Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine ß The Author 2010; all rights reserved. Health Policy and Planning 2010;25:i43 i47 doi:10.1093/heapol/czq057 Critical interactions between Global Fund-supported programmes and health systems: a case study in Indonesia Monica Desai, 1 * James W Rudge, 2 Wiku Adisasmito, 3 Sandra Mounier-Jack 2 and Richard Coker 2 1 Communicable Diseases Policy Research Group, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK, 2 Communicable Diseases Policy Research Group, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, Bangkok, Thailand and 3 Faculty of Public Health, University of Indonesia, Jakarta, Indonesia *Corresponding author. Communicable Diseases Policy Research Group, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15 17 Tavistock Place, London, WC1H 9SH, UK. E-mail: Monica.Desai@lshtm.ac.uk Accepted 23 September 2010 The Global Fund to Fight AIDS, Tuberculosis and Malaria has played an important role in financing the response to HIV/AIDS and tuberculosis (TB) in Indonesia. As part of a series of case studies, we assessed the nature and extent of integration of Global Fund portfolios into the national HIV and TB programmes, integration of the HIV and TB programmes within the general health system, and system-wide effects of Global Fund support on the health care system in Indonesia. The study relied on a literature review and interviews with 22 key informants using the Systemic Rapid Assessment Toolkit and thematic analysis. Global Fund programmes in Indonesia are highly vertical and centralized, in contrast with the decentralized nature of the Indonesian health system. Consequently, there is more integration of all functions at local levels than centrally. There is a high level of integration of planning of Global Fund HIV and TB portfolios into the National AIDS and TB programmes and some limited integration of these programmes with other disease programmes, through joint working groups. Other synergies include strengthening of stewardship and governance and increased staff recruitment encouraged by incentive payments and training. Monitoring and evaluation functions of the Global Fund programmes are not integrated with the disease programmes, with parallel indicators and reporting systems. System-wide effects include greater awareness of governance and stewardship in response to the temporary suspension of Global Fund funding in 2008, and increased awareness of the need to integrate programme planning, financing and service delivery. Global Fund investment has freed up resources for other programmes, particularly at local levels. However, this may hinder a robust exit strategy from Global Fund funding. Furthermore, Global Fund monetary incentives may result in staff shifting into HIV and TB programmes. Keywords Indonesia, Global Fund, integration, health system strengthening i43
i44 HEALTH POLICY AND PLANNING KEY MESSAGES Health system decentralization presents a challenge to the integration of Global Fund-supported programmes in Indonesia, where HIV and TB programmes are largely vertical. Temporary suspension of Global Fund support in 2008 has increased awareness of stewardship and governance practices. Global Fund investment has freed up national resources for other priorities, although this hinders the development of an exit strategy. Background Indonesia is a lower-middle-income country in South-East Asia. With a population of over 222 million, it is the most populous Muslim-predominant country in the world and is ethnically diverse (SEARO 2009). Indonesia has significant geographical challenges that impact on healthcare; it spans a total land area of over 1.8 million km 2, consists of over 17 000 islands and is prone to major earthquakes and volcano eruptions. Since 2001, there has been decentralization of government authorities, impacting the health system. Central government has overall regulatory function but responsibilities for planning, financing and distribution of services lie with local governments (World Bank 2008). Similar to other lower-middle-income countries, Indonesia faces the dual challenge of communicable and non-communicable disease morbidity and mortality. The HIV epidemic in Indonesia is concentrated among injecting drug users (IDU) and sex workers; however, there is a generalized epidemic in Papua province. Although national HIV prevalence is still low (0.16%), there has been a rapid increase in reported cumulative AIDS cases, making the epidemic in Indonesia one of the fastest growing in Asia (SEARO 2007). Indonesia has had a National AIDS Strategy since 1995, but financing was initially affected by the economic crisis. There has been recent political commitment by the President to AIDS, with reinforcement and restructuring of the National AIDS Commission and a step-up in the responses to HIV/AIDS. The government contributes approximately 30% of funds for AIDS programmes, the remainder comes from bilateral donors and Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund). Indonesia has the third highest prevalence of tuberculosis (TB) infection in the