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

Annex 17: Options for funding of the Centres of Excellence

The CoE are intended to be PHO facilities, located at the district level. AusAID funds will be used to pay for the CoE for the first three years, with the expectation that PHOs will take over the funding from the fourth year. CHAI considered options for funding mechanisms for the Coe. For non-salary operational costs it was decided that CHAI will directly pay for these costs, using AusAID funds, as this will avoid logistical obstacles that would slow program implementation.

For CoE staff salaries, the CHAI considered two options regarding how AusAID funds could be channelled to support the CoE:

1. 
   CHAI sub-grants to the two PHOs for CoE staff salaries with CoE staff being employed directly by the PHOs; or
   
2. 
   CHAI employs all CoE staff and pays for salaries directly from its AusAID funding.
   

There will be no difference in the level of salaries and benefits between the two options. If option one is adopted, it will be necessary to make a direct grant to the PHOs using CHAI’s MoU with the MoH as the umbrella. It would not be feasible to channel the grant to PHOs through the Regional Development Planning Agencies (BAPPEDA) as this would require going through the annual strategic planning process for approval which would be too time consuming, especially as REACH will commence operations in July 2012.

A17.1 Direct granting to PHOs option

CHAI would transfer money annually to the PHOs to cover CoE salaries. Technical Arrangements would be developed between CHAI and the two PHOs. The agreements would be approved by the provincial governors and the provincial Regional Development Planning Agencies. Accountability for proper use of the funds would rest with the PHOs. Funding would cover salaries, health insurance, social insurance and tax.

Benefits with this system are:

• 
  In addition to CoE staff being placed within the PHO structure they would be employees of the PHOs. This would reinforce PHO ownership of the CoE and may assist with realising the expectation that PHOs will take over CoE funding from year four.
  
• 
  PHOs will develop improved skills in budget and human resource management.
  
• 
  There would be no need to transfer employment of CoE staff from CHAI to the PHOs in year four. Any potential problems with such a transfer would be avoided.
  

Risks with this system are

• 
  Misuse of funds.
  

To mitigate this risk a finance officer would be seconded from CHAI to help the PHOs with financial management, monitoring and reporting. Control mechanisms would be developed and followed as standard operating procedures. CHAI’s Finance Manager together with the PHOs would develop a manual incorporating all control mechanisms before any money is released in the first quarter of year one. The manual will cover bank account arrangements, payments and funds transfers from the account, reporting, acquittals, invoicing, accounting policies and commitments, authorizations, roles and responsibilities, and conditions for ongoing support. A separate impress account would be used. Two signatures, one by CHAI and one by the PHOs, would be needed to transfer money.

The PHOs would regularly account for use of the funding to the Regional Development Planning Agency and the Ministry of Finance. CHAI would require the PHOs to submit financial reports every quarter.

A17.2 Direct employment by CHAI

CHAI would employ all CoE staff and place them in the CoE. The CoE would be PHO facilities, but the staff would be CHAI employees.

Benefits with this approach are:

• 
  CHAI will have strong fiduciary control over the use of funds.
  
• 
  Controls to mitigate against risks associated with using the government financial systems wold not be needed.
  
• 
  Implementation could occur more quickly.
  

Risks with this approach are:

• 
  The CoE staff may be viewed as CHAI project staff by other health facility staff. This could lead to unclear lines of authority and responsibility which could result in tension between health facility and CoE staff.
  
• 
  If CoE staff are seen as CHAI staff, the overall perception may be that the CoE is a CHAI facility rather than a PHO facility.
  
• 
  CoE staff may view themselves as CHAI staff, leading to different expectations and different affiliations and allegiances. This could make it difficult to absorb these staff into the PHOs in year four.
  
• 
  The cost of the CoE staff would be less apparent to the PHOs. This may make it more difficult in the future for this aspect of the program to be absorbed into PHO budgets.
  

Overall, the benefits of direct sub-granting to the PHOs outweigh the risks, especially as the risks can be satisfactorily mitigated. CHAI will only directly employ the CoE staff if a grant cannot be made because of political, structural, or time constraints. A third option would for CHAI to employ all CoE staff in the first year, with a sub-grant being made to PHOs to cover salaries for years two and three.

Annex 18: Bibliography

AusAID, An effective aid program for Australia: Making a real difference – Delivering real results. Canberra, 2011.

AusAID, AusAID Strategy for Assistance to Indonesia’s Papuan Provinces. Canberra, Undated.

AusAID, Australia Indonesia Partnership Country Strategy 2008-2013. Canberra, 2008.

AusAID, Australia Indonesia Partnership for Decentralisation Delivery Strategy 2010-2015. Jakarta, 2010.

