February 2018 Assessing HIV, TB, Malaria and Childhood Immunization Supply-Side Readiness in Indonesia Assessing HIV, TB, Malaria and Childhood Immunization Supply-Side Readiness in Indonesia iv Abbreviations vi Acknowledgments vii Executive Summary viii Section 1. Background 14 Section 2. Methodology 16 Assessment Objectives and Framework 16 Modules 17 Sampling 18 Analysis 19 Section 3. Epidemic and Program Overview 20 Tuberculosis (TB) 22 Malaria 23 Childhood Immunization 24 Section 4. Service Availability and Readiness 26 HIV Counseling and Testing (HCT) 26 HIV Care, Support and Treatment (CST) 28 Anti-retroviral Therapy (ART) 30 Prevention of Mother-to-Child Transmission (PMTCT) 32 Tuberculosis (TB) 34 Malaria 37 Childhood Immunization 40 Cross-Program Issues 43 Section 5. Summary and Policy Implications 48 Appendix 1. Sampling Summary Table 54 Appendix 2. Composition of the National Sample 55 Appendix 3. Composition of the Priority Districts for the HIV, TB and Malaria Programs 56 Appendix 4. Service Readiness Tracer Indicators Used in the Analyses 57 Appendix 5. Full Service Availability and Readiness Tabulations 58 Appendix 6. Full Service Readiness Tabulations 64 References 70 Assessing HIV, TB, Malaria and Childhood Immunization Supply-Side Readiness in Indonesia v Abbreviations AIDS Acquired immune deficiency syndrome MH Maternal Health ANC Antenatal Care MoF Ministry of Finance API Annual Parasite Incidence MoH Ministry of Health ART Antiretroviral therapy MSM Men who have sex with men ATMI AIDS, Tuberculosis, Malaria, and Immunization MSS/SPM Minimum Service Standards/ Standar Pelayanan BAPPENAS Badan Perencanaan Pembangunan Nasional Minimal (National Development Planning Board) NCD Noncommunicable Disease BCG Bacillus Calmette–Guérin Vaccine NGO Nongovernment organization BDD Bidan di Desa (Village Midwife) NMP National Malaria Program BIAS Bulan Imunisasi Anak Sekolah (Schoolchildren’s NPS National Prevalence Survey Immunization Month) NTP National TB Program BPJS-K Badan Penyelenggara Jaminan Sosial-Kesehatan OOP Out-of-pocket payments (Social Security Agency for Health Insurance) PITC Provider-initiated testing and counseling CQI Continuous quality improvement PMTCT Prevention of mother-to-child transmission CST Care, support and treatment Polindes/ Pos Bersalin Desa ( Village Maternity Post)/ DAK Dana Alokasi Khusus (Special Allocation Funds) Poskesdes Pos Kesehatan Desa (Village Health Post) DCE Discrete Choice Experiments Posyandu Pos Pelayanan Terpadu (Integrated Service Post) DOTS Directly-observed treatment (short-course) PPP Public-private partnership DPT Diphtheria, pertussis and tetanus Puskesmas Pusat Kesehatan Masyarakat (Community Public EQAS External quality assurance system Health Center) FBO Faith-based organization PWID Persons who inject drugs GoI Government of Indonesia QSDS Quantitative Service Delivery Survey GP General physician/practitioner RDT Rapid diagnostic test HCT HIV counseling and testing Rifaskes Riset Fasilitas Kesehatan (Health facility survey) HepB Hepatitis B RR/MDR-TB Rifampicin-resistant/multidrug resistant TB HIV Human Immunodeficiency Virus SARA Service Availability and Readiness Assessment HRH Human resources for health SDI Service Delivery Indicators (World Bank initiative) IPT Intermittent Preventive Therapy SDP Service-delivery point IPV Inactivated poliomyelitis vaccine STI Sexually transmitted infection JEMM Joint External Monitoring Mission (for TB) Susenas National Socioeconomic Survey JMPR Joint Malaria Program Review TB Tuberculosis JKN Jaminan Kesehatan Nasional (National Social TBCA TB/HIV collaborative activities Health Insurance) UHC Universal Health Care Kader Community health volunteer VCT Voluntary counseling and testing KAFKTP Komisi Akreditasi Fasilitas Kesehatan Tingkat Primer (Accreditation Commission for Primary- WHO World Health Organization level Health Care Facilities) XDR-TB Extensively drug-resistant TB KAPs Key Affected Populations MDR-TB Multidrug-resistant TB vi Acknowledgements The QSDS descriptive report was prepared by a The team also would like to acknowledge that team comprised Robert Magnani (consultant), this work is funded by MDTF of Integrating Donor Pandu Harimurti (Senior Health Specialist, GHN02, Funded Programs from generous contributions by and task team leader) and Eko Pambudi (Research Australia Department of FAT and the Global Fund Analyst, GHN02), with support from Rachmat Reksa through the sustainability of external-funded Samudra (Consultant) and Liza Munira (consultant). health programs. The team also received substantive inputs from Overall guidance was provided by Rodrigo A. Chaves health team members Reem Hafez (Senior Health (World Bank Indonesia Country Director, EACIF), Economics, GHN02), Puti Marzoeki (Senior Health Camilla Holmemo (Program Leader, EACIF), and Specialist, GHN02), and Vikram Rajan (Senior Health Toomas Palu (Practice Manager, GHN02). Specialist, GHN02). During the report writing, the study results have been presented in several occasions and received useful feedbacks from the audience. The team is grateful to the counterparts from the Government of Indonesia, from the Ministry of Health Republic of Indonesia, Dr Mohammad Subuh (now the Senior Adviser to the Minister of Health), Dr. Wiendra Waworuntu (Director of Directly Transmissible Diseases, MOH), Vensya Sitohang (previously the Director of Vector-transmitted Diseases), Dr Endang Budi Hastuti (Head of Sub Directorate HIV and STI), Dr. Asik Surya (previously the Head of Sub Directorate TB), Dr. Elvieda Saraswati (previously the Head of Malaria), and Dr Prima Yosephine (previously the Head of Immunization). Also the Program and Information Division team under the leadership of Dr Siti Nadia Wiweko, the team from the Center for Health Financing and Risk Protection under the leadership of Dr Kalsum Komaryani. Also, continuous support and input from the Director of Health and Community Nutrition, Bappenas Pungkas Bahjuri Ali PhD and his team, and also Special Adviser to the Minister on Health Financing Development Dr Donald Pardede. Assessing HIV, TB, Malaria and Childhood Immunization Supply-Side Readiness in Indonesia vii Executive Summary The Indonesian health sector is currently actions that might be pursued in response by the experiencing a financing transition that will have a Government of Indonesia (GoI). profound impact on the country’s efforts to achieve universal health coverage (UHC) and national health The QSDS data reveal wide variations in service goals. The transition is marked, on the one hand, by availability across the ATMI programs and types increasing per capita expenditure on health and, on of facilities. Among the ATMI programs, service the other, by declining of out-of-pocket payments availability is the most variable for Human (OOP) and a significant reduction of external Immunodeficiency Virus (HIV). HIV counseling funding for health as a source of health financing. and testing (HCT) is the most widely available Assuming steady economic growth, Indonesia is among HIV-related services, being universally soon projected to greatly reduce or transition from available in public hospitals and in about three- its reliance on external financing for the national fourths of puskesmas and private hospitals. AIDS1, Tuberculosis (TB), Malaria, and Childhood Despite efforts to decentralize public sector HIV Immunization (ATMI) programs. While varying care, support and treatment (CST) services from somewhat from program to program, the extent hospitals to puskesmas, however, such services of financial transition required will be substantial remain concentrated in hospitals, primarily public for all four programs. Complicating the transition hospitals. Antiretroviral therapy (ART) services process is the fact that all four programs are are also concentrated in hospitals, but to an even currently engaged in making significant changes in greater degree in public vs. private hospitals. program strategies and implementation processes Prevention of mother-to-child transmission (PMTCT) in response to both underperformance and services are also far more likely to be found in Indonesia’s commitment to reaching global targets. public than private service-delivery points (SDPs). Nearly all public hospitals (89 percent) and 65 An objective assessment of the current supply- percent of puskesmas in HIV-priority districts side readiness situation is essential to inform offer such services, as do 54 percent of puskesmas policy actions aimed at attaining UHC and in nationally. Services at puskesmas and private achieving a nondisruptive and sustainable general physicians (GPs) are, however, largely transition from external financing for the ATMI limited to counseling, meaning that HIV-positive programs. To at least partially fill this information pregnant women and neonates are referred to other need, the World Bank Indonesia facilitated the facilities in most cases. conduct of a Quantitative Service Delivery Survey (QSDS) in 2016. The QSDS entailed a comprehensive TB services are universally available at puskesmas assessment of supply-side readiness across public and public and private hospitals, but at only about and private primary care facilities in Indonesia 50 percent of private GPs, however, the package using the WHO’s Service Readiness and Availability of services being provided varies considerably Assessment (SARA) conceptual framework and by type of SDP. The most comprehensive package methodology, adjusted as per national guidelines. of services is offered at puskesmas and, except The assessment was intended to provide a for diagnostic testing, at satellite puskesmas. All snapshot of financing and supply-side readiness public hospitals offered examination and testing across public and private primary care facilities, services, but only 81 percent in priority districts expanding and updating previous public facility prescribed treatment. Private hospitals have assessments. This report presents detailed similarly high levels of diagnostic capacity, but less findings of the QSDS and a discussion of policy than one-half prescribe TB treatment. Most private 1 AIDS: Acquired Immune Deficiency Syndrome. viii GPs (85-90 percent) prescribe treatment for TB, for these two programs), followed by puskesmas but only about one-third had diagnostic capacity. (59 percent), private hospitals (54 percent) and DOTS (Directly-observed Treatment – Short Course) private GPs (32 percent). is nearly universal in puskesmas but is followed in only about 60 percent of public hospitals and A more rigorous standard for assessing service far fewer private sector SDPs. Treatment follow- readiness is in terms of the proportion of SDPs up, which is also nearly universal in puskesmas, is that meet all tracer conditions across all programs offered by few private GPs and hospitals. and program components. Only 18 percent of public hospitals and 9 percent of puskesmas in Malaria services were available at virtually priority districts met this higher standard. The all puskesmas in malaria-priority districts (98 corresponding figures for private sector SDPs were percent) but in fewer puskesmas nationally (88 15 percent and 1 percent for hospitals and private percent). Of those providing malaria services, 87 GPs, respectively. The highest readiness levels percent of puskesmas in priority districts had were observed at public hospitals for HCT (45 testing capacity to confirm malaria diagnoses, percent) and clinical management of HIV and AIDS the most common form being by Rapid Diagnostic (42 percent). Test (RDT) (71 percent) followed by microscopy (60 percent). The availability of malaria services Insufficient human resources for health (HRH) was much lower at the private providers. Only 49 continue to plague the health system and should percent of private GPs in malaria-priority districts be a high priority for action. The QSDS revealed and 28 percent nationally provided malaria lack of staff with training relevant to the ATMI services. Most diagnoses by private GP practises program at many health facilities. This is despite in priority districts were by detection of clinical the considerable resources that have been invested symptoms (78 percent). in recent years in public-sector staff capacity for these programs. The Ministry of Health (MoH) Childhood immunization services are widely needs to reassess its core in-service training model available in puskesmas nationally (98 percent), and explore new training modalities that include but only in a minority of private sector GPs (15 more mentoring and on-the-job training, perhaps percent). The service package offered by private merged into enhanced supervisory protocols and/ GPs is, however, more complete than that found at or continuous quality improvement (CQI) processes. puskesmas. Two-thirds of puskesmas offer daily Better advantage might also be taken of the or weekly immunization services, and 92 percent extensive information technology infrastructure provide outreach services on at least a monthly available in Indonesia which is capable of, for basis. Among private GPs offering immunization example, supporting much wider use of distance services, the frequency of services is roughly learning and real-time, online technical support. comparable to that at puskesmas, but few private Strengthened preservice training in HIV, TB, Malaria GPs offer outreach services. and Immunization should also be pursued as a means of reducing the capacity-building burden on The QSDS data indicate significant supply-side the MoH over the medium term. readiness weaknesses for each of the ATMI programs. Service readiness was measured in A surprisingly high proportion of SDPs lacked ATMI terms of the proportion of the 74 tracer conditions service guidelines to support delivery of services across the ATMI programs that were satisfied per national standards. This is a health system at SDPs chosen for the QSDS. With respect to governance issue that, in principle, should be programs, service readiness was highest for relatively easy to mitigate. The MoH at the central childhood immunization, with average readiness level is clearly responsible for developing service scores of 84 percent at puskesmas and 55 percent standards and guidelines. Responsibility for at private GPs. Service readiness scores for HIV, TB distribution needs to be as clearly established and and Malaria in priority districts were generally in communicated. The MoH might consider adding the 60-70 percent range for puskesmas and 20- the availability of all relevant program-specific 50 percent range for private GPs. Based upon the service guidelines at all public-sector health weighted averages of readiness scores aggregated facilities as one of the MSS/SPM (Minimum Service across program components and programs, public Standards/Standar Pelayanan Minimal) as a means hospitals were the most service ready for HIV and of motivating provincial and district governments TB at 75 percent (hospital data were only collected to act. Assessing HIV, TB, Malaria and Childhood Immunization Supply-Side Readiness in Indonesia ix Comparing 2016 QSDS results with prior more established hospital accreditation system comparable data indicates that overall only can be used as a mechanism for strengthening marginal improvements in supply-side readiness hospital-based ATMI services. for TB, Malaria or Immunization have taken place.2 Comparisons of QSDS data with data from Other options for strengthening service readiness a health facility census undertaken in 2011 (Riset should be considered in addition to accreditation. Fasilitas Kesehatan - Rifaskes) on selected service Accreditation is not a quick fix, and other actions readiness “tracer” SARA indicators recommended will, in any event, need to be taken to correct by the WHO that measured in both data collection deficiencies observed in the accreditation review exercises indicate that gains in some tracers such process. One option is to strengthen the current as some cold chain equipment, and first line drugs, MoH quality assurance system. There are several and diagnostic kits. However, there were declines quality assurance subsystems currently in operation in others, notably availability of trained staff and at the MoH, including an external quality assurance guidelines. In the aggregate, only improvements system (EQAS) for laboratories, a technical quality in TB service readiness at public hospitals were assurance process implemented as part of the apparent from these data. Service readiness supervisory system, and a data quality assurance continues to be a major concern in both the public process that manifests as an annual data validation and private sectors. exercise. All three subsystems have significant limitations, but also have established mandates The widespread nature of service readiness and structures that can be built upon rather than weaknesses indicated by the 2016 QSDS mandates having to start from scratch. The subsystems that broad governance and systems interventions need to be more systematically and intensively will be needed in addition to ATMI-specific implemented and, most importantly, must result responses to address observed ATMI service in action being taken to correct observed quality readiness issues. One ongoing GoI response issues as opposed to merely being platforms for to addressing such issues is via expanding documenting problems. The goal would be the the accreditation of primary care facilities. refinement of the current system into a CQI system/ Accreditation not only ensures that all inputs process that systematically covers key elements (infrastructure, equipment, supplies and human of health programs, including ATMI, and health resources) are available to provide necessary system functioning. Incentives for health facilities services but also focuses on improving managerial, demonstrating improved service quality might be clinical and public health processes that are considered by the MoH, such as linking the quality important to ensure quality service delivery. assurance processes with the SPM accountability The MoH initiated an accreditation system for mechanism and/or the intergovernmental financial puskesmas in 2015. To date, the large majority of transfers as incentives. puskesmas that have been accredited (85 percent) have received ratings at the two lower tiers of The health MSS/SPM provide the MoH a lever to the four-tier rating system (World Bank 2018a), so compel local governments to address ATMI service this is clearly a work in progress. To ensure that readiness weaknesses. Although it will require the process continues and achieves the intended some adjustment of priority indicators to focus results, the MoH (with the Ministry of Finance on key service readiness and service-delivery – MoF – and BAPPENAS3) needs to ensure that performance issues, the MSS/SPM provides the the Accreditation Commission for Primary-level MoH with a regulatory basis for holding subnational Health