AIPHSS Progress Report July 2015

Australia Indonesia Partnership for Health Systems Strengthening is managed by Coffey on behalf of the Australian Department of Foreign Affairs and Trade

Australia Indonesia Partnership for Health

Systems Strengthening (AIPHSS)

Fifth Six Monthly Progress Report

Table of contents

Executive Summary ... i

1 Introduction ... 1

1.1 Background to AIPHSS ... 1

1.2 The AIPHSS Reform Agenda for Health System Strengthening ... 2

1.3 Program Framework ... 4

2 Relevance of AIPHSS ... 8

2.1 Contextual Analysis ... 8

3 Progress towards End of Program Outcomes (EOPOs) ... 10

3.1 An Effective National Health Insurance System ... 10

3.2 Minimum Service Standards (MSS) to support Primary Health Care Delivery ... 12

3.3 Accreditation of Local Health Service Centres ... 14

3.4 Equitable Allocation of Health Resources ... 16

3.5 Governance and Supervision of the Health System ... 19

3.6 Summary of Investment against EOPOs and Building Blocks ... 22

4 Implementation of the 2015 Work Plan ... 23

4.1 Management and Operational Systems ... 23

4.2 Implementation Progress against the Annual Plan ... 28

4.3 Challenges and Emerging Risks ... 32

5 Evaluative Summary ... 33

6 Priorities and Recommendations for the next reporting period ... 34

Annexes

Annex 1 Status of Implementation of Activities (Jan 2015 – June 2015) Part A – Progress of each AIPHSS intervention (June 2015)

Part B – Actual versus expected expenditure for each AIPHSS intervention (June 2015) Annex 2 Interventions and their contributions to end of program outcomes (EOPOs)

Annex 3 Status of AIPHSS Policy Notes including their dissemination, use and attributable changes Annex 4 Policies, Regulations and Guidelines produced during the reporting period and their

current status Annex 5 Risk Matrix

Annex 6 Knowledge Management Strategy – Executive Summary

Annex 7 Technical Assistance and Staff Mobilisation (Jan 2015 – June 2015) Annex 8 Draft Exit Strategy Outline

Abbreviations

ADINKES Association of Health Office (Asosiasi Dinas Kesehatan)

APBN Indonesian State Budget (Anggaran Pendapatan dan Belanja Negara) AIPHSS Australia Indonesia Partnership for Health Systems Strengthening AIPMNH Australia Indonesia Partnership for Maternal and Neonatal Health

ARF Adviser Remuneration Framework

BAPPENAS State Ministry of National Development Planning (Kementerian Perencanaan Pembangunan Nasional/Badan Perencanaan Pembangunan Nasional (Bappenas)

BAST Record of Transfer (Berita Acara Serah Terima)

BOK Health Operational Funding (Biaya Operational Kesehatan)

BPJS Agency for the Organisation of Social Insurance (Badan Penyelenggara Jaminan Social)

BUKD Directorate of Basic health Services (Direktorat Jenderal Bina Upaya Kesehatan)

CPMU Central Program Management Unit

CBG Case Based Group

DFAT Department of Foreign Affairs and Trade DHA District Health Account

DHO District Health Office

DTPK Special Program for Remote and low Resource Areas (Daerah Tertinggal, Perbatasan, dan Kepulauan)

EDP Executive Development Program

EOPO End of Program Outcomes

Flotim Flores Timur (East Flores)

GFTAM Global Fund to Fight Tuberculosis, AIDS and Malaria GIS Geographical Information Systems

GoA Government of Australia

GoI Government of Indonesia

HIV Human Immunodeficiency Virus

HPN Health Policy Network

HPU Health Policy Unit

HRH Human Resources for Health

HRMIS Human Resources Management Information System

HSR Health Sector Review

HSSCU Health System Strengthening Coordination Unit

HTA Health Technology Assessments

IPR Independent Progress Review

ISP Implementing Service Provider

IT Information Technology

IU Implementing Unit

Jamkesda Jaminan Kesehatan Daerah JATIM East Java (Jawa Timur)

JKN National Health Insurance (Jaminan Kesehatan Nasional) Kepmenkes Decree of the Health Minister (Keputusan Menteri Kesehatan) KSI Knowledge Systems Initiative

M&E Monitoring and Evaluation

MEP M&E Plan

MNCH Maternal Neonatal Child Health

MoH Ministry of Health

MoHA Ministry of Home Affairs

MSS Minimum Service Standards

NIHRD National Institute for Health Research and Development

NCDs Non Communicable Diseases

NHA National Health Accounts

NSPK Norms Standards Procedures and Criteria (Norma, Standar, Prosedur, dan Kriteria)

NTT East Nusa Tenggara (Nusa Tenggara Timur)

PBI Payment Premium for Poor

PERMATA Primary Health Care Strengthening and Maternal and Newborn Health

PF Performance Framework

PHA Provincial Health Account

PHC Primary Health Care

PJJ Distance Education Program (Pendidikan Jarak Jauh)

PMU Program Management Unit (PMU staff at province and district level) Poskesdes Village Health Post (Pos Kesehatan Desa)

PPJK Centre for Health Financing and Insurance (Pusat Pembiayaan dan Jaminan Kesehatan)

PPSDMK Centre for Human Resource Development in Health (Pusat Pengembangan Sumber Daya Manusia Kesehatan)

PD Project Director

PS (AIPHSS) Program Secretary (Roren)

PSC Program Steering Committee

PTS Program Technical Specialist

Pusdatin Data Centre of MoH (Pusat Data dan Sistem Informasi)

Pusdiklat Centre for in Service Education and Training of Human Resources (Pusat Pendidikan dan Pelatihan)

Puskesmas Community Health Centre (Pusat Kesehatan Masyarakat)

PusRengun Centre for Workforce Planning (Pusat Perencanaan Dan Pendayagunaan) Pustanser Centre for Standardisation, Certification of Human Resources (Pusat

Standardisasi, Sertifikasi dan Pendidikan)

RA Reform Agenda

Renstra Strategic Plan (Rencana Strategis)

RJPMD Regional Mid Term Development Plans (Rencana Jangka Menengah Pembangunan Daerah)

RJPMN National Mid Term Five Year Development Plan (Rencana Jangka Menengah Pembangunan Nasional)

Roren Ministry of Health, Bureau of Planning and Budgeting (Biro Perencanaan dan Peranggaraan)

SBD South West Sumba (Sumba Barat Daya)

SG Secretary General

SIKDA District Health Information System (Sistem Informasi Kesehatan Daerah) SKN National Health System (Sistem Kesehatan Nasional)

SLO Senior Liaison Officer

SOP Standard Operating Procedures

SP2TP Strengthening Information System for Primary Care

TA Technical Assistance

TNP2K The National Team for The Acceleration of Poverty Reduction (Tim Nasional Percepatan Pengentasan Kemiskinan)

ToR Terms of Reference

TTU North Central Timor (Timor Tengah Utara)

UHC Universal Health Coverage

UI University of Indonesia

UU Law or Act (Undang-Undang)

VFM Value for Money

Executive Summary

The Australia Indonesia Partnership for Health System Strengthening (AIPHSS) provides the Government of Indonesia (GoI) with a funding facility to address critical gaps in the health system at all levels of government. It addresses key reform issues including revitalisation of the primary health system; technical support for the national insurance scheme; strengthening health legislation under decentralisation of government; and the implementation of new minimum service standards. These make a significant contribution to improving access to better quality health care for poor and disadvantaged people in Indonesia. It is well recognised that investment in health outcomes contributes to thriving stable and economically productive communities.

AIPHSS has reached the point at which it is most relevant and demonstrating high levels of

sustainability for the majority of activities being implemented. The reforms being implemented align with national priorities and there is sustained and close interaction with senior policy makers in the Ministry of Health (MoH). The program has gained momentum and is delivering technical assistance that would otherwise be unavailable while providing models and tools for health system improvements at district and national levels and information to support evidence based decision making for policy development and allocative efficiency.

The partnership with the MoH remains strong, where AIPHSS continues to be a highly valued program. The most important factor which may affect this relationship is the impending budget cuts and the potential loss of impact on end of program outcomes due to the reduction in activities. During this reporting period (January – June 2015) adequate progress has been made in a number of critical areas and the level of activity expenditure has increased compared to the previous six months. There have been a number of factors contributing to the improvement in overall performance and effectiveness. These include:

 The development of the Health Systems Reform Agenda (RA), based on the Health Sector Review (HSR), the release of the new National Development Plan and the Ministry of Health’s Strategic Plan to guide investment priorities; and a clearer articulation of end of program outcomes to provide overall direction.

