Rapidly Expanding Access to Care for hiv in Tanah Papua (reach) 2012 2016
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- Bu səhifədəki naviqasiya:
- 2.5 Component 1: Care, support and treatment in Tanah Papua
- Sub-Component 1.1: Antiretroviral therapy
- Will the benefits last
- Sub-Component 1.2: Tuberculosis
- Sub-Component 1.3: Sexually transmitted infections 36
- Sub-Component 1.4: Laboratories
- Sub-Component 1.6: Support for effective decentralised systems
- Sub-Component 1.7: Medical waste management
- Why are we doing this Medical waste is poorly managed in Papua and West Papua with consequent health and safety and environmental problems. How will we do it
- Programmatic needs for Papua and West Papua post 2016
- Sexually transmitted infections
2.3 Program logicThe program logic is presented in Figure 1 on the next page. Figure 1: REACH program logic 2.4 Guiding principlesREACH will be guided by the following seven key principles:
2.5 Component 1: Care, support and treatment in Tanah Papua
Sub-Component 1.1: Antiretroviral therapy
Why are we doing this?There are an estimated 38,000 plus individuals living with HIV in Papua and West Papua. Approximately one-third are likely to be eligible for ART: some 12,500 plus people. Currently, only 1,879 are receiving ARVs and another 1,300 of these are on cotrimoxazole as the first step to ART. While HIV testing rates are currently low, experience from CHAI Phase II suggests that where HIV testing is actively promoted through PITC, uptake is high. The other most prominent obstacle to treatment is accessibility: services are currently concentrated in cities. Legitimate concerns about drop-out and poor drug adherence means some service providers are reluctant to start people on ARVs. However, an overemphasis on these concerns has become an obstacle for getting more people on treatment. Making HIV medication available nearer to people's homes will reduce some of these barriers. ARVs will keep adults with young families alive and economically active. But they have a secondary benefit too. When they are taken consistently and where other STIs are controlled, ART significantly reduces the likelihood that an infected person will pass on HIV.33 Better treatment in Papua could therefore mean less ongoing spread of HIV.
How will we do it?REACH will first review and compile all current training materials for CST, VCT, PITC, TB and HIV management, PMTCT, and integrated management of adult illness (IMAI) and create efficiencies by consolidation to reduce training time. Provincial and district staff selected from hospitals and puskesmas will be trained as trainers so that the province and districts can train locally and are not dependent on Jakarta to send training teams for new staff. Draft SOPs for all aspects of care and treatment will be reviewed and adapted for each type of treatment site. CHAI’s SCM team and the AIDS Sub Directorate will review the supply chain needs of the expanded ART program as well as the need for TB and STI laboratory and treatment commodities and ensure that there are appropriate projections, budgets and logistic arrangements in place. Current data collection systems will be reviewed with the AIDS Sub Directorate to create a leaner system which only collects data that will be used. Opportunities for consolidation of databases and automation of reporting will be identified. REACH will establish seven new CoE for HIV, TB and STI care and PMTCT that will serve as referral centres for complicated cases in addition to the existing two CoE in Jayapura and Wamena. The CoE team will be additional to the normal hospital staffing contingent and will include doctors, nurses, midwives, laboratory technicians, data management specialists, a communication specialist and an administrator. Compared to CHAI Phase II, the CoE staffing has been strengthened by inclusion of positions for laboratory, data management and communication. Priority tasks for this team will be to develop the hospital staff where the CoE is located as ‘experts’ and improving clinical, laboratory and data management systems and establishing patient friendly management systems. The CoE mentoring function will allow the immediate adaptation of national policy changes into local policy. CoE will be a PHO owned facility, but working at the district level. Selection criteria for the CoE and puskesmas are in Annex 6 along with a map showing locations. The new CoE will be established progressively over an 18 month period. Table 19 in Annex 9 provides a timeline for the roll-out of the CoE and REACH supported hospitals and puskesmas. Special areas of focus for hospitals based care will be:
