Program Management
|
CHAI intends to scale up a successful demonstration program very rapidly. Management systems may become strained.
|
Moderate
|
Possible
|
High
|
The staffing structure of CHAI has been enhanced, with additional positions including new management, administrative and financial positions. Management procedures will be systematised and SoPs developed. Clear job descriptions and performance indicators will be developed for staff. Existing
|
Medium
|
CHAI management
|
2012 – 2013
Delays in filling new positions or development of systems
|
CHAI may be unable to find sufficient numbers of skilled staff to meet its staffing needs, especially (but not exclusively) in Tanah Papua.
|
Moderate
|
Possible
|
High
|
An active formal and word of mouth recruitment campaign will be conducted. The opening of new Centres of Excellence may need to be delayed. Less skilled staff may be recruited and trained. On-the-job training and intensive mentoring will be made available to develop staff skills rapidly. For CoE staff, CHAI will collaborate with local government to prioritize recruitment of local health care workers, former PTT clinicians, as well as staff finishing contract on other donor-funded programs. CHAI will also utilize its staff’s extensive Indonesian network.
|
Medium
|
CHAI management
|
2012- 2013
Lack of suitable applicants
|
The AIPH Program Coordination Committee (PCC) will be the national level governance mechanism for REACH. At the provincial level there will be two Provincial Steering Committees (PSCs); one in each province. There may be differences in strategic directions between national and provincial level committees.
|
Moderate
|
Possible
|
High
|
The PSCs will meet shortly before PCC meetings and report to the PCC to promote alignment between the issues being considered by all three committees. Should there be differences in the strategic directions recommended by the PCC and PSC which cannot be resolved, the PCC and ultimately AusAID will be final arbiter.
|
Low
|
CHAI management and AusAID
|
Ongoing
Differences in strategic directions
|
CHAI may be unable to retain staff in Tanah Papua due to the difficult conditions; highly trained and skilled staff also may seek better paying positions.
|
Moderate
|
Possible
|
High
|
CHAI will offer competitive salary and benefits package; trainings and other professional development opportunities for staff will always be prioritized as a means to train successors in the likely event that some staff will leave. CHAI will conduct rolling interviews to bring new staff onboard as needed in a standardized yet efficient pace. Existing
|
Medium
|
CHAI management
|
2015-2016
|
Component 1: Care, Support and Treatment
|
Overarching Objective: To increase the number of GoI supported health facilities that are well staffed and equipped and providing quality HIV-related clinical services in Tanah Papua
|
Success breeds demands. CHAI is facing demands to increase coverage beyond the area envisioned in this funding proposal. A refusal to help may be politically unpalatable, and may hobble opportunities for collaboration in the future. Increasing coverage will, however, further strain capacity and threaten program quality.
|
Minor
|
Possible
|
Moderate
|
CHAI and AusAID have held extensive discussion with provincial and national partners, and have been clear about limiting the coverage of the program. MoUs will be developed at the provincial level defining districts to be covered by the program. Provincial Steering Committees will review all requests for expansion by non-REACH districts and work with CHAI management regarding inclusion of additional sites.
|
Low
|
CHAI management
CHAI Tanah Papua staff
|
2012 – 2013
Additional demands for coverage
|
Centres of Excellence (CoE) staff will be required to work in remote areas, at pay scales equivalent to those of government health staff. CHAI may be unable to hire and retain adequate skilled staff to meet CoE needs.
|
Moderate
|
Likely
|
High
|
CHAI will take a proactive approach to hiring and/or retaining motivated, qualified staff, even if the hiring process does not fit exactly with implementation timing. CHAI will work with AusAID and MoH to explore incentive structures, including study and professional development opportunities, to attract and retain staff. Less skilled staff may be recruited and trained. On-the-job training, cross-placement in functioning centres and intensive mentoring will be made available to develop staff skills rapidly. CHAI will advocate with hospital directors (who are accountable to Bupati) to minimise staff rotation and to assign staff according to training and qualifications. AusAID sector manager to explore bridge financing possibilities. CHAI to develop mechanisms for rapid hiring. The opening of new Centres of Excellence may need to be delayed.
