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

Annex 8: Community empowerment proposal

The Catholic Dioceses of Jayapura, Timika and Sorong-Manokwari and the protestant Christian Gospel Church of Tanah Papua in collaboration with UNOPS Indonesia 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 and TB and TB-HIV cases, promote treatment and to advocate for better services. A copy of the concept note submitted to USAID follows.

A8.1 Background

Papua and West Papua Provinces (Tanah Papua) comprise a vast, largely undeveloped and underserved area in Indonesia. While population densities are low, disease burden are among the highest in the country. HIV and TB are emerging as the greatest threats to public health and development given their impact on productive age groups. HIV at 2.4 per cent prevalence overall is nearly 30 times the national average. HIV, poor nutrition, poverty, crowded living conditions and limited health services have created a perfect TB storm with TB as the highest proportion of HIV-related opportunistic infections in Indonesia (49%)⁶³. Results from the Basic Health Research 2010 referred to by Indonesia’s National TB Control Program (NTP) show that both provinces have prevalence rates of TB higher than the national rate of 1.0 per cent; West Papua, with a prevalence of 2.5 per cent, has the highest TB prevalence in the country.

Development has been largely in the coastal cities. The native Papuan population, however, is widely dispersed in small villages that are often not connected by roads to these more developed areas where health and other services are available. This is particularly true in Papua Province where 60 per cent of the local population lives in the central highlands. Most Papuans live below the poverty level as subsistence farmers and have little disposable income to pay for transport to distant medical facilities. Insurance reimbursement schemes at treatment hospitals confuse and frustrate rural villagers. Many who make it to hospitals give up in frustration. Others may live in areas that have health centres (PUSKESMAS) but these facilities often lack staff, medicines, laboratory or equipment necessary to treat their illnesses.

Cultural issues also complicate service delivery for illnesses like TB and HIV. Historically tribal communities excluded individuals who appeared sick with illnesses. That behaviour has led to stigmatization of individuals with TB, HIV or both. Infected individuals often do not seek or stop treatments owing to the discrimination and embarrassment they experience. Moreover, the rural poor are unfamiliar with chronic illnesses that require long term treatments. Completing courses of medicines for asymptomatic illnesses is often very difficult. Patients often take their medicine if they feel sick, not when they are ostensibly well.

A8.2 Strategic cooperation

Addressing the shortfalls in health services as well as improving health seeking behaviour, decreasing stigma, and improving drug adherence for the many affected residents of the highlands and West Papua will require a combination of health system strengthening, community mobilization and lobbying.

Communities are formed around tribe and church in this largely Christian area. Christian churches, Catholic and Protestant, are growing in influence socially and politically. The Department of Religious Representatives estimates 4,121 Protestant places of worship and 1,427 Catholic churches in Papua Province.⁶⁴ They are able to reach even the most remote villages to support their members thereby taking on social mobilization issues.

The Protestant Gereja Kristen Injil (GKI or Christian Gospel Church) and the Catholic Dioceses of Timika, Jayapura and Sorong-Manokwari have partnered together to propose using their broad reach to mobilize the Papuan highland communities and West Papua to better detect TB cases and to complete TB treatment, and to press national, provincial and district governments to increase and improve services for TB and HIV. These faith-based organizations see healthy communities as vital goals of their mission to help low-resourced and underserved areas. This partnership will work in concert with the AusAID funded KEMKES-Provincial Health Office (DINKES)-Clinton Health Access Initiative (CHAI) effort to rapidly scale-up access to HIV and TB diagnosis and treatment. Given the program scale, the GKI-Diocese partnership has asked the United Nations Office for Project Services (UNOPS) to assist in program and financial management during the first two years of implementation.

