STRATEGIES AND CHALLENGES OF COMBATING HIV AND AIDS UNDER SPECIAL AUTONOMY
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not always been smooth, especially given that in many cases there is an absence of relevant regulations or accompanying technical guidelines needed by civil servants or districtmunicipal
governments to implement regulations and policies. As one participant put it:
“The Special Autonomy Law is excellent in spirit and letter. It opens the room for Papuans to govern Papuans in accordance with the perspectives and the needs of Papuans. However,
implementation of the law is a whole different matter. Papuan leaders do need to provide explicit and specific instructions on the implementation of the law on the ground. Those
instructions should be contained in special provincial regulations. It took the provincial government a long time to draft and enact the regulations necessary to even implement the
law.” Government staff, Jayapura, 13 September 2009
There are a number of other challenges of implementing Special Autonomy, not all of which are discussed here. Many relate to a political environment where, in response to a Papuan sense of
marginalisation and government sponsored transmigration programmes, some Papuans have felt they have lost control of their own homeland to the Indonesians and have become marginal
to Papua’s political and economic life, leading to expressions of Papuan nationalism with a strong ethnic tone.
282
These dynamics - migration and tribal arrangements, local conflicts and the demands for indigenous Papuans to occupy civil servant positions under the ‘sons of the region’
putra daerah phenomenon - are discussed in a number of other studies.
283
Suffice to say that such politics and dynamics do impact the implementation of Special Autonomy and complicate
the process of achieving consensus in policymaking among the various levels of government, parties, the parliament at the provincial and district levels, and with the Papuan People’s
Congress. As one respondent put it:
“Special Autonomy is like a double-edged sword. On one hand, it has afforded many opportunities Papuans never had before, such as access to funds and educational
opportunities. On the other hand, its implementation has roused primordial sentiments and regional affiliations within the regional government bureaucracy and the community.
The primordial sentiment is partly a consequence of social inequality in Papua in terms of distribution of government positions.” 14 September 2009
4.3.5.3 Weaknesses in the regulatory environment and service provision under Special Autonomy in general
Tackling HIV and AIDS as has been outlined above is challenging in Papua, considering the wide geographic area, underdevelopment, poor education levels, and sexual practices, among others.
However, it is further complicated by the weaknesses in the institutional environment as Papua builds governance and new institutions under Special Autonomy. The following discussion
alludes to just a few of these challenges, namely passing legislation, budget disbursement, civil servant capacity, and the effectiveness of consultative planning processes. While Papua
avoids some of the problems experienced under decentralisation discussed in the case study on the province of NTT where the provincial government has little authority to instruct district
governments or to undertake direct programme and policy implementation, it faces similar problems of poor institutional capacity to deliver services across such a large area, due in part to
the regulatory environment and the skills of civil servants.
282 Bertrand, J. 2007 Papuan and Indonesian nationalisms: Can they be reconciled?; Chauvel, R. 2007 Refuge, displacement and dispossession: Responses to Indonesian rule and conflict in Papua
; McGibbon, R. 2004 Plural society in peril: Migration, economic change and the Papua conflict
; McGibbon, R. 2004 Secessionist challenges in Aceh and Papua: Is Special Autonomy the solution? 283 Hoey, B. A 2003 ‘Nationalism in Indonesia: Building imagined and intentional communities through transmigration’, Ethnology,
Vol.422: 109-126; Brata, A. G. 2008 The creation of new regions in Papua: Social welfare vs. elite interests, Atmajaya University: Yogyakarta; McGibbon, R. 2004 Plural society in peril: Migration, economic change and the Papua conflict; McGibbon, R. 2004
Secessionist challenges in Aceh and Papua: Is Special Autonomy the solution?; Universitas Cendrawasih. 2006 Studi evaluasi kebijakan dan implementasi Otonomi Khusus di Tanah Papua tahun 2002-2006
Division of powers and creating legislation Legislation has been passed in Jakarta for the purpose of reining the original Special Autonomy
laws, but it has often exacerbated confusion. The decentralisation laws passed in 1999 devolved power to the districtmunicipal level, but under Special Autonomy in Aceh and Papua power was
devolved to the provincial level instead. This has caused some confusion among some authorities at the district level. As one government civil servant in Jayapura observed,
“It seems as if we have two masters, the provincial and the national government. Sometimes we don’t know who we should listen to, particularly if they have conflicting
demands.” Jayapura, 14 September 2009
Under Special Autonomy, there are several ambiguities in the division of powers between the provincial and district parliaments and the MRP, and the role of the governor includes both
representing Papua’s interests as well as being responsible for implementing central government policies in Papua.
284
One important difference between the provincial parliament DPRD and the MRP, for example, is that the former represents all the people living in Papua, including migrants
from other regions who constitute a significant portion of the population. The MRP, however, more specifically represents indigenous Papuans. The process by which the MRP can review
legislation affecting indigenous rights is not entirely clear.
285
Aside from being able to voice and formally contest legislation or regulations that infringe on Papuan rights or customs, there are no
legal mechanisms by which these measures can be halted.