world with multi-drug resistant TB being a major challenge (WHO 2008). Co-infection rates of TB with HIV infection are estimated to be low but there is no formal surveillance programme. The National TB Programme (NTP) has been long established, with directly observed treatment (DOT) coverage of 98% in 2006 (WHO 2008). Indonesia has been successful in securing Global Fund funding in several rounds, accumulating an approved maximum of more than US$331 million (Table 1). This equates to an annual average disbursement of US$11.5 million to TB, US$10 million to malaria and US$8.3 million to HIV/AIDS. However, there was suspension of Global Fund funding in Indonesia in 2008 due to concerns about governance and conflict of interest. Methods The study design was based on that described for a Vietnam case study in Conseil et al. (2010), with the analytical framework and toolkit extended to assess not only the integration of the national HIV and TB programmes with the general health system, but also the integration of Global Fund HIV and TB portfolios within their respective disease programmes, and any system-wide effects of Global Fund support. As in Conseil et al. (2010), data were collected through a literature review and the use of the Systemic Rapid Assessment Toolkit (SYSRA) for gathering information about structures and modes of operation of complex health systems (Atun et al. 2004; Atun et al. 2010). Primary data were collected through qualitative interviews using a semi-structured interview topic guide designed as part of the SYSRA, conducted during August 2009. Overall, 22 interviews were conducted with government health officials, partners and civil society actors at national, regional and district levels, both within the disease programmes and in the general health care system. All interviews were conducted within Jakarta Province. Full details of data analysis can be found in Conseil et al. (2010). Briefly, the six health system functions proposed by the SYSRA framework (stewardship and governance, financing, planning, service delivery, monitoring and evaluation, and demand generation) were subdivided into 25 elements (as defined in Table 2), for which we classified the level of integration as not integrated, partly integrated or fully integrated, through iterative analysis and triangulation of the collected data. Classification of the level of integration was agreed upon by two staff of the London School of Hygiene & Tropical Medicine, one of whom was also an assessor across three other case studies presented in this supplement, to ensure consistency. Results and discussion Integration The Global Fund programmes in Indonesia are highly vertical and centralized, which is in contrast and sometimes in conflict with the decentralized nature of the Indonesian health system. As a result, there is generally more integration of all functions, particularly planning and service delivery, at local levels compared with centrally. There is a concern about ensuring sustainability of programmes and an exit strategy from donor funding. A strategy has been built into the National AIDS Programme, and other donors have tried to encourage a
GLOBAL FUND PROGRAMMES IN INDONESIA i45 Table 1 Summary of approved Global Fund proposals in US$, Indonesia Intervention Global Fund Round and time period Funding requested Total approved funding Amount disbursed till Nov 2009 HIV/AIDS Rd 1: 1 Jul 03 to 31 Dec 07 5 400 174 5 400 174 5 400 174 Rd 4: 1 Apr 05 to 31 Mar 10 49 770 446 49 770 446 41 534 594 Rd 8: 2009 to 2014 125 090 721 39 821 706 11 504 803 Total 180 261 341 94 992 326 58 439 571 Malaria Rd 1: 1 Jul 03 to 30 Jun 08 19 723 871 19 723 871 19 723 871 Rd 6: 1 Mar 08 to 28 Feb 10 57 920 195 27 683 015 23 838 786 Rd 8: 2010 to 2015 107 316 003 63 486 150 28 338 878 Total 184 960 069 110 893 036 71 901 535 Tuberculosis Rd 1: 1 Aug 03 to 31 Jul 08 51 766 023 51 766 023 51 766 003 Rd 5: 1 Jan 07 to 31 Dec 11 49 978 433 49 978 433 25 522 019 Rd 8: 2009 to 2015 89 026 218 24 131 410 11 781 946 Total 190 770 674 125 875 866 8 906 968 Grand total 555 992 084 331 761 228 219 411 074 disengagement strategy from donor funding. However, there are concerns at both local and national level that this could be jeopardized by shifting of government resources earmarked for HIV and TB into other disease and non-disease programmes that require additional funding. Despite these concerns, there is a high level of integration of the Global Fund HIV and TB portfolios into the National AIDS and TB Programmes (Table 2) in terms of planning, with the establishment of the National AIDS Commission (NAC) and the National TB Programme, which have overall responsibility for their programmes. There is partial integration of these programmes with other programmes and the general health system (Table 2). For example, there are formal joint working groups for planning activities for HIV and maternal health, and decisions are incorporated into planning documents of both disease programmes with clear lines of action. Both HIV and TB programmes use Global Fund funding to fill gaps in financing of their