analysed on a quarterly basis. Ongoing processes like this will feed into the development of REACH’s annual plan and target setting.

3.3.5 CHAI’s management, technical, finance and administrative capacity

A description of staffing for REACH and the organizational chart is shown in Annex 12 . The Annex also outlines the support that will be provided by CHAI’s South East Asia Regional Team, the CHAI PNG program and the CHAI Global Teams and CHAI’s procurement procedures. Key considerations in developing the staffing structure included 1) maximizing staff placed in Papua and West Papua in preference to the national office; 2) integrating most human resources for operational research and monitoring and some SCM and policy human resources within the CST teams in the Papuan provinces; 3) increasing monitoring capacity in the program overall; 4) supporting the partnerships with PHOs with resources; 5) strengthening of CHAI’s management capacity and 6) ensuring finance and administrative systems have adequate support. Efficient management processes have been established to ensure adequate oversight and quality of the program especially at the service delivery level.

To support the significant program scale up, the number of CHAI staff will double from 27 to 57 staff, with a majority of these positions in the Papuan provinces. Recruitment of a significant number of additional staff for CHAI and the CoE will be challenging, although new positions will be recruited progressively over an 18 months period, aligned with the phased expansion of the program. To maximise recruitment of good staff, CHAI has commenced proactive recruitment through formal and informal channels. CHAI’s technical staff who collectively have over 80 years of work experience in healthcare in Papua are using their extensive networks to find suitable applicants. Through a rolling hire process, CHAI is able to hire new staff as opportunities are presented. For example, AusAID transition funding will be used to employ seven Medecin Du Monde staff whose program in Nabire is ending in May. CHAI is seeking to fill many positions with Papuan staff. While the supply of qualified healthcare workers in the Papuan provinces is limited, if needed, CHAI may recruit less qualified staff and upgrade their skills through on-the-job training and intensive mentoring. This is included in the year one budget.

One of the criteria for staff selection will be an understanding of gender-related issues and the ability to integrate the principle of gender equality into program work.