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

1.6 Rationale for AusAID’s involvement

There is a strong degree of coherence between this funding proposal for REACH and AusAID’s overarching aid policy, sector strategies and the Indonesia Country Strategy. REACH will be in alignment with AusAID’s overarching policy statement An effective aid program for Australia: Making a real difference – Delivering real results and Australia’s International HIV Strategy. Table 7 sets out the key areas of alignment.

Australia’s international development strategy for HIV states that given Australia’s comparative advantage in prevention programming, strategic priorities and gaps in donor support, AusAID will not usually provide direct assistance for treatment and care. An exception is the Pacific region, including Papua New Guinea, where Australia is a major donor and does support comprehensive responses, including treatment and care.²⁷ A similar rationale applies in the Papuan provinces of Indonesia where AusAID is a major donor and there are no other donors currently in a position to support comprehensive HIV CST programming. The low level generalised epidemic in the Papuan provinces (2.4%: IBBS, 2006) is similar but larger than that of PNG, where HIV prevalence is estimated to be 0.9 per cent.²⁸ These levels of prevalence in both PNG and Indonesia’s Papuan provinces point to the need for comprehensive HIV programming.

Table 7: Alignment between AusAID’s international development objectives and REACH

AusAID development objectives	Contribution by REACH
Saving lives is one of the five strategic goals of Australia’s aid program. A key mechanism of achieving this goal is improving public health for poor people (Making a real difference – delivering real results)	REACH will work through public services to increase the number of people in the Papuan provinces on effective HIV treatment and related care which will reduce HIV-related morbidity and mortality and may contribute to reduced transmission risk
A ‘value for money’ perspective—one that balances effectiveness, efficiency and economy in decision-making—will drive improvements across the aid program. This focuses on results and returns for poor people, rather than just input costs. (Making a real difference – delivering real results)	REACH will focus on measurement of results to determine the effectiveness and efficiency of the program. Measurement of cost-effectiveness is a priority area for operational research, subject to partner agreement.
Working in partnership with government and within government systems (Paris Declaration, Accra Agenda for Action and Jakarta Commitment)	REACH is a technical assistance program fully aligned with the MoH’s Care, Support and Treatment program. It will support the delivery of services by technical assistance to government health services
Integration of HIV CST services into primary health care (Australia’s International HIV Strategy)	REACH will support decentralisation of HIV CST by developing the capacity of puskesmas linked to referral hospitals
Stronger linkages between HIV services and other health services (Australia’s International HIV Strategy)	REACH will take an integrated approach to service delivery incorporating HIV, TB, STIs and PMTCT in hospitals and puskesmas
Strengthening coordination and capacity to scale up HIV responses to overcome barriers to universal access, including strengthening of health systems and improving workforce development and health financing systems (Australia’s International HIV Strategy)	In partnership with AIPD, REACH will support provincial and district health offices in planning and mobilising funding to scale up HIV CST. The development of the capacity of puskesmas to provide HIV and related CST will strengthen the overall primary health capacity of puskesmas. Training and mentoring of health care workers (HCWs) will result in a more skilled workforce
Building the evidence base for an effective HIV response (Australia’s International HIV Strategy)	REACH includes an operational research component and strong monitoring focus that will be used for program improvement and to feed into evidence informed national and provincial policy and programming development

The design of REACH outlined in this funding proposal is also consistent with AusAID’s health strategy (Saving Lives), with direct alignment with five of the six pillars for AusAID’s investment in health (see Table 8²⁹).

Saving Lives also provides that in fragile or humanitarian situations, Australia may provide targeted support, including HIV programming, to improve specific health outcomes among poor and vulnerable groups.³⁰ However, the rationale for AusAID funding of REACH is not as a traditional donor in an aid dependent environment. Rather, REACH is a partnership with Indonesia which seeks to ensure that government funding is used effectively to secure positive health outcomes for PLHA, while contributing to the development of stronger primary health care services overall. Different levels of government will be responsible for meeting particular components of service delivery costs, (excepting some start up equipment and infrastructure costs), with AusAID funding being used primarily for technical assistance, training and mentoring.

Table 8: Correlation between the six pillars for AusAID investment in health and REACH

AusAID’s six pillars for investment in health	Contribution by REACH
1. Supporting partner countries to deliver more and better quality health services for poor and vulnerable people	REACH will increase the number of people on HIV-related treatment, increase the number of trained GoI HCWs in primary health care, and reduce stock outs of HIV-related medicines.
2. Closing the funding gap to provide essential health services for all	The national and district governments will be responsible for financing of service delivery costs from program commencement. REACH will work with provincial and local governments to address planning and financing, with provinces taking over funding for technical assistance (the Centres of Excellence) from year four.
3. Empowering poor and vulnerable people to improve their health	REACH will collaborate with other donor programs and CSOs to increase supply of and demand for HIV testing and treatment and to address HIV-related stigma and discrimination
5. Reducing the impact of global health threats, particularly in Asia and the Pacific	By increasing the number of people on effective HIV-related treatment, REACH will reduce HIV-related morbidity and mortality in the Papuan provinces and contribute to reduced transmission risk
6. Maximising the impact of Australia’s total health ODA investment in partner countries	REACH is based on international best practice (demonstrated efficacy of providing effective HIV-related treatment through primary health care in resource poor settings). Operational research and monitoring will be used to improve programming at service delivery and national levels.

Pillar 2, ‘Investing in People’, in the Australia Indonesia Partnership Country Strategy 2008-2013, (AIP), states that Australia will work with Indonesia to deliver better health access and systems. HIV prevention and care, especially in the Papuan provinces, is one of the AIP’s high priority areas. REACH is consistent with the AIP health access and systems objective and priority areas. Modalities for support outlined in the AIP are technical assistance, direct funding of key Indonesian programs, trialling innovative pilot activities in support of GoI programs, and working with local government to implement policies and develop long-term capacity. The REACH funding proposal is consistent with these approaches.

Papua and West Papua are two of Australia’s five focus provinces for development assistance in Indonesia. The AIP identifies the need for AusAID engagement at national as well as provincial levels, with national activities informing work at provincial and district level, and practical support at these levels feeding into national level engagement. This dual national-provincial focus is reflected in this proposal. The proposal is consistent with AusAID’s Strategy for Assistance to Indonesia’s Papuan Provinces, particularly in regard to partnership with the GoI at national and provincial levels and a focus on improved service delivery in key sectors such as health. The strategy identifies HIV as a priority area, including expansion of HIV CST programming, particularly in the highlands.

In summary, the design of this REACH funding proposal is consistent with AusAID’s approach to development of its health portfolio in Indonesia in that it:

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  is evidence based
  
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  will be supporting the government to improve the effectiveness of its national program, with a focus on decentralisation
  
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  will be implemented through a partnership with the GoI at national, provincial and district levels
  
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  will result in increased GoI investment in HIV CST at the level of primary care
  
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  is focussed on improving access to primary care for poor and vulnerable people
  
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  has clearly defined outcomes meaning measurable results will be available
  
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  is coherent with and complementary to other AusAID programs
  
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  seeks to leverage off the work of other development partners through identification of synergies and collaboration; and
  
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  reflects the priority AusAID is placing on development assistance to the Papuan provinces.