CHAI in collaboration with PHOs and DHOs will conduct a puskesmas facilities assessment to develop a prioritized list of puskesmas where ART will be initiated. Training needs for both hospital and puskesmas staff will be identified (VCT, CST, PITC, PMTCT, IMAI, TB-HIV, STI). Training will occur progressively, linked to the roll-out schedule for inclusion of new puskesmas. The focus issues addressed at hospitals/CoE sites (see list above) will also be addressed at puskesmas but at a service level appropriate to a puskesmas. As puskesmas come on-line, the CoE teams and PHOs/DHOs will make regular joint mentoring and monitoring visits. Will it work?Where the CoE model has been piloted to date, there has been remarkable success with dramatic increases in the number of people on treatment. Still there are many challenges to increasing access to ART. HIV testing needs to increase and this needs to happen close to where people live. Effective communication, assured confidentiality, and easy access to testing and treatment will be needed. Patient friendly, responsive health systems with quality laboratories, adequate drug supply and necessary community support will need to be in place. Missteps will occur and damage control and corrective action will be needed. Staff motivation will be key and CoE and DHO teams will need to provide encouragement and recognition of success. How will we know?This proposal prioritises strong monitoring and analysis as a core part of the REACH design, (see section 3.4). Indicators will be finalised in the first quarter of REACH when the monitoring framework is developed in consultation with the AIDS Sub Directorate. Indicative indicators include:
Will the benefits last?Sustainability will be enhanced by establishing provincial, and potentially district, training teams that provide training for rotating staff. SOPs will ensure consistency. Provincial budgets will include funds for CoE and continued training, mentoring and monitoring from year four. The continuity of the program over the long term will depend on provincial governments taking over the funding for CoE. This will be difficult to achieve, not least because there is currently no operational agreement between provincial and district governments about who should pay for what. REACH anticipates this hurdle, and will be working with AIPD and other partners from the start to promote GoI assumption of CoE financing by year four of the program. Sub-Component 1.2: Tuberculosis
Why are we doing this?TB is the most common opportunistic infection among those infected with HIV and the most common cause of death among HIV patients. HIV prevalence among new TB patients in Tanah Papua averages 13%34,35. TB among HIV patients varies from 9-100% depending on the site where the examination is done and the stage of HIV disease. Activities under this sub-component will promote adherence to TB treatment and result in a reduction in cases of TB drug resistance. Only 24 of 38 hospitals and 153 of 460 puskesmas in Tanah Papua are able to provide TB diagnostics and care. Not all VCT sites provide TB diagnostics and treatment and not all TB treatment facilities can provide HIV testing. To reduce morbidity and mortality of TB-HIV co-infected patients, both HIV and TB diagnostic and treatment facilities need to be co-located and easily accessible. Early initiation of ART in TB-HIV co-infected patients reduces death rates, preserves failing immune systems and enhances TB cure rates if patients are adherent to both TB and HIV medications. TB diagnosis can be difficult in patients with low bacterial counts in their sputum despite severe disease. Some clinicians are unwilling to start treatment if sputum is negative. Laboratory skills need to be sharpened, equipment in working order and external quality control in place in order to make an accurate diagnoses. In some circumstances, molecular techniques are necessary to confirm a diagnosis in highly suspect cases.
How will we do it?During preliminary assessments of hospitals and puskesmas to be part of REACH, we will check SOPs and records for TB screening. This will include the extent to which screening of TB patients for HIV and HIV patients for TB is occurring, sputum positivity rates, treatment initiation rates, use of directly observed treatment short course therapy (DOTS), adherence, sputum clearance rates, cure rates and TB therapy completion rates. Staff capacity will be reviewed and training plans developed. Training materials prepared for the TB-HIV program will be used. REACH will collaborate with the USAID funded Community Empowerment of People against Tuberculosis (CEPAT) in Indonesia program which will work with churches, mosques and NGOs to support patients in treatment completion and advocate for more support for TB programming. The work of CoE in relation to TB are outlined above in sub-component 1.1. Special attention will be paid to laboratory staffing and facilities, (see sub-component 1.4 below). Will it work?As with ART, TB diagnosis and treatment is fraught with many challenges. Like ART, patients must be tested close to where they live in patient friendly, easy to access, professional facilities where they are assured of confidentiality and easy access to treatment if tests are positive. Results must be reproducible from high quality laboratories, adequate drug supply must be assured and necessary community support will need to be in place. Adherence rates must be high to assure a cure and reduce the possibility of resistance developing. Staff motivation will be key and CoE, PHO and DHO teams will need to provide encouragement and recognition of success. Similar one-stop facilities set up and managed by members of the CHAI team in Timika achieved high sputum conversion rates, with 85 per cent cure and medication completion rates. With CoE support, mentoring and monitoring, similar results should be achievable. How will we know?REACH results will be measured by NTP program indicators:
Will the benefits last?Part of the CEPAT project is focused on advocacy to district and provincial decision makers regarding support for sustained TB and TB-HIV programming. REACH will also work with Kinerja and AIPD to ensure both financing and leadership for TB control. Sustainability will be further enhanced through training for rotating and new staff. Routine monitoring will highlight successes and correct under performance. Sub-Component 1.3: Sexually transmitted infections36
How will we do it?To reduce the prevalence of STIs in the Papuan provinces we need to use a combination of strategies; those that rely on laboratory diagnosis and those that rely on presumptive diagnosis. The key components of these strategies are outlined in Box 2 in Annex 7. We need to use most of the STI control strategies in the toolbox. Countries with good access to high quality laboratory diagnosis can afford to focus on improving access to services. Countries with weaker laboratory systems, including Indonesia, need to include strategies that rely on presumptive diagnosis. Two broad strategic approaches are needed in the Papuan provinces:
Targeted STI interventions for high prevalence populations Targeted STI interventions based on presumptive diagnosis are designed as transition strategies to achieve rapid reductions in STI prevalence in high prevalence populations that have poor uptake of services. The plan over the longer term is to shift to strategies that rely on laboratory diagnosis as prevalence drops and laboratory capacity improves. The emphasis in targeted STI interventions is on the population rather than the individual. The challenge is to achieve high population participation rates rather than individual demand for services. The interventions are not based on waiting for individuals to decide to go to a clinic for a check-up. For example, health staff need to go to brothels with a supply of doxycycline and cefixime for PPT and condoms. NGO partners (for example, SUM sub-grantees) can map street sex work sites and work with health staff to provide PPT medications every three months. The puskesmas and district hospitals , in partnership with local NGOs, will have a key role to play in the scale-up of targeted STI interventions for high prevalence populations including presumptive treatment on arrival, three monthly PPT, regular syphilis screening and PPT for sex workers’ boyfriends and husbands. REACH will work with staff at selected puskesmas to build their ability to implement targeted STI interventions with FSWs, MSM and waria. This will be in partnership with NGOs that have existing relationships with FSWs, waria, and especially with harder to reach groups such as MSM and street-based sex workers . Specific attention will be given to providing STI diagnosis and treatment for HIV-positive FSWs. Table 17 in Annex 7 lists the recommended key strategies for each high prevalence population. Additional background is given in Annex 7 on four of the recommended strategies – PPT, syphilis screening, enhanced syndromic management and use of surveillance activities for STI control. Improve the quality of STI diagnosis and treatment There are three reasons why it is important to improve the quality of STI diagnosis and treatment at the level of the puskesmas and district hospital:
Key activities will be:
Will it work?The MoH looks to WHO for leadership on STI technical issues. WHO support will be needed to move ahead with these strategies. The success of targeted STI interventions in high prevalence populations depends on how well the strategies are implemented. PPT works best:
The effectiveness of PPT will be undermined if FSWs have low condom use rates with clients and do not use condoms at all with their boyfriends. Similarly, the effectiveness of PPT will be undermined if the boyfriends of FSWs are not treated as well. How will we know?The IBBS rounds will provide prevalence data for syphilis, gonorrhoea and chlamydia. CoE and REACH staff will monitor the standard of STI care provided by health services and provide mentoring during regular visits. STI-related policy changes, such as additions to the EDL, can be easily measured. The REACH monitoring system will record key information for each puskesmas. Examples include:
The monitoring system will use clinic and quality control records to report on:
Will the benefits last?The benefits of changes to the national EDL and guidelines will last. Accurate syphilis diagnosis and effective treatment will require ongoing low cost support from districts. The best sustainability strategy for STI diagnosis and treatment for MSM and waria is increased demand from those communities for the services. The turnover of FSWs in the Papuan provinces is high. This means that programmes must work consistently to maintain benefits. REACH has chosen to work principally with government rather than NGO clinics for MARPs in the expectation that they are more likely to continue support for programming when external funding is not available. Sub-Component 1.4: Laboratories
