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

1.5 Synergies and linkages with AusAID and other donor programs

In the course of designing this funding proposal the team identified multiple areas where strong synergies exist between REACH, other AusAID programs and other donor programs where outcomes for all programs could be enhanced through a collaborative approach. Key areas where consistency or synergies exists are: 1) facilitation of decentralisation processes; 2) health system strengthening; 3) demand creation for HIV testing and treatment and prevention; 4) technical assistance for health programs; 5) policy support to the MoH; and 6) operational research. However, at present coordination between donor programs in the Papuan provinces is generally poor. This includes coordination within the Australia Indonesia Partnership for HIV (AIPH). Strategies for improving program coordination are outlined in sections 3.3.2 and 3.3.3.

1.5.1 Facilitation of decentralisation

The Australian Indonesia Partnership for Decentralisation (AIPD) supports national, provincial and local governments to improve the provision of effective services in health, education and infrastructure by dual track strategies addressing supply side issues such as resource management and planning and demand side issues such as community mobilisation and effective democratic processes. REACH is consistent with AIPD in that it is seeking to make decentralisation work through advocacy for increased funding for health and improved health sector planning, service delivery and accountability. Many of the core supply side issues that REACH will need to address with provincial and district governments are the same as those being addressed by AIPD through a health sector wide focus. REACH will work closely with AIPD at the provincial level and in the districts where both programs will be working. Those districts are Pegunungan Bintang in Papua and Manokwari and Fak Fak in West Papua. AIPD is undertaking public expenditure analyses, including for HIV, in these districts, which can be used by AIPD and REACH for advocacy. The two government relations positions on CHAI staff will work closely with AIPD at the provincial level and in the districts where both programs are working. They will undertake similar work to that of AIPD in respect of advocacy, HIV CST-related planning, financial management and programming in non-AIPD districts where REACH is working.

The Indonesian National Program for People’s Empowerment (PNPM) which is co-funded by AusAID has reach to the village level in the Papuan provinces and is a vehicle that can facilitate community mobilisation around HIV and demand creation for services, as can AIPD’s work with civil society organisations.

1.5.2 Health system strengthening and governance

Kinerja Papua is a new USAID health governance activity that will overlap geographically with REACH in Jayapura City and District and Jayawijaya District. The program aims to improve delivery of public health services (especially related to TB, HIV and MCH) in Papua by strengthening health sector management and good governance, including increased participation, accountability, and access to information. Information on Kinerja’s work was not available at the time this funding proposal for REACH was being developed due to USAID contractual requirements. USAID has indicated that it is keen for close collaboration between Kinerja and REACH.

The Australian Indonesia Partnership for Health System Strengthening (AIPHSS) 2011-2016 focusses on improving MCH outcomes through addressing workforce and health financing issues. An additional three provinces will join the program in 2014, with the Papuan provinces being possibilities. Both REACH and AIPHSS have been designed on the basis of a common problem analysis that concluded that improving health outcomes of the poor requires interventions and capacity development at the puskesmas level, enhancing the management and supervision capacity of PHOs and DHOs, and effective policy stewardship by the MoH. By the time AIPHSS possibly starts work in the Papuan provinces, REACH will be at an advanced stage of implementation and would be able to share lessons learned with AIPHSS, in addition to ongoing program collaboration. There is potential for REACH and AIPHSS to work in tandem with the MoH, PHOs and DHOs on common policy and operational issues.

1.5.3 Demand creation for HIV testing and treatment, and prevention

AIPH (2008-2016) seeks to prevent and reduce the risk of HIV transmission, improve the quality of life of people living with HIV and alleviate the socio-economic impacts of HIV. AIPH works at the national level and in six provinces, including the two Papuan provinces. REACH will come under the umbrella of AIPH, as does CHAI Phase II. The HIV Cooperation Program for Indonesia (HCPI) is AIPH’s largest program. HCPI’s work in the Papuan provinces focusses on strengthening local leadership on HIV and HIV prevention.

By treating both HIV and STIs, REACH will reduce the infectiousness of people with HIV, thus reducing the likelihood that they will infect others. But treatment programmes can never be a substitute for effective primary prevention, especially in groups with high partner turnover. There is an opportunity for AIPH to reconceptualise its Papuan programming within a continuum of prevention to care, support and treatment approach. Synergies between the work of HCPI and REACH primarily relate to effective communication and community mobilisation strategies to create demand for HIV testing to increase early diagnosis and as an entry point to treatment, coupled with assertive promotion of the benefits of treatment. Support for adherence to ARV treatment as well as treatment seeking for STIs can also be addressed by HCPI. The programming interface could operate at two levels; through the civil society organisations (CSOs) and faith based organisations supported by HCPI and through the HCPI supported mass media communications work being undertaken by the Provincial AIDS Councils. The other key interface is HCPI’s work in support of provincial, local government and civil society leadership on HIV which is critical for government support of CST programming and community mobilisation.