programmes at the national level. However, as Global Fund funding is vertical and strictly earmarked, gaps at the local level must be filled under the decentralized government structure. In practice, this involves the shifting of resources between disease programmes. Furthermore, this structure does not take into account changing demands on services due to changes in epidemiology and demand generation. At both the national and local levels, staff for the AIDS and TB programmes are recruited through the Ministry of Health (MoH) system and receive incentive payments from the Global Fund. However, concern was expressed that this system attracts health care workers away from non-global Fund funded projects, resulting in staff shifting, even within the same disease programme. The picture is less distinct at local level, where the nature of health care provision means that TB and HIV staff tend to care for patients under both the MoH and Global Fund schemes, as well as patients with other diseases. Training for HIV and TB health care workers, despite being coordinated by the MoH, is specific for these two diseases, with limited skill-specific modules that overlap other diseases, such as behaviour change and monitoring and evaluation (M&E). This provision of specific training is a further staff incentive. This coordinated approach is applied to procurement of drugs at the local levels, but less so at national level, where drug procurement and supply of Global Fund funded drugs is separate from that of MoH-procured drugs for HIV and TB. This is in part due to Indonesian pharmaceutical companies not being WHO pre-registered. There is partial integration of stewardship and governance functions of Global Fund programmes and the disease programmes. For example, both the MoH and the Secretariat of the NAC are represented on the Country Coordinating Mechanism for Global Fund programmes. In 2008 there was temporary suspension of Global Fund financing due to concerns about a conflict of interest within the Country Coordinating Mechanism (CCM). In response, there has been greater awareness of governance and stewardship; for example, an Oversight and Scrutiny Committee has been formed, which also has MoH representation. Despite some integration of other functions, there is no integration of M&E for the Global Fund HIV and TB portfolios within the national AIDS and TB programmes; each has different indicators and reporting systems. System-wide effects There have been several system-wide effects, both benefits and unintended consequences of Global Fund investment. As a consequence of the temporary suspension of Global Fund funding in 2008, several respondents felt that there is generally increased awareness of good governance practice within the MoH. However, this mechanism does not appear to have been formally carried over to the general health care system. Some stakeholders also felt that Global Fund support has freed up
i46 HEALTH POLICY AND PLANNING Table 2 Extent of integration of Global Fund portfolios for HIV and TB into the disease programmes, and the disease programmes into the general health system, for each health system element and function in Indonesia Global Fund portfolio into the disease programme Disease programme into the health system Health system functions Elements of integration HIV TB HIV TB Stewardship and governance 1: Regulatory mechanisms Service delivery 2: Accountability framework 3: Human resources for counselling and testing 4: Human resources for laboratory testing 5: Human resources for care and treatment 6: Human resources for delivery of HIV-positive mothers 7: Physical infrastructure for counselling and testing 8: Physical infrastructure for laboratory testing 9: Physical infrastructure for care and treatment 10: Physical infrastructure for pregnant HIV-positive females 11: Procurement and supplies of laboratory equipment Demand generation Monitoring and evaluation Planning Financing 12: Procurement and supplies of medicines 13: Care pathways for opportunistic infections 14: Care pathways for preventing mother-to-child transmission (PMTCT) 15: Financial incentives 16: Information, education and communication 17: Data collection and recording 18: Data analysis 19: Reporting systems 20: Performance management system 21: Planning 22: Fund pooling 23: Provider payment methods 24: Funding source 25: Cross-programme use of funds Key: This element is fully or predominantly integrated into the general health system, i.e. this element is (quasi) exclusively under the management and control of the general health care system. This element is partially integrated into the health system or; this element is integrated in some but not all cases, i.e. this element is managed and controlled both by the general health care system and a specific programme-related structure. This element is not, or only to a very limited extent, integrated into the health system as a whole, i.e. this element is (quasi) exclusively under the management and control of a specific programme-related structure which is distinct from the general healthcare system. Does not apply.