AusAID, Australia Indonesia Partnership for Health System Strengthening 2011-2016. Program Design Document. Canberra, 2011.

AusAID, Intensifying the response: Halting the spread of HIV. Australia’s international development strategy for HIV. Canberra, 2009.

AusAID, Promoting practical sustainability. Canberra, 2000.

AusAID, Saving lives. Improving the health of the world’s poor. (AusAID’s Health Strategy). Canberra, 2011.

Cohen, Myron S, Ying Q Chen, Marybeth McCauley, et al. 2011. Prevention of HIV-1 infection with early antiretroviral therapy. The New England Journal of Medicine 365 (6) (August 11): 493-505. doi:10.1056/NEJMoa1105243.

Elmslie, J., West Papuan Demographic Transition and the 2010 Indonesian Census. CPACS Working Paper 11/1. University of Sydney. 2010.

Government of Indonesia and its Development Partners, Jakarta Commitment: Aid FOR Development Effectiveness. Indonesia’s Road Map to 2014. Jakarta, 2009.

Government of Indonesia, Global Fund Proposal – Round 10. Cross-cutting health systems strengthening interventions.

GRM, Papua Assessment. USAID/Indonesia. Jakarta, 2009.

Indonesian National AIDS Commission, National HIV and AIDS Strategy and Action Plan 2010-2014. Jakarta, 2010.

Kambodji, A., M. Linnan, and M. Kestari, Adult sexual behaviour and other risk behaviours in East Java. 1995, Yayasan Prospektiv: Surabaya.

Linnan, M., AIDS in Indonesia: The Coming Storm. 1992, USAID: Jakarta.

Miller P. Donovanosis: control or eradication? A situation review of donovanosis in Aboriginal and Torres Strait Islander populations in Australia. Office for Aboriginal and Torres Strait Islander Health, 2000.

Ministry of National Development Planning/National Development Planning Agency, Summary of the Roadmap to Accelerate Achievement of the MDGs in Indonesia. Jakarta, 2010.

Majid N, Bollen L, Morineau G, et al. Syphilis among female sex workers in Indonesia: need and opportunity for intervention. Sex Transm Infect. 2010 Oct; 86(5): 377-83.

Miller P, Otto B. Prevalence of sexually transmitted infections in selected populations in Indonesia. Indonesia HIV/AIDS and STI Prevention and Care Project. June 2001

Pontororing et al. The burden and treatment of HIV in tuberculosis patients in Papua Province, Indonesia: a prospective observational study, BMC Infectious Diseases 2010, 10:362

Provincial AIDS Commission, Papua and West Papua Provinces, Communications Plan for HIV and AIDS Prevention and Management in Tanah Papua. 2008.

Steen R, Chersich M, de Vlas SJ. Periodic presumptive treatment of curable sexually transmitted infections among sex workers: recent experience with implementation. Curr Opin Infect Dis. 2012 Feb;25(1):100-6.

Sutrisna A, Soebjakto O, Wignall FS, et al, Increasing resistance to ciprofloxacin and other antibiotics in Neisseria gonorrhoeae from East Java and Papua, Indonesia, in 2004 – implications for treatment. Int J STD AIDS. 2006 Dec;17(12):810-2.

Vogel IC, Richens J. Donovanosis in Dutch South New Guinea: History, evaluation of the epidemic and control. PNG Med J 1989: 32; 203-218.

World Bank, Making the New Indonesia Work for the Poor (Overview), Jakarta, 2006.

World Health Organisation, World Health Statistics 2010. Geneva, 2010.

Zachariah R, Ford N, Maher D, Bissell K, Van den Bergh R, van den Boogaard W, et al. Is operational research delivering the goods? The journey to success in low-income countries. The Lancet Infectious Diseases [Internet]. 2012 Feb [cited 2012 Apr 3];Available from: http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(11)70309-7/fulltext

Zachariah R, Harries AD, Ishikawa N, Rieder HL, Bissell K, Laserson K, et al. Operational research in low-income countries: what, why, and how? The Lancet Infectious Diseases. 2009 Nov;9(11):711–7.

1^ HIV-related is an inclusive term referring to HIV, TB, STIs and PMTCT.

2^ Tanah Papua refers to the ‘land of Papua’, including both Papua and West Papua provinces.

3^ MoH AIDS Sub Directorate, Indonesia 2011 IBBS.

4^ Puskesmas are primary health care centres and are the backbone of primary health care in Indonesia.

5^ WHO, World Health Statistics 2010.

6^ ibid.

7^ Puskesmas are primary health care facilities at the sub-district level. They are the backbone of primary health care in Indonesia.