Why are we doing this?HIV, TB and STI diagnosis and treatment are all dependent on accurate, reproducible laboratory results. A false negative result may lead to unprotected sex and infection of a partner and delayed treatment. A false positive result may lead to unnecessary stress and worry, potentially harmful medications and discrimination. No diagnosis of HIV or TB can happen without a laboratory. STIs can be managed by syndromic treatment but often with over treatment, and with asymptomatic infections, most often among women, going untreated. Many puskesmas in REACH targeted areas do not have laboratory staff or staff trained to perform HIV, TB and STI diagnostics. Facilities are also often lacking. A functioning microscope is necessary for TB and STI diagnosis and syphilis testing needs a rotator that requires electrical power. Refrigeration may be necessary for some reagents and a constant supply of laboratory reagents and consumables will be necessary to safely and accurately conduct testing. How will we do it?During REACH’s preliminary assessment of hospitals and puskesmas, laboratory capacity and quality will be assessed by CoE laboratory staff and Provincial Health Laboratory (PHL/BLK) staff. Staff capacity will be reviewed and training plans developed. Training materials used for HIV, TB and STI will be reviewed and laboratory trainers prepared. Draft SOPs will be developed for all laboratory procedures, shipment of specimens, data management, record keeping, external quality assurance (EQA), occupational safety and health, waste management, and supply chain management, including inventories and forecasting. CoE laboratory staff will make periodic visits to ensure SOPs are being followed. Initially, REACH will target puskesmas that already have laboratory technicians while it lobbies PHOs and DHOs to provide laboratory technicians to other priority puskesmas. HIV and syphilis testing can be task shifted to nurses. Microscopy for TB and STI requires significant experience both in specimen preparation and use of a microscope. Task shifting for these tests may be attempted with some nurses on a case by case basis. CoE sites will have CD4 testing, both fixed and mobile. Blood samples for CD4 testing must be examined within 24 hours. It is much more practical to bring a portable CD4 machine to the field to test a group of patients rather than attempt to send patients or blood to distant laboratories. Allere PIMA point of care portable CD4 machines have proved themselves durable, and produce reliable results. They are used extensively by CHAI in PNG with good results and will be used by REACH. Conventional TB sputum exams can be insensitive if TB bacterial load in sputum is low. Making an early diagnosis of TB in HIV infected patients is critical. X-ray examinations that might provide indirect evidence of TB infection are not available in puskesmas. Molecular polymerase chain reaction (PCR) testing for TB DNA has been simplified through new technology. The GeneXpert performs PCR assays which are significantly more sensitive for TB detection than conventional light microscopy. It is battery operated, with self-contained cartridges for safe specimen management. The GeneXpert has revolutionized resistance testing as it also provides information on whether the organism is resistant to rifampin, one of the primary antibiotics used in TB treatment. GeneXpert equipment will be placed in each of the CoE and suspect negative samples from conventional microscopy will be re-examined in CoE laboratories. Will it work?The technology is available to ensure accurate and reliable laboratory results. To employ that technology, space, equipment, reagents, consumables, electricity, water and, above all, trained and dedicated staff will be needed to make accurate laboratory diagnoses. Facilities improvements should ensure space, power and water, (see sub-component 1.5 below). Advocacy around budgets and staffing and SCM work (see sub-component 1.6 and section 2.6 below) will be essential. Equipment will be purchased with three year warranties and maintenance plans will be developed. REACH will work with PHOs and DHOs to ensure long term maintenance plans are developed and that the capacity exists to implement these plans. How will we know?The key indicator will be the number of health facilities with laboratories providing comprehensive HIV, TB and STI services. Monitoring visits will confirm adherence to SOPs. EQA will confirm the accuracy of HIV and STI testing. GeneXpert results will confirm negative and positive conventional microscopy for TB. Will the benefits last?Results of laboratory strengthening will be sustained if advocacy for program support, (see sub-component 1.6 below), is successful in ensuring sufficient budget, necessary staffing and reduced rotation of key laboratory personnel. Sub-Component 1.5: Infrastructure
