AIDS Commodities Situation in Tanah Papua

Report of HIV/AIDS Commodities Survey and Supply Chain Status Assessment in Tanah Papua Survey of HIV/AIDS Commodities Situation in Tanah Papua February 2008

Report of HIV/AIDS Commodities Survey and Supply Chain Status Assessment in Tanah Papua Survey of HIV/AIDS Commodities Situation in Tanah Papua February 2008 Andy Barraclough Malcolm Clark Ned Heltzer Yos Hudyono

About SCMS The Supply Chain Management System (SCMS) was established to enable the unprecedented scale-up of HIV/AIDS prevention, care and treatment programs in the developing world. SCMS procures and distributes essential medicines and health supplies, works to strengthen existing supply chains in the field, and facilitates collaboration and the exchange of information among key donors and other service providers. SCMS is an international team of 16 organizations funded by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). The project is managed by the U.S .Agency for International Development. This document was made possible through support provided by the US Agency for International Development, under the terms of contract number GPO-I-00-05-00032-00. The opinions expressed herein are those of the author(s) and do not necessarily reflect the views of the U.S. Agency for International Development or the U.S. Government. Recommended Citation This report may be reproduced if credit is given to SCMS. Please use the following citation. Supply Chain Management System (SCMS). 2008. Survey of HIV/AIDS Commodities in Tanah Papua. Submitted to the U.S. Agency for International Development by SCMS. Arlington, VA: SCMS. This document may be reproduced if credit is given to SCMS.

Supply Chain Management System 1616 Ft. Myer Drive, 12th Floor Arlington, VA 22209 USA Telephone: +1.571.227.8600 Fax: +1.571.227.8601 E-mail: [email protected] Website: www.scms.pfscm.org

Acknowledgements and Thanks To the Provinces of Papua and West Papua who provided permission, support and gave freely of their time to assist activities Sub-dit HIV and all Central Level operational staff The Districts, hospitals and Puskesmas visited for their assistance and cooperation The literally hundreds of players who consented to be interviewed and provide their information and opinions Thank you all.

Table of Contents Acronyms ............................................................................................................................................................ii Indonesian language terms ..............................................................................................................................iv Executive Summary..........................................................................................................................................vi Summary, Conclusions, and Recommendations ...........................................................................................1 Background.........................................................................................................................................................7 Objectives and Scope ........................................................................................................................................9 Methodology.....................................................................................................................................................10 Collected Data ..................................................................................................................................................15 Key Findings.....................................................................................................................................................19 Annex 1. Scope of Works for the Study.......................................................................................................64 Annex 2. HIV/AIDS Data.............................................................................................................................66 Annex 3. Survey Parameters...........................................................................................................................67 Annex 4. Survey Instruments.........................................................................................................................75 Annex 5. Data Extracts................................................................................................................................ 119 Annex 6. Respondents ................................................................................................................................. 122

i

Acronyms AIDS

acquired immunodeficiency syndrome

AMA

Associated Mission Aviation

ART

antiretroviral therapy

ARVs

antiretrovirals

ASA

Aksi ( action to) Stop AIDS

ASEAN

Association of South East Asian Nations

AusAID

Australian Agency for International Development

BKKBN

Badan Koordinasi Keluarga Berencana Nasional (National Family Planning Coordinating Board)

BPS

Badan Pusat Statistik (Central Bureau of Statistics)

BPOM

Badan Pengawas Obat dan Makanan Food and Drug Agency

CBO

community-based organization

CCM

country coordinating mechanisms

CDC

MoH Indonesia Directorate of (CDC)

DOT

directly observed treatment

DOTS

internationally recommended strategy for tuberculosis control [WHO]

FHI

Family Health International

GDF

Global Drugs Facility

GFATM

Global Fund to Fight AIDS, Tuberculosis and Malaria

GoI

Government of Indonesia

HAPP

HIV/AIDS Prevention Program

HIV

human immunodeficiency virus

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Report of HIV/AIDS Commodities Survey and Supply Chain Status Assessment in Tanah Papua

IHPCP

Indonesia HIV/AIDS Prevention and Care Project

KPA

Komisi Penanggulangan AIDS (National AIDS Commission)

MIS

management information system

MJM

PT. Manggala Jiwa Mukti A pharmaceutical management consultancy company

MSH

Management Sciences for Health

NACP

National Aids Control Program

NGO

nongovernmental organization

NMCP

National Malaria Control Program

NTP

National Tuberculosis Control Program

OI

opportunistic infections

PSI

Population Services International

SCMS

Supply Chain Management System

STI

sexually transmitted infections

TTC

testing and treatment center

UNAIDS

United Nations Program on HIV/AIDS

UNDP

United Nation Development Program

UNICEF

United Nations International Children's Emergency Fund

VCT

voluntary counseling and testing ( for HIV)

WHO

World Health Organization

PMS

Penyakit Menular Seksual

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Indonesian language terms Bahasa

Language

Binfar

An abbreviation of Direktorat Jenderal Pelayanan Kefarmasian dan Alat Kesehatan or Department of Pharmaceutical Services and Health supplies, a Directorate General Office below the Minister

Depkes

Departemen Kesehatan – Department of Health

Dinas

Official Government office

Dinas Kesehatan Kabupaten

The Official Health Office at the District

Dinas Kesehatan Propinsi

The Official Health Office at the Province

Dit.Jen

Directorate General – an office in the Government organization structure below the Ministerial Office a major section within the Ministry of Health Structure

GFK

Gudang Farmasi Kabupaten – A district level, government drug warehouse

Kabupaten

District

Kepala

Head

Kepala Dinas Kesehatan Kabupaten

Head of District Health Office ( Local Government)

Kesehatan

Health

Kimia Farma

An Indonesian pharmaceutical manufacturer and distributor

Kota

City

MJM

Manggala Jiwa Mukti - A pharmaceutical management consultancy company

Propinsi

Province

Puskesmas

Pusat Kesehatan Masyarakat-community primary Health Care Center

RS

Rumah Sakit hospital

Tanah Papua

Land where the Papua people lived. Geographically this region encompassing more than one province

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Walikota

Mayor of a city

Dit.Jen Yanfar

Former name of the Directorate General of Binfar dan Alkes , within the ministry of Health,

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Executive Summary Background Tanah Papua is the Indonesia language term used to refer to the geographical region of Papua within Indonesia. This encompasses the western half of the geographical island of New Guinea and comprises the two provinces of Papua and West Papua—formerly known as Iran Jaya. From AIDS reports, the cumulative number of AIDS cases in Papua at the end of March 2007 was the second highest in the country after Jakarta. However, if the case rate is counted as a proportion to its population number, (number of cases/total population times 100,000), in Papua, the rate was 60.93 per 100,000 or 15.4 times higher than the national average (3.9), while in Papua Barat (West Papua Province) was 10.24 per 100,000 or 2.60 times higher than the national average. This gives Tanah Papua the highest proportion of AIDS cases in Indonesia.1 The head of the Papua Provincial Health Office recognizes the limitations of the existing supply chain management system for all essential medicines and has asked for urgent assistance. A full situational assessment and development of a set of recommendations needs to be undertaken to adequately support the health systems strengthening effort required. In response to concerns expressed by active players on HIV/AIDS commodity availability and management within Tanah Papua and fears that commodity availability could be a major restricting factor in the region’s rate of HIV/AIDS control and management, USAID has agreed to fund an indepth study of HIV/AIDS commodity and supply chain situation within Tanah Papua. SCMS has been engaged to undertake that work and this report includes the results of the surveys and situation assessment undertaken and recommendations for future logistics activities.

The Survey •

The main objective was to undertake a comprehensive HIV/AIDS health commodities situation assessment in Tanah Papua that will include the logistics of antiretroviral (ARV) commodities, distribution and supply to hospitals, and the provision of voluntary counseling and testing (VCT) materials in hospitals and puskesmas (primary health centers).

•

The survey was designed to include the two Provinces of Papua and West Papua and the 12 Districts, which represents 70 percent of the total population in Tanah Papua and encompasses the regions corresponding to 99 percent of the identified cases reported in 2006 in Tanah Papua.

•

All first appointed ARV hospitals (those listed in the first MoH list of hospitals approved to receive ARVs) in the region were surveyed, and all hospitals in the 12 chosen districts were also surveyed. At least two puskesmas in each district was chosen, especially those which already provide VCT services or had prepared themselves through participating in VCT trainings.

1

Risk Behavior and HIV Prevalence in Tanah Papua 2006 Results of the IBBS 2006 in Tanah Papua ISBN: 978-979-724-595-5 No. Publication: 04210.0705

vi


•

All district and province AIDS commission were surveyed and all district pharmaceutical warehouses and province pharmaceutical warehouses were assessed.

Findings Total HIV prevalence in Papua has been estimated at 2.4 percent.2 Modeling estimates have indicated around 13,000 People Living with HIV/AIDS in 2005 rising to 29,000 by 2010, 3,4 Assuming that around 20 percent of the HIV-positive people require antiretroviral therapy (ART) suggests that there are about 2,600 requiring ART. Data from sub-directorate HIV and from FHI 5 indicate around 400 to 500 people are receiving ART in Tanah Papua. In comparison with estimated need, therefore, the current numbers receiving ART remain low. A key element in determining the ability of the system to respond to future demand is the estimation of likely ART patient uptake. An Australian Agency for International Development (AusAID) epidemiological study based its costing projections on a projected 1,000 patients on ART by 2010; between 1,200 and 2,000 by 2015; and 3,000 to 5,750 by 2025.6 These relatively low numbers were “reflective of the constraint on the health sector to provide ART.”7 In response to that study, and the data obtained in this survey, it is considered that the most likely perspective is one of continued slow growth in the expansion of the HIV program and for the numbers receiving ART to remain modest compared to need. Even major new initiatives such as the recently announced Indonesian President’s Initiative are unlikely to be able to bring a significant impact on the overall health care infrastructure and capacity in the short term. Indeed, it remains uncertain that the doubling-to-quadrupling of the numbers on ARV treatment to achieve even the AusAID report modest projections for treatment numbers in the next 24 months can be achieved. In relation to the supply system, however, it means that the current system, as deficient as it is, is likely to be able to cope with the realistic projected growth in the short-to-medium term. This removes the pressure for urgent, large-scale system strengthening in the near future, which is probably impractical for the current system in Papua. It also provides an opportunity for designing and implementing a custom-built system in two or three districts over the next two to three years, which could then be used as an implementation model for the rest of the province in time to meet the needs of a substantively expanded HIV program in future years. The recommendations for strengthening the supply system in Papua are made in light of this judgment.

2

Risk Behaviour and HIV Prevalence in Tanah Papua 2006, Results of the IBBS 2006 in Tanah Papua, Statistics Indonesia and Ministry of Health; page 49. 3 Impacts of HIV/AIDS 2005–2025 in Papua New Guinea, Indonesia and East Timor Final Report of HIV Eppidemiological Modeling and Impact Study MODELING AND IMPACT STUDY, February 2006 http://www.ausaid.gov.au/publications/pdf/impacts_hiv.pdf 4 http://irja.bps.go.id/LEFT%20FRAME/Proyeksi%20Penduduk%20%20menurut%20Kabupaten.htm 5

Meeting with FHI, Bob Magnani, FHI Country Director, Karen Smith, Deputy Director, Dr. Nurban Silitonga, Medical Director (I think), Dr. Flora Tanujaya, care and treatment consultant; December 12, 2007 6 Ibid, Figure 3.8.5, Numbers of People on ART – 18%; page 113 7 Ibid page 112 vii

Summary, Conclusions, and Recommendations Conclusions While there are clear problems with the functioning of the supply system in Papua, these should not be exaggerated; the challenging terrain and poor infrastructure, which makes transportation around the province difficult, should also not be taken as an indication of especially poor supply systems. In general, the health supply system in Papua is not unusually bad when compared to elsewhere in Indonesia or with public health systems in other countries. With regards to antiretrovirals (ARVs), the current system has been able to assure the supply of all first-line regimens and there is no evidence that disruptions to the supply chain have led to treatment interruptions. Nevertheless, real and significant problems do exist that require resolution if the HIV program is to scale up to any significant degree in the medium- to long-term. These include— •

Central level/sub-directorate HIV/AIDS is providing the bulk of ARVs and significant quantities of sexually transmitted infections (STIs)/opportunistic infections (OIs) medicines and HIV rapid test kits, but lacks many resources and is and viewed as not sufficiently responsive to site needs

•

Inventory management is generally poor with stock holdings out of balance with demand

•

Record keeping and subsequent data quality is poor

•

Management of expiry dates is weak

•

Order planning is not rationally based at all treatment sites Any program of strengthening the logistics system in Tanah Papua that does not first seek to strengthen Central Level procurement and logistic activities is unlikely to be successful.

On the basis of this analysis, it can be concluded that— •

A program of strengthening of Central Level procurement and logistics functions that brings a bottom-up, site level focus to Central Level activities is required.

•

To be responsive to actual demand at health facilities, the supply chain should be driven by accurate data from the point of use, through District and/or Provincial stores and/or private distributors contracted for supply services and, from there, back to a Central Level.

•

There is a general need for improving inventory management and order planning at treatment sites. As the numbers on treatment reaches significant levels, the need for this will become more urgent.

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Capacity Building in Supply Chain Management of ARV Drugs and HIV Tests

•

In developing an improved public health supply chain, therefore, efforts should be made to put in place a system where every hospital and puskesmas involved in providing HIV care and treatment is recording and reporting data of medicines dispensed and supplies consumed and each level reports upwards. It is particularly necessary that central level receive accurate information. On this basis it would be possible to improve inventory management and procurement and thereby achieve improvements in service to clients.

•

It is therefore important to see the process of strengthening the health supply chain as an integrated and composite one, with success in improving one aspect of core operations being dependent on making improvements in related operations. Sustained improvement in demand planning and procurement, for example, cannot be achieved without an effective inventory management system, which in turn requires more accurate data. In this way the work of strengthening district and provincial procurement and supply systems will be interwoven with each other.

Recommendations Central Level Supply Management Numerous players are already actively assisting Central Level to address logistics problems, and subdirectorate HIV/AIDS is currently developing major plans for logistics strengthening. In these circumstances, it could be considered inappropriate for a study focusing primarily on the Tanah Papua situation to be used as a major influence on Central Level operational considerations. Nonetheless, because of the pivotal, and in terms of supply volumes, dominant role, that Central Level plays in the overall supply chain process for HIV/AIDS commodities, and the identified supply chain difficulties arising from Central Level supply found in this study; which are further supported by the similar findings of the World Health Organization (WHO)-sponsored five Province rapid HIV/AIDS commodity survey; it is clear that the supply chain situation in Tanah Papua, or indeed any other province/region, cannot be adequately addressed without reference to Central Level functions. The following comments should therefore be considered as contributions for supporting subdirectorate HIV’s development program, and not as a master plan for Central Level activities. Furthermore, it should be acknowledged that the sub-directorate HIV/AIDS is already active in attempting to address a number of the areas, but would benefit from further support and especially further resource allocation. The HIV/AIDS program does not operate in isolation, and the ability of any single sub-directorate, even one as important as HIV/AIDS, within a ministry, to influence major, national, generalized financial procedures and regulations is severely limited. Similarly, at the Province and District levels, all sectors and programs remain bound by overarching financial and procurement mechanisms.

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There are severe restraints on practical short- to medium-term strengthening planning options. •

The de-centralized health system is a reality. Major changes and reform of the system must be viewed as unlikely in the short to medium term. It will be necessary to cope with, and develop systems, appropriate to the highly fragmented supply chain system which has resulted from decentralization.

•

Multiple funding streams have a long and complex history. While advocacy for rationalization is possible, reforming the various funding streams is well outside the scope of influence of an individual Ministry of Health sub-directorate. In the short- to medium- term, it will be necessary to cope with, and develop systems appropriate to, multiple funding stream operations.

•

The standard, budget, funding and procurement mechanisms of the Indonesian public health system, at all levels from Central through Province to District and, to a lesser extent, at treatment site level, are not appropriate to any scale-up program, regardless of the thematic area, and not to any program element that requires a response time of less than two years. This process applies to all public sector funding, so while advocacy is possible, reform of the various financial and procurement procedures is well outside the scope of influence of an individual Ministry of Health sub-directorate. Therefore, in the short- to medium- term, it will be necessary to cope with, and develop systems appropriate to, a two-year forward budget cycle with uncertain funding levels and restrictive procurement regulations.

Within these many severe restraints, however, it is believed that it is still possible to formulate plans which can bring significant improvements. Identified key areas include— •

Allocation of resources for pharmaceutical management. The overwhelming conclusion that programs, especially those handling high value medicines, cannot afford not to have full pharmaceutical management is still not widely acknowledged. Experience from other countries in South East Asia suggest that in the initial stages of ART scale-up, as a guideline figure resource allocation for the operational cost of pharmaceutical management should be at least 20 percent of the commodity cost.

•

Communication of logistics/supply chain information to Province and Districts

•

–

Planning information

–

Central level issues/dispatches to provinces/treatment sites

–

General information

Dynamic stock and patient treatment protocol uptake management. A full program of dynamic stock and patient treatment profiles management needs to be developed, and perhaps over the longer term, would lead to using developed software packages such as Quantimed and Pipeline, but certainly ensuring, as a minimum, a monthly review of stock levels and patients’ numbers and adjustment of allocated patient numbers.

3


•

Long-term planning of at least two years into the future and updated at least every three months, and communicated to all parties involved in the supply process, and especially including national manufacturers and the international procurement agent, is essential if future supplies are to be obtained in a reliable manner.

•

Warehousing/storage space. Rationalization and provision of an adequate volume of quality storage space, with active stock management, is an essential starting point to take control of the medicines and commodity stocks. The sub-directorate HIV/AIDS is already using the services of a pharmaceutical distributor for some of the materials but, if necessary, this entire function can be contracted to a commercial/parastatal pharmaceutical distributor having adequate quality storage space and stock management capacity, such as the Philippines and Vietnam have done.

•

Technical assistance. The requirement for sub-directorate HIV/AIDS to leap into being a major, de-facto supply agency in addition to its other many functions, is an onerous burden and will require the formation of a full logistics unit, which is in the process of development. As a guideline figure, experiences from other countries in South East Asia suggest that technical assistance programs in the region of 1 million U.S. dollars (USD) per year for 3 to 5 year are often required to establish full dynamic logistics functions at Central Level for HIV/AIDS commodities.

Papua Supply Chain—Step 1. Strategic Design The essential aim of the strategic design is to develop a supply chain that consistently meets the needs of the health system and its patients with the central focus being on individual hospital and puskesmas needs.

Design Criteria The needed work would cover— •

Strengthening Central Level functions so as to respond to the needs and requirements of operations in Tanah Papua

•

Using current knowledge, design and plan the creation of a supply chain tailored to the logistics, communications, and human resource realities of Papua

•

Creating a fixed and skilled team to control the process and the implementation

•

Obtaining records from each health facility of issues and create usage databases for each one

•

Developing replenishment targets for each hospital and puskesmas for each product

•

Creating an impress-type replenishment system with each hospital and puskesmas

•

Creating the process that facilitates transfer of the usage data to the appropriate storage/supply point

•

Using replenishment trigger points to activate replenishment of health facility stocks up to a maximum stock level for each product

•

Improving storage facilities at all levels as required 4


•

Selecting appropriate transport modes between each storage and receiving unit (e.g., air, sea, road, foot)

•

Determining appropriate ordering and distribution schedules for each health facility and storage point

•

Selecting and implementing appropriate management information systems/information technology systems that facilitate the management of the supply chain in which each hospital and puskesmas would be maintained as a separate stockholding point with the system consolidating stocks and orders for higher level demand and procurement planning

•

Developing key performance indicators to ensure that all targets (e.g., availability, order-fill) are met

To expect hospitals and/or puskesmas to run a complex inventory management program with what are likely to be relatively low computer literacy levels is unlikely to be an option. Whatever system is developed and installed, whether that is a manual or computer-based system or a mix of the two, will have to reflect the ability of health staff to manage and control the data recording and reporting. Conversely, however, the system has to be able to facilitate the recording and collection of usage data for preparing and transmitting orders to the District and/or Provincial stores and/or private distributors in their stock replenishment role. Immediately implementing such a plan province-wide would probably not be advisable. It is therefore recommended that a pilot be put in place in two to three districts that tests every aspect of the proposed solution, identifies potential problems, and ensures the feasibility of the design.

Step 2. Pilot System The profile of the pilot is much along the lines of what is proposed to complete the strategic design except that it will be conducted in a limited geographical area. The work to be done after selecting the districts to be included would include— •

Select one major hospital and its relevant supply point

•

Select a number of puskesmas (such as eight), and the appropriate district stores

•

Assess the need for and feasibility of using larger/better managed puskesmas as a sub-district storage point

•

Collect all stock data on a monthly basis from all points in the pilot study supply chain

•

Calculate usages for each product used by each puskesmas and the hospital, including analysis to incorporate seasonality, substitutions, and out-of-stocks

•

Develop target stocks for each stockholding point

•

Implement a dispensing and replenishment system into the hospital and the puskesmas with onsite training

•

Undertake operational process design to determine the required supply chain resources

•

Assess existing communications, electricity supply and other utilities as relevant

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•

Create appropriate communication links and methods of transferring data

•

Use the replenishment system by the hospital and puskesmas with frequent update of usage data to the provincial and/or district store

•

Test all aspects of the process

•

Assess problems, determining solutions or enhancements, effecting changes to the processes

•

Validate the weighted distribution analysis for roll-out on a provincial basis

•

Demonstrate the working system to other districts and to the Provincial health authorities

•

Create an implementation plan for each district to which formal agreement must be obtained

•

Undertake roll-out on a district by district basis

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Background Tanah Papua is the Indonesia language term used to refer to the geographical region of Papua within Indonesia which encompasses the western half of the geographical island of New Guinea and many associated islands. It comprises the two Provinces of Papua and West Papua and was formerly known as Iran Jaya. Figure 1. Indonesia

Unlike in the rest of Indonesia, where the HIV/AIDS epidemic is highly concentrated in most-atrisk-groups recent surveillance data indicate that Tanah Papua (i.e., the provinces of Papua and West Papua) has a “mixed” epidemic. HIV prevalence levels among female sex workers are the highest in the country, with 2005 sentinel surveillance data indicating HIV prevalence in the largest Papuan cities in the 15-25 percent range. From AIDS reports, cumulative AIDS cases in Tanah Papua until the end of March 2007 was the second highest in the country after Jakarta. However, if the number of HIV/AIDS cases is accounted as a proportion to its population number, the case rate (number of cases/total population times 100,000) in Papua was 60.93 per 100,000 or 15.4 times higher than the national average (3.9), while in Papua Barat (West Papua Province) was 10.24 per 100,000 or 2.60 times higher than the national average. This gives Tanah Papua the highest proportion of AIDS cases in Indonesia. 8

8

Statistics Indonesia in collaboration with the Ministry of Health. 2006. Risk Behavior and HIV Prevalence in Tanah Papua 2006 Results of the IBBS 2006 in Tanah Papua. http://siteresources.worldbank.org/INTINDONESIA/Resources/Publication/PapuaHIV_en.pdf (accessed February 2008).

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Anecdotal evidence has suggested for some time that Tanah Papua was on the verge of a general population epidemic, and in the past two–three years, efforts have begun to assist the two provincial governments in addressing the growing epidemic. Confirmation of the general population epidemic has significantly elevated concern over HIV/AIDS in Tanah Papua, and it appears probable that the level of resources flowing into Tanah Papua to combat HIV/AIDS will grow substantially over the next few years. With assistance from Family Health International (FHI) and the World Health Organization (WHO), the Papua Provincial Health Office has developed a health systems strengthening plan that will serve as a blueprint for development activities over the next few years. What is missing from the current plan is a parallel plan for strengthening supply chain management. The existing system may be best described as ad-hoc. Some commodities are procured centrally and then shipped to the Provincial health offices, with scheduling driven mainly by when funds become available in the national and provincial budgets (usually quite late in the fiscal year). The existing system, which covers only a fraction of the medicines and commodities that will be needed to implement the health systems strengthening plan, is weak across the board. The Head of the Papua Provincial Health Office recognizes the limitations of the existing supply chain management system and has asked for urgent assistance. What is needed as a starting point is a full situational assessment and development of a set of recommendations as to what needs to be done to adequately support the health systems strengthening effort. FHI arranged for a rapid assessment of the commodities management system in Tanah Papua to be undertaken by a local consultant so that whatever “quick fixes” which were feasible could be implemented immediately to keep the health systems strengthening initiative moving forward. However, the results of the rapid survey have indicated that the problems are highly complex and that a more in-depth assessment is needed to provide sufficient information to develop a more comprehensive response. •

Various proposals and efforts for the expansion of HIV/AIDS management activities in Papua are in progress ranging from voluntary counseling and testing (VCT) at primary health centers through provincial led efforts to improve hospital/healthcare access for People Living with HIV/AIDS through to national level initiative. It is clear that all will require an effective supply chain and commodities management system if they are to be able to achieve their goals.

•

In response to concerns expressed by active players on the condition of HIV/AIDS commodity availability and management within Tanah Papua and fears that commodity availability could be a major restricting factor in the rate of HIV/AIDS control and management within the region; and following the results of FHI-sponsored Rapid Survey of HIV/AIDS commodities in Tanah Papua, the U.S. Agency for International Development (USAID) has agreed to fund an in-depth study of HIV/AIDS commodity and supply chain situation within Tanah Papua.

•

The Supply Chain Management System (SCMS) was engaged to undertake the study. A detailed scope of work for the study is in Annex 1.

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Objectives and Scope Objectives The main objectives is to undertake a comprehensive HIV/AIDS health commodities situation assessment in Tanah Papua which will include the logistics of antiretrovirals (ARVs) commodities, distribution and supply to hospitals, the provision of VCT materials in hospitals and puskesmas (primary health centers).

Scope The survey aimed to consult widely with active players in both the public and private sectors and to undertake survey activities in both of the two provinces in Tanah Papua and collect data from public hospitals and health centers in at least 12 Districts. Additionally it was also intended to collect information on the private sector health activities, and related logistics support functions such as provision, storage, transportation, and communication services.

9

Methodology Overall Drawing on the experiences of numerous previous surveys including the WHO essential medicine surveys and District Level Assessment Tool (DLAT) and the more recently FHI- managed rapid assessment of HIV/AIDS commodities in Tanah Papua SCMS developed an outline plan which was then discussed with active partners and sub-directorate HIV/AIDS. SCMS arranged to contract with Manggala Jiwa Mukti (MJM) Consultants to provide comprehensive in-country support, field survey teams, data collection, processing, and management services. The overall methodology was to collect information from— •

Collection of records and reports (bin cards, stock cards, ledgers, periodic logistics reports)

•

Field observations

•

Publications

•

Interviews

In logistics/distribution terms, Tanah Papua can be considered as three distinct areas, each requiring a rather different logistic response, especially in relation to distribution and transport of commodities—highlands, easily accessible lowlands, and hard to access lowlands. Figure 2. Area stratification of Tanah Papua.

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The majority of the population is located in the easily accessible lowlands. In designing the geographical range of the survey it was therefore necessary to endeavor to encompass all three logistical designated regions, and to also endeavor to attain a degree of balance between covering the largest population with the more challenging logistically highlands area with its relatively small populations.

Survey Design Overall logistics parameters were designed for each level of the system: •

Central

•

Province

•

District

•

Hospital

•

Puskesmas

The detailed parameters for each level can be found in Annex 3 (Table 1 is a sample).

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Table 1. Parameters for Hospital Levels HOSPITAL LEVEL ARV/STI/OI/RAPID TEST REAGENTS Inventories Inventory building Requisition and deliveries Inventory record/stock cards Supply capacity Stock out Expiration/damage Write Off and Disposal authorization procedures Emergency logistics Storage condition and capacities Distribution Distribution to satellite hospital Requisition and deliveries Inventory record/stock cards Supply capacity Stock out Expiration/ damage Write off and disposal authorization procedures Emergency logistics Storage condition and capacities Organization and staffing Manuals and guidelines Operating budget Tools and equipment IT support Training and supervision Monitoring and evaluation

Detailed data collection forms were then designed for each level of the system (Annex 4). Geographical Range

•

The survey was designed to include the 2 provinces of Papua and West Papua and the 12 Districts, which represents 70 percent of the total population in Tanah Papua and encompasses 99.2 percent of the identified cases reported in 2006 in the Tanah Papua.

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•

All first appointed ARV hospitals are surveyed and all hospitals in the 12 districts were also surveyed. At least 2 puskesmas in each District was chosen, especially puskesmas which already provide VCT services or had prepared themselves through participating in VCT trainings.

•

All District and Provincial AIDS commissions were surveyed and all District pharmaceutical warehouses and Provincial pharmaceutical warehouses were assessed.

•

MoH Indonesia Directorate of (CDC) Control warehouses where available in Province or District were also visited.

•

Nongovernmental organizations –

Association of Voluntary Health Services in Merauke

–

Saint Anthony Foundation in Merauke

–

FHI in Jayapura

Data Collectors and Training Activities Field data collection staff included MJM staff and also members from the Province pharmaceutical warehouse in Jayapura and the Municipality of Jayapura Pharmaceutical Warehouses. In total, the field team consists of six staff members, with four of them being pharmacists. Field survey team training in the survey instruments was undertaken in Jayapura including demonstration field training. The draft data collection instruments were tested during the field training and numerous modifications made in response to the radically different situations encountered between puskesmas and hospitals. While it was known in advance that substantially different operating systems were used for logistics management at hospitals and puskesmas, within Tanah Papua a radically different logistics vocabulary and set of definitions were used between puskesmas and hospitals, and it was necessary to adopt the different versions of the survey instruments to use the relevant vocabulary at each level surveyed. Pharmacists within the region were also invited to attend and contribute to the field staff training, but only three pharmacists from Jayapura did attend and participate. Private and commercial organizations, both nationally and within Tanah Papua, were identified and were surveyed by the international consultants.

Data Collection and Management Data Collection

•

Field data were collected mainly during October and November 2007, with some additional documents and clarifications received through to the end of January 2008.

•

Each survey team had one person in charge to make notes of the interviews, physical observations, and to review the collected data every evening, so that any gaps and missing data could be identified, and efforts made to try to collect any missing data the following day before leaving the site.

13


•

The huge variation in the ways that individual Districts were classifying and recoding data meant that each team had to be granted wide ranging powers to decide which data could realistically be collected in the time available. For those sites that had information technology (IT) facilities, it was generally possible to collect all information and decide later which would be the most appropriate to use; but for the many sites operating totally manual systems with largely uncollated records such as stock movement ledgers, extensive on-site calculations were necessary and only the prime parameters could be extracted.

•

An interim presentation report on the survey activities was made and presented on the November 27 in Jayapura and November 30 in Manokwari. The last presentation of survey activities was made on December 6, 2007, at CDC premises in Jakarta.

