The significant scale up planned under REACH will pose new risks. The Issues Management Register (Annex 14) details the key program risks, potential impact, rating, controls to mitigate these risks, and residual levels of risk after the control intervention. Risks are grouped into three main categories: 1) overarching risks relating to the program as a whole, 2) implementation risks relating to specific program components; and 3) external risks such as the operating environment.
The top critical issues for REACH are related to human resources, government systems and other external factors. The huge scale up in staffing at CHAI and at the CoE and the related management responsibilities pose a significant challenge for the program. The government’s ability and willingness to absorb costs beyond the life of the program also is a concern for long-term sustainability. Safety and security concerns will be an ongoing issue. While these risks are substantial, CHAI has already implemented measures to address some of these concerns in Phase II. CHAI also has developed new controls that mitigate other issues to acceptable levels.
The identified risks fall under the following themes:
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Human resources issues including the ability to recruit, hire, train, and retain qualified new staff; reinvigorate and motivate existing health facility staff; and address civil servant rotation, understaffing, and absenteeism
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GoI willingness and capacity to absorb and sustain new positions and related operational and programmatic costs
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Technical challenges such as low ART initiation rates for fear of poor adherence and potential loss to follow up
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Political challenges such as mobilising government funding, the volatile political landscape and changing leadership
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Budgetary inflexibility to respond to unexpected demands for drugs, reagents, or other commodities beyond current projections
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External factors that will affect REACH’s HIV-related CST outcomes but are not fully within CHAI’s area of responsibilities, including downstream activities (like the need for HIV testing campaigns that include the benefits of treatment) and upstream efforts (like better policies on HIV testing or realistic civil servant pay scales)
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Other supply-side risks like multi-stream SCM systems for HIV-related commodities and donor coordination-related concerns; and coordination with stakeholders
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Other demand-side risks, for example, patient demand may outstrip supply
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Safety and security issues including tribal conflicts and political instability
The set of responses listed in Annex 14 represent a broad and flexible mix of controls:
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Create realistic budgeting for human resources along with non-monetary career-related incentives like training and mentoring opportunities
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Work towards sustainability through planned and negotiated transition between CHAI and GoI partners; broaden number of training and mentoring recipients to institutionalise interventions at the health facility level
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Prioritize heightened engagement with GoI to advocate and support public finance interventions that affect health facilities, their patients, and staff; integrate CoE budgeting into government systems and recurrent budgeting process; assist with evidence-based policy development and dissemination
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Promote policies at local levels to enhance acceptance and uptake at health facilities
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Provide ongoing technical assistance and capacity building to support interventions and future program absorption into GoI systems
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Support regular coordination, communication, and networking with partners to ensure harmonization of services; engage closely with AIPH and AIPD and other donor programs
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Implement ongoing program monitoring through a strong focus on data collection and analysis with regular feedback loops to programs and stakeholders
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Increase local engagement including prioritisation of local Papuan hires; partner with local NGOs and faith-based organizations
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Implement robust safety and security protocols to mitigate risks to acceptable levels
CHAI will implement a cascading issues management framework that regularly monitors issues or risks from site level upwards as a standard management tool. This structured framework will be integrated into an adaptive management approach. CHAI will develop this tool in quarter one of the program in consultation with AusAID’s Risk Management Unit.
3.6 Sustainability
This section gives an overview of the sustainability of REACH. More specific details on the sustainability of particular program sub-components are outlined in section 2: Program description, under the sub-headings ‘will the benefits last?’
Sustainability is defined as “the continuation of benefits after major assistance from a donor has been completed”39 and is assessed in relation to the end of program goal and long term goal. They are “increased access to and increased number of people on HIV-related care and treatment in Tanah Papua” and “reduced HIV-related morbidity and mortality in Tanah Papua.”
The key elements to ensuring sustainability of REACH will be:
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improved planning for HIV CST services, reflected in continuing funding of health service delivery from national, provincial and district budgets
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adequate ongoing technical support for service delivery from the CoE
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generation of demand for HIV CST services.
Factors that will enhance the sustainability of REACH’s CST component are:
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The program is fully aligned with the MoH’s national HIV CST program.
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Decentralisation of HIV CST to puskesmas has been shown to be a viable in the current CHAI Phase II program and has resulted in a significant increase in the number of people on treatment. Program improvements based on lessons learned in Phase II will improve the model.
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REACH is based on mutual responsibilities and accountabilities in regard to who pays for what. During the life of the program the MoH will pay for most drugs and reagents; PHOs will take over funding for CoE in year four; DHOs will pay for the operating costs of health services; and AusAID will pay for CHAI technical assistance and the cost of CoE for the first three years, some equipment and reagents and share in some facilities upgrade costs.
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The key focus of REACH’s CST component will be training and ongoing mentorship of health care workers to develop their skills. Due to staff turnover and the need for ongoing mentoring, there will be a need for the CoE to continue beyond four years, with funding being provided by PHOs. While PHO commitments need to be cemented during the course of the program, early indications from PHOs are positive.
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REACH has a strong emphasis on improving the implementation of decentralisation by working with provincial and district governments in collaboration with AIPD to ensure that there is improved planning by PHOs and DHOs, linked to adequate budget support for HIV CST service delivery. Provinces and districts have the fiscal space to increase health service funding. Consultations during the development of this proposal indicated that there is strong support for REACH from provincial and district governments, accompanied by an understanding that they will be responsible for the cost of health service delivery and technical support.
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REACH will only provide technical assistance to puskesmas if Districts are prepared to provide sufficient staffing for the provision of services and the facility itself can support the provision of high-quality service.
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This proposal has a strong focus on identifying risks that will affect sustainability and effective management of these risks.
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A potential AusAID follow-on program post-REACH would involve higher level technical assistance to CoE to facilitate sustainability.
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While the focus of REACH is primarily on supply side factors, the development of effective HIV services and demonstrable benefits in terms of restoring and maintaining people’s health will result in creation of community demand for services, as has been demonstrated by CHAI Phase II, (see section 1.4.1).
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Monitoring will be aligned with government monitoring systems which mean that ongoing monitoring of service delivery should be feasible, post-REACH.
In summary, all these factors will contribute positively to the sustainability of the CST component.
The SCM and policy support work will involve a clearly articulated phased transition for withdrawal of AusAID funded CHAI technical support, with these functions to be fully supported by the MoH by the end of the program. A mid-point IPR will determine whether the program is on-track for a full transition of SCM and policy support to the AIDS Sub Directorate by mid-2016. The IPR will also assess progress with sustainability of the CST component and make recommendations for any necessary corrective action.
The operational research component of REACH will cease at the end of the program. However, findings from operational research will be used for program improvement, which should contribute to the sustainability of the program. This component may also create demand post-REACH for evidence and application of results. Development of the local capacity of researchers to provide evidence in accessible formats to policy makers may also contribute to sustainability. Through data analysis of the broader implications of Papuan data, REACH will also seek to influence national HIV CST policies and programming where replication is appropriate.
This proposal has recommended that AusAID schedules an evaluation to assess the sustainability of REACH benefits two years after the program ends, (see section 3.4.4).
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