Why are we doing this?Key infrastructure required to enable provision of effective health services includes water, electricity, sanitation, safe medical waste disposal, information technology systems, communication and adequate housing for staff at remote sites. Water, electricity and staff housing are usually already available in urban health facilities but are commonly not available in rural and remote puskesmas. There is a need to upgrade sanitation and medical waste disposal at all health facilities, including hospitals. Transmission of data to CoE, PHOs and DHOs will be optimized by sites using hard copies, SMS, email, single side band radio or telephone. Laptops, printers and print supplies, UPS, solar charger and data collection software will be provided to each site. In rural and remote areas, staff housing is required to attract and retain staff to work in puskesmas. All aspects of infrastructure development will strengthen the capacity of health facilities to provide both HIV-related and non-HIV services. How will we do it?It will be necessary to undertake a sub-design to quantify the type and extent of infrastructure needs as the team developing this proposal did not have the expertise nor time to do this. Specialists in infrastructure will be engaged by AusAID to conduct the sub-design, in close consultation with CHAI. A national survey of all health facilities has recently been completed by the MoH’s NIHRD and the results may be available shortly. Data from the survey will be used for the REACH infrastructure sub-design. Puskesmas that were surveyed will need to be visited for structural assessments and identification of local suppliers and labourers/contractors that can implement facilities improvements. Twenty-eight active puskesmas were not included in the NIHRD survey and will need a more comprehensive assessment. Prior to the infrastructure sub-design, CHAI will identify the proposed hospital and puskesmas sites that will be involved in the REACH program, using the selection criteria outlined in Annex 6. The infrastructure sub-design will:
REACH will cover 120 puskesmas. In keeping with the flexible adaptive management approach to implementation, it may prove possible to extend the program to additional puskesmas as the program rolls out. The infrastructure sub-design should incorporate flexibility; with the option of additional infrastructure development should funding be available. However, the initial assessment of infrastructure needs will be confined to 120 puskesmas. In the interests of promoting mutual obligation and responsibility, it would be desirable to cost-share the infrastructure component with district governments. However, given the lead times for development of district budgets and the scope of REACH (21 districts) it is not feasible to reach agreement with a large number of districts within the timelines for the first wave of facilities improvements. However, district investment may be able to be leveraged for infrastructure development in the second and third years. The infrastructure sub-design should incorporate clear plans for DHOs to be responsible for operational and maintenance costs and seek the agreement of districts for this to be their responsibility. To ensure expert technical oversight of the infrastructure component of REACH, it is proposed that the Infrastructure Unit in AusAID, Indonesia be involved in two ways:
These functions most appropriately rest with the Infrastructure Unit, given their technical expertise, rather than the Health Unit. Will it work?There may be significant delays in the release of data from the NIHRD survey of health facilities. If this is the case, AusAID and CHAI will negotiate with the MoH for access to the data prior to its broader release. If access is not possible it will be necessary for the infrastructure sub-design to undertake more comprehensive assessments when it visits sites. Completion of even the early stages of infrastructure work will not occur until well after REACH has commenced implementation. However, CoE will come on-line over 18 months and the first puskesmas to be involved will primarily be those in urban areas where there will be a lesser need for infrastructure development. CHAI Phase II has demonstrated that it is feasible to decentralise HIV CST to puskesmas lacking in key areas of infrastructure, although this limits their capacity to provide some services such as those laboratory tests which require electricity or specialized equipment. As the infrastructure work is completed, the range of services provided by puskesmas will be enhanced. Some puskesmas, particularly those in rural and remote areas, will only start to provide HIV CST services in years 2 – 4 which should allow sufficient time for infrastructure development. The sub-design will identify infrastructure needs for specific puskesmas. As REACH is rolled out puskesmas selection may change because of emerging factors such as emerging security concerns or lack of sufficient staffing. If different puskesmas are chosen for inclusion in REACH, their infrastructure needs are likely to be similar to those of puskesmas dropped from expansion plans, so this should not have a significant budgetary effect. Prior to any infrastructure work taking place in puskesmas not yet part of REACH, CHAI will update its assessment that inclusion of that facility in REACH remains viable.