Data Management

•

Initial data cleaning and qualitative checking were conducted in Jayapura as teams returned.

•

Even in other areas very little response was received to follow-up queries from puskesmas and District level.

•

New data from Provincial and Central levels continued to be received up until the end of January 2008.

•

The majority of data was verified, collated, and then entered into Excel spreadsheets to have the widest availability to units within Tanah Papua.

•

Final data verification was undertaken by proof reading the data entry tables against the original documents.

Survey Team SCMS–MSH

The team SCMS-MSH team consists of three SCMS international consultants— • Andy Barraclough (Thailand) •

Malcolm Clark (Australia)

•

Ned Heltzer (USA)

MJM Field Organization

The MJM team was lead by Pak Yos Hudyono with three members— •

Murni Mursini

•

Tommy A. Djalung

•

Naning Yasmiatini

The three pharmacists are— •

Lucia Ang—Province Pharmaceutical Warehouse, Jayapura

•

Lucky E. Borumey—Municipality Pharmaceutical Warehouse, Jayapura

•

Linda S. – Dok II Province Hospital, Jayapura (accompanied the training, but can’t visit to the field, since her personal reason).

14


Collected Data Overview A large volume of data was collected. Summarized tabulated data will be available in electronic form on CD Rom, but only pertinent extracts will be presented in this report and are included in Annex 5.

Data Restrictions The data collected for private commercial operators has potential commercial sensitivities and is therefore available only in summary overview.

Data Scope and Range Interviews A full list of respondents is included in Annex 6. Interviews were conducted with 196 persons at various levels at 68 institutions—Provincial AIDS commission—3 Provincial Health office staff—7 District Aids Commission—15 District Health Office staff—44 District pharmaceutical warehouse staff—32 AIDS working groups in hospitals—44 AIDS working groups in puskesmas/clinics—28 Private sector—9 Nongovernmental organization (NGO)—3 Association of Voluntary Health Services (Merauke branch) and the Yasanto Foundation in Merauke and FHI—2 AIDS commission in Province and Districts—14 Hospitals—13 Puskesmas and Private Clinics—15 Provincial Health Laboratories—1 District Pharmaceutical Warehouses—12 Provincial Pharmaceutical Warehouse—1 Provincial Offices in Transportation–Communication and Electricity—3 Others—11 15


Private offices of the Pharmaceutical Business and the Association of Papua and the Association of Private Expeditors—2 Commercial sector operators—5

Geographical Range Table 2. Districts and Hospitals

2007 DISTRICT

HOSPITAL WITH

HOSPITAL Public

Private

Special

VCT

CST

1

1

Papua Districts Jayapura Municipality

0

Jayapura District

1

Yapen Waropen District

1

Biak District

1

Nabire District

1

1

1

Jaya Wijaya District

1

1

1

Merauke District

1

2

1

Asmat District

0

Mimika District

1

2

2

2

SURVEYED DISTRICTS IN PAPUA

7

6

7

6

MANOKWARI DISTRICT

1

2

1

1

FAK-FAK DISTRICT

1

0

1

1

SORONG DISTRICT

1

0

1

1

SURVEYED DISTRICTS IN W.PAPUA

3

2

0

3

3

Total

10

8

1

10

9

3

1

1

1

Data Limitations The complexity of the fragmented supply system described later in detail in the Key Findings— Commodity Flow section requires special care in the use, analysis, and interpretation of the collected data. Most importantly, the data must be considered in its entirety and not as individual funding/supply stream activities, which is often the way in which records are kept and the data is 16


reported, and sometimes, of necessity, collected. For example, on a crude analysis of a single funding stream supply for ARVs, it could be concluded that 25 percent of ARVs were out of stock. This would be an entirely wrong interpretation of the data and provide a false perception of the supply system by failing to take into account the multiple supply routes. In treatment terms, it is not important whether the supplies came through the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM)-funded route or the Government of Indonesia (GoI)funded route, provided there were supplies available at dispensing point to serve the patient. To report an item such as stavudine 30 mg out of stock because there is no GFATM-funded supply available but there are ample stocks of a generic equivalent of the same product from GoI-funded sources available, may have some documentary merit within the individual funding stream administration, but can provide a quite misleading impression of availability of medicine to the patient. ARV supply routes and different supply stream reports are considered together instead of in isolation, in fact, no ARV treatment protocol stock outs are recorded during the last six months. Again, the collected data must be collated from the multiple supply streams and considered in its entirety before any meaningful attempt at system analysis can be undertaken. The quality of the data collected varies considerably between the different commodity classifications and between sites, but Table 3 shows the general trend.

Table 3. Data Quality of Different Commodities. Higher data quality

Medium data quality

Lower data quality

ARV

STI/OI medicines

HIV rapid test kits

At nearly all sites surveyed which provide ARVs, historical stock records and reports were available. The situation for STI/OI medicines wavers between good and no records; and no sites were found to have any historical stock records for HIV rapid test kits. This is not to say that no commodity records were available, but rather that historical stock data—the key to measuring logistics system performance—was not always available or accessible. The ARV data generally appears adequate for system appraisal and while there are, in some instances, arithmetical stock errors and numerous inventory discrepancies in the reports, the overall quantity discrepancies do not appear huge. It is possible to reasonably determine the overall supply situation for ARVs. It was further found that the use of computers was not always a reliable indicator of data record accuracy. In some cases, the computer is being used only as a memory typewriter and not as a computational tool. For sexually transmitted infections (STIs)/opportunistic infections (OIs) medicines and HIV rapid test kits, the data is more diffuse and the overall effect is to require a greater reliance on the observational/directly measured values than would be the case if good and complete records were available, and thereby to limit the value of analysis that can be drawn from such historical data as does exist.

17


Given the considerable variations between surveyed sites, it is suggested that some caution must be exercised in n interpreting the data. Overall, it is believed that the data accuracy is adequate to support analysis of major logistics system components, such as availability of medicine at site, stock outs, but should not be taken beyond that level. Fortunately, the measured effects of the major logistics components are such that there can be little doubt of the overall findings.

18

Key Findings Reporting Findings and Assessments of Consequences It is a sad feature of developing country public sector health commodity logistics systems that they are universally grossly under-funded and lack resources and skilled staff; consequently, they are often very weak. Reviewing such logistics systems in absolute terms can often be unenlightening, since such assessments fail to take into account the reality of the overall health care environment and funding levels. The logistics systems will nearly always be judged to be appalling and in need of massive strengthening for which it is unlikely that the necessary funding will ever be available. Rather, the logistics system should be considered within the overall health care delivery context and formulate recommendations which are in keeping with overall health care delivery strengthening activities. The major output from this report is intended to be the development of a logistics workplan/policy which will correspond to the overall HIV/AIDS control activities workplan/policy being undertaken in Tanah Papua. As such, it is essential that the logistics system is viewed in the light of overall planned developments and recommendations formulated accordingly.

The Need for Data, not Perceptions—De-bunking the myths and Misconceptions Many persons and bodies consulted concerning the Tanah Papua situation have expressed strong views and opinion on the functioning of the logistics system. Even with the caveats and cautions ascribed to the limitations of the data, it must be recognized that a number of these views are misconceptions. It was not uncommon for interviewees to report many out of stock occurrences during discussion, but when the stock records for that unit are examined it is clear that the commodities had not been out of stock within the last six months. A few frustrating experiences were being generalized to represent the normal functioning of the system when they are, in fact, more the exception than the rule. Similarly, there appears to be a widely held view that the logistics system is dysfunctional. The system has many difficulties and shortfalls, but medicines and especially antiretrovirals (ARVs) are clearly reaching patients. The impossibility of transport was also raised repeatedly, yet it was clearly obvious that goods can be transported through the region. It is difficult and expensive, but it can and does happen through the services of a number of commercial and nonprofit organizations operating in the Province. We would, therefore, stress the need to view the findings of this report in light of the data, and not from positions of perceptions, however strongly held.

19


Geography and Logistics of Tanah Papua Comprising most of the western half of New Guinea and a number of offshore islands, the geography of Papua is dominated by a central east-west mountain range that is about 600 km long and 100 km across. These mountains are the highest in the world after the Himalayas and the Andes, rising to over 5,000 m in height. 9,10 These high mountain regions are broken by valleys covered with coarse grass, and tropical rainforest vegetation is common. The low-lying areas north of the central mountain range are clothed with dense rainforests. Elsewhere, a wide swampy area imperfectly drained by a series of rivers, such as the Digul, adds to the geographical challenges. The Region’s limited infrastructure combines with the difficult geography to make transportation around the province very challenging. The road network is by and large limited to a few secondary coastal roads with the most important transport links between population and economic centers being provided by sea and, more especially, air. 11 The difficult geography does not make for the easy transportation of people and goods around the provinces. Nevertheless, the survey found that there are a number of private sector companies, and commercial and not-for-profit operations that provide regular and reliable air services to most, if not all, population centers. For example, the Associated Mission Aviation (AMA) has five flight bases in the province, in Manokwari, Timika, Nabire, Sentani and Wamena with at least one plane stationed at each base. With the exception of the month of December, when AMA has responsibility for transporting mission staff to and from their work places, AMA is able to offer freight services throughout the year. Similarly, Mission Aviation Fellowship (MAF) is able to use its 13 planes to transport goods and people to the more than 400 airstrips that are accessible in Papua, weather and runway conditions permitting. MAF has experience transporting supplies for the Provincial health department. In addition to AMA and MAF, the Swiss organization, Helimission, provides a helicopter service from its base in Wamena and there are commercial carriers also able to transport medicines and medical supplies around the province. None of this is to say that transport and logistics are problem-free in Tanah Papua; clearly they are not. The United Nations Children’s Fund (UNICEF), for example, reported that they have faced transportation problems when they need to distribute their supplies. Space on flights may not be available and sometimes there are no convenient flights. However, the main issue is not transportation but budget availability, the flow of funds, and government capacity to access the services. UNICEF also reported that the government’s poor payment record sometimes becomes an obstacle to accessing the transport services that are available.

9

Sources: Wikipedia, http://en.wikipedia.org/wiki/Papua_(Indonesian_province)#Geography 5,029 m; highest in the nation at Jaya Peak, http://www.infoplease.com/ce6/world/A0909767.html 11 Source: Papua. (2008). In Encyclopædia Britannica. Retrieved January 24, 2008, from Encyclopædia Britannica Online: http://www.britannica.com/eb/article-9042764 10

20


Although the terrain and limited infrastructure undoubtedly present challenges to supply managers, transportation resources are generally available for distributing essential medical supplies to all parts of the provinces to those who are able and willing to pay. Therefore, it would be a mistake to see availability of transport services and difficult geography as obstacles to providing a regular supply of essential health commodities. Moreover, these transportation services can either be accessed directly or through a third party, such as Dexamedica, one of the private pharmaceutical distributors, which have experience with distributing its own products around the province. The key to accessing these services is having a reliable budget available with which the services can be paid for. 12 In thinking about the specific supply problems for the Tanah Papua health services, it is often assumed that the challenging geography must inevitably lead to problems with the supply system. In fact, this is not the case. Transportation is readily available from Jayapura to all of the main population centers as well as many of the smaller centers. Transport to puskesmas levels is far more problematical, but is not impossible to achieve through a number of service providers in each of the Districts. Moreover, as the data presented in this report demonstrate, although the essential medicine supply system is not without its problems, its performance is generally no worse than that found in public health supply systems elsewhere. This is important to bear in mind when considering recommendations for strengthening the supply system in Tanah Papua

Commodity Flow Overview The flow of HIV/AIDS commodities in Tanah Papua largely reflects the effects of de-centralization on the health service structure and the huge fragmentation that has resulted to the essential medicines and health commodities supply systems and network. A general explanation with specific examples from Tanah Papua follows in this overview section and then specific survey findings for individual commodities are reported. Pre-Decentralization

The situation on public-sector drug supply in Indonesia, in common with many lower income countries, was complex before decentralization occurred. The legacy of previous donor/program driven operations had produced numerous, largely independent, vertical programs undertaking program-specific commodity supply; historical responses to particular difficulties and availability of finance had produced various funding sources/budget lines which greatly varied in value over time and a centralized procurement mechanism but locally administered supply for other essential drugs was in operation. The splits and responsibilities for provision of different medicines categories, and sometimes on the same medicines for different uses, were variably defined by various parties. Decentralization

Decentralization of government services was undertaken as a “big bang” operation on January 1, 2001, with 11 sectors (including health) decentralized largely to District level. Under the laws implemented in 2001, the responsibility and authority for planning, budgeting, implementing, and 12

Note: MAF also reported that this was the biggest constraint with working with the health authorities.

21


monitoring primary health care delivery were transferred to districts and municipalities. Within these newly transferred responsibilities, Districts and Municipalities were required to assume a greater role in the funding, procurement, and management of essential medicines. These new responsibilities required that new management skills and leadership practices be developed at District and Municipal levels and that the role and functions of central institutions evolve to reflect the changed circumstances. Decentralization Laws and Regulation

There is no mention of drugs or diagnostic materials in the main Decentralization Law No. 22, and only 12 words contained in the main decentralization regulation No. 25. There are multiple, and often conflicting, ministerial decrees establishing operating practice, but while such decrees carried legal status pre-decentralization, the legal/regulatory value/weighting of such decrees in a post decentralization framework is uncertain. The current legal consensus appears to be that they can serve only as guidelines as to how Provinces and Districts should act. The situation is confused, not all responsibilities contained in the regulations are being observed, and there are widely varying interpretations of every aspect of the regulations. Terminology

Different Provinces and Districts have responded to decentralization in different ways, have developed and are using entirely differing methods and procedures, and sometimes, through varying definitions and practices, provide apparently conflicting information on their medicine management activities. Results of the District level Assessment Tool (DLAT) for pharmaceuticals survey showed that following decentralization, all terminology is interpreted differently by different groups. Even terms such as budget, essential drug, and purchase volume no longer have a standard interpretation. Great care must be used in referring to any specific logistics term as the definition in individual districts varies widely. Responsibility Splits

The best interpretation of the various regulations suggest that at decentralization, responsibility for essential drugs was split between the three major levels of government. Literal translations of the Indonesian language definitions are used to maintain direct links to the regulations even though this produces some rather unusual terminology in the English language. Table 4. Division of Responsibility for Essential Drugs Level Center Province District

Responsibility

Estimated Drugs in List

very, very essential drugs list (vvEDL)

around 80 line items

very essential drug list (vEDL)

no clear list

essential drugs list (EDL)

around 145 line items

The precise definitions of the drugs included in each of the classifications are unclear, and the interpretation of ‘responsibility’ varies considerably.

22


vvEDL

Even though vvEDL drugs are by regulation to be supplied by Central Level, there is no longer any clear mechanism in place for the overall, main stream, Central level supply of essential medicines. Numerous small scale funds/programs operate for emergency drugs, shortfall drugs, etc. Currently 13 vertical programs (including HIV and STI) have been identified which undertake commodity supply. Each of these programs operates independently and often has multiple streams of supply within a program. There is no mechanism or clear delineation of which section at Central Level should undertake the supply of the remaining 40 items thought to be included in the vvEDL. Table 5. OI and STI Medicines Currently Supplied from the Central Level Under the vvEDL Definition* OI MEDICINES Ofloxacin 200 mg Fluconazole 100 mg (flucoric 100)

PRESENTATION bottle

UNIT/PACK 100

tab

AMOUNT in PACKS

Expiration Date

1,240

September 08 December 07

box

100

caps

55

Acyclovir 200 mg (acivir)

bottle

500

tab

260

November 08

Acyclovir 400 mg

bottle

100

tab

810

January 11

vial

0

July 08

tab

0

tab

240

July 10 January 09

STI medicines Benzathinebenzil penicillin

vial

Cyprofloxacin 250 mg Erythromycin 250 mg

bottle

100

Metronidazole 500 mg

tab

tab

42

Fluconazole 150 mg

Not Available

caps

0

Amphotericin 50 mg

vial

vial

9,119

November 07

Doxycycline 100 Mg

bottle

tab

28.300

March-08

1000

*Available at DCD warehouse in Jakarta during the survey vEDL

There is no agreed list for vEDL drugs, and the Provinces have a wide range of interpretations. Some Provinces physically supply EDL drugs, some provide budget funding to Districts, and some provide emergency/buffer stocks in event of shortfalls at Districts, while others decline to undertake any drugs activities. The inventory of OI/STI medicines at the Papua Provincial warehouse reflects this situation. Some medicines have been provided from Central Level, some of the same medicines have also been procured independently by the Province, and the Province has procured further medicines (formulations) from the vEDL list to supplement the range of OI/STI medicines available.

23


Table 6. Inventories of OI and STI Medicines in the Papua Province warehouse, Jayapura OI MEDICINES Ofloxacine

Presentation box

Unit/pack 50

Fluconazole

tab

290

cps

0

Acyclovir 200 mg Acyclovir 400 mg

Amount

0 box

100

tab

1,215 0

STI MEDICINES Benzathinebenzil penicillin 1.2

box

10

vial

1,252

Benzathinebenzil penicillin 2.4

box

10

vial

758

Ciprofloxacin 250 mg

0

Cyprofloxacin 500 mg

box

50

tab

1,648

Erythromycin 250 mg

box

100

caps

1,500

Erythromycin 500 mg

box

100

caps

332

Metronidazole 500 mg

box

100

tab

5,351

Doxycycline 100 mg

box

100

caps

3,388

EDL

Districts are procuring not just EDL drugs but all drugs that they feel they require, sometimes including vaccines, and other vvEDL drugs. The current uncertainty on the supply of vvEDL and vEDL drugs renders it almost impossible for Districts to undertake effect planning and management of drugs. The system becomes widely diverse as it reaches lower levels. Survey data indicates that, on average for Tanah Papua, Central Level is providing 7 STI medicines, but at dispensing point to patients (hospitals/puskesmas) across the region, more than 27 STI medicines, all procured from different levels of the system, can be in use. In essence, in addition to the medicines received from Central Level and Province, different Districts are buying entirely different medicines, and all are using entirely different treatment regimens.

24


Table 7. Variation of OI/STI medicines Between Health System Levels ITEMS

OI/STI MEDICINES OI

Total Tanah Papua

10

Province of Papua

7

Average districts

OI

8

35

Central CDC warehouse, Jakarta

DOSAGE FORMS 11

45 STI

27

OI

3 7

OI

3

STI

34

OI

4

4

OI

0.5

STI

7

OI

3

STI

4

STI

35

OI

4

STI

7

OI

3

STI

8

OI

1

STI

5

11 STI

8

OI

1 6

5.75

4.5

11

11

11 STI

OI 46

11 STI

PRESENTATION FORMS

STI

4.75

National Level Drug Supply Information Prior to decentralization, a medicine management information system (MIS) was in place. When decentralization occurred, this system collapsed as Districts and Provinces declined to report their pharmaceutical activities to higher levels in the system. Currently, the only way to determine the overall drug supply situation is by survey. The sub-directorate HIV/AIDS does have a system of monthly reporting from treatment sites for ART and requisitions for re-supplying ARVs by fax and e-mail. The system appears to be getting stronger with time. Budgets

Budgets had a degree of complexity before decentralization, and post-decentralization, the situation has been compounded by variations in terminology. During the DLAT reporting and, again, during this survey, not even an agreed definition of the prime District budget General Allocation Fund could be obtained. District level budgets for commodities are characterized by a wide variance and multiple sources.

25


Figure 3. Average of 25 districts divided in use of budget sources for commodities—DLAT data.*

PD - PSE / PKPS BBM 16%

Others 6%

JPS - BK 2% Askes 5% Foreign funds 0%

DAU 65% PAD 6%

*District Level Assessment Tool (DLAT) Survey, Indonesia, MSH, 2005

District drug managers have limited experience in undertaking budget advocacy for essential medicines. There is no observed correlation between any factors in District budgets used for commodities—funds requested, income level of District, District Health budget, population, etc.— and fund allocated for drugs at District level by District administrations.

26


Dok Ii Hospital

1

Abepura Hospital

1

Dian Harapan Hospital

1

Merauke Hospital

1

Mitra Masyarakat Hospital

1

SELF FINANCING FHI

1 1

Wamena Hospital Biak Hospital

DISTRICT BUDGET

CENTRAL BUDGET

HOSPITALS

PROVINCE BUDGET

Table 8. Budget sources for HIV rapid test kits at surveyed sites in Tanah Papua

1 1

1

Serui Hospital

1

1

Nabire Hospital Manokwari Hospital

1

Sele Be Solu Hospital

1

Sorong Gen. Hospital

Referred To Sele Be Solu Hospital

1 FHI

Fak - Fak Hospital

1

SPM Minimum Service Standards

Standar Pelayanan Minimal bidang kesehatan di kabupaten/kota (SPMs) Minimum Service Standards in Health for Districts and Cities, were imposed by ministerial decree promulgated in October 2003, autonomous Districts are required to achieve certain minimum standards in the provision of health services. Various essential drug regulations are incorporated into the decree and include both direct drug management requirements and indirect drug requirements— •

The “drug” SPMs Chapter 2, paragraphs w and x, specify minimum standards of supplying 90 percent of need, 100 percent procurement of essential drugs, and 100 percent generic drug use

•

Health service levels which require specific drugs are included an additional 10 times in the decree for contraceptives, vaccinations, vitamin A, iron/folate, polio vaccination, tuberculosis, STIs, diarrhea, leprosy, and malaria

The SPMs clearly make Districts/Municipalities responsible for the delivery of health services and for ensuring the availability of medicines (defined as 90 percent of need).

27


Unfortunately, the SPMs as they apply to medicines have been largely ignored by Districts and few systematic attempts to comply with the health SPMs has been made by the drug units at Districts. Many Districts are still making no attempt to measure their compliance with the SPM and in the absence of strong Central Level activities on pharmaceutical management, there is little incentive or drive to comply with what some vocal Districts perceive as yet another Central Level edict made without consideration of the reality of their funding situation. Overall Assessment of Decentralized Commodity Flows

The huge variations between Districts makes generalizations on the overall situation especially problematical, but the size of some problems are such that certain points can be clearly discerned. For overall commodity provision the major problems center on— •

The low level of funding allocated for drugs

•

The poor supply mechanisms in the vertical programs

•

The high level of confusion throughout the system –

Lack of knowledge and awareness of all major aspects of drug management, and especially of quality control, throughout all system levels

•

No individual commodity has a single funding or flow channel

•

Each commodity has a unique set of flow channels

•

There are multiple different funding channels, sometimes as many as six, possible for each commodity

•

There is a huge variation between Districts and individual hospitals on which flow and funding channels are used

•

There is little evidence of any structured coordination between the funding and flow channels

Such findings are not unique to HIV/AIDS related health commodities and have been regularly reported for all health related commodities in Indonesia. HIV/AIDS related diagnostic materials, as there The main problem appears to be no clear body responsible for their handling. Some Districts include them within the remit of the District Pharmacy Warehouse (GFK), but for many they remain outside the mainstream commodity flow.

Individual Commodities ARVs ARVs are largely provided from Central Level, but in theory, under the decentralized health system, any health level and every individual hospital within the system, can procure ARVs, which are available on the national market, utilizing a number of possible budgets. There is evidence that some emergency procurements of ARVs appear to have been undertaken at Province, Districts, and

28


hospital level, but no major volumes within Tanah Papua, where the prime supply is from Central Level. At Central Level there are two main funding streams, and two independent distribution systems for ARVs. Major commodity streams for ARVs— •

•

GFATM –

Budget/funding provided by GFATM so subject to GFATM procurement and financial regulations; in effect only WHO pre-qualified suppliers/products can be used; at present, no Indonesian manufacturer has obtain WHO prequalification status

–

Procurement is undertaken through UNICEF, commodities are imported, and materials are stored at different sites within Jakarta and then distributed directly to treatment site

–

Dual funding budget/funding streams have been provided by GoI at Central Level.

–

There is a Memorandum of Understanding (MOU) from the Government directly to the manufacturer Kimia Farma to produce ARVs and deliver through their distribution network directly to the treatment sites.

–

There are additional regular program funds provided annually under the control of sub-directorate HIV/AIDS. These are subject to GoI procurement and financial regulations; procurement on national market by tender, with preference to stateowned enterprise manufactured products.

–

Procurement has previously been undertaken through Central Level Center for Disease Control procurement mechanisms.

–

For direct MOU distribution, materials have been stored at manufacturer’s/distributors depots, and sent to distributor’s regional/provincial depots, and from there to treatment sites. For annual program funds, materials are intended to be stored at CDC warehouse but when space is inadequate arrangements for storage at Kimia Farma are undertaken.

GoI

GFATM Funded In the past, procurement through UNICEF and importation has been reported as a major problem with lead times in excess of 200 days. More recent information indicates that the situation is now greatly improved, but the difficulties of the importation process and, in particular, of obtaining the necessary duty-free permission and exemptions act as a serious time constraint on the whole supplies process. Long-term planning is essential for this process to operate effectively. There is inadequate space at Central Level for commodities storage and it appears that wherever space is available, commodities are stored there ad-hoc. There is a small store consisting of two office rooms equipped with temperature control equipment refrigerators within the CDC compound but the storage volume is very limited. There are further stores which CDC utilizes which are within 29


the Food and Drug Authority (BPOM) compound adjacent to the CDC compound. When large shipments are received, however, this space is also inadequate and arrangements are made to store materials with a distributor, usually Kimia Farma, at one of its warehouses typically at Metadon. Table 9. GFATM-Funded ARV Medicines in Stock at Central Level During the Survey Period ITEMS

UNITS

PRESENTATION

PACK

AMOUNT

EXPIRY DATES

(Zidolam)

60

tablets

bottle

9,436

Exp. date 11–2008

Nevirapine*

60

tablets

bottle

12,018

exp. 31–01–2007

Efavirenz (EFV) (Stocrin 600 mg)

30

tablets

bottle

0

exp. 10–2008

EFV (200 mg)

90

capsules

bottle

267

exp. 12–2008

60

tablets

bottle

5,456

exp. 01–2008, 08–2008

60

tablets

bottle

1,318

exp. 12–2008

Triomune 40

60

tablets

bottle

2,718

exp. 12–2007, 09–2008

Triomune 30

60

tablets

bottle

7,748

exp. 12–2007, 09–2008

Didanosin

60

tablets

bottle

761

exp. 02–2008

30

tablets

bottle

465

exp. 05–2008

Zidovudine (AZT)/Lamivudine

Lamivudine 150 mg + stavudine 40 mg Lamivudine 150 mg + stavudine 30 mg

Tenofovir (TDF) 300 mg * Already expired

Distribution to hospitals is financed through GFATM funding. Logistics are executed by CDC Logistics Unit.

GoI Funded Dual funding budget/funding streams have been provided by GoI at the Central Level. There is a MOU from the Government directly to Kimia Farma to produce and deliver ARVs through their distribution network directly to treatment sites. The funding under this program appears to be now exhausted and no further deliveries in 2008 are currently expected, but Kimia Farma has continued to provide ARVs to secure sustainable ART and negotiations are still in process to accommodate those ARVs distributed beyond the existing contracted volumes. There are additional normal annual program funds under the control of sub-directorate HIV/AIDS. These are subject to GoI procurement and financial regulations—procurement on national market by tender, with preference to SOE manufactured products. Binfar (Department of Pharmacy within Ministry of Health). For direct MOU distribution materials have been stored at manufacturer’s/distributors depots, and sent to distributor’s regional/provincial depots, and for there to treatment sites. For annual program funds, materials are intended to be stored at CDC warehouse but when space is inadequate arrangements for storage at Kimia Farma. 30


Figure 4. Commodity flow of GOI-direct MOU funded supplies

Requisition from Referral Hospital

SubDirectorate HIV/AIDS Via fax, email, or post office

Delivery Instruction

Annual production of ARVs E-mail or Fax

Marketing department KF

Batch deliveries

Central warehouse Kimia Farma

Wholesaler Kimia Farma in the region

Internal KF instructions Delivery of goods

Flow of receipt of ARV

ARV Availability for Procurement

Production of ARVs for the public sector by Kimia Farma started in 2004 based on a presidential instruction. Since 2005, requisitions of ARV have always been greater than the available national budget allocation. ARV allocations have always been depleted before the next procurement agreement is signed. It is reported that this was particularly evident in 2007 where inventories were almost zero and Kimia Farma provided ARV’s before new procurement agreements had taken place. ARV Re-supply Distribution Process

The formal re-supply requisition process to site level is undertaken every quarter; by filling a request to CDC in Jakarta for ARV as well as OI drugs in hospitals. A report is also made monthly on the consumption and the inventory levels. Unfortunately, there is a major mismatch between the way that treatment sites are computing necessary inventory levels and the way that Central Level is computing inventory levels. In effect, sites base their ARV quantifications upon the forecast of the number of patients they expect to receive in the next quarter, which is usually significantly higher than in the previous quarter. The following graph from Dok II Hospital illustrates the dynamic uptake being achieved on just one regimen.

31


Figure 5. Utilization of one regiment in DOK II Hospital, Jayapura (X-axis months of the year, y-axis number of tablets)

.

*Duviral is a combination of AZT 300 mg + 3TC 150 mg.

Central level computes the ARV requirement on the average consumption during the last quarter, which in any program of scale-up will always lead to a shortage of supply. not match, and when the treatment sites feel they are not receiving the volumes they need, they distrust the Central Level logistics team. In addition to the calculation/quantification mismatches, sites report that the Central Level responds erratically to their requests. However, this must be tempered against the reality that the Center can only supply to sites what it has available and that when it has a short stock situation, it often endeavors to substitute one product for another. ARV Summary

•

The majority of ARVs are provided from Central Level

•

The system is fragmented

•

There appear to be inadequate budgets, and many burdensome and restrictive procedures

•

Treatment sites do not believe the response from Center to their requests is adequate and they are not receiving the quantities of the specific medicines they request

ARV Overall Conclusion

It will be impossible for any logistics system for ARVs in Tanah Papua to operate effectively until major strengthening of Central Level procurement and logistics functions for ARVs has taken place.

32


STIs/OI Medicines STI and OI medicines are provided by every level within the health system. In general, the medicines are not specific to STI/OI use so that at Provincial and District levels, where only total quantity procurement records are available, it is usually not possible to quantify the volume of medicine procured specifically for STI/OI use. At Central Level, STI and OI medicines are obtained with GFATM funding, procured through UNICEF, and distributed to treatment sites. As with ARVs, procurement of STIs and OIs through UNICEF has been a problem and numerous shelf-life issues have arisen due to the long lead times inherent in the importation process, particularly relating to obtaining duty-free importation permissions and documentation. In reviewing the documentation of the Central Level supply to Tanah Papua, many anomalies and discrepancies arise— •

Pyrimethamine and co-trimoxazole were not in the list of items in the CDC Jakarta warehouse but there are deliveries from the Central CDC store to Papua.