|
Medium
|
CHAI management
CHAI Tanah Papua staff
AusAID
|
2012 – 2013
Lack of suitable applicants
High staff turnover
|
Health services are delivered by existing staff through existing government health services, largely at puskesmas level. Especially in the context of ongoing division of districts as regional autonomy expands, there is a risk that services will be understaffed, and that competent, trained staff will quickly rotate to jobs that do not deliver services in program areas.
|
Major
|
Likely
|
High
|
CHAI has worked with government to include staffing questions into the recent health facilities survey in Tanah Papua, and will use results to reassess this risk. Site selection criteria will prioritise adequately staffed sites with supportive management. CHAI will work with AIPD, Kinerja and other partners to advocate with District Health Offices (DHO) for adequate financing and staffing of health centres in the short and longer term. CHAI will support infrastructural development, including construction or upgrading of staff housing, to help the government attract and retain staff in remote locations. Scale down target for health centres actively supported and mentored.
|
Medium
|
CHAI management
CHAI Tanah Papua staff
|
2012 – 2013 & ongoing
Understaffed services
High staff turnover
|
Objective 1.1 Antiretroviral therapy: To increase access to ART at puskesmas and hospitals in Tanah Papua, and adherence to ART among patients treated.
|
People cannot access ARVs if they do not know their HIV status. Testing levels are currently low. CHAI will work on the supply side of testing, but relies on other partners, including HCPI, to provide messaging to increase demand. There is a risk that organisations that have in the past focused on prevention messaging do not develop successful campaigns to support treatment initiation and adherence.
|
Major
|
Possible
|
High
|
CHAI's program approach focuses on increasing routine HIV testing in health care settings and minimises the role of VCT. CHAI will appoint staff to engage more actively with other partners, including HCPI, to provide quality messaging around HIV testing and treatment. AusAID staff will monitor progress of HCPI in treatment related messaging in Tanah Papua. Switch partners for treatment-related messaging if necessary.
|
Low
|
CHAI management
CHAI Tanah Papua staff
AusAID
|
Ongoing
Numbers of HIV tests
Effectiveness of campaigns to promote HIV testing and treatment
|
The intention is to decentralise initiation of ARVs to puskesmas level. It is possible that this strategy will meet with resistance from health service gatekeepers. Concerns among service providers about poor adherence and loss to follow-up are known to be a barrier to initiation.
|
Major
|
Likely
|
High
|
Support for decentralised initiation of ARVs has been secured from the MoH. Component 3 (Policy) will work at the central level to support the development and dissemination of policies and protocols which encourage decentralised initiation of ARVs. CHAI will work with partners to develop community-based systems to support adherence. Existing
|
Medium
|
CHAI Tanah Papua staff
|
Ongoing
Low levels of treatment initiation
|
If cultural as well as logistic barriers to adherence and continued follow-up are not addressed effectively, the program goal cannot be achieved.
|
Severe
|
Possible
|
High
|
The program is designed to minimise logistic barriers to adherence and follow-up by taking services closer to patients. CHAI will work with partners to develop community-based systems to support adherence, including working through the churches that have wide community reach in remote areas. This work is proposed under a separate funding partnership - if this funding is not available it will need to be secured within the AusAID program. Lessons from CHAI's work supporting adherence through cell-phones and other mechanisms in other countries will be applied where possible. The program will work to develop province-wide unique identifiers to allow for better control of follow-up between sites. CHAI will encourage partners including HCPI to develop effective messages to reduce cultural barriers to adherence. CHAI monitoring systems are designed to monitor adherence and follow-up on a monthly basis, and to take immediate action as necessary. Component 4 (Operational research) will explore the effectiveness of different models of adherence support, and scale up those proven most effective in the Papuan context. Existing
|
Medium
|
CHAI Tanah Papua staff
CHAI management
AusAID
|
Ongoing
Moderate to low levels of adherence
Moderate to high levels of loss to follow up
Funding not available from other donors for community support
Unique identifiers prove not feasible
Ineffective messaging on adherence
Lack of timely and quality operational research
|
Objective 1.2 Tuberculosis: To improve quality of TB diagnosis and treatment in Tanah Papua
|
The TB and HIV programs are currently vertically funded and managed from different units of the Ministry of Health, and communication between programs is limited. Cross-referral of HIV and TB patients may be hampered in some sites.