 Significant ownership of interventions under AIPHSS by implementing partners and a greater level of participation in work plan development and implementation activities under the guidance of a Technical Director (TD) and Program Technical Specialist (PTS) and support from the Implementing Service Provider (ISP).

 A reorganisation and consolidation of the ISP and Central Program Management Unit (CPMU) program delivery model to streamline management and operational processes. This has reduced transaction time and enabled the development of a more effective management system.

 Strengthening the monitoring and evaluation system to improve accountability and tracking of activity progress and relevance to outcomes.

Despite improvement in overall performance and strategic direction, many activities are still falling behind planned schedules; in particular progress at the national level has been slow. This is especially the case for the Bureau of Budgeting and Planning (Roren)1 and Bappenas (Ministry of National Development Planning). This is in part due to implementing units underestimating the technical complexity of many activities and the time required to develop and agree terms of reference (ToRs). There is also varying availability of staff in implementing units (IUs) to lead implementation. At the sub national level, East Java (JATIM) is on track with implementation while East Nusa Tenggara (NTT) is behind schedule by several months due to a lack of response from the District Health Office (DHO) regarding taking responsibility for AIPHSS initiatives and revision of work plans.

While only 36 per cent of the expected funding allocation has been spent for this period, over 62 per cent of activities are deemed to still be on track for completion as planned. The remaining 38 per cent are behind schedule, cancelled or have not commenced. Given the impending aid program budget cut

1 In Roren no staff were available to work on AIPHSS and two short term technical staff were recruited to specifically manage AIPHSS activities. This places Roren six months behind schedule for most of their work plan.

many of these activities will need to be re-assessed or postponed until other funding sources are available. 2

During the reporting period there have been over 8,000 (4016 males: 4345 females) participants engaged in training sessions and workshops. 3 The program has a significant reach across many different areas of the health sector and across different levels of government.

Progress and Achievements towards End of Program Outcomes (EOPOs)

General progress towards each of the EOPOs has been adequate, with the greatest progress being made towards achieving policies and procedures to improve the equitable allocation of health resources, followed by governance and supervision of the health system. These areas also have the highest level of program investment.

An Effective National Health Insurance Scheme

The Organisation of Social Insurance (BPJS) began operations in January 2014. Membership to the scheme has increased to nearly 140 million over this time (out of a population of 250 million) and demand is increasing. The scheme is designed to provide improved access to health care services and financial protection for individuals and families. However, by November 2014 the annual allocation was depleted and the fund required a government bailout. This is consistent with global experience.

To improve the effectiveness of the scheme, AIPHSS has been providing technical assistance and policy advice to BPJS with a focus on strategic purchasing including elements of cost containment and quality assurance. Further technical and financial support has been provided on National Health Accounts (NHA), Hospital Provider Payment System (INA-CBGs) and Health Technology Assessment (HTA) implementation for cost effective health care treatments. District Health Accounts (DHA) and Provincial Health Accounts (PHA) are also being produced to strengthen local financial planning and decision making.

Initial results indicate the scheme is on track to being more effective. The aim is to achieve improved quality and cost control, closer stakeholder collaboration to manage the hospital payment system and the institutionalisation of HTA in Indonesia.

Minimum Service Standards (MSS) to support Primary Health Care Delivery

New MSS were finalised during this reporting period. The delivery of MSS must be underpinned by legislation to ensure local governments allocate adequate resources to meet standards. This includes ensuring there are qualified staff, supervised correctly and provided with resources, guidelines and technical procedures.

During 2013-14 AIPHSS funded the revision of the MSS and health section of the decentralisation law. This revision is now encapsulated in Law-23/2014 which was enacted September 30th 2014. It is one of the most important achievements of the AIPHSS program which will have a major impact on the national service delivery system over time. The major activity in this reporting period was the preparation of the Norms, Standards, Procedures and Criteria (NSPK) which act as the implementing rules and regulations for the MSS.

The new law and MSS will impose a performance based planning and budgeting system for health programs at the district level. A model for this will be developed in the next reporting period. AIPHSS is now preparing a strategic approach to implementing the new legislation which places new functions and responsibilities on the DHO and Puskesmas. All of the AIPHSS districts are currently in the planning phase of providing technical assistance for restructuring to meet the new policies.

AIPHSS has also been instrumental in developing and supporting a Distance Education Program (PJJ) for midwives and nurses. This program is in its second semester with 87 students. So far the system has proven to be a cost effective way to facilitate training and there are already plans to scale

2

The overall aid program was cut by 40%. The actual reduction in budget for AIPHSS is currently under discussion.

3

Since the beginning of the program there have been over 26,000 participants involved in training and workshops comprising 13,049 males and 12,989 females.

up access with an estimated 116,000 nurses and midwives required to meet the new standards across Indonesia. The advantage is that students do not have to leave their place of work to undergo training and health services are not disrupted. As with most online education programs the main issues revolve around adequate bandwidth to ensure learning functionality, such as video

conferencing, and a requirement to be familiar with the technology or ensuring adequate technology support is available. A number of these constraints have been identified and actions taken to mitigate or minimise negative impacts (for example provision of hard copy materials up front). An evaluation of this training delivery mechanism was undertaken during this reporting period. The preliminary report indicating that despite constraints, it is an effective method of delivering training and the ‘best solution’ to improving the qualifications of health personnel (particularly women) in Indonesia.

Accreditation of Local Health Service Centres

AIPHSS is providing technical assistance to develop an accreditation system for primary health services that has the potential to improve the quality of frontline services nationally. The objectives for Puskesmas accreditation are to achieve:

1. Formal recognition by government that the Puskesmas has the right competencies to serve a community to the required standard providing 155 medical and referral services

2. A credentialing system for the BPJS to contract Puskesmas as the first level health service 3. Self-evaluation to enable continuous improvement to meet customer needs.

AIPHSS has been providing technical assistance to develop the accreditation system since October 2014. Overall the accreditation system has been implemented well. It is a high priority and a strategic investment by AIPHSS. It is expected that all activities related to the accreditation system will be completed in the next reporting period.

A future national roll out of the system will be a significant achievement attributable to the groundwork established by AIPHSS.

Equitable Allocation of Health Resources

AIPHSS has promoted evidence based policies and decision making to achieve a more equitable allocation of health resources. It has done this by supporting the Health Sector Review (HSR), completed in 2014, which identifies emerging health needs and gaps; revising legislation to clarify roles and responsibilities of health functions at all levels of government to ensure efficient use of resources; developing policies for human resource management for efficient allocation based on demand for services; and providing technical assistance to the national health insurance scheme which provides greater access to the poor. In addition, AIPHSS has provided technical assistance to support the efficient allocation of financial and human resources by supporting the development of district health accounts (DHAs) and workforce planning tools and guidelines.

All of these initiatives are considered sustainable because they are embedded in national and local policy processes and systems. There is a strong sense of ownership by partners. The uptake of policies and targets from the HSR indicate that AIPHSS has been able to help shape national health policy. The HSR was developed using a government led process with technical assistance provided by a range of international and national experts who were closely engaged in the government policy process. This led to a higher level of uptake of the HSR recommendations and targets in the governments five year mid-term development plan (RJPMN) and the MoH Strategic Plan. AIPHSS has been providing technical assistance to also promulgate these policies and strategies to regional and local level strategic plans to influence the allocation of health resources at the local level, and ensure a focus on public health and prevention.

To further strengthen evidence-based policy development, a Health Policy Unit (HPU) was established on April 1 in the MoH during this reporting period. The intention is to provide senior advisers with current information on emerging health policy priorities and to channel research

provided by AIPHSS to assist in policy formulation and lead policy dialogues. The first policy dialogue was conducted in May 2015 on pharmaceutical policy and the high cost of drugs in the era of the national health insurance scheme. This discussion resulted in a recommendation to seek cross-sector partnerships involving the private sector to address the issues. The HPU have also prepared

provincial-level stewardship guidelines for North Sulawesi; a policy brief on stunting; and guidelines for integrated Monitoring and Evaluation (M&E) for Roren.