•

There were no requests from Tanah Papua for benzathine benzylpenicillin although it belongs to the orphan drugs classification in Indonesia, and is not available in the private sector. In effect, CDC is the only source.

•

In 2007, it appears that there has been no procurement for OI and STI drugs at the Central Level.

•

It is reported that when OI and STI medicines are required and requests are sent to the Central CDC office, often no clear answer is available. There appears to be no information flow on STI and OI drugs availability in the Central CDC warehouse to hospitals.

STI/OI Medicines Summary The system is highly fragmented. STI/OI Medicines Conclusion It will be unlikely for any logistics system for ARVs in Tanah Papua to operate efficiently until strengthening of Central Level procurement and logistics functions for STI/OI medicines has taken place.

HIV Rapid Test Kits Once again budgets for HIV rapid test kits are highly fragmented.

33


Dok Ii Hospital

1

Abepura Hospital

1


1

Merauke Hospital

1

Mitra Masyarakat Hospital

1

SELF FINANCING FHI

1 1

Wamena Hospital Biak Hospital

DISTRICT BUDGET

CENTRAL BUDGET

HOSPITALS

PROVINCE BUDGET

Table 10. Budget Sources for HIV Rapid Test Kits at Surveyed Sites in Tanah Papua

1 1

1

Serui Hospital

1

1

Nabire Hospital Manokwari Hospital Sele Be Solu Hospital Sorong General Hospital

1

1

1

FHI

Referred To Sele Be Solu Hospital

Fak - Fak Hospital

1

Seven out of 13 hospitals surveyed received their rapid test reagents from Central CDC. The other six hospitals had not been listed as a provider of VCT, yet they had rapid test reagents procured with their own budgetsOf the total 13 hospitals, 54 percent surveyed in the Tanah Papua had a dual budget source for rapid test kits. Perhaps not surprisingly with such divergent budget sources, widely different test kits are in use at the different hospitals, and sometimes even within a hospital.

34


ADVANCE QUALITY RAPI HIV TEST

ACON HIV

HIV TRIDOT

BIOLINE

HIV TRIDOT

1

Hexagon HIV

1

ENTEBE DIPSTICK

DETERMINE HIV

1

IMMUNOCOMB orgenics

Available

ONCOPROBE

DOK II HOSPITAL

SD HIV

HOSPITALS

AVAILABILITY ON VISIT

Table 11. HIV Test Kits Used in Hospitals in Tanah Papua

Not Av. Available ABEPURA HOSPITAL DIAN HARAPAN HOSPITAL MERAUKE HOSPITAL MITRA MASYARAKAT HOSPITAL

Not Av.

1

Available

1

1

1

1

1

1

Not Av. Available Not Av. Available

1

1

1

Not Av. Available

1

1

1

1

1

WAMENA HOSPITAL Not Av. Available

1

1

BIAK HOSPITAL Not Av. Available

1

1

1

1

SERUI HOSPITAL Not Av. Available

1

1

1

1

1

1

1

1

1

1

1

1

NABIRE HOSPITAL Not Av. MANOKWARI HOSPITAL SELE BE SOLU HOSPITAL SORONG GEN. HOSPITAL

FAK - FAK HOSPITAL

Available

1

Not Av. Available Not Av. Available Not Av. Available

1

1

"DALF" IS NOT IN THE RECOMMENDED LIST OF MOH

1

Not Av.

35


A key component in the use of HIV test kits is the ancillary materials and commodities used to support of the test kits in particular, such as Equipment –

Centrifuges

–

Timers

–

Test tube racks

–

Refrigerators

Consumables –

Pipette tips

–

Specimen tubes

–

Syringe and needles

–

Disposable gloves

–

Disinfectants and cleaning supplies

–

Sharp disposable bins

–

Waste disposal (biohazards)

No Central or Provincial budget support was identified, and only RS Merauke received District level budget support. All other sites had to purchase these items with their own resources.

36


Table 12. Budget Allocation for Commodities Used to Support Use of HIV Rapid Test Kits Commodities

Syringe

Hand Gloves

Disinfectant s (Chlorine)

Biohazard Bags For Syringe/ Specimen

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

RS. Dian Harapan

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

RS Manokwari

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

RS Biak

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

RS Sele Be Solu

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

RS Fak-Fak

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

RS Merauke

Dist. Budget

Dist. Budget

Dist. Budget

Dist. Budget

Dist. Budget

Dist. Budget

RS Mitra Masyarakat, Timika

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

RS Wamena

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

RS Nabire

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

Sorong General Hospital

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

Serui General Hospital

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hosp. Budget

Hospital

Pipette Tips

Vacutainer

RS Dok Ii Jayapura

Hosp. Budget

RS Abepura

The history of rapid test reagents in puskesmas in Papua has been relatively short. It started in the third quarter of 2006 in two puskesmas in Jayapura under the support and supervision of Dok II Hospital. Since then, the Province and the Districts are developing a program to increase the VCT service coverage.

37


Table 13. Availability of HIV Rapid Test Kits at Puskesmas Level RAPID TEST USER

First reagent

SECOND reagent

THIRD reagent

Puskesmas Kampung Harapan Kab.Jayapura

SD HIV

Determine

Immunocomb/ HIV Tridot

Puskesmas Hamadi- Kota Jayapura

SD HIV

HIV Tridot

Bioline

Puskesmas Mopah Merauke

SD HIV

Puskesmas Kurik Merauke

SD HIV

Oncocorpe

Immunocomb

Bioline

Puskesmas Fak-Fak Kota

SD HIV

Determine

Oncocorpe

Puskesmas Wamena Kota

SD HIV

Determine

Oncocorpe

Determine

Hexagon

Acon HIV

SD HIV

Determine

Oncocorpe

Puskesmas Agats - Asmat Puskesmas Kwamki Lama Mimika Puskesmas Maripi Manokwari

Puskesmas Aimas Sorong Puskesmas Karang Tumaritis Nabire Puskesmas Menawi Serui Puskesmas Biak Kota Numfor Private clinic Bintang Timur Private clinic "Fatima" Fak-Fak

Oncocorpe

There is no clear mechanism of who should handle test kits at any level, and no clear procedures for reporting and restocking. HIV Rapid Test Kits Summary

Clear allocation of responsibilities and development of procedures for procurement and logistics is an essential first step in any system development. Many sites are endeavoring to self finance HIV testing kit procurement. HIV Rapid Test Kits Overall Conclusion

Adequate budgets for providing HIV test kits are the key requirement in improving provision.

Essential Medicine Supply System Essential medicines stock data reveals a system exhibiting all the classic inventory management problems of developing country public health supply systems with large imbalances in stock levels. Assuming that three to six months of stock is a reasonable target, then it can be seen that only 7 percent to 11 percent of essential medicine stocks across the five sites analyzed falls within that range (Table 13). There appears to be a particular problem with overstocking, with 30 percent to 58 percent of essential medicine items being more than 12 months in stock. In actual fact, it is worse 38


than that as there is enough stock for many items to last for many years at the current rate of use. Similarly, and predictably, low stocks are also a problem with up to 27 percent of items being out of stock on the day of survey and a further 7 percent to 19 percent having less than 3 months supply. Table 14. Essential Medicines Supplies, Inventory Performance Table 1: Essential Meds & Supplies, Inventory performance Biak

Mimika

Fak-Fak

Merauke

Sorong

Range

Total Items

151

%

36

%

278

%

220

%

122

%

High

Low

3 to 6 months stock

14

9

5

17

21

8

16

7

12

10

7%

17%

0 stock

29

19

2

6

72

26

8

4

20

16

4%

26%

>6 months

94

62

31

86

117

42

158

72

76

62

42%

86%

0 to 3 months

12

8

7

25

20

7

17

8

8

7

7%

25%

>12 months

62

41

29

81

82

29

126

57

63

52

29%

81%

Comparable data for a full range of HIV medicines and supplies at the same sites was not available. However, the situation for ARVs reveals a similar pattern to that for the general essential medicines, namely that most items are outside of a range that would considered a reasonably balanced stock level. Table 14 provides details for ARVs and Table 15 provides a summary comparison of essential medicines and ARVs.

39


Table 15. ARVs, Inventory Performance

ARV

Months on hand 10/07

TDF

30.2

AZT

14.37

3TC Lamividine

8.88

3TC + NVP Duviral*

8.64

D4T Stavudine 30 mg

7.26

D4T Stavudine 40 mg

6.88

NVP Neviral**

4.76

EFV 600 mg

3.71

D4T Stavudine

1.69

AZT Antivir

0.43

EFV 200 mg D4T STAG*** 40 mg

0 0

D4T STAG 30 mg

0

* Durival is Indonesia’s generic version of 150 mg lamivudine and 300 mg nevirapine. * *Neviral is Indonesia’s generic version of 100 mg nevirapine. ***STAG is Indonesia’s generic version of stavudine.

Table 16. Summary Comparing Essential Drugs with ARVs IN Tanah Papua Range for essential drugs

ARV

High

Low

3 to 6 months stock

7%

17%

15%

0 stock

4%

26%

23%

>6 months

42%

86%

46%

0 TO 3 months

7%

25%

15%

>12 months

29%

81%

15%

Although these figures relate to only a single, albeit important, aspect of supply management and should therefore be treated with some caution in drawing general conclusions, they do nevertheless point towards the typical kinds of problems usually found in public health supply systems, such as The situation at the national medical store of the Solomon Islands in 2007 (Table 17). 13

13

Source: Unpublished AusAID assessment of the National Medical Stores in the Solomon Islands, 2007.

40


Table 17. Solomon Islands National Medical Store, 2007 Items

%

>12 months

128

31

6-12 months

46

11

3-6 months

38

9

0-3 months

177

43

O/S

18

4

Total

407

The situation at the Tanzanian Medical Stores Department in 2001, for example, was 14 — Table 18. Tanzanian Medical Stores Department, 2001 # of Items*

Stock on Hand

% of total

147

< 1 month

24

196

> 12 months

32

*Total No. of Items: 610

As well as revealing problems with core inventory management function, this is also indicates more general problems with supply management. Other data collected from Papua indicates problems with record keeping and expiry date management. The following table summarizes the situation in relation to data quality and the management of expiry dates. Of the items analyzed, less than 40 percent had accurate records. The table also illustrates some problems with managing expiry dates, which is what you would expect given the general poor inventory management picture. Table 19. Picture of Inventories and Inventory Data Quality Total Items Data

50

Accurate Data

19 (38.0%)

Total Items Expired

10

Table 20 provides data collected from Sele be Solu Hospital as an example.

14

Center for Pharmaceutical Management. 2003. Access to Essential Medicines: Tanzania, 2001. Prepared for the Strategies for Enhancing Access to Medicines Program. Arlington, VA: Management Sciences for Health. 41


Table 20. Comparison of Stock Figures from Different Sources for Sele Be Solu Hospital Drug

PP Graph Average Consumption

Stock Card Record (Excel) Avg Consumption

Graph Stock

Stock Record (stock card)

Neviral

376

2,247.2

4,233

4,233

Duviral

421

228

17,700

17,160

EFV 600 mg

375

84

0

0

STAG 30mg

113

132

0

0

Other hospital data have similar problems. Table 21 summarizes the situation for Jayapura DOK II hospital. Table 21. Comparison of Stock figures from Different Sources for DOK II Hospital Drug

Graph Average Consumption

Excel Avg Consumption

Graph Stock

Excel Stock

Lamivudine

862

650

10,358

10,726

Duviral

877

1,684

9,884

4,117

In this example, the hospital could have either more than 10 months stock of Duviral or less than 3 depending on the data source used. This would obviously matter a great deal when the hospital was deciding what and when to order. Merauke hospital data revealed the same issues (Table 22). Table 22. Comparison of Stock Figures from Different Sources for Merauke Hospital Drug Lamivudine ZDV

Graph Average Consumption

Excel Avg Consumption

Graph Stock*

Excel Stock*

608

3,012

6,465

5,884

0

2,173

0

67

*Stock numbers listed on graph and on Excel sheet did not match.

ZDV has zero demand and therefore, having no stock is rational, or ZDV has large demand and very low stocks.

Impact of Stock Management on Providing ART The tables presented on the accompanying CD RoM make it clear that overall, ARV stock availability does not appear to be a problem at any of the sites investigated, especially for first-line regimens, such as ZDV/3TC/NVP. 15 This is an important finding because it indicates that, 15

A basic assumption underlying this analysis was that if one dosage form of the drug required was available then the patient would have received it. If stock was available at the beginning and end of the month in the original data, it was assumed that the patient received the medicine and, if they did not, it was for reasons other than stock availability. 42


although transportation within Papua is difficult and the supply system does not run perfectly, at current treatment numbers the supply system is generally assuring supply of ARVs to patients receiving ART. That does not say that the same dosage form or strength was always available, but that it was possible to find a suitable substitute as and when necessary. So, for example, while records at Mimika hospital show EFV 600 mg as out of stock from the end of August 2007, efavirenz 200 mg was always available. Similarly, at Mimika, it is not possible from the data provided to tell if ZDV was in or out of stock after May 2007. However, the fixed-dose combination of ZDV/3TC was available through the period reviewed. Frequent reference has been made by various parties to the importance of stock transfer (borrowing) between treatment sites to minimize treatment disruptions, and there is some anecdotal evidence that hospitals occasionally have to borrow ARV stock to ensure continuation of treatment. Data was collected on this, but the borrowed quantities reported represent only a minor percentage of overall use; so, despite the status being accorded to such functions, the data does not support the contention that borrowing is a major factor in maintaining uninterrupted supply. The most thorough analysis of borrowing was for Mimika hospital. In 2007, Mimika borrowed six bottles of Duviral on February 2 and 40 bottles on September 11. Their stock position for Duviral in each of these months was as follows. Table 23. Stock Position of Duviral at Mimika for February and September, 2007 Month February September

Opening Stock

Receipts

Usage

Closing Stock

304

4,684

1,627

3,057

2,530

4,200

2,762

3,968

Mimika also borrowed 10 bottles of 3TC/d4t on May 2. The stock situation for this combination and the single dose forms of 3TC and d4t in May was as follows— Table 24. Stock Position of 3TC and d4t at Mimika for May 2007 Product 3TC/d4t d4t 3TC

Opening Stock

Receipts

Usage

Closing Stock

0

1,218

195

1,023

741

1,620

703

1,658

12,353

2,340

694

13,999

Although the FDC may have been a problem for part of the month, the single dosage forms could have been used as substitutes until the fresh combination stock arrived. In any case, it does not look like a significant problem. With regards to Mimika, therefore, it was generally getting a few bottles while waiting for new stock, which arrived during the same month of the borrowing. Tables 25 and 26 below provide a summary of all stock borrowed during 2007.

43


Table 25. Details of ARVs Borrowed and Returned, 2007

Date

Institution FROM

TO

Items

Amount borrowed

Units

6-Feb-07

Mitra Masyarakat Hosp

Mimika

Duviral

6

btls

2-May-07

Mitra Masyarakat Hosp

Mimika

Stavudine + Lamivudine

10

btls

7-Jun-07

Nabire Hospital

Papua

Stavudine

1

btls

Efavirenz

1

btls

28-Jul-07

Abepura Hosp

Jayapura

Efavirenz

3

btls

28-Jul-07

Merauke Hospital

Papua

Stavudine

5

btls

14-Aug-07

Abepura Hosp

Jayapura

Triomune

6

btls

Stavudine

2

btls

11-Sep-07

Mitra Masyarakat Hosp.

Mimika

Duviral

40

btls

25-Oct-07

Abepura Hosp

Jayapura

Efavirenz

3

btls

8-Dec-07

Merauke Hospital

Papua

Stavudine

5

btls

Date of Return

22-Aug-07

10-Sep-07

25-Aug-07

Table 26. Number of Occasions ARVs Borrowed, 2007 Items

# occasions

%

Stavudine

4

36.4

EFV

3

27.3

Duviral

2

18.2

Triomune*

1

9.1

Stavudine + lamivudine

1

9.1

*Triomune is a combined D4T 40 mg, 3TG 150 mg, NVP 200 mg. formulation

Ordering and Delivery Data was collected at Merauke, Manokwari, and Mimika hospitals that allowed analysis of stock ordering and receiving to get a sense of what, if any, kind of system they had in place for determining when and what to order and what, if any, response this generated from the central authorities responsible for receiving the orders and distributing new stocks. Although the data is fragile and care is needed not to over-analyze it, Merauke generally presents a picture of a situation that is somewhat under control with a system in place. Orders are regular, moderate in terms of quantities, and able to be replenished steadily and reliably. Manokwari also has these features for some products, but not for all. Mimika, on the other hand, has no obvious systems in place. Usable data for this analysis was not available from DOK II or Sele Be Selu.

44


Data that would have permitted an analysis of lead times was unfortunately not available, although data from Merauke hospital suggests that lead times, at least for that hospital, are between 1 and 2 months. Individual hospitals’ analyses follow. Mimika

The data from Mimika does not show any real correlation between what they ‘requested’ and what they actually received. In this particular case, it is difficult to avoid the conclusion that there is not system in place that connects requisitions with what is sent to hospitals. It seems very ad hoc at both the ordering and order processing/distribution ends of the supply system (Table 27). Table 27. Duviral Orders and Receipts for Mimika, 2007 Month

Quantity Ordered

Usage during month

Qty Received

Jan

4,500

1,491

300

Feb

4,200

1,627

4,380

March

1,077

9,120

April

1,100

0

May

295

32

2,005

4,200

1,062

0

June

9,000

July August

9,000

3,147

0

September

5,400

2,762

4,200

October

7,162

3,750

1,440

Total

39,262

18,316

23,672

There is no obvious method here for determining individual orders that can be related to demand, although a case could be made for saying that the overall quantities ordered over the January to October period are not unreasonable given the demand. However, there is a less clear correlation between the order quantity and demand when you look month-by-month. Merauke

The Merauke data shows some signs of there being a system in place. Table 27 is for ZDV/3TC, for example and, with the exception of the 10,000 ordered in March, it looks like there is some rational correlation between what was ordered and what/when it was received. At the same time, the quantities ordered and delivered don’t look unreasonable in relation to reported usage, further adding to the impression of a rational system of some kind being in place.

45


Table 28. ZDV/3TC Orders and Receipts for Merauke, 2007 Month

Lead Time Data Usage

Jan

3,192

Feb

2,391

March

2,721

April

2,500

May

4,090

June

2,684

July

2,630

Sept

2,830

Oct

3,363 26,401

Received

Received

16,203 17,340

17,340

10,020

10,020

10,000

19,000

3,513

Aug

Total

Ordered

Stock Record

10,020

10,020

12,000

57,203

12,180

12,180

49,560

39,540

Table 29 tells a similar story for NVP although, as with ZDV/3TC, it appears that the March order was overlooked. Merauke placed orders for both products in the same months and received deliveries for both products also in the same months, which is suggestive of some kind of a system. The quantities of NVP ordered compared to demand don’t look quite as tidy as for ZDV/3TC (between three and seven months stock ordered every three months), but neither are they outrageous. Table 29. NVP Orders and Receipts for Merauke, 2007 Lead Time Data Usage Jan

2,998

Feb

2,094

March

2,409

April

2,603

May

3,621

June

Ordered

Received

Stock Record Received

4,670 5,760

5,760

2,306

9,300

9,300

July

3,500

9,300

9 ,300

Aug

2,642

Sept

2,882

Oct

3,191

14,580

14,580

38,940

29,640

Total

24,746

9,000

20,000

12,000

45,670

46


Data for EFV 600 mg at Merauke (Table 29) tells a similar story, but with a poorer response in terms of deliveries. However, while the real reasons why stock was not delivered are unclear, it is possible that there was no February delivery of EFV 600 mg because the quantity ordered in January was small. However, unlike ZDV/3TC and NVP, there was also no delivery in October. Again, however, the hospital is ordering two to six months stock at regular intervals. Table 30. EFV 600 mg Orders and Receipts for Merauke, 2007 Month

Lead Time Data Usage

Jan

510

Feb

353

March

455

April

439

May

547

June

560

July

Ordered

Received

100

1,000

1,500 2,370

540

2,370

Aug

325

Sept

352

Oct

664

2,000

4,205

7,600

Total

Received

Stock Record

2,370 2,370

3,000

4,740

2,370

Overall, the data from Merauke is suggestive of a system being in place for ordering regularly and also for processing and responding to those orders. While the picture that emerges is not perfect, neither is there anarchy. There appears to be something in place at Merauke on which to build. There is no real lead time information for Merauke. However, assuming that the receipts in February, June, July, and October were in response to the orders placed in January, March, May, and August, then we can estimate that lead times are generally about one to two months, which would not be unreasonable for Papua. Manokwari

In terms of having a system in place, Manokwari presents a mixed picture, but one that is generally less favorable than Merauke, perhaps because it is a new treatment site. No orders were placed for Duviral during the period January to October and no new stocks were received. However, they had stocks of 2,500 at the beginning of May when treatment started. Monthly demand from May to October was 70, 60, 146, 190, 281, and 660 in successive months. Manokwari then placed an order for 2,340 in November, which doesn’t look unreasonable. However, Retrovir, Hiviral (3TC) and STAG 40 (d4t 40 mg) don’t look as rational and under control as Duviral. No usage is recorded for any of these products and both Retrovir and STAG 40 saw stocks apparently expire in August only to be replaced with fresh stock in September/October.

47


Orders were placed in April for all three products, which can be ascribed to the fact that the program began treatments starting in May. However, that wouldn’t explain why new orders were placed for Retrovir and STAG 40 in September, unless it was anticipated that some patients would be switching to those drugs. However, although stocks of STAG 40 and Retrovir were available in September and October, there was still no reported usage and patients largely stayed on a regimen of ZDV/3TC/NVP.

Private Sector Private sector in Tanah Papua The two largest corporations providing health care in Tanah Papua are British Petroleum (BP) and PT Freeport Indonesia (Freeport). British Petroleum

BP is constructing a USD 5 billion Liquid Natural Gas plant in Bintuni Bay, in the Birds Head region. They have 10,000 construction workers there now, but staffing will drop to 1,000 (40 to 50 percent of which will be Papuan) once construction is complete and production starts in the first half of 2008. BP provides health care to their employees and their families, and has also provided support to health and micro-finance projects with special focus on the control and treatment of malaria where they have had some success reducing malaria mortality through socially marketing chloroquine and sulfadoxine-pyrimethamine in kits, including through private shops. BP has also done capacity building with Bintuni Regency (district) government, including training village health workers. The company has an MOU with the Regency and is working on developing a joint work plan with the district. Overall, BP is supporting health services covering a population of about 12,000 while Bintuni has a population of about 60,000. The company also has some relations with Fak-Fak Regency. More broadly, BP has demonstrated their commitment to health care in Papua by being represented on the National AIDS Commission Working Group on Papua and by also being a founding member of the Indonesian Business Coalition on AIDS, which has a particular, but not exclusive focus on Papua. In addition, the company has been instrumental in establishing a small health NGO, the Papua Children’s Health Foundation. Originally started to support a single child with a heart defect, the NGO now has ambitions to become an independent entity supporting children’s health. In relation to HIV, BP is planning to provide the following services to the Birds Head region— •

Training Catholic clinics

•

STI clinics

•

VCT

•

Outreach with Commercial Sex Workers

48


•

Community awareness raising; “stepping stones” project with Project Concern, contracted through FHI

In terms of HIV/AIDS treatment, BP does plan to provide this, but will restrict it to BP employees and families only. More broadly, it appears unlikely that BP would be interested in investing to any significant degree in broader community health care. In terms of assisting with logistics and supply management, BP as a company would be unlikely to provide direct support. However, their transport contractors, such as Firma Irian Jaya would be interested in providing such services. Freeport and International SOS

Freeport mine provides a broad range of health services to its staff, their families, and the communities living in the vicinity of the mine. The provision of those services, however, is contracted to International SOS (ISOS) which employs about 1,000 staff on about 65–75 projects across Indonesia. Freeport, however, is their biggest contract, employing 280 people. The Freeport services provided by ISOS are provided through the following facilities— •

Two hospitals –

One for mine staff and families

–

One for general public

•

Clinic in Timika

•

Seven other clinics spread from port to mine, including reproductive health clinic

ISOS is providing general public health and malaria services, including HIV testing and treatment. Freeport receives supplies from government for this program, which can then be further supplemented by Freeport should there be problems with government supply. While Freeport does support government services in the area of the Freeport mine, as a company they have no plans to expand their health services or health responsibilities outside of the geographic area covered by their mining operations. In terms of supply, ISOS annually procures more than 2,000 line items of medicinesand medical supplies to the value of about USD 6 million for all of their Indonesian projects. Their procurement unit has about 20 staff working with both international and Indonesian suppliers and they also hold the licenses needed to do medicine distribution in Indonesia. ISOS have a small central store in Jakarta (about 400–500 square meters, 4 meters high) through which all medicines purchased by the company pass through. Although not large, it is a good quality, temperature controlled facility with secure, caged receiving and dispatch areas. More broadly, ISOS is a logistics business and could, if called on, set up and run a medical supply system in Tanah Papua that could reach puskesmas level, although at present they only have infrastructure and staffing for Freeport and other project sites. In principle, therefore, contracting with ISOS would be an option for the HIV program. In practice, however, it is an option that would probably be prohibitively expensive.

49


Private sector in Tanah Papua Private drug distribution in Tanah Papua is a relatively small, but thriving sector comprising a range of companies, such as Dexamedica, that are usually branches of larger companies based in Jakarta and operating nationally. Not all of the companies in this sector operate to the standard that would be required for the public health authorities to consider contracting with them, but there are some that clearly do and, should the national and/or provincial health authorities wish to consider this as an option for their supplies service, then it would, in principle, be feasible. Of the companies visited, Dexamedica appeared to have the most professional management. The company has a stocking policy in place of holding a minimum of six weeks of stock; stock holdings can be replenished weekly, usually by sea, although urgent orders can be flown in to Jayapura from Jakarta. Their warehouse space is small, but in good condition, temperature controlled, organized and well managed with electronic and bin card-based stock records, a perpetual inventory system in place, and with a cold store that is monitored regularly and has an alarm system. Their business is split 60 percent–40 percent private–government and they have the capacity to transport supplies to customers in almost all parts of the province for a freight charge of 1 percent to 1.5 percent. Other companies, such as Enseval Putera Megatrading, also had some capacity, but provide services that are limited in one way or another. Enseval, for instance, operated mainly in Jayapura, although it is planning to open a branch in Sorong. The standard of their stores and general management was also lacking in some respects when compared to Dexamedica. Outside of the pharmaceutical sector, there are a number of companies, commercial and not-forprofit, that are providing regular and reliable air services to most, if not all, population centers.

Conclusion While the larger private companies, such as BP and Freeport, are providing important support to the public health systems in the areas where they are working, it is unlikely that they would be willing and able to expand those services to support a broader supply service to other parts of the province. In principle, it would be possible to contract with ISOS for those services, but it is likely that the cost would be prohibitive. In thinking about working with the private sector, therefore, the most feasible options would be to work with private pharmaceutical distributors and/or air companies already operating in Tanah Papua. The main obstacles to accessing those services would beensuring nsuring a rigorous selection and contracting process, and, perhaps most importantly, assuring the budget and the flow of funds from the government to pay for the services. It has been reported, for example, that the government’s poor payment record sometimes becomes an obstacle to accessing available transport services . Overall, therefore, availability of transport and distribution services is not an obstacle to providing a regular supply of essential health commodities. Moreover, these transportation services can either be accessed directly or through a third party, such as one of the private pharmaceutical distributors, that has experience with distributing their own products around the province. The key to accessing these

50


services is generally a case of having a reliable budget available with which the services can be paid for in a timely fashion.

Overall Picture and Basis for Future Approach It has been reported that Tanah Papua “may be experiencing an emerging generalized epidemic with HIV prevalence several times the national average, which is estimated in 2006 at 0.16 percent among the general adult population.” 16 Total prevalence in Tanah Papua is estimated at 2.4 percent. 17 . 18 Modeling estimates have indicated around 13,000 People Living with HIV/AIDS in 2005 rising to 29,000 by 2010, 19,20 Assuming that around 20 percent of the HIV-positive people require antiretroviral therapy (ART) suggests that there are about 2,600 requiring ART in Tanah Papua at the present time. Complete data was not available for the current numbers on ART during the survey period. Table 30 shows that there were 228 on treatment in October 2007 at the five treatment sites surveyed for this evaluation. Table 31 provides data from sub-directorate HIV/AIDS, which also indicates the numbers on treatment as being around 230. However, due to reporting problems, the overall total may be considerably higher than this, with 400 to 500 being reported by sub-directorate HIV/AIDS and FHI, for example. 21 . Compared with estimated need, therefore, the numbers receiving ART remain low. Among the reasons for this situation, an AusAID epidemiological study concluded that “Programmatic responses to HIV in Papua have been primarily impeded by the lack of health systems infrastructure.” 22 A joint WHO South-East Asia Regional Office (SEARO)-Ministry of Health report in 2007 similarly concluded that “service infrastructure is underdeveloped to support comprehensive HIV Care Support and Treatment .” 23 Even basic services are reported to be not always available to remoter communities who have also suffered from “fewer improvements in health, education, and other basic services.” 24 Clearly, having such services in place will be a sine qua non to scaling up the response to the HIV epidemic. Stigma is also reported to be a significant obstacle to program expansion. 25 16

WHO SEARO and Indonesia Ministry of Health. 2007. Review of Health Sector Response to HIV and AIDS in Indonesia 2007.New Delhi: WHO-SEARO, pp. 2, 27. Available at http://www.searo.who.int/LinkFiles/Publications_REVIEW_HIV_AIDS_Indonesia_2007.PDF (accessed Feb. 2008). 17 Statistics Indonesia. Risk Behavior and HIV. p 49. 18

Ibid.

19

Impacts of HIV/AIDS 2005–2025 in Papua New Guinea, Indonesia and East Timor Final report of hiv epidemiological modeling and impact study, February 2006 http://www.ausaid.gov.au/publications/pdf/impacts_hiv.pdf 20

Population Projection by Regency/Municipality, 2001 – 2005, Papua, Indonesia.

http://irja.bps.go.id/LEFT%20FRAME/Proyeksi%20Penduduk%20%20menurut%20Kabupaten.htm 21

Meeting with FHI, Bob Magnani, FHI Country Director, Karen Smith, Deputy Director, Dr. Nurban Silitonga, Medical Director (I think), Dr. Flora Tanujaya, care and treatment consultant; December 12, 2007. 22 AusAID, 2006. Impact of HIV/AIDS 2005-2025 in Papua New Guinea, Indonesia and East Timor. Final report of the HIV epidemiological modeling and impact study. Canberra: Commonwealth of Australia, p 101. http://www.ausaid.gov.au/publications/pdf/impacts_hiv.pdf 23 WHO-SEARO. 2007. Review of Health. p 61. 24 Ibid, p 108. 25 WHO-SEARO. 2007. Review of Health. p 61. 51


The AusAID epidemiological study based its costing projections on a projected 1,000 patients on ART by 2010; between 1,200 and 2,000 by 2015; and 3,000 to 5,750 by 2025.26 These relatively low numbers were “reflective of the constraint on the health sector to provide ART.” 27 As things stand, therefore, the most likely perspective is one of continued slow growth in the expansion of the HIV program and for the number of people receiving ART to remain modest compared to need. Even major new initiatives such as the recently announced Indonesian President’s Initiative are unlikely to be able to bring a significant impact on the overall health care infrastructure and capacity in the short term. Indeed, it is even uncertain that doubling-toquadrupling the numbers on treatment to achieve AusAID’s modest projections for treatment numbers in the next 24 months can be achieved.