|
Moderate
|
Possible
|
High
|
The CoE model focuses on integrating care for HIV, TB and STIs in hospital settings, and will extend this model to puskesmas settings.
|
Low
|
CHAI Tanah Papua staff
|
Ongoing
Moderate to low levels of cross referral
|
Objective 1.3 Sexually transmitted infections: To reduce STI prevalence in high prevalence populations in Tanah Papua
|
High population mobility and low consistent condom use among sex workers undermines the effectiveness of periodic presumptive treatment (PPT) as a STI control strategy in sex worker populations.
|
Major
|
Likely
|
High
|
Work with Indonesia Planned Parenthood Federation clinic staff at Tanjung Elmo, Puskesmas Amben staff in Manokwari and Kalvari staff in Wamena to develop an ‘on arrival’ package of STI services for sex workers that includes PPT for gonorrhea and chlamydia, syphilis screening and 100% condom use
|
Medium
|
CHAI Tanah Papua staff
|
2012 – 2013
STI prevalence does not decrease
|
There are sometimes political obstacles to providing effective services for sex workers.
|
Major
|
Possible
|
High
|
CHAI liaison staff will work with HCPI, SUM, KPAP and other partners actively to lobby for service provision for sex workers and their partners.
|
Low
|
CHAI Tanah Papua staff
|
2012 – 2013
Sex workers not accessing services
|
STI control among sex workers is difficult to achieve unless their regular partners (with whom condom use is low) are also treated. There is limited experience with partner treatment programs in Indonesia; finding an effective model may take some time.
|
Moderate
|
Possible
|
High
|
The program intends to implement active referral and treatment of regular partners of sex workers, including providing positive presumptive treatment. Component 4 (Operational research) will explore the effectiveness of different models of partner referral and treatment
|
Low
|
CHAI Tanah Papua staff
|
2012 -2014
STI prevalence does not decrease
Lack of timely and quality operational research
|
Gonorrhoea sensitivity to cefixime falls and treatment becomes less effective
|
Moderate
|
Possible
|
High
|
Support a Gonococcal Antimicrobial Sensitivity survey at the time of the next routine IBBS among sex workers in Tanah Papua.
|
Low
|
CHAI management
|
2014
IBBS conducted without survey
|
Diagnosis of syphilis requires TPHA and RPR tests done in conjunction. If health staff continue to use the TPHA rapid diagnostic test as a stand-alone syphilis diagnostic test they will not identify the high titre infectious cases that need priority in treatment and contact tracing. This will reduce the effectiveness of the syphilis control efforts.
|
Moderate
|
Possible
|
High
|
Provide technical input to MoH on revision of National STI Guidelines. Adapt the Australian Syphilis Diagnosis Training manual for use in Tanah Papua. Existing
|
Low
|
CHAI Tanah Papua staff
|
2013 and ongoing
RPR not used
|
STIs are common; people often fail to recognise symptoms. When they do recognise symptoms they self-treat or seek treatment outside government health facilities. It may therefore be difficult to increase service provision for populations other than sex workers and their regular partners.
|
Moderate
|
Likely
|
High
|
CHAI liaison staff will work with HCPI, SUM, KPAP and other partners to strengthen messaging around STI symptom recognition and service availability. CHAI program staff will seek opportunities to provide mentoring and support through CoE to those who see STI patients outside the government health system.
|
Medium
|
CHAI Tanah Papua staff
|
2012- 2013 and ongoing
Ineffective messaging
No increase in STI clients in health services
|
Objective 1.4 Laboratories: To strengthen laboratory capacity to provide HIV, TB and STI related diagnostic testing and monitoring
|
Some specimens are better examined centrally in provincial health laboratories for cost and quality reasons. Treatment center budgets do not allow for specimen shipment.