GLOBAL FUND PROGRAMMES IN INDONESIA i47 investment for other disease and non-disease programmes that require extra investment, particularly at local levels. However, this is not beneficial to ensuring a robust exit strategy from Global Fund support in the long term. In terms of service delivery, monetary incentives provided under the Global Fund programmes for staff working on HIV and TB may have had some unintended consequences. This incentivization is not carried over to other disease programmes, and there were reports of staff shifting towards the HIV and TB programmes away from other programmes such as health promotion. Finally, there has been increased awareness of co-infection and the need to integrate programme planning, financing and service delivery to avoid duplication and for a coordinated response. This relates not only to HIV-TB co-infection, but has been recognized for other diseases, such as TB-leprosy. Policy implications for the Global Fund Our analysis shows that there have been some wider benefits from Global Fund support, in particular in allowing an integrated approach to planning HIV and TB services, increasing service provision and demand generation. At local levels, due to the more integrated nature of health care provision, there has been greater integration of Global Fund funding with disease programmes. However, there have been several unintended consequences that form the basis of policy recommendations for the Global Fund. The conflict between the verticality of Global Fund funding and the decentralized nature of the Indonesian health system has resulted in reduced integration of financing, service delivery, demand generation and M&E. As a result, there should be more alignment of the vertical nature of Global Fund funding with the decentralized nature of the Indonesian health system, with flexibility in funding allocations to respond to the changing epidemiology of the diseases and changing needs. The introduction of non-governmental organizations as Principal Recipients of Global Fund grants may help facilitate this. Furthermore, concerns expressed by respondents regarding sustainability of the programmes, along with reports of shifting of government resources to other diseases or non-disease programmes requiring additional funding, highlights the need for an exit/sustainability strategy at both national and local level for the Global Fund programmes. Reports of staff shifting to Global Fund programmes due to incentive payments and training opportunities may suggest a threat of staff shortages in other disease programmes. The potential impact of incentive payments in terms of staff imbalances therefore requires further assessment, and the possibility of offering wider access to training for all staff could also be evaluated. There is already greater awareness of governance and stewardship mechanisms within the MoH following temporary suspension of Global Fund funding in 2008 and this has begun to have a system-wide impact. However, there is a need for increased capacity building support for the Country Coordinating Mechanism and continued support for the governance structure. Several stakeholders noted the need for increased collaboration between partners to ensure a coordinated response. Global Fund should consider formulation of subsidiary agreements with other donors to ensure a coordinated response to HIV and TB, and there needs to be increased partnership with non-governmental organizations and other donor organizations, and more engagement with the private sector. Alignment of the M&E systems for the Global Fund, other donors and the general health system should be considered in order to ultimately create a single robust and integrated system. Acknowledgements We are very grateful to all interviewees who took part in the study, and to Prof Hasbullah Thabrany and Mr Dian Kusumu of the Faculty of Public Health, University of Indonesia for their support in arranging and conducting interviews. Funding This work was funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria. Conflict of interest The methods used to conduct this study were developed in consultation with Professor Rifat Atun, Dr Jeffrey Lazarus and Dr Sai Pothapregada of the Global Fund. They played no part in the conduct of the research or in drafting the manuscript. References Atun R, de Jongh T, Secci F et al. 2010. Integration of targeted health interventions into health systems: a conceptual framework for analysis. Health Policy and Planning 25: 104 11. 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