Building a human resource information system at the national level is a major ongoing activity. This is complemented by technical assistance to develop needs-based workforce planning approaches. In addition AIPHSS has assisted in formalising the tools to ensure all Human Resources (HR) planners have approved guidelines in planning HR requirements in health facilities. Together these initiatives will lead to a more efficient and effective approach to the allocation of human resources for health as well as strengthened capacity. These initiatives have commenced during this reporting period and are on target for completion in 2016.

A revision of health data collected by Puskesmas (SP2TP) has been an ongoing activity. The current extensive data collection requirements are creating a significant burden with limited utility. The purpose is to streamline collection so that data can be better used for planning and decision making, particularly in the allocation of health resources. The activity is going through a technical review due to problems with the technical team not conducting adequate coordination with the district levels. This process should be completed in the next reporting period.

Governance and Supervision of the Health System

A wide range of AIPHSS interventions contribute to improving the governance and supervision of the health system. In this reporting period the focus has been on the implementation of an Executive Development Program (EDP) for strategic management of human resources. Forty senior staff from MoH have participated in the first part of the program and another 40 are being trained in workforce planning techniques and tools.

At the local level, the focus has been on getting technical assistance to support restructuring and organisational development to meet the new legislative requirements and roles and responsibilities under MSS implementation. This initiative is currently underway but once completed will provide a new organisational model that can be potentially be used in other provinces and districts.

Communication and coordination within the MoH and across levels of government is a key strength of the program and is an ongoing process, which is contributing to good governance. Specific initiatives

undertaken during this reporting period include: conducting quarterly technical coordination meetings; holding policy dialogues or discussion forums on key policy issues; implementing the Health Policy Unit (HPU); and implementing the Health Systems Strengthening Coordination Unit (HSSCU). All of the initiatives have the support of the Secretary General and will be important in transitioning program interventions to counterpart operations towards the end of AIPHSS. The HSSCU was established at the request of the Secretary General to coordinate all donor funded activities. This Unit could be instrumental in helping AIPHSS initiatives gain ongoing support from other donors towards program completion.

Distribution of Investment

The figure below illustrates the level of investment for 2015 in each health system building block and the corresponding contribution towards the EOPOs. The greatest proportion of investment in this reporting period is directed towards achieving an equitable allocation of health resources based on evidence-based decision making, good governance and strengthening human resources for health.

Challenges and Emerging Risks

Without sustained investments in some key areas the program is in jeopardy of not achieving all desired outcomes. This impact can be mitigated through the development of an AIPHSS exit strategy that focuses on transitioning key activities to other funding sources and prioritising those that will provide the most benefits to stakeholders.

The proposed 40 per cent budget cut4 during the last phase of the program will have a significant impact on many parts of the program that have begun to gain ownership and momentum. The key risks and challenges are:

 Cutting existing programs risks losing the full investment in the activity: Many activities are only partially completed and may not be sustainable if cut prematurely. Careful consideration will need to be given to how activities will be transitioned.

 Expectations will need to be managed. During the first quarter of 2015 IUs were strongly encouraged to progress rapidly with their work plans in order to disburse funds. The potential budget cuts will now mean many activities will need to be scaled back rapidly.

 Developing an Exit Strategy: Each activity will need to be examined in terms of strategic importance, level of investment, time to completion and funding required for ensuring sustainable outcomes. The exit strategy will need to identify how existing investment can be preserved and what can be transitioned to other government programs.

The other significant challenges will be staff retention and knowledge management. As the program nears completion, there is a likelihood that staff will seek other opportunities. Knowledge management therefore becomes critical during this period. A knowledge management strategy has been developed and it will be critical that it is implemented successfully in the next 12 months to ensure ongoing initiatives developed by AIPHSS can be continued by partners and the program is used as a foundation for future health system strengthening.

4

This is the overall budget cut to the aid program. The specific budget cut to AIPHSS is currently under negotiation.

1 2 3 4 5

Service Delivery 0 293,701.4 1,001,584.06 1,457,759.81 184,002.47

HRH 0 0 0 5,120,877.67 1,851,550.42

Health Financing 2,060,277.40 12,620.95 - 1,590,072.91

-Leadership 90,314.62 556,568.40 0 1,721,803.62 1,684,556.85

2,000,000.00 4,000,000.00 6,000,000.00 8,000,000.00 10,000,000.00 12,000,000.00

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Health Insurance

MSS Accreditation

Equitable allocation of resources

Governance and supervision

Evaluative Summary

Relevance: The AIPHSS is at its most relevant phase. The Reform Agenda has ensured that the program is aligned with the Ministry of Health’s strategy and highly relevant in addressing the underperformance and equity problems related to health systems development. The program is valued by partners as a mechanism which provides national and international technical assistance and financial resources which is difficult for them to access at short notice. The program is also strongly aligned with DFAT’s Health for Development Strategy (2015-2020) with investment in xxx ? strengthened, resilient public health systems being the highest priority.

Effectiveness: The AIPHSS program is now mainly focused on national level policy development and systems change, guided by the new Reform Agenda but also includes testing and piloting policy implementation at the sub national level. The success of the HSR, changes to the decentralisation laws and MSS demonstrate effectiveness of the program at a policy and sectoral reform level. This has the potential to influence organisational changes of district health offices and the quality of health care at a much broader scale than just AIPHSS provinces. With the addition of the TD and changes to the management structure, the program has a more effective delivery system. Access to senior management has improved, which facilitates more effective uptake and ownership. Interventions are now aligned with end of program outcomes so their effectiveness in contributing to end of program outcomes can be evaluated for priority setting.

Efficiency: A clearer and more efficient management model is now in place with increased activity over the current reporting period. There is now a more efficient flow of information and decision making with one management and operations unit. The rate of implementation and disbursement was slow in the first half of this reporting period, nevertheless by June 2015 almost 62% of the work plan activities have commenced to the planning and or implementation stage; 36% of overall funds have been disbursed against planned expenditure. However, activity expenditure by IUs is still low at just over 10% of budget indicating either inefficient government systems or poor planning and internal resourcing.

Monitoring and Evaluation: The monitoring and evaluation system continues to respond to changes in the program and is now aligned with new EOPOs. The M&E Plan was updated and three

independent evaluations have been completed with another eight planned. The M&E system has restructured around the new program logic model and monitors progress against EOPOs as well as health system building blocks.

Sustainability: The AIPHSS is embedded in the national systems, where all key decisions about activities are made by partners. Outputs and outcomes have a higher probability of being sustained. The majority of AIPHSS activities are part of larger GoI policy development and program

implementation. The program provides resources which accelerates implementation of GoI initiatives and targets system bottlenecks.

Gender equality: An internal review of gender and social inclusioncommenced during this reporting period. The report will highlight any key areas of focus for the remainder of the program. . Based on available sex disaggregated data collected during meetings, workshops and training for the reporting period, there is a high level of participation of both sexes across all intervention areas.

Risk Management and Safeguards: Risks are carefully monitored and managed as part of the programs management. The risk register is updated monthly and distributed to partners. Any critical areas are escalated immediately when they become apparent. The most significant risk at this juncture is the cut to budgets at a point when the program has gained significant momentum.

Innovation and Private Sector: The program has developed many innovative approaches to addressing development problems in the health sector such as distance learning for nurses and midwives. Many pilot activities represent good models for scale up. AIPHSS has developed a unique approach to implementing a horizontal strategy (health systems strengthening approach) while cognisant of the need to integrate vertical programs. The program has also identified areas where cross-sector partnerships, involving the private sector as key partners, could address critical issues such as the distribution of drugs to the poor and disadvantaged. There is no direct activity related to the private sector except in the work force planning and projection activity, which is analysing the scope of the private sector in the production of human resources that are then active in the private sector facilities.

1

Introduction

This report is the fifth Six Monthly Report for the Australian Indonesia Partnership for Health System Strengthening (AIPHSS). It covers the period from the beginning of January 2015 until the end of June 2015.

The structure of reporting has changed during this period to provide a focus on End of Program Outcomes (EOPOs)5 and contributing intermediate outcomes. A revised program logic model was developed by key stakeholders in February 2015 and five revised end-of-program outcomes were agreed with the Department of Foreign Affairs and Trade (DFAT) Health team. This led to a revision of the interim Monitoring and Evaluation Plan (April, 2015) and changes to the performance

framework. The program reporting now reports progress against these revised end-of-program outcomes which is discussed in Section 3.