|
Moderate
|
Almost certain
|
High
|
REACH will work with provincial government to try to establish central specimen shipping contracts paid for by the province to facilitate shipments to central laboratories.
|
Medium
|
CHAI Tanah Papua staff
|
2012 – 2013
Provinces do not agree to cover this cost
|
Reagent costs are often centrally funded and budgets not allocated until mid-year. Unanticipated increases in supply needs may result in reagent stock-outs.
|
Major
|
Likely
|
High
|
SCM system will review monthly use and projections to better predict increase needs and work with the AIDS Sub Directorate, provinces and districts to address and pay for unanticipated needs.
|
Medium
|
CHAI Tanah Papua and SCM staff
|
2012 -2013
Low stock levels and stock outs
|
External quality control for hospitals and puskesmas can be provided by the Provincial Laboratories. Their external quality control will need to be arranged with commercial suppliers outside the country. These are unbudgeted costs that must be covered.
|
Moderate
|
Likely
|
High
|
REACH will cover costs for EQA program for the first two years while discussions are held with DHOs and PHOs and Bappeda to define ongoing funding mechanisms.
|
Low
|
CHAI Tanah Papua staff
|
2012 – 2013
Provinces do not agree to cover this cost
|
Objective 1.6 Infrastructure: To strengthen infrastructure at puskesmas level to support care, support and treatment services
|
There may be significant delays in the release of data from the NIHRD survey of health facilities.
|
Major
|
Possible
|
High
|
AusAID and CHAI will negotiate with the MoH for access to the NIHRD data prior to its broader release. If access is denied it will be necessary for the infrastructure sub-design to undertake more comprehensive assessments when it visits sites. Existing
|
Low
|
AusAID and CHAI management
Sub-design team
|
2012
Delay in release of data
|
Infrastructure needs for specific puskesmas will be identified by the sub-design. As REACH is rolled out over four years, puskesmas selection may change because of emerging factors.
|
Minor
|
Likely
|
Moderate
|
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 would not have a significant budget 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.
|
Low
|
CHAI Tanah Papua staff
|
Ongoing
Prior to contracting for new infrastructure work at puskesmas not yet part of REACH
|
Completion of even the early stages of infrastructure work will not occur until well after REACH has commenced implementation. If delays in infrastructure development take place this will exacerbate the situation.
|
Moderate
|
Certain
|
High
|
Puskesmas and hospitals will come on-line over 18 months and the first facilities to be involved will primarily be those in urban areas where there is 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. 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 two to four which should allow sufficient time for infrastructure development.
|
Medium
|
Infrastructure sub-contractor
|
2012 – mid 2014
Delays in infrastructure development
|
Districts may not agree to cost share. The investment will be wasted if adequate maintenance is not provided. There is the danger of theft of infrastructure.
|
Moderate
|
Likely
|
High
|
Sustainability will be enhanced by the sub-design choosing infrastructure solutions with feasible maintenance requirements in rural and remote areas, the development of realistic maintenance plans, with a non-negotiable requirement for firm undertakings by DHOs for meeting operational and maintenance costs and monitoring of maintenance. CHAI and CoE staff will monitor maintenance and problems with maintenance will be addressed through technical advice and advocacy to DHOs. Anti-theft strategies will be incorporated into the infrastructure sub-design.
|
Medium
|
CHAI Tanah Papua and CoE staff
AusAID Infrastructure Unit
|
2102 – 2013
Delays in provision of infrastructure
Maintenance is not occurring
|
Objective 1.6 Support for effective decentralised systems: To support policies that increase the efficiency, transparency and sustainability of service delivery in a decentralised health system
|
Governmental structures in Indonesia and Tanah Papua remain in flux. Division of responsibilities between levels of government is unclear. Vested interests between levels are sometimes not aligned, leading to obstacles in the development and implementation of effective funding mechanisms and policies. There is risk that policy improvements achieved at one level are not translated into policies or practice at other levels.