26 27

Ibid, Figure 3.8.5, Numbers of People on ART – 18%; p 113. Ibid, p 112. 52


Table 31. Numbers of Patients on ART at Five Treatment Sites, October 2007

ARV REGIMENTS, October 2007

DOK II Gen. Hospital

Gen.Hosp of Merauke

Mitra Masyarakat Hosp in Mimika

16

4

Manokwari Hosp.April Oct 07

Sele Be Solu Hospital

ZDV300/3TC/NVP ZDV300/3TC/EFV ZDV/3TC/NVP

29

22

ZDV/3TC/EFV200

26

19

ZDV/3TC/EFV600

7

ZDV100/3TC/NVP

4

1

6

12

4

33

ZDV100/3TC/EFV ZDV100/3TC/TDF

1

d4T30/ 3TC/NVP

15

11

2

7

5

d4T40/3TC/NVP d4T30/3TC/EFV 600

4

d4T40/3TC/EFV

19

d4T30/3TC/EFV 200

3

TDF/3TC/EFV

1

ZDV100/NVP ZDV100 ZDV100/3TC/Tenfovir TDF/3TC/NVP

2

Total visits with ARV (total all hospitals 228)

58

67

50

13

40

Table 32. HIV Situation in Most Affected Districts of Tanah Papua, June 2007

HIV-positive

Eligible for ART

Cumulative ever on ART

Currently on ART

Jayapura

318

291

84

45

Abepura

130

24

18

14

Merauke

418

310

117

71

Miltra Masyarakat

496

173

72

54

Sele be Solu

364

75

62

43

Manokwari

146

55

2

-

1,872

928

355

Source: Sub Dit HIV report, “ART - Juni 2007 Papua.pdf”

53

227


This is clearly horrific for those individuals and families affected by HIV/AIDS. In relation to the supply system, however, it means that the current system, as deficient as it is, is likely able to cope with the projected growth in the short-to-medium term. This removes the pressure for urgent and large scale system strengthening in the short term, and provides an opportunity for designing and implementing a custom-built system in two or three districts over the coming two to three years, which could then be used as a model, ready for roll out to the rest of the province in time to meet the needs of an substantively expanded HIV program in the years to come. The recommendations for strengthening the supply system in Papua are made in light of this judgment.

Summary, Conclusions, and Recommendations While there are clear problems with the functioning of the supply system in Tanah Papua, these should not be exaggerated; the challenging terrain and poor infrastructure, which makes transportation around the province difficult, should equally not be taken as an indication of especially poor supply systems. In general, the health supply system in Tanah Papua is not unusually bad when compared to elsewhere in Indonesia or with public health systems in other countries. With regards to ARVs, the current system has been able to assure the supply of all first-line regimens and there is no evidence that stock ruptures have led to treatment interruptions. Nevertheless, problems do exist that will require resolution if the HIV program is to scale up to any significant degree in the medium- to longer-term, such as— •

Inventory management is generally poor with stock holdings out of balance with demand

•

Record keeping and subsequent data quality is poor

•

Expiry dates are not well managed with consequent loss of stock

•

Order planning is not rationally based at all treatment sites

Furthermore, the supply system is Tanah Papua does not operate in isolation but, especially for ARVs, and to lesser extent STI/OI medicines and HIV rapid test kits, is heavily dependent on the activities, levels of effort, and budget of the Central Level HIV/STI CDC program. Any program of strengthening of logistics system in Tanah Papua which does first seek to strengthen Central Level procurement and logistic activities is unlikely to be

On the basis of this analysis it can be concluded that— 1. A program of strengthening of Central Level procurement and logistics functions is required--it must bring a bottom-up, site level focus to Central Level activities. 2. To be responsive to actual demand at health facilities, the supply chain should be driven by accurate data from the point of use, through district and/or provincial stores and/or private distributors contracted for supply services, and back to a central distributor and, eventually, to the supplier.

54


3. There is a general need for improving inventory management and order planning at treatment sites. Strengthened inventory management will require the creation of mechanisms for making usage and stock data from treatment centers visible to district, provincial, and central stores. As the numbers on treatment reaches significant levels, the need for this will become more urgent. 4. In developing an improved public health supply chain, therefore, efforts should be made to put in place a system where every hospital and puskesmas involved in providing HIV care and treatment is recording and reporting data of medicines dispensed and supplies consumed. On this basis, it would be possible to improve inventory management and procurement and thereby achieve improvements in service to clients. 5. It is therefore important to see the process of strengthening the health supply chain as an integrated and composite one, with success in improving one aspect of core operations being dependent on making improvements in related operations. Attempting to strengthen logistics functions in Tanah Papua without concurrently strengthening Central Level functions is not likely to be effective. Sustained improvement in demand planning and procurement, for example, cannot be achieved without an effective inventory management system, which in turn requires more accurate data. In this way the work of strengthening district and provincial procurement and supply systems will be interwoven with each other. The recommendations outlined here, therefore, are designed to address these and other problems and thereby help Tanah Papuan health authorities get better control over their supply system from provincial and district store to hospital and puskesmas level.

Recommendations Supply chain management in the commercial sector delivers products to customers in such a way that company-wide costs are minimized without compromising service to customers. These basic principles apply to all supply chains, including public health systems in developing countries. The fundamental elements of a supply chain include— Demand management Order capture and fulfillment Inventory planning Procurement Customer service planning and monitoring Management information and MIS Key performance indicators to monitor and manage performance The supply chain management systems that will deliver an effective service to Papuan hospitals and their patients will need to have all the above elements in balance. Although the terminology, products, equipment, and level of sophistication of a public health supply system for Papua may not be those of a modern commercial company, the basic processes are the same; there is no

55


fundamental difference between what is done in other supply chain environments and what is required for a medical supplies supply chain. Central to these processes is the availability and utilization of demand data. Without it, no supply chain can operate effectively. If there is no knowledge of what the hospitals and puskesmas actually need to deliver care to their patients, then the district, provincial, and national stores will be operating in the dark and required service levels cannot be achieved. Demand data for each product at each storage point and health facility must be used to generate orders using an appropriate replenishment formula. These orders would then be communicated to the appropriate stockholding point which, in turn, responds either with a delivery to the health facility making the request or preparation of the order for collection. The same demand data is then used to establish overall usage for each product and are used to plan provincial and/or district procurement and orders to the national offices of vertical programs, such as HIV/AIDS. Central Level Supply Management

Numerous players are already active in assisting Central Level, and sub-directorate HIV/AIDS is developing major plans for logistics strengthening. In such circumstances, it could be considered inappropriate for a study focusing primarily on the situation in the region of Tanah Papua to be the predominant influence on Central Level operational considerations because of the pivotal, and in terms of supply volumes, dominant role that Central Level plays in the overall supply chain process for HIV/AIDS commodities. Also, because of the identified supply chain difficulties arising from Central Level supply outlined in this study, it is clear that the supply chain situation in Tanah Papua, or indeed any other Province/region, cannot be adequately addressed without reference to Central Level functions. The following comments should therefore be considered as contributions for supporting subdirectorate HIV/AIDS’s development program, and not as a master plan for Central Level activities. Further it should be acknowledge that sub-directorate HIV/AIDS are already active in attempting to address a number of the areas, but would benefit from further support and especially resource allocation. The HIV/AIDS program does not operate in isolation, and the ability of any single sub-directorate, even one as important as HIV/AIDS, within a Ministry, to influence major, national, generalized procedures and regulations must be recognized as being severely limited. Similarly at Province and District level, all sectors and programs remain bound by overarching financial and procurement mechanisms which even Central Level, in its entirety, now has only a limited ability to influence. In effect there are severe restraints on practical, short- to medium-term strengthening planning options. •

The de-centralized health system is a reality. Major changes and reform of the system must be viewed as unlikely in the near future, if only because in addition to the need to reach a consensus among over 400 autonomous District entities for any major changes, it would also require legislative changes, which generally can only be enacted over the long term. Whilst subdirectorate HIV/AIDS, and many other sub-directorates and bodies, may be able to advocate for change, enacting such major national changes to generalized regulations is well outside the

56


scope of influence of an individual Ministry of Health sub-directorate. In the current environment, it will be necessary to cope with and develop systems appropriate to the highly fragmented supply chain system which has resulted from de-centralization. •

Multiple funding streams have a long and complex history. While there is scope for reform, many of these funding streams, especially at Province and District level, are not unique to the health sector, and even those streams which are solely or largely health related, such as Asuransi Kesehatan (Social Health Insurance), are not always in the direct control of the Ministry of Health or Province and District governments. Once again, while advocacy is possible, reform of the various funding streams is well outside the scope of influence of an individual Ministry of Health sub-directorate, and in the short to medium term it will be necessary to cope with and develop systems appropriate to multiple funding stream operations.

•

The standard, budget, funding and procurement mechanisms of the Indonesian public health system, at all levels, are simply not appropriate to any program of scale-up, regardless of the thematic area, nor to any element of any program that requires a response time of less than two years. The mechanisms are exceptionally complex but in essence— –

It is impossible to ever know with any degree of certainty what the funding level will be before the actual funds arrive, especially at Province and District level. A provisional allocation of a budget is no certainty that there will be adequate funds available to meet that budget.

–

Funds often arrive so late in the year that in effect they are available for the following year. The nominal budget year may be January to December, but the funds for that year typically do not arrive until September. By the time the goods can be procured and delivered, they cannot be used until the following January. This is difficult for all programs, but in programs endeavoring to undertake expansion/scale-up it means a complete mismatch between planning and execution. The planning and funding application will have been undertaken on the anticipated level of use/patient volume for this year, but the goods will not be available for use until next year, when, with scale-up, a much higher level of use/patient volume is expected. Even if full funding is received, there will never be enough goods to meet the demand in scale-up programs because there is a one-year time difference between planned activities and the actual execution.

–

There is no allowance for procurement/lead times in the budget/financial process. There is often a scramble when funds are finally received to complete the complex procurement procedures before the end of the financial year, resulting in few considerations being given to shelf life and the need for phased delivery of shortdated products.

–

In most cases, no level in the system knows what the other level is planning, still less what they will actually be able to supply. It is virtually impossible for Province to plan effectively because they do not know what Center will be able to supply. For Districts, they do not know what Center and Province will supply, and at Treatment

57


site level, it is unknown what all levels of the system will provide to them. Similarly, it is exceedingly difficult for Center to know what is being planned at Province and District levels. This process applies to all public sector funding, so while advocacy is possible, reform of the various financial and procurement procedures is well outside the scope of influence of an individual Ministry of Health sub-directorate and, in the short to medium term, it will be necessary to cope with, and develop systems appropriate to a two-year forward budget cycle with uncertain funding levels and restrictive procurement regulations. Within these many and severe restraints, however, it is believed that it is still possible to formulate plans which can bring significant improvements. Identified key areas include— •

Allocation of resources for pharmaceutical management—No commercial sector organization would ever consider programs of supplying multi-million dollars of medicines, or indeed any other commodity, without a very active and efficient supply chain management system being in place. Yet nearly all the public sector medicines systems within Indonesia are so fragmented that active modern logistic management functions have not developed significantly. Instead programs are best by onerous and highly restrictive procurement and financial procedures. The starting point must be the recognition of the sheer volume and cost of materials being procured now, and perhaps more importantly, likely to be needed in the future, and the critical need for the active management of those materials to achieve the best possible results. While at individual Province level, the HIV/AIDS commodities volumes may not yet be especially significant, nationally the volumes are a certainly significant and warrant serious attention. For ARVs alone, in the absence of active pharmaceutical management, 30 percent of the cost of the ARVs may not be utilized 28 without dynamic supply chain management. This could mean that fewer patients than possible will be started on treatment, large volumes of drugs will date expire before they are used (as has already occurred), and there will be regular needs for high cost emergency purchases to prevent treatment interruptions.

•

At an average ARV cost of 300 USD per patient year, and an initial targeted 5,000 patient receiving ART, this equates to annual national ARV drug requirement of 1.5 million USD before allowances for buffer and pipeline stocks are made. Thirty percent equates to 500,000 USD, which would be more than adequate to fund a full pharmaceutical management operation. The overwhelming conclusion that programs, especially those handling high value medicines, cannot afford not to have full pharmaceutical management is regrettably still not widely acknowledged.

•

Experience from other countries in South East Asia suggest that in the initial stages of ART scale-up resource allocation for the operational cost of pharmaceutical management should be at least 20 percent of the commodity cost. This percentage can be expected to decrease as patient volumes exceed 10,000 patients receiving ART and economies of scale can be enacted.

28

World Health Organization (WHO) and Management Sciences for Health (MSH). 2006. Joint Who and MSH Workshop on Forecasting, Stock Management, Monitoring and Reporting on Antiretroviral Commodities. Manila, WHO. http://www.wpro.who.int/NR/rdonlyres/63814D6A-6925-4B1F-B111EF0241DEDC38/0/JointWHOandMSHWorkshopMeetingReport.pdf.

58


Additionally, many countries will need to receive substantial technical assistance to establish suitable logistics units, train staff and design and implement appropriate procedures. 29 •

•

Communication of logistics/supply chain information to Province and Districts –

Planning information—Central Level should communicate what commodities are available, how much of each commodity is available, when will each commodity be available, now and over the next two years, to be updated at least quarterly and preferably monthly. Much of this information may only be available as a crude estimate, but it will at least serve as a basis for Provincial and District planning.

–

Provinces, Districts, and even individual treatment sites may be willing to commit their own funds to supplement supplies (as is already happening in Tanah Papua for HIV test kits) if they could plan and identify potential shortfalls. Whilst sub-directorate HIV/AIDS have made sterling efforts to advise Provinces on ARV medicines, the situation on STI/OI medicines and rapid test kits is less clear. At present it is exceedingly difficult for Districts to ever know what they are likely to receive.

–

Central level issues/dispatches to Provinces/treatment sites—Central level is not always able to meet the treatment site request for supplies. Sometimes substitutions and/or alternative products must be provided because only those supplies are currently available. If clear explanations could be provided as to the rationale and reasoning on the substitution, the potential for alienation when different supplies to those requested, or no supplies, are received could be reduced

–

General information—A monthly pharmaceutical management newsletter could assist in bringing cohesion to a highly fragmented system, and assist in ensuring that Province and Districts felt informed on latest developments. While this may initially sound like a weak recommendation, the extreme state of fragmentation of the supply system, and the resulting disconnects between operational levels, should not be underestimated. The previous, bilingual, Essential Medicines Pharmaceutical Management newsletter, which ran for three years, was highly regarded and not quoted as a source of reliable information at Province and District level.

Dynamic stock and patient treatment protocol uptake management –

29

Dynamic management and time critical adjustment of allocated patient numbers uptake by treatment protocol is essential. In essence, it is necessary to obtain the best balance possible between the conflicting requirements of starting more patients on treatment than there are medicines available, which could lead to interruption of treatment and the many clinical problems and longterm problems of resistance, with the need to have the most number of

WHO and MSH. Joint Workshop

59


patients possible on treatment within the existing resources, or otherwise denying patients treatment when there are medicines available. 30 •

Stock storage is split over multiple sites –

Funding for medicines is erratic and uncertain. Funding is almost certainly inadequate to meet demand, especially for STI and OI medicines. Supply is split between multiple funding streams and delivery times are uncertain. The ratio of specific treatment protocol usage and thereby individual medicine usage is not yet established. (What percentage of patients will require EFV protocols in the future? All country programs in S.E. Asia are trying to grapple with such requirements). 31 Yet, to avoid potential treatment interruption, it is essential to match stocks and secure pipeline supply with patient numbers by specific treatment protocol and planned patient uptake.

Sub-directorate HIV/AIDS is currently grappling with this requirement but as the program continues to scale-up, the volume of supplies to be handled and the complexity of the treatment regimens increases, especially when pediatric formulations are introduced, will render the situation beyond manual control techniques. A full program of dynamic stock and patient treatment profiles management needs to be developed, and perhaps over the longer term, leading to the use of the developed software packages such as Quantimed and Pipeline, but certainly ensuring, as a minimum, a review of stock levels and patients numbers and adjustment of allocated patient numbers, every month. •

Long-term planning –

With the many variables and unknowable quantities inherent in the current public sector commodity operations, long-term planning is especially difficult, but it remains essential that it occurs

–

Medicine supplies and especially ARVs, whether from the international marketplace or national manufacturers, are difficult to obtain and require long-term planning and order commitment if supplies are to be secured

–

Long-term planning for up to two years, and updated at least every three months, and communicated to all parties involved in the supply process, and especially including national manufacturers and the international procurement agent, is essential if future supplies are to be obtained in a reliable manner

30

Barraclough, A. 2005. ARV Treatment: The Challenges of Scaling-Up: Procuring/Distributing/Managing ARVs. Arlington, VA: Rational Pharmaceutical Management Plus/Management Sciences for Health. PowerPoint slides.

http://www.synergyaids.com/announce/Kobe/Andy_Barraclough_presentation.ppt

31 Barraclough, A. 2005. Rational Drug Use—Prescribing, Dispensing, Counseling and Adherence in ART Programs. Arlington, VA: Rational Pharmaceutical Management Plus/Management Sciences for Health. PowerPoint slides.

http://www.who.int/hiv/amds/RationalDrugUseBKK.ppt

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•

Warehousing/storage space –

•

The current Central Level storage space is split between multiple sites, none of which is under the sole, direct control of the sub-directorate HIV/AIDS. Ad-hoc provisions of using whatever space is available at the time, in generally poor quality storage sites, is simply not appropriate for the volume and cost of commodities being procured, and such inadequate storage threatens to compromise the quality of the materials before they ever reach Province level. Rationalization and provision of an adequate volume of quality storage space, with active stock management, is an essential starting point to take control of the medicines and commodity stocks. Sub-directorate HIV/AIDS is already using the services of a pharmaceutical distributor for some of the materials but, if necessary, this entire function can be contracted as it has been in the Philippines and Vietnam, to a commercial/parastatal pharmaceutical distributor having adequate quality storage space and stock management capacity.

Technical assistance –

The requirement for sub-directorate HIV/AIDS to become a major, de-facto supply agency, in addition to its many functions, is an onerous burden and will require the formation of a full logistics unit, which is currently being developed.

–

Experiences from other countries in South East Asia suggest that technical assistance programs costing approximately USD 1 million per year for 3 to 5 years are often required to establish full dynamic logistics functions required for HIV/AIDS commodities.

Tanah Papua Supply Chain – Step 1: Strategic Design Essentially, the strategic design is to develop a supply chain that consistently meets the needs of the health system and its patients with the central focus being on individual hospital’s and puskesmas needs. What has to be designed is a supportive environment for each link in the supply chain, without compromising on flexibility. The supply chain, therefore, has to be driven by the needs of individual health facilities, which means that the focus has to be on maintaining sufficient product in the health facility to prevent stock-outs without running the risk of expiry. The recommended supply chain, therefore, establishes a dependency between each level of inventory-holding with the supporting inventory being designed to “top-up” the monthly usage of each of the next storage points in the chain. To establish the nature of these relationships between the various storage points and individual health facilities, a weighted distribution analysis will have to be undertaken that establishes a time, distance, and cost parameter for each delivery made by the District and/or Province and each collection made by each health facility. The weighted distribution analysis would model time and distances, together with known costs, of the supply chain between all points linked in the system. Using this model, it would be possible to evaluate alternative storage and distribution networks to maximize service to health facilities at minimum acceptable cost to the health service while, at the same time, not overburdening the

61


management capacity of District and Provincial health authorities and individual health facilities. Such an analysis would also identify where investments in storage facilities and equipment are required.

Tanah Papua Supply Chain - Design Criteria The work that has to be carried out would — •

Strengthen Central Level functions to respond to the needs and requirements of operations in Tanah Papua

•

Using current knowledge, design and plan the creation of a supply chain tailored to the logistics, communications and human resource realities of Tanah Papua

•

Create a fixed and skilled team to control the process and the implementation

•

Obtain records from each health facility of issues and create usage databases for each one

•

Develop replenishment targets for each hospital and puskesmas for each product

•

Create an imprest-type replenishment system with each hospital and puskesmas

•

Create the process that facilitates transfer of the usage data to the appropriate storage/ supply point

•

Using replenishment trigger points, the relevant supply point to replenish health facility stocks up to a target stock level for each product

•

Improve storage facilities at all levels as required

•

Select appropriate transport modes between each storage and receiving unit (e.g. air, sea, road, foot)

•

Determine appropriate ordering and distribution schedules for each health facility and storage point

•

Select and implement appropriate MIS/IT systems that facilitate the management of the supply chain in which each hospital and puskesmas would be maintained as a separate stockholding point with the system consolidating stocks and orders for higher level demand and procurement planning

•

Develop “Key Performance Indicators” to ensure that all targets (e.g., availability, order-fill) are met

To expect hospitals and/or puskesmas to run a complex inventory management program with what are likely to be relatively low computer literacy levels is unlikely to be an option. Whatever system is developed and installed, whether it is a manual or computer-based inventory system or a mix of the two, will have to reflect the ability of health staff to manage and control the data recording and reporting. Conversely, however, the system has to be able to facilitate the recording and collection of usage data for preparing and transmitting orders to the District and/or Provincial stores and/or private distributors in their stock replenishment role.

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To try to immediately implement such a plan Province-wide would probably not be advisable. It is therefore recommended that a pilot be put in place in two districts that tests every aspect of the proposed solution, identifies potential problems and ensures the feasibility of the design.

Tanah Papua Supply Chain – Step 2: Pilot system The profile of the pilot is much along the lines of what is proposed to complete the strategic design except that it will be conducted in a limited geographical area. The work to be done after selecting the districts to be included would include— •

Select one major hospital and its relevant supply point

•

Select, eight or so puskesmas, and the appropriate district stores

•

Assess the need for and feasibility of using larger/better managed puskesmas as a sub-district storage point

•

Collect all stock data on a monthly basis from all points in the pilot study supply chain

•

Calculate usages for each product used by each puskesmas and the hospital, including analysis to incorporate seasonality, substitutions and out-of-stocks

•

Develop target stocks for each stockholding point

•

Implement a dispensing and replenishment system into the hospital and the puskesmas with onsite training

•

Undertake operational process design to determine the required supply chain resources

•

Assess existing communications, electricity supply and other utilities as relevant

•

Create appropriate communication links and methods of transferring data

•

Use replenishment system by the hospital and puskesmas with frequent update of usage data to the provincial and/or district store

•

Test all aspects of the process

•

Assess problems; determine solutions or enhancements; and effect changes to the processes

•

Validate weighted distribution analysis for roll-out on a provincial basis

•

Demonstrate the working system to other districts and to the Provincial health authorities

•

Create a formal implementation plan for each district to which formal agreement must be obtained

•

Undertake roll-out on a district by district basis

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Annex 1. Scope of Works for the Study Scope of Work for Short-Term Technical Assistance Intervention Background statement setting context for the STTA USAID/Indonesia has communicated a need for supply chain technical assistance (TA), specifically; for a supply chain assessment of Papua Region. There are several other players working in Indonesia (Clinton, GF, WHO, UNICEF, the Government of Australia). Unlike in the rest of Indonesia, where the HIV/AIDS epidemic is highly concentrated in most-at-riskgroups (MARG), recent surveillance data indicate that Tanah Papua (i.e., the provinces of Papua and West Papua) has a “mixed” epidemic. On the one hand, HIV prevalence levels among female sex workers are the highest in the country, with 2005 sentinel surveillance data indicating HIV prevalence in the largest Papuan cities in the 15-25 percent range. On the other hand, 2006 general population surveillance data confirm that a low-level general population epidemic has indeed broken out in Papua (2.5 percent general population prevalence). Anecdotal evidence has suggested for some time that Tanah Papua was on the verge of a general population epidemic, and in the past two-three years efforts have begun to assist the two provincial governments in addressing the growing epidemic. Confirmation of the general population epidemic has significantly elevated concern over HIV/AIDS in Tanh Papua, and it is virtually certain that the level of resources flowing into Tanah Papua to combat HIV/AIDS will grow substantially over the next few years. In order to prevent a larger epidemic, among other things the pace of health system strengthening in Tanah Papua will have to be accelerated significantly. At present, comprehensive HIV/AIDS-related services are available only in a few of the larger cities, and even there at a very limited number of hospitals. With assistance from Family Health International (FHI) and WHO, the Papua Provincial Health Office has developed a health systems strengthening plan that will serve as a blueprint for development activities over the next few years. The plan envisions the development of networks of hospitals and community health centers that, jointly, will provide the full range of necessary HIV/AIDS-related services in areas with sizeable population concentrations. In less densely populated areas, the plan calls for the enhancement of community health centers to provide many of the necessary services. In all areas, networks of care and support in communities will be strengthened through the existing networks of NGOs, CBOs and FBOs, and the roles of PLHA in community- and facility-based activities will be promoted as well. To date, the USG, working through FHI, has been the primary supporter of the initiative. What is missing from the current plan is a parallel plan for strengthening supply chain management. The existing system may be best described as ad hoc. Most procurement is done centrally and commodities shipped to the Provincial Health Offices, with scheduling driven mainly by when funds become available in the national and provincial budgets (usually quite late in the fiscal year). The

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existing system, which it should be, noted covers only a fraction of the drugs and commodities that will be needed to implement the health systems strengthening plan, is weak more or less across the board. The Head of the Papua Provincial Health Office recognizes the limitations of the existing supply chain management system and has asked for urgent assistance. What is needed as a starting point is a full situational assessment and development of a set of recommendations as to what needs to be done to adequately support the health systems strengthening effort. FHI has arranged for a rapid assessment of the commodities management system in Tanah Papua to be undertaken by a local consultant so that whatever “quick fixes” as are feasible can be implemented immediately in order to keep the health systems strengthening initiative moving forward. However, a more comprehensive assessment along the lines outlined below is needed to provide sufficient information to develop a more comprehensive response. Brief purpose statement To undertake a comprehensive situational assessment of the commodities management system in Tanah Papua as a starting point in the development of a master plan to strengthen the system in parallel with the ongoing health system strengthening initiative (likely with support from multiple donors). All components of a commodities management system should be assessed, including product selection, procurement, quality assurance, freight forwarding, warehousing, distribution, and a management information system to monitor these activities. Challenges such as the following should be noted: stock-outs, lack of buffer stock protection, delayed delivery and distribution, insufficient projections of need, lack of quality information, insufficient trained personnel, and lack of accountability. While the full commodities management system should be assessed, priority is on the following: HIV test kits and reagents, STI test kits and reagents, ART drugs, STI drugs, OI drugs (including TB), laboratory equipment and supplies. Deliverables or products to be developed 1. A detailed, written assessment of the functioning, strengths and weaknesses of the commodities management system in Tanah Papua, including the identification of requirements and priorities for system enhancement and initial steps for moving forward two to three weeks upon end of in-country work. 2. A briefing in Jayapura for Tanah Papua health officials on the findings and recommendations of the visiting team. 3. A national-level briefing in Jakarta for staff of the Ministry of Health, USAID and other organizations that may be interested in the results, including donors. 4. Two-page trip report, to be submitted within one week of the end of in-country work.

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Annex 2. HIV/AIDS Data Presented on CD ROM only

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Annex 3. Survey Parameters Supply Source Domestic or import Suppliers for ARV in the country Procurement method Procurement cycle Quality standards /product spec. Inventories Forecasting Quantification Quality control Recording /reporting FEFO management Budget sources State budget/Donation Budget cycle Warehousing CDC warehouse/ suppliers Warehouse condition Capacity and location FEFO management Quality Assurance Distribution Push/pull distribution network lead times Refill cycle/ procedures/techniques Recording and reporting Organization and staffing Manuals and guidelines Operating budget Tools and equipment IT support Training and supervision Monitoring and Evaluation

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ARV/STI/OI/RAPID TEST REAGENTS HOSPITALS Inventories Inventory building Requisition and Deliveries Inventory record/ stock cards Supply capacity Stock Out Expiration/ damage Write Off and Disposal Authorization procedures Emergency logistics Storage condition and capacities Distribution Distribution to Satellite Hospital Requisition and Deliveries Inventory record/ stock cards Supply capacity Stock Out Expiration/ damage Write Off and Disposal Authorization procedures Emergency logistics Storage condition and capacities Organization and staffing Manuals and guidelines Operating budget Tools and equipment IT support Training and supervision Monitoring and Evaluation

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ARV/STI/OI/RAPID TEST REAGENTS PROVINCIAL CDC WAREHOUSE Supply Source National or Province suppliers Procurement method STI/RAPID TEST REAGENT/TEST RELATED COMMODITIES PUSKESMAS Supply sources Central/ Province program/ Routine purchase Procurement method Procurement cycle Quality standards / product Spec Inventories Inventory building Requisition and Deliveries Inventory record/ stock cards Supply capacity Stock Out Expiration/ damage Write Off and Disposal Authorization procedures Emergency logistics Storage condition and capacities Organization and staffing Manuals and guidelines Operating budget Tools and equipment IT support Training and supervision Monitoring and Evaluation Procurement cycle Quality standards / product Spec Inventories Forecasting Quantification Quality control recording / reporting FEFO management

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Budget sources State budget/ Donation Budget cycle Warehousing CDC warehouse Warehouse condition Capacity and location FEFO management Quality Assurance Distribution Push/pull distribution network lead times Refill cycle/ procedures/techniques Recording and reporting Organization and staffing Manuals and guidelines Operating budget Tools and equipment IT support Training and supervision Monitoring and Evaluation

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DISTRICT DRUG WAREHOUSE Supply Source National or Province suppliers Procurement method Procurement cycle Quality standards / product Spec Inventories Forecasting Quantification Quality control recording / reporting FEFO management Budget sources State budget/ Donation Budget cycle Warehousing CDC warehouse Warehouse condition Capacity and location FEFO management Quality Assurance Distribution Push/pull distribution network lead times Refill cycle/ procedures/techniques Recording and reporting

Planning of Inventory Data were collected in the following offices/institutions a. Provincial Pharmaceutical Warehouse b. CDC warehouse in the Province c. Provincial Health Laboratory 1. The Municipality of Jayapura a. Dok II Hospital b. Dian Harapan Hospital

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c. Abepura Hospital d. Hamadi Puskesmas e. The Municipality Pharmaceutical Warehouse 2. The District of Jayapura a. The District AIDS Commission b. District Health Office c. Kampung Harapan Puskesmas d. District Pharmaceutical Warehouse o The District of Biak Numfor a. The District AIDS Commission b. District Health Office c. Biak General Hospital d. Puskesmas Kota e. District Pharmaceutical Warehouse 3. The District of Yapen Waropen a. The District AIDS Commission b. District Health Office c. Serui General Hospital d. Menawi Puskesmas e. District Pharmaceutical Warehouse 4. The District of Nabire a. The District AIDS Commission b. District Health Office c. Nabire General Hospital d. Karang Tumaritis Puskesmas e. District Pharmaceutical Warehouse 5. The District of Mimika a. The District AIDS Commission b. District Health Office c. Mitra Masyarakat Hospital d. Kwamki Lama Puskesmas e. District Pharmaceutical Warehouse 6. The District of Asmat a. The District AIDS Commission b. District Health Office

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c. The Puskesmas of Asmat (hospital to be) d. District Pharmaceutical Warehouse 7. The District of Merauke a. The District AIDS Commission b. District Health Office c. General Hospital of Merauke d. “Bunda Pengharapan” Catholic Hospital e. Mopah Puskesmas f. Kurik Puskesmas g. District Pharmaceutical Warehouse 8. The District of Jaya Wijaya a. The District AIDS Commission b. District Health Office c. General Hospital of Wamena d. Wamena Kota Puskesmas e. District Pharmaceutical Warehouse

2. The Province of West Papua (3 Districts) 1. Provincial AIDS Commission 2. Province Health office 3. The District of Manokwari a. The District AIDS Commission b. District Health Office c. General Hospital of Manokwari d. Maripi Puskesmas e. District Pharmaceutical Warehouse 4. The District of Sorong a. The District AIDS Commission b. District Health Office c. General Hospital of Sorong District d. Aymas Puskesmas e. District Pharmaceutical Warehouse f. The Sele be Solu Municipality Hospital of Sorong 5. The District of Fak-Fak a. The District AIDS Commission

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b. c. d. e.