USAID’s Scaling Up for Most-at Risk Populations I and II programs (SUM), provide assistance in technical areas and organisational performance to scale up HIV behaviour change interventions among most-at-risk populations, including FSWs and their clients. SUM I and II primarily work with CSOs. In Papua Province, SUM I and II will overlap geographically with REACH in Jayapura City and District and Jayawijaya and in West Papua in Sorong. Synergies between SUM and REACH primarily relate to STI diagnosis and treatment; effective communication and community mobilisation strategies to create demand for HIV testing to increase early diagnosis as an entry point to treatment, coupled with assertive promotion of the benefits of treatment with a focus on most-at-risk populations, particularly FSWs. CSOs supported by SUM may also play a role in patient support. To take advantage of these synergies, there will need to be close collaboration between SUM supported CSO’s and REACH at the site level. While USAID’s programs are mostly focused on CSO interventions, linkages to GoI health facilities need to be more strongly supported. REACH can assist in facilitating this type of linkage.

UNFPA is in an early stage of planning a small scale sexual and reproductive health and HIV program in Papua that will include comprehensive condom programming and HIV prevention for FSWs and their clients. The only area of geographic overlap with REACH will be in Jayapura. The program will commence in 2013. UNFPA has indicated a willingness to collaborate and discussions with CHAI will take place when more detailed planning commences.

1.5.4 Technical assistance for health programs

At the national level, REACH will bring lessons learned from its field work in the Papuan provinces to inform WHO’s technical support for the MoH in areas such as revisions to the National STI Control Strategy, national STI guidelines and the EDL for STIs.

REACH will be taking a comprehensive, multi-component approach to HIV CST. There are two quite small donor technical assistance programs, one for PMTCT and the other for TB, that are or will be doing work similar to specific components of REACH. CHAI will also seek to maximise a common approach between REACH and other donor programs through promoting alignment in donor supported work with relevant national programs such as PMTCT and TB and look for efficiencies such as joint trainings, using common curricula.

The United Nations Fund for Children (UNICEF) is currently planning a small scale PMTCT program through puskesmas in the Papuan provinces. REACH will collaborate with UNICEF in site selection to avoid working in the same sites. Discussion between the team developing this proposal and UNICEF indicated a high degree of willingness for inter-program collaboration if the two programs are working in the same areas.

USAID’s TB Care Project provides technical support to four districts in the Papuan provinces through FHI 360. Where REACH and the TB Care Project are working in common districts (Sorong, Jayapura and Jayawijaya) there will be collaboration to avoid overlap.

A Global Fund grant to Papua Province of A$1.05 million will support STI, PMTCT and HIV CST activities through government health services from July 2012 - June 2015. No data on Global Fund support to West Papua was available. REACH will collaborate with Global Fund activities through its support for HIV-related services through government systems. However, REACH will not be providing any incentive payments to health staff.

1.5.5 Supply chain management

The successful Indonesian proposal for health systems strengthening interventions under Global Fund Round 10 included training and human resource capacity building for SCM, providing the potential opportunity for REACH and the Pharmaceutical Directorate to collaborate. However, the grant has since been modified, with these activities being dropped. The grant will now be used for physical infrastructure improvements at district warehouses, but this does not include warehouses in the Papuan provinces. Therefore, there are no opportunities for collaboration between REACH and this Global Fund supported project.

1.5.6 Policy support to the Ministry of Health

The proposed support by REACH for the development of an evidence-based MoH national policy framework on HIV-related CST, (see section 2.7), will be provided in close collaboration with other development partners such as WHO, FHI 360 and ASHM. These partners have indicated their support for the establishment of an AusAID/CHAI supported Policy Secretariat in the MoH.

1.5.7 Operational research

The MoH research arm, The National Institutes of Health Research and Development (NIHRD/LitBangKes) has an office in Jayapura. They work mostly in areas of basic science. While the REACH operational research program will focus on learning that helps to improve service delivery, possibilities for collaboration exist around areas such as genotyping of HIV specimens. NIHRD has indicated an interest in discussing this and other possible areas of collaboration.

The WHO is supporting a program of research around the use of ARVs for HIV prevention, with funding from the US National Institutes of Health. Though protocols have not yet been developed, there is a possibility that some of this research could be embedded within REACH's knowledge generation activities. There are currently no other operational research components of other development partner funded programs of relevance to REACH.