286
The MRP has only restricted rights of consultation and approval on issues related to native rights and only in relation to special
regulations for implementation of the Special Autonomy Law. No such approval is required for normal legislation and regulations of the provincial parliament.
287
In 2007 the Indonesian government issued Presidential Instruction Inpres No. 52007 concerning the Acceleration of Development in Papua and West Papua. This Presidential Instruction
indicates five priority areas for the provinces’ development. They are: 1 food resources and poverty reduction; 2 education quality improvement; 3 health service improvement; 4 basic
infrastructure increase for improved access to remote areas, the interior and border areas; and 5 affirmative action in quality development of indigenous Papuan human resources. This
has generated confusion in Papua among Papuan local governments since the content of the Presidential Instruction seemed to overlap with the goals of the Special Autonomy Law which
also emphasises the development of health, education, economics and infrastructure, and was perceived to have the potential to undermine Special Autonomy.
288
As one interviewee argued, “The Presidential Instruction was made by the central government alone, without input from
Papuans. Yes, the priorities are well thought out. But I have to ask this: who are the intended beneiciaries of development in Papua? Papuans, right? How can the government identify
Papuan’s needs and priorities without consulting Papuans?” Medical doctor, Jayapura district, 15 September 2009
284 Halmin, M. Y. 2006 The implementation of special autonomy in West Papua, Indonesia: Problems and recommendations; Sullivan, L. 2003 Challenges to Special Autonomy in the province of Papua, Republic of Indonesia, Research School of Pacific and Asian Studies,
the Australian National University: Canberra; USAID. . 2009 Papua assessment. 285 Halmin, M. Y. 2006 The implementation of Special Autonomy in West Papua, Indonesia: Problems and recommendations; McGibbon,
R. 2004 Plural society in peril: Migration, economic change and the Papua conflict; McGibbon, R. 2004 Secessionist challenges in Aceh and Papua: Is Special Autonomy the solution?
286 Ibid. 287 Ibid.
288 King, P. 2004 West Papua since Suharto: Independence, autonomy, or chaos?
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The implementation of the Special Autonomy Law requires the production of Provincial Regulations Perdasi, Peraturan Daerah Propinsi and Special Regional Regulations Perdasus,
Peraturan Daerah Khusus. As of January 2010, only eight Special Regulations had been passed in the province to implement the Special Autonomy Law, whereas it was estimated that at least
24 were required in order to specify necessary details for the implementation of the Law.
289
One of the reasons for the delay was the ambiguity in the division of roles between the MRP and
provincial parliament.
290
Interviewees working in HIV and AIDS prevention argued that the poor regulatory environment impedes government action and policy development in Papua.
Coordination between different levels of government One problem identified by FGD participants was that of coordination between each level of
government. First, participants argued, if the central government gives the go-ahead for a programme and the programme is to be implemented by the district offices, the provincial
authorities are sometimes not informed of this development or involved in coordination, especially because under decentralisation the district has plenty of leeway in executing its duties.
This is problematic in all of the case study regions, but in Papua the provincial government does have greater authority than in other areas where Special Autonomy does not operate. In the case
that districts do not coordinate with the provincial government in Papua, the provincial offices do not have access to district data, making data-driven planning especially difficult.
Budget allocation and disbursement Under decentralisation and Special Autonomy, Papua and Aceh receive general budget
allocations DAU, Dana Alokasi Umum and special allocations DAK, Dana Alokasi Khusus, and they can raise revenues through local taxes and levies like all other provinces. However, Papua
and Aceh also receive a greater share of mining and natural resource revenues DBH, Dana Bagi Hasil, and a Special Autonomy budget allocation Dana Otsus for a temporary period. The
Special Autonomy Law does not stipulate in detail how the Special Autonomy funds in particular are to be distributed among districts and municipalities in Papua, stating only that allocations
should be decided by Special Regional Regulations, with priority to be given to lagging regions. The law only makes vague references to how the funds should be used, the ultimate goal of
Special Autonomy being “to reduce the disparities between Papua Province and other provinces, promote the living standard of people in Papua Province, and give opportunities to the original
inhabitants of Papua.”
291
The funds for Special Autonomy should be two per cent of the national general budget allocation pool, amounting to IDR 1.8 trillion in 2005. It now accounts for 60 per
cent of provincial revenues, and between 7-23 per cent of district and municipal revenues.
292
A joint Ministry of Home Affairs and Ministry of Finance Decree KMK160a2003, issued in April 2003, clarified that districtsmunicipalities are to receive a larger share of the fund than the
province because of their greater responsibilities in delivering education and health services.
293
Consequently, in 2004 the province reduced its own allocation to 40 per cent; in 2002 and 2003 the province had kept 60 per cent of the funds and only allocated the remaining 40 per cent to local
governments.