The Bishop of Timika and Head of GKI Synod will be responsible for the overall program implementation which is expected to last four years. UNOPS will station an international Program Coordinator and national finance personnel in Papua to work with GKI and the Diocese to build their capacity to deliver. UNOPS personnel will report to the UNOPS Project Centre in Jakarta. The Diocese of Timika will coordinate with the Dioceses of Jayapura and Sorong-Manokwari. Program personnel will be co-located with the AusAID funded KEMKES-DINKES_CHAI Centers of Excellence ( CoE). Parishes and churches will be selected for cadre training as PUSKESMAS are selected for medical care scale-up. Program personnel will be responsible for district advocacy activities and the UNOPS Program Coordinator, Bishops, and Synod Head will coordinate provincial advocacy work. Data from community mobilization efforts and from the health sector will be fed to religious advocates for discussions with MUSPIDA, DPR and BAPPEDA.

A8.3 Technical approach

The AusAID funded KEMKES-DINKES-CHAI program will focus on the 15 highlands districts of Papua and Manokwari, Sorong and Fak-Fak in West Papua. Centres of Excellence ( CoE) for the management of HIV, TB and sexually transmitted illnesses will be established in referral hospitals and later extended to PUSKESMAS in the surrounding areas with a target of established decentralized HIV-TB management in 150 facilities in the highlands and 35 facilities in West Papua over a four-year period. The church-based community mobilization work within the CEPAT program will be implemented in tandem with the development of clinical services provided through the AusAID program. The CEPAT program is proposed for Jayawijaya, Jayapura Peg. Bintang, Nabire, Sorong, Mulia, Manokwari, Enarotali Fak Fak and Mimika.

Component 1: Community mobilization:

Community awareness, early case identification and drug adherence will be largely in the hands of cadres recruited at the parish and church level. Training materials will provide basic information about TB, TB-HIV; signs and symptoms of TB infection; importance of early diagnosis; referral mechanisms for patients to the nearest qualified medical centre; contact tracing and referral; medications; importance of drug adherence; their roles as adherence monitors; record keeping and reporting. All activities will be in line with the Advocacy, Communication and Social Mobilization (AKMS) component of the NTP 2011-2014. Activities will thus also include familiarization of cadres with the Patient’s Charter for Tuberculosis Care. Cadres will be trained during one week training sessions in the villages with practical training. Village TB Posts (Pos TB Desa) will be established as bases for the cadres to operate from using church or village health post facilities. Records, spare meds, and supplies will be kept there. Baseline data from each parish or church will be collected during the initial training. Cadres will record daily activities including new cases detected and referral for sputum examination; case contacts referred; adherence support through DOTS; patients lost to follow-up; and patients completing treatment successfully. This information will be collected monthly. Cadres will report in writing to program personnel concerning shortfalls in medical services. Simple brochures and posters in local languages will be developed that promote early diagnosis and drug adherence. Medical personnel from local health centres will make periodic support visits and contact cadres to discuss any problems or issues with patients, medication supplies, side-effects or challenges to their work. Training programs will also be developed for ministers, parish priests, nuns, teachers and other religious leaders. Religious leaders and school teachers will be encouraged to include information on TB, TB-HIV and early detection and treatment in their sermons and classroom curriculum. Brochures, stickers, banners and event support will be provided. All activities will be documented on a monthly and quarterly basis. Data on case detection will include numbers tested; number positive; adherence; drop outs; cases completing treatment. This data can be analysed from province down to the cadre level and will aim at complementing the indicators identified within the 2011-2014 NTP Strategy. Success stories will be documented and circulated locally and nationally.

Component 2: Advocate for increased resources, improved services and legal issues:

The Musyawarah Pimpinan Daerah (MUSPIDA - Regional Leadership Consultative Group), Dewan Perwakilan Daerah (Parliament), Badan Pengembangan Daerah (Regional Development Agency) and Provincial and District Health Officers determine how health programs are funded, staffing levels, and the legal framework under which they operate. The new Special Unit for the Accelerated Development of Papua and West Papua (UP4B) which reports directly to the President will serve as a coordinating office when obstacles to implementation are identified. Senior GKI ministers, Catholic pastors, nuns and bishops will be trained in the elements of the TB program and program personnel will provide district and provincial data and justifications for budgets and personnel resources based on local disease burdens, impacts, and short falls in service deliver. Church officials will hear directly the service needs from TB positive and TB negative HIV patients, and may bring them or their representatives/families along when church officials meet with MUSPIDA, DPR, BAPPEDA and health officials at district or provincial levels or with UP4B officials. The Catholic Church in Papua New Guinea has been particularly active and successful in mobilizing Catholic Church parishioners to participate in awareness, adherence support and advocacy activities. A group of Catholic and GKI leaders may visit PNG at program kick-off.