Care Facilities (Komisi Akreditasi Fasilitas governments accountable for the delivery of basic Kesehatan Tingkat Primer – KAFKTP) is sufficiently health services. To be effective, the system of well funded to complete the mission. It is also monitoring compliance with the MSS/SPM must be important that the KAFKTP begins to accredit linked to a constructive supervisory system under private-sector facilities, although this would likely which districts and service providers are provided require incentives to encourage private sector guidance and assistance in addressing observed participation. The MoH should assess whether the shortcomings. If not, monitoring of MSS/SPM 2 The WB team recommends the report on QSDS that cover general supply side readiness and overall health programs, ‘Is Indonesia Ready to Serve’ World Bank 2018 3 Badan Perencanaan Pembangunan Nasional (National Development Planning Board). x compliance will be perceived as a punitive exercise Actions to strengthen service readiness should and will likely not result in improvements at a take into account the need for improved sufficiently rapid pace. It is acknowledged that the integration of ATMI services. Recent program finalization of MSS/SPM as a government regulation reviews have highlighted that the ATMI programs has not yet been completed and MoH realization of tend to operate as vertical programs without the potential of the MSS/SPM, therefore, remains sufficient integration of key services. Examples just that–potential. of inadequate linkages include HIV with sexually transmitted infection (STI) diagnosis and Additional resources will be needed to address treatment, HIV with TB, PMTCT with antenatal care current weaknesses, prepare the health system (ANC), and malaria with ANC. for what is likely to be growing demand for health services, and compensate for the anticipated Service readiness strengthening actions should reduction in international financing for HIV, TB, also take into account the need to further Malaria and Childhood Immunization. Low GoI decentralize HIV treatment services from per capita spending on health will, however, likely hospitals to puskesmas. It will be challenging remain a significant constraining factor. The rate for the MoH to reach its goal of significantly of growth of health spending at the central and increasing the number of persons being started district levels has accelerated in recent years and retained on treatment without an accelerated but faces stiff competition with other national pace of decentralization of treatment services. and local priorities. A series of policy options for This will require improvements in the functioning creating additional fiscal space have been outlined of supportive systems–supply-chain management, in other recent World Bank reports. laboratory support, supervision, and referral systems–in addition to better-trained puskesmas- Linking central-level fiscal transfers and JKN level staff. ( Jaminan Kesehatan Nasional – National Social Health Insurance) payments with performance Increasing meaningful private sector participation has considerable potential to influence district is essential to the national roll-out of the JKN to government and service provider behaviors. One achieve universal coverage and has also been of the interfiscal transfer mechanisms, the Dana identified by BAPPENAS as a key in transitioning Alokasi Khusus (DAK - Special Allocation Funds), from international financing for HIV, TB and and JKN program payments are the two sources of Malaria (Ali 2017). Private sector involvement is funding that offer the most scope for improving especially crucial for the national TB program the quality of health spending. These two sources as it is estimated that more than 70 percent make up a significant share of district health of TB cases seek care at private-sector health revenues, where most health spending occurs. facilities (WHO 2017). Private facilities, however, Currently DAK transfers are tied to performance have significantly lower supply-side readiness indicators that are largely administrative, while JKN than public-sector facilities–more or less across payments are based on a set of agreed indicators the board. GoI action on this front must focus that primarily concern the use of health facilities. both on engaging the private sector in pursuit of national health priorities as well as on increasing DAK transfers have the potential to be used private provider service readiness. For the GoI to leverage districts to increase investment in to be able to marshal these resources, a health health and focus on improved readiness for basic sector public-private partnership (PPP) framework public health programs, including ATMI. As a part needs to be developed and implemented. In the of strategic purchasing for JKN, payments can absence of such a framework, it would be difficult be used to incentivize providers–especially at to develop a strategic approach and a regulatory the primary level–to find and report new cases response to ensure productive involvement and retain them in treatment. These financing of the private sector. The GoI might consider instruments might also include incentives that accelerating extension of the accreditation system foster the integration of care across primary to the private sector and implementing strategic health and referral services to ensure improved purchasing in JKN as points of entry in influencing continuity of care. Better integration of supply- private-sector standards and practices. and demand-side and central- and subnational- level financing can further simplify implementation and increase efficiency. Assessing HIV, TB, Malaria and Childhood Immunization Supply-Side Readiness in Indonesia 11 section 1 . Background 12 The health sector in Indonesia is currently Reliable and updated information about service experiencing a health-financing transition that availability and supply-side readiness is a key will influence the country’s efforts to achieve to better planning and budgeting. To at least universal health coverage (UHC). The transition in partially fill this information need, the World health financing is marked by increasing per capita Bank Indonesia facilitated the conduct of a health expenditure because of increasing public Quantitative Service Delivery Survey (QSDS) in financing for health (Fan and Savedoff 2014). This 2016 following a comprehensive analysis of MoH’s includes mobilization of public financing with JKN 2011 health facility census (Rifaskes) in 2013. The in 2014 as the Government of Indonesia’s (GoI) QSDS entailed a comprehensive assessment of aspiration to provide comprehensive social health supply-side readiness across public and private insurance protection to all Indonesians by 2019. On primary care facilities in Indonesia using the World the other side of the financing transition is the fall Health Organization’s (WHO) Service Readiness in out-of-pocket payments (OOP) and a significant and Availability Assessment (SARA) conceptual reduction of external sources for health financing. framework, adjusted as per national guidelines. The assessment was intended to provide a Assuming ongoing economic growth, Indonesia is snapshot of financing and supply-side readiness projected to transition from, or at least greatly across public and private primary care facilities, reduce its reliance on, external financing for expanding and updating previous public-facility the national HIV, TB, Malaria and Childhood assessments. A major focus was on assessing Immunization (ATMI) programs in the near future. the extent to which the 2014 increase in BPJS-K4 While varying somewhat from program to program, demand-side financing and changes in puskesmas5 the extent of financial transition required will be autonomy had impacted the availability and use substantial for all four programs. Complicating of funds, identifying bottlenecks and inefficiencies the transition process is the fact that all four related to supply-side gaps in service delivery, and programs are currently engaged in making assessing service-provider ability to perform key significant changes in program strategies and/ service-related tasks. or implementation processes in response to both underperforming programs, and the country’s This report presents the detailed findings of commitment to global targets. the 2016 QSDS concerning the ATMI programs. The report was prepared with an eye toward Understanding the current supply-side readiness providing information necessary to take stock situation is essential to inform policy reforms of the current health sector situation on ATMI aimed at attaining UHC and in achieving a service availability and readiness, as well as nondisruptive and sustainable transition from to serve as a benchmark for further policy and external financing. Government health spending program deliberations and planning. The report per capita has increased threefold in the 15 years complements other recent World Bank Indonesia to 2017. This should translate to improved basic publications, including: (i) a report on QSDS results service availability and supply-side readiness– from a broader health systems perspective (World especially for the public sector. A significant Bank 2018a); (ii) a report on service readiness share of the public financing has been spent for for maternal health (World Bank 2017); and (iii) a program inputs, such as infrastructure, equipment report on transitioning from external ATMI funding (including cold chain), pharmaceuticals (including (World Bank 2018b). The balance of this report is vaccines), and supplies (including diagnostic organized as follows: Section Two documents the kits). At the same time, JKN program payment has methodology used in collecting and analyzing become a significant source of financing, especially the 2016 QSDS; Section Three provides relevant at the district and facility level. The increase of background information on the current epidemic GoI’s investment in the health sector and JKN and national program situation for the ATMI financing are expected to result in improved health programs; Section Four presents the main findings outcomes for Indonesian citizens and enable on service availability and supply-side readiness progress toward achieving national goals and for the four program areas; while Section Five global commitments for the ATMI programs. concludes with a summary of main findings and a discussion of the key policy implications emerging from the data and options for addressing them. 4 Badan Penyelenggara Jaminan Sosial-Kesehatan (Social Security Agency for Health Insurance). 5 Puskesmas: Pusat Kesehatan Masyarakat (Community Public Health Center). Assessing HIV, TB, Malaria and Childhood Immunization Supply-Side Readiness in Indonesia 13 section 2 . Methodology Assessment Objectives and Framework The QSDS was designed to provide the data The conceptual basis for the QSDS was the SARA needed for a comprehensive assessment conceptual framework, adjusted to be consistent of supply-side readiness across public and with Indonesian national guidelines and the World private primary care facilities in Indonesia. A Bank’s Service Delivery Indicators (SDI) initiative major interest was in assessing the extent to (World Bank 2012). SARA is a comprehensive which the 2014 increase in BPJS-K demand-side framework for monitoring and assessing key financing and changes in puskesmas autonomy aspects of service delivery in a health system had impacted availability and use of funds, as (O’Neill et al. 2013; WHO 2015. It was designed to well as identifying bottlenecks and inefficiencies provide a conceptual basis to guide the collection related to supply-side gaps in service delivery and and analysis of health facility-level data to assessing service-provider ability. The potential support assessment of whether facilities have the for the assessment to help link the issue of health minimum staffing, equipment, diagnostic capacity, financing with service delivery was highly valued. medicines, and commodities for a given disease Specific measurement objectives included: (i) to or condition. In this sense, the SARA-based QSDS provide a baseline for the JKN in terms of its ability can also help provide some sense of the extent to improve supply-side readiness; (ii) to include to which a health system is able to provide the private-sector primary health care supply-side minimum benefits that are included under the readiness (that is important as private-sector health services component of both the JKN and providers but were not covered in the Rifaskes the ATMI programs. The framework has three 2011; (iii) to measure any changes in supply- dimensions: (i) service availability, which refers side readiness from the Rifaskes 2011 given the to physical access and distribution of facilities; increased investments in supply-side readiness; (ii) service readiness, which refers to general (iv) to measure urban-rural differences; and (v) to service readiness (for example, with regard to measure factors that affect service delivery at the facilities having access to water and electricity) facility level such as governance, health and health as well as specific service readiness (for example, financing (but not costing information). for specific diseases and conditions); and (iii) service utilization, which refers to outpatient and inpatient utilization at the facility level. The present assessment was limited to the first two dimensions–service availability and service readiness. 14 Modules Data collection fieldwork for the QSDS was undertaken between June and November 2016. Data were collected using the following modules: • District Health Office Module; • Health Facilities Module, which covers the following types of health facilities: Puskesmas, Polyclinic/GP practice, Polindes/Poskesdes,6 Maternity clinic/private midwife practice; • Health Care Workers Module, including vignettes; • Patient Exit Survey Module, including Discrete Choice Experiments (DCE). This module was implemented only in DKI Jakarta: • Posyandu7 Module, including volunteer health workers (that is, “Kader”); and • Hospital Module (only for HIV and TB). The content of the modules focused on nutrition, maternal and child health, communicable diseases (particularly, HIV and AIDS, TB, and malaria), and noncommunicable diseases (NCDs). 6 Polindes: Pos Bersalin Desa (Village Maternity Post); Poskesdes: Pos Kesehatan Desa (Village Health Post). 7 Posyandu: Pos Pelayanan Terpadu (Integrated Service Post) Assessing HIV, TB, Malaria and Childhood Immunization Supply-Side Readiness in Indonesia 15 Sampling Four samples were chosen for the QSDS: Samples of predetermined size were then chosen from each type of facility, again via simple random • a national sample; sampling with equal probability. At the third stage • a sample of priority districts for three of the of sample selection, samples of: (i) posyandu; (ii) four health programs of interest in this report health workers; and (iii) patients (for the purpose (HIV, TB and Malaria); of conducting exit interviews) were randomly • a sample of matched nonpriority districts to chosen from each sample puskesmas. serve as counterfactuals for the priority district sample; and The sample design for the priority district/city • a Jakarta sample. samples for HIV, TB and Malaria was identical to that for the national sample, except that Appendix 1 provides summary documentation of the sampling frame used to select sample the sampling undertaken for the QSDS. districts was restricted to districts that had been designated as priorities for the respective This report uses data collected from three of the programs. If any given district was chosen in both samples (excluding the “counterfactual” sample). the national and the priority district samples, The sample design for the national sample was a the data collected in the district were included in stratified, multistage, cluster design. The sampling both samples for analytic purposes. Appendix 3 frame consisted of separate lists of districts and summarizes the priority district samples chosen. cities–the two strata used in the sampling. From The Jakarta sample was selected by selecting with each list or stratum, a sample of districts or cities certainty any municipalities that had not been of predetermined size was chosen via simple chosen in either the national or district samples. random sampling with equal probability. A total Data were thus available for all municipalities of 22 districts were so chosen. Details on the in Jakarta. Details of the sample facilities and composition of the national sample may be found numbers are presented in Table 2.1. in Appendix 2. At the second stage of sample selection, health Table 2.1 QSDS Data Collection facilities in each chosen district or city were Unit of Observation Total Sample stratified into the following categories: Provinces 23 • Public primary care (puskesmas); Districts/Municipalities 56 • Private primary care (polyclinics and private Puskesmas 915 medical practice); Private Primary Providers 835 • Public maternity care (polindes/poskesdes); Polindes/Poskesdes/BDD 8 647 • Private maternity care (maternity clinics and Private Maternal Health (Private MH) 655 private midwife practices); and Posyandu 649 • Hospitals (only in HIV and TB priority districts Public Hospitals 78 and stratified by public and private, excluding Private Hospitals 118 military/police hospitals). Patient Exit Interviews 1,018 Health Care Workers 4,359 8 Bidan di Desa : Village Midwife. 