District Health Office The General Hospital of Fak Fak District Aymas Puskesmas District Pharmaceutical Warehouse

3. Central Offices a. Sub-directorate HIV/AIDS b. Kimia Farma Warehouse c. Other Government offices in Jayapura such as the Telecommunication – Transportation and power supply offices, and also private organizations in pharmacy and courier and expedition offices.

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Annex 4. Survey Instruments Brief English Language Survey Instruments ( Full instruments in Indonesian language follow)

Content of the Instruments for HIV/AIDS Survey in Papua • Committee for AIDS in the Province / District. The Committee for Controlling AIDS in Papua Province and West Papua (Komite Penanggulangan AIDS Propinsi [KPA]). 1) What components are in the committee and what is their role? 2) After the announcement of a prevalence of 2.4 percent of HIV pos cases, what is the response and plan in the near future— collect strategic plan—operational plan? 3) The major strategy is to extend promotion – prevention of STI -HIV, behavior change (Behavior change communication), inform where people can get Health Facilities for VCT - Care support and Treatment – PMTCT – IMAI, and to stop stigma and discrimination? What is the KPA priority and extension – intensification – coordination of donor support- among Government agencies and NGO’s directed? Where and when? 4) 5)

6) 7)

Collect the information! What are the constraints and problems? What are KPA concerns on the fact that those activities need continuous and undisturbed logistics supplies – management and resources (physical and financial – human resources?) How does the KPA address these concerns in the strategic plan? Is there any strategic plan or operational plan to discuss or address these concerns?

• Province Health Office/ District Health offices 1) Since the announcement of 2.4 percent of HIV pos cases, what is the response and plan in the near future – collect strategic plan – operational plan. 2) What is the major strategic / changes and plan to address the new situation? Extension of VCT services – CST services (intensification or intensification) - PMTCT – IMAI – TB HIV; what is the KPA priority and extension – intensification directed? Where and when? Collect the information!

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3) What are the strategic of operational plan to make those strategies happen? What activities are prioritized? What resources are needed (physical and financial – human resources?) Collect the information on new public and private hospitals, puskesmas, and private clinics which will be assigned in the new program strategy, ensure there is a detailed timeline /time target. 4) Are these strategies and operational plan agreed at the Parliament levels and gain strong political support? Is it in line with the priority of development in Papua and West Papua? Collect the information! 5) Will these strategies also involve the private health providers sector? What are the 6) 7) 8) 9)

10)

needs for support in the private sector? Collect the information! Is there a strong commitment in the private sector, which organization shows a strong commitment? What about NGO – CBO – faith-based organization? What are the constraints and problems? What are PHO/DHO concerns on the fact that those activities need continuous undisturbed Logistics supplies – management and resources (physical and financial – human resources?) How does the PHO/DHO address these concerns in the strategic plan? Collect the

information! If any 11) Is there any strategic plan or operational plan to discuss or address these concerns? Collect the information! 12) Until now we do have Supplies and Logistics support the Central to the Hospitals directly. An intensification of new Hospital services/ Primary Health Centers or Policlinics throughout Papua and West Papua will make more burden to the Central, is there any plan to decentralize it to the Provinces or Districts? Where will it be assigned? Since we have complicated – constrains in integration and coordination of storage management and distribution in HIV/AIDS related commodities ( such as ARV, OI, STI, TB/HIV, Reagents, laboratory supplies, Condoms, Universal Precaution supplies, disposals needs) what would the future logistics services will arrange? At present, commodities are stored and distributed from different locations and agencies and procured or financed by various budget sources in various Government level. Will there be actions or decisions to improve coordination and management between Logistics and Program.

13) If not, is Logistics and Distribution/Drug management is already in the agenda for discussion in the near future? When or where will it be done? 14) Different requirements are needed in the storage and distribution of HIV/AIDS-related commodities—it needs effective quality assurance activities and handlings, including monitoring of expiration dates. Whom do you think to should be assigned to handle these matters? 76


15) If the pharmacy component already in the strategic plan, can we get the complete plan? Collect the information! If any. 16) To conduct such a major undertaking in the Province of Papua and West Papua, do you have an idea how much resources (providers, human resources, financial resources, physical resources, telecommunication, transportation, power/electricity, etc.) is needed to make it happen? Do you think that we have to optimize any potential available in Papua or West Papua to undertake this huge undertaking?

• Hospitals (Working Group on HIV/AIDS) 17) VCT and CST services 18) Since the announcement of 2.4 percent of HIV positive cases, are there any new strategies to response to the new situation? What are the new policies or guidance from the Province or District Health Offices? Are there new plans or strategies to address the new situation? 19) Are there any written plans or strategies? 20) What would you anticipate for this hospital, will there be a new networking mechanism for referral mechanism and will it be more of a burden to the working group in the Hospital? 21) Do you think (to address the new situation the Government will add more hospitals and even involved more puskesmas, private sector to participate in addressing the new situation) that something should be done to improve the present logistics of ARV and other drugs and other commodities. Do you agree if it would be a more burden to the logistics when it is handled from the Central? o Would you anticipate a new working mechanism will be introduced to allow more VCT access for people to go to health providers for various diseases, such as TB, STIs, OIs, Mother and Child services (prevention for the child). Do you anticipate the number of tests to increase and to what level? o What about CST services would you expect an increase? What about the availability of supplies for medicines, reagents, and supplies to support universal precaution measures – Laboratory supplies? o Will there changes in priority in the hospital/ puskesmas or clinics with regard to the new situation? o Based on the previous experiences what is your comment or evaluation on the logistics and supplies for HIV-related commodities (such as ARVs, OIs, STI, TB/HIV, Reagents, laboratory supplies,condoms, universal precaution supplies, disposals needs) what would the future logistics services will arrange?

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At present commodities are stored and distributed from different locations and agencies and procured or finance by various budget sources in various Government levels, will there be actions or decisions to improve coordination and management between logistics and Program.

• Logistics/Pharmacy staff (it is shortened) o o

o

o

o o o o

•

Which organization/staff is supporting the inventory control – of those commodities? And who is handling the storage of those commodities? Meet them! Collect information (for all HIV/AIDS-related commodities) on stock building policies, expiration dates, source of supply, requisition procedures, periodic reports, forms and user/operating manuals, inventory controls mechanism, planning mechanism /techniques, training for staff, drug information and updates, problems and constraints Collect storage capacity, warehouse sizes, humidity or temperature control equipment, lighting, internal communication, distribution means in hospitals, storage mechanisms, and material handling (stacking, location management, and in- and out-going service) What pharmacy services are available for HIV/AIDS services, dispensing, drug information services, drug interaction services, side effects monitoring, Quality Assurance, patient drug monitoring? Recording of stock movement, periodic Logistics /Distribution reporting, data processing WODA Are there HIV/AIDS related commodities which your organization has to plan? Where is the budget source? Can it always be fulfilled or is it only available for critical situations? Are you part of the working group or not? In what way are you involved in the provision of HIV/AIDS medicines to the patient? What do you think is needed to improve the services?

Province/ District Warehouses (Pharmaceutical or Program warehouses) The survey in the warehouses are exactly the same with our rapid survey, which cover all storage requirement – inventory control – quality assurance – recording and reporting = monitoring and evaluation additional questions are added to acquire storage capacities, distribution mechanism and cost – constraints – integrated monitoring and evaluation with the programs activities/ planning – budget review and budget proposals.

• Non-Health Organizations o

Public telecommunication, transportation mode, power supply Information regarding present situation, capacity, and future development to address the Papua development plan. We want to know their present supply capacities, short-

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o

comings, their future development plan to extent and intensity of their capacities, what are their priorities in development. Present cost of these services, coverage and sustainability of supply / services, quality, etc.

Private telecommunication, transportation mode, power supply Gathering information on specific issues regarding price, scheduling, sustainability and supply capacity, total supply and demand, their option to support the health/ social responsibility, and willingness to support.

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Questionnaire for Private Sector Companies General Information 1. Name of company 2. What is the nature of business operations in Papua and West Papua Provinces? 3. Physical location(s) in Papua and West Papua 4. Name of official contact 5. E-mail, phone, fax 6. How many years has the company been in operation in Papua and West Papua, and what business development plans does the company have for the next 5 to 10 years 7. How many people does the company have working for it in Papua and West Papua a. Total number b. Expatriate c. Indonesian d. Indigenous 8. Is the latest annual report available describing operations in Papua and West Papua? If yes, ask for a copy Health and Social Services 9. What, if any, health and social services does the company provide to— a. Staff (expatriate and Indonesian) b. Families of staff c. Broader community 10. What, if any, services are provided to people suffering or at risk from HIV/AIDS and/or TB, such as a. Public education b. Prevention activities c. Testing and counseling d. Treatment, including provision of medication e. Support for orphans and other vulnerable groups f. other 11. Does the company support the provision of general health services for any of the following, including the delivery of health-related products? a. Public sector b. Private sector c. NGO

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d. Faith-based organization e. Voluntary agencies f. Other 12. Does the company supply any of the following types of products a. Pharmaceuticals, general b. Pharmaceuticals, HIV/AIDS and/or TB c. Gloves d. Syringes and needles e. Blood bags f. Administrative sets g. Cannulas h. Catheters and tubes i. Dressings j. Diagnostic imaging k. Other diagnostic imaging consummables l. Sutures m. Lab supplies n. Other Supply chain operations 13. Does the company manage its own supply chain to support its business operations? a. Receiving and Storage b. Logistics/transportation within Indonesia and within Papua and West Papua i. Road ii. Air iii. Sea c. Importing and customs clearance into Indonesia. d. Transport from point of importation to Papua and West Papua. Is a freight forwarder used? 14. Describe the main problems faced by the logistics/distribution function in general and in relation to health in particular. 15. Describe any major logistics/distribution strategies that are planned to be implemented over the coming 3 to 5 years. For example: a. Are the number and location of warehouses to be expanded or reduced? b. Are the volumes moved by air/sea/road to be changed, e.g. more by sea? Warehousing and Distribution 16. Does the company own and operate its own warehouses and/or transport? a. How many are there, where are they located, and how are they accessed (e.g. by air, road, sea). Map these showing roads, sea and air links.

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Warehouse Number Location Reached by air, sea, road Size (square metres) Refrigeration capacity Number of staff

1

2

3

4

5

b. For each warehouse, if possible, get the following statistical information— i. ii. iii. iv.

Units received (12 months) Units shipped (12 months) List of product lines stored and distributed Number of cold chain lines

c. For each warehouse visited, note the following— i. Type of storage, e.g. shelving, pallet racking, etc. ii. For pallet racking, number of pallets high and number of pallet spaces iii. Condition of floor (e.g., surface flatness, general impression, visible cracks, etc.) iv. Condition of roof and ventilation v. Security of site (perimeter fencing, guards, CCTV, security procedures for entering/exiting warehouse, alarms, fire doors, fire extinguishers, etc vi. Electric supply, lighting vii. Back up generator available and in working order? For all warehouse, only offices, cold store, etc. viii. Pest control 17. What is the geographic reach of your company’s supply services (districts, towns, etc.)? 18. Provide/collect information for a customer profile and scale of distribution activities to each of them. Indicate whether customers receive deliveries or collect their supplies

‘Customer’

Location

Warehouse serving ‘customer’

Delivery or Collection

Distributions

Volume/Units

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Value


19. How frequently do customers place/receive orders? Average orders per month

Customer/delivery point

Average deliveries per month

20. How does the company typically receive resupply requests? a. Telephone b. E-mail c. Fax d. Other 21. Does the company either provide or is willing to provide supply services to other organizations, e.g., to the government health service, to private health services, other private and/or government organizations? If yes, please describe.

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Inventory 22. If the company does hold stocks of pharmaceuticals and medical supplies or arranges for delivery from vendor to end user, provide/collect the following details Annual Volume S/D

Vendor

Unit of

Item Description

Measure

Current Year

Annual Value Current

2006

Year

2006

23. For each item, if item is stocked in more than one warehouse, indicate location 24. For each item, indicate if item is stocked (S) or drop shipped by vendor (D) 25. Do you expect these volumes to change in the coming 1 to 3 years or to be about the same this year? Please explain. 26. Does the company use a computerised MIS for inventory management?

Transportation 27. Draw a diagram/map of distribution network showing: a. Storage facilities b. Delivery points c. Routes, distances and travel times d. Mode of transport for each route 28. How does the company transport its supplies, medical or otherwise? What is the relative frequency of use for each mode of transport ( percent) a. Company owned trucks/automobiles b. Hired trucks/automobiles c. Planes, scheduled d. Planes, chartered e. Planes, company owned f. Ship/boat, scheduled g. Ship/boat, chartered h. Ship/boat, company owned i. Other

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29. For contracted transportation, does the company have preferred carriers? Who are they and what are the rates paid? 30. For the company’s own transport: a. Are they maintained by the company’s own technicians or is it contracted out? b. Are there any plans to change the current transport fleet? 31. What are the costs per kg/ton per kilometer for the following— a. Company owned trucks/automobiles b. Hired trucks/automobiles c. Planes, scheduled d. Planes, chartered e. Planes, company owned f. Ship/boat, scheduled g. Ship/boat, chartered h. Ship/boat, company owned i. Other

32. What is the cost of transporting supplies as a percent of the total value of supplies distributed? 33. Is fuel available in all parts of the provinces where supplies are distributed and what mechanism does the company use to ensure adequate fuel stocks 34. If the company contracts with others for transportation services a. which companies are used b. on what basis are the contracts awarded (e.g., volume, value) c. what is the negotiated cost 35. How does a company control loss during distribution, e.g., type of packaging, seals, secure vehicles/containers, etc.

Capacity for and interest in providing a supply service to HIV/AIDS and/or TB programs 36. Would the company be interested in supporting HIV/AIDS and/or TB programmes being established and expanded in Papua and West Papua by providing a supply service for medicines and supplies required by those programmes? a. Government services b. Nongovernment/faith-based services 37. What kind of services would the company have the capacity and interest in providing? For example, a. Storage

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b. Distribution c. Inventory management at warehouses, including requesting new stocks 38. Which areas of Papua and West Papua would the company be willing and able to provide supply services to? 39. What would be the most significant obstacles to overcome in order to participate in this effort, for example a. Financial, e.g., sharing cost of any investments b. Infrastructure, e.g., improved, expanded warehousing, transport, etc. c. IT/MIS, additional software/functionality for managing and accounting for pharmaceuticals and medical supplies d. Other 40. What conditions would the company insist on for providing such a service? 41. Would the company make any charge for the service? If yes, what would be the likely cost/cost basis for the service? 42. What would be the company’s main concerns with respect to providing this kind of supply service? 43. Would the company be interested in participating in a pooled procurement/group purchasing scheme for acquiring pharmaceuticals and essential medical supplies in order to assure availability and quality, reduce costs and standardize regimens in use?

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INDONESIAN LANGUAGE SURVEY GUIDES

LATAR BELAKANG YANG MENDASARI SURVAI INI Penyakit AIDS pertama kali ditemukan di Indonesia di Propinsi Kalimantan Barat pada tahun 1992, sejak itu ditemukan pelbagai temuan kasus dipelbagai propinsi di Indonesia. Subdit HIV/AIDS dibentuk dan melakukan upaya monitoring dan membentuk team ahli untuk memantau perkembangannya sambil melakukan pelbagai upaya untuk mengenal penanggulangan AIDS di Indonesia. Penunjukkan 25 RS pertama merupakan salah satu langkah pertama tahun 2003 yang diharapkan akan mencapai 300 RS pada tahun 2009 yang akan datang. Sementara itu pada tahun 2006 melalui Peraturan Presiden no 75 tahun 2006 ditingkat Nasional telah dibentuk Komite Nasional Penanggulangan AIDS untuk melakukan upaya – upaya terpadu yang dipimpin Menko Kesra dengan Menteri Kesehatan dan Menteri Dalam Negeri sebagai intinya. KPA dimaksudkan untuk melakukan koordinasi upaya secara Nasional dan berjenjang ke bawah untuk melakukan koordinasi penanggulangan penyakit AIDS yang memiliki pelbagai dimensi aspek permasalahan baik politik – social kemasyarakatan – hokum – ekonomi - agama disamping kesehatan. Disetiap Pemda dibentuk kemudian KPA untuk mendampingi Gubernur dan Bupati/ Walikota dalam melakukan penanggulangan AIDS yang memiliki demikian banyak dimensi permasalahan. Sejak 14 Agustus 2006 Gubernur Papua menyerukan penanggulangan AIDS di tanah Papua yang harus dilaksanakan secara menyeluruh, dan bahwa Penanggulangan AIDS merupakan salah satu agenda Pemerintah yang mendapat prioritas. MENGAPA SURVEY? MJM Pharmaceutical Management Consultants telah melakukan Rapid survey dibidang Logistik yang didukung oleh FHI dan didanai USAID, dalam survey tersebut ditemukan permasalahan – permasalahan mendesak dibidang Logistik komoditi yang terkait dengan penyediaan pelayanan penanggulanan HIV/AIDS. Namun belum dilihat masalah – masalah yang lebih strategis dibidang Logistik yang lebih strategis dihari mendatang, khususnya dengan meluasnya kebutuhan pelayanan AIDS di tanah Papua. USAID bersama MSHSCMS bekerja sama untuk lebih mendalami permasalahan strategis ini untuk mengantisipasi kebutuhan ditahun – tahun mendatang yang diantisipasi akan menjadi beban besar bagi Pemerintah dan Masyarakat. Untuk tujuan tersebut MSH – SCMS telah minta kepada MJM untuk menyelenggarakan survey yang lebih terarah pada semua potensi yang ada ditanah Papua yang berpeluang untuk dimanfaatkan dan dikelola secara efektif dan efisien khusus untuk mengantisipasi / mengkaji sumber daya dibidang Logistik serta pengembangan alternatif – alternatif pembiayaan maupun pengelolaan Logistik yang lebih efektif dan efisien.

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PANDUAN WAWANCARA BAGI SURVEYOR KOMITE PENANGGULANGAN AIDS Penyakit AIDS pertama kali ditemukan di Indonesia di Propinsi Kalimantan Barat pada tahun 1992, sejak itu ditemukan pelbagai temuan kasus dipelbagai propinsi di Indonesia. Subdit HIV/AIDS dibentuk dan melakukan upaya monitoring dan membentuk team ahli untuk memantau perkembangannya sambil melakukan pelbagai upaya untuk mengenal penanggulangan AIDS di Indonesia. Penunjukkan 25 RS pertama merupakan salah satu langkah pertama tahun 2003 yang diharapkan akan mencapai 300 RS pada tahun 2009 yang akan datang. Sementara itu pada tahun 2006 melalui Peraturan Presiden no 75 tahun 2006 ditingkat Nasional telah dibentuk Komite Nasional Penanggulangan AIDS untuk melakukan upaya – upaya terpadu yang dipimpin Menko Kesra dengan Menteri Kesehatan dan Menteri Dalam Negeri sebagai intinya. KPA dimaksudkan untuk melakukan koordinasi upaya secara Nasional dan berjenjang ke bawah untuk melakukan koordinasi penanggulangan penyakit AIDS yang memiliki pelbagai dimensi aspek permasalahan baik politik – social kemasyarakatan – hokum – ekonomi - agama disamping kesehatan. Disetiap Pemda dibentuk kemudian KPA untuk mendampingi Gubernur dan Bupati/ Walikota dalam melakukan penanggulangan AIDS yang memiliki demikian banyak dimensi permasalahan.

Daftar pertanyaan:

SEJARAH BERDIRINYA 1. Kapan KPA di sini dibentuk? Dan siapa yang menjadi komponen – komponen dalam KPA ini, siapa pula yang menjadi Pengurus hariannya? a.

Apakah ada daftar pengurus KPA serta struktur organisasinya?

2. Apa visi dan misi KPA di Propinsi Papua / Papua Barat? Untuk itu fungsi dan peran apa yang dimainkan KPA di Propinsi / Kabupaten? 3. Apakah sudah terbentuk KPA disemua tingkatan Pemerintahan? Apakah ada Daerah yang belum memiliki KPA? 4. Sejak diumumkannya PAPUA dan PAPUA BARAT (Tanah Papua) mencapai tingkat epidemic yang berkembang menjadi “generalisata” dan sudah mencapai prevalensi diatas 2.4 percent, maka Gubernur telah menyampaikan seruan dan instruksi untuk mengerahkan pelayanan kesehatan secara menyeluruh di tanah papua untuk menghadapi AIDS. Langkah / Program apa yang dibuat oleh KPA sehubungan dengan perkembangan tersebut baik dibidang kesehatan maupun dibidang social kemasyarakatan?

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Catatan: a. b.

c.

Secara umum telah dicanangkan upaya pencegahan – Komunikasi – Informasi dan Edukasi masyarakat mengenai HIV/AIDS – Penyediaan perluasan pelayanan kesehatan untuk HIV/AIDS Dibidang kesehatan mungkin adanya pengerahan semua RS di Papua untuk menyediakan pelayanan HIV/AIDS dan perluasan pelayanan VCT hingga ke tingkat Puskesmas, bahkan terkandung maksud untuk menyediakan mobile VCT Dibidang social kemasyarakatan dilakukan upaya pencegahan – KIE telah dilakukan seminar yang melibatkan semua pihak di masyarakat.

RENCANA STRATEGIS

5. Apakah sudah dirumuskan Rencana Strategis untuk Papua / Papua Barat? Apa sasaran – sasaran jangka pendek dan jangka panjangnya? Unsur – unsur utama dalam strategi penanggulangan dalam meningkatkan sumber – sumber daya di Papua/ Papua Barat ini bagaimana? Catatan: a.

b. c.

Unsur – unsure utama adalah dalam rangka meningkatkan kemampuan penanggulangan KPA memiliki rencana apa? Misalnya pemahaman dan kemampuan masyrakat – upaya pencegahan factor – factor yang memperluas penularan – peningkatan kemampuan SDM aparat / petugas kesehatan – penyediaan dana / sarana dan prasarana yang menunjang pelayanan kesehatan misalnya? Apakah juga sudah dirumuskan sasaran upaya KPA dimasing – masing bidang dan sasaran antara yang harus dicapai? Khusus dibidang kesehatan dilakukan upaya apa hingga tahun 2010 yang akan dating?

d. Apakah ada dokumen tertulis yang dapat kami peroleh?

6. Disamping upaya – upaya sendiri (Pemerintah) apakah ada upaya untuk mencari dukungan dari pihak lain, baik dalam maupun luar negeri? Catatan: a. Yang berbentuk penyertaaan oleh masyarakat dan swasta, baik dalam maupun luar negeri. Dapatkah diperoleh datanya? b. Dalam bentuk dukungan dalam upaya pemberdayaan SDM? c. Dalam bentuk dukungan pembiayaan? Dan lain-lainnya? Technical support? d. Apakah ada publikasi mengenai upaya – upaya ini? PRIORITAS RENCANA STRATEGIS

7. Dalam melakukan upaya – upaya tersebut, apakah yang dijadikan prioritas utama pada saat ini? Mana diantara upaya – upaya ini yang merupakan upaya yang paling mahal? Dan mana yang membutuhkan sarana dan prasarana yang terbesar? Bagaimana pendapat Bapak/Ibu

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mengenai dana memastikan kesinambungan penyediaan komoditi habis pakai yang digunakan untuk menunjang pelayanan Kesehatan. a. ( seperti ARV – Obat – obat OI, TB, PMS, pencegahan penularan Ibu ke anak dalam kandungan, obat – obat paliatif – obat untuk Harm reduction pada Narkoba – Alat kesehatan habis pakai untuk menunjang Universal Precaution termasuk didalamnya Sarung tangan – desinfektan Chlorine – penyediaan alat sekali pakai, sarana pemusnahan yang aman – alat laboratorium habis pakai seperti Test Kit untuk HIV – TB – PMS – fungsi hati – Reagens untuk alat diagnostik CD4 counter ataupun menghitung Viral Load - Kondom untuk mencegah perluasan penularan baik untuk Pria dan Wanita).

b. Penyediaan dana pengadaan tersebar dipelbagai tingkatan Pemerintahan dan instansi hingga ke unit pelayanan kesehatan sendiri, belum sarana dan prasarana penyimpanan / Gudang, sinkronisasi dan integrasi dengan kegiatan program melalui Monev dan perencanaan kebutuhan. 7. Apakah masalah dan kendala utama KPA dalam menanggulangi AIDS di Propinsi/ Kabupaten/ Kota ini? Bagaimana Monitoring dan Evaluasi serta koordinasi kegiatan ini dilakukan? Apakah ada laporan dan pertemuan periodik? Baik ditingkat Nasional/ Propinsi /Kabupaten/ Kota? Berapa jenis pertemuan dalam setahun yang merupakan agenda tetap? RENCANA OPERASIONAL 8. Dalam pertemuan KPA kegiatan mana/ apa yang menurut Bapak pada saat ini membutuhkan perhatian utama? Aspek Kesehatan atau aspek Sosial di Papua ini? Mengapa? 9. Mungkin Bapak/Ibu sependapat bahwa bidang yang perlu memperoleh perhatian adalah bidang Preventif – KIE - bidang pelayanan , dukungan dan Pengobatan - Rehabilitasi 9. Bidang Logistik adalah bidang yang mendukung pelayanan yang disediakan untuk VCT dan CST disektor Kesehatan? Sesuai dengan hasil monitoring Apakah masalah Logistik komoditi untuk HIV/AIDS ini sudah membutuhkan perhatian? 10. Bagaimana dengan penyiapan dana untuk aspek Logistik ini? Apakah akan memadai dihari kemudian? Apabila benar, langkah - langkah apa yang direncanakan/ disiapkan?

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PANDUAN WAWANCARA KEPALA DINAS KESEHATAN / PROPINSI / KABUPATEN / KOTA Penyakit AIDS pertama kali ditemukan di Indonesia di Propinsi Kalimantan Barat pada tahun 1992, sejak itu ditemukan pelbagai temuan kasus dipelbagai propinsi di Indonesia. Subdit HIV/AIDS dibentuk dan melakukan upaya monitoring dan membentuk team ahli untuk memantau perkembangannya sambil melakukan pelbagai upaya untuk mengenal penanggulangan AIDS di Indonesia. Penunjukkan 25 RS pertama merupakan salah satu langkah pertama tahun 2003 yang diharapkan akan mencapai 300 RS pada tahun 2009 yang akan datang. Sementara itu pada tahun 2006 melalui Peraturan Presiden no 75 tahun 2006 ditingkat Nasional telah dibentuk Komite Nasional Penanggulangan AIDS untuk melakukan upaya – upaya terpadu yang dipimpin Menko Kesra dengan Menteri Kesehatan dan Menteri Dalam Negeri sebagai intinya. KPA dimaksudkan untuk melakukan koordinasi upaya secara Nasional dan berjenjang ke bawah untuk melakukan koordinasi penanggulangan penyakit AIDS yang memiliki pelbagai dimensi aspek permasalahan baik politik – social kemasyarakatan – hokum – ekonomi - agama disamping kesehatan. Disetiap Pemda dibentuk kemudian KPA untuk mendampingi Gubernur dan Bupati/ Walikota dalam melakukan penanggulangan AIDS yang memiliki demikian banyak dimensi permasalahan. Sejak 14 Agustus 2006 Gubernur Papua menyerukan penanggulangan AIDS di tanah Papua yang harus dilaksanakan secara menyeluruh, dan bahwa Penanggulangan AIDS merupakan salah satu agenda Pemerintah yang mendapat prioritas.

PERTANYAAN WAWANCARA: A. SEJARAH PEMBENTUKAN

1. Dalam pernyataan Gubernur dinyatakan bahwa penanggulangan AIDS memperoleh prioritas besar, dimana letak prioritas bidang kesehatan dalam prioritas pembangunan Propinsi/ Kabupaten? 2. Dimana letak prioritas program HIV/AIDS dalam pembangunan bidang Kesehatan? Apa alasannya? 3. Kapan Dinkes membentuk unit organisasi penanggulangan HIV AIDS? B, RENCANA STRATEGIS

4. Apakah Dinkes sudah merumuskan Rencana Strategis (RENSTRA) penanggulangan HIV/AIDS? • Kapan dan siapa saja yang terlibat dalam penyusunan Renstra ini? • Apakah ada masukan dari KPA/KPA Nasional mengenai Rencana Strategis ini? Bisakah kami memperolehnya? 5. Apa arah dan sasaran rencana strategis penanggulangan penyakit HIV/AIDS ini? • memperluas upaya penyuluhan, memperluas jangkauan pelayanan kesehatan , membina sumber daya pelayanan Kesehatan, meningkatkan mutu pelayanan sehingga dapat

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menjangkau sekian Kab/Kota dan menemukan sekian banyak pasien dengan HIV positif, mengobati sekian banyak penderita AIDS 6. Apakah yang menjadi Sasaran Antara dan kapan sasaran antara ini akan dicapai? • Mis: Sasaran antara pertama adalah penyuluhan di sekian Kab. Atau Kecamatan pada tahun 2008. • Sasaran kedua adalah jumlah temuan HIV di sekian Kabupaten/ kecamatan adalah sekian penderita HIV positif pada tahun 2008 • Sasaran ketiga adalah jumlah penderita AIDS yang ditemukan sejumlah sekian pada tahun 2009.