This period also reflects the implementation of the new “Reform Agenda for Health System Strengthening” finalised during the last reporting period and emanating from the Independent Progress Review (IPR) conducted in the first quarter of 2014. This process adopts a systemic approach to health systems reform focussing on four components or “health system building blocks”: (1) Leadership and Governance; (2) Health Financing; (3) Human Resources for Health; and (4) Service Delivery. Work plans implemented by Implementing Units (IUs) for this period use this building block structure for reporting on activities and outputs.

Given these recent changes, the introduction section of this report provides an updated summary on the background to AIPHSS, the Reform Agenda (RA), and the current Program Framework. This illustrates how the implementation framework, which is based on the Reform Agenda and health system building blocks, is used to deliver the end-of-program outcomes in support of the broader program goals (see program conceptual framework p.6 below).

Section 2 provides a more detailed analysis of the relevance of the program in relation to the current Australian government aid policy. It explores the political economy, key contextual factors and the expected benefits of the investment.

Section 3 provides a summary of progress towards end-of-program outcomes. This is a synthesis of the program’s contribution to each of the outcomes through an analysis of major activities and outputs facilitated by AIPHSS.

Section 4 describes current implementation processes, challenges and emerging risks, as well as progress against the Annual Implementation Plan including planned versus actual expenditure. Section 5 provides an evaluative summary of the program against the Aid Quality Criteria, including cross cutting issues such as gender and social inclusion.

Section 6 outlines priorities for the next period and recommended improvements to program implementation.

1.1 Background to AIPHSS

AIPHSS commenced in December 2012 and is jointly undertaken by the Governments of Indonesia (GoI) and Australia (GoA) to support the development and implementation of health sector reforms and health systems strengthening.

The ultimate goal of the program is “to improve the health status of poor and disadvantaged people of Indonesia”. The program focuses on improving access to better quality health care services, including public health. It does this by reducing financial barriers to accessing quality health care and

strengthening governance and systems that facilitate improved local health service delivery. Across the health system it focuses on four areas: (1) governance, with a specific focus on improving health

policy, influencing behavioural change through the development and implementation of regulation, and the use of information for evidence based decisions; (2) financing and equitable access and distribution of resources; (3) improving the skills and distribution of the health workforce; and (4) providing quality health service delivery to obligatory minimum standards.

AIPHSS approach to health system strengthening. is guided by the GoI Ministry of Health (MoH)) which has identified interventions that are designed to strengthen institutional, organisational and individual performance, and address bottlenecks in health policy , system weaknesses in human resources, health financing , governance and health service delivery. Interventions are selected from an analysis of health system gaps which have been identified in the Reform Agenda and the Health Sector Review (HSR). This approach involves multiple stakeholders, including, ministries, departments and professionals to identify gaps and to reach agreement on interventions and priorities.

AIPHSS has adopted a flexible and adaptive management approach. Some AIPHSS interventions are modified to adapt to changing circumstances or to the local provincial and district environment. Interventions are also added at any time to the program when perceived gaps or needs are identified by partners. This responsive approach provides the MoH with rapid access to technical and financial resources during shifts in policy which planning and budgeting GoI systems do not permit. This approach is a key factor in strengthening the partnership between the Government of Australia and the Government of Indonesia.

The Implementing Service Provider (ISP), Coffey International Development (Coffey), sources technical expertise for the MoH and provides management support for the implementation of partner selected interventions. These technical experts work in partnership with the MoH to identify and respond to key health policy and systems gaps. Interventions are selected by partners based on partner experience of the health system weaknesses and the changes required alongside available evidence. These technical experts also assist with the development of evidence, advocacy and implementation of policy and strategic plans.

The main MoH Departments supported by AIPHSS include: 1. Bureau of Planning and Budgeting (Roren) for governance;

2. The Pusat Pembiyaan dan Jaminan Kesehatan (PPJK) for health financing; 3. The Centre for Human Resource Development (PPSDMK);

4. MoH Directorate for Development Standards (BUKD); and 5. Bureau of Law and Organisation

AIPHSS is also supporting activities implemented through the Ministry of Planning and Development’s (BAPPENAS) Health and Nutrition Department.

The program also collaborates with the other DFAT funded program such as the, Australian Indonesian Partnership for Maternal Neonatal and Child Health (AIPMNH), the Knowledge Sector Initiative (KSI) and the health team from the Poverty Reduction and Social Protection Program (TNP2K) as well as the Governance Reform Partnership (Reform the Reformers).

AIPHSS works with eight district level governments in two provinces which have a high poverty incidence as well areas that have been socially excluded due to ethnicity. These are: Situbondo, Bondowoso, Sampang and Bangkalan in East Java Province; and Timor Tengah Utara (TTU), Flores Timur (Flotim), Ngada and Sumba Barat Daya (SBD) in East Nusa Tenggara Province (NTT). AIPHSS is scheduled to end on 30 June 2016.

1.2 The AIPHSS Reform Agenda for Health System Strengthening

The Reform Agenda acts as a guiding framework for the MoH partners in the selection and

implementation of AIPHSS program activities. It provides a problem analysis and current challenges faced by the national health system to respond to sectoral reforms to meet changing health care demands of communities. It was formulated based on consultations with MoH officials taking into account the following:

 Key policy directions from the National Five Year Mid Term Development Plan (RJPMN)

 Analysis conducted as part of the Health Sector Review (HSR)

 Decentralisation legislation for health functions

 Minimum Service Standards (MSS) for primary health care.

The implementation of the Reform Agenda through the AIPHSS program aims to strengthen the health system at the national and subnational levels while contributing to the implementation of RPJMN and the new five year MoH National Health Strategic Plan (RENSTRA).

The Reform Agenda identified the following weakness in health policy related to the four AIPHSS focus areas:

Governance and Decentralisation

Decentralisation laws and regulations between the different tiers of government (central, provincial and district) require revision for the following reasons:

 The current functional distribution is not consistent with the health system functions as stated in the Perpres-72/2012 on the National Health System (SKN);

 The functions do not meet the needs of all population segments;

 The Minimum Services Standard, as listed in the Minister of Health Decree-741, does not provide comprehensively cover for essential health needs of communities;

 In many districts the recruitment of the District Health Officer by the local government (Bupati/Walikota) is not competency or merit based.

Human Resources

The human resource policy direction provided RPJMN 2015–2019 and the MoH Strategic Plan 2015– 2019 is “improving the availability, distribution and quality of human resources for health”. The rationale for seeling significant improvement in this area is based on the following:

 There is no strategic plan on the number, competencies and production of health workers, the quality and production of the health workforce is not in aligned with the changing demand for services.

 There is no strategy on how to produce “primary health care physicians” as stated in the Law on Medical Education (UU Pendidikan Kedokteran (Medical Education)).

 Mal-distribution of the health workforce, and insufficient availability, quality and low productivity of public health workers.

 Lack of accessible and up-to-date information on human resources for health.

 The quality of graduates in many cases does not meet the standard criteria, especially for midwives, and there is a general mismatch in the recruitment and placement of health workers.

 There is no career development pattern for the health workforce.

Health Financing

The Health Sector Review identified a range of important policy and systems challenges in health financing which informed the RA. These include amongst others a severe underfunding of public health services, which in the long term will have a negative impact on the National Health Insurance Scheme (JKN) financial burden by not addressing prevention and promotion services to address risk behaviour. In addition, there is a need to find innovative and alternative sources of health financing to ensure public health programs are funded.

The RA highlighted other areas that need addressing:

 JKN membership to include non-PBI6 participants, especially workers in the informal sector

 Guidelines for a benefit package/clinical pathway and procedures of use

 Cost sharing by participants at service points

 Development of cost control and quality control systems

 Efficiency and effectiveness of payment of health services provider (provider payment).

 Defining the basic package of public health and clinical services and ensuring it is costed

 Strengthening planning and performance-based budgeting

 Strengthening MoH capacity in health financing policy analysis.

Primary Health Care

The RA follows the GoI definition of the main task of a Puskesmas which is "improving area

wide/sub-district health status" through: (1) promoting community participation and empowerment; (2) implementing public health programs; (3) providing individual clinical health care services; and (4) encouraging health oriented development (healthy public policy). Since 1 January 2014, the

Puskesmas has a new function as the primary health care provider for the national health insurance members and now must be equipped to respond to the treatment of 150 different categories of health conditions which focus the Puskesmas on curative care. This requires Puskesmas reforms related to human resources, management, equipment, financing, information systems, accreditation, referral and reporting systems. These all need to be tested at the district level requiring collaboration between government at the provincial and national levels.