|
Moderate
|
Likely
|
High
|
CHAI will appoint government relations staff to engage actively with government partners at both the provincial and the district level. These staff will also liaise proactively with other externally funded activities with a policy and programmatic focus, including AIPD. Component 3 (Policy) will try to ensure that central level policies provide an umbrella that covers Papua's special needs. Where national policies seem to obstruct the particular needs of the Papuan situation, AusAID's sector dialogue could become more actively devolved if necessary, with less focus on the central level and more on levels more likely to achieve program goals.
|
Medium
|
CHAI Tanah Papua staff
Policy Secretariat in MoH
AusAID
AIPD
|
2012 and ongoing
Lack of effective funding mechanisms and policies
|
Further splitting of provinces and districts in Tanah Papua may undermine progress in achieving political support for program goals. Program development work may go back to square one in newly established provinces or districts.
|
Moderate
|
Almost certain
|
High
|
CHAI intends to support a regional program oversight mechanism which will include the people and institutions likely to be involved in any new provincial/ district governments in program areas.
|
Medium
|
CHAI Tanah Papua staff
|
Ongoing
Creation of new provinces and/or districts
|
The intention is to transition funding and staffing support for CoE to PHOs by the end of the program. If division of responsibilities between province and district remain unclear, this may be difficult to achieve.
|
Major
|
Possible
|
High
|
CHAI will work with AIPD, Kinerja and other partners actively to advocate for PHOs to take over funding of CoE. Sectoral dialogue between AusAID and provincial level partners to reinforce the need to adequately fund the training, mentoring and QC roles of the PHOs. At AusAID’s request, CHAI has included in the design a process to make recommendations to AusAID for post-program activity. AusAID could extend funding for CoE posts though CHAI or other mechanism beyond 2016.
|
Low
|
CHAI management and Tanah Papua staff
AIPD
AusAID
|
2015 – 2016
Reluctance by PHOs to take over CoE funding
|
Component 2: Supply chain management for HIV and related commodities
|
Overarching Objective: To decrease stock outs and increase efficiency of strengthened supply chain management of HIV-related commodities
|
Currently for ARV commodities, 70 per cent of the funding is from the Government of Indonesia and 30 per cent is from the Global Fund. With Global Fund phasing out in 2014, GoI needs to seek out other mechanisms to fund ARV purchases. If not, ARVs will not be available.
|
Major
|
Unlikely
|
Moderate
|
CHAI will advocate to the AIDS Sub Directorate and Tanah Papua PHO to provide funding in order to secure availability of ARV. Existing
|
Medium
|
CHAI SCM staff
CHAI Tanah Papua staff
|
2013-2014
Stock outs of ARV
|
Objective 2.1 Provincial level: To strengthen supply chain management systems for HIV-related commodities in Tanah Papua
|
Associated reagent of HIV/AIDS test are not available
|
Major
|
Likely
|
High
|
CHAI will advocate to the AIDS Sub Directorate and Tanah Papua PHOs to provide funding in order to secure availability of ARV. Existing
|
Medium
|
CHAI SCM staff
CHAI Tanah Papua staff
|
Ongoing
Stock outs of reagen rapid test
Accuracy and timeliness of site reporting for commodities
|
Supply chain management of HIV-related commodities are not effective and inefficient in Tanah Papua (stock out, shortage stock, overstock and expired) due to decrease quality of coordination and monitoring among the provinces, districs and treatment site as leadership change
|
Major
|
Likely
|
High
|
CHAI will improve coordination between all stakeholders in Tanah Papua and also in national level through training and capacity building process of SCM Management. Existing
|
Medium
|
CHAI SCM staff
CHAI Tanah Papua staff
|
2013
stock out, shortage stock, overstocks and expired
|
Supply chain management in West Papua province is currently weak. Intensive efforts will be needed to improve systems in West Papua. Any further division of provinces will multiply this challenge to other areas.
|
Moderate
|
Possible
|
High
|
CHAI plans to support decentralisation of SCM for ARVs to West Papua Province. The head of the Papua Province Provincial Warehouse is willing to support this process and is a significant asset. If additional provinces are created decentralisation of SCM may need to occur for these provinces. Following approval of REACH a sub-design of SCM for other HIV-related commodities will be undertaken which will include strategies for strengthening SCM in West Papua. Existing
|
Low
|
CHAI Tanah Papua and SCM staff
|
2012 and ongoing
Creation of additional provinces
|
With REACH, CHAI’s SCM work will broaden to include supply chains for TB and STI treatment and related diagnostics in Tanah Papua. These involve different players, with different incentive structures. There is a possibility that turf wars could develop.