7. Untuk menjamin agar Arah dan sasaran tadi dapat dicapai, program apa yang perlu dikembangkan? • •

Program adalah serangkaian kegiatan untuk memungkinkan kita mencapai sasaran antara? Misalnya program penyuluhan Propinsi, untuk mencapai sekian banyak Kabupaten yang diprioritaskan, akan mengundang petugas penyuluhan Kesehatan di Kabupaten2 dan menjelaskan program kegiatan yang harus mereka lakukan, antara lain mempelajari pedoman yang sudah dibuat oleh pusat, melaksanakan training of trainers Kabupaten, merekrut tenaga trainers untuk memandu pelatihan ini, menyiapkan anggaran untuk dapat melakukan training of trainers; menyiapkan sarana dan prasarana training untuk peserta pelatihan dari Kabupaten.

8. Sumber daya apa yang sudah dimiliki Dinas pada dewasa ini untuk melaksanakan program penanggulangan HIV/AIDS? Catatan: Untuk melaksanakan program baru tersebut terlebih dahulu kita perlu menginventarisir dan mengkaji sarana dan prasarana yang ada, serta program – program sudah ada pada dewasa ini atau program baru yang perlu diawali? i. Sarana pelayanan kesehatan yang dimiliki Kabupaten: •

Berapa jumlah RS Pemerintah dan jumlah RS swasta maupun total keseluruhan RS di Propinsi / Kabupaten. Berapa diantaranya yang sudah menyediakan pelayanan untuk penderita HIV/AIDS? Berapa RS yang belum menyediakan pelayanan? Apakah masih ada RS yang perlu dibina menjadi RS rujukan? Atau apakah ada pelayanan baru yang perlu dikembangkan misalnya TB/HIV? Apakah dari total jumlah RS itu sudah memadai atau masih ada RS lagi yang perlu dibangun lagi?

•

Berapa jumlah Puskesmas dan jumlah BP swasta maupun total keseluruhan di Propinsi / Kabupaten. Berapa diantaranya yang sudah menyediakan pelayanan untuk penderita

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HIV/AIDS? Berapa Puskesmas yang belum menyediakan pelayanan? Apakah masih ada Puskesmas yang perlu dibina menjadi Puskesmas Pelayanan Mandiri (PPM) atau Puskesmas Rujukan Mikroskopis (PRM)? Apakah dari total jumlah Puskesmas dan BP swasta itu sudah memadai atau ada yang perlu dibangun lagi? •

Berapa jumlah sarana pelayanan Laboratorium Diagnostik yang ada di seluruh Propinsi / Kabupaten yang ada dan berapa banyak yang sudah mampu menyediakan pelayanan untuk mendukung Diagnosa / Test HIV ? Apakah dari total jumlah Laboratorium di unit pelayanan kesehatan itu sudah memadai atau ada yang perlu dibangun lagi?

ii. Sumber daya Manusia di unit pelayanan Kesehatan •

Berapa jumlah tenaga Medis di Propinsi / Kabupaten pada saat ini? Dan berapa pula yang sudah dilatih untuk dapat melayani penderita HIV/AIDS? Apakah jumlah total tenaga Medis yang ada sudah memadai atau masih ada yang harus diadakan?

•

Berapa jumlah tenaga Paramedis di Propinsi / Kabupaten pada saat ini? Dan berapa pula tenaga paramedis dan tenaga lainnya yang sudah dilatih untuk dapat melayani diagnosa HIV/AIDS? Apakah jumlah total tenaga paramedis yang ada sudah memadai atau masih ada yang harus diadakan?

•

Berapa jumlah tenaga teknis Laboratorium di Propinsi / Kabupaten pada saat ini? Dan berapa pula jumlah tenaga teknis Laboratorium yang sudah dilatih untuk dapat melakukan pemeriksaan diagnostik HIV/AIDS? Apakah jumlah total tenaga Laboran yang ada sudah memadai atau masih ada yang harus diadakan?

•

Berapa jumlah tenaga farmasis di Propinsi / Kabupaten pada saat ini? Dan berapa pula jumlah tenaga farmasis yang sudah dilatih dan mampu memberikan pelayanan kefarmasian kepada penderita HIV/AIDS? Apakah jumlah total tenaga Farmasis yang ada sudah memadai atau masih ada yang harus diadakan?

•

Berapa jumlah tenaga logistik dan pengelola obat di Propinsi / Kabupaten pada saat ini? Dan berapa jumlah tenaga logistik dan pengelola obat yang sudah terlatih untuk dapat menjamin ketersediaan obat HIV/AIDS yang efektif dan efisien? Apakah jumlah total tenaga logistic dan pengelola obat yang ada sudah memadai atau masih ada yang harus diadakan?

•

Apakah ada buku / publikasi tertulis mengenai data – data tadi, bolehkah kami peroleh?

iii. Sarana dan prasarana •

Berapa jumlah Gudang / ruang penyimpanan yang ada untuk menyimpan pelbagai Komoditi yang ada dalam persediaan di Propinsi dan Kabupaten pada dewasa ini?

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•

Apakah masih ada kapasita penyimpanan yang masih dapat menampung komoditi untuk memenuhi kebutuhan persediaan yang makin berkembang? Dimanakah letak gudang – gudang penyimpanan tersebut?

•

Apakah kami dapat mengunjunginya, untuk mengetahui kapasitas dan kondisi penyimpanannya, administrasinya?

•

Apa status kepemilikan masing-masing gudang tersebut, siapa yang mengelola gudang – gudang tersebut?

•

Apakah gudang – gudang tersebut tersedia untuk penggunaan sementara saja atau memang diperuntukkan untuk keperluan program saja? Sehingga mampu digunakan untuk semua komoditi HIV/AIDS.

iv. System • Apakah Fungsi dan Peran dari setiap unit organisasi yang terkait dalam penanggulangan HIV/AIDS sudah bekerja secara efektif dan efisien dalam mencapai sasaran – sasaran yang telah ditetapkan? v. Sumber dana •

Apakah alokasi dana yang dibutuhkan dan kemampuan untuk memperoleh / menyediakan dana dapat terpenuhi?

iv. Waktu •

9.

Apakah alokasi ketersediaan waktu dalam renstra untuk mencapai sasaran- sasaran tadi cukup memadai?

Dengan memperhatikan semua tantangan dan kendala pengembangan sumber daya yang dimiliki dan yang dibutuhkan untuk mencapai sasaran dalam rencana strategis tersebut; upaya apa yang perlu diprioritaskan untuk mengatasi tantangan dan kendala yang dihadapi? Tantangan dan kendala mana yang paling menghadang pencapaian Sasaran Renstra ini? Bagaimana urutan skala prioritas yang telah ditetapkan dalam upaya mengatasi tantangan dan kendala tersebut?

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RENCANA OPERASIONAL Upaya Pembinaan pelayanan kesehatan yang dilakukan oleh Dinas Kesehatan dilakukan dengan: a. upaya menyediakan Technical assistance untuk unit pelayanan kesehatan baik untuk UPK Pemerintah maupun swasta, b. melaksanakan Quality Control terhadap penyediaan pelayanan oleh UPK tersedia untuk masyarakat, c. Penyediaan pelatihan untuk staf maupun petugas UPK d. Penyediaan obat dan Reagens untuk lembaga pelayanan Kesehatan. 10. Upaya mana yang menjadi prioritas pada tahun ini? v. Technical assistances • Program/ kegiatan technical assistance apa saja yang tersedia didalam di Propinsi / Kabupaten ini? • SDM untuk melakukan Technical asistance ini ada didalam Dinkes atau Dinas Kesehatan atau yang diperoleh dari Pusat atau Lembaga seperti WHO - lembaga NGO baik dalam atau luar negeri? • Program bantuan Technical assistance apa saja yang diprioritaskan pada saat ini?

•

Apakah sudah diidentifikasi kebutuhan akan program bantuan technical assistance yang direncanakan untuk pembinaan pelayanan kefarmasian atau pembinaan pengelolaan untuk mendukung penanggulangan HIV/AIDS, Logistik dan Distribusi? Pertanyaan ini disampaikan untuk mengantisipasi penyediaan Obat – alkes habis pakai – reagens dan komoditi lain yang pada saat ini tersebar dipelbagai unit/ tingkatan organisasi Pemerintahan serta akan makin besar tantangannya dalam waktu dekat ini?

vi. Quality Control

•

Program quality control, untuk menjaga ketersediaan pelayanan kesehatan yang bermutu kepada masyarakat program sudah melakukan upaya Monitoring dan Evaluasi (MONEV) baik yang bersifat internal maupun eksternal. Dari hasil Monev tersebut aspek apa yang peling menonjol yang diidentifikasi yang perlu memperoleh prioritas untuk ditindak lanjuti segera?

•

Apakah monev yang telah dilakukan juga dilakukan untuk bidang penyediaan komoditi yang dibutuhkan untuk menunjang penanggulangan HIV/AIDS , mengingat pengalaman menunjukkan bahwa “No drugs – No program” Rapid survey lalu sudah mengidentifikasi adanya kendala dan tantangan yang significant dan khusus untuk program HIV/AIDS aspek ini memperoleh perhatian yang khusus? (contoh: ARV – Obat – obat OI, TB, PMS, pencegahan penularan Ibu ke anak dalam kandungan, obat – obat paliatif – obat untuk Harm reduction pada Narkoba – Alat kesehatan habis pakai untuk menunjang Universal Precaution termasuk didalamnya Sarung tangan – desinfektan Chlorine –

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penyediaan alat sekali pakai, sarana pemusnahan yang aman – alat laboratorium habis pakai seperti Test Kit untuk HIV – TB – PMS – fungsi hati – Reagens untuk alat iagnostic CD4 counter ataupun menghitung Viral Load – Kondom untuk mencegah perluasan penularan baik untuk Pria dan Wanita)

vii. Training •

Program Kegiatan training apa yang tahun ini sedang dilakukan oleh Dinkes Propinsi / Kabupaten?

•

Apakah program untuk meningkatkan kemampuan Pengelolaan Obat atau komoditi HIV/AIDS dan khususnya fungsi Logistik / Distribusi komoditi HIV/AIDS sudah menjadi salah satu prioritas P2 di Propinsi/ Kabupaten ini?

viii. Pengadaan Obat dan Reagens Pengadaan Obat dan Reagens atau komoditi AIDS yang dibutuhkan. untuk mendukung program penanggulangan HIV/AIDS di tanah Papua ini, menurut hasil Rapid survey yang belum lama dilakukan ditanah Papua, telah menunjukkan bahwa Pengadaan komoditi ini terpecah dan menyebar dipelbagai tingkatan Pemerintah mulai dari Pusat – Propinsi – Kabupaten hingga pengadaan yang dilakukan oleh UPK, baik yang bersifat rutin atau karena keadaan yang amat mendesak. Pengadaan yang dilakukan oleh pelbagai unit organisasi ini juga melibatkan Gudang Farmasi di tingkat Propinsi Salah satu masalah yang amat penting dalam pengadaan Obat dan Reagens yang tersebar dipelbagai unit dan tingkatan organisasi ini adalah keterpaduan untuk melakukan sinkronisasi dan integrasi upaya perencanaan – pengadaan – distribusi dan pelayanan yang efektif (One hand and One door policy) untuk menjamin ketersediaan komoditi yang mendukung pelayanan VCT ataupun CST. ix PENGELOLAAN KOMODITI TERMASUK OBAT

Pada dasarnya unit organisasi mana yang bertanggung jawab untuk melaksanakan fungsi ini ?

Apakah ada TUPOKSINYA? Bolehkah kami memperolehnya?

Fungsi pengelolaan komoditi Seleksi untuk menetapkanan jenis – standard mutu komoditi •

Dalam rapid survey ditemukan pelbagai merk Rapid Test. Kebutuhan Lab yang tidak sesuai, kekurangan Obat. Pelbagai merk obat yang disediakan di UPK, komoditi yang tiba

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dengan masa kadaluarsa yang pendek, penanganan komoditi yang tidak sesuai standard, dan lain – lain. Siapakah yang seharusnya melakukan seleksi komoditi untuk HIV/AIDS ini dan menetapkan mutu untuk acuan pengadaan dan standarisasi serta pengawasan? Perencanaan kebutuhan • •

Komoditi apa saja yang diadakan ditingkatan Propinsi ini? Siapakah yang melakukan / unit organisasi mana saja yang terlibat dalam perhitungan dan perencanaan kebutuhan komoditi HIV/AIDS tersebut?

•

Apakah perencanaan kebutuhan komoditi HIV/AIDS ini dan pengadaannya dilakukan secara terpadu? atau terpecah – pecah tanpa koordinasi? (contoh: ARV – Obat – obat OI, TB, PMS, pencegahan penularan Ibu ke anak dalam kandungan, obat – obat paliatif – obat untuk Harm reduction pada Narkoba – Alat kesehatan habis pakai untuk menunjang Universal Precaution termasuk didalamnya Sarung tangan – desinfektan Chlorine – penyediaan alat sekali pakai, sarana pemusnahan yang aman – alat laboratorium habis pakai seperti Test Kit untuk HIV – TB – PMS – fungsi hati – Reagens untuk alat diagnostik CD4 counter ataupun menghitung Viral Load – Kondom untuk mencegah perluasan penularan baik untuk Pria dan Wanita)

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Sumber dana untuk pengadaan di Propinsi ini apakah memadai sehingga mampu menyelaraskan / menyetimbangkan kebutuhan menyeluruh untuk kebutuhan komoditi HIV/AIDS?

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Apakah anggarannya yang disediakan untuk pengadaan komoditi yang direncanakan tersebut dapat memenuhi kebutuhan?

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Apabila tidak memadai Sumber mata anggaran dan belanja mana yang dapat dijadikan alternatif untuk memenuhinya? (Misalnya: Mata anggaran dari anggaran Belanja Pemda khusus untuk belanja komoditi – untuk program HIV/AIDS – Belanja yang diperoleh dari ASKES – Pengadaan melalui program ASKESKIN – Pengadaan yang bersumber dari dana OTSUS – anggaran yang bersumber dari anggaran belanja operasional – anggaran ABT)

• Berapa anggaran yang telah disediakan sejak tahun pembentukannya? • Dapatkah kami memperoleh datanya? Penyimpanan dan Distribusi •

Siapa yang melakukan penyimpanan sementara komoditi tersebut sebelum disalurkan ke unit pelayanan kesehatan di Propinsi atau Kabupaten? (Penyimpanan dapat dilakukan didalam kantor petugas karena jumlah sedikit – dititipkan digudang umum Dinas Kesehatan dibawah KTU- dititipkan di Gudang Immunisasi atau digudang Farmasi Kabupaten / Propinsi atau bahkan di Gudang Obat Rumah sakit)

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Apakah kegiatan distribusi dilakukan secara teratur – efektif dan efisien? (Distribusi dilakukan sesuai kebutuhan – waktunya juga tidak ditentukan, distribusi dilakukan secara teratur dan berjadwal )

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Sistem distribusi yang digunakan sering tidak didukung dengan penggunaan formulir yang standard dan kurang menerapkan ketentuan pencatatan dan pelaporan yang baku. Permintaan sering dibuat karena keadaan yang mendesak, karena sistem pengendalian persediaan efektif belum ada untuk semua komoditi habis pakai ini. Apakah sudah ada upaya untuk merumuskan pedoman sistem distribusi yang terpadu? Sebab permintaan untuk mengisi ulang pada dewasa ini ada yang disampaikan ke Pusat. Propinsi, bahkan ada di Kabupaten ataupun ke internal organisasi UPK sendiri.

•

Apakah sistem informasi pengelolaan komoditi tersebut sudah dinilai berjalan dengan baik, sehingga perencanaan dan penyediaan komoditi tersebut dapat dilaksanakan secara efektif dan efisien? (Ada laporan pemakaian, ada laporan persediaan dan pemakaian, laporan berisi persediaan awal dan akhir periode serta data penerimaan dan pemakaian, dsb.)

• Apakah ada laporan periodik yang disampaikan kepada Dinas mengenai ketersediaan komoditi yang terkait dengan kegiatan program AIDS secara periodik?

• Dimanakah lokasi penyimpanan sementara untuk komoditi itu di Propinsi? • Bolehkah kami mengunjunginya? Dimana lokasi dan alamatnya? Siapa penanggung jawabnya? • Apakah ada pedoman mengenai bagaimana mengendalikan persediaan komoditi tersebut? Apakah sudah ada dalam pedoman juga? PENGGUNAAN KOMODITI •

Khusus untuk pasca penggunaan komoditi terutama komoditi yang tercemar specimen HIV/AIDS nampak belum ada perlengkapan standard dan pedoman standard yang diterapkan untuk pemusnahan dan pembuangan komoditi habis pakai ini, bahkan dibeberapa wilayah dibuang tanpa diproses. Mengingat bahaya penularan ini apakah ada pedoman untuk masalah ini? Dan apakah sudah ada penetapan peralatan dan program penyediaan alat yang standard?

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Penggunaan perlengkapan alat untuk mendukung Universal precaution, masih terasa belum memadai baik di Laboratorium – dalam pelaksanaan pelayanan VCT maupun CST di RS. Apakah aspek ini sudah diidentifikasi dan diambil langkah efektif untuk memastikan tersediaannya komoditi ini dan penggunaannya? Apakah ada rencana untuk

menyediakan Mobile VCT? Kalau ada dimana ? •

Untuk pelayanan Obat (Dispensing) khusus untuk obat ARV ternyata demikian banyak interaksi obat yang harus dicermati agar pengobatan dapat dilakukan secara optimal, juga didalam monitoring efek samping obat, ketidak mampuan obat dalam menekan viral load atau menaikkan CD4, demikian pula dengan Quality assurance baik untuk obat maupun reagensnya ; apakah dalam hal ini petugas Lab atau Apoteker telah dilibatkan dan dididik untuk dapat mendukung POKJA HIV/AIDS terutama di rumah sakit maupun di Kabupaten?

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Bagaimana dengan pengembangan program TB/ HIV di Propinsi ini?

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Apakah ada pengawasan Mutu dan apakah langkah – langkah yang dilaksanakan dalam penyimpanan komoditi HIV/AIDS ini dilaksanakan dengan mempertimbangkan Jaminan Mutu

ESTIMASI PROYEKSI KASUS HIV POS DAN AIDS

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Semua upaya tersebut pada dasarnya mengacu pada proyeksi dari estimasi jumlah penyebaran kasus HIV pos dan AIDS di masyarakat. Proyeksi ini amat tergantung dari keberhasilan program pencegahan melalui upaya pada perubahan sikap dan pola hidup masyarakat dalam pencegahan penularan HIV/AIDS. Apakah sudah tersedia proyeksi jangka panjang sesuai dari estimasi jumlah penderita yang tertular HIV dan menderita HIV/AIDS?

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Dapatkah kami memperoleh data – data serta publikasi tertulis yang ada mengenai hal ini untuk Tanah Papua ini? Sebab perencanaan jangka panjang untuk penyediaan dan pembiayaan komoditi HIV/AIDS serta sistem pengelolaannya akan amat terkait dengan data ini.

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Apakah sudah ada pihak yang sudah menganalisa dan merumuskan tantangan dan masalah yang dapat dijumpai dimasa mendatang ini?

PELAYANAN KESEHATAN PROGRAM HIV/AIDS Apa program pelayanan HIV/AIDS yang tersedia untuk masyarakat pada dewasa ini di Unit pelayanan Kesehatan? Program VCT • • • •

Akses pelayanan kesehatan khususnya VCT tersedia dimana saja pada dewasa ini? Kegiatan utama apa saja yang dilaksanakan pada dewasa ini, perluasan dan peningkatan, pengembangan?(Mobile VCT misalnya atau apa?) Berapa jumlah unit kesehatan yang telah memberi pelayanan VCT? Berapa Puskesmasatau Poliklinik swasta – berapa RS Pemerintah atau swasta dan apakah ada NGO yang ikut membantu pada saat ini? Siapa yang akan melakukan pelatihan dan berapa lama magangnya? Bolehkah kami memperoleh rencana tertulisnya? Apakah ada NGO yang ikut membantu?

Program CST • • •

Apakah perlu perluasan akses pelayanan kesehatan seperti pelayanan CST ini ditambah? Berapa Rumah sakit Pemerintah yang ada dan berapa RS swasta? Berapa lagi yang direncanakan dikembangkan? Apakah ada sistem pelayanan rujukan untuk pelayanan CST ini?

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• • •

Bagaimana sistem pembinaan rujukan pelayanan ini? Mana yang rujukan dan mana yang satelit? Untuk melaksanakan pembinaan teknis ini , siapa yang melakukannya, berapa lama dan siapa yang akan melakukan pelatihan dan menyediakan pelatihan magang? Apakah ada NGO yang membantu?

PELAYANAN OLEH MASYARAKAT ix. Selain lembaga pelayanan Kesehatan Pemerintah yang bergerak dibidang kesehatan, siapa yang melakukan pembinaan pelayanan HIV/AIDS oleh masyarakat? (dibidang sosial kemasyarakatan dan komunitas sebaya), x. Siapa yang menjadi pembinanya? Apa hubungan antara kelompok masyarakat yang menyediakan pelayanan kepada penderita HIV/AIDS ini dengan pelayanan Kesehatan? xi. Siapa yang memotivasi sampai terbentuknya komunitas sebaya yang memperhatikan aspek sosial kemasyarakatan? xii. Pelayanan untuk penderita HIV/AIDS ini apa lagi yang ada? Hospice , = atau apa lagi yang telah ada? xiii. Apakah kami dapat memperoleh datanya? EPIDEMIOLOGI Menurut estimasi / hasil survailans di Propinsi berapa kecepatan perkembangan jumlah penderita HIV di Propinsi ini dari tahun - ketahun? i. Di pengalaman negara – negara lain ada profil dalam setiap kegiatan yang dapat dipergunakan untuk mengestimasi temuan HIV pos. Apakah di Propinsi ini sudah ada indikator untuk melakukan perbandingan antara jumlah kunjungan dan temuan HIV pos? ii.

Bagaimana mengenai jumlah penderita AIDS pada dewasa ini? Berapa perkembangannya di Propinsi / Kabupaten ini?

iii.

Dibidang pengobatan ada berapa rejimen pengobatan untuk penderita HIV/AIDS? Apakah ada profile penggunaan rejimen obat ARV di Propinsi?

iv.

Bagaimana dengan kasus – kasus penyakit yang terkait dengan HIV/AIDS seperti OI – PMS – TB dan lain2? Berapa banyak dan mana yang paling sering dijumpai di Propinsi / Kabupaten? Obat – obat apa yang disediakan oleh Propinsi / Kabupaten untuk penyakit tersebut? Siapa yang melakukan pengadaan dan siapa pula yang merencanakan penyediaan obat – obat tersebut?

v.

Penyakit terkait dengan HIV mana yang dijumpai di Propinsi / Kabupaten ini?

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vi.

Siapa dan bagaimana perencanaan dan penyediaan obat Kotrimoksasl baik untuk anak dan dewasa? Apakah ketersediaan obat ini dimonitor atau dilaporkan?

vii.

Apakah kami dapat memperoleh datanya?

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PANDUAN WAWANCARA BAGI SURVEYOR LABORATORIUM KLINIK RUMAH SAKIT Penyakit AIDS pertama kali ditemukan di Indonesia di Propinsi Kalimantan Barat pada tahun 1992, sejak itu ditemukan pelbagai temuan kasus dipelbagai propinsi di Indonesia. Subdit HIV/AIDS dibentuk dan melakukan upaya monitoring dan membentuk team ahli untuk memantau perkembangannya sambil melakukan pelbagai upaya untuk mengenal penanggulangan AIDS di Indonesia. Penunjukkan 25 RS pertama merupakan salah satu langkah pertama tahun 2003 yang diharapkan akan mencapai 300 RS pada tahun 2009 yang akan datang. Sementara itu pada tahun 2006 melalui Peraturan Presiden no 75 tahun 2006 ditingkat Nasional telah dibentuk Komite Nasional Penanggulangan AIDS untuk melakukan upaya – upaya terpadu yang dipimpin Menko Kesra dengan Menteri Kesehatan dan Menteri Dalam Negeri sebagai intinya. KPA dimaksudkan untuk melakukan koordinasi upaya secara Nasional dan berjenjang ke bawah untuk melakukan koordinasi penanggulangan penyakit AIDS yang memiliki pelbagai dimensi aspek permasalahan baik politik – social kemasyarakatan – hokum – ekonomi - agama disamping kesehatan. Disetiap Pemda dibentuk kemudian KPA untuk mendampingi Gubernur dan Bupati/ Walikota dalam melakukan penanggulangan AIDS yang memiliki demikian banyak dimensi permasalahan.

Daftar pertanyaan: ORGANISASI 1. Organisasi ini berada dibawah unit organisasi mana dalam Rumah Sakit/ Puskesmas 2. Bagaimana struktur organisasi Laboratorium ini? 3. Siapa penanggung jawab di Laboratorium ini? 4. Berapa orang staf yang pernah dilatih untuk pemeriksaan PMS – HIV/AIDS – TB – Malaria? Kapan pelatihan tersebut dilaksanakan dan lembaga mana yang melatihnya? Apa pendidikan peserta latih tersebut dan sudah berapa lama mereka bekerja di Laboratorium> KEMAMPUAN PEMERIKSAAN 5.

Dalam rangka mendukung program pengendalian penyakit HIV/AIDS pemeriksaan apa saja yang dapat dilakukan di Laboratorium ini? Diagnosa HIV, PMS, TB, Malaria, Kehamilan?

6. Apakah ada pedoman pemeriksaan secara tertulis yang dimiliki Laboratorium? Baik untuk metoda pemeriksaan maupun untuk Universal precaution?

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7. Apakah semua perlengkapan yang disebutkan dalam pedoman tersebut tersedia? Alat dan perlengkapan apa saja yang dituntut? Apakah perlengkapan tersebut tersedia? Apakah ada komponen habis pakai dalam melaksanakan pemeriksaan tersebut? 8. Untuk melakukan pemeriksaan – pemeriksaan tersebut, Reagens apa yang dipergunakan? Apakah reagens tersebut dibuat disini atau dipasok oleh unit organisasi lain? Apakah anda memperoleh alokasi persediaan tanpa diminta> Atau ada mekanisme permintaan untuk memperoleh persediaan Reagens tersebut? Bagaimana prosedur permintaannya? 9. Apakah reagens tersebut Basah – kering ? Apakah ada masa kadaluarsa dari reagens ini? Bagaimana caranya untuk mengetahui apakah reagens tersebut masih baik atau sudah rusak? Apakah ada metoda pengujian untuk reagens, apabila kita ragu? Atau kemana pengujian ini dilakukan? Atau apakah ada sampling yang dilakukan oleh Balai Laboratorium Kesehatan ? 10. Specimen apa yang diperiksa? Apa yang dibutuhkan untuk mengambil/menampung specimen pemeriksaan? Apakah sarana untuk menampung atau mengambil specimen tersebut penggunaannya untuk sekali pakai/ atau dapat dipergunakan berulang? 11. Bagaimana dan darimana pasokan sarana untuk mengambil/ menampung specimen tersebut diperoleh? 12. Bagaimana prosedur untuk mengamankan pembuangan specimen tersebut sehingga tidak mencemari lingkungan? Apakah ada pedoman untuk melakukan pengamanan terhadap semua specimen yang sudah tidak dipakai? 13. Apakah ada bahan/ alat yang digunakan untuk melakukan metoda pengamanan tersebut? Bagaimana mekanisme pemusnahan alat / specimen tersebut dan cara pembuangannya? Apakah ada tempat pembuangan khusus atau tempat pembuangan limbah umum? 14. Dalam melakukan prosedur pengamanan dan pemusnahan tersebut, apakah ada bahan habis pakai atau alat yang dipergunakan? Apakah alat dan bahan tersebut tersedia dan berfungsi dalam Lab. Ini? 15. Apakah ada cross examination yang dilakukan oleh Laboratorium independen/ rujukan? Apakah ada umpan balik atas mutu pemeriksaan Lab. Ini? Apakah ada mekanisme atau prosedur untuk melakukan sampling ini? Apakah sampling dilakukan oleh Lab. Tersebut atau kita yang mengirimkannya?

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16. Semua komoditi habis pakai yang dipergunakan dalam pemeriksaan Laboratorium ini memiliki persediaan? Apakah ada ketentuan/ kebijakan untuk menetapkan berapa jumlah persediaan yang harus ada? Atau apakah ada kebijakan untuk mengajukan permintaan apabila persediaan sudah mencapai tingkat persediaan tertentu? Atau kebijakan untuk membatasi persediaan tersebut? Dimana persediaan tersebut ditampung? Apakah ada pencatatan mengenai persediaan yang ada dalam tempat penyimpanan ini? (Bolehkah kami melihatnya? Berapa daya tampungnya?rekam melalui gambar?) 17. Bagaimana dengan pencatatan hasil pemeriksaan dan pelaporannya> Siapa yang melakukannya? Berapa jenis dan jumlah pemeriksaan yang dapat dilakukan oleh Laboratorium ini? Dapatkah kami memperoleh datanya? 18. Apakah ada data tahunan mengenai jumlah pemeriksaan yang terkait dengan pemeriksaan diagnosa HIV/AIDS? Berapa lama waktu untuk melakukan pemeriksaan HIV? TB / PMS? Berapa waktu yang dibutuhkan untuk melakukan pemeriksaan hingga ke hasil pemeriksaan tersebut dibuat? 19. Dari mana komoditi habis pakai tersebut diperoleh? Apakah melalui pengadaan sendiri atau melalui mekanisme pengisian ulang?

20. Apa masalah dan kendala yang dihadapi dalam penyediaan komoditi habis pakai di Laboratorium ini? Kemampuan dari pemeriksaan untuk HIV/AIDS ini dibatasi oleh kemampuan alat atau staf pemeriksanya?