1.3 Program Framework

A revised program logic model was developed with key stakeholders in February 2015. This was based on lessons learnt through implementing the original program design. It now ensures priorities of the partners are aligned towards a common goal and agreed end-of-program outcomes (EOPOs). This guides investments of AIPHSS taking into account synergies with future donor funded programs such as the Primary Health Care Strengthening and Maternal and Newborn Health Program

(PERMATA).

The goal of AIPHSS is to contribute to “improving the health status of poor and disadvantaged people in Indonesia”. The focus is on improving access to better quality health care by removing financial barriers to accessing health care services; and by improving local health service delivery including providing effective public health care and promotion.

There are five EOPOs that AIPHSS is expected to make a contribution toward in support of the broader goal:

1. Effective national health insurance policy, rules and regulations implemented

2. Minimum service standards (MSS) are adhered to at all levels of health service delivery 3. Local health service centres achieve accreditation

4. Health resources equitably allocated at all levels of government

5. Good governance and supervision practiced at all levels of government

The implementation framework is based on the four health system building blocks outlined in the Reform Agenda. These are functional areas that guide investment aligned to Implementing Unit (IU) work plans at the national and sub-national levels. These health system building blocks are:

1. Governance and Leadership, including health sector decentralisation 2. Health Financing

3. Human Resources for Health 4. Service Delivery

The program framework ensures that the interventions funded by AIPHSS under the RA contribute to achieving the end-of-program outcomes (EOPOs). Each intervention is mapped against its

contribution to EOPOs (see Annex 2) and scrutinised using a quality assurance process including a value for money assessment. Success is measured according to the quality of outputs (e.g. policies,

guidelines, standards and regulations etc.) and how each of these are implemented by the GoI to achieve intermediate outcomes such as the extent to which:

 An adequate, capable and supervised workforce is in place

 Health legislation is enacted to implement the minimum service standards

 Polices and decision making are based on evidence and accurate information

 Good governance is practiced at all levels of government supported by improved communication and coordination

 Strategic planning is improved and there is an improved ability to identify health system needs based on evidence

A key indicator of future success will be the percentage of AIPHSS activities that are funded in the national and regional budgets (2016-2017) for roll out at the national and regional levels. The source of data for this indicator will be from national and regional budgets. For many activities this may not be measurable until 2017 due to budgetary planning cycles, however, the next 6 monthly progress report and end of program report will use this as an indicator of sustainability and impact.

Other headline indicators (key performance indicators or aggregated development results (ADRs)) to be reported in the next report period and at the end of the program are given in Table 1 (as outlined in the revised M&E Plan, June 2015).

The overall conceptual framework is illustrated in Figure 1.

Table 1. Key Performance Indicators

Indicator Measurement

Proportion of people covered by health insurance

Enrolment in health insurance over time to indicate participation levels.

Supporting indicators will include:

 Number of memberships being converted from local (e.g. Provincial health insurance system) to national health insurance

 Number of health facilities now incorporated with BPJS Puskesmas achieving the required

level of accreditation by passing all 9 chapters

Number and percentage as a total of all Puskesmas involved in the program achieving accreditation

Legislation, policies, regulations, manuals / guidelines that have been (1) adopted and (2) implemented

Number and percentage of legislative changes, policies, regulations, manuals and guidelines supported by AIPHSS that have been adopted and/or implemented within the life of the program.

Percentage of AIPHSS activities funded in the national and regional budgets (2016-2017) for roll out at the national and regional levels.

Change in District budgets allocated to health and the percentage allocated to public health programs

Change in budget allocations as a percentage increase from the beginning of the program (baseline).

Change in health budget value in each district per capita. Changes in the number of health

workers by province disaggregated by occupation, specialisation, location

Difference in per capita ratio between number of health workers on commencement and on completion of the program by occupation, specialisation, location and sex

Indicator Measurement

and sex

Technical assistance delivered as planned by building block and contribution to end of program outcome and level of result achieved

Number and dollar value of TA delivered as planned and per cent achieving intended results by building block and end of program outcome.

TA scored as less than satisfactory (limited results achieved); satisfactory (meets most requirements); highly satisfactory (meets all requirements, exceeding some)

Number of Training

programs/workshops and participants (sex disaggregated) by building block and implementing units – totalled every six months

Total male/female participants totalled every 6 months attending workshops, meetings and training sessions Total number of training sessions and workshops every 6 months by building block.

Figure 1 Conceptual Program Framework

Improved health status of poor and disadvantaged people

in Indonesia

More people have improved access to better

quality health care and benefit from effective

public health and promotion services

Local health service deliver inclusive of public health is

improved (AIPHSS/PERMATA) Financial barriers to

accessing health services are removed for the

poor Broader Goals End of Program Outcomes Immediate Outcomes Minimum service standards are adhered to at all

levels of health service delivery

Health resources equitably allocated at

all levels of government

Good governance and supervision practiced at all levels

of government Enabling Outcomes

Adequate, capable, well supervised and monitored workforce

in place

Health legislation to enforce minimum service standards is

enacted

Evidence based policies promote equitable allocations

Improved quality of strategic planning

Improved ability to identify health system

needs

Improved communication and

coordination

Service Delivery

Puskesmas Primary Health Care

Governance and Leadership

Decentralisation Policy and Planning

Human Resources for Health

Strategy and Policy Information Systems Health Financing National Insurance Health Accounts Effective monitoring evaluation and learning systems implemented in all levels of government

Implementing the Reform Agenda

Outputs and Activities of Implementing Units

(National and Sub national)

Health System Building Blocks

Appropriate, relevant and accurate information

provided in a timely manner Evidence based decision making between key stakeholders Effective national health insurance policy, rules and

regulations implemented

Local health service centres achieve

accreditation

Guidelines on delivery, standards and procedures are implemented

Box 1. Economic Growth and Health Outcomes

The recent UK Lancet Commission on Investing in Health (Jamison, et al., 2013) estimates that:

 Up to 24% of economic growth in low- and middle-income countries was due to better health outcomes.

 Increasing life expectancy by one year can increase gross domestic product (GDP) by 4 per cent.

 Reductions in mortality account for about 11 per cent of recent economic growth in low-income and middle-income countries.

 Investing in health yields a 9 to 20-fold return on

investment.

2

Relevance of AIPHSS

It is recognised that investment in health outcomes contributes to thriving stable and economically productive communities. For example increasing life expectancy by one year can increase gross domestic product (GDP) by 4 per cent. Reductions in mortality account for about 11 per cent of recent economic growth in low-income and middle-income countries as measured in their national income accounts7. Australia’s investment in health will contribute to building economically productive

communities in Indonesia. This leads to growing markets and trade within the region where Indonesia is a key market and trading partner. Indonesia is approaching a middle class of 100 million by 2020. The World Health Report (2000) demonstrated the importance of investing in health systems strengthening as an essential aspect of improving health

outcomes for communities. Without sustained investments in health systems strengthening the investments in vertical programs such as MNCH; Malaria, Tuberculosis and HIV cannot be sustained if the backbone of the health system is not strengthened and maintained.

AIPHSS has reached a point where it is at its most relevant. This is evidenced by the alignment through the Reform Agenda with national policy priorities and a close interaction with senior policy making levels in the MoH which ensures the program has the potential to influence policy and adapt to policy change. The focus on revitalisation of primary health care models, technical support for the national insurance scheme, changes to health legislation under decentralisation, and the implementation of a new minimum services standards are key reform issues for the government partners placing the AIPHSS at the centre of the health policy environment.

The program is also strongly aligned with DFAT’s new Health for Development Strategy (2015-2020) with

investment in strengthened, resilient public health systems being the highest priority. The AIPHSS program achieves this through providing the GoI with access to flexible small scale funding which can be used for innovation and catalytic activities which GoI systems cannot deliver quickly. The

program is also valued for delivering rapid technical assistance and the provision of information and evidence to inform the implementation of priority areas.

Currently the AIPHSS program is leading the way in how other development partners now want to address health systems strengthening to improve delivery of essential services. This is evidenced by the senior staff from the USAID and the Global Fund for AIDS, TB and Malaria regularly consulting AIPHSS senior management on how to invest in and implement health systems strengthening at the national level.

2.1 Contextual Analysis

A number of recent changes at the political and partnership level have occurred which affects the future of the AIPHSS program.