How will we know?AusAID’s Infrastructure Unit or its contractor will monitor design and construction to ensure quality. CHAI and CoE staff will monitor maintenance planning, budgeting and implementation of facilities maintenance. This will be included in the checklist for routine monitoring visits, as well as in regular reporting forms used in the monitoring system. Will the benefits last?Sustainability will be enhanced by choosing infrastructure solutions with feasible maintenance requirements in rural and remote areas, development of anti-theft strategies and realistic maintenance plans with a requirement for budget allocation by DHOs for facilities monitoring and maintenance. Problems with maintenance will be addressed through technical advice and advocacy to DHOs. Sub-Component 1.6: Support for effective decentralised systems
Why are we doing this?Despite national and local policies for universal access to HIV CST, access in Tanah Papua primarily exists only in coastal urban areas in a limited number of hospitals and even more limited number of puskesmas. DHOs have neither focused on nor invested in the expansion of HIV CST. This may be due a lack of understanding of the long-term financial burden that will arise if little is done now. Decentralisation has complicated the picture. There are a number of different funding streams for health services; some money comes from Jakarta, often (but not always) routed through vertical programs. ARVs and some HIV-related laboratory supplies are funded centrally but systems are not responsive to rapid scale up. Special autonomy funds are routed through the province, with an earmark for health. A portion remains at the provincial level, but the bulk is passed on to districts who also allocate funds to health. A number of different health insurance schemes are provided from different sources for different levels of care. The bureaucracy around reimbursement for these schemes is highly variable and not always patient friendly. Understanding at the district level of whose responsibility health care is under decentralization may be limited. District Governors (Bupatis) and DHOs need to understand their care obligations, and should have CST targets based on MDGs, and be held accountable by the Ministry of Home Affairs. There is no shortage of government funds in the Papuan provinces. The key issues are the low priority accorded to health sector funding, limited capacity for planning and budgeting, and the efficiency and effectiveness of how money is spent. What is needed is advocacy around funding for the health sector and more efficient and effective planning, budgeting, monitoring and accountability. This includes clarification of budgets and lines of responsibility, both between levels of government, and between major players in health within provinces and districts. Procedures need to be worked out so that they are transparent and simplify access to care for patients. Mechanisms for local emergency budgetary responses need to be in place in the event that central systems fail. Achieving progress in this area would have important benefits for the health system as a whole. In the interest of sustainability and replication of the decentralised model in other parts of Tanah Papua beyond the scope of REACH, it will be critical to develop a financing model that is lean and uses funds efficiently.
How will we do it?REACH will assign a government relations officer to be placed in the PHOs or Regional Development Planning Agencies (BAPPEDA) in Papua and West Papua. These officers will work with provincial and district governments and AIPD and Kinerja to develop health financing plans that include prevention and care for HIV, TB and STIs. This will include the operational cost of scaling up these services and funding by PHOs of CoE from year four. The plans will explore the possibility of multiple districts contributing to the cost of the CoE that supports their puskesmas. Plans will be developed in Jayapura and Jayawijaya districts first where CHAI has strong working relationships and a better understanding of existing policies and procedures. These plans will serve as working models for other districts in the future. The government relations officers will also work with provincial governments and AIPD and Kinerja to:
CoE mentors will take new national policies and work with PHOs, DHOs and health facilities for local adaptation and implementation, as was done successfully in Jayapura and Jayawijaya by CHAI Phase II with the new PITC policy. Will it work?Senior provincial and district government officials consulted during the development of this proposal clearly understood that REACH is designed around the principle of mutual responsibility, with governments being responsible for the cost of service delivery and funding for CoE from year four. In principle commitments were received. A clear health financing strategy at the provincial and district level with transparent public policies for access to care will be reassuring to facilities responsible for service delivery. Early discussions with the Regional Development Planning Agencies and PHOs in Papua and West Papua indicate a commitment to resolve the confusion around payments, continuity of service for chronic illness and quality assurance. AIPD and Kinerja have extensive experience in working with local governments on decentralization and will support REACH’s technical efforts to ensure financing for long term sustainability and health service quality assurance. How will we know?The monitoring system will pioneer the use of relationship mapping as a tool for assessing the success of efforts to strengthen, streamline and clarify relationships between different actors in the health system. This tool can also be used to map financial flows. Concrete outcomes we expect are 1) provincial and district health financing strategies and plans that include care costs, personnel, mentoring and monitoring; 2) actual flow of funds to PHOs, DHOs and to health facilities; 3) clear and widely publicised policies for patients on costs for services; and 4) local policies, rapidly and appropriately adapted from the national level. Will the benefits last?Inclusion of the cost of HIV-related CST into the annual budget planning cycle will provide the greatest assurance that the programs will be sustained. However this is subject to the political cycle. Provincial elections are overdue in Papua and district elections are due in several areas. Progress made in this area will be most secure for the term in office of the head of local government under whom commitments were made. Sub-Component 1.7: Medical waste management
Why are we doing this?Medical waste is poorly managed in Papua and West Papua with consequent health and safety and environmental problems. How will we do it?