294
However, one complication that added to delays in policymaking and service
289 Mansai, A. 2008 Perdasus perdasi, penantian tak berujung, available at: http:taboloidjubi.wordpress.com20080728perdasus- perdas-penantian-tak-berujung Last accessed 15 January 2010
290 Conoras, Y and Mayabubun, K. 2010 Efektivitas otonomi khusus Papua butuh political will Jakarta dan Papua: Catatan untuk satu tahun terakhir
, available at: http:www.infidorgindex.phpnews201090827efektifitas-otonomi-khusus-papua-butuh-political-will- yusman-conoras-amp-kenny-mayabubun.html
Last accessed 26 January 2010 291 World Bank 2005 Papua public expenditure analysis, p95
292 Ibid. 293 World Bank 2005 Papua public expenditure analysis; USAID 2009 Papua assessment
294 Ibid.
provision in the province was that disbursement of the Special Autonomy budget allocation from the province to the districtsmunicipalities did not begin until 15 July 2003. In fact, more than half
of the funds were not disbursed until the end of November.
295
Established districtsmunicipalities receive their entire shares as cash transfers, whereas newly formed district and municipal
governments received only 40 per cent of their share as cash transfers, while the remaining 60 per cent stayed under provincial control to fund programmes mutually agreed on by the
provincial and districtmunicipal governments.
296
According to a 2009 USAID report, development funds have mostly been used to fund the civil service and government administration, followed by infrastructure.
297
Only a very small portion has been allocated for development activities in the villages. There is a widespread realisation
that this condition needs to be reversed so that the majority of the budget is available for the people. In an attempt to realize this purpose, the utilization of Special Autonomy budget
allocations is focused on increasing public services for people in the districts and villages. Funds are channelled through the Village Strategic Development Plan RESPEK, Rencana Strategis
Pembangunan Kampung.
298
Evaluation of the impact of this strategy as it begins to take hold will be important for ascertaining whether it has been an effective approach to accommodating
community needs and providing local level services.
A second problem related to budgets in practice under Special Autonomy is the extent to which they are child-friendly and prioritise children’s needs. For example, improving education is
important so children will attend schools that mainstream HIV awareness and knowledge of reproductive health in the province. With the passing of the Special Autonomy Law, 30 per cent
of central government transfers were to be allocated for education. Some stated during the interviews that despite the promise of free education, the burden on poor families remains see
FGD results discussed earlier in this subsection. Others saw the funds from Special Autonomy as having accelerated education in the province.
“Special Autonomy funds have been opening doors for educational opportunities to Papuan children. Prior to the Special Autonomy Law, children whose parents were too poor to
afford school would probably never have had a chance to obtain a good education. Not anymore. Now all Papuan children can go to school for free, not only here in Papua, but also
outside of Papua. Our school has alumni who have attended some of the best universities in Indonesia. They receive full scholarships from the provincial government. Without the
Special Autonomy funds that may not have been possible. High school teacher, Jayapura, 15 September 2009
However, the provincial government faced serious criticism in 2008 for allocating insuficient funds to education, in breach of the Special Autonomy Law. The disbursement of Special
Autonomy funds was arguably not in line with existing regulations. An NGO worker explained that only 4.7 per cent of the provincial budget APBD, Anggaran Pendapatan Belanja Daerah in
2008 was actually being spent on education, which was in contravention of the national law on the education system, which stipulated that at least 20 per cent of regional budgets must be spent
on education, and of the Provincial Regulation No. 52006, which mandates that the provincial government spend 30 per cent of the Special Autonomy funds on education.
299 295 World Bank 2005 Papua public expenditure analysis
296 World Bank 2005 Papua public expenditure analysis; USAID 2009 Papua assessment 297 USAID 2009 Papua assessment
298 UNDP 2007 Harmonization of human development programme and donors in Papua Province; USAID 2009 Papua assessment 299 Interview, Jayapura 14 September 2009; APBD Papua 2008 Abaikan Anggaran Pendidikan, available at: http:www.inilah.comberita
politik2008020210283apbd-papua-2008-abaikan-anggaran-pendidikan Last accessed 25 January 2010
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Furthermore, in 2009 the education budget gave insufficient funds at the provincial level for the nine-years compulsory education programme, which is a priority programme for the provincial
government.
300
Funds for early childhood education were slashed from IDR 6.65 billion in 2008 to IDR 930 million in 2009.
301
Likewise, funds for junior secondary school have fallen from IDR 35.01 billion in 2008 to IDR 2.83 billion in 2009.
302
In contrast, operational fees saw a dramatic increase, from IDR 8.48 billion in 2008 to IDR 28.04 billion in 2009.
303
These additional funds were allocated to cover fees related to coordination, development and monitoring in general.
304
Others have criticized the provincial government for expanding tertiary education at the expense of basic education.
305
A number of prominent educators in the province have highlighted the shortage of vocational training opportunities for Papuans, a key gap in the educational system.
306
In the absence of a better education policy and a stronger commitment to elementary education, it is difficult to see how Papuans’ participation rates in the growth sectors of the economy can be
improved.
307
Consultative development planning processes: The musrenbang Section 4.1 outlined how the musrenbang consultative development planning system was
designed as a bottom-up process to incorporate community views on needs and priorities. The case study on NTT highlighted that this process tends to be dominated by elites at each level and
that in some districts there is an absence of women’s and children’s voices both as participants in the forum and as reflected in the priorities which are set, and consequently in the planning
process, regulations and budgets.