8^ World Bank, Making the New Indonesia Work for the Poor (Overview), 2006

9^ Tanah Papua means the land of Papua and refers to both Papua and West Papua provinces.

10^ Elmslie, J., West Papuan Demographic Transition and the 2010 Indonesian Census. CPACS Working Paper 11/1. University of Sydney. 2010.

11^ GRM, Papua Assessment. USAID/Indonesia. p. 32.

12^ UNDP, Human Development Report, 2009.

13^ GRM, Papua Assessment. USAID/Indonesia. p. 32.

14^ This figure is commonly rounded up in national documents to 0.2 per cent.

15^ National AIDS Commission, National AIDS Strategy and Action Plan 2010-2014. p. 19.

16^ National AIDS Commission, National AIDS Strategy and Action Plan 2010-2014. p. 19.

17^ The difference in prevalence between ethnicities reached statistical significance at the 95% level only in West Papua.

18^ The rates of extramarital sex reported in the 2006 IBBS is far higher than that reported in the 2007 Demographic and Health survey. Just 2.8 per cent of currently married men in Papua and no currently married men in West Papua reported extramarital sex in the previous 12 months in the DHS survey, compared with 18.6 per cent and 11.2 per cent respectively in the far larger IBBS sample.

19^ These estimates differ from the official 2009 national estimates because they use more detailed district level prevalence (which raises the estimate slightly compared with the previous mid-value) and adjust for previous double counting (which lowers it). The official mid-level estimate for HIV infections among high risk populations and the general population in Papua in 2009 was 32,700.

20^ For the purposes of this proposal, HIV-related is an inclusive term referring to HIV, TB, STIs and PMTCT.

21^ Since there is no unique identifier system, these data will double or multiple-count anyone who has had more than one positive test, for example at different service providers or in different cities.

22^ A fuller description of the existing issues and challenges in STI control programming in Tanah Papua is provided in Annex 7.

23^ AusAID-CHAI REACH Design Mission, February 2012

24^ Posyandu are centres for pre and post natal health care and children under 5 years health care.

25^ AusAID, AIPHSS Program Design Document, p. 4.

26^ ibid.

27^ AusAID, Intensifying the response: Halting the spread of HIV. Australia’s international development strategy for HIV. 2009. p. 3 and 20.

28^ National AIDS Council, Papua New Guinea National HIV and AIDS Strategy 2011-2015. p. 13. An IBBS has not been conducted in PNG.

29^ AusAID, Saving lives. Improving the health of the world’s poor. p. 1. The contribution of REACH in Table 10 is in part based on indicative health indicators in Appendix A of Saving lives. The 4^th pillar – working with other sectors to address the causes of poor health – will not be addressed by REACH.

30^ ibid. p. 4.

31^ The current WHO recommendation is for treatment to commence at 350 CD4 cells.

32^ Cohen, Myron S, Ying Q Chen, Marybeth McCauley, et al. 2011. Prevention of HIV-1 infection with early antiretroviral therapy. The New England Journal of Medicine 365 (6) (August 11): 493-505. doi:10.1056/NEJMoa1105243.

33^ Cohen, Myron S, Ying Q Chen, Marybeth McCauley, et al. 2011. Prevention of HIV-1 infection with early antiretroviral therapy. The New England Journal of Medicine 365 (6) (August 11): 493-505. doi:10.1056/NEJMoa1105243.

34^ Monitoring and Evaluation presentation, TB-HIV, Jayapura, 13-16 July 2011.

35^ Pontororing, et al. The burden and treatment of HIV in tuberculosis patients in Papua Province, Indonesia: a prospective observational study. BMC Infectious Diseases 2010, 10:362

36^ Additional details on REACH’s approach to STI programming are in Annex 7.

37^ Steen R, Chersich M, de Vlas SJ. Periodic presumptive treatment of curable sexually transmitted infections among sex workers: recent experience with implementation. Curr Opin Infect Dis. 2012 Feb;25(1):100-6.

38^ Zachariah R, Ford N, Maher D, et al. Is operational research delivering the goods? The journey to success in low-income countries. The Lancet Infectious Diseases [Internet]. 2012 Feb [cited 2012 Apr 3];Available from: http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(11)70309-7/fulltext and Zachariah R, Harries AD, Ishikawa N, , et al. Operational research in low-income countries: what, why, and how? The Lancet Infectious Diseases. 2009 Nov;9(11):711–7.

39^ AusAID, Promoting practical sustainability. 2000. p. 1.

40^ Linnan, M., AIDS in Indonesia: The Coming Storm. 1992, USAID: Jakarta.

