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

1. Situation analysis and strategic context

Section 1 provides a situational analysis of relevant issues considered in the design of this funding proposal. The analysis is organised into six categories:

1. 
   Indonesian health sector overview and decentralisation
   
2. 
   Papua and West Papua overview
   
3. 
   HIV in Indonesia and the response
   
4. 
   Programmatic needs
   
5. 
   Consistency with AusAID and other donor programs
   
6. 
   Rationale for AusAID’s involvement
   

1.1 Indonesian health sector overview and decentralisation

1.1.1 Indonesian health sector overview

Government of Indonesia (GoI) funding to the health sector is low by international standards. Total health spending in 2008 accounted for only 2.2 per cent of GDP.⁵ The low levels of government spending on health are reflected in weak service delivery and poor health indicators in a number of key areas. However, the GoI has strengthened its resolve to reform, placing health high on its development agenda and devoting more funds to the sector. Government expenditure on health increased from 4.5 per cent to 6.5 per cent of total government expenditure between 2000 and 2007.⁶

Out of pocket expenses on health care are high and are a potential cause of poverty. In 2008, almost 60 per cent of Indonesians did not have health insurance. The GoI is committed to achieving universal coverage for health insurance that will include HIV care, support and treatment (CST), although plans for how this will be achieved are under development.

Primary health care has become increasingly reliant on central government funding and user fees, with limited support from district governments, although the level of district support is variable. While the government has increased funding for a number of priority health issues, targeted funding is primarily directed to hospitals rather than primary care for the poor. The Ministry of Health’s (MoH) Strategic Plan includes targets to strengthen primary health care, including HIV CST, through enhancing the role of puskesmas. ⁷

Although there is an extensive infrastructure of primary health care facilities, they are under-funded, poorly staffed and often not well maintained, particularly in more remote sites. A significant number of puskesmas do not have doctors and shortages of nurses are common. Many do not have laboratory technicians to support even rudimentary testing. Shortages of health workers are particularly severe in rural and remote areas in the Papuan provinces. Service utilisation of primary health care in Indonesia is low, particularly in rural and remote areas. Poor access to health care can be both a cause and consequence of poverty. Barriers to accessing health care include distance from services, especially in rural and remote areas; user fees and the cost of transport; lack of knowledge of entitlements under health financing schemes; cultural barriers, including a preference for traditional therapies; health seeking behaviours; and consumer perceptions of the quality of care.

1.1.2 Decentralisation and health care

Decentralisation in Indonesia has resulted in much of the responsibility for health care service delivery resting largely with provincial and district governments. However, many provinces and districts have not yet developed the capacity to identify local health needs, take a population health approach to service planning, manage their health budgets, or set targets, establish accountability and monitor progress.⁸ As a result, decentralisation has not yet resulted in improved health outcomes. Districts are constrained by multiple funding channels with different reporting requirements, delays in funding disbursements both centrally and locally, and by the centralised control over health workforce regulations. Service delivery capacity has been further weakened by the creation of new provinces and districts, which has been particularly common in the Papuan provinces. There is a high likelihood that additional provinces and/or districts will be created in Tanah Papua in coming years⁹.

From a supply-side perspective, effective strategies to make decentralisation work require interventions at the national, provincial and district levels. The national government still sets policies and decides on program directions and has a strong influence over the bulk of funding. Provincial governments are expected to play important support, capacity building and monitoring/accountability roles in relation to service delivery. District governments have primary responsibility for delivery of health services and are key in resource allocation and local programming. From a demand side perspective, civil society organisations could have a key role to play in advocating for services and in monitoring delivery and community mobilisation but their voice has not been heard in the Papuan provinces to any great extent. Local parliaments could also play a key ‘watchdog’ role but need service delivery targets and data to effectively perform that function. Both of these roles are currently underdeveloped.

1.2 Papua and West Papua overview

The total population of Papua and West Papua is 3.65 million people, with 79 per cent living in Papua. (Table 1 below, outlines the demographic data.) It is estimated the proportion of ethnic Papuan and non-Papuan people living across the two provinces is now roughly equal,¹⁰ although there are significantly more Papuans living in the highlands and hard to access lowlands, with larger numbers of non-Papuans living in the cities and easy to access lowlands. There is significant ethnic diversity among Papuans, reflected in 250 different spoken languages. Social, cultural and economic systems are also hugely varied.¹¹

The Papuan provinces have the highest levels of poverty in Indonesia, with the proportion of people living below the poverty line being almost three times the national average. Ranking on the Human Development Index in relation to Indonesia’s 33 provinces is 30 for West Papua and 33 for Papua.¹²

Christianity is the dominant religion, particularly among Papuans. The extensive reach of both Protestant and Catholic churches to the village level provides potential opportunities for community mobilisation around health and social issues.

Health standards in the Papuan provinces are considerably worse than in other parts of Indonesia. Special autonomy for the Papuan provinces is designed to devolve authority on funding to boost spending in key sectors such as health. Government spending on health in Papua Province in 2008 was 2.4 per cent of the total provincial budget, significantly below the level of national government expenditure on health (6.5%).¹³ The central government has made considerable additional financial resources available to the Papuan provinces to accelerate development though these funds are mostly being used for infrastructure projects in preference to human services. There is a need for provincial and district government in the Papuan provinces to give considerably higher priority to health services and to use funds more effectively by improved prioritisation, planning, resource allocation, management and accountability.

Extensive development of health service infrastructure in the 1970s is reflected in the existence of 460 puskesmas across the two provinces. However, these facilities suffer from understaffing, underfunding, problems with medical supplies, poor planning and coordination, limited infrastructure and poor maintenance. A lack of staff housing makes it difficult to attract staff to remote areas. Access to primary health care is poor, especially in rural areas, where villages are scattered throughout mountainous and forested areas, with very limited transport infrastructure.

There is a significant sex industry in urban areas and the shipping ports of Papua and West Papua and also in more isolated parts, usually associated with natural resource extraction sites and infusion of development funds.

Table 1: Key demographic and other indicators: Papua and West Papua provinces

Key demographic and other indicators	Papua	West Papua
Total population	2.9 million	0.75 million
People living below the poverty line (national average 14%)	38%	36%
Human Development Index (national average 72)	65	69
Provincial ranking for Human Development Index	33	30
People who nominate Christianity as their religion	83%	61%
Districts	29	11

Source: Indonesia Census, 2010 and CHAI