In Papua various studies have found that community participation in district priority-setting and planning varies widely across districts. There is uneven commitment from regional
leadership, partly because the process is new.
308
Participatory development cannot be introduced successfully without the strong political support of local government leaders. The degree of
commitment to such ideas and willingness to implement a participatory approach also varies across Papua.
309
The government at the provincial level and in some districts in Papua does express willingness to involve multiple stakeholders in the decision-making process. However, effective participatory
planning in the region faces a number of challenges, especially for women, children and CSOs who often have the best idea of how to improve their situation. In 2006, a study of the
policymaking process in Papua by the University of Cenderawasih found that policy impacts on the poor and women are also scarce.
310
Furthermore, it found that CSOs often participate in an evaluation of budgets only after they are spent.
311
Members of these groups still frequently have a limited understanding of the complex steps regional governments take to decide on allocation
300 USAID 2009 Papua assessment 301 Ibid.
302 Ibid. 303 Ibid.
304 Brata, A. G. 2008 The Creation of new regions in Papua: Social welfare vs. elite interests; USAID 2009 Papua assessment 305 Elsham Papua Barat 2007 2006 year end report, available at: http:www.westpapua.ca?q=ennode459 Last accessed 10 November
2010 306 Ibid.
307 Ibid. 308 Halmin, M. Y. 2006 The implementation of Special Autonomy in West Papua, Indonesia: Problems and recommendations
309 USAID 2009 Papua assessment 310 Universitas Cendrawasih 2006 Studi evaluasi kebijakan dan implementasi otonomi khusus di Tanah Papua tahun 2002-2006
311 Ibid.
of regional budgets.
312
The resulting lack of partnerships with local government and legislatures means that the overall influence of CSOs remains limited.
313
This is particularly problematic for HIV and AIDS prevention, given that people in these organisations are often working most closely
with affected populations and providing the supporting services that they need.
The needs of women and the poor are often not taken into account in budgeting because these groups are not represented in regional executives or legislatures.
314
There is also a general lack of community confidence that the musrenbang process will satisfy their needs, with many
stakeholders viewing the practice as part of window dressing by regional elites to push forward narrow, self-serving agendas.
315
As a result, people’s participation is mostly still deemed cosmetic.
316
Participants in the FGDs in Jayapura municipality, including government workers and NGO activists, asserted that at the sub-district level they are increasingly resigned to the reality
that inputs from communities are either not incorporated into the municipal plans, or are not translated into budgeted programmes. As one government worker in Jayapura put it,
“Musrenbang is just pro forma. It’s in place because we have to do it. But we can’t say that it represents people voice if people’s needs are not taken into account in planning and policy
implementation which follows on from the musrenbang.” 17 September 2009
Other participants stated that public participation does not matter much since ultimately those who run the campaign for particular political candidates tim sukses will determine policymaking
and implementation.
From both secondary data collection and interviews conducted for this report, it is evident that in the two-step process to policymaking, community needs, including those of women and children,
are not generally captured in the musrenbang. If these needs are represented, they are not always prioritised when it comes to the formulation of strategic plans, government regulations, action
plans and budget processes. Indeed, practitioners working in communities, for example on the issue of HIV and AIDS, are not always consulted in the policymaking process.
Nevertheless, the provincial government has gone some way to trying to elicit community views about widespread needs through the ‘Going Down to the Village’ TURKAM, Turun Kampung
programme. This initiative has been undertaken annually by Governor Barnabas Suebu in an effort to talk directly to constituents. For example, between 4 June and 30 August 2007, the
Governor visited 34 locations. In each location, the Governor not only met and held dialogues with local authorities, districtmunicipal, sub-district and village governments, but also with
community members in villages. Following the TURKAM, according to Governor Suebu 2007, the provincial government was further alerted to the pervasive poor condition of public health,
including nutrition, health services and health seeking behaviour.
317
While this was no surprise, dialogues resulted in not only greater attention to the problems and a closing of the gap between
policymakers and beneficiaries, it also encouraged a holistic approach to beginning to address the
312 Ibid. 313 Ibid.
314 USAID 2009 Papua assessment 315 Ibid.
316 Ibid. 317 Suebu, B. 2007 People driven development, Provincial Government of Papua: Jayapura
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problem based on the ideas presented by villagers and local level policymakers themselves.
318
While it is unclear to what extent women’s and children’s voices were accommodated in the TURKAM, in the future it could provide a useful space for ensuring not only that women’s and
children’s needs are prioritized, but also also it could drive the commitment needed to ensure that policies and budgets will be woman- and child-friendly.
Institutional capacity to deliver services The 2007-2011 Strategic Plan for HIV and AIDS Reduction in Papua Province is very much in line
with the national Operational Plan for HIV and AIDS Reduction. The 2007-2011 Papuan Strategic Plan for HIV and AIDS Reduction attempts to create ownership of the HIV and AIDS problem
among Papuans through the motto ‘Mari kitorang bertanggung jawab’ Let’s be responsible. In light of the severity of HIV and AIDS problem in Papua, the 2007-2011 Papuan Strategic Plan for
HIV and AIDS Reduction calls for all districtsmunicipalities with at least 5 per cent HIV and AIDS prevalence to create strategic plans and work-plans to address HIV and AIDS with comprehensive
and sustainable programmes.