|
Moderate
|
Likely
|
High
|
CHAI will undertake a sub-design for these commodities. CHAI will conduct an initial assessment, including identification of key stakeholders, opportunities for collaborations and constraints. SCM, CST, and the Policy teams will focus its efforts to for address bottlenecks, not recreating parallel supply chain systems.
|
Medium
|
CHAI SCM, Tanah Papua, and Policy staff
|
2012-2014
Politically-motivated blockages in commodities
|
The supply chain for TB diagnostic tests and treatment differs from that of ARVs. These commodities may not be available at all treatment sites.
|
Moderate
|
Possible
|
High
|
SCM will extend its work to cover TB-related commodities. SCM will work with the CST and Policy teams to ease blockages and support, not recreate the existing TB supply chain system.
|
Medium
|
CHAI SCM staff
|
Ongoing
Stock outs of TB commodities
|
The supply chain for STI diagnostic tests and treatment differs from those of ARVs and TB. These commodities may not be available at all treatment sites.
|
Moderate
|
Likely
|
High
|
SCM will extend its work to cover STI-related diagnostic tests and commodities. Component 3 (Policy) will work at the central level to support the development and dissemination of policies and protocols which improve STI control. Efforts will be made to include effective STI treatment drugs in the national essential drugs list. SCM will work with the CST and Policy teams to ease blockages and support, not recreate the existing STI supply chain system.
|
Medium
|
CHAI SCM staff and the Policy Secretariat in MoH
|
Ongoing
Stock outs
Inaccurate and late site reporting for commodities
|
Objective 2.2 National level: To strengthen national and decentralised supply chain management systems for HIV-related commodities
|
The intention is to phase out AusAID support for SCM by the end of the program. The government currently has a moratorium on hiring staff; it is not clear how they will fill the posts currently filled by CHAI/GF-supported staff. In addition, experience suggests that staff are rarely assigned to replace donor-supported posts until funding has ended, leaving inadequate time for training and mentoring of replacement staff.
|
Major
|
Likely
|
High
|
Develop a clear transition strategy with timelines for a progressive shift of technical support for SCM so that the AIDS Sub Directorate is progressively able to take on functions currently undertaken by CHAI technical support, with a full exit of AusAID funded support by June 2016.
|
Medium
|
CHAI management and SCM staff
|
2012 and ongoing
AIDS Sub Directorate is unable to devote staff to SCM functions
|
CHAI support for supply chain management currently relies extensively on funding from the Global Fund. The future of this funding is uncertain; if it is withdrawn, several SCM positions will be un-funded. The Phasing out of Global Fund and AusAID in SCM activities through CHAI in almost same time will have major impact in the quality of supply chain management of HIV-related commodities.
|
Major
|
Possible
|
High
|
Advocate for the MoH to take over funding of these funding positions. Existing
|
Medium
|
CHAI SCM staff
|
2013
Global Fund funding for SCM positions ceases
|
Transition of SCM activities to Subdit AIDS will not run well and impact the quality of supply chain management due to the lack of skills and/or lack of dedicated government staff to manage SCM activity successfully without technical assistance from CHAI or other donors
|
Major
|
Possible
|
High
|
CHAI will provide the AIDS Sub Directorate with the management methods and establish indicators to ensure the quality of work carried out by related stakeholders
|
Medium
|
CHAI SCM Staff and CHAI Management
|
2014
Subdit AIDS fails to manage the supply chain of HIV-related commodities independently
|
Objective 2.3 One Gate: To support the medium to long-term shift of incorporating supply chain management of HIV-related commodities within the national one gate policy
|
In order to achieve the overall SCM objective, a pragmatic approach to supply chain management may be necessary. This may involve setting up or entrenching systems which undermine the longer-term interests of an effective national supply chain for all health-related commodities. Integration with the broader health system supply chain will be a complicated transition.