The most important development is the 40 per cent budget cut to the Australian Aid budget in Indonesia8. At this stage it is uncertain which health programs will be affected but it is clear there will be a substantial reduction in resources. This creates high levels of uncertainty amongst the partners and AIPHSS staff about the future of the program. AIPHSS senior managers have commenced the preparation for an exit strategy.

There has been only one major announcement in the health policy environment. The newly appointed Minister of Health has announced a policy priority titled “Nusantara Sehat” which is a healthy Indonesia initiative. There are no major implications for the AIPHSS program as it is already supporting health systems strengthening at a national level as well as having a provincial focus in NTT and East Java. A number of AIPHSS activities are high on the policy agenda for the MoH. These are capacity building for the provider payment system for the national health insurance scheme; the accreditation of the primary health care centres; the next stages of implementing the Minimum Service Standards including costing. The program has also commenced the implementation of the policy dialogue series led by the Technical Director (TD) and the Secretary General of the MoH. The first of these took place in May 2015 focusing on Pharmaceutical Policy in the era of JKN. The initial feedback from participants and MoH is that this was a successful event which has led to cross sectoral follow up on specific recommendations on pharmaceutical policy. Consequently there is now a further demand for policy dialogue from the MoH in areas such as

strengthening the roles and functions of Puskesmas; improving the quality and distribution of health workers; and synchronising MoH regulations.

The partnership remains strong with the MoH and AIPHSS continues to be a highly valued program. The most important factor which may affect this relationship is the differing priorities between the Australian and Indonesian governments in terms of health sector investment. A message emerging from the Secretary General’s office is that if the health programs are to be cut then there is a preference for the continuation of AIPHSS over introducing new initiatives.

Another emerging factor which may affect the partnership is the extension of the program to 2017. The current subsidiary agreement has been amended to extend the AIPHSS program to 2017, however, if budget cuts result in AIPHSS ending in June 2016 there is the potential that the

partnership will be negatively affected with a possible impact on the acceptance of the PERMATA and Papua programs. This will require careful management in the next reporting period.

8

This is the overall budget cut to the aid program. The specific budget cut to AIPHSS is currently under negotiation.

Box 2. A Growing Market: Changing Demand

Indonesia is a rapidly growing market for health services. Demand for health care is expected to rise significantly in the next few years due to a combination of factors:

 A population growing at a rate of 5 million per year. The middle class is estimated to reach 100 million by 2020.

 An ageing population: The majority of the population growth is expected in the over 45 age group. By 2025, the elderly population will almost double to 23 million

 The changing burden of disease. Non-communicable chronic

diseases are rising significantly and, unless detected early, are

expensive to treat.

 New and expensive treatments becoming available and a growing middle class with higher

expectations.

 Greater insurance coverage and use of health services as the current inequity in access and utilisation is addressed.

3

Progress towards End of Program Outcomes

(EOPOs)

General progress against each of the new EOPOs is adequate. The greatest progress is being made in achieving the equitable allocation of resources, followed by governance and supervision. This is associated to the higher level of activity investment being allocated to these EOPOs.

All activities under accreditation will be completed in the next reporting period and will mean that a high level of progress against this EOPO will be accomplished. All other EOPOs require sustained implementation and investment in order to be successfully accomplished.

Progress at the national level is slow and behind schedule for the majority of activities. This is especially the case for the Bureau of Budgeting and Planning (Roren)9 and Bappenas. This is due to the technical complexity of many activities and time taken to develop and agree terms of reference (ToRs) and the varying availability of IU staff to lead implementation. At the sub national level East Java is on track with implementation while NTT is behind schedule by several months due to a complete revision of the work plans following inputs from the PTS in the second quarter of this reporting period. These delays may inevitably result in the roll-over of activities to 2016, however, in order to accelerate technical aspects, the ISP is facilitating regular meetings on TA coordination to ensure local staff manage AIPHSS activities and local budgets are allocated to meet future requirements.

3.1 An Effective National Health Insurance System

Progress under this EOPO is measured against the intermediate outcomes and effectiveness of the technical assistance provided to the government counterparts by an international health financing expert; the contribution of the PTS to a BPJS expert group on quality control and health financing; the institutionalisation of Health Technology Assessments (HTA); and the strengthening of the hospital provider payment systems based on Case Based Groups (CBGs).

In January 2014, the new Agency for the Organisation of Social Insurance (BPJS) began operations. Membership to the scheme has increased by 114 million people to nearly 140 million out of a population of over 250 million and the demand for coverage is increasing. Overall global experience shows that an increase in coverage for health care leads to better health outcomes10 by providing; improved access to care and medicines; higher quality of services; and improved financial protection for individuals and families.

A primary objective of the scheme was to ensure claims for care services were reimbursed within 15 days which was successful, however, by November 2014 its annual allocation had depleted and the fund was out of money requiring a bailout by the new government. Nevertheless the experience of year one is consistent with global experience. In discussions with the AIPHSS senior management, it was agreed that the BPJS must focus more closely on “strategic purchasing” that includes elements of cost containment and quality assurance.

An international financing expert commenced in February 2015 and four policy notes have been produced during the reporting period (see Annex 3 for a full list of policy notes and their contributions to achieving EOPOs). AIPHSS has provided advice to BPJS on their policies such as: 1) increasing the premium for the poor; 2) tools for cost containment, and 3) improving quality by using the Health Insurance Fund. In addition a health financing policy research and assessment agenda has been developed in collaboration with the Vice President’s office (TNP2K team). Technical and financial support has also been provided on National Health Accounts (NHA), Hospital Provider Payment System (INA-CBGs) and Health Technology Assessment (HTA) implementation. District Health

9 In Roren no staff were available to work on AIPHSS and two short term technical staff were recruited to specifically manage AIPHSS activities, this places Roren six months behind schedule for most of their work plan

10 Better health outcomes lead to increased economic growth through improved financial protection and a more productive workforce. This allows greater household spending for other parts of the economy.

3. Data analysis was conducted using the standard evaluation criteria to describe which components have met and have not met the standard criteria for the implementation of ODL. Results of this analysis are used to answer four key evaluation questions.

4. The preparation of the evaluation report which contains a description of the findings and

observations; the results of the analysis of the findings according to the standard criteria; and the determination of the success factors and recommendations based on the results of the analysis. Key Informants

The key informants for data collection consisted of the key decision makers at the national, provincial, and district level; implementers of learning activities including lecturers and tutors; organizers of the distance learning unit (USBJJ); SBD and East Flores district health bureau chief; Director of Kupang Health Polytechnic; and the Head of Education and Training of Health (PUSDIKLATNAKES). Key Finding

Effectiveness of Online Learning

The implementation of a distance education program should be an effective way of addressing current health care quality issues. As a concept, distance education is a flexible method of education delivery; has good teaching materials; and has robust modules that could enable independent learning. This concept requires a variety of learning materials provided to students that can easily be understood even without being face-to-face with the lecturers. Face-to-face meetings are a supporting process carried out when the students have difficulty understanding the modules or teaching materials. It is carried out at the initiative of the students.

The self-learning process is critical in the process of study completion. The quicker the student understands the material through the modules and teaching materials, the quicker they will complete the course. The weighting for of distance learning education is: self-learning 50%, 30% face-to-face and online 20%.

This evaluation found the process of learning in both nursing and midwifery courses have a face-to-face schedule of 6-8 times in one semester for each course. Face-to-face-to-face learning methods carried out by the tutor includes lectures, discussions, and formative evaluation. Online learning is conducted in two ways: 1) teleconference, and 2) email / LMS. The achievement of exercises and lectures is through self-learning, face-to-face meetings, face-to-face tasks, independent tasks, exams, and online learning in each course including general subjects. These processes mean that the characteristics of distance education as open, indirect, and flexible are unfulfilled.

In terms of the curriculum, both midwifery and nursing programs have 120 credits load which is completed in 4 years. Up until this evaluation, the process has been running for two semesters and some common subjects are still being given (such as English language, Indonesian, Religion, Citizenship) which should be reconsidered given the urgency to quickly address the needs of health services. ODL is a quick answer to the need for health human resources that must be met by the government of Indonesia as soon as possible, so it should have a competency equivalency process for the student compared to the learning objectives. This equivalency process should enable acceleration of the study period in ODL.