The 2007-2010 Papuan Strategic Plan for HIV and AIDS Reduction emphasises the goal of enhancing the independence of people including children with HIV and AIDS, and afirms
their rights to obtain education, employment, and to access social and health services and alternative care. The focus on children and young people is crucial in planning for HIV and AIDS
interventions, given that the previous discussion has highlighted the fact that many young people in Papua are sexually active.
However, implementation of such plans may be weakened by institutional capacity to deliver services, as discussed in the case of malnutrition in NTT and thus will not be further elaborated
here. Similar to the case of NTT, the following challenges were identified in Papua based on a number of in-depth interviews and FGDs conducted:
• Uneven and insuficient numbers of staff with the training and capacity to deliver health and education services, particularly in remote regions.
• Problems of interpreting laws and regulations enacted by the province, or absence of such laws and regulations.
• Uneven capacity and insuficient time in some districts to conduct musrenbang and concurrent district planning processes in coordination with local development planning agencies
BAPPEDA, local sectoraltechnical offices, the district executive and the parliament. This includes incorporating musrenbang priorities into strategic plans, drafting these plans,
designing appropriate action plans, regulations and policies, and drafting local budgets, as well as monitoring progress.
• Staff turnover and greater staff requirements with formation of new districts and administrations.
At the most basic level, some government institutions in Papua are ill-equipped to handle all of their responsibilities under Special Autonomy, especially at the districtmunicipal and sub-
district levels, although this is slowly improving. An important pre-condition for the successful implementation of the Special Autonomy Law and the achievement of Papua’s development
vision and mission is the development of key capacities within local government and civil society to formulate and implement appropriate, locally-specific and targeted development
318 Ibid.
programmes across Papua.
319
All districtmunicipal governments have attempted to make adjustments in planning, operations, budgeting and staffing during the transition toward Special
Autonomy, to ensure that the provision of public services is not disrupted and that governance reform progresses smoothly. Capacity, however, is still far from adequate to achieve operational
efficiency under the Special Autonomy Law and related developmental programmes. For example, schools are often understaffed to the extent that teachers teach multiple grades.
320
Results from in-depth interviews and FGDs also highlighted the need to strengthen the capacities in data collection, analysis and reporting, policy preparation, planning, programme
implementation, and monitoring among local government agencies. This is in line with the similar challenges outlined in the case study on NTT and will not be further elucidated here.
Nevertheless, the following quotations from participants in Jayapura are illustrative:
“The bottom line is that many practitioners are not aware of the importance of data for planning. We need to scale up the socialisation on the importance of data gathering and data
management. We also need to collect different types of data for planning different kinds of programmes.” Child protection oficer, Jayapura, 15 September 2009
“Due to limited human resource capacity in the civil service, allocated budgets often do not correspond to district needs. How can it possibly correspond to needs when ‘budget
planning’ consists mostly of copypasting budget figures from other districts’ budgets?” Jayapura, 15 September 2009
4.3.5.4 Local government initiatives and challenges to combating HIV and AIDS: The scale of the problem within a context of institution building
A number of initiatives are underway to endeavour to reduce the spread of HIV and AIDS in Papua, but they continue to face the complex environmental and institutional challenges outlined
above as well as problems of coverage, outreach, quality and availability. These initiatives include the following:
• The provincial government has introduced counselling in schools to increase awareness about
HIV and AIDS. • The National Family Planning Coordinating Board BKKBN, Badan Koordinasi Keluarga
Berencana Nasional distributes medicines and vitamins for free in cooperation with some NGOs, such as Yayasan Harapan Ibu YHI, or Mother’s Hope Foundation. However, this
initiative faces a number of challenges. Often only female sex workers with knowledge of HIV transmission are willing to come to mobile clinics for check-ups, and this is difficult due to the
limited facilities.
321
Even though infected street sex workers are encouraged to use protection during the sex, this doesn’t always take place, especially if they have been drinking with clients
or the clients refuse to use protection. Some clients find other sex workers who are willing to not use protection, while others beat the sex workers who refuse to have unprotected sex.