16 Analysis All survey data were weighted prior to analysis to It will be noted that a high survey interview compensate for differing probabilities of selection refusal rate was encountered in sampling private of service-delivery points (SDPs) included in the GPs and it was subsequently necessary to choose respective samples. The weights were calculated “substitute” private GPs. This will not influence as the inverse of the joint probability of selection the way the data were weighted but raises the across the two or three stages of selection, possibility of selection bias to the extent that depending upon the type of sampling unit (that private GPs who agreed to participate in the is, hospital, puskesmas, posyandu, polindes/ survey differed from those refusing participation poskesdes). The analyses presented in this report with regard to service readiness. Unfortunately, were based upon data collected from sample SDPs there is no way to assess the magnitude of this (that is, puskesmas, private GPs, public and private potential bias. hospitals), so only two stages of sampling were relevant. The probabilities of selection of SDPs The service readiness indicators used in the in both the national and priority district samples analyses consisted of key “tracer” conditions were calculated as follows: defined based upon the WHO SARA tracer conditions and national program guidelines. The PRi,j = (k / K) * (nij / SDPij) tracer conditions for each program consisted of Where: the service guidelines, trained staff, drugs and PRi,j = Probability of selection SDP “j” in district “i”, medicines, and diagnostic equipment/capacity k = Number of sample districts chosen (varies for the needed to provide packages of services that met national and priority district samples), WHO SARA and/or national program guidelines. K = Total number of districts in the sampling frame The relationship between the tracer conditions (varies for the national and priority district samples), used in the analyses and corresponding WHO SARA njj = Number of SDPs of type “j” in district “i” chosen for tracer conditions and national program guidelines the sample, and for each of the ATMI programs are documented in SDPjj = Total number of SDPs of type “j” in district “i.” Appendix 4. In addition to examining individual tracer conditions, the service-readiness tracer Data from sample SDPs were then weighted as elements in the analyses are aggregated into a follows: service-readiness index that was calculated as the percentage of health facilities included in the Wi,j = 1 / PRi,j analyses that satisfied all tracer conditions for a Where: given service package. Full tabulations of service Wi,j = Sampling weight for SDP “j” in district “i”, and readiness results may be found in Appendix 5. PRi,j = Joint probability of selection SDP “j” in district “i”. Assessing HIV, TB, Malaria and Childhood Immunization Supply-Side Readiness in Indonesia 17 section 3 . Epidemic and Program Overview Indonesia is undergoing a rapid epidemiological Recent data suggest that subepidemics among transition. NCDs now account for the largest KAPs–except for MSM–may no longer be expanding. share of the burden of disease in Indonesia. Until fairly recently, Indonesia was among the few Although no longer the dominant cause of countries in which annual numbers of new HIV morbidity and mortality, communicable diseases infections were continuing to rise, however, the continue, however, to pose a challenge to MoH 2016 epidemic modeling update suggests that– achieving health-related sustainable development except among MSM–numbers of new HIV infections goals, as do diseases that can be prevented by among KAPS have stabilized (MoH 2016). But, the immunization. Indonesia is roughly on course modelling also indicates that, with the current with other comparator countries in terms of trajectory, there would still be over 40,000 new HIV progress in implementing WHO recommendations infections in the year 2030 (Figure 3.1). for traditional and new vaccines for childhood immunization but does not fare well vs. MoH program data indicate that the availability of comparator countries in terms of immunization HIV-related services has increased significantly coverage. Of the communicable diseases, HIV and over the five or so years to 2017. The number of AIDS, TB and malaria continue to exact significant public-sector health facilities offering sexually tolls on the health and well-being of Indonesians transmitted infection (STI) diagnostic and and on the national economy. Indonesia stands treatment services increased significantly from out in relation to comparator countries regarding only 92 in 2010 to 2,026 in 2016; HIV counseling and the disease burden of TB and HIV. testing (HCT) service sites increased from 385 to 3,771, methadone maintenance therapy from 65 to Indonesia continues to experience a concentrated 92, Antiretroviral therapy (ART) services from 195 HIV epidemic comprised of multiple, intertwined to 704, and PMTCT services from 29 to 277 during subepidemics among several ”Key Affected the same timeframe. The above figures reflect the Populations” (KAPs). These include female sex MoH policy of decentralizing HIV and AIDS testing workers and their clients, transgendered women and treatment from hospitals to puskesmas, (Waria)9 and their clients, persons who inject however, most of these services are still provided drugs (PWID), men who have sex with men (MSM) as vertical interventions (vs. part of an integrated and prison inmates. The epidemic has developed package of services) and providing a mandatory differently in Tanah Papua, where it has reached minimum standard of service everywhere has the general population (2.3 percent general proven challenging. population prevalence in 2013). 9 Waria = Wanita pria: A third gender role found in Indonesia. 18 Figure 3.1 Estimated and Projected Numbers of Annual New HIV Infections among KAPs 80.000 Clients MSW MSM TG FSW Non-KAP males Non-KAP females IDU 60.000 40.000 20.000 0 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 2022 2024 2026 2028 2030 Source Ministry of Health 2016. Estimates and Projections of HIV/AIDS in Indonesia 2015 – 2020 Note MSW (Male Sex Worker), MSM (Man having sex with Man), TG (Transgender), FSW (Female Sex Worker), KAP (Key Affected Populations), IDU (Injecting Drug User) The national response to HIV and AIDS has evolved Stigma and discrimination remain important in recent years to focus on getting HIV-positive barriers to effectively combatting HIV and AIDS. persons onto treatment as a means of both Although efforts have been made to create saving lives and curtailing onward transmission an enabling environment for HIV and AIDS and decentralizing treatment from hospitals to interventions, a general societal drift toward puskesmas. There were nearly 78,000 persons reduced tolerance for persons with alternative receiving ART as of December 2016, however, this lifestyles and PLHIV has hindered progress, is only around 13 percent of the estimated number including among health service providers. Pressure of persons living with HIV (PLHIV) in the country, a from conservative religious groups has limited the low level of coverage by both regional and global policy space of recent governments. standards. The MoH plans to further ramp up the response by phasing in a “Test and Start All” policy under which all persons testing positive for HIV will Figure 3.2 HIV Treatment “Cascade” – Cumulative be immediately eligible for treatment–irrespective Through September 2016 of CD4 count. It is estimated that the number of 613,435 persons tested annually for HIV would have to at least double for the new strategy to be effective. Treatment initiation and retention rates also must be improved if the GoI strategy emphasising “treatment as prevention” is to succeed. Cumulative data over the life of the national HIV 226,574 program indicate that only 63 percent of persons 171,900 141,596 testing positive for HIV and enrolled in HIV care 73,037 have ever started treatment (Figure 3.2). Of those who have started treatment, only 52 percent have been retained on treatment. MoH “cohort data” HIV + HIV + in care Eligible for Started ART Still on ART indicate, however, that treatment retention rates ART (MOH) are gradually improving. Source MoH 2016 Assessing HIV, TB, Malaria and Childhood Immunization Supply-Side Readiness in Indonesia 19 Tuberculosis (TB) Indonesia has the second highest national TB burden but notes that “TB control could therefore act as a in the world, but incidence and prevalence of all marker of good practice in the ways districts address forms of TB appear to be on long-term decline. The their decentralised responsibilities” (WHO 2017). 2015 incidence rate of 395 per 100,000 population calculated by WHO translates into 1,020,000 new National TB Program (NTP) monitoring results and relapse TB cases annually (WHO 2017). These indicate that case notification has been level at estimates were revised upwards from an estimate of about 330,000 cases (all forms, new and relapse) 460,000 incident cases in 2012 following the National annually since 2011.10 This yielded a case detection Prevalence Survey (NPS) results in 2013 which found ratio against the new incidence estimate of only there were 1.6 million prevalent cases. Despite 32 percent in 2015. The biggest single challenge to these revised estimates, the burden of TB is falling TB control in Indonesia is the estimated 690,000 in Indonesia–TB incidence and prevalence rates are “missing cases” that occur each year but for which estimated to be falling at a rate of 1 percent and 2 the NTP is not notified. Mandatory notification percent per year, respectively (Figure 3.3). came into effect in 201611 to provide a stronger basis for engagement of the private sector in The “headline” conclusion of the Joint External quality TB care and should, in principle, improve Monitoring Mission (JEMM) 2017 was that the this situation. The JEMM report estimated that up implementation of the TB National Strategic Plan for to 70 percent of the missing TB patients are likely 2015-2019 is not on track. The final JEMM 2017 report to have already been picked up and are receiving notes that “the anticipated upswing of performance care from public and private service providers not in response to the 2013-2014 TB NPS has not yet currently reporting to the NTP. Private providers, happened.” To achieve this, greater attention needs especially the private pharmacies, account for 74 to be paid to the quality of TB service provision percent of initial care-seeking, and 51 percent of throughout the health system. The JEMM team treatment, but only 9 percent of case notification. recognized that some constraints to implementation are part of the wider challenge of decentralization Coverage of TB-HIV coinfections and multidrug- resistant TB (MDR-TB) remains very low. Although TB/ HIV collaborative activities (TBCA)12 began in Indonesia Figure 3.3 Trend of TB Incidence in Indonesia in 2007, WHO estimates that HIV is contributing as (1990-2015) many as 78,000 extra TB patients per year, yet less Rate per than 5 percent of those who are coinfected are 100,000/year currently being identified. Only 15 percent of TB 600 patients in 2016 had a documented HIV status, and only 28 percent of coinfected patients started on ART. Incidence, all forms Indonesia has a high number of cases of rifampicin- 400 resistant/multidrug resistant TB (RR/MDR-TB), and ranks in the 20 highest MDR-TB burden countries in the world. The precise MDR-TB burden in Indonesia is unknown as there are no nationally representative 200 Notified, all forms data on RR/MDR-TB prevalence. Precise estimates of XDR-TB are also unavailable. Based on data from Incidence, HIV+ smaller resistance surveys, WHO estimates there 0 could be as many as 32,000 incident cases of RR/MDR- 1990 1995 2000 2005 2010 TB, corresponding to around 10,000 cases among the Source WHO, JEMM, Report 2017 notified cases (WHO, JEMM for TB, 2017). 10 As a “notifiable” disease (that is, communicable diseases that can result in epidemic outbreak), notification of confirmed new cases of both TB and malaria is required by the MoH, although compliance is an issue. HIV does not require notification of new infections detected, only registration of cases in which ART is being initiated. 11 Ministry of Health Decree No. 67 2016 on TB Control, Article 23, page 14 12 TBCA entail: (i) intensification of TB case finding among people living with HIV/AIDS and key populations; (ii) expanded use of INH (Isoniazid) prophylaxis; (iii) improved TB infection control at sites with HIV patients; and (iv) early ART initiation for TB/HIV 20 Malaria Indonesia is characterized by complex malaria to a 2008 baseline (85 percent accomplishment, epidemiology with more than 21 confirmed which also met the GoI Millennium Development mosquito vectors of malaria and five Plasmodia Goal target, it fell short of achieving an 80 commonly infecting humans (WHO, JMPR 2017)13. percent reduction in malaria-related mortality Malaria transmission in Indonesia is unsurprisingly (accomplishment = 60 percent) and of eliminating highly variable as well, including by district and malaria in four provinces (Java, Bali, Aceh within districts. Consequently, the national malaria Darussalam and Riau islands) by 2015 (the target program needs to be developed to address these was achieved only in Bali). The joint review team complexities. Over the decade to 2016 the MoH has concluded that the latter result is because the made a concerted effort to collect malaria data by NMP is not yet implementing a true elimination district for the entire country. Table 3.1 summarizes strategy, although some elements are present. these data, for three broad regions of the country: (i) Java and Bali; (ii). Sumatra, Kalimantan, Sulawesi The primary barriers to access for malaria control and West Kalimantan; and (iii) Eastern Indonesia, services are socioeconomic and geographic. including Nusa Tenggara, Maluku, and Tanah Malaria in Indonesia is more prevalent in poor, Papua. These regions roughly correspond to areas geographically isolated areas. As poor people of the country in WHO-defined stages of malaria living on the margins of Indonesian society, the elimination, pre-elimination, and control. The response of the formal health sector to their five easternmost of Indonesia’s 33 provinces have complaints and demands may be suboptimal. only 8 percent of the country’s population but 70 The formal health sector is weakest in eastern percent of its malaria cases. Indonesia, where facilities may exist, but the few posted staff are poorly trained. In this part of the A review of accomplishments against targets in country, nongovernment organizations (NGOs) the National Malaria Strategic Plan 2010-2015 and faith-based organizations (FBOs) play a reveals mixed results. While the program was more important role in outreach to the main risk successful in reaching its target of an 80 percent groups–the rural poor and migrants–than in the reduction in malaria case load by 2015 relative rest of Indonesia. Table 3.1 Distribution of Annual Parasite Index (API) by Provinces and Districts (2016) Sumatra, East Nusa Kalimantan, Number of API Java-Bali Tenggara, Population Sulawesi, West Districts Maluku, Papua Nusa Tenggara Bebas 2 0 0 2 14,477,697 <1 5 22 0 27 232,241,411 Province 1<5 0 0 3 3 8,104,974 >=5 0 0 2 2 4,100,806 Total 7 22 5 34 258,924,888 Bebas 113 134 0 247 178,715,165 <1 15 138 13 166 63,653,328 Kab/Kota 1<5 0 26 34 60 11,681,806 >=5 0 3 38 41 4,874,589 Total 128 301 85 514 258,924,888 Source MoH, Malaria Program Report 2017. 13 Ministry of Health and WHO, The Joint Malaria Program Review, 2017 Assessing HIV, TB, Malaria and Childhood Immunization Supply-Side Readiness in Indonesia 21 Childhood Immunization Indonesia’s current immunization schedule There are a variety of estimates of immunization covers all WHO’s recommendations for traditional coverage available that paint a somewhat different vaccines. Indonesia is currently in the process of picture of national accomplishments. MoH facility- launching a combination measles/rubella vaccine, based data for 2016 show that 93 percent of children which will become part of the routine immunization 12-23 months were fully immunized, while various package. Indonesia has not yet adopted WHO’s new surveys have produced estimates ranging between vaccine recommendations but is in the process of 59 percent and 68 percent during the 2012-16 period. doing so. This is similar to the situation in most Data from the annual National Socioeconomic comparable countries. Indonesia has sustained Survey (Susenas) between 2012 and 2015 indicate polio-free status and, in line with the commitment that full immunization coverage has hovered to global polio eradication, has switched from tOPV between 65 percent and 70 percent during the (trivalent oral polio vaccine) to bOPV (bivalent oral reference period (Figure 3.4). Mild upward trends are polio vaccine) and has introduced one dose IPV observed for DPT3 and POL3 coverage, but not for (inactivated poliomyelitis vaccine) into the routine Bacillus Calmette–Guérin (BCG) or Measles. immunization program in 2016. Despite increases in coverage rates in recent Indonesia has also achieved Maternal and decades, Indonesia does not compare favorably Neonatal Tetanus Elimination which validated to its peers when it comes to immunization. in 2016 and has improved equity in vaccination Indonesia is richer than Cambodia, the Philippines, coverage. Nontraditional vaccines that have been and Vietnam, but has significantly lower coverage added onto the national program include Hepatitis rates for DPT3 and measles immunization (World B (HepB) and Hib in the form of a pentavalent Bank 2016). WHO and UNICEF estimates indicate vaccine and an introduction campaign for the that Indonesia’s immunization coverage has Human papilloma virus vaccine. Other new plateaued in recent years, and there remains as vaccines for Japanese Encephalitis, pneumococcal, much as a threefold difference in immunization and rotavirus are scheduled for introduction by coverage rates across provinces. DPT14 2019. In addition to the national schedule for immunization rates, for example, are almost 90 infants less than one year of age, a second dose of percent or more in Bali and Yogyakarta but only measles vaccine is administered at 24 months in 35 percent in Papua and less than 50 percent in selected provinces. Maluku, Banten, and West Sulawesi (World Bank 2016). Inequalities are large by economic status as well, and these have been persistent over time. Figure 3.4 Estimates of Immunization Coverage (2012-16) % 100 90 80 70 60 BCG Measles POL3 DPT3 Fully Immunized 50 2012 2013 2014 2015 2016 Source National Socioeconomic Survey (Susenas) 2012-16 14 DPT: Diphtheria, pertussis and tetanus. 23 section 4 . Service Availability and Readiness HIV Counseling and Testing (HCT) The availability of HIV-related services varies all tracer conditions, yielding an overall readiness widely by type of service and type of health facility. index score of 85 percent (Figure 4.1). Readiness at HIV counseling and testing (HCT) services are the private hospitals lagged that at public hospitals most widely available among HIV-related services, on all tracers and overall (mean index score of 72 being universally available in public hospitals and percent). Puskesmas in priority districts are better in the large majority of puskesmas (73 percent prepared to provide HCT services in comparison nationally and 77 percent in HIV priority districts) with puskesmas in the national sample (mean and private hospitals (72 percent) (Table 4.1). HCT index score of 67 percent vs. 54 percent), and far services are more readily available in public vs. more service-ready than private sector GPs who private facilities, and by a sizeable margin. Nearly in the aggregate are ill-prepared to provide HCT all public-sector facilities offer both voluntary services. The major contributing factors to low counseling and testing (VCT) and provider- readiness index scores for puskesmas were lack of initiated testing and counseling (PITC). Only minor HCT service guidelines (available in only 49 percent differences are observed among puskesmas in the of puskesmas in priority districts and 29 percent national and priority district samples. nationally) and privacy amenities (49 percent in priority districts and 40 percent nationally). The highest level of HCT service readiness is found Condoms were available in only 44 percent of at public hospitals in priority districts. Public puskesmas in the national sample, but in 71 hospitals scored in the 75-100 percent range for percent in priority districts. Table 4.1 SDPs with HIV Counseling & Testing Services Available (by Sample and Type of SDP) (%) Services Sample Puskesmas Private GP Public Hospital Private Hospital National 73 (n=268) 21 (n=289) – – HCT Priority 77 (n=371) 34 (n=491) 100 (n=37) 72 (n=53) National 86 (n=195) 26 (n=61) – – VCT * Priority 90 (n=285) 37 (n=167) 100 (n=37) 61 (n=38) National 87 (n=195) 19 (n=61) – – PITC * Priority 89 (n=285) 20 (n=167) 100 (n=37) 67 (n=38) Note *The percentages shown pertain to the SDPs providing any relevant services as shown in the first row of the table. The figures in parentheses in each cell indicate the number of SDPs contributing to the service readiness score. 