Will it work?There is minimal awareness or interest in district hospitals and puskesmas in the potential occupational health and environmental risks and consequences associated with poor management of infectious medical waste. Medical waste is usually incinerated. There is no awareness of the consequences of persisting organic pollutants. REACH will need to create this awareness and change the existing waste management culture. Based on global experience, approaching MWM as occupational health and safety issue is the most successful in building health staff commitment. How will we know?The CoE will supervise transition to non-incineration technology and REACH will monitor medical waste handling and disposal in accordance with SOPs. Will the benefits last?The infrastructure sub-design will draw on international MWM technical expertise to identify non-incineration technologies that are appropriate for the conditions in urban-based, rural and isolated health facilities in including electricity, water and maintenance requirements to maximize sustainability. REACH will work with DHOs and PHOs to ensure commitments for maintenance. Community empowermentThe Catholic Dioceses of Jayapura, Timika and Sorong-Manokwari and the protestant Christian Gospel Church of Tanah Papua have submitted a community empowerment funding proposal to USAID, called Community Empowerment of People Against Tuberculosis (CEPAT), which is designed to complement REACH. The proposal seeks to use the broad reach of the churches to mobilise communities to support better detection of HIV, STI and TB and TB-HIV cases, promote treatment and to advocate for better services. The two components of this program are:
A copy of this proposal concept is in Annex 8. The outcome of the funding proposal should be known in the near future. On the assumption the proposal will be successful, community mobilisation and support activities have not been included in this REACH funding proposal. However, these activities are essential to the success of REACH. Should USAID funding not be available, CHAI will seek funding for these activities from AusAID. REACH will also work with CSOs supported by HCPI and SUM I and II. REACH will seek to incorporate gender-related issues into all aspects of the CST sub-component. As noted in section 1.3.2, men are more likely to be HIV infected than women, particularly in West Papua, although it is likely that this differential will be eroded over time. However, women appear to have better access to HIV testing, with a higher number of men being diagnosed only when they have developed HIV-related symptoms. Increasing access to HIV testing for all people will be a priority for REACH, and this will particularly be the case for men. REACH will be guided by an understanding of the unequal place of women in Papuan society. For example, gender based violence, including rape, increases the vulnerability of women to HIV infection; males may determine when and how women are able to access health services; and women who are diagnosed as HIV infected through PMTCT may be reluctant to inform their male partners of the result for fear of the consequences. As part of the progressive development of the REACH model, CHAI will consult with males and females on gender-related aspects of the program. Training provided by CHAI and CoE will incorporate an understanding of gender-related issues and how this may impact on access to services. Health staff at hospitals and puskesmas will also be trained in basic trauma counselling skills to deal with domestic violence, and referral networks with gender based violence services, where they exist, will be developed.
HIV care, support and treatmentWhile the primary focus in developing this proposal has been on program implementation over the next four years, a longer term program approach (5 – 10 years) needs to be considered for the achievement of medium to long term outcomes. Within this context there is the option of a further program phase beyond mid-2016, upon completion of a satisfactory mid-term assessment. Future programming needs to be based on an assessment of what can realistically be achieved by REACH in four years and the likely shape form of AusAID’s Indonesian health program in 2016 and beyond. Characteristics of AusAID’s health sector support by mid-2016 relevant to the Papuan provinces may be:
The end of program goal is increased access to and increased number of people on HIV-related care and treatment in the Papuan provinces. The long-term goal is for reduced HIV-related morbidity and mortality in the Papuan provinces. The long-term goal will be able to be partially measured by mid-2016. However, the phased roll-out of HIV-related CST to puskesmas, some of which will come on line in the last year of the program, will mean that full measurement of the long-term goal will take place post-REACH. This proposal recommends that AusAID conduct a sustainability evaluation two years after the end of REACH, (see section 3.4.6). Assuming that REACH achieves its end of program goal in its 21 focus districts, it is likely that there will be demand from other districts to provide similar support. Mid-term review should provide insight into the program’s successes, strengths and weakness and should inform the planning process for beyond 2016. In addition, a second phase of REACH could provide higher level technical support and monitoring function to the nine CoE to ensure they remain on track, although it is anticipated they would be largely self-supporting by this stage and that REACH would concentrate its activities in new districts. Sexually transmitted infectionsAusAID could consider providing post-program support for STIs including:
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