322
319 UNDP 2005 Papua needs assessment; Universitas Cenderawasih 2005 Papua public expenditure analysis and capacity harmonization: Papua province report
320 Universitas Cenderawasih 2005 Papua public expenditure analysis and capacity harmonization: Papua province report; Universitas Cendrawasih 2006 Studi evaluasi kebijakan dan implementasi Otonomi Khusus di Tanah Papua tahun 2002-2006
321 Interview with counsellor, Yayasan Harapan Ibu 15 July 2010 322 Ibid.
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• The ‘Jayapura meeting’ was held on 19 November 2008 with several goals: o To establish commitment and agreement among the national government, provincial
and districtmunicipal governments, 29 districtmunicipal parliaments, as well as cultural, religious, and community leaders to accelerate and widen efforts to control the HIV and
AIDS epidemic in Papua.
o To develop a strategy and work-plan for prevention and control of HIV and AIDS in 29 districtsmunicipalities in Papua, to be supported by strengthening and improving public
services related to HIV and AIDS throughout Papua. • The beginning of 2006 saw the establishment of speciic budget allocation for prevention and
control of HIV and AIDS in the provincial budget. Since 2002, the Papua provincial budget had already made budget allocations for prevention and control of HIV and AIDS in 29 districts and
municipalities, as follows
323
: o 2002: IDR 490 million
o 2003: IDR 3,487 million o 2004: IDR 4,435 million
o 2005: IDR 2,162 million o 2006: IDR 6,500 million
o 2007: IDR 28,389 million
• The Special Autonomy fund has enabled some districts, such Jayapura, to build dormitories for homeless children.
324
• Joint initiatives between regional governments and NGOs such as Family Health International and the Global Fund for an initiative on information, education and communication IEC,
known in Indonesia as ‘KIE’. Billboards have been placed along the street in Jayapura promoting safe sex and monogamy. Earlier discussions on the need for culturally appropriate
messages have pointed out that mass communication drives without the participation of traditional leaders are less effective. Leaflets have been also been distributed and are available
in puskesmas and distributed in schools.
325
Mobile clinics are used by some puskesmas for KIE to spread knowledge and information in isolated areas. Others visit bus terminals, places
where motorcycle taxis congregate, schools, and student accommodations. Such initiatives are usually undertaken by CSOs. However, some indicate that they are not always welcome and
have been asked to leave because due to embarrassment causes at the target locality, where people think they are being accused of engaging in risky behaviour.
• Free condoms are provided at puskesmas in boxes near the exit. The boxes are placed in a discrete location so that people are not embarrassed to take them.
326
• VCT services are available at some puskesmas, but not all due to insuficient staff, and at present are prioritised for high-prevalence and strategic areas, for example areas where
migration is concentrated. A VCT team should consist of one doctor, two counsellors, two case managers and one laboratory technician. More staff are needed in newly formed regions,
which have been created since Special Autonomy.
327
However, similar to the case of poor parents’ reluctance to take their children to hospital for treatment for malnutrition for reasons
like lack of provision of food for accompanying parents, some are reluctant to undertake the journey to VCT centres as they cannot afford transport and other associated costs.
• An HIV and AIDS peer education programme was introduced to junior secondary schools in Papua to provide basic information on HIV prevention and transmission. These activities were
conducted mainly in grade seven, in seven districts.
323 Researcher at Cendrawasih University and founder of Yayasan Harapan Ibu 16 July 2010 324 Government staff, Jayapura 9 September 2009
325 Puskesmas staff 13 August, 2010 326 Staff of different puskesmas in the region 10 and 13 August 2010
327 Health service providers in a variety of puskesmas and health clinics 10-13 August 2010
However, challenges for government initiatives to combat the problems have been identiied by a number of different interviewees working in HIV and AIDS prevention, particularly relating to the
district level parliaments and some executives. These include:
• Weak political commitment to tackling the problem • Weak leadership and lack of awarenessconcern among bureaucrats
• A tendency to view HIV and AIDS purely as a health issue • Low technical capacity of programme staff
• A tendency not to view HIV and AIDS as a real threat to the people’s welfare
In addition, not all districtsmunicipalities have set up the legal apparatus and regulations pertaining to the prevention and control of HIV and AIDS.
328
On 2 February 2007, a Special Regional Regulation was passed on Special Autonomy Budget Allocations, mandating a 15 per
cent special budget allocation for health. Funding for prevention and control of HIV and AIDS is taken from this health budget. However, to this day the health sector budget allocation remains
under 15 per cent of the regional budget.
Newly created regions have added to the need for greater administration capacity, larger numbers of civil servants and more service provision. In some cases, more service provision may
have been required previously but larger districts were unable to accommodate these needs. As one puskesmas nurse describes it,
“District splitting means more services need to be provided. Previously, one institution would have handled one region. Suddenly, there are two regions. Automatically this splits
the manpower base. Some stay in the original part of the district, others move to the new district. This leads to high levels of transfers but new staffs are limited in their capacity. At
the very least we can try to hold on to staff until their replacements come. We can’t avoid transfers, often they are the result of promotions. But it does mean that we lose staff who
are trained to handle things such as VCT.” Puskesmas Head, Padang Bulan, 10 August 2010
Various nurses and medical staff in the interviews described challenges for those who are suffering from AIDS. They are often not able to stay in hospital for an extended period as
required. Even if they have health insurance for the poor, it does not cover all of the costs associated with care, such as for prescriptions. Often they end up in hospices or being cared for
by CSOs. When hospices are unable to accommodate a patient, relevant organisations working in the region encourage home-based care, and they send voluntary teams usually from faith-based
organisations to provide support for families.
329
The hospices are often funded by churches, but the voluntary teams represent all five nationally recognized religions.