|
Major
|
Almost certain
|
Very high
|
Component 2.3 will work with national systems to support longer term solutions into which short-term fixes can be integrated. Existing
|
Medium
|
CHAI SCM staff
|
Ongoing
Systems which entrench disease specific SCM systems
|
In order to meet the overall SCM objective, the activities of Components 2.1 and 2.2 are of necessity at odds with this sub-objective. CHAIs credibility in providing support to the Pharmaceutical Directorate, the principal partner for this sub-objective, may be compromised.
|
Moderate
|
Likely
|
High
|
CHAI has already established a good working relationship with the Pharmaceutical Directorate. Talks with the Directorate and partners currently controlling other parts of the supply chain have begun. All have expressed willingness to work towards a long-term solution. Existing
|
Medium
|
CHAI SCM staff
|
Ongoing
Relations with the Pharmaceutical Directorate deteriorate
|
Component 3: Policy support to the Ministry of Health
|
Overarching Objective: To implement an evidence- based Ministry of Health national policy framework relevant to HIV-related care, support and treatment
|
Objective 3.1: National level policy: To strengthen the national policy framework relevant to HIV-related care, support and treatment.
|
Previous attempts to provide similar support to the AIDS Sub Directorate have failed because it was not possible to arrive at a salary structure acceptable to the Sub Directorate and attractive to people with the requisite skills. This may be the case again.
|
Major
|
Possible
|
High
|
The current head of the AIDS Sub Directorate has expressed support for the proposed policy secretariat. Active recruitment may be needed. If a suitable candidate cannot be found a fallback option would be to recruit at above the government salary level, but this would need to be carefully considered as it would increase the risk that the position would be discontinued when AusAID funding ceases. Alternatively, REACH could focus its policy development work at the provincial and district levels in Papua, where CHAI supported services will be delivered. Existing
|
Medium
|
CHAI management
|
2012 and ongoing
Recruitment difficulties for Policy Secretariat staff
|
In the past, decisions of the treatment working group have reflected the views of one or two long-serving group members. The secretariat aims to synthesise recent advances in research for group consideration, and to develop a systematic decision-making process which prioritises the weight of evidence rather than individual opinions. It is possible that important group members will resist this process.
|
Moderate
|
Likely
|
High
|
The work of the Secretariat aims to orient the policy working groups towards evidence based decisions rather than current practices of individual members. A blinded voting system is proposed to minimise the influence of individual clinicians. The Secretariat will need to invest time in stakeholder management.
|
Medium
|
CHAI management and Policy Secretariat staff
|
2012 – 2013
Policy decisions are not evidence based
Slowness of policy development
|
The intention is for the policy secretariat to be an ongoing function of the AIDS Sub Directorate after AusAID funding ceases. While staff positions will initially be funded by AusAID, they will be seconded to the Sub Directorate. Office space shortage in the Sub Directorate may mean that this is not possible which would weaken the Sub Directorate’s ownership
|
Moderate
|
Possible
|
High
|
If need be, policy secretariat staff can be located in the CHAI national office. This should be seen as a temporary measure and options for co-location with the Sub Directorate will be actively pursued till this is resolved
|
Medium
|
CHAI management
|
2012 and possibly ongoing
Policy secretariat staff cannot be located in the Sub Directorate
|
Component 4: Operational research
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Overarching Objective: To generate and apply knowledge that contributes to achieving the program goal of increasing access to high quality HIV-related treatment in Tanah Papua
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Operational research is an unglamorous field that is relatively new to Indonesia. In the CHAI program, it is very heavily integrated with routine monitoring activities. It may be difficult to recruit an experienced Indonesian to lead this program of work to success in Papua.
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Moderate
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Likely
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High
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Provide external support for the development of a program of operational research in the early phase of the program. Consider hiring people with experience in operational research not directly related to HIV or health service provision.
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Medium
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CHAI management
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2012
Lack of suitable applicants
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Decentralisation has led to an immense heterogeneity of policy and programming contexts, even within the program area supported by CHAI. This provides great opportunities to use simple comparative designs in operational research, but results may be hard to interpret.