41^ Kambodji, A., M. Linnan, and M. Kestari, Adult sexual behaviour and other risk behaviours in East Java. 1995, Yayasan Prospektiv: Surabaya.

42^ The occupational groups included in surveillance have relatively low incomes and are more likely to buy from direct sex workers than from the more expensive sex workers working in bars and massage parlours. It would be more useful to compare HIV prevalence in sex workers and the men who say they buy sex from sex workers. These data have been collected with funding from GFATM, but the Ministry of Health’s AIDS Sub Directorate has declined to make this data available to partners for analysis.

43^ Inconsistencies in responses to behavioural questions in this data set suggest the results should be interpreted with caution.

44^ Nurholis Majid, Liesbeth Bollen, Guy Morineau, et. al. Syphilis among female sex workers in Indonesia: need and opportunity for intervention. Transm Infect 2010; 86:377-383 doi:10.1136/sti.2009.041269.

45^ The difference in prevalence between ethnicities reached statistical significance at the 95% level only in West Papua.

46^ The rates of extramarital sex reported in the 2006 IBBS is far higher than that reported in the 2007 Demographic and Health survey. Just 2.8 per cent of currently married men in Papua and no currently married men in West Papua reported extramarital sex in the previous 12 months in the DHS survey, compared with 18.6 per cent and 11.2 per cent respectively in the far larger IBBS sample.

47^ These estimates differ from the official 2009 national estimates because they use more detailed district level prevalence (which raises the estimate slightly compared with the previous mid-value) and adjust for previous double counting (which lowers it). The official mid-level estimate for HIV infections among high risk populations and the general population in Papua in 2009 was 32,700.

48^ Sutrisna A, Soebjakto O, Wignall FS et al. Increasing resistance to ciprofloxacin and other antibiotics in Neisseria gonorrhoeae from East Java and Papua, Indonesia, in 2004 – implications for treatment. Int J STD AIDS. 2006 Dec;17(12):810-2.

49^ Personal communication Steve Wignall, February 2011

50^ Data provided by MoH AIDS Sub Directorate, February 2011.

51^ Nurholis Majid, Liesbeth Bollen, Guy Morineau et al. Syphilis among female sex workers in Indonesia: need and opportunity for intervention. Transm Infect2010;86:377-383 doi:10.1136/sti.2009.041269

52^ Pedoman Penatalaksanakaan Infeksi Menular Seksual 2011, page 95.

53^ Engelkens HJ, Stolz E. A small yaws survey on the island of Sumatra, Indonesia. Acta Leiden 1992; 60(2):19-29.

54^ Vogel IC, Richens J. Donovanosis in Dutch South New Guinea: History, evaluation of the epidemic and control. PNG Med J 1989: 32; 203-218.

55^ Miller P. Donovanosis: control or eradication? A situation review of donovanosis in Aboriginal and Torres Strait Islander populations in Australia. Office for Aboriginal and Torres Strait Islander Health, 2000.

56^ REACH Design Mission, February 2012

57^ Majid N, Bollen L, Morineau G et al. Syphilis among female sex workers in Indonesia: need and opportunity for intervention. Sex Transm Infect. 2010 Oct; 86(5): 377-83.

58^ http://www.cenderawasihpos.com/index.php?mib=berita.detail&id=119

59^ Steen R, Chersich M, de Vlas SJ. Periodic presumptive treatment of curable sexually transmitted infections among sex workers: recent experience with implementation. Curr Opin Infect Dis. 2012 Feb;25(1):100-6.

60^ Miller P, Otto B. Prevalence of sexually transmitted infections in selected populations in Indonesia.

Indonesia HIV/AIDS and STI Prevention and Care Project. June 2001

61^ Dewan Perwakilan Rakyat Daerah (DPRD)

62^ Anggaran Pendapatan dan Belanja Daerah (APBD)

63^ National TB Control Program (NTP), TB-HIV National Action Plan 2011-2014

64^ Papua Dalam Angka (Papua in Numbers) 2010, BAPPEDA Papua Province and BPS – Statistics of Papua Province

65^ Treatment will be initiated in accordance with current MoH policy of <350 CD4 cells.

66^ All amounts are average yearly costs for 2012-2016

67^ There are no laboratory and diagnostic supplies in this budget. All these costs have been included in transition funding for the duration of the four year program. Procurement through the national supply chain system for additional laboratory commodities will be utilized as needed.

68^ Note that data managers at puskesmas are outside the control of REACH. All the facilities visited for development of this proposal had active record-keepers, but that may not be the case in all potential REACH sites.

69^ Environmental Management Guide for Australia’s Aid Program

70^ Stockholm Convention on Persisting Organic Pollutants

71^ World Health Organization. Policy Paper. Safe health-care waste management.