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PANDUAN WAWANCARA BAGI SURVEYOR GUDANG / GUDANG FARMASI Penyakit AIDS pertama kali ditemukan di Indonesia di Propinsi Kalimantan Barat pada tahun 1992, sejak itu ditemukan pelbagai temuan kasus dipelbagai propinsi di Indonesia. Subdit HIV/AIDS dibentuk dan melakukan upaya monitoring dan membentuk team ahli untuk memantau perkembangannya sambil melakukan pelbagai upaya untuk mengenal penanggulangan AIDS di Indonesia. Penunjukkan 25 RS pertama merupakan salah satu langkah pertama tahun 2003 yang diharapkan akan mencapai 300 RS pada tahun 2009 yang akan datang. Sementara itu pada tahun 2006 melalui Peraturan Presiden no 75 tahun 2006 ditingkat Nasional telah dibentuk Komite Nasional Penanggulangan AIDS untuk melakukan upaya – upaya terpadu yang dipimpin Menko Kesra dengan Menteri Kesehatan dan Menteri Dalam Negeri sebagai intinya. KPA dimaksudkan untuk melakukan koordinasi upaya secara Nasional dan berjenjang ke bawah untuk melakukan koordinasi penanggulangan penyakit AIDS yang memiliki pelbagai dimensi aspek permasalahan baik politik – social kemasyarakatan – hokum – ekonomi - agama disamping kesehatan. Disetiap Pemda dibentuk kemudian KPA untuk mendampingi Gubernur dan Bupati/ Walikota dalam melakukan penanggulangan AIDS yang memiliki demikian banyak dimensi permasalahan.

Daftar pertanyaan:

Pengertian Gudang Ruang simpan atau Gudang obat/ alkes adalah tempat sementara penyimpanan obat/ alkes sebelum digunakan dan merupakan tempat cadangan persediaan untuk melakukan pengisian ulang obat/ alkes ke unit pelayanan kesehatan sehingga senantiasa mampu mendukung pelayanan obat/ alkes secara berkesinambungan dan teratur alkes dalam jumlah dan jenis serta mutu yang ditetapkan. Tempat penyimpanan sementara ini mampu menjaga keamanan obat dari pelbagai ancaman seperti pencurian, kerusakan karena factor iklim, kerusakan karena hama, kebakaran atau musibah lainnya. Tempat ini juga mampu melakukan pelayanan secara cepat – akurat dan efisien/ ekonomis untuk pelayanan penerimaan barang dan pencarian kembali komoditi yang dibutuhkan, pelayanan penyediaan barang sesuai permintaan. Pelayanan ini dikelola oleh tenaga professional, kebutuhan pelayanan dapat disediakan secara professional sehingga mendukung pelayanan Logistik dan Distribusi yang bermutu – efektif dan efisien.

KEBIJAKAN DAN KETENTUAN GUDANG •

Apakah tersedia pedoman pelayanan gudang yang efektif dan efisien? Kalau ada apakah dapat kami copy atau peroleh?

Catatan:

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Pedoman berisi rancang bangun gudang yang benar, sehingga pengelola Gudang mampu melakukan pelayanan dengan waktu – mutu pelayanan dan biaya operasional pelayanan yang ekonomis dan efektif . Apakah ada pedoman untuk pengelolaan Logistik dan Distribusi yang memungkinkan tersedianya pelayanan Logistik dan Distribusi yang teratur , berkesinambungan serta efektif dan efisien? Kalau ada apakah dapat kami copy atau peroleh? Catatan: Pedoman tersebut dimaksudkan agar pengelola Logistik dan distribusi mampu menjaga tingkat persediaan yang aman sehingga memungkinkan pelayanan isi ulang obat/ alkes secara teratur - berkesinambungan – efisien / ekonomis untuk mengisi ulang persediaan di unit pelayanan kesehatan yang berada dibawah tanggung jawabnya

FUNGSI DAN KAPASITAS GUDANG 1. Fungsi pelayanan Gudang merupakan salah satu fungsi vital dari proses pemasokan dalam mata rantai proses pengelolaan Logistik setelah fungsi pengadaan dilaksanakan Unit organisasi manakah yang mengelola pelayanan Gudang ini ditingkat Dinas Kesehatan Prop./ Kab/RS/Puskesmas? 2. Apakah sarana Gudang ini memiliki kemampuan untuk menyimpan komoditi yang dibutuhkan untuk jangka waktu yang telah ditetapkan? (Mulai dari kedatangan komoditi ini sampai pengisian ulang pada periode mendatang) Berapa lama periode pengisian ulang komoditi ini ? (rata – rata sebulan – triwulan – semester atau tahunan) 3. Berapa jenis komoditi yang sekarang ditampung? Dari program nama saja komoditi tersebut? 4. Dalam perkembangan apakah volume komoditi tersebut bertambah dalam jenis atau jumlahnya? Kalau ya, apakah daya tampung nya masih memadai? Berapa volume daya simpan Gudang tersebut? (Mintalah copy Laporan Mutasi Gudang tahunan dan daftar patokan harga)

5. Apabila perlu dikembangkan apakah lahan yang ada masih dapat digunakan? Berapa luas lahan? Rekam denah lahan dan gudang? Lengkap dengan lokasinya ! 6. Siapakah yang memiliki Gudang tersebut berikut lahannya? Dinas Kesehatan? Dan diserahkan pengelolaannya kepada unit organisasi manakah?

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ORGANISASI GUDANG

7. Apakah ada dokumen yang menyatakan peruntukan penggunaan Gudang? Siapa yang menetapkan peruntukkan Gudang tersebut? 8.

Siapa yang bertanggung jawab untuk melakukan pemeliharaan atau mengusulkan perluasan Gudang tersebut apabila kapasitanya sudah tidak memadai? UNIT ADMINISTRASI GUDANG

9. Unit administrasi memiliki buku Register untuk barang keluar masuk – mengarsipkan semua doukmen bukti penerimaan barang – dokumen bukti pengeluaran barang – semua surat perintah penerimaan – surat pengantar – surat perintah pengeluaran – semua dokumen transaksi internal (pindah lokasi gudang/ rusak/ hilang/ kadaluarsa, tembusan surat untuk pemusnahan dan penghapusan). Apakah semua dokumen itu tersedia, mana yang tidak tersedia? tolong direkam? 10. Apakah ada lokasi penyimpanan barang dimonitor dan dicatat? 11. Apakah ada prosedur pemutakhiran data persediaan setiap akhir tahun atau lebih dari 1 kali dalam setahun? Berapa kali? 12. Formulir apa yang digunakan untuk pengisian ulang persediaan dan formulir permintaan> Apakah pemilik barang memberikan persetujuan? 13. Apakah ada laporan mutasi Gudang? Laporan tersebut dibuat pada akhir tiap periode? Berapa lamanya satu periode laporan itu? Apakah kami dapat memperoleh copynya?

UNIT ORGANISASI PENGELOLA LOGISTIK 14. Siapa penanggung jawab Logistik atas komoditi yang disimpan dalam Gudang tersebut? ( pejabat yang boleh menyetujui permintaan dan pengeluaran barang dari Gudang tersebut, sebutkan jabatan dan unit organisasinya). Apakah jabatan ini dirangkap dengan jabatan / fungsi lain? 15. Apakah yang bersangkutan juga bertanggung jawab terhadap kesinambungan persediaan tersebut sehingga senantiasa mampu memasok unit pelayanan kesehatan yang melakukan pelayanan kesehatan? 16. Apakah pejabat Logistik tersebut memiliki staf yang senantiasa melakukan monitoring atas tingkat persediaan (kemampuan memasok), jumlah , jenis dan mutu, umur kadaluarsa

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komoditi yang berada dibawah tanggung jawabnya? Apakah ada kartu stok yang mampu menyediakan data jumlah, jenis, mutu/kondisi barang dan umur kadaluarsa komoditi tersebut? Bolehkah kami memperoleh contohnya? 17. Apakah pejabat Logistik tersebut memonitor indikator kecukupan secara periodik? Berapa lamanya periode tersebut? Mingguan, bulanan, tribulanan, semesteran, tahunan? Kepada siapakah ia melaporkan keadaan persediaan Logistik tersebut? 18. Apabila persediaan komoditi tersebut menipis, bagaimana ia mengajukan pengisian ulang persediaan komoditi tersebut? Kepada unit organisasi manakah? Jabatan apa? 19. Apakah ia mengendalikan persediaan di gudang tersebut hingga mampu menetapkan/ mengantisipasi kebutuhan komoditi hingga pengisian berikutnya? Data apa yang digunakan untuk menetapkan volume/ jumlah komoditi yang diminta? 20. Siapakah yang melakukan perhitungan perencanaan pengadaan ke pemasok? Apakah juga dilaksanakan oleh pejabat Logistik diunit organisasi manakah? Pengadaan tersebut dilaksanakan selang periode berapa lama? 21. Data – data apa saja yang digunakan untuk melakukan perencanaan kebutuhan tersebut? Dapatkah kami memperoleh contohnya? 22. Apakah dalam melakukan pengadaan tersebut ada klasifikasi komoditi sesuai dengan tingkat kepentingannya? Atau volume penggunaannya? Atau harganya? Volume nilai belanjanya? Dapatkah kami memperoleh klasifikasinya? 23. Upaya apa yang harus dilakukan apabila alokasi anggaran belanja komoditi terbatas? Sumber – sumber anggaran belanja apa lagi yang tersedia? Apakah selalu dapat diupayakan, mengingat pentingnya komoditi tersebut dalam pelayanan kesehatan kepada masyarakat? 24. Bagaimana klasifikasi ini digunakan untuk menetapkan jumlah dan jenis komoditi yang diminta, apabila jumlah anggaran belanja komoditi terbatas? 25. Apabila ternyata jumlah yang dipesan untuk diadakan tidak memadai, langkah apa yang akan dilakukannya? 26. Bagaimana dengan patokan harga untuk menghitung kebutuhan alokasi anggaran atau menghitung jumlah permintaan agar dapat terpenuhi, siapa yang menetapkan atau bagaimana patokan harga ini diperoleh atau ditetapkan? Siapa yang menetapkan? Apakah kami dapat memperoleh daftar patokan harga tersebut? 27. Apakah diperkenankan adanya peminjaman barang komoditi? Apabila ada unit pelayanan yang membutuhkan segera dan di unit lain tersedia ? Bagaimana pembiayaan relokasi tersebut?

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28. Apakah unit Logistik menetapkan persediaan cadangan untuk mengantisipasi peningkatan permintaan? Berapa persediaan yang ditetapkan? 29. Apakah unit Logistik juga menetapkan cadangan untuk mengantisipasi keterlambatan pengisian ulang persediaannya> Berapa persediaan yang ditetapkan? Apakah data – data yang digunakan untuk menetapkan persediaan cadangan tersebut? 30. Apakah Logistik menetapkan persyaratan masa kadaluarsa untuk barang yang masuk kedalam persediaan atau untuk barang yang akan didistribusikan? 31. Apabila jumlah persediaan yang ada digudang terbatas maka pedoman apa yang digunakan untuk menetapkan alokasi distribusinya/ permintaannya? 32. Berapa jumlah pelayanan yang terjadi dalam waktu setahun? Pelayanan pengisian ulang? Pelauyanan Permintaan? Pelayanan Penataan ulang? Pelayanan Re-distribusi? Pelayanan pemusnahan barang dan penghapusan barang? 33. Berapa staf yang melaksanakan pelayanan di Gudang tersebut? Bagaimana struktur organisasinya? 34. Unit organisasi mana yang melakukan pemusnahan? Apa sudah pernah dilakukan? 35. Berapa rata – rata nilai barang yang rusak atau kadaluarsa barang di gudang setiap tahun? Berapa nilai barang yang tidak bergerak dalam setahun? Apakah barang yang tidak bergerak untuk suatu periode waktu tertentu dimonitor? Apakah ada barang yang masa kadaluarsanya setahun atau kurang dalam daftar permintaan isi ulang? 36. Bagaimana ketentuan yang berlaku apabila komoditi yang didiustribusikan rusak/ kadaluarsa? Apa ketentuan tersebut tertulis> Apakah ada kewajiban dari Logistik untuk memberitahukan unit yang dilayaninya mengenai komoditi yang mendekati atau sudah kadaluarsa dalam waktu dekat? 37. Siapa yang melakukan pelayanan pemberitahuan dan memonitor dan melaksanakan mutu pelayanan ini? 38. Siapa yang menetapkan jenis komoditi yang ditarik/ dihentikan atau baru untuk disediakan logistiknya? UNIT ORGANISASI PENGADAAN/ PEMBELIAN 39. Berapa lama yang dibutuhkan sejak permintaan tersebut disampaikan sampai komoditi tersebut tiba digudang?

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40. Berapa lama proses pengadaan tersebut berlangsung? Ketentuan apa yang dipakai? Apakah kami dapat memperolehnya? 41. Apakah ada penetapan persyaratan mutu – jenis – kemampuan – khasiat – ukuran – takaran – masa kadaluarsa – umur teknis – jaminan yang dibutuhkan? Siapa yang menetapkan persyaratan tersebut? Apakah mengikuti persyaratan umum atau sesuai dengan persyaratan yang ditetapkan oleh pemakai? 42. Pengadaan / pembelian tersebut mengikuti ketentuan apa? 43. Proses pembelian tersebut menggunakan metoda apa saja? 44. Apakah pemasok yang ada tersedia di Pusat /Propinsi/ Kabupaten? 45. Kapan proses pengadaan tersebut dimulai dan siapa yang menetapkan waktunya? Panitya pengadaannya? Bagaimana struktur organisasi Panitya dan siapa yang menetapkan? OBSERVASI GUDANG • • •

• • • • • • •

Rekam cara penataan barang digudang Rekam tempat penyimpanan barang rusak/ kadaluarsa digudang Rekam sarana untuk menyesuakan persyaratan simpan, catat alat dan kemampuan alat yang mengendalikan peryaratan penyimpanan? AC, dehumidifier , Ventilating Fan, Roof Fan kesinambungan tenaga penggerak dan kemampuannya – alat monitoring suhu – kelembababn dan catatan monitoringnya Rekam sarana kerja untuk relokasi didalam gudang – sarana transportasi untuk distribusi Peta penyimpanan Gudang Sarana pengamanan terhadap pencurian – kebakaran Musibah alam apa yang pernah terjadi yang mengancam penyimpanan, banjir , gempa bumi dll Akses gudang oleh alat transportasi umum, fasilitas penerimaan barang / karantina dan fasilitas ruang distribusi / penyimpanan barang rusak? Rekam luas lahan dan kapasita Gudang Mintalah copy pedoman pelayanan Gudang dan pelayanan Logistk – Volume / daftar permintaan isi ulang tahunan selama 4 tahun?

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PEDOMAN WAWANCARA UNTUK POKJA HIV/AIDS DI RUMAH SAKIT Penyakit AIDS pertama kali ditemukan di Indonesia di Propinsi Kalimantan Barat pada tahun 1992, sejak itu ditemukan pelbagai temuan kasus dipelbagai propinsi di Indonesia. Subdit HIV/AIDS dibentuk dan melakukan upaya monitoring dan membentuk team ahli untuk memantau perkembangannya sambil melakukan pelbagai upaya untuk mengenal penanggulangan AIDS di Indonesia. Penunjukkan 25 RS pertama merupakan salah satu langkah pertama tahun 2003 yang diharapkan akan mencapai 300 RS pada tahun 2009 yang akan datang. Sementara itu pada tahun 2006 melalui Peraturan Presiden no 75 tahun 2006 ditingkat Nasional telah dibentuk Komite Nasional Penanggulangan AIDS untuk melakukan upaya – upaya terpadu yang dipimpin Menko Kesra dengan Menteri Kesehatan dan Menteri Dalam Negeri sebagai intinya. KPA dimaksudkan untuk melakukan koordinasi upaya secara Nasional dan berjenjang ke bawah untuk melakukan koordinasi penanggulangan penyakit AIDS yang memiliki pelbagai dimensi aspek permasalahan baik politik – social kemasyarakatan – hokum – ekonomi - agama disamping kesehatan. Disetiap Pemda dibentuk kemudian KPA untuk mendampingi Gubernur dan Bupati/ Walikota dalam melakukan penanggulangan AIDS yang memiliki demikian banyak dimensi permasalahan. Sejak 14 Agustus 2006 Gubernur Papua menyerukan penanggulangan AIDS di tanah Papua yang harus dilaksanakan secara menyeluruh, dan bahwa Penanggulangan AIDS merupakan salah satu agenda Pemerintah yang mendapat prioritas.

RAPPORT Perkenalan: • • • •

Perkenalkan diri dan tim Jelaskan maksud dan tujuan serta kemungkinan waktu yang akan dipakai Berikan kesempatan untuk menanggapai Bincang – bincang ringan untuk membentuk iklim yang santai

PERTANYAAN WAWANCARA: A. ORGANISASI • Kapan pembentukan POKJA HIV/AIDS di Rumah sakit ini? • Bagaimana struktur organisasinya? Apa kita bias memperoleh gambar struktur organisasinya? • Profesi apa saja / jabatan apa saja yang membangun POKJA ini? • Apakah komponen farmasi ada/ kalau tidak ada tanyakan mengapa? • Jelaskan perannya sehubungan dengan makin banyaknya interaksi obat dengan obat ARV. Oleh karena ARV amat vital untuk penderita HIV, maka interaksi yang mengurangi atau merugikan penderita perlu dicegah. Mengingat obat ARV ini bekerja di hati, maka interaksi dengan obat lain demikian banyak. Untuk ini sebaiknya komponen farmasi ada yang disertakan dan dididik/ dilatih/ dimuthakirkan dengan informasi terakhir, sehingga dapat berkontribusi dalam dispensing obat dan menjadi sumber informasi bagi POKJA. Disarankan menjadi Pusat Informasi untuk Obat ARV, pusat komunikasi dan pusat untuk pencatatan effek samping maupun efektivitas obat. 111


B. PEMERIKSAAN VCT Perhatikan dalam struktur tadi apabila sudah ada tim VCT, maka pertanyaan diarahkan kepada tim VCT. • Berapa besar timnya dan siapa ketua/koordinatornya? Apakah ada jadwal kegiatannya atau sudah rutin tiap hari> • Apakah anggota tim ini bekerja paruh waktu atau penuh? • Apakah ada kegiatan Mobile VCT bagaimana cara kerjanya dan kemana wilayahnya atau kelompok mana? • Berapa orang teamnya dan komponen dan sarana bagaimana dengan Testingnya? • Apakah ada LSM yang melakukan penyuluhan dan mengorganisir pertemuan VCT ini? • Dari kegiatan tersebut apakah masih diarahkan pada kelompok masyarakat berisiko tinggi atau sudah diarahkan kepada masyarakat umum?/ Dari catatan yang sudah kami peroleh selain kelompok berisiko tinggi (PSK) juga ibu Rumah Tangga dan profesi yang tidak termasuk kelompok berisiko tinggi ditemukan. Sehubungan dengan kondisi ini apakah ada pengarahan dari tim VCT kepada LSM? • Untuk memastikan agar tidak ada kekecewaan dari mereka yang hadir untuk VCT< berapa waktu yang dibutuhkan untuk melakukan VCT ini? Terutama untuk mereka yang berisiko tinggi yang sudah memperoleh penyuluhan? Dan berapa waktu yang dibutuhkan untuk mereka yang dating secara sukarela/ coba – coba atau belum dibekali penyuluh? • Untuk Councellor pre dan post test apakah ada rekaman waktu? • Bagaimana dengan waktu dan perlengkapan testing? Apakah Universal precaution juga diterapkan dalam pengambilan specimen dan pemeriksaan? Bagaimana dengan penyiapan jumlah Rapid Test dan bagaimana agar mutu Rapid Test dapat dipertahankan? • Apakah pada pemeriksaan tersebut terutama untuk mereka yang berisiko tinggi dilakukan juga pemeriksaan IMS (Infeksi Menular Seksual)? Atau ada rujukan untuk temuan kasus IMS – Ibu Hamil – penyakit TB dari klinik/ puskesmas yang belum melakukan VCT disekitarnya? • Bagaimana dengan pemusnahan dan pembuangan specimen dan alat yang terpapar specimen? Peralatan apa saja yang dibutuhkan? Apakah sudah ada konsep/ pemikiran VCT toolkit untuk kegiatan Mobile VCT? • Bagaimana dengan hasil VCT baik yang stasioner (tetap dan tidak bergerak) dan bagaimana dengan hasil dari VCT yang bergerak/ mobile atau VCT ditempat outreach tetap? Kumpulkan data/jumlah kunjungan / /jumlah yang mengikuti councelling/ pra dan pasca testing , jumlah yangyang ikut testing, berapa diantara yang positif dan undetermined? Apakah dijumpai yang sudah ada reaksi dan perlu dirujuk? C. PEMERIKSAAN CST •

Kapan tim ini terbentuk?

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Siapa saja yang termasuk dalam tim ini? Komponen profesi apa saja yang dilibatkan dalam team ini? Apakah ada pertemuan monev yang rutin dari team ini> kapan saja/ frekuensinya? Untuk mendukung tim pokja HIV/AIDS ini, jenis pemeriksaan Laboratorium apakah yang dibutuhkan? Apakah semuanya tersedia di RS ini? Apakah yang dapat dilakukan disini, apa yang harus dirujuk dan apa yang belum ada? Apakah ada pencatatan mengenai jenis dan jumlah pemeriksaan yang dilakukan atas permintaan tim POKJA ini, baik yang dilakukan oleh Lab. Disini ataupun Laboratorium rujukan keluar? Dapatkah kami memperoleh datanya secara retrospektif (2003 sampai sekarang?)? Bagaimana dengan pemeriksaan CD4 pada saat ini? Apakah digunakan untuk mengindikasikan perlu dimulainya pengobatan ARV atau dihentikannya ARV? Apakah ada rencana juga pemeriksaan Viral Load untuk penderita anak? Dalam mendukung pemeriksaan – pemeriksaan tersebut, siapa yang melakukan perencanaan pengadaannya? Siapa yang melakukan pengadaan? Apakah ada yang disediakan oleh Pusat – Propinsi – Kabupaten? Apa saja? Ataukah dilakukan melalui pengadaan sendiri dari anggaran Rumah Sakit? Apakah ada daftar dari kebutuhan reagens – alat habis pakai dalam pemeriksaan Lab. – universal precaution – pemusnahan dan disinfeksi – lain-lain yang habis pakai? Dapatkah kami memperolehnya> Upaya apa yang diketahui telah dilakukan Pemerintah untuk memastikan bahwa reagens tersebut bermutu (pra pemasaran dan sampling pasca pemasaran reagens), atau cross check untuk hasil pemeriksaan Lab. ? Bagaimana hasilnya? Sekiranya pelayanan CST ini berkembang, apakah sarana penyimpanan sementara dari alat habis pakai ini masih dapat ditampung? Bagaimana kapasitas penyimpanannya? Dapatkah kami melihatnya?

Pengobatan untuk penderita • •

• •

Apakah ada penderita yang juga pengguna NAPZA di rumah sakit ini? Obat – obat apa yang dibutuhkan? Apakah tersedia atau darimana memperolehnya? Dalam pelayanan CST kasus apakah ada pencatatan mengenai profile kasus yang dirawat disini? Berapa IO – penyakit IMS – TB/HIV ataupun Ibu melahirkan dengan komplikasi HIV? penderita anak? Dapatkah kami memperoleh datanya secara retrospectif (sejak 2003)? Bagaimana profile rejimen ARV yang digunakan di RS ini , apakah ada rekaman data retrospektifnya, sejak tahun 2003? Menurut pendapat Dr apakah ada perubahan dalam profile penggunaan rejimen obat ARV ini?

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o Apakah ada Monitoring efektivitas dan effek samping obat ARV siapa yang melakukannya? o Obat Pencegahan ARV pada Ibu Hamil o Obat untuk mereka yang terpapar Kotrimoksasol o Monitoring efektivitas dan effek samping o Bagaimana apabila timbul reaksi alergi? Pernahkah dijumpai ? Apa Substitusinya? Obat untuk OI dan PMS o Obat – obat jenis apa saja yang digunakan? Apakah ada data konsumsi obat – obat tersebut secara retrospektif sejak tahun 2003? o Apakah dilakukan Monitoring dan evaluasi efektivitas dan Resistensi pada obat – obat tersebut? Apakah ada / Pengujian resistensi? Dimana ini dapat dilakukan? Obat TB o Apakah RS ini sudah mengikuti program DOTS? o Berapa banyak kasus TB-HIV yang sudah dijumpai dan diobati? Kasus HIV lebih dahulu kemudian menderita TB atau penderita TB dan terinfeksi HIV? o Apakah masalah yang dihadapi dalam pengobatan kasus-kasus tersebut? Rejimen dan Masa pengobatan

Kumpulkan data Retrospektif konsumsi obat? • Dalam melaksanakan pengobatan tersebut bagaimana dengan masalah ketersediaan obatobatnya? Mutunya? D. ESTIMASI PENDERITA HIV/AIDS Dengan pengalaman yang dimiliki, apakah dapat digambarkan estimasi jumlah penderita HIV/AIDS yang membutuhkan pelayanan CST dikemudian hari? Bagaimana dengan sarana dan prasarana penyimpanannya? Dapatkah kami melihat lokasi simpan/ gudangnya? Kumpulkan data E. SARANA DAN PRASARANA 1. Ketentuan dan Persyaratan Universal Precaution di RS • Apa sarana – sarana yang dibutuhkan untuk Universal precaution di RS/Puskesmas • Apa sarana habis pakai yang digunakan • Bagaimana pengadaannya / pasokannya? • Apakah ketersediaannya terjamin baik jenis maupun jumlah?

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Apakah sudah ada dampak dari kekurangan – kekurangan tersebut?

2. Penyediaan dan Pengisian Ulang • Kebijakan dan ketentuan • Seleksi / Uji mutu dan jaminan mutu • Pengadaan/ Pengisian Ulang • Penyimpanan persediaan/ Fungsi dan Kapasita Gudang • Distribusi dan Dispensing • Penggunaan dan Pelayanan Informasi/ [peran Farmasis

3. Sarana diagnostic dalam pengobatan • CD4 • Kebutuhan akan Viral Load Darimana sumber pasokannya? Mana yang diadakan sendiri dan mana yang perlu diisi ulang melalui Pusat – Propinsi – Kabupaten – UPK sendiri? Bagaimana mengenai upaya untuk mengendalikan persediaannya agar terjaga kesinambungan pelayanan – mutu – jenisnya? Lakukan Observasi dan rekaman gambar?

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PEDOMAN WAWANCARA UNTUK POKJA HIV/AIDS DI PUSKESMAS Penyakit AIDS pertama kali ditemukan di Indonesia di Propinsi Kalimantan Barat pada tahun 1992, sejak itu ditemukan pelbagai temuan kasus dipelbagai propinsi di Indonesia. Subdit HIV/AIDS dibentuk dan melakukan upaya monitoring dan membentuk team ahli untuk memantau perkembangannya sambil melakukan pelbagai upaya untuk mengenal penanggulangan AIDS di Indonesia. Penunjukkan 25 RS pertama merupakan salah satu langkah pertama tahun 2003 yang diharapkan akan mencapai 300 RS pada tahun 2009 yang akan datang. Sementara itu pada tahun 2006 melalui Peraturan Presiden no 75 tahun 2006 ditingkat Nasional telah dibentuk Komite Nasional Penanggulangan AIDS untuk melakukan upaya – upaya terpadu yang dipimpin Menko Kesra dengan Menteri Kesehatan dan Menteri Dalam Negeri sebagai intinya. KPA dimaksudkan untuk melakukan koordinasi upaya secara Nasional dan berjenjang ke bawah untuk melakukan koordinasi penanggulangan penyakit AIDS yang memiliki pelbagai dimensi aspek permasalahan baik politik – social kemasyarakatan – hokum – ekonomi - agama disamping kesehatan. Disetiap Pemda dibentuk kemudian KPA untuk mendampingi Gubernur dan Bupati/ Walikota dalam melakukan penanggulangan AIDS yang memiliki demikian banyak dimensi permasalahan. Sejak 14 Agustus 2006 Gubernur Papua menyerukan penanggulangan AIDS di tanah Papua yang harus dilaksanakan secara menyeluruh, dan bahwa Penanggulangan AIDS merupakan salah satu agenda Pemerintah yang mendapat prioritas.

RAPPORT Perkenalan: • • • •

Perkenalkan diri dan tim Jelaskan maksud dan tujuan serta kemungkinan waktu yang akan dipakai Berikan kesempatan untuk menanggapai Bincang – bincang ringan untuk membentuk iklim yang santai

PERTANYAAN WAWANCARA: F. ORGANISASI • Kapan pembentukan POKJA HIV/AIDS di PUSKESMAS ini? • Bagaimana struktur organisasinya? Apa kita bias memperoleh gambar struktur organisasinya? • Profesi apa saja / jabatan apa saja yang membangun POKJA ini? • Apakah komponen farmasi ada/ kalau tidak ada tanyakan mengapa? Jelaskan perannya sehubungan dengan makin banyaknya interaksi obat dengan obat ARV. Oleh karena ARV amat vital untuk penderita HIV, maka interaksi yang mengurangi atau merugikan penderita perlu dicegah. Mengingat obat ARV ini bekerja di hati, maka interaksi dengan obat lain demikian banyak. Untuk ini sebaiknya komponen farmasi ada yang disertakan dan dididik/ dilatih/ dimuthakirkan dengan informasi terakhir, sehingga dapat berkontribusi dalam dispensing obat dan menjadi sumber informasi bagi POKJA. Disarankan menjadi Pusat Informasi untuk Obat ARV, pusat komunikasi dan pusat untuk pencatatan effek samping maupun efektivitas obat.

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G. PEMERIKSAAN VCT Perhatikan dalam struktur tadi apabila sudah ada tim VCT, maka pertanyaan diarahkan kepada tim VCT. • • • • • •

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Berapa besar timnya dan siapa ketua/koordinatornya? Apakah ada jadwal kegiatannya atau sudah rutin tiap hari> Apakah anggota tim ini bekerja paruh waktu atau penuh? Apakah ada kegiatan Mobile VCT bagaimana cara kerjanya dan kemana wilayahnya atau kelompok mana? Berapa orang teamnya dan komponen dan sarana bagaimana dengan Testingnya? Apakah ada LSM yang melakukan penyuluhan dan mengorganisir pertemuan VCT ini? Dari kegiatan tersebut apakah masih diarahkan pada kelompok masyarakat berisiko tinggi atau sudah diarahkan kepada masyarakat umum?/ Dari catatan yang sudah kami peroleh selain kelompok berisiko tinggi (PSK) juga ibu Rumah Tangga dan profesi yang tidak termasuk kelompok berisiko tinggi ditemukan. Sehubungan dengan kondisi ini apakah ada pengarahan dari tim VCT kepada LSM? Untuk memastikan agar tidak ada kekecewaan dari mereka yang hadir untuk VCT< berapa waktu yang dibutuhkan untuk melakukan VCT ini? Terutama untuk mereka yang berisiko tinggi yang sudah memperoleh penyuluhan? Dan berapa waktu yang dibutuhkan untuk mereka yang dating secara sukarela/ coba – coba atau belum dibekali penyuluh? Untuk Councellor pre dan post test apakah ada rekaman waktu? Bagaimana dengan waktu dan perlengkapan testing? Apakah Universal precaution juga diterapkan dalam pengambilan specimen dan pemeriksaan? Bagaimana dengan penyiapan jumlah Rapid Test dan bagaimana agar mutu Rapid Test dapat dipertahankan? Apakah pada pemeriksaan tersebut terutama untuk mereka yang berisiko tinggi dilakukan juga pemeriksaan IMS (Infeksi Menular Seksual)? Atau ada rujukan untuk temuan kasus IMS – Ibu Hamil – penyakit TB dari klinik/ puskesmas yang belum melakukan VCT disekitarnya? Bagaimana dengan pemusnahan dan pembuangan specimen dan alat yang terpapar specimen? Peralatan apa saja yang dibutuhkan? Apakah sudah ada konsep/ pemikiran VCT toolkit untuk kegiatan Mobile VCT? Bagaimana dengan hasil VCT baik yang stasioner (tetap dan tidak bergerak) dan bagaimana dengan hasil dari VCT yang bergerak/ mobile atau VCT ditempat outreach tetap? Kumpulkan data/jumlah kunjungan / /jumlah yang mengikuti councelling/ pra dan pasca testing , jumlah yangyang ikut testing, berapa diantara yang positif dan undetermined? Apakah dijumpai yang sudah ada reaksi dan perlu dirujuk?