A8.4 Exit strategy

GKI and Catholic Dioceses will be responsible for program management and implementation. They will see the benefits among their members in terms of increased numbers of individuals on treatment, increased adherence to medication regimens, increased survival rates and improved health services as a result of the program. We hope that through the program advocacy efforts and demonstrable results revealed in the health statistics, budget and staff allocations will be made by DINKES, DPR and BAPPEDA to sustain and strengthen the program. UNOPS supporting role will be gradually phased out after the second year of the program.

A8.5 Expected results

Church stakeholders such as ministers, bishops, nuns and educational personnel will have access to information and materials on TB treatment and patient care. Materials will reach patients and their families directly. Patient needs for seeking and continuing with treatment will be identified and met, vulnerable and marginalized populations will receive special attention (for example, women through posyandus). Health Seeking Behaviour of patients will be improved. Program supported lobbying for resources will be documented along with results of additional budget and personnel allocations. The churches will take the lead in monitoring public service provision and identifying shortcomings and opportunities for improvement. There were 6,287 pulmonary and extra pulmonary TB cases diagnosed in 2010 in Papua Province from 16,900 suspected cases. We expect to see substantial increases in suspect and diagnosed cases and a substantial drop in defaulters. We will have baseline data from each of the parishes and churches where cadres and Pos TB are established, on population and current number of cases under treatment. We will be able to monitor recruitment for testing; adherence rates; drop-out rates; and treatment completion rates. All program activities will be in line with and complement the Indonesia’s NTP Strategy 2011-2014, especially the components of Advocacy, Communication and Social Mobilization (AKMS) and the TB-HIV National Action Plan.

A8.6 Management and administrative capabilities

Founded in October, 1956, GKI has 1,237 churches and around 650,000 members, including 14 isolated tribes, in Papua and West Papua. GKI pastors and members are found in all districts where the program will be implemented. With the support of USAID and UNOPS, the GKI structure will allow for ready socialization and recruitment of cadres at the individual church level. The Synod Office in Jayapura has been working with the United Evangelization Mission on smaller scale endeavors since 2009. GKI has established a drop-in centre in Sentani for HIV positive people, performed youth HIV awareness activities across the highlands, and provides support for HIV positive individuals. The Dioceses of Timika, Jayapura and Sorong-Manokwari similarly have wide membership of at least 391,000 according to statistics from BAPPEDA. Catholic parish cadres have been trained for a number of health and non-health activities but their most notable effort has been a 2010 shelter program for HIV positive people in Wamena. Like GKI, the Diocese organizational structure similarly allows for ready socialization and recruitment of cadres in the individual parishes.

UNOPS has more than 30 years experience in implementing complex management and operational support services in peace building, humanitarian and development environments. In 2010, UNOPS implemented US$1.27 billion worth of projects for its partners, providing implementation support and management services, procuring goods and services, managing human resources and providing financial oversight of projects in some of the world’s most challenging environments. US$21 million was delivered for USAID in 2010. UNOPS is currently supporting the Faculty of Public Health at the University of Indonesia as part of a Global Fund TB grant. UNOPS is also monitoring and evaluating the progress of the UN Partnership for Development Framework (UNPDF) in connection to the Government of Indonesia’s Medium Term Development Plan (RPJMN) which includes health indicators for Papua and West Papua.

The funding proposal to USAID totals approximately A$3.8 million for four years of funding.