The availability and utilization of instructional media still needs special attention. Geographical and infrastructure conditions in some districts and counties in SBD is a constraint most frequently faced by both the students and the delivery of distance education. However, with the philosophy of distance education that specifically targeted the underdeveloped and remote areas, this factor should not become a constraint to the process. Ideally, this problem is solved with significant infrastructure improvements in the area; however, the innovation in independent learning should provide an important role in reducing the existing barriers.

Although this process is only in its first two semesters, it is already able to provide additional academic knowledge and introduce the theory in a better way for the students. All students have professional experience as a nurse and midwife for more than 5 years and have skills in health care, but still have weak knowledge in theory. ODL contributes to their knowledge by providing a broader

understanding on why there are different procedures performed in different situations and the theoretical rationale behind health care procedures.

Processes Quality and Their Impact on Health Services

Successful distance education requires students to have high motivation and initiative to complete a given learning module. The quicker a student is able to complete an evaluation modules and the exam, the quicker the completion of the study will be.

There has been a variety of changes in the behaviour of the students as a result of the program such as the initiative to form study groups based on geographic proximity. This allows them to discuss concepts, finish tasks together and exchange information. In SBD district, for example, the study group not only includes ODL students, but the discussion and learning involves their colleagues and doctors in their workplace. Knowledge gained in ODL has begun to be transmitted to a fellow midwife who had not been in the ODL program. The learning model uses a problem-solving approach in the workplace and the willingness to involve colleagues could potentially form a larger learning

community. The emergence of a learning community in the workplace could form a good working culture in which everyone will continue to learn, discuss, and find solutions to the issues in the health service.

Another observed impact is the improvement of the ODL students in their communication skills with patients. The additional knowledge gained during the program is perceived as a helpful source of information in answering the questions from the patients. They are more confident in face to face interaction with patients and have a desire to increase their understanding of the case by discussing it with the study group. The perceived positive interaction is also felt when dealing with Traditional Birth Attendant (TBA). Students feel more confident in teaching the TBAs about better birth processes according to the theory of health, thus encouraging better cooperation with the TBAs.

Online Learning Accessibility

The students are able to follow and understand the online learning system. The ICT training done at the beginning of the implementation of ODL and the handbook provide sufficient guidance. The students are more familiar with the previous LMS display compared to the new user interface. They felt that the previous was friendlier and less confusing. The new LMS display raised complaints and some students needed to adjust. The constraints of poor Internet access (low bandwidth), especially in the SBD, forced the tutors to manually assign tasks in hard-copy form more frequently.

Poor Internet access is experienced in almost all regions of Southwest Sumba. This impacted on the ability to access websites, video conferencing, and other online learning materials. East Flores is less constrained by this situation. It is perceived that they get more benefits from the program. Information can be updated more quickly, tasks can be submitted quicker, and the completion of the process is also more effective.

One consequence of poor Internet access was the initiative for students to regularly meet in the capital, Tambolaka, to update information and conduct study group sessions. However this constraint still limited the process of distance learning.

The limited number of lecturers, tutors and administrative support in the implementation of ODL is perceived as area that needs to be improved. Skills in using online media and the online system need to be given not only to students but also to the lecturer and organizers. Some students complained about the difficulty in understanding the practical material presented using animation, video, and power point. This indicates that the material delivery technique has not been well mastered by tutors and lecturers, and also the limited availability of learning media materials.

It was observed that local governments are taking the initiative to cooperate with local telecommunications service providers to improve Internet coverage in the area. The Telecommunication Company is still investigating this issue.

Despite the limitations distance education is still considered the best solution available to meet the challenges of achieving standard qualification requirements for health professionals in remote areas while maintaining a presence in the workplace to deliver services. Improvements in Internet access in the region will result in greater opportunities for online learning courses to be expanded.

Determinants of Success and Prerequisites for Expansion

Distance Learning (ODL) is an effective solution to meet the needs of health personnel in the field who have basic academic qualifications. Distance Education can be a win-win solution for health workers to keep working while studying. However, in order for the online learning system continue to grow and run consistently some areas need improvement: (1) the management of the program; (2) lecturers and education personnel; (3) curriculum; (4) Instructional methods and media.

The management of the program: increasing the quality and quantity of human resource professionals for tutors and lecturers is needed to ensure good performance in the implementation of distance education. The difference experience levels between tutors and students can actually be used to combine theory and practice during the discussion in the classroom. Tutors must have the skills to facilitate classes in adult education settings and take advantage of the student experience to strengthen the learning experience. Improving the mechanism of payment of honorariums and operational conditions will also create a more conducive working environment needed to ensure the quality of the education services.

Lecturers and Education Personnel: tutor qualifications are important to ensure the targeted competency for the students can be achieved. Improving academic standards of the tutors through training on an on-going basis is needed.

Curriculum: Subjects which directly leads to the skills needed for the students for their jobs are very popular. Subjects that have a direct application with the real problem in the field should be increased. There is currently around 400 learning modules and there is still room to condense the subject matter to be more practical to directly answer the real needs of the student in their workplace. Some general subjects could be modified into one independent learning subject that does not take up one semester and the evaluation can be provided independently online when a student has completed a module. Conversion system into a number of credits based on the student experience is needed to take account of their previous experience. This could shorten the duration of the program and could bring more efficiency in term of cost and increase the probability for replication in other areas.

Instructional Methods and Media: Adjustment between teaching methods and the use of instructional media is still not utilized optimally. The tutors need to increase their creativity in creating innovative learning methods (micro teaching). These innovations could thrive if there is a regular discussion and sharing between the teaching team. Adult learning should be more practical and innovative in how learning occurs in the workplace.

Conclusion and Recommendation

 Distance education is considered the best solution in answering the challenge of improving the qualifications of health personnel in Indonesia due to its geographical setting and limited human resources in health care. This program could ensure that all health workers who participate in education remain active in the health services and continue learning.

 There are challenges in terms of implementation management and lecturing, however there are also great expectations in accelerating the implementation of this education program to to other areas in Indonesia. This can be done by shortening the duration of the program and implementing

conversion of student work experience into credits using work experience as a learning resource. This could lead to a wider implementation for other areas that have limited resources but similar needs.

 Distance education does not only impact students positively, but also stimulates the emergence of a learning community in health care by encouraging discussion among peers facilitating knowledge transfer.

 The distance education program should be able to capitalise on the emergence of the learning community by identifying cases to be solved together in the student’s workplace. These cases can also be drawn from real experiences encountered in everyday health care. Such processes could familiarise students with the real problems in everyday work and improve problem solving skills.  The limitation of the facilities and infrastructures in the implementation of distance education can

be perceived as a continuous improvement process. Involvement and cooperation from various public and private institutions is necessary to improve the learning quality.

The Evaluation Report on the Use of the 2015-2019

Health Sector Review (HSR)

Introduction and Key Findings

2014 was politically uncertain because of the tension during the presidential election and inauguration of President Joko Widodo on 20 October 2014 and the formation of the new cabinet including the appointment of the current Minister of Health (27 October 2014). It was during these national events that the process of drafting the Health Sector Review (HSR), the National Medium Term Development Plan (RPJMN) 2015-2019; and the Strategic Plan of the Ministry of Health (Renstra-MoH) took place. The background studies (the ten Situational Analysis reports) of the RPJMN 2015-2019, were initiated in June 2013, and completed in May-June 2014. The compilation of the summaries of the ten

Situational Analysis reports into HSR Policy Briefs, using a format of 5 pages each topic area, was done in parallel with the drafting of the RPJMN and the Renstra-MoH.

The drafting of the HSR Policy Briefs and the RPJMN were under the control of the Ministry of National Development Planning Agency (Bappenas), which appointed the Chairman of HSR Policy Briefs drafting as the Chairman of the RPJMN drafting process too. He also led the preparation of the ten situational analysis reports that served as the background studies (then summarized as the HSR) of the RPJMN 2015-2019, to make sure that the RPJMN followed directions prescribed in the HSR. The drafting of Renstra-MoH was not under the control of Bappenas. It was an internal MoH process and drafted almost in parallel to the drafting of the RPJMN. This made it difficult for the Renstra to

adopt the RPJMN’s targets and indicators. Hence, some MoH officials perceived that Renstra should

differ from the RPJMN because Renstra was drafted using the MoH’s perspective, MoH’s

achievements, problems and alternative solutions, while the RPJMN was developed using outsiders’ perspectives, not the MoH officials’ perspectives.