The Provincial AIDS Commission has no specific programme targeting children, despite this being a part of the national strategy. The chairman explained:
“The problem of HIV and AIDS is very complex, particularly because tackling the problem involves changing behaviour which is not easy in populations with low education, let alone
in a region which is as large as Papua. So we try and work together with our friends from civil society organisations - divide up the tasks, you know. Indeed, to date we have not
begun to talk about the problem in terms of teenagers, because of the scope of the HIV
328 Ibid. 329 Director of the Waena and Abepura hospices 12-13 August 2010
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THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 261
and AIDS problem. We very much know that preventing HIV infection can be strengthened through educating teenagers. We have high hopes for UNICEF to be able to tackle the
problem of educating teenagers.” Chairman of the Provincial AIDS Commission, Jayapura, 10 August 2010
However, some CSOs Youth Forum; Life Skill Education, supported by UNICEF and religious organisations, such as Muhamadiyah, are working in education and information dissemination
in the region and work both in partnership with and independently of the Provincial AIDS Commission. Some use peer educators, others work through religious boarding schools, in state
schools and in universities, using modules developed by the Provincial AIDS Commission and the Global Fund.
330
However, some parents resist provision of education on reproductive health in religious institutions because they consider it to be in contradiction with religious values.
331
A youth centre was established in Jayapura by the Provincial AIDS Commission using UNICEF funding.
4.3.5.5 CSO and NGO innovations and challenges It is clear from the discussion above that CSOs and NGOs have played a large role in filling the
gaps in government service provision for HIV and AIDS prevention, and care for people living with HIV or AIDS. Some of these receive grants from government such as from the Ofice of
Social Affairs for staple foods for PLHIV and AIDS sufferers, and others from international agencies including from USAID, Global Fund, UNICEF, HCPI AusAID and the Mennonite Central
Committee. As has been discussed previously, non-government support includes education and outreach through KIE, providing hospice and home-based care, halfway houses for street children
or children forced into sex work, and other forms of care and support for livelihoods. Many of the HIV and AIDS prevention and education initiatives are implemented by NGOs.
However, coverage is uneven, as is the quality of the information and services provided. NGOs face tremendous challenges in their ight against HIV and AIDS in Papua. An in-depth interview
with a medical doctor revealed that the NGO community in Papua is small in number and local in focus. Many of the staff are young, and new NGOs that are still ‘learning to be NGO’.
332
Despite their efforts to improve HIV prevention, their size and numbers are insuficient to change the
direction of the epidemic. Some common issues raised by NGO staff during the interviews for this research include:
• Concern about over reliance on donors and sustainability of their own organisations; • Dificulty of access to timely technical information, support and skill training;
• Weak but improving collaboration among NGOs; and, perhaps most importantly, • The continuing urgent challenge of scaling up - either on their own or in collaboration with
government - to increase quickly and significantly the coverage and effectiveness of prevention and care services.
According to interviewed sex workers, they need assistance from the state in the form of: • Housing, especially if they are infected with HIV or AIDS.
• Free ART and related medicines, and easier access to this for PLHIV and AIDS.
333
• Assistance in skills building and inding alternative employment. Yayasan Harapan Ibu also focuses on skills improvement in book keeping and crafts.
334 330 Variety of CSO practitioners and religious organisation staff working in HIV and AIDS prevention 10-14 August 2010
331 Ibid. 332 Jayapura 15 September 15, 2009
333 Interview with Natalia and Sheila names changed, Jayapura 10 August 2009 334 Interview with a counsellor, Yayasan Harapan Ibu 15 July 2010
4.3.5.6 Recommendations for improving HIV and AIDS prevention The discussion above highlights the institutional challenges for policymaking under Special
Autonomy in general, and also speciically as it relates to HIV and AIDS prevention. To improve service provision overall, so that it redresses the multitude of vulnerabilities that women and
children face in Papua, the discussion above has identified that greater efforts need to be made under Special Autonomy to:
• Strengthen the regulatory framework; • Improve coordination among sectoral agencies and between levels of government;
• Increase the disbursement of funds for education and health and related to HIV and AIDS
prevention campaigns; • Increase the number and capacity of civil servants to plan, budget, implement and monitor
programmes that redress vulnerabilities for women and children at both the provincial and the districtmunicipal levels;
• Establish sectoral budget lines for HIV and AIDS in addition to the budget of the AIDS Commission;
• Provide greater facilitation in the musrenbang process to ensure that the voices and needs of children and women are both prioritised and acted upon;
• Build the commitment of government leaders to both prioritise the musrenbang and to incorporate it into district strategies, plans, budgets and programmes; and
• Provide greater guidance and support for district level governments. FGD participants identiied that more effective efforts to combat HIV and AIDS in the province
should take into account the following:
• Programme synchronisation and a joint focus are crucial. • Prevention and control programmes must be in line with initiatives in other sectors to tackle
the roots of the problem. A comprehensive approach is needed whereby HIV and AIDS programmes collaborate with prevention and control programmes for other communicable
diseases, such as tuberculoses.
• Prevention and control programmes must be better coordinated in order to involve all relevant stakeholders. A comprehensive approach is necessary because the incidence of HIV and AIDS
among children shows that the problem must be managed with inter-sectoral cooperation. For example, many children leave home due to parental neglect or because of domestic abuse,
and hence the issue is closely related to child protection. In order to make a living, some of these children leave school and enter into prostitution, making this an issue closely related to
education. Many are then exposed to HIV and AIDS due to a lack of knowledge on the risks and transmission mechanisms of HIV and AIDS, which is a health and education issue.
• Widespread information and education campaigns on healthy living, prevention of STIs, nutrition, healthy homes, education and the economy are important.
• Prominent cultural and religious igures should play a large role in child development, educating the community on HIV and AIDS transmission in culturally appropriate ways. The
World Vision Hope project is one effort to work together with local leaders for prevention. • School lessons can and should be synchronized with cultural and religious teachings, such as
teachings on self-respect and respect for others. However, one challenge to this is convincing religious leaders to not treat the disease as one ‘which affects sinners’, which has been
problematic in the past. This is necessary for reducing the stigma attached to the disease. Furthermore this is problematic in relation to promotion of condom use, as some see such
messages as promoting sex outside of marriage, which goes against some religious teachings.
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THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 263
• Interventions need to be targeted in rural areas as much as urban areas, especially in places where migration is taking place, and where education levels are low. So far, most of the KIE
activities are targeted at urban areas.
Results of in-depth interviews and FGDs held at the provincial level and in Jayapura and Jayawijaya at the provincial and district levels have revealed that many believe that the single
most important priority for Papua Province is to decrease transmission of the HIV virus. This also requires better efforts at targeting both prevention and care initiatives for high-risk groups in the
main urban areas, and in and around rural areas that are rapidly developing. The respondents argued that emphasis should be on:
• Increasing the use of condoms among high-risk groups • Treating and preventing other STIs
• Discouraging the frequent change of sexual partners, or encouraging the practice of safe sex • Efforts to prevent the sharing of needles by IDUs
• Education on HIV transmission and condom use aggressively targeting young men and
women in both urban and rural sites • More services and care need to be provided for PLHIV
• Improving the provision and use of VCT and support and treatment services for pregnant women and youth
They also pointed out that not only have youth been identified as a vulnerable group, but they are the group that carries knowledge, beliefs and practices into the next generation. The impact
of a growing HIV prevalence, FGD participants argued, will irst increase as people move into towns for treatment and, second, as people migrate home to their villages in the end stages of the
disease. This second type of migration will place immense strain on families and communities in coping with sick and dying relatives.
Butt et al. 2002a and b argue that HIV prevention efforts need to be widespread in rural and urban areas.
335
In particular, rural men and women are highly mobile and frequently visit urban sites where they can engage in sexual behaviour with less fear of repercussions than in
their home communities.
336
To be effective, any intervention in an urban centre must have its counterpart in nearby and rural communities.
337
This issue is particularly crucial for Jayawijaya district, which at present has no signiicant urban or rural HIV education campaigns underway. It
is important to bear in mind that youth-specific health services are nonexistent, despite increases in risky behaviour.
338
It is important to note that Papua is the only province of Indonesia that has embarked on a systematic process to mainstream HIV and reproductive health education into the education
sector, to empower young people to take responsibility for their health and to provide them with the necessary skills to achieve this. UNICEF has supported this programme in the implementation
of life skills based HIV-related education in junior high schools. HIV and AIDS is integrated into the curriculum and into teaching and learning materials of a variety of different subjects, including
biology, religious studies and physical education. However, during the Veriication Reference
335 Butt, L., Numbery, G. and Morin, J. 2002 Preventing AIDS in Papua; Butt, L., Numbery, G. and Morin, J. 2002 ‘The smokescreen of culture: AIDS and the indigenous in Papua, Indonesia’
336 Ibid. 337 Ibid.
338 Ibid.
Group discussion held for the research for this SITAN in Yogyakarta about the indings of the studies in the case study provinces, it was clear that even in places such as Yogyakarta, where
there are higher levels of education compared with Papua, there is resistance to mainstreaming reproductive health in education for fear that education officials will be accused of condoning
sexual activity among students.
339
Papua may face similar challenges in mainstreaming reproductive health in education.
Furthermore, as was highlighted above in the discussion on the transmission of knowledge on HIV in culturally appropriate ways, education efforts need to take into account the local context
for communications strategies. Butt 2005 argues in line with the FGD respondents that tribal leaders need to be included in the education process.
340
Not only are they familiar with Papuan culture, but they also tend to stay in a particular location for a long time, providing an anchor for
their community. Butt 2005 further argues that both male and female tribal elders should be involved in education and communications efforts so that they can explain their concerns about
reproduction and the successful regeneration of the tribal group. Specifically, they need to help design the cultural components of province-wide rural health promotion and HIV communications
efforts. Their participation will ensure materials reflect widespread norms and values.
341
AIDS education efforts might consider how indigenous people can act as peer educators within specific
tribal groups and communities.
342