24 HCT service readiness varies significantly by percent vs 55 percent, respectively – Annex 5b), district. This has significant implications for and interestingly BPJS-K-empaneled private GPs both capacity strengthening efforts and further are more service-ready than nonempaneled GPs service expansion. Urban puskesmas in general (30 percent vs 13 percent), although their level of have higher levels of preparedness than their preparedness remains low. rural counterparts (mean index scores of 69 Figure 4.1 HCT Readiness (by Tracer and Type of SDP) Puskesmas Private Clinic/GP Public Hospital Private Hospital 49 12 Guidelines 76 61 29 5 74 32 Staff Trained 79 50 68 31 49 28 Visual and auditory privacy 88 50 40 44 91 17 HIV diagnostic capacity 100 83 89 9 71 13 Condoms 82 33 44 15 67 20 HCT Readiness Index (mean) 85 72 54 21 19 0 HCT Readiness Index (met all) 45 31 6 0 Percentage Priority National Source World Bank staff calculations. Figure 4.2 HCT Service Readiness Index Scores (by District) (%) 47 49 50 54 60 60 61 63 64 66 68 71 75 75 75 80 85 90 93 67 54 20 21 85 72 Districts Public Hospital Banyuwangi Semarang Banyumas Majalengka Bandung Puskesmas-Priority Cilacap Banjarmasin Merauke Manokwari Mataram Cilegon Deli Serdang Tegal Jakarta Timur Private-Priority Private-National Private Hospital Jakarta Pusat Padang Tanjung Pinang Pare-Pare Puskesmas-National Tangerang Source World Bank staff calculations. Assessing HIV, TB, Malaria and Childhood Immunization Supply-Side Readiness in Indonesia 25 HIV Care, Support and Treatment (CST) Despite efforts to decentralize public sector Although the availability of CST services at HIV CST services from hospitals to puskesmas, puskesmas is limited, service readiness at those such services remain concentrated in hospitals, puskesmas that do offer CST services approached primarily public hospitals. CST service availability that for public hospitals (mean index value of is far and away the highest at public hospitals 80 percent for priority district puskesmas vs. (89 percent). By way of comparison, even in HIV 84 percent for public hospitals) (Figure 4.4). priority districts only 22 percent of puskesmas Private hospitals were far less ready to provide provide CST services (15 percent in the national CST services (63 percent). The main tracer sample). While service availability at private conditions that differentiated public hospitals hospitals exceeds that of puskesmas (34 percent), from puskesmas were: (i) availability of service this lags considerably behind public hospitals. guidelines; and (ii) presence of staff trained in Very few private GPs offer CST services. Treatment CST in the past two years. Public hospitals were initiation (that is, prescription of ART) remains less well prepared for dealing with opportunistic even more concentrated–only 38 percent and 39 infections, in particular, fungal infections. As with percent of puskesmas in HIV priority districts, and other services, CST service readiness at puskesmas national sampling respectively, that offer HIV CST varies significantly by district (Figure 4.5). services can prescribe treatment (Figure 4.3). The corresponding figures for hospitals are 88 percent of public hospitals and 50 percent of private hospitals. About two-thirds of puskesmas offered treatment services for opportunistic infections associated with HIV, but a surprisingly small proportion of puskesmas prescribed micronutrient supplementation to PLHIV (20 percent in priority districts). Figure 4.3 SDPs with HIV CST Services Available (by Sample and Type of SDP) (%) Puskesmas Public Hospital Private Hospital 62 Treatment of opportunistic infections 94 67 64 85 Provide or prescribe treatment for TB 88 61 78 Prescription of micronutrient supplementation for 20 76 61 People Living with HIV 22 Family planning counseling 83 76 61 for People Living with HIV 71 Prescription of ARV for 38 88 50 People Living with HIV 39 Screening or testing for TB 85 88 61 among People Living with HIV 79 Provision of male condoms to 93 prevent further transmission of HIV 88 44 82 86 Nutritional rehabilitation services 76 61 75 Priority National Source World Bank staff calculations. 26 Figure 4.4 HIV CST Service Readiness (by Tracer and Type of SDP) Puskesmas Public Hospital Private Hospital Guideline 41 76 50 18 Staff Trained 67 91 56 50 System for diagnosis of TB among HIV + clients 85 88 61 79 Intravenous solution with infusion set 99 99 IV treatment fungal infections 74 67 67 74 Co-trimoxazole cap/tab 96 85 72 95 First-line TB Medications 97 94 78 98 Palliative Care Pain Management 94 95 Condoms 72 53 88 56 CST Readiness Index (mean) 80 74 84 63 CST Readiness Index (met all) 26 16 42 33 Priority National Source World Bank staff calculations. Figure 4.5 HIV CST Service Readiness Index Scores (by District) (%) 67 67 67 69 72 72 73 74 83 84 85 86 89 89 93 96 96 100 100 80 74 84 63 Districts Public Hospital Banyuwangi Banyumas Cilegon Bandung Banjarmasin Mataram Merauke Cilacap Manokwari Majalengka Deli Serdang Jakarta Timur Tegal Pare-Pare Puskesmas-Priority Tangerang Jakarta Pusat Padang Semarang Puskesmas-National Tanjung Pinang Private Hospital Source World Bank staff calculations. Assessing HIV, TB, Malaria and Childhood Immunization Supply-Side Readiness in Indonesia 27 Anti-retroviral Therapy (ART) ART services are also highly concentrated in ART service readiness was weak at all types of hospitals, but to a greater degree in public facilities. Public hospitals were the most service- hospitals. The limited availability of ART ready (mean service readiness index of 52 percent) prescription and/or follow-up services at (Figure 4.6). Readiness at puskesmas in priority puskesmas (38 percent in priority districts vs. 88 districts (37 percent) and private hospitals (38 percent of public hospitals – Figure 4.3 above) percent) lagged behind. Puskesmas readiness reflects the still limited decentralization of HIV was constrained by a number of factors, including CST services from large hospitals. The private lack of service guidelines, limitations in trained sector has, to date, been slow in filling this gap, staff, capacity to perform several of the tests with only 56 percent of private hospitals in priority required to initiate treatment, and availability districts offering ART services and no private GPs. of some/many of the large number of drugs As a result of service limitations at puskesmas, currently included in the national treatment residents of a number of districts have few options guidelines. Limited availability of drugs was the as to which puskesmas to use to receive services. main constraining factor at both public and private hospitals. Extreme variations in service readiness are observed in comparing service readiness in priority districts (Figure 4.7). Figure 4.6 HIV ART Service Readiness (by Tracer and Type of Facility) Puskesmas Public Hospital Private Hospital Guideline 62 80 80 33 Staff Trained 67 83 80 53 75 N/A N/A Full blood count 69 CD4 or Viral load 5 70 60 9 Renal function test(serum creati 47 N/A N/A 28 Liver function test (ALT or othe 45 N/A N/A 26 Zidovudine Cap/tab (ZDV, AZT) 37 67 50 37 Zidovudine syrup/suspension (ZDV 8 3 0 11 Abacavir Cap/tab (ABC) 10 0 0 0 59 Lamivudine Cap/tab (3TC) 68 3 0 Tenofovir Disoproxil Fumarate ca 54 90 50 66 Emtricitabine cap/tab (FTC) 17 83 70 14 Didanosine cap/tab (DDI) 2 90 70 2 Zidovudine + Lamivudine cap/tab( 71 10 10 50 Nevirapine cap/tab (NVP) 53 87 70 48 13 Nevirapine syrup/suspension (NVP 13 20 10 Efavirenz Cap/tab (EFV) 68 53 20 68 Lopinavir + Ritonavir Cap/tab (L 19 17 10 13 ARV syrups for children (AZT + 3 18 80 30 28 Stavudine + Lamivudine + Nevirap 14 N/A N/A 15 ART Readiness Index (mean) 37 52 38 33 Readiness Index (met all) 0 0 0 0 Priority National Source World Bank staff calculations. 28 Figure 4.7 ART Service Readiness Index Scores (by District) (%) 0 0 0 0 0 8 13 15 23 23 30 33 37 40 50 51 55 65 70 37 33 52 38 Districts Public Hospital Kab. Banyuwangi Puskesmas-National Kota Mataram Kota Banjarmasin Kab. Majalengka Kab. Merauke Kota Padang Kab. Manokwari Kota Cilegon Kab. Cilacap Kota Tegal Kab. Banyumas Kota Pare-Pare Kota Jakarta Timur Puskesmas-Priority Kab. Tangerang Kota Tanjung Pinang Kab. Deli Serdang Kota Jakarta Pusat Kota Bandung Kab. Semarang Private Hospital Source World Bank staff calculations. Prevention of Mother-to-Child Transmission (PMTCT) PMTCT services are far more likely to be found in The mean service readiness index for PMTCT public than private SDPs. A high share of public was above 45 percent for all categories of SDPs, hospitals (89 percent), provide PMTCT services. except for private primary care. Puskesmas in Meanwhile, although PMTCT has been rolled priority districts and hospitals, both public and out as a horizontally integrated service with private, all scored in the 36 - 53 percent range for maternal health, only 65 percent of puskesmas Puskesmas, and between 49 and 79 percent for in HIV-priority districts offer such services, as hospitals (Annex 5b). Readiness of private GPs do 54 percent of puskesmas nationally. Just was very low (15 percent in priority districts). The under 40 percent of private hospitals in priority main readiness constraints at both puskesmas and districts (38 percent) provide PMTCT services, as public hospitals were insufficient staff training, do 15 percent of private GPs in priority districts lack of service guidelines and drug availability. (19 percent nationally). Services at puskesmas Diagnostic capacity for adults was stronger at and private GPs are, however, largely limited to public hospitals than at puskesmas. Service counseling as very small proportions of such readiness at private hospitals lagged that at service providers provide ARV prophylaxis for public hospitals in all service categories other neonates or ART for pregnant women, meaning than availability of service guidelines. Private GPs that referral of HIV-positive pregnant women and had extremely limited capacity to provide PMTCT neonates to other facilities is required in most services. As with other services, PMTCT service cases. ARV prophylaxis for neonates and ART for readiness at puskesmas varies significantly by pregnant women at private hospitals are available district (Figure 4.10). at only 25 percent and 40 percent of such facilities, respectively (Figure 4.8). Assessing HIV, TB, Malaria and Childhood Immunization Supply-Side Readiness in Indonesia 29 Figure 4.8 SDPs with PMTCT Services Available (by Sample and Type of SDP) (%) Puskesmas Private Clinic/GP Public Hospital Private Hospital Counseling to all pregnant women 100 100 on reproductive health, STI, and HIV 82 95 100 95 HIV counseling and testing 73 32 88 70 services to pregnant women 70 22 Provide ARV as treatment for 15 2 76 40 HIV positive pregnant women 18 1 Provide ARV prophylaxis for neonates 9 4 of HIV positive pregnant women 70 25 12 3 Nutritional counseling for HIV positive 80 68 pregnant women and their infants 76 70 78 59 Family planning counseling to 77 76 HIV positive pregnant women 76 60 74 69 Priority National Source World Bank staff calculations. Figure 4.9 PMTCT Service Readiness (by Tracer and Type of SDP) (%) Puskesmas Private Clinic/GP Public Hospital Private Hospital 60 17 Guidelines on HIV PMTCT 61 70 45 19 Guidelines on infant and young child 56 15 feeding practices (IYCF/PMBA) 56 8 60 35 Staff Trained in HIV PMTCT 79 55 56 31 Visual and Auditory PrivacyRoom 39 7 85 40 31 10 HIV diagnostic capacity for adults 72 5 97 65 67 2 ARV syrups for children (AZT+3TC+NVP) 3 0 73 15 4 0 50 15 PMTCT Readiness Index (mean) 79 49 46 12 PMTCT Readiness Index (met all) 0 0 30 10 0 0 Priority National Source World Bank staff calculations. 30 Figure 4.10 PMTCT Service Readiness Index Scores (by District) (%) 34 34 35 36 41 44 45 49 49 50 51 53 56 57 59 60 62 68 70 50 46 15 12 79 49 Districts Public Hospital Banyuwangi Semarang Banyumas Cilegon Private Clinic/GP-Priority Private Clinic/GP-National Deli Serdang Bandung Puskesmas-Priority Banjarmasin Manokwari Jakarta Timur Puskesmas-National Majalengka Pare-Pare Mataram Tegal Cilacap Merauke Jakarta Pusat Tangerang Tanjung Pinang Padang Private Hospital Source World Bank staff calculations. Tuberculosis (TB) TB services are universally available at TB service readiness varied widely by type of puskesmas, public and private hospitals, SDP, with readiness index scores ranging from but at only about 50 percent of private GPs, 25 (private) - 74 percent (puskesmas referral and however, the package of services being provided independent). Independent/Referral puskesmas varies considerably by type of SDP. The most were well prepared regarding diagnosis via comprehensive package of services is offered at sputum smear microscopy and clinical symptoms, puskesmas and, except for diagnostic testing, at provision of medicines to patients and availability satellite puskesmas (Table 4.2). All public hospitals of first-line TB drugs, but quite limited with offered examination and testing services, but regard to matters related to TB-HIV coinfection only 81 percent in priority districts prescribed and management of MDR-TB. First-line TB treatment. Private hospitals have high levels medications–Isoniazid, Rifampicin, Pyrazinamide, of diagnostic capacity, but less than one-half and Ethambutol–were available nationally in 94 prescribe TB treatment. Most (85-90 percent) percent of front-line puskesmas, 88 percent of private GPs prescribe treatment for TB, but only satellite puskesmas, and 95 percent of public about one-third had diagnostic capacity. DOTS hospitals. This represents a marked improvement therapy is nearly universal in puskesmas but is from the 2011 and 2013 data reported in the 2014 provided in only 62 percent of public hospitals in Health Sector Review, where such drugs were priority districts, 50 percent of private GPs and available in less than one-half of puskesmas (48 one-third of private hospitals. Treatment follow- percent) and only 27 percent of public hospitals. up, which is also nearly universal in puskesmas, is Public hospitals, which on average had the offered by even fewer private GPs and hospitals. highest readiness index scores (Figure 4.12), were constrained by limitations in case management and follow-up, staff training in MDR-TB treatment, Assessing HIV, TB, Malaria and Childhood Immunization Supply-Side Readiness in Indonesia 31 and laboratory capacity (specifically diagnosis via is modest, with a maximum difference of 9 culture and GeneXpert). Private hospitals were less percentage points. Differences in service readiness ready in every category of tracer conditions. between priority and nonpriority districts are As for other ATMI programs, there is considerable negligible. variability in levels of TB service readiness at Independent/Referral Puskesmas across districts Comparison of 2016 QSDS data with 2011 health (Figure 4.13), however, the degree of interdistrict facility census data (Rifaskes) reveals mixed variability is lower for TB than for the other ATMI results regarding improvements in TB service programs. readiness at puskesmas. On the positive side, significant improvements in the availability of TB service readiness in priority districts is first-line TB drugs and a modest improvement systematically higher at urban than rural SDPs. in sputum smear microscopy readiness were This is true of all puskesmas (all categories) observed (Figure 4.14). These were, however, offset and private GPs in priority districts (Table 4.3), by declines in readiness regarding the availability however, the magnitude of differences in readiness of trained staff and service guidelines. Table 4.2 SDPs with TB Services Available (by Sample and Type of SDP) (%) Puskesmas Public Private Indicator Sample Referral & Private GP All Satellite Hospital Hospital Independent National 99 (n=268) 100 (n=212) 100 (n=55) 49 (n=289) – – TB Services Available Priority 100 (n=371) 100 (n=241) 100 (n=129) 49 (n=491) 100 (n=37) 100 (n=53) Examination and National 89 (n=266) 100 (n=212) 42 (n=55) 27 (n=141) – – Diagnostic Test * Priority 69 (n=371) 100 (n=241) 23 (n=129) 36 (n=240) 100 (n=37) 94 (n=53) Prescription of TB National 99 (n=266) 100 (n=212) 94 (n=55) 85 (n=141) – – Treatment * Priority 99 (n=371) 100 (n=241) 98 (n=129) 87 (n=240) 81 (n=37) 47 (n=53) National 96 (n=266) 95 (n=212) 100 (n=55) 43 (n=141) – – DOTS * Priority 98 (n=371) 97 (n=241) 99 (n=129) 51 (n=240) 62 (n=37) 34 (n=53) Treatment Follow- National 97 (n=266) 97 (n=212) 97 (n=55) 26 (n=141) – – up * Priority 99 (n=371) 99 (n=241) 99 (n=129) 27 (n=240) 35 (n=37) 17 (n=53) Note * The percentages shown pertain to the SDPs providing any relevant services as shown in the first row of the table. The figures in parentheses in each cell indicate the number of SDPs contributing to the service readiness score. Source World Bank staff calculations Table 4.3 Average TB Service Readiness Index Scores at Primary Care SDPs (by Type of SDP, Priority District Status and Urban-Rural) (%) National Sample Priority District Sample Type of facility All Urban Rural All Urban Rural Referral & Independent 70 (n=212) 72 (n=137) 68 (n=75) 74 (n=241) 75 (n=191) 69 (n=50) Puskesmas Satellite 58 (n=55) 57 (n=21) 58 (n=34) 58 (n=129) 58 (n=106) 54 (n=23) Puskesmas All type of 65 (n=267) 70 (n=158) 61 (n=109) 61 (n=370) 61 (n=297) 61 (n=73) Puskesmas Private GP 25 (n=130) 25 (n=111) 28 (n=19) 37 (n=222) 37 (n=203) 28 (n=19) Note The figures in parentheses in each cell indicate the number of SDPs contributing to the service readiness score. Source World Bank staff calculations 32 Figure 4.11 TB Service Readiness at Primary Health Care Level (by Tracer and Type of SDP) (%) Puskesmas Puskesmas Puskesmas-Satellite Private Clinic/GP Laboratory Referral & Independent Guideline 73 69 78 30 48 48 47 14 Training: TB diagnosis and treatment 39 47 28 32 47 49 40 19 Training: Client MDR-TB treatment 34 40 26 22 36 37 32 15 Microscopy 52 74 71 79 HIV diagnostic capacity 45 63 38 42 Sputum smear and microscopy examination 54 92 77 95 Clinical symptoms 60 86 23 32 76 84 42 24 Provision of drugs to TB patients 99 100 97 45 98 98 97 38 First-line TB medications 96 96 96 59 94 95 88 43 TB Readiness Index (mean) 61 74 58 32 65 70 58 25 6 10 2 1 TB Readiness Index (met all) 2 3 6 1 Priority National Source World Bank staff calculations. Figure 4.12 TB Service Readiness at Hospitals (by Tracer and Type) (%) Public Hospital Private Hospital Guideline 86 49 Guideline: Management of HIV-TB 70 28 Training: TB diagnosis and treat 59 28 Training: Management of HIV-TB c 59 25 Training: Client MDR-TB treatmen 41 17 Microscopy 97 89 HIV diagnostic capacity 92 45 Sputum smear and microscopy exam 95 72 Mantoux test for diagnosis 70 51 Clinical symptoms 95 85 X-Ray/Rontgen 100 81 Provision of drugs to TB patient 86 60 Management and treatment follow 35 17 First-line TB medications 95 79 Readiness Index (mean) 77 50 Readiness Index (met all) 5 0 Source World Bank staff calculations. Assessing HIV, TB, Malaria and Childhood Immunization Supply-Side Readiness in Indonesia 33 Figure 4.13 TB Service Readiness at Independent/Referral Puskesmas (by District) (%) 61 62 67 68 70 71 73 74 74 74 75 75 78 80 81 81 81 83 84 74 32 77 50 Districts Kab. Deli Serdang Kab. Tangerang Public Hospital Kota Tanjung Pinang Kota Padang Kota Tegal Kab. Banyumas Kota Jakarta Timur Kota Banjarmasin Kab. Cilacap Kab. Manokwari Kota Cilegon Kota Pare-Pare Kota Mataram Kab. Merauke Kota Bandung Kota Jakarta Pusat Puskesmas Referral/Independent Private GP Kab. Semarang Private Hospital Kab. Majalengka Kab. Banyuwangi Source World Bank staff calculations. Figure 4.14 Changes in Selected TB Service Readiness Tracer Conditions in Puskesmas (2011 to 2016) First-line TB medications Sputum smear and microscopy examination Rifaskes-2011 QSDS-2016 Staff Trained Guideline 0 20 40 60 80 100 Percentage Source World Bank staff calculations. 