Although the HSR and RPJMN documents were shared with the MoH Renstra drafting committees at various times during the drafting of RPJMN, the Renstra team decided on their targets and indicators

independently based on MoH’s internal reports. Thus, many of the RPJMN and HSR recommended

strategies and success indicators were not adopted. This was unfortunate because the ten situational reports as the back-up studies for preparing the HSR and RPJMN have valuable sources of

information regarding the achievements, challenges, key policy options, and potential constraints to be considered in achieving the goals of the national health agenda 2015 -2019.

Compared to the 2010-2014 RPJMN, four priority topics were added and became the priority topics for the 2015-2019 RPJMN. These topics were:

1. Changing Demand for Health Services and the double burden diseases

2. Health Human Resources in facing the double disease burden and the implementation of the National Health Insurance ( Jaminan Kesehatan Nasional or JKN)

3. Health financing for poor people and poor financing of public health activities - JKN in relation to decentralization-related laws and regulations

4. Health institutions and structures under decentralization-related laws and regulations. These additional four priority areas were added in the context of strengthening the national health system. The focus is on primary health services, and regulations and information systems that should be prioritized in the development of the RPJMN and Renstra 2015-2019. This is also in line with the findings of the World Health Organization (WHO) that health systems strengthening in Indonesia is still neglected.

All three documents, the HSR, RPJMN and Renstra, recognize the five general drivers of increased demand for health care:

1. A growing population overall

2. Changing disease profile from acute infectious diseases to non-communicable diseases (NCDs) such as hypertension and diabetes

3. An aging population which will have more than 11% of people 60 years or older by the year 2020 4. Changes in expectations and health seeking behavior that was estimated at 100 million in 2015,

and will change the level of care demanded and the mix of services

5. The new ‘insurance effect” with people seeking more services for previous unmet needs, and

because the effective price was lowered.

Similarly, all three documents recognised that although various indicators of Indonesian health programs have shown improvements in the last decade, the maternal mortality rates (MMR), infant mortality rates (IMR) and nutritional status have not declined significantly. In addition, there are noticeable gaps in access to health services by geographical location and by family income level. Health financing has not been considered as an investment, because there is an insufficient level of understanding that one cannot put a price for health prevention and promotion because these services are categorized as public goods. The government is responsible for payment of public goods, according to Presidential Regulation No 72/2012. The Constitution underlined that the government is responsible for covering payment for curative services consumed by the poor,

including services provided by the private sector. Although the existing National Health System (NHS or Sistem Kesehatan Nasional, SKN) promotes primary health care for all, the system is currently unable to overcome challenges in achieving the Universal Health Coverage (UHC) by 2019. One causality is the constraint posed by current decentralization of authority to local governments. All three documents agreed that the health budget allocation at local level has not complied with the Health Regulation no. 36/2009, Article 171 Clause (2): “The provincial and district government must allocate at least 10% (ten percent) of the Local Budget, excluding wages”. The local government’s argument for not meeting this target is that the central government spent only 1.2% of the Gross-Domestic Product (GDP) in 2012 on health, much lower than the required 5%. The per capita health expenditure in Indonesia in 2011 (US $95) was far lower than Malaysia and Thailand, putting

Indonesia 14th out of 15 countries in Southeast Asia (only higher than Myanmar) in terms of health expenditure, still far below Timor Leste and Nepal which have health expenditure totaling more than 5% of their GDP.

The following findings show how influential the HSR has been in preparing the RPJMN and the Renstra MoH according to the ten identified areas:

1. The Burden of Disease and Changing Demand for Health Services has been inserted in both the RPJMN and Renstra-MoH;

2. Fertility, Family Planning and Reproductive Health was influential and adopted in the RPJMN 2015-2019; but was not mentioned in the Renstra-MoH. However, the Renstra-BKKBN adopted the RPJMN targets and measures.

3. Maternal, Neonatal and Child Health were influential and adopted by the RPJMN 2015-2019. But,

the concept of “continuum of care” in the HSR was not included in the Renstra-MoH 2015-2019.

4. The strategies recommended in the HSR’s fourth area, Human Resources for Health, were

adopted by the RPJMN but not fully adopted by the Renstra.

5. The HSR recommended strategies for Health Financing were not fully adopted by the RPJMN and the Renstra, in particular the strategies to increase financial protection; to improve the design and implementation of INA-CBGs; to increase fiscal space (i.e., tobacco taxes); and to

mainstream public health by prioritizing disease prevention and healthy lifestyle promotion. On the other hand, the HSR’s recommendation to improve managerial skills in dealing with financial inefficiencies has been included in the RPJMN but not in the Renstra.

6. Institutional Analysis in the Context of Decentralization is one of the most important areas. Out of 11 strategies in the HSR, the RPJMN adopted only one recommendation: “Regulate relationships between district health offices (DHOs) with district hospitals and health centers”; and the Renstra

–MoH adopted “Strengthen business and operational planning in autonomous/semi–autonomous

7. Pharmaceuticals Review and Medical Technology were adopted by the Renstra of BPOM (Badan Pengawas Obat dan Makanan) (or, Food and Drugs Agency under the MoH), because BPOM sought guidance from a consultant who contributed to the drafting of this area in the HSR. 8. Quality and Safety in Health Care was not influential in persuading the MoH to establish a

National Quality and Safety advisory group.

9. Nutrition and Food Security strategies were adopted by the RPJMN, however, the Renstra-MoH does not include a focus on delivering nutrition-specific packages during the first 1000 days of life. The RPJMN document adopted the HSR strategy to promote appropriate health, nutrition,

sanitary, hygiene and parenting behaviors among pregnant women, caregivers of young children and the general population. The Renstra only states that health promotion such as “PHBS or Perilaku Hidup Bersih dan Sehat” should be done.

10. Supply-side Readiness was mostly adopted by RPJMN using 7 of 10 strategies and the Renstra-MoH adopted 6 strategies out of the 10 HSR strategies. It is interesting to see that strategy number 2 on socializing governance and accountability was not picked up by both the RPJMN and the Renstra-MoH. Research (no. 8) is also not included. While the RPJMN included no. 6 on improving accountability through a better system of regular and independent monitoring and evaluation, the Renstra did not.

Conclusions

A number of strengths and weaknesses of the HSR have been identified. Overall, the 2015-2019 HSR is a more comprehensive document with evidence-based strategies and targets compared to the previous HSR.

The Health Sector Review (HSR) prepared as part of the 2015-2019 Technocratic Mid-term Development Plan has been very influential in preparing the National Mid Term Development Plan (RPJMN 2015-2019), but was not used as the main reference document during the drafting of the Renstra-MoH by the Ministry of Health’s drafting team. In-depth interviews indicated that (a) the MoH has its own template (previous Renstra) as their main reference; and (b) the drafting of the RPJMN and the Renstra took place almost at the same period, reducing the possibility of adopting the RPJMN strategies and targets.

Learning from this process, the HSR and RPJMN documents should be completed by the time the Renstra MoH team starts the drafting process. The RPJMN background studies should begin two years before the drafting of RPJMN.

The appointment of the same chairperson for both HSR and RPJMN drafting process has its

advantages and disadvantages. If the chairperson is recognized as knowledgeable and respected by all parties, the HSR will be very influential in preparing the RPJMN, however, it is not necessarily

influential in the drafting of Renstra which is viewed as an “internal ministerial process” and which

reflects MoH’s own perspectives. The appointment of a “retiree” may not be optimum because they are not perceived as an active MoH insider.

The Institutional Analysis in the Context of Decentralization is the most important aspect because it defines the legitimacy of national, provincial and district authorities in the management of the national health system (Sistem Kesehatan Nasional or SKN). The two Laws, the Law no 23/2014 and the Law no 36/2009, have a very strong influence on what should and should not be included in the Renstra. The HSR has the potential to influence investment strategies for the health sector, however, at this development stage, the inequity issues remain, regardless of the significant amount of investment over the past four decades. To obtain a more equitable distribution of resources other factors should be considered to better address the needs of poor rural and remote communities. Cost adjustments taking into account greater weightings for lower population density, distances to the hospital and distance to the nearest health care facility should be key factors.

The senior management officials in the MoH have shown minimum response to the evidence provided in the Health Sector Review Policy Briefs. In-depth interviews also indicate that officials who have not been part of the writing team have not read the MoH Renstra. Many are therefore not aware of the specific strategies, targets and indicators for 2019. This is perhaps not to be unexpected given the recent change in government and administration.