117


H. ESTIMASI PENDERITA HIV/AIDS Dengan pengalaman yang dimiliki, apakah dapat digambarkan estimasi jumlah penderita HIV/AIDS yang membutuhkan pelayanan CST dikemudian hari? Bagaimana dengan sarana dan prasarana penyimpanannya? Dapatkah kami melihat lokasi simpan/ gudangnya? Kumpulkan data

I. SARANA DAN PRASARANA 4. Ketentuan dan Persyaratan Universal Precaution di RS • Apa sarana – sarana yang dibutuhkan untuk Universal precaution di RS/Puskesmas • Apa sarana habis pakai yang digunakan • Bagaimana pengadaannya / pasokannya? • Apakah ketersediaannya terjamin baik jenis maupun jumlah? • Apakah sudah ada dampak dari kekurangan – kekurangan tersebut? 5. Penyediaan dan Pengisian Ulang • Kebijakan dan ketentuan • Seleksi / Uji mutu dan jaminan mutu • Pengadaan/ Pengisian Ulang • Penyimpanan persediaan/ Fungsi dan Kapasita Gudang • Distribusi dan Dispensing • Penggunaan dan Pelayanan Informasi/ [peran Farmasis Darimana sumber pasokannya? Mana yang diadakan sendiri dan mana yang perlu diisi ulang melalui Pusat – Propinsi – Kabupaten – UPK sendiri? Bagaimana mengenai upaya untuk mengendalikan persediaannya agar terjaga kesinambungan pelayanan – mutu – jenisnya? Lakukan Observasi dan rekaman gambar

118

Annex 5. Data Extracts The AIDS commissions There were 12 AIDS commissions at the District level and 2 at Province level which were interviewed. The first commission was established in 2000 is in the Province of Papua, 2 were established in 2003, 4 in 2004, and 1 in 2007 (West Papua) but there were no clear information on the other 5 Districts. Eight among these 14 AIDS commission have shown activities, but 6 of them are passive. Six among the AIDS commission interviewed have prepare a long-term strategic plan while the others have not. Physical Resources

2007 NO

DISTRICT

HOSPITAL WITH

HOSPITAL Public

Private

Special

VCT

CST

1

1

1

JAYAPURA MUNICIPALITY

0

2

JAYAPURA DISTRICT

1

3

YAPEN WAROPEN DISTRICT

1

4

BIAK DISTRICT

1

5

NABIRE DISTRICT

1

1

1

6

JAYA WIJAYA DISTRICT

1

1

1

7

MERAUKE DISTRICT

1

2

1

8

ASMAT DISTRICT

0

9

MIMIKA DISTRICT SURVEYED DISTRICTS IN PAPUA

1

2

2

2

7

6

7

6

10

MANOKWARI DISTRICT

1

2

1

1

11

FAK-FAK DISTRICT

1

0

1

1

12

SORONG DISTRICT SURVEYED DISTRICTS IN W.PAPUA

1

0

1

1

3

2

3

3

3

1

1

1

0

Total 10 8 1 10 9 A total of 55 percent of hospitals are ready to provide VCT services and 50 percent could provide CST services in District visited in the survey. In Puskesmas, the challenges for the health providers are greater and so are the logistics for Rapid Test Kits and ARV. Only nine percent of Puskesmas are providing VCT services in the Puskesmas in the surveyed District. 119


2007 NO

DISTRICT PUSKESMAS

AUX. PUSKESMAS

PUSKESMAS WITH VCT

1

JAYAPURA MUNICIPALITY

9

22

2

2

JAYAPURA DISTRICT

12

34

2

3

YAPEN WAROPEN DISTRICT

7

44

0

4

BIAK DISTRICT

15

32

1

5

NABIRE DISTRICT

25

40

0

6

JAYA WIJAYA DISTRICT

32

108

1

7

MERAUKE DISTRICT

11

108

5

8

ASMAT DISTRICT

6

21

0

9

MIMIKA DISTRICT

12

40

2

Total

129

449

13

10

MANOKWARI DISTRICT

16

84

0

11

FAK-FAK DISTRICT

9

35

1

12

SORONG DISTRICT

12

45

1

37

164

2

166

613

15

Total

120


Human Resources

Counselors’ training

Case Manager training

Hospital in Wamena

2

2

Biak General Hospital

1

1


2

Sele Be Solu Hospital Bhayangkara (Police) Hospital

2

1

1

1

Marine Hospital

1

1

Abepura Hospital

1

1

2

2

2

2

1

1

HOSPITALS

1

Dok II Hospital Sentani General Hosp Fak-Fak General Hospital Manokwari General Hospital Hospital in Preparation Mappi Nabire General Hospital Merauke General Hospital

Total

cst for doctors

cst nurse

1

1

2 3

2

2

2

2

1

1 intensive in house traing with MSF 20

2

1

16

1 6

PUSKESMAS

7

Lab. Counselors Technician training

Case Manager training

TOTAL PUSKESMAS AND CLINICS

12

40

28

TOTAL PARTICIPANTS

27

105

74

TOTAL PUSKESMAS INTERESTED

51

121

Annex 6. Respondents LIST OF RESPONDENTS

Survey of HIV AIDS Commodities at Tanah Papua NO.

Date

Name

Position

Organization

1

1-Nov-07

P. Pasaribbu

Staf Subdin BPP&PL HIV AIDS

Dinkes Propinsi Papua

Jl. Raya Kotaraja, Abepura

0967-582332 - 08124843806

2

1-Nov-07

Yacobus

Staf Subdin BPP&PL TB


[email protected]

0812-4806550

3

1-Nov-07

dr. Mariana

Staf Subdin BPP&PL Imunisasi


[email protected]

0812-4896917

4

1-Nov-07

dr. Beery W

Staf Subdin BPP&PL Imunisasi


[email protected]

0967-582332-0813-44164428

5

1-Nov-07

Hendrikson

Kasubdin P2PL


Jl. Raya Kotaraja, Abepura

0967-582332, 0813-44526129

6

1-Nov-07

P.S. Ukung

Pej.Ketua Harian KPA Prop Papua

KPA Propinsi Papua

[email protected]

0811-480931

7

1-Nov-07

Yuliana Marsyom

Staf KPA / PKM Hamadi

KPA Propinsi Papua

[email protected]

8

1-Nov-07

dr. Esterlina Ayomi, Mkes

Kadinkes

Dinkes Kabupaten Jayapura

Jl. A. Yani No. 70, Jayapura

0812-4801951

9

1-Nov-07

dr. Petronella MR

Plt Kasubdin PP&PL



0812-4808324

10

1-Nov-07

Pungut Sunarto, Skm

Kasie Pengamat & Pembinaan



11

1-Nov-07

Sumiati Sugiyo

Kasie Wasdal Koslkes



0813-44241601

12

2-Nov-07

Primus D. Aroit

Staf Subdin Farmasi


Jl. Kayu Batu Tanjung Ria, Base G

0813-44880078

13

2-Nov-07

Marta, S.Si. Apt.

Staf Subdin Farmasi



0813-44011755

14

2-Nov-07

Dra. Linda Sundari, Apt.

Kasubdin Farmasi



0811-483345

15

2-Nov-07

Darmi La'biran

VCT Manager

RS. Dian Harapan, Propinsi Papua

[email protected]

0813-44779003

16

2-Nov-07

Kisworo Untari

Farmasi


Jl. Teruna Bakti Yabansai, Abepura

0967-572123, 0813-19910049

17

2-Nov-07

Yosep Jalong

Laboran


Jl. Teruna Bakti Yabansai, Abepura

0815-6642534

18

2-Nov-07

Royke Lumendek

Program Manager


[email protected]

0816-4332353

19

3-Nov-07

dr. Ni Nyoman Sri Antari

RSUD Abepura, Propinsi Papua

[email protected]

0852-54497891

122

Address / email

Phone


20

3-Nov-07

dra. Andiasih, Apt.

RSUD Dok II, Propinsi Papua

[email protected]

0812-4803647

21

3-Nov-07

Lea Alexander, AMF


Jl. Kesehatan No 1, Jayapura

0813-44988860

22

3-Nov-07

Siti Sortief

MK/Konselor


[email protected]

0812-4804093

23

3-Nov-07

Idham

Administrasi


Jl. Kesehatan No 1, Jayapura

0852-54107787

24

5-Nov-07

Christina Lintin

P2ML

Dinkes Kota Jayapura


0813-44776335

25

5-Nov-07

Sujono A

Kadinkes Kota Jayapura


[email protected]

0811-489508

26

5-Nov-07

Lysa Nainggolan

Kasie Farmasi & GFK


Jl. Amepura, Komp. Perum Kota

0811-488515

27

5-Nov-07

Hadira Fenni

Staf Gudang Farmasi Kota


Jl. Raya Kotaraja, Komp. PKM Kotaraja

0852-44122420

28

5-Nov-07

Sudjarwo

KPA Kota Jayapura

Kantor Walikota

Jl. Balai Kota No. 1, Jayapura

0811-481819

29

5-Nov-07

Adnan

Seksi Perencanaan & Pengembangan

PLN Wil. Propinsi Papua

Jl. Jend. A. Yani . 14, Jayapura

0852-44479018

30

5-Nov-07

Sugeng Widodo

Mgr Data & Vas

Kandatel Propinsi Papua

[email protected].

0967-5106275

31

5-Nov-07

Ade Fatri Yanti

Sek. DPW Gafeksi

Propinsi Papua

0811-488950

32

5-Nov-07

Eddu Elex Makabori

Bid/Udara PW Gafeksi

Propinsi Papua

0813-44244340

33

5-Nov-07

M. Cholil

Wkl. Ketua DPY

Propinsi Papua

0811-483267

34

5-Nov-07

Elisabeth Tan

Bid/Udara

Propinsi Papua

0811-481793

35

5-Nov-07

DF. Vaisal

EMKL

Propinsi Papua

0813-44231767

36

6-Nov-07

dr. Fitri Ria Dini P.

Ka. Puskesmas Hamadi


[email protected]

0852-44789567

37

6-Nov-07

Youke A. Supit, SKM

PJ. Klinik IMS,HIV/AIDS PKM Hamadi


Jl. Perikanan, Jayapura

0813-44288810

38

6-Nov-07

dr. Anne U. Yupan

Ka. PKM Kampung Harapan


Jl. Chalkotte, Kec. Sentani Timur

0813-44559842

39

6-Nov-07

Elisabeth Soor

Staf PKM Kampung Harapan



0813-44144476

40

6-Nov-07

Seflien S. Lumanauw




0852-54244476

41

6-Nov-07

Marthina Manufandu




0852-54204801

42

6-Nov-07

Tun Tumiar




43

7-Nov-07

Bambang Sumanto

Kasubdin Phb Udara

Dinas Perhubungan Propinsi Papua

44

7-Nov-07

Olivia Wangloan

Staf KPA Kab. Jayapura

KPA Kabupaten Jayapura

Jl. Kemiri Sentani, Dpn Kantor Pos

0811-4801672

45

7-Nov-07

Maria Deda, Amd




0852-44393598

123

0812-48114127


46

7-Nov-07

Agus Widodo




0852-54146585

47

7-Nov-07

Karen H. Smith

Deputy Director FHI

FHI - Propinsi Papua

[email protected]

08124811824

48

8-Nov-07

Drg. Joseph Rinta R.

Ka. Dinkes Kab. Merauke

Dinkes Kabupaten Merauke

Jl. Garuda Mopah Lama, Merauke

0811-484068

49

8-Nov-07

dr. Mala Hayati

Staf Pokja

Pokja RSUD Kabupaten Merauke

[email protected]

0812-4820892

50

8-Nov-07

Ishak Hilal

Staf Pokja


Jl. Sulawesi No 1, Merauke

0852-44030351

51

8-Nov-07

dr. Merylin Ronoko

Staf Pokja


[email protected]

0813-44486878

52

8-Nov-07

dr. Inge Silvia

Stof Pokja



0812-4881254

53

9-Nov-07

Susan Fintarti S

Staf Farm RSU Merauke

RSUD Kabupaten Merauke


0813-80194742

54

9-Nov-07

Hendrika M Karung

Staf PKR



0971-321489, 0812-4873297

55

9-Nov-07

Sri Wahyuni

Staf PKR



0971-321484, 0813-44751882

56

9-Nov-07

Mila

Staf PKR



0852-44388831

57

9-Nov-07

Sr M. Fatima, PRR

Staf RS Bp/Perawat

RS Bunda Pengharapan

Jl. Angkasa I, Kelapa Lima - Merauke

0971-325906, 0813-17572702

58

10-Nov-07

Runggu Manurung

Bidan Konselor

PKM Mopah, Kabupaten Merauke


0971-324650, 0813-440406401

59

10-Nov-07

Surip Kristini

Bidan Konselor

PKM Kurik, Kabupaten. Merauke

60

10-Nov-07

Beatrix AM. Rahawarin, SP

Staf BPKM Yasanto

Yay. Santo Antonius, Kabupaten Merauke

[email protected]

61

10-Nov-07

Leonard Mahuse

Staf BPKM Yasanto

Yay. Santo Antonius, Kabupaten Merauke

Jl. RE. Martadinata, Merauke

62

13-Nov-07

Drs. Kaimudin LM, Apt.

Ka Bid. Yanfar


kai_mudin@

0813-44058667

63

13-Nov-07

Henny Y Liebun, S.Si. Apt.

Bid. Yanfar



0852-44768233

64

14-Nov-07

Nathalia Noman

Staf IFK


Jl. Johar, Meraueke

0812-4883231

65

14-Nov-07

Edwardes P. Tumanggar

Kasie Rencana&Distribusi Obat



0812-4820778

66

14-Nov-07

Ferdinandus

Sfaf Gudang



67

14-Nov-07

Susana

Staf Gudang



68

14-Nov-07

Dra. Erny Siahaya, Apt.

KTU



0813-44070054

69

14-Nov-07

Dr. Nevile Muskita

Kabid P2PL



0811-484841

70

15-Nov-07

Talip Rianto

KTU

Dinkes Kabupaten Asmat

Jl. Ahmat Yani no. 1, Agats

0812-4882840

71

15-Nov-07

Darman

Kasubag Progarm



0813-44655500

124

0813-44380120 0971-325371, 0811-484505


72

15-Nov-07

Abdul Munir

Kasie Farmasi



0813-44631833

73

15-Nov-07

Jonas Janjaan

Kasub. Umum



0813-44187096

74

16-Nov-07

Karel Burum

Kepala Bidang Yanfar



0902-31208, 0813-44942618

75

16-Nov-07

Andreas Numbery

Kasie Farmasi&Pengawasan Makanan



76

16-Nov-07

Faridah Syam, Ssi. Apt.

Staf



77

16-Nov-07

Gatot Tresno Nugroho

Staf



78

16-Nov-07

Nelson Sitepu

Staf



79

16-Nov-07

dr. Steven Langi

PKM Agats

PKM Agats, Kabupaten Asmat


0902-31112, 0813-44486889

80

16-Nov-07

Waluyo

Perawat

PKM Agats, Kabupaten Asmat


0852-44579293

81

16-Nov-07

Dewi Linggasari

Kasubag Program

Dinkes Agats, Kabupaten Asmat


0813-44561221

82

19-Nov-07

Pati Tangsopati

Kantor KPA

Kabupen Mimika

[email protected]

0811-492910

83

19-Nov-07

Milka Lapi

KPA Kab. Mimika

Kabupten Mimika

[email protected]

0901-322460, 0812-4020476

84

19-Nov-07

Saiful Taxim

Dinkes & KB Kab. Mimika

Jl. Yos Sudarso, SP I

0815-27000130

85

19-Nov-07

Reynold Ubra

Dinkes & KB Kab. Mimika

[email protected]

0852-81355024

86

20-Nov-07

Dr. Paulus S. Sugiarto

RS. Mitra Masyarakat, Mimika

[email protected]

0811-490658

87

20-Nov-07

Lusia Imelda

Farmasi


Jl. Charitas No. 1, Timika

0901-323571

88

20-Nov-07

Dr. Lili Indrawati Irawan

Ketua Tim


[email protected]

0811-492288

89

20-Nov-07

Dr. J.J. Malonda

Kabag Lab.


[email protected]

0811-492306

90

20-Nov-07

Drs. Edy P

Kasie Farmasi

Gudang Farmasi Kab. Mimika

Jl. BudiUtomo, Timika

91

20-Nov-07

Susan J. Wulansari

Staf Farmasi

Dinkes Kabupaten Mimika

Jl. Pemuda no. 299 SP I

0811-494809

92

20-Nov-07

Nasriah

Staf Farmasi

Dinkes Kabupaten Mimika

Jl. Yos Sudarso, SP I

0852-44915520

93

20-Nov-07

dr. Moses Untung

dokter PKM

PKM Timika, Kabupaten Mimika

94

20-Nov-07

Fransisca K

Bidan PKM

PKM Kwamki, Kabupaten Mimika

95

26-Nov-07

George Remutwa

Kabag Lab. - PMI

UTDC Kota Jayapura

0815-27064845

96

26-Nov-07

Ita

Staf PMI

UTDC Kota Jayapura

0813-44569900

97

26-Nov-07

Atik

Staf Imunologi

BLK Kota Jayapura

0813-448900095

Programer HIV/AIDS

125

0811-493023 Kwamki Baru, Timika


98

5-Nov-07

Ruslan, S.sos, SKM

Surveilans

Dinkes Kabupaten Biak Numfor

ruslan_skm07

0813-44020277

99

5-Nov-07

Lukas Linggi

staf subdin P2M


Jl. Sam Ratulangi No. 1, Biak

0813-44002787

100

5-Nov-07

A.M. Ridway Halim

Kasubdin P2M



0811-487118

101

5-Nov-07

Patriac Rumbaras

Kasie Pemb. Penyalur



102

5-Nov-07

dr. Leonora Komboy

dokter poli anak, PKM Biak Kota

PKM Biak Kota


0812-4825508

103

5-Nov-07

Glaser, S.Farm.,Apt

Staf GFK



0852-54895455

104

5-Nov-07

Titus Manukrante

Staf GFK



0852-44212195

105

5-Nov-07

Drs. Sefnat Korwa

Kadinkes



0811-483115

106

6-Nov-07

Wawan

Program officer

KPA Kabupaten Biak Numfor

[email protected]

0981-27246, 23138

107

6-Nov-07

O. Momoribo

Sekretaris KPA



108

6-Nov-07

Selvi Rumbiak

Staf KPA



0852-54313049

109

6-Nov-07

Drs. Robert S. Apt.

Ka. Inst. Farmasi



0813-54128384

110

6-Nov-07

dr. Ricardo M

Kasie Yanmen

RSUD Kabupaten Biak Numfor

Jl. Sriwijaya Ridge, Biak

0813-44071840

111

6-Nov-07

Linda Sianipar

Lab.

RSUD Kabupaten Biak Numfor

Jl. Sriwijaya Ridge, Biak

0812-4892032

112

8-Nov-07

Otto Parorrongan

Kabid

Dinkes Propinsi Papua Barat

Jl. Kotaraja No. 2, Monokwari

0813-44016525

113

8-Nov-08

Jenny Payung, S.Hut.

Adm. Officer

KPAD Kabupaten Manokwari

Jl. S. Condronegoro, SH, Manokwari

114

8-Nov-07

Marthen L. R

Staf Pengelola P2 HIV

Dinkes Kabupaten Manokwari


0852-44344681

115

9-Nov-07

Zul Azmi

Staf GFK



0812-4884419

116

9-Nov-07

Wiesye Pelamonia, Ssi. Apt.

Staf GFK



0813-44072323

117

9-Nov-07

drg. Henry Sihombing

Kadinkes



118

9-Nov-07

Dermawan Simanjutak



119

9-Nov-07

Drs. Bactiar, Apt.

Ka. GFK



120

9-Nov-07

M. Ilham Ssi, Apt.

Staf GFK



121

10-Nov-07

dr. J.M. Panggelo

Ka. PKM

PKM Maripi, Kabupaten Manokwari

Jl. Trikora Km 23, Maripi

0813-44139198

122

10-Nov-07

Fritje Linggar

MK



0813-44440114

123

10-Nov-07

Agus Rumaikewi

Perawat/Konsuler



0852-54422523

126

0813-44097485


124

10-Nov-07

Paulin Kambong

MK, Perawat CST

Klinik Blimbing, Kabupten Manokrari

Jl. Bayangkari No. 1, Manokwari

0813-44321646

125

10-Nov-07

Ferdinand Kapitarauw

Pelaporan Perawatan ARV

Klinik Blimbing, Kabupten Manokrari

Jl. Bayangkari No. 1, Manokwari

0813-44355892

126

10-Nov-07

Heriyati

Ka IFRS


Komp. RSUD Manokwari

0812-4830325

127

10-Nov-07

dr. Alberthina

Ka. Lab.

RSUD Kabupaten Manokwari

Komp. RSUD Manokwari

0813-44138100

128

10-Nov-07

dr. Frans Runsumbre

Direktur RSUD Sorong

RSUD Kabupaten Sorong

Jl. Kesehatan No. 2, Sorong

129

15-Nov-07

dr. I Ramandey, M.Kes

Kabid Yankes

Dinkes Propinsi Papua Barat

Jl. Kotaraja No. 2, Monokwari

0986-212817, 0854-4575288

130

15-Nov-07

dr. Arnold Tiniap

Kasie pemberantas penyakit/sekr KPA

Dinkes / KPA Prop. Papua Barat

[email protected]

0812-4835978

131

15-Nov-07

Octavina A.

Petugas Lab

PKM Aimas, Kabupaten Sorong

Jl. Nusa Indah Kel. Mariyai, Sorong

0813-44248891

132

15-Nov-07

I Wayan, Skep

VCT PKM Aimas



0812-4840701

133

15-Nov-07

dr. Ronny Kalesaran

dokter PKM Aimas



0813-44181510

134

15-Nov-07

dr. M.E. Hukom, S.ked

Ka. Dinas

Dinkes Kabupaten Sorong

JL. Kesehatan, Sorong

135

15-Nov-07

Dra. Hadijah, Apt

Ka. GFK



136

15-Nov-07

Riris

Petugas GFK



137

15-Nov-07

Tetty Pangaribuan

Petugas GFK



138

15-Nov-07

Tiruana Marpaung

Petugas GFK


JL. Kesehatan, Sorong JL. Kesehatan, Sorong

139

11/15/2007

Debbie Tumanggor, S.sos

Wasor TB/HIV


140

11/15/2007

Ampi

Adm. Officer

KPAD Kabupaten Sorong

141

16-Nov-07

Zr. Poppy S.

Ka. Perawat Penyakit Dalam

RSUD Kabupaten Sorong

Jl. Kesehatan, Sorong

0852-44477714

142

16-Nov-07

Prayudhi F

Petugas Case Manager

RSU Selebesolu, Kabupaten Sorong

Jl. Basuki Rachmat km XII, Sorong

0951-335811, 0852-44611937

143

16-Nov-07

Fery Y. Peday

Petugas Lab



0813-44226330

144

16-Nov-07

Ruslan Belang Ssi., Apt.

Apoteker



145

16-Nov-07

Appolos Umpain

Konsuler



146

16-Nov-07

Irnawati

Adm VCT



147

16-Nov-07

Zr. Zitta

Pimpinan

BP Bintang Timur, Kabupaten Sorong

Jl. R.A. Kartini No. 2, Sorong

148

16-Nov-07

Dr. Riswar

dokter CST



149

16-Nov-07

Trijoko Irawan

Manajer Kasus



127


150

16-Nov-07

Debbie Gael Hindige

Konsuler



151

17-Nov-07

Drs. Sulaeman R

Kadinkes

Dinkes Kabupaten Fak-Fak

Jl. Nuri 1, Waagom - Fak-fak

152

17-Nov-07

Frits Wamaer

Kasubdin P2P



0813-44374376

153

17-Nov-07

Muh. Yaman

Sekretaris KPA



0813-44441222

154

17-Nov-07

S. Muskita

Ka Gudang Perbekalan Kesehatan


Jl. Sudirman, Fak-fak

0812-4859083

155

19-Nov-07

dr. Irma S.B.

dr. Fungsional

PKM Kabupaten Fak-Fak

Jl. Cendrawasih No. 1, Fak Fak

0813-44606767

156

19-Nov-07

M. Erni Alzubaidy

Manajer Kasus



0852-44327387

157

19-Nov-07

Nuke Salakay

Lab.



0815-623308

158

19-Nov-07

Rosima

Bidan



0813-44621506

159

19-Nov-07

Zr. Beatrix

Pimpinan

BP Fatima, Kabupaten Fakfak

Jl. Trikora Merapi, Fakfak

160

19-Nov-07

Y. Masella

Petugas Lapangan



0852-54129299

161

19-Nov-07

Syamsuddin

Petugas Lapangan



0852-54466077

162

19-Nov-07

Dr. Januarius Thie, MPH

Dokter



163

19-Nov-07

Dr. Fachry

Direktur

RSUD Kabupaten Fak-fak

Jl. Jend. Sudirman, Fakfak

164

20-Nov-07

Sri Widayati, Apt.

Instalasi Farmasi



0812-4841059

165

20-Nov-07

dr. Herlan N.

dokter CST



0812-2370997

166

20-Nov-07

Ijal Labangi

Lab.



0852-44407155

167

5-Nov-07

dr. Luddy Suthelia

Kadinkes

Dinkes Kabupaten Yapen Waropen

Jl. Maluku, Serui

0983-31145, 0812-4855158

168

5-Nov-07

dr. Johnny B. Aboo, Mkes

Direktur RSUD Serui

RSUD Kabupaten Yapen Waropen

0983-31238, 0811-486336

169

5-Nov-07

dr. Ita Octawati

Ka. Lab.


0813-445789990

170

5-Nov-07

Lenny Marlina K

Perawat (Konsuler VCT)


0813-44032898

171

5-Nov-07

Drs. M. Ali Naharuddin, Apt.

Ka. IFK

IFK Yawa, Kabupaten Yapen Waropen

0983-33266

172

6-Nov-07

Sukmawati, SKM

Staf Perencanaan-Data


173

6-Nov-07

Imelda

KPAD Kab. Yapen Waropen

KPAD Kabupaten Yapen Waropen

0852-54136247

174

7-Nov-07

Hans Wamea S.Kep.

KA PKM Menawai

Kabupaten Yapen Waropen

0852-44688441

175

8-Nov-07

Mulyadi

Kabag TU


128

[email protected]

Jl. Merdeka No. 72, Nabire

0983-31145

0984-21688, 0815-27031578


176

8-Nov-07

Dr. Daniel UL

Kabid P2M



0984-23506, 0812-4849410

177

9-Nov-07

Musa Mallisa

Ka GFK

Dinkes Kabupaten Nabire


0984-21092, 0813-44257050

178

10-Nov-07

dr. Dwi Heru

Ka PKM Karang Tumaritits

PKM Karang Tumaritis, Kabupaten. Nabire

[email protected]

0813-54074000

179

10-Nov-07

Marice Yabdi Sembut

CST Konselor RSUD


Jl. RE. Martadinata, Nabire

0813-440225510

180

10-Nov-07

Milka M Yoku

Konsuler

Pokja RSUD Kabupaten Nabire

Jl. Samoba Atas, Nabire

0852-54254701

181

10-Nov-07

Dr. M. Faris SpM

Ketua Pokja RSUD

Kabupaten Nabire


0813-44193850

182

10-Nov-07

Staf Laboratorium

Staf

Kabupaten Nabire


183

12-Nov-07

Samadara Idris

Sek. KPAD Kab. Nabire

KPA Kabupaten Nabire


0813-44188202

184

12-Nov-07

Andreas Kakiay

Kasubbag Yankes



0812-4864827

185

15-Nov-07

Ardian Suma

Staf Laboratorium RSUD Wamena

RSUD Kabupaten Jayawijaya

Jl. Trikora, Wamena

0815-27711117

186

15-Nov-07

Fransiskus Obeth Dabi

Staf VCT RSUD Wamena

RSUD Kabupaten Jayawijaya

Jl. Trikora, Wamena

0852-54163394

187

16-Nov-07

Winarko, SKA

Ka. IFK Dinkes Kab. Jayawijaya

IFK Kabupaten Jayawijaya

Jl. Trikora, Wamena

0812-4885828

188

16-Nov-07

Staf IFK

IFK Dinkes Kab. Jayawijaya

IFK Kabupaten Jayawijaya

Jl. Trikora, Wamena

189

16-Nov-07

Dr. Viviana MP

Kasubdin Farmasi-Perencanaan

Dinkes Kabupaten Jayawijaya

Jl. Trikora, Wamena

190

16-Nov-07

Titus Asso

Kabag TU


Rogapura

191

16-Nov-07

Mesak Kogoya

Wasor TB/Kusta

Staf Dinkes Kabupaten Jayawijaya

Wamena

192

16-Nov-07

Natalius Boga

Wasor HIV/AIDS

Staf Dinkes Kabupaten Jayawijaya

Wamena

193

16-Nov-07

Willem W Oagay

Kasubdin Yankes


194

17-Nov-07

Daud

Staf KPA (AO)

KPA Kabupaten Jayawijaya

[email protected]

0969-32757

195

17-Nov-07

dr. Antony

Ka. PKM Wamena Kota

PKM Wamena Kota, Kabupaten Jayawijaya

Jl. Trikora, Wamena

0815-73561522

196

17-Nov-07

Lydia Parwa

Staf Lab. PKM Wamena Kota

PKM Wamena Kota, Kabupaten Jayawijaya

Jl. Bhayangkara NO. 41 A

0813-44272702

129

0812-4853235

0813-44545759 0862-54428813

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