34 Malaria Malaria services were available at virtually districts offered some malaria services, service all puskesmas in malaria priority districts readiness was relatively low (mean readiness score (98 percent) and in 88 percent of puskesmas of 33 percent). nationally. Ninety-seven percent of puskesmas in priority districts had testing capacity to Levels of malaria service readiness by district are confirm malaria diagnoses (Figure 4.15), the most extremely variable, even among priority districts. common form being by RDT (71 percent) followed The range from low to high readiness index scores by via microscopy (60 percent). Only 49 percent in priority districts was from 26 percent to 88 of private GPs in malaria priority districts and percent (mean 66 percent) (Figure 4.17). As these 28 percent nationally provided malaria services. districts are all located in malaria endemic areas, Most diagnoses by private GP practices in priority this poses a significant threat to capacity to districts were by clinical symptoms (78 percent). control malaria. Both puskesmas and private GPs in urban areas were better prepared to provide Service readiness was considerably lower, with malaria services meeting national standards than mean readiness index scores of 64 percent in the were their rural counterparts. Urban puskesmas national sample and 66 percent in the priority in priority districts had a mean readiness score district sample. On the positive side, 82 percent of 86 percent vs. 61 percent for rural puskesmas of puskesmas in priority districts were prepared (Appendix 5b). The corresponding figures for to conduct rapid malaria testing (76 percent via private GPs were 35 percent and 29 percent, microscopy), 76 percent had first malaria drugs respectively. (up from 62 percent in 2011) and 86 percent had paracetamol in stock (Figure 4.16). Less positively, Comparison of 2016 QSDS data with 2011 Rifaskes only 31 percent reported having malaria service reveals mixed results regarding improvements in guidelines. Puskesmas in the national sampled malaria service readiness at puskesmas. Modest, districts scored higher in five out of seven tracers, but statistically significant, improvements are but priority district puskesmas were significantly observed for three of the five tracers shown higher in two commodity tracers (rapid malarial in Figure 4.18, but this was accompanied by a test kit and first line drugs). Although a significant significant decline in the availability of service proportion of private GPs in malaria priority guidelines. Figure 4.15 Percent of Primary Care Facilities with Malaria Services Available (by Sample and Type of Facility) (%) Puskesmas Private Clinic/GP 97 94 Availability of Malaria Diagnosis 91 90 97 100 Availability of Malaria Treatment 88 75 71 29 Malaria IPT 46 20 Percentage Priority National Source World Bank staff calculations. Assessing HIV, TB, Malaria and Childhood Immunization Supply-Side Readiness in Indonesia 35 Figure 4.16 Malaria Service Readiness (by Tracer and Type of SDP) (%) Puskesmas Private Clinic/GP 31 21 Guideline 42 18 50 12 Staff Trained 55 7 82 38 Rapid Malaria Testing 63 4 63 21 Malaria smear test 66 11 76 38 Capacity to conduct malaria microscopy 84 30 76 50 First-line antimalarial in stock 42 19 86 74 Paracetamol cap/tab 96 65 66 33 Malaria Readiness Index (mean) 64 22 0 3 Malaria Readiness Index (met all) 11 0 Percentage Priority National Source World Bank staff calculations. Figure 4.17 Average Malaria Service Readiness Index Scores (Priority Districts) (%) 27 40 52 54 57 58 66 69 76 76 77 60 56 33 19 Deiyai Dogiyai Tegal Labuhan Batu Utara Malaka Mamberamo Tengah Pesawaran Sorong Maluku Tenggara Barat Bangka Barat Aceh Jaya Puskesmas-Priority Puskesmas-National Private Clinic/GP-Priority Private Clinic/GP-National Source World Bank staff calculations. 36 Figure 4.18 Changes in Selected Malaria Service Readiness Tracer Conditions (2011 to 2016) Paracetamol cap/tab First-line antimalarial in stock Rifaskes-2011 Rapid malaria testing QSDS-2016 Staff Trained Guidelines 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Source World Bank staff calculations. Childhood Immunization Immunization services are offered at several to boost immunity to measles, diphtheria, and to SDPs within the health system. These include provide future maternal immunity against tetanus. posyandu, polindes, puskesmas, schools, and at government and/or private hospitals or clinics. The QSDS data indicate that childhood Indonesia also sometimes conducts national or immunization services are widely available in subnational immunization campaigns. A large puskesmas nationally (98 percent), but only in a majority (almost three-fourths) of all vaccinated minority of private sector GPs (15 percent). The children in Indonesia receive their immunization at service package offered by private GPs is, however, posyandus, followed by 10 percent at puskesmas, more complete than that found at puskesmas 10 percent at private clinics and hospitals (Figure 4.19). While only 4 percent of puskesmas (although this can be as high as 50 percent in some offer polio injections (IPV) and 44 percent Combo provinces), and the remainder at polindes and Tetravalent (DPT-HepB), virtually all private GPs other places (including midwives’ homes). Routine offer these immunizations. immunization is also provided for school children via the school-based BIAS15 program. This program Two-thirds (67 percent) of puskesmas offer daily targets children in the first through third grades or weekly immunization services, and 92 percent 15 BIAS: Bulan Imunisasi Anak Sekolah (Schoolchildren’s Immunization Month). Assessing HIV, TB, Malaria and Childhood Immunization Supply-Side Readiness in Indonesia 37 provide outreach services on at least a monthly Puskesmas service readiness varies significantly basis (Figure 4.20). Among private GPs offering across priority districts. Although high overall, immunization services, the frequency of services is service readiness dips to below 75 percent in a roughly comparable to that at puskesmas but few number of priority districts (Figure 4.22). On the private GPs offer outreach services. other hand, service readiness indexes of over 90 percent are observed in nine districts. Service Service readiness for childhood immunization at readiness tends to be higher among urban than puskesmas is higher than for HIV, TB or malaria. rural puskesmas (mean readiness index of 89 The mean service readiness index score for percent vs. 80 percent) (Appendix 5b). The urban- puskesmas in 2016 was 84 percent, with 28 percent rural differential was higher among private GPs– of all puskesmas satisfying all tracer conditions mean readiness index of 55 percent in urban areas (Figure 4.21). Vaccines at puskesmas were widely vs. 52 percent in rural area. BPJS-K-empaneled available–80-90 percent of all puskesmas had private GPs were only slightly less service-ready government-mandated vaccines such as measles, than nonempaneled GPs (mean readiness index of DPT, polio, and BCG vaccines in stock at the time 54 percent vs. 58 percent). of the 2016 QSDS, although this is slightly lower than the 90 percent plus figure reported in the Comparison of 2016 QSDS data with 2011 2011 MoH health facility census (MoH and World Rifaskes data indicates mixed results Bank 2014). Cold-chain equipment was functioning regarding improvements in child immunization in more than 90 percent of puskesmas. The major service readiness at puskesmas. Of the 11 puskesmas service readiness constraints observed tracers considered in Figure 4.23, there were were lack of service guidelines (69 percent), improvements in four, no change in one, insufficient trained staff (76 percent), and lack of and declines in six. All measured changes auto-disable syringes (available in only 69 percent were statistically significant. The substantial of puskesmas). Service readiness at private GPs improvement in the availability of trained staff is lagged that at puskesmas in every category of noteworthy. tracer indicator–except for the availability of a sharps container (Figure 4.21). Figure 4.19 Changes in Selected Malaria Service Readiness Tracer Conditions (2011 to 2016) HepBo 100 100 BCG 100 100 Polio vaccine (oral) 99 100 Polio vaccine (injection) 4 100 DTP+HepB (Tetravalent) 44 99 DTP+HebB+HiB (Pentavalent) 96 99 Measles 100 100 Percentage Puskesmas Private Clinic/GP Source World Bank staff calculations. 38 Figure 4.20 Frequency of Immunization Services (by Type of Service and SDP) In Facillity Service Schedule Outreach Schedule 60 80 65% 50 60 40% 40 33% 30 27% 29% 40 23% 19% 20 15% 20 18% 11% 10 9% 9% 7% 0% 2% 4% 0 0 Daily Weekly Monthly Not Reguler Daily Weekly Monthly Not Reguler Puskesmas Private GP Source World Bank staff calculations. Figure 4.21 Frequency of Immunization Services (by Type of Service and SDP) Guideline 69 34 Staff Trained 76 47 Cold box/vaccine carrier 93 65 Refrigerator 96 90 Sharps container/safety box 88 94 Auto-disable syringes 69 56 Temperature monitoring device 92 53 Adequete refrigerator temperatur 84 42 Measles Vaccine 86 46 DPT+Hib+HepB Vaccine 82 36 Oral Polio Vaccine 85 47 BCG Vaccine 84 49 Readiness Index (mean) 84 55 Readiness Index (met all) 28 3 Percentage Puskesmas Private Clinic/GP Source World Bank staff calculations. Assessing HIV, TB, Malaria and Childhood Immunization Supply-Side Readiness in Indonesia 39 Figure 4.22 Average Childhood Immunization Service Readiness Index Scores (by District) (%) 100 80 60 40 20 69 70 75 77 78 79 81 81 81 82 83 85 86 90 91 91 93 93 93 94 64 99 84 55 0 Yalimo Tapanuli Selatan Indragiri Hilir Merauke Cirebon Pasuruan Cilacap Tomohon Pesisir Selatan Simeulue Aceh Jaya Tegal Banjarbaru Lhokseumawe Banjarmasin Padang Tangerang Bima Semarang Sungai Penuh Mataram Banjar Puskesmas Private Clinic/GP Source World Bank staff calculations. Figure 4.23 Changes in Selected Immunization Service Readiness Tracer Conditions (2011 to 2016) BCG Vaccine Oral Polio Vaccine DPT+Hib+Hepb Vaccine Measles Vaccine Temperature monitoring device in refrigerator Auto-disable syringes Sharps container/safety box Refrigerator Cold box/vaccine carrier with ice pack Staff Trained Guidelines 0 20% 40% 60% 80% 100% Rifaskes-2011 QSDS-2016 Source World Bank staff calculations. 40 Cross-Program Issues One striking finding from the 2016 QSDS data is The predominant explanation for lack of service the lack of service guidelines at many SDPs across guidelines among respondents to the QSDS at all four programs of interest. Satisfying this tracer reference SDPs was that the facility had never condition required having a copy of MoH service received such guidelines. Data were collected at guidelines at public SDPs, while either MoH or hospitals for HCT, PMTCT and TB and at puskesmas facility-generated guidelines satisfied the tracer for immunization. In priority districts, the condition for nonstate SDPs. The availability of proportions of public hospitals reporting never service guidelines was uniformly insufficient in having received service guidelines were 38 percent puskesmas, the front line of the public health for HCT, 57 percent for TB and 63 percent for system (Table 4.4). Availability was generally higher PMTCT. The corresponding figure for immunization in public versus private hospitals. Relatively few at priority puskesmas was 34 percent. Except private GPs had service guidelines for the program for PMTCT, the proportion of private hospitals areas of interest. (and private GPs in the case of immunization) reporting never having received service guidelines One of the frustrations often voiced by MoH was higher than at comparator public facilities. central-level staff is their inability to compel Significant proportions of respondents at public districts to provide services following national hospitals in priority districts reported not knowing standards . The lack of service guidelines at that relevant service guidelines existed: for HCT many public-sector facilities is certain to be a 19 percent and, TB 14 percent, meanwhile for contributing factor to this. Responsibility for immunization was 19 percent. Relatively high ensuring that all public SDPs have up-to-date proportions of hospitals in priority districts service guidelines is unclear. The MoH central level reported having other (presumably non MoH) is clearly responsible for communicating current guidelines available–25 percent of public hospitals guidelines and updates to at least provincial and 33 percent of private hospitals. health offices. Beyond this, there does not appear to be a common understanding as to who is responsible for disseminating copies of service guidelines to individual SDPs. Table 4.4 SDPs with Service Guidelines Available (by Program Component and Type of SDP) (%) Program Component Sample Puskesmas Private GP Public Hospital Private Hospital National 29 (n=146) 5 (n=21) – – HCT Priority 49 (n=219) 12 (n=29) 76 (n=33) 61 (n=13) Clinical Management of National 18 (n=45) 0 (n=3) – – HIV & AIDS Priority 41 (n=83) 0 (n=6) 76 (n=33) 50 (n=18) National 33 (n=15) – – – ART Priority 62 (n=33) – 80 (n=30) 80 (n=10) National 45 (n=162) 19 (n=58) – – PMTCT Priority 60 (n=257) 17 (n=70) 61 (n=33) 70 (n=20) Diagnosis and Treatment National 48 (n=267) 14 (n=130) – – of TB Priority 73 (n=370) 30 (n=222) 86 (n=37) 49 (n=53) Management of TB-HIV National – – – – Coinfection Priority – – 70 (n=37) 28 (n=53) Diagnosis and Treatment National 42 (n=216) 18 (n=74) – – of Malaria Priority 31 (n=104) 21 (n=34) – – Child Immunization National 69 (n=265) 34 (n=41) – – Note The figures in parentheses in each cell indicate the number of SDPs contributing to the service readiness score. Source World Bank staff calculations Assessing HIV, TB, Malaria and Childhood Immunization Supply-Side Readiness in Indonesia 41 Shortages of trained staff continue to limit the The explanations given by QSDS respondents for service readiness at health facilities of all types. lack of trained staff at primary care facilities point Although varying by program, generally less than to insufficient training opportunities as a primary 60 percent of puskesmas have staff trained in key cause. Overall, staff at sample puskesmas not components of the four programs of interest (Table having been selected for training was the primary 4.5). Puskesmas located in priority districts for the reason given (Table 4.6). Between 30 percent and respective programs tend to have more adequate over 40 percent of puskesmas respondents in staffing in relation to program needs, but this is priority districts for HIV and malaria reported that not always the case. Availability of trained staff there had been no HIV CST or malaria training is higher at public hospitals than puskesmas, but in their district which is surprising given that the priority district program designation does not they were located in priority districts for the appear to influence staffing in hospitals. Staffing respective programs. This, along with the numbers adequacy tends to be lower at nonstate SDPs, both of respondents reporting never having heard of hospitals and private GPs, than at puskesmas. such training suggests communications issues Staff preparedness to provide key services on surrounding capacity-building efforts. Limited the basis of training appears to be highest for training opportunities were also reported at immunization and lowest for TB and Malaria. Staff private GPs (Table 4.7). Respondents at GP offices turnover and insufficient provision of training of were generally unaware of MoH-related training replacement staff are likely contributing factors to initiatives. these results. Table 4.5 SDPs with Trained Staff Available (by Program Component and Type of SDP) (%) Program Component Sample Puskesmas Private GP Public Hospital Private Hospital National 68 (n=146) 31 (n=21) – – HCT Priority 74 (n=219) 32 (n=29) 79 (n=33) 50 (n=13) Clinical Management of National 50 (n=45) 77 (n=3) – – HIV & AIDS Priority 67 (n=83) 70 (n=6) 91 (n=33) 56 (n=18) National 53 (n=15) – – – ART Priority 67 (n=33) – 83 (n=30) 80 (n=10) National 56 (n=162) 31 (n=58) – – PMTCT Priority 60 (n=257) 35 (n=70) 79 (n=33) 55 (n=20) TB Diagnosis and National 47 (n=267) 19 (n=130) – – Treatment Priority 39 (n=370) 32 (n=222) 59 (n=37) 28 (n=53) Management of TB National – – – – Coinfection Priority – – 59 (n=37) 25 (n=53) National 36 (n=267) 15 (n=130) – – MDR-TB Treatment Priority 34 (n=370) 22 (n=222) 41 (n=37) 17 (n=53) Diagnosis and Treatment National 55 (n=216) 7 (n=74) – – of Malaria Priority 50 (n=104) 12 (n=34) – – National 33 (n=216) – – – IPT Priority 42 (n=104) – – – Child Immunization National 76 (n=265) 47 (n=41) – – Note Number of sample SDPs are indicated by the figure in parentheses shown beneath the percent of SDPs with services available in each cell of the table. Source World Bank staff calculations 42 Table 4.6 Reasons for Insufficient MoH-related Training at Puskesmas (by Program Component and Sample) (%) Reasons Program Component Sample n No Staff Selected as No Such Training in Never Heard of Training No Longer Participants This District Such Training Available National 28 56 