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Minor
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Likely
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Moderate
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While the program intends to base its operational research on routine monitoring and limit the use of complex designs, Component 4.2 allows for more complex research questions to be addressed using external funding.
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Low
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Operational Research Manager
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Ongoing
External funding for more complex research is not available
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The heterogeneity of the Papuan and the Indonesian contexts may limit the transferability of findings between different ethnic, cultural, geographic infrastructural and economic situations.
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Minor
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Likely
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Moderate
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The routine monitoring system will include relationship mapping and expenditure tracking, allowing differences in contexts to be described and their potential influence on produceability of results to be assessed.
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Low
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Operational Research Manager
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Ongoing
The routine monitoring system does not pick up contextual differences
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Objective 4.1 Embedded research: Undertake embedded research that generates reliable knowledge with the potential to contribute to the program goal
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REACH will have access to populations in Tanah Papua about whom little is known. The intention is to maximise learning by working synergistically with other partners to develop joint research from funding sources external to the program. There is a risk that these research goals could hijack staff time and even service delivery, diverting REACH from the principle goal of increasing HIV treatment for Papuans in need of it.
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Moderate
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Possible
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High
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Risk assessments will be developed for any externally-funded research activities. The opportunity costs for CHAI and CoE staff time, the potential impacts on REACH program goals and community-related reputation risks will all be systematically considered. Any proposed externally-funded research will be referred to the appropriate governance bodies for consideration before agreement is reached.
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Low
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CHAI management, Operational Research Manager and Tanah Papua staff
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Ongoing
Research taking up too much staff time
Research diverting health services from their core function
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Objective 4.2 Local engagement: Increase the use of operational research data to achieve program goals
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Ideally, the principle users of the results of operational research are those responsible for program implementation locally. If the operational research component does not meet local information needs, the results are unlikely to be useful, or used.
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Minor
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Possible
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Moderate
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The REACH design includes a consultative phase during which potential end users will be asked to identify knowledge gaps and information needs. These users will include AusAID and Indonesian government agencies at all levels, as well as service providers and users.
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Low
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Operational Research Manger
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2013 – 2013
Operational research results are not being applied
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Operating environment
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Elections for Governor in Papua Province are more than a year overdue. Discussions and agreements around program design have been held with a Sub Directorate for AIDS whose leadership is very much in flux. Changes in key ministerial or Sub Directorate staff or the provincial government in Papua may lead to a change in priorities or otherwise undermine support for the program.
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Moderate
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Possible
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Medium
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CHAI will continue to maintain an open dialogue with Ministry of Health and other government staff; Papua province staff will engage with key figures in the provincial government and key political parties. Existing
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Low
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CHAID management
CHAI Tanah Papua staff
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2012 – 2013
As leadership positions change
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Papua province and some program districts in Papua and West Papua will hold elections during the life of the program. Local elections have in the past triggered violence. This may restrict CHAI and government staff movement, and threaten mentoring and service delivery.
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Moderate
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Possible
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High
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Proactively hire indigenous staff wherever possible. Develop a staff safety plan including evacuation plans. Scale down or eliminate support in any conflict areas if needed. Existing
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Medium
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CHAID management
CHAI Tanah Papua staff
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Ongoing
Local elections
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Safety and security concerns will continue to be an issue throughout this four year program. This will affect staffing, implementation, and operations.
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Major
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Almost Certain
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Very high
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Security policies and protocols will be strengthened; implementation will be tested on a regular basis. Ongoing monitoring of safety and security situation through on-the-ground sources and regular communications. Prioritise hiring of indigenous staff wherever possible. Collaborate with UN security, AusAID security, CHAI HQ, and local police team to build early warning and alarm system for security.
Developed and implement evacuation protocol if the event of extraordinary situations, including negotiating contract with local airlines as part of evacuation protocol and having cash reserve available for emergency charter flight. Existing
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High
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CHAI management, CHAI Tanah Papua staff
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Ongoing
Alerts of protests, tribal fights, and escalating violence
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