19 15 20 HIV CST Priority 47 45 48 8 7 National 78 58 11 13 10 PMTCT Priority 114 62 26 10 10 TB diagnosis and National 267 54 17 3 9 treatment Priority 370 49 20 3 10 Malaria diagnosis and National 113 51 23 4 16 treatment Priority 60 32 42 10 22 Note Row percentages may not add to 100 percent due to multiple responses and “Other” responses not shown. Source World Bank staff calculations Table 4.7 Reasons for Insufficient MoH-related Training at Private GPs (by Program Component and Sample) (%) Reasons Program Component Sample n Not Selected as No Such Training in Never Heard of Training No Longer Participant This District Such Training Available National 42 -- 36 19 3 PMTCT Priority 52 -- 36 19 6 TB diagnosis and National 130 -- 31 25 4 treatment Priority 222 -- 27 31 8 Malaria diagnosis National 63 -- 35 31 8 and treatment Priority 30 -- 33 37 13 Note Row percentages may not add to 100 percent due to multiple responses and “Other” responses. Source World Bank staff calculations Table 4.8 Training Options Suggested by Puskesmas Respondents (by Program Component and Sample) (%) Training Options Program Component Sample n Provide Book/ Convene Sharing Internal Attend Independent Module to Read Session Training Seminar Study National 146 0 19 0 33 30 HCT District 21 5 14 4 9 11 National 28 18 25 11 13 45 HIV CST District 47 20 34 10 21 42 National 78 23 31 12 11 17 PMTCT District 114 23 46 12 18 42 TB diagnosis and National 267 16 35 7 15 30 treatment District 370 14 43 8 21 23 Malaria diagnosis National 113 22 32 6 13 42 and treatment District 60 15 32 12 2 57 Note Row percentages may not add to 100 percent due to multiple responses and “Other” responses. Source World Bank staff calculations Assessing HIV, TB, Malaria and Childhood Immunization Supply-Side Readiness in Indonesia 43 QSDS respondents proposed a wide range of stocked out items. The practice of substituting options to supplement current training regimens. similar items or doing nothing, the two least In the public sector, training tends to be top- preferred responses, were more common in down (led by central-level staff and provincial priority than in other districts. Borrowing from trainers) and didactic in character. The suggestions other facilities is widely practiced for TB, but rarely included self-initiated and facility- or locality- practiced for Malaria. Referrals to other facilities specific options to supplement the formal MoH are uncommon for both programs. training model (Table 4.8). Staff of private GPs tended to favor attending seminars more so than Puskesmas and private sector providers respond puskesmas staff (Table 4.9). The responses indicate quite differently to stock-outs of immunization amenability to alternative mechanisms and vaccines. Puskesmas respond to stock-outs formats for staff capacity building. by asking clients to return when vaccines are available, and borrowing from another facility and Supply-chain problems at district warehouses doing nothing in about equal proportions (20-21 appear to be primarily responsible for stock-outs percent each). In contrast, no private sector SDPs of TB and Malaria drugs at puskesmas (Table 4.10). reported asking clients to return or doing nothing. This was followed by facility errors in failing to Private sector SDPs respond to stock-outs by reorder drugs in a timely fashion. Reorder failures borrowing vaccines from, or referring clients to, were less common in priority TB and Malaria other facilities, or by purchasing new vaccines. districts. Due to relatively infrequent stock-outs at private GPs, comparable information was not available from a sufficient number of private GPs to present a clear picture, and thus private GP data are not shown. Stock-outs of TB and Malaria drugs at puskesmas prompt a variety of different responses. For TB, the two most common responses were to reorder the drugs or borrow from another facility (Table 4.11). For Malaria, the two most common responses were to substitute similar items or reorder the Table 4.9 Training Options Suggested by Respondents at Private GPs (by Program Component and Sample) (%) Training Options Program Area Sample n Provide Book/ Convene Sharing Internal Attend Independent Module to Read Session Training Seminar Study National 21 5 16 4 19 15 HCT District 29 11 9 7 33 33 National 42 17 25 4 43 17 PMTCT District 52 22 14 7 52 31 TB diagnosis and National 130 17 14 2 32 37 treatment District 222 16 9 5 43 31 Malaria diagnosis and National 63 18 12 2 44 44 treatment District 30 23 27 3 27 70 Note Scores shown are for the National/Priority District samples, respectively. * Row percentages may not add to 100 percent due to multiple responses and “Other” responses. Source World Bank staff calculations 44 Table 4.10 Reasons for Stock-outs – Puskesmas No Transport Increased District Warehouse No Time to Forgot to Program Area Sample n to Collect Number of Could Not Supply Collect Item(s) Reorder Item(s) Patients TB diagnosis and National 19 46 0 9 15 0 treatment Priority 34 52 0 11 8 8 Malaria diagnosis National 31 29 0 0 26 2 and treatment Priority 18 50 0 0 17 11 Note Row percentages may not add to 100 percent due to “Other” responses. Source World Bank staff calculations Table 4.11 Selected Stock-out Coping Mechanisms for TB and Malaria Drugs at Puskesmas (%) Refer to Program Purchase Reorder Substitute Borrow From Do Sample n Another Component New Item(s) Item(s) Similar Item(s) Another Facility Nothing Facility TB diagnosis and National 19 10 52 4 13 7 4 treatment Priority 34 10 41 11 28 7 8 Malaria diagnosis National 31 15 39 23 10 6 18 and treatment Priority 18 0 22 28 0 6 28 Note Row percentages may not add to 100 percent due to multiple responses and “Other” responses. Source World Bank staff calculations Table 4.12 SDPs Following Selected Stock-out Coping Mechanisms for Childhood Immunization Vaccines (by Type of SDP) (%) Borrow From Purchase New Refer to Another Asked Client to Type of Facility n Do Nothing Another Facility Vaccines Facility Return Puskesmas 25 20 1 6 21 20 Private GP 17 33 22 33 0 0 Note National sample only. Row percentages may not add to 100 percent due to multiple responses and “Other” responses. Source World Bank staff calculations Assessing HIV, TB, Malaria and Childhood Immunization Supply-Side Readiness in Indonesia 45 section 5 . Summary and Policy Implications The QSDS data point to a health system in need program components, public hospitals are the of strengthening. Cross-program weaknesses most service-ready for HIV, TB, Malaria and stand out in the data shown in Table 5.1, which immunization, followed by puskesmas, private provides a summary of the detailed data on hospitals and private GPs. Of interest is that the supply-side readiness presented above. Mean magnitude of difference in service readiness service readiness index scores of 80 percent or between priority and other districts are small above for programs/program components are to nonexistent, indicating the priority district relatively rare and lowering the bar to 70 percent classification scheme has not been effective in adds only a few additional programs/program producing greater service readiness in priority components. Based upon the weighted averages districts. This observation applies across of readiness scores aggregated across programs/ programs. Table 5.1 Average Service Readiness Index Scores (by Program Component, Sample, and Type of SDP) (%) Public Private Program Area Sample Puskesmas Private GPs Hospitals Hospitals National 54 (n=146) 21 (n=21) – – HCT Priority 67 (n=219) 20 (n=29) 85 (n=33) 72 (n=13) National 74 (n=45) 57 (n=3) – – Clinical Management of HIV & AIDS Priority 80 (n=83) 54 (n=6) 84 (n=33) 63 (n=18) National 15 (n=15) – – – ART Priority 37 (n=33) – 52 (n=30) 38 (n=10) National 46 (n=162) 12 (n=58) – – PMTCT Priority 50 (n=257) 15 (n=70) 79 (n=33) 49 (n=20) National 65 (n=267) 25 (n=130) – – Diagnosis and Treatment of TB Priority 61 (n=370) 37 (n=222) 77 (n=37) 50 (n=53) National 64 (n=216) 19 (n=74) – – Diagnosis and Treatment of Malaria Priority 66 (n=104) 33 (n=34) – – Child Immunization * National 84 (n=265) 55 (n=41) – – National 60 35 – – Weighted Average Priority 60 32 75 54 Note *Only national data available. The figures in parentheses in each cell indicate the number of SDPs contributing to the service readiness score. Source World Bank staff calculations. 46 A more rigorous standard for assessing service at public hospitals for TB. Overall, service readiness is in terms of the proportion of SDPs readiness continues to be a major concern in both that meet all tracer conditions across all programs the public and private sectors. and program components (Table 5.2). Only 18 percent of public hospitals and 7 percent of Additional resources will be needed to address puskesmas in priority districts met this higher current weaknesses, prepare the health system standard of satisfying all 74 tracer conditions. The for what is likely to be growing demand for health corresponding figures for private sector SDPs were services, and compensate for the anticipated 15 percent for private hospitals and 1 percent for reduction in international financing for HIV, TB, private GPs. Malaria and Childhood Immunization. Low GoI per capita spending on health will, however, likely Comparing the results of the 2016 QSDS with prior remain a significant constraining factor. The rate comparable data, there is limited evidence of of growth of health spending at the central and marked improvements in supply-side readiness. district levels has accelerated in recent years The 2014 Health Sector Review report on Supply- but faces stiff competition with other national Side Readiness (MoH and World Bank 2014) and local priorities. A series of policy options for analyzed data from the 2011 Rifaskes and the 2013 creating additional fiscal space have been outlined IFLS surveys regarding 38 of the 50 “tracer” SARA in other recent World Bank reports, both the HFSA indicators recommended by WHO (WHO 2015). Table and the deep-dive ATMI report and will be followed 5.3 provides a summary of supply-side readiness by policy briefs (REFS). by program area and type of health facility based upon the 2011-2013 data. Comparable 2016 QSDS The policy options to increase fiscal space include results are shown in Table 5.4.16 Comparing the increasing overall spending for the health sector by results yields a mixed picture. On the one hand, reprioritization and earmarking revenue specifically the data suggest only minor improvements, for health (for example, tobacco taxation). Other notably in the form of improved service readiness options include improving efficiency and optimizing Table 5.2 SDPs Satisfying All Tracer Conditions (by Program Component, Sample, and Type of SDP) (%) Public Private Program Area Sample Puskesmas Private GPs Hospitals Hospitals National 6 (n=146) 0 (n=21) – – HCT Priority 19 (n=219) 0 (n=29) 45 (n=33) 31 (n=13) National 16 (n=45) 0 (n=3) – – Clinical Management of HIV & AIDS Priority 26 (n=83) 0 (n=6) 42 (n=33) 33 (n=18) National 0 (n=15) – – – ART Priority 0 (n=33) – 0 (n=30) 0 (n=10) National 0 (n=162) 0 (n=58) – – PMTCT Priority 0 (n=257) 0 (n=70) 30 (n=33) 10 (n=20) National 2 (n=267) 1 (n=130) – – Diagnosis and Treatment of TB Priority 6 (n=370) 1 (n=222) 5 (n=37) 0 (n=53) National 11 (n=216) 0 (n=74) – – Diagnosis and Treatment of Malaria Priority 0 (n=104) 3 (n=34) – – Child Immunization * National 28 (n=265) 3 (n=41) – – National 9 1 – – Weighted Average Priority 7 1 18 11 Note *Only national sample data available. The figures in parentheses in each cell indicate the number of SDPs contributing to the service readiness score. Source World Bank staff calculations. 16 Ratingsin both analyses were based upon the following classification scheme: Good–80 percent and above of all tracer conditions satisfied; Fair–60-80 percent of all tracer conditions satisfied; Poor–less than 60 percent of tracer conditions satisfied. Assessing HIV, TB, Malaria and Childhood Immunization Supply-Side Readiness in Indonesia 47 existing financial instruments, for instance by more (infrastructure, equipment, supplies and human effectively implementing strategic purchasing, resources) are available to provide necessary and strengthening capitation payments linked services but also focuses on improving managerial, to performance. Linking intergovernmental clinical and public health processes that are fiscal transfers–especially Dana Alokasi Khusus important to ensure quality service delivery. Fisik (DAK Fisik, or Special Allocation Funds, The MoH initiated an accreditation system for Physical) for physical infrastructure, equipment, puskesmas in 2015. pharmaceuticals and supplies) and DAK Non Fisik (DAK for operational costs, previously known To date, the large majority of puskesmas that as Bantuan Operasional Kesehatan or Health have been accredited (85 percent) have received Operational Funds)–with program indicators rather ratings at the two lower tiers of the four-tier than administrative indicators (as is currently the rating system (World Bank 2018a), so this is clearly case) is also a viable option. As these have been a work in progress. To ensure that the process discussed at some length in other World Bank continues and achieves the intended results, the documents17, they are not addressed further in this MoH (with MoF and BAPPENAS) needs to ensure report. that the Accreditation Commission for Primary- level Health Care Facilities (Komisi Akreditasi The widespread nature of service readiness Fasilitas Kesehatan Tingkat Primer – KAFKTP) is weaknesses indicated by the 2016 QSDS mandates sufficiently well funded to complete the mission. that broad governance and systems interventions It is also important that the KAFKTP begins to will be needed in addition to ATMI-specific accredit private-sector facilities, although this responses to address observed ATMI service would likely require a system of incentives to readiness issues. One ongoing GoI response encourage private-sector participation. The to addressing such issues is via expanding MoH might also consider using the established the accreditation of primary-care facilities. hospital accreditation system to address observed Accreditation not only ensures that all inputs readiness deficiencies. Table 5.3 Program-specific Overall Readiness Assessment Results (2011-13) Health Services Puskesmas Private Clinics Public Hospitals Private Hospitals TB Fair Poor Poor Poor Malaria Fair * Fair Fair Immunization Good Fair * * Note *Insufficient data. Source MoH and World Bank 2014. Table 5.4 Service-specific Overall Readiness Assessment Results (2016) Health Services Sample Puskesmas Private Clinics Public Hospitals Private Hospitals National Poor * Fair Poor HIV & AIDS Priority Districts Poor * Fair Poor National Fair Poor Fair Poor TB Priority Districts Fair Poor Fair Poor National Poor Poor – – Malaria Priority Districts Fair Poor – – Immunization National Good Poor – – Note *Insufficient data. Source QSDS 2016. World Bank staff calculations 17 The other documents from the World Bank that are referred here include 2016 Health Financing System Assessment for Indonesia, and the ‘deep dive’ on issues and priorities in transitioning of donor funded programs 48 Other options for strengthening service readiness It is acknowledged that the finalization of MSS/ should be considered in addition to accreditation. SPM as a Government Regulation has not yet been Accreditation is not a quick fix, and other actions completed and MoH realization of the potential of will, in any event, need to be taken to correct the MSS/SPM remains just that–potential. deficiencies observed in the accreditation review process. One option is to strengthen the Linking central-level fiscal transfers and JKN current MoH quality assurance system. There are payments with performance has considerable several quality assurance subsystems currently potential to influence district government and in operation at the MoH, including an external service-provider behaviors. One of the interfiscal quality assurance system (EQAS) for laboratories, a transfer mechanisms (the DAK) and JKN program technical quality assurance process implemented payments are the two sources of funding that as part of the supervisory system, and a data offer the most scope for improving the quality of quality assurance process that manifests as health spending. These two sources make up a an annual data validation exercise. All three significant share of district health revenues–where subsystems have significant limitations, but also most health spending occurs. DAK transfers are have established mandates and structures that currently tied to performance indicators that are can be built upon vs. having to start from scratch. largely administrative, while JKN payments are The subsystems need to be more systematically based on a set of agreed indicators that primarily and intensively implemented and, most concern the use of health facilities (Kapitasi importantly, must result in action being taken to Berbasis Komitmen – KBK or Commitment-based correct observed quality issues as opposed to Capitation). DAK transfers have the potential to be being merely platforms for documenting problems. used to leverage districts to increase investment The goal would be the refinement of the current in health and focus on improved readiness for system into a continuous quality improvement basic public health programs, including ATMI. As (CQI) system/process that systematically covers a part of strategic purchasing for JKN, payments key elements of health programs, including ATMI, can be used to incentivize providers -especially and health system functioning. Incentives for at the primary level– to find and report new cases health facilities demonstrating improved service and retain them in treatment. These financing quality might be considered by the MoH. instruments might also include incentives that foster the integration of care across primary The Minimum Service Standards (MSS/SPM) for health and referral services to ensure improved health provide the MoH with another means continuity of care. Better integration of supply- of compelling local governments and service and demand-side and central- and subnational- providers to address ATMI service readiness level financing can further simplify implementation weaknesses. Although it will require some and increase efficiency. adjustment of priority indicators to focus on key service readiness and service delivery Insufficient human resources for health (HRH) performance issues, the MSS/SPM provides continue to plague the health system and should the MoH with a regulatory basis for holding be a high priority for action. The QSDS also subnational governments accountable for the revealed significant staff training deficiencies for delivery of basic health services. To be effective, the ATMI program at many health facilities. This the system of monitoring compliance with the is despite the considerable resources that have MSS/SPM must be linked to a constructive been invested in public-sector staff capacity supervisory system under which districts and for these programs in recent years using both service providers are provided guidance and domestic and external resources. In the short assistance in addressing observed shortcomings. term, the MoH needs to systematically reassess Examples of such guidance and assistance its core in-service training model and explore new include addressing problems that originate at training modalities that include more mentoring higher levels of the health system (for example, and on-the-job training, perhaps merged into commodity procurement and distribution and enhanced supervisory protocols and/or CQI laboratory connection issues) and assistance processes. This would require mobilization of in arranging training to meet observed needs. If expertise at the provincial and district levels to not, monitoring of MSS/SPM compliance will be augment central-level staff. Better advantage perceived as a punitive exercise and will likely not might also be taken of the extensive information result in improvements at a sufficiently rapid pace. technology infrastructure available in Indonesia Assessing HIV, TB, Malaria and Childhood Immunization Supply-Side Readiness in Indonesia 49 which is capable of, for example, supporting much Increasing meaningful private-sector participation wider use of distance learning and real-time, is essential to the national roll-out of the JKN to online technical support. Strengthened preservice achieve universal coverage and has also been training in HIV, TB, Malaria and immunization identified by BAPPENAS as a key in transitioning should also be pursued as a means of reducing from international financing for HIV, TB and the capacity-building burden on the MoH over the Malaria (Ali 2017). Private sector involvement is medium term. especially crucial for the national TB program as it is estimated that more than 70 percent of TB cases The QSDS revealed the somewhat surprising seek care at private-sector health facilities (WHO finding that a high proportion of SDPs lacked 2017). Private facilities have significantly lower basic ATMI service guidelines to support delivery supply-side readiness than public-sector facilities of services per national protocols and standards. more or less across the board. This appears to be a health system governance issue that, in principle, should be relatively Future GoI action on this front must focus both on easy to mitigate. The MoH central level is clearly engaging the private sector in pursuit of national responsible for developing service standards and health priorities and goals as well as on increasing guidelines. Responsibility for distribution needs the service readiness of private providers. For to be as clearly established and communicated. the GoI to be able to marshal these resources to The MoH might consider adding the availability of meet growing demand for health services, a health all relevant program-specific service guidelines sector public-private partnership (PPP) framework at all public-sector health facilities as one needs to be developed and implemented. In of standards of the MSS/SPM as a means of the absence of such a framework, it would be motivating provincial and district governments difficult to develop a strategic approach and to act. The MoH has some leverage to encourage a regulatory response to ensure productive compliance in the private sector via requirements involvement of the sector. The GoI might consider for participation in the JKN network and through accelerating extension of the accreditation the health facility accreditation system. system to the private sector and implementation of strategic purchasing in JKN as the points of The need for improved integration of ATM services entry in influencing private sector standards and Actions to strengthen service readiness should practices. Although their service readiness was take into account. Recent program reviews have not addressed in the present report, engaging highlighted that the ATM programs tend to operate Community Service Organizations and KAP-related as vertical programs without sufficient integration groups and supporting them financially is equally of key services. Examples of inadequate linkages essential to success for HIV and AIDS. include HIV with STI diagnosis and treatment, HIV with TB, PMTCT with antenatal care (ANC), and malaria with ANC. Addressing supply side gaps needs to include the projection of demand increase due to GoI’s strategy to expand coverage and decentralize services. The expansion from hospital focus ART services to primary care facilities, and also efforts to increase TB case detection and notification will require improved availability and readiness for these basic services at puskesmas. This will be challenging indeed for the MoH to reach its goal of significantly increasing the number of persons being started and retained on treatment without an accelerated pace of treatment service decentralization. This will require, in addition to more and better-trained puskesmas-level staff, improvements in the functioning of supportive systems–supply-chain management, laboratory support, supervision, and referral systems. 50 Appendixes Assessing HIV, TB, Malaria and Childhood Immunization Supply-Side Readiness in Indonesia 51 Appendix 1. QSDS Sampling Summary Table Polindes / Public Private Sample Representatives Puskesmas Private Primary Care Private MH Puskesdes / Hospital Hospital BDD NO District Name Maternal HIV Malaria facility HCW facility HCW facility HCW facility HCW facility facility Health National counter counter counter Main Main Main T R T R T R T R T R T R T R T R R R factual factual factual 1 Kab. Simeulue Yes No Yes No Yes No No 9 8 18 16 5 2 5 2 NA NA NA NA NA NA NA NA 1 0 2 Kab. Aceh Jaya Yes No Yes Yes No No No 9 9 18 18 9 6 9 6 NA NA NA NA NA NA NA NA 1 0 3 Kab. Lhokseumawe Yes No Yes No No No No 6 6 12 12 17 3 17 3 NA NA NA NA NA NA NA NA 1 7 4 Kab. Tapanuli Selatan Yes No Yes No No No No 14 14 28 29 12 7 12 6 NA NA NA NA NA NA NA NA 1 0 5 Kab. Labuhan Batu No No No No Yes Yes No 13 13 26 26 19 28 19 28 30 30 30 30 38 38 38 38 0 0 6 Kab. Deli Serdang No Yes No No No No No 23 23 46 46 23 46 23 46 NA NA NA NA NA NA NA NA 2 7 7 Kab. Labuhan Batu Utara No No No Yes No No No 15 17 30 34 18 29 18 29 NA NA NA NA NA NA NA NA 0 0 8 Kab. Pesisir Selatan Yes No Yes No Yes No Yes 15 15 30 30 15 10 15 10 32 32 32 32 49 49 49 49 1 0 9 Kota Padang Yes Yes No No No No Yes 17 17 34 34 22 36 22 36 33 33 33 33 20 25 20 25 3 8 10 Kab. Indragiri Hilir Yes No Yes No No No Yes 20 20 40 40 18 18 18 18 31 31 31 31 32 24 32 24 3 1 11 Kota Sungai Penuh Yes No Yes No No No No 7 6 14 12 14 3 14 3 NA NA NA NA NA NA NA NA 0 0 12 Kab. Muara Enim No No Yes No Yes Yes No 15 17 30 34 17 9 17 9 31 28 31 28 54 74 54 74 2 1 13 Kab. Kaur No No No Yes No No No 14 14 28 28 9 6 9 6 NA NA NA NA NA NA NA 0 0 14 Kab. Pesawaran No No Yes Yes No No Yes 11 11 22 22 12 6 12 6 29 32 29 32 32 34 32 34 1 1 15 Kota Bandar Lampung No No No No No Yes No 21 21 42 42 0 14 0 14 31 31 31 31 40 40 40 40 0 0 16 Kab. Bangka Barat No No No Yes No No No 8 8 16 16 14 13 14 12 NA 1 0 NA NA NA NA NA 0 0 17 Kota Tanjung Pinang No Yes No No No No No 7 6 14 12 17 1 17 1 NA NA NA NA NA NA NA NA 2 0 18 Kab. Adm. Kep. Seribu No No No No No No No 6 6 12 12 2 24 2 24 NA NA NA NA NA NA NA NA 0 0 19 Kota Jakarta Selatan No No No No No No No 36 36 72 72 23 72 23 61 NA NA NA NA NA NA NA NA 0 0 20 Kota Jakarta Timur No Yes No No No Yes No 38 38 76 76 23 30 23 30 34 34 34 34 NA NA NA NA 11 9 21 Kota Jakarta Pusat No Yes No No No No No 27 27 54 54 23 22 23 23 NA NA NA NA NA NA NA NA 6 9 22 Kota Jakarta Barat No No No No No Yes No 35 35 70 71 23 25 23 23 31 31 31 31 NA NA NA NA 0 0 23 Kota Jakarta Utara No No No No No Yes No 29 29 58 58 23 25 23 NA 32 32 32 33 NA NA NA NA 0 0 24 Kab. Bandung No No No No No Yes Yes 32 32 64 62 NA NA NA NA 35 34 35 33 41 33 41 32 0 0 25 Kab. Majalengka No Yes No No No No No 22 22 44 47 21 21 21 NA NA NA NA NA NA NA NA NA 2 1 26 Kota Bandung No Yes No No No No No 35 37 70 75 24 40 24 NA NA 34 35 34 34 NA NA NA 6 8 27 Kab. Cilacap Yes Yes No No No No No 25 26 50 52 22 50 22 NA NA NA NA NA NA NA NA NA 2 3 28 Kab. Banyumas No Yes No No No No No 25 28 50 54 22 48 22 NA NA NA NA NA NA NA NA NA 4 6 29 Kab. Pati No No Yes No No Yes No 21 22 42 44 22 24 22 NA 35 35 35 35 53 67 53 67 2 5 30 Kab. Semarang Yes Yes No No No No No 19 19 38 38 21 28 21 NA NA NA NA NA NA NA NA NA 2 1 31 Kota Tegal Yes Yes No No No No No 8 8 16 16 19 12 19 NA NA NA NA NA NA NA NA NA 1 1 32 Kab. Banyuwangi No Yes No No No No Yes 27 27 55 55 22 22 22 NA 35 NA 35 35 52 52 52 52 2 3 33 Kab. Pasuruan No No Yes No Yes Yes No 23 23 46 46 21 27 21 NA 34 66 34 65 31 31 31 31 1 4 34 Kota Pasuruan Yes No Yes No No No No 8 8 16 16 18 6 18 NA NA NA NA NA NA NA NA NA 1 1 35 Kota Surabaya No No No No No Yes No 33 33 66 66 NA NA NA NA 32 33 32 33 46 51 46 51 0 0 36 Kab. Tangerang No Yes No No No No No 27 27 54 55 23 23 23 NA NA NA NA NA NA NA NA NA 2 7 37 Kota Tangerang Yes No Yes No No No Yes 23 23 46 46 23 26 23 NA 34 35 34 35 NA NA NA NA 2 19 38 Kota Cirebon Yes Yes No No No No No 8 8 16 16 18 18 18 NA NA NA NA NA NA NA NA NA 1 1 39 Kota Mataram Yes Yes No No No No No 9 9 18 18 21 16 21 NA NA NA NA NA NA NA NA NA 3 3 40 Kota Bima Yes No Yes No Yes No No 5 5 10 10 12 8 12 NA NA NA NA NA NA NA NA NA 0 1 41 Kab. Malaka No No No Yes No No Yes 14 14 28 28 9 2 9 NA 11 1 11 1 14 14 14 14 0 0 42 Kab. Banjar Yes No Yes No No No No 18 18 36 36 15 10 15 NA NA NA NA NA NA NA NA NA 2 4 43 Kota Banjarmasin Yes Yes No No No No Yes 19 19 38 38 21 18 21 NA 28 28 28 28 29 28 29 28 3 2 44 Kota Banjar Baru Yes No Yes No Yes No Yes 7 7 14 14 17 4 17 NA 22 22 22 22 14 15 14 15 1 1 45 Kota Tomohon Yes No No No Yes No No 7 7 14 14 12 13 12 NA NA NA NA NA NA NA NA NA 0 2 46 Kab. Jeneponto No No No No Yes Yes No 14 14 28 28 11 4 11 NA 14 7 14 7 29 29 29 29 0 0 47 Kab. Wajo No No Yes No Yes Yes No 17 17 34 35 17 7 17 NA 25 4 25 4 38 42 38 42 2 0 48 Kota Pare-Pare No Yes No No Yes No No 6 6 12 12 11 7 11 NA NA NA NA NA NA NA NA NA 1 1 49 Kab. Maluku Tenggara Barat No No No No No No No 10 10 20 20 5 2 5 NA NA NA NA NA NA NA NA NA 0 0 50 Kab. Manokwari No Yes No No No No No 15 12 30 24 16 5 16 NA NA NA NA NA NA NA NA NA 1 0 51 Kota Sorong No No No Yes No No No 5 5 10 10 12 4 12 NA NA NA NA NA NA NA NA NA 0 0 52 Kab. Merauke Yes Yes No No No No No 13 13 26 26 14 NA 14 NA NA NA NA NA NA NA NA NA 2 1 53 Kab. Mamberamo Tengah No No No Yes No No No 5 4 10 8 2 NA 2 NA NA NA NA NA NA NA NA NA 0 0 54 Kab. Yalimo Yes No Yes No No No Yes 4 3 8 6 2 NA 2 NA 2 2 0 1 0 1 0 0 0 55 Kab. Dogiyai No No No Yes No No No 8 8 16 16 2 NA 2 NA NA NA NA NA NA NA NA NA 0 0 56 Kab. Deiyai No No No Yes No No No 8 6 16 12 2 NA 2 NA NA NA NA NA NA NA NA NA 0 0 TOTAL 915 915 1830 1837 835 855 835 396 655 615 655 647 613 646 613 645 78 118 52 Appendix 2. Composition of the QSDS National Sample Province District Puskesmas Private Primary Care Kab. Simeulue 8 2 Aceh Kab. Aceh Jaya 9 6 Kota Lhokseumawe 6 3 North Sumatra Kab. Tapanuli Selatan 14 7 Kab. Pesisir Selatan 15 10 West Sumatra Kota Padang 17 36 Riau Kab. Indragiri Hilir 20 18 Jambi Kota Sungai Penuh 6 3 Kab. Cilacap 26 50 Central Java Kab. Semarang 19 28 Kota Tegal 8 12 East Java Kota Pasuruan 8 6 Kota Tangerang 23 26 Banten Kota Cilegon 8 18 Kota Mataram 9 16 West Nusa Tenggara Kota Bima 5 8 Kab. Banjar 18 10 South Kalimantan Kota Banjarmasin 19 18 Kota Banjar Baru 7 4 North Sulawesi Kota Tomohon 7 13 Kab. Merauke 13 0 Papua Kab. Yalimo 3 0 12 Provinces 22 Districts 268 289 Assessing HIV, TB, Malaria and Childhood Immunization Supply-Side Readiness in Indonesia 53 Appendix 3. Composition of the QSDS Priority Districts for the HIV, TB and Malaria Programs HIV/AIDS & TB Sample Priority Districts Province District Puskesmas Private Primary Care Public Hospitals Private Hospitals North Sumatra Kab. Deli Serdang 23 43 2 7 West Sumatra Kota Padang 17 36 3 8 Riau Islands Kota Tanjung Pinang 6 12 2 0 Kota Jakarta Timur 38 65 11 9 DKI Jakarta Kota Jakarta Pusat 27 31 6 9 Kab. Majalengka 22 21 2 1 West Java Kota Bandung 37 40 6 8 Kab. Cilacap 26 49 2 3 Kab. Banyumas 27 47 4 6 Central Java Kab. Semarang 19 28 2 1 Kota Tegal 8 11 1 1 East Java Kab. Banyuwangi 27 22 2 3 Kab. Tangerang 27 23 2 7 Banten Kota Cilegon 8 18 1 1 West Nusa Tenggara Kota Mataram 9 15 3 3 South Kalimantan Kota Banjarmasin 19 18 3 2 South Sulawesi Kota Pare-Pare 6 7 1 1 West Papua Kab. Manokwari 12 5 1 0 Papua Kab. Merauke 13 0 2 1 13 Provinces 19 Districts 371 491 56 71 Malaria Sample Priority Districts Province District Puskesmas Private Primary Care Aceh Kab. Aceh Jaya 9 6 North Sumatra Kab. Labuhan Batu Utara 17 29 Bengkulu Kab. Kaur 14 6 Lampung Kab. Pesawaran 11 6 Bangka-Belitung Kab. Bangka Barat 8 13 East Nusa Tenggara Kab. Malaka 14 2 Maluku Kab. Maluku Tenggara Barat 10 2 West Papua Kota Sorong 5 4 Kab. Mamberamo Tengah 4 0 Papua Kab. Dogiyai 8 0 Kab. Deiyai 6 0 9 Provinces 11 Districts 106 68 54 Appendix 4. Service Readiness Tracer Indicators Used in the Analyses Health Guideline Training Equipment Diagnostics Medicines and Commodities Services • Vaccine carrier(s)/cold • Guideline on • Training on microplanning box/thermos Immunization • Training on immunization service • Refrigerator Delivery delivery • Measles vaccine • Sharps container/safety • Guideline on • Training on injection safety • DPT-Hib+HepB vaccine Routine child box Monitoring and • Training on vaccine management/ • Oral polio vaccine immunization • Auto-disable syringes Management handling and cold chain • BCG vaccine • Temperature monitoring of Adverse • Training on data reporting and device in refrigerator Effects Following data monitoring of service delivery • Adequate refrigerator Immunization (AEFI) • Training on handling AEFI temperature • Artemisinin Combination Therapy (ACT): • Training on malaria diagnosis and • Rapid Malaria Testing Artesunat + Amodiakuin + Primakuin National Guideline for treatment • Malaria Smear Test • Paracetamol 500 mg Malaria Malaria Diagnosis and • Any intermittent preventive • Light microscope or • Insecticide-treated net Treatment treatment of malaria in pregnancy Diagnostic Microscopy • Insecticide-treated net voucher (IPTp) training • Light microscope • Rapid test HIV • Screening or testing for • National Guideline • Training on diagnosis and TB among People Living for TB Diagnosis treatment of TB with HIV (e.g. system for and Treatment Isoniazid, Pyrazinamide, Rifampicin, and • Training on management of HIV diagnosis of TB among Tuberculosis • National Guideline Ethambutol, or combinations to meet first- and TB coinfection PLHIV) for Management line TB treatment • Training on management and • Mantoux Test of HIV and TB treatment of MDR-TB • Provision of drugs to TB coinfection patients • Sputum smear and microscopy examination Counseling room has to be comfortable, private, HIV – National guidelines Training on HIV Counseling and separate from waiting room Counseling on HIV Counseling Rapid test HIV Condoms Testing (VCT and/or PITC), others and blood sampling room, and Testing and Testing, others and has separate entry and exit • National guidelines • Normal saline IV solution, Ringer’s for ARV therapy for lactate IV solution, 5% dextrose IV adults solution Screening or testing for HIV – Care • National guidelines • Oral antifungal drugs: (e.g. Fluconazole • Training on HIV CST TB among People Living Support and on the HIV Training on management of capsule/tablet, Ketoconazole capsule/ • Training on HIV and TB coinfection with HIV (e.g. system for Treatment treatment for HIV and TB coinfection tablet, Griseofulvin capsule/tablet, • Any training on HIV CST diagnosis of TB among (CST) children Nystatin capsule/tablet) PLHIV) • Any guidelines • Oral sulfa-trimethoprim antibiotic: on CST Cotrimoxazole • First-line TB treatment medications • Zidovudine Cap/tab (ZDV, AZT) • Zidovudine syrup/suspension (ZDV, AZT) • Abacavir Cap/tab (ABC) • Lamivudine Cap/tab (3TC) • Tenofovir Disoproxil Fumarate cap/ Hemoglobin testing, tab(TDF) white blood cell testing, • Emtricitabine cap/tab (FTC) HIV – thrombocyte testing • Didanosine cap/tab (DDI) Antiretroviral National guidelines Training on management and CD4 count • Zidovudine + Lamivudine cap/tab(AZT prescription for ARV therapy for Training on HIV CST treatment of MDR-TB Specific assay kit, + 3TC) and client adults centrifuge, biochemistry • Nevirapine cap/tab (NVP) management analyzer • Nevirapine syrup/suspension (NVP) • Efavirenz Cap/tab (EFV) • Lopinavir + Ritonavir Cap/tab (LPV/r) • Zidovudine + Lamivudine + Nevirapine Cap/tab (AZT + 3TC + NVP) • Stavudine + Lamivudine + Nevirapine Cap/tab (D4T + 3TC + NVP) • Oral NRTI antiretroviral drugs: Zidovudine syrup/suspension (ZDV, AZT) • PMTCT guidelines • Oral NNRTI antiretroviral drugs: (e.g. guidance book, • Training on prevention of mother- Nevirapine syrup/suspension (NVP) poster on the wall) to-child transmission of HIV Option A: • Guidelines on (PMTCT) • AZT, NVP, and 3TC HIV - PMTCT • Visual and auditory privacy • Rapid test HIV infant and young • Training on counseling on Infant Option B: child feeding Young Child Feeding Practices • AZT + 3TC + LPV or practices (IYCF/ (IYCF • AZT + 3TC + ABC or PMBA) • AZT + 3TC + EFV or • TDF + 3TC (or FTC) + EFV Assessing HIV, TB, Malaria and Childhood Immunization Supply-Side Readiness in Indonesia 55 Appendix 5. Full Service Availability and Readiness Tabulations Service Readiness: HCT (%) Indicator Sample Puskesmas Private GP Public Hospital Private Hospital No. of Tracer Conditions 5 5 5 5 National 29 5 n.a. n.a. Guidelines Priority 53 13 76 61 National 68 31 n.a. n.a. Staff trained Priority 74 34 79 50 National 40 44 n.a. n.a. Privacy amenities Priority 54 30 88 50 National 89 9 n.a. n.a. Diagnostic capacity Priority 91 18 100 83 National 44 15 n.a. n.a. Condoms Priority 77 14 82 33 National 54 21 n.a. n.a. Mean Service Readiness Index Score Priority 70 22 85 56 National 3 0 n.a. n.a. Percent Satisfying All Tracer Conditions Priority 12 0 41 8 Service Availability: HIV CST (%) Indicator Sample Puskesmas Private GP Public Hospital Private Hospital National 15 1 n.a. n.a. HIV/AIDS Services Priority 22 0 89 34 National 64 n.a. n.a. n.a. Treatment of Opportunistic Infections * Priority 63 n.a. 94 67 Provide or Prescribe Treatment of TB for National 78 n.a. n.a. n.a. PLHIV * Priority 86 n.a. 88 61 National 22 n.a. n.a. n.a. Micronutrient Supplementation for PLHIV * Priority 19 n.a. 76 61 National 71 n.a. n.a. n.a. Family Planning Counseling for PLHIV * Priority 83 n.a. 76 61 National 39 n.a. n.a. n.a. Prescription of ART * Priority 35 n.a. 88 50 National 79 n.a. n.a. n.a. Screening PLHIV for TB * Priority 84 n.a. 88 61 National 82 n.a. n.a. n.a. Provision of Male Condoms * Priority 83 n.a. 88 44 National 75 n.a. n.a. n.a. Nutrition Rehabilitation * Priority 86 n.a. 76 61 Note *The percentages shown pertain to the SDPs providing any relevant services as shown in the first row of the table. 56 Service Availability: HIV CST (%) Indicator Sample Puskesmas Private GP Public Hospital Private Hospital No. of Tracer Conditions 9 9 9 9 Guidelines for clinical National 18 0 81 25 management of HIV & AIDS Priority 44 0 76 50 Staff trained in clinical National 50 77 100 38 management of HIV & AIDS Priority 69 83 91 56 System for diagnosis of TB National 79 77 81 25 among HIV+ clients Priority 84 0 88 61 National 99 89 100 100 IV solution for infusion set Priority 100 100 100 100 IV treatment for fungal National 74 11 56 50 infections Priority 74 17 67 67 National 95 89 81 63 Cotrimoxazole cap/tab Priority 98 100 85 72 National 98 77 94 75 First-line TB medications Priority 97 100 95 78 Palliative care pain National 95 89 100 100 management Priority 95 100 100 100 National 54 0 88 25 Condoms Priority 74 43 88 56 Mean Service Readiness National 74 * 83 52 Index Score Priority 82 * 84 63 Percent Satisfying All Tracer National 16 * 38 0 Conditions Priority 26 * 42 0 Note *Insufficient number of SDPs. Assessing HIV, TB, Malaria and Childhood Immunization Supply-Side Readiness in Indonesia 57 Service Readiness: ART (%) Indicator Sample Puskesmas Private GP Public Hospital Private Hospital No. of Tracer Conditions 20 20 20 20 National 33 n.a. 81 100 Guidelines for therapy Priority 65 n.a. 80 80 Staff trained in ARV prescription and National 53 n.a. 88 100 management Priority 72 n.a. 83 80 National 69 n.a. 98 98 Full blood count Priority 73 n.a. 98 98 National 9 n.a. 63 100 CD4 or viral load Priority 4 n.a. 70 60 Renal function testing (serum National 28 n.a. 98 98 creatinine or other) Priority 53 n.a. 98 98 National 26 n.a. 98 98 Liver function testing (ALT of other) Priority 53 n.a. 98 98 National 37 n.a. 69 0 Zidovudine cap/tab (ZVD, AZT) Priority 37 n.a. 67 50 Zidovudine syrup/suspension (ZVD, National 11 n.a. 0 0 AZT) Priority 7 n.a. 3 0 National 0 n.a. 0 0 Abacavir cap/tab (ABC) Priority 13 n.a. 0 0 National 68 n.a. 6 0 Lamivudine cap/tab (3TC) Priority 59 n.a. 3 0 National 66 n.a. 88 50 Tenofovir disoproxil cap/tab (TDF) Priority 55 n.a. 90 50 National 14 n.a. 75 50 Emtricitabine cap/tab (FTC) Priority 17 n.a. 83 70 National 2 n.a. 88 50 Didanosine cap/tab (DDI) Priority 0 n.a. 90 70 Zidovudine + Lamivudine cap/tab National 50 n.a. 13 0 (AZT + 3TC) Priority 76 n.a. 10 10 National 48 n.a. 88 50 Neverapine cap/tab (NVP) Priority 54 n.a. 87 70 National 13 n.a. 31 1 Neverapine syrup/suspension (NVP) Priority 11 n.a. 20 10 National 68 n.a. 63 50 Efavirenz cap/tab (EFV) Priority 72 n.a. 53 20 Lopinavir + Ritonavir cap/tab (AZT + National 13 n.a. 25 0 3TC + NVP) Priority 19 n.a. 17 10 Zidovudine + Lamivudine + National 28 n.a. 81 50 Neverapine cap/tab (AZT + 3TC + NVP) Priority 15 n.a. 80 30 Stavudine + Lamivudine + Neverapine National 15 n.a. – – cap/tab (D4T + 3TC + NVP) Priority 9 n.a. – – Mean Service Readiness Index Score National 33 n.a. 54 38 (0-100%) Priority 38 n.a. 52 38 Facilities Satisfying All Tracer National 0 n.a. 0 0 Conditions Priority 0 n.a. 0 0 58 Service Availability: PMTCT (%) Indicator Sample Puskesmas Private GP Public Hospital Private Hospital National 54 19 n.a. n.a. PMTCT service Priority 63 13 89 38 Counseling in RH, HIV and National 100 95 n.a. n.a. STIs * Priority 100 100 82 95 HIV Counseling & Testing National 70 22 n.a. n.a. Services for Pregnant Women * Priority 75 39 88 70 National 18 1 n.a. n.a. ART for HIV+ Pregnant Women * Priority 14 2 76 40 ART for Neonates of HIV+ National 12 3 n.a. n.a. Pregnant Women * Priority 89 5 71 25 Nutrition Counseling for HIV+ National 78 59 n.a. n.a. Pregnant Women and Infants * Priority 81 68 76 70 Family Planning Counseling for National 74 69 n.a. n.a. HIV+ Pregnant Women * Priority 79 77 76 60 Note *The percentages shown pertain to the SDPs providing any relevant services as shown in the first row of the table. Service Readiness: PMTCT (%) Indicator Sample Puskesmas Private GP Public Hospital Private Hospital No. of Tracer Conditions 9 9 9 9 National 45 19 59 67 Guidelines for PMTCT Priority 64 21 61 70 Guidelines for infant and young National 56 8 n.a. n.a. child feeding practices (IYCF/PMBA) Priority 57 20 n.a. n.a. National 56 31 82 44 Staff trained in PMTCT Priority 59 41 79 55 National 64 29 76 33 Staff trained in HIV CT (VCT or PITC) Priority 67 28 76 40 National 53 29 35 33 Staff trained in prevention of PMTCT Priority 58 39 36 30 National 10 3 29 11 Other training on PMTCT Priority 12 13 24 15 National 67 2 94 56 HIV diagnostic capacity for adults Priority 70 6 97 65 National 1 0 0 0 Zidovudine syrup (AZT) Priority 1 0 0 0 National 0 0 12 0 Neverapine syrup (NVP) Priority 0 0 9 5 Mean Service Readiness Index Score National 38 10 45 31 (0-100%) Priority 42 15 44 35 Facilities Satisfying All Tracer National 0 0 0 0 Conditions Priority 0 0 0 0 Assessing HIV, TB, Malaria and Childhood Immunization Supply-Side Readiness in Indonesia 59 Service Readiness: TB (%) Puskesmas Public Private Indicator Sample Private GP All Referral & Independent Satellite Hospital Hospital No. of Tracer Conditions 8 8 8 8 13 13 Guidelines for diagnosis and National 48 48 47 14 83 56 treatment of TB Priority 79 78 80 35 86 49 Guidelines for diagnosis and National n.a. n.a. n.a. n.a. 56 39 treatment of TB-HIV coinfection Priority n.a. n.a. n.a. n.a. 70 28 Staff trained in diagnosis and National 47 49 40 19 61 22 treatment of TB Priority 39 50 28 34 59 28 Staff trained in diagnosis and National n.a. n.a. n.a. n.a. 61 22 treatment of TB-HIV coinfection Priority n.a. n.a. n.a. n.a. 59 25 Staff trained in MDR-TB National 36 37 32 15 39 22 treatment Priority 34 41 26 23 41 17 National 71 79 n.a. n.a. 100 80 Microscopy Priority 46 72 n.a. n.a. 97 89 National 38 42 n.a. n.a. 89 50 HIV diagnostic capacity Priority 41 65 n.a. n.a. 92 45 Smear sputum and microscopy National 77 95 n.a. n.a. 94 67 diagnosis Priority 45 89 n.a. n.a. 95 72 National 76 84 42 24 100 83 Clinical symptom diagnosis Priority 54 84 23 32 95 85 National n.a. n.a. n.a. n.a. 100 72 X-Ray Diagnosis Priority n.a. n.a. n.a. n.a. 100 81 Management and treatment National n.a. n.a. n.a. n.a. 22 22 follow-up Priority n.a. n.a. n.a. n.a. 35 17 National 98 98 97 38 83 56 Provision of drugs to TB patients Priority 98 99 97 48 86 60 National 93 95 88 21 94 67 First-line TB medications Priority 96 96 96 31 95 79 Mean Service Readiness Index National 65 70 58 12 74 50 Score (0-100%) Priority 59 75 58 19 77 50 Facilities Satisfying All Tracer National 0 0 0 0 6 0 Conditions Priority 0 0 0 1 5 0 60 Service Readiness: Malaria (%) Indicator Sample Puskesmas Private GP No. of Tracer Conditions 9 8 National 42 18 Guidelines for diagnosis and treatment Priority 31 21 National 55 7 Staff trained in diagnosis and treatment Priority 50 12 National 33 n.a. Staff trained in IPT Priority 42 n.a. National 68 4 Rapid malaria testing Priority 82 38 National 66 11 Malaria smear test Priority 63 21 National 84 30 Capacity to conduct malaria microscopy Priority 76 38 National 37 5 First-line anti-malarial in stock Priority 75 25 National 96 65 Paracetamol tabs/caps Priority 86 74 National 21 0 ITNs or vouchers Priority 33 12 Mean Service Readiness Index Score (0- National 52 5 100%) Priority 61 16 National 0 0 Facilities Satisfying All Tracer Conditions Priority 0 1 Service Readiness: Childhood Immunization (%) Indicator Puskesmas Private GP No. of Tracer Conditions 13 13 Guidelines for childhood immunization 69 41 Staff trained in childhood immunization 76 32 Cold box/vaccine carrier with ice pack 93 65 Refrigerator 96 76 Sharps container/safety box 88 90 Auto-disable syringes 69 63 Temperature monitoring device 92 52 Adequate refrigerator temperature 84 38 Measles vaccine 86 44 DPT-Hib+Heb vaccine 82 37 Oral polio vaccine 85 40 BCG vaccine 84 33 Energy source and power supply 90 73 Mean Service Readiness Index Score (0-100%) 84 53 Facilities Satisfying All Tracer Conditions 27 1 Assessing HIV, TB, Malaria and Childhood Immunization Supply-Side Readiness in Indonesia 61 Appendix 6. Full Service Readiness Tabulations Service Readiness: HCT Medicines & Guideline and Equipment Diagnostic “HIV HCT Commodities Training Item Item Supply Side” Items District/Type of Number of Representativeness facility Visual and HIV “Readiness “Readiness Facilities Staff Gudeline auditory diagnostic Condoms Index Index Trained privacy capacity (mean)” (met all)” Priority Districts Puskesmas urban 55% 76% 52% 91% 72% 69% 22% 177 rural 17% 67% 35% 90% 66% 55% 7% 42 All 49% 74% 49% 91% 71% 67% 19% 219 Private: Single & Multiple Provider Urban 13% 34% 27% 11% 10% 19% 0% 27 Rural 0% 0% 50% 100% 50% 40% 0% 2 BPJS network 16% 44% 42% 17% 29% 30% 0% 13 Not BPJS network 9% 23% 17% 17% 0% 13% 0% 16 All Private GP 12% 32% 28% 17% 13% 20% 0% 29 Hospital Public 76% 79% 88% 100% 82% 85% 45% 33 Private 61% 50% 50% 83% 33% 72% 31% 13 All 71% 69% 75% 94% 65% 81% 41% 46 National Puskesmas Urban 31% 70% 47% 92% 46% 57% 9% 109 Rural 26% 65% 29% 85% 41% 49% 1% 37 All 29% 68% 40% 89% 44% 54% 6% 146 Private: Single & Multiple Provider Urban 2% 27% 46% 10% 13% 20% 0% 19 Rural 50% 100% 0% 0% 50% 40% 0% 2 BPJS network 0% 37% 54% 0% 16% 21% 0% 11 Not BPJS network 14% 21% 26% 26% 14% 20% 0% 10 All Private 5% 31% 44% 9% 15% 21% 0% 21 62 Service Readiness: HIV CST “HIV-CST Guideline and Training Diagnostics Items Medicines & Commodities Items Supply Side” Number District / System for Intravenous IV treatment Co- Palliative of Type of facility Staff First-line TB “Readiness Index “Readiness Index Guideline diagnosis of TB solution with fungal trimoxazole Care Pain Condoms Facility Trained Medications (mean)” (met all)” among HIV + clients infusion set infections cap/tab Management Priority Districts Puskemas urban 47% 71% 85% 99% 75% 97% 96% 97% 74% 82% 29% 67 rural 7% 45% 86% 100% 64% 93% 100% 81% 62% 71% 7% 16 All 41% 67% 85% 99% 74% 96% 97% 94% 72% 80% 26% 83 Private GP: Single & Multiple Provider Urban 0% 70% 13% 91% 21% 91% 82% 91% 30% 54% 0% 6 Rural n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. 0 BPJS network 0% 86% 0% 86% 0% 86% 86% 86% 45% 53% 0% 3 Not BPJS network 0% 38% 38% 100% 62% 100% 74% 100% 0% 57% 0% 3 All Private 0% 70% 13% 91% 21% 91% 82% 91% 30% 54% 0% 6 Hospital Public 76% 91% 88% n.a. 67% 85% 94% n.a. 88% 84% 42% 51 Private 50% 56% 61% n.a. 67% 72% 78% n.a. 56% 63% 33% 33 All 67% 78% 78% n.a. 67% 80% 88% n.a. 76% 76% 39% 18 National Puskesmas urban 27% 57% 83% 99% 88% 99% 97% 96% 47% 77% 23% 30 Assessing HIV, TB, Malaria and Childhood Immunization Supply-Side Readiness in Indonesia rural 9% 42% 75% 100% 59% 91% 100% 93% 61% 70% 9% 15 All 18% 50% 79% 99% 74% 95% 98% 95% 53% 74% 16% 45 Private: Single & Multiple Provider Urban 0% 77% 77% 89% 11% 89% 77% 89% 0% 57% 0% 3 Rural n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. 0 BPJS network 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 1 Not BPJS network 0% 87% 87% 100% 13% 100% 87% 100% 0% 64% 0% 2 All Private 0% 77% 77% 89% 11% 89% 77% 89% 0% 57% 0% 3 Service Readiness: Antiretroviral Treatment Guideline and “HIV-ARV Diagnostic Items Medicines & Commodities Items Training Supply Side” Stavu- Teno- Zidovu- dine + Renal fovir Nevi- ARV syr- Liver dine + Lopina- Lamivu- “Read- District/Type of function Zidovudine Lami- Diso- Emtric- Nevi- rapine Efa- ups for “Read- Number of Full CD4 or function Abacavir Didanosine Lami- vir + Ri- dine + iness facility Guide- Staff test(serum Zidovudine Cap/ syrup/ vudine proxil itabine rapine syrup/ virenz children iness Facilities blood Viral test Cap/tab cap / tab vudine tonavir Nevirap- Index line Trained creatinine tab (ZDV, AZT) suspension Cap/tab Fuma- cap/tab cap/tab suspen- Cap/tab (AZT + Index count load (ALT or (ABC) (DDI) cap/ Cap/tab ine Cap/ (met testing or (ZDV, AZT) (3TC) rate (FTC) (NVP) sion (EFV) 3TC + (mean)” Representativeness other) tab(AZT (LPV/r) tab (D4T all)” other) cap/ (NVP) NVP) + 3TC) + 3TC + tab(TDF) NVP) Priority Districts Puskesmas Puskesmas-urban 69% 68% 81% 0% 51% 49% 43% 9% 11% 66% 60% 20% 3% 79% 62% 15% 73% 22% 21% 13% 41% 0% 28 Puskesmas-rural 22% 62% 41% 37% 21% 21% 0% 0% 0% 16% 16% 0% 0% 22% 0% 0% 38% 0% 0% 22% 16% 0% 5 All Puskesmas 62% 67% 75% 5% 47% 45% 37% 8% 10% 59% 54% 17% 2% 71% 53% 13% 68% 19% 18% 14% 37% 0% 33 Private: Single & Multiple Provider Urban n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. 0 Rural n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. 0 BPJS network n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. 0 Not BPJS network n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. 0 All Private n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. 0 Hospital Public Hospital 80% 83% n.a. 70% n.a. n.a. 67% 3% 0% 3% 90% 83% 90% 10% 87% 20% 53% 17% 80% n.a. 52% 0% 30 Private Hospital 80% 80% n.a. 60% n.a. n.a. 50% 0% 0% 0% 50% 70% 70% 10% 70% 10% 20% 10% 30% n.a. 38% 0% 10 All Hospital 80% 82% n.a. 68% n.a. n.a. 63% 3% 0% 3% 80% 80% 85% 10% 82% 17% 45% 15% 68% n.a. 49% 0% 40 National Puskesmas Puskesmas-Urban 47% 61% 84% 0% 40% 37% 38% 15% 0% 54% 51% 6% 3% 57% 54% 18% 54% 18% 25% 21% 34% 0% 12 Puskesmas-Rural 0% 35% 35% 30% 0% 0% 35% 0% 0% 100% 100% 35% 0% 35% 35% 0% 100% 0% 35% 0% 29% 0% 3 All Puskesmas 33% 53% 69% 9% 28% 26% 37% 11% 0% 68% 66% 14% 2% 50% 48% 13% 68% 13% 28% 15% 33% 0% 15 Private: Single & Multiple Provider Urban n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. 0 Rural n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. 0 BPJS network n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. 0 Not BPJS network n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. 0 All Private n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. 0 63 64 Service Readiness: PMTCT Medicines & Diagnostics “HIV-PMTCT Representativeness Guideline and Training Equipment Commodities Items Supply Side” Items District/Type of Guidelines Number of facility on infant Staff Visual and HIV diagnostic ARV syrups “Readiness “Readiness Facilities Guidelines and young Trained Auditory capacity for for children Index Index on HIV PMTCT child feeding in HIV Privacy Room adults (AZT+3TC+NVP) (mean)” (met all)” practices PMTCT (IYCF/PMBA) Priority Districts Puskesmas Puskesmas-urban 65% 62% 63% 41% 72% 3% 53% 0% 209 Puskesmas-rural 35% 28% 44% 28% 70% 2% 36% 0% 48 All Puskesmas 60% 56% 60% 39% 72% 3% 50% 0% 257 Private Urban 17% 16% 36% 6% 2% 0% 14% 0% 63 Rural 26% 0% 19% 26% 52% 0% 20% 0% 7 BPJS network 13% 20% 31% 13% 8% 0% 14% 0% 30 Not BPJS network 20% 12% 38% 3% 3% 0% 15% 0% 40 All Private 17% 15% 35% 7% 5% 0% 15% 0% 70 Hospital Public Hospital 61% n.a. 79% 85% 97% 73% 79% 30% 33 Private Hospital 70% n.a. 55% 40% 65% 15% 49% 10% 20 All Hospital 64% n.a. 70% 68% 85% 51% 68% 23% 53 National Puskesmas Puskesmas-Urban 48% 61% 67% 40% 75% 3% 51% 0% 122 Puskesmas-Rural 40% 49% 38% 19% 56% 5% 38% 0% 40 All Puskesmas 45% 56% 56% 31% 67% 4% 46% 0% 162 Private: Single & Multiple Provider Urban 18% 9% 27% 12% 3% 0% 11% 0% 50 Rural 26% 0% 51% 0% 0% 0% 13% 0% 8 BPJS network 19% 10% 35% 12% 0% 0% 13% 0% 31 Not BPJS network 19% 4% 25% 6% 6% 0% 10% 0% 27 All Private 19% 8% 31% 10% 2% 0% 12% 0% 58 Assessing HIV, TB, Malaria and Childhood Immunization Supply-Side Readiness in Indonesia 65 Service Readiness: Tuberculosis Medicines & “Tuberculosis Guideline and Training Diagnostics Items Commodities Supply Side” Items Representativeness Number District/Type of Guideline: Training: Training: Sputum Provi- Manage- Training: HIV smear Man- “Read- of facility Manage- TB Manage- sion of ment and “Read- Facility Client diag- and toux Clinical iness Guide- ment of diagno- ment of Micros- X-Ray/ drugs treatment First-line TB iness MDR-TB nostic micros- test for symp- Index line HIV-TB sis and HIV-TB copy Rontgen to TB follow medications Index treat- capac- copy diag- toms (met co-infec- treat- co-infec- pa- up for TB (mean)” ment ity exam- nosis all)” tion ment tion tients patients ination Priority Districts Puskesmas Laboratory Referral and Independent 73% n.a. 46% n.a. 43% 75% 65% 92% n.a. 83% n.a. 100% n.a. 97% 75% 11% 191 - Urban Laboratory Referral and Independent 53% n.a. 48% n.a. 24% 71% 53% 89% n.a. 96% n.a. 98% n.a. 92% 69% 6% 50 - Rural Laboratory Referral 69% n.a. 47% n.a. 40% 74% 63% 92% n.a. 86% n.a. 100% n.a. 96% 74% 10% 241 and Independent Satellite-Urban 83% n.a. 26% n.a. 27% n.a. n.a. n.a. n.a. 20% n.a. 98% n.a. 97% 58% 1% 106 Satellite-Rural 45% n.a. 39% n.a. 19% n.a. n.a. n.a. n.a. 40% n.a. 91% n.a. 91% 54% 4% 23 Satellite 78% n.a. 28% n.a. 26% n.a. n.a. n.a. n.a. 23% n.a. 97% n.a. 96% 58% 2% 129 All Puskesmas - 77% n.a. 37% n.a. 36% 49% 44% 53% n.a. 56% n.a. 99% n.a. 97% 61% 6% 297 Urban All Puskesmas - 50% n.a. 45% n.a. 22% 62% 47% 59% n.a. 77% n.a. 95% n.a. 91% 61% 4% 73 Rural All Puskesmas 73% n.a. 39% n.a. 34% 52% 45% 54% n.a. 60% n.a. 99% n.a. 96% 61% 6% 370 Private GP Urban 31% n.a. 33% n.a. 23% n.a. n.a. n.a. n.a. 33% n.a. 45% n.a. 59% 37% 1% 203 Rural 4% n.a. 12% n.a. 8% n.a. n.a. n.a. n.a. 8% n.a. 61% n.a. 75% 28% 0% 19 BPJS Network 35% n.a. 41% n.a. 31% n.a. n.a. n.a. n.a. 36% n.a. 63% n.a. 60% 44% 2% 88 Not BPJS Network 27% n.a. 25% n.a. 16% n.a. n.a. n.a. n.a. 29% n.a. 33% n.a. 59% 32% 0% 134 All Private GP 30% n.a. 32% n.a. 22% n.a. n.a. n.a. n.a. 32% n.a. 45% n.a. 59% 37% 1% 222 Hospital Public Hospital 86% 70% 59% 59% 41% 97% 92% 95% 70% 95% 100% 86% 35% 95% 77% 5% 37 Private Hospital 49% 28% 28% 25% 17% 89% 45% 72% 51% 85% 81% 60% 17% 79% 50% 0% 53 All Hospital 64% 46% 41% 39% 27% 93% 64% 81% 59% 89% 89% 71% 24% 86% 61% 2% 90 National Puskesmas Laboratory Referral 48% n.a. 49% n.a. 37% 79% 42% 95% n.a. 84% n.a. 98% n.a. 95% 70% 3% 212 and Independent Laboratory Referral and Independent- 48% n.a. 44% n.a. 36% 78% 55% 97% n.a. 87% n.a. 100% n.a. 99% 72% 4% 137 Urban Labpratory Referral and Independent- 49% n.a. 53% n.a. 37% 79% 29% 93% n.a. 81% n.a. 96% n.a. 92% 68% 1% 75 Rural Satellite 47% n.a. 40% n.a. 32% n.a. n.a. n.a. n.a. 42% n.a. 97% n.a. 88% 58% 6% 55 Satellite-Urban 60% n.a. 26% n.a. 46% n.a. n.a. n.a. n.a. 32% n.a. 100% n.a. 80% 57% 3% 21 Satellite-Rural 44% n.a. 43% n.a. 28% n.a. n.a. n.a. n.a. 45% n.a. 97% n.a. 90% 58% 7% 34 All urban 49% n.a. 42% n.a. 37% 76% 56% 89% n.a. 82% n.a. 100% n.a. 97% 70% 4% 158 All rural 48% n.a. 51% n.a. 35% 69% 25% 68% n.a. 71% n.a. 96% n.a. 91% 61% 1% 109 All Puskesmas 48% n.a. 47% n.a. 36% 71% 38% 77% n.a. 76% n.a. 98% n.a. 94% 65% 2% 267 Private: Single & Multiple Provider Urban 15% n.a. 19% n.a. 15% n.a. n.a. n.a. n.a. 26% n.a. 37% n.a. 38% 25% 1% 111 Rural 9% n.a. 18% n.a. 11% n.a. n.a. n.a. n.a. 14% n.a. 46% n.a. 70% 28% 0% 19 BPJS Network 23% n.a. 28% n.a. 20% n.a. n.a. n.a. n.a. 24% n.a. 46% n.a. 39% 30% 2% 64 Not BPJS Network 5% n.a. 11% n.a. 9% n.a. n.a. n.a. n.a. 24% n.a. 31% n.a. 46% 21% 0% 66 All Private 14% n.a. 19% n.a. 15% n.a. n.a. n.a. n.a. 24% n.a. 38% n.a. 43% 25% 1% 130 66 Service Readiness: Immunization Guideliine and “Immunization Equipment Items Medicines & Commodities Items Traning Supply Side” Representativeness District/Type of Number of Cold box/ facility Sharps Temperature Facilities vaccine Auto- Adequete DPT + Hib “Readiness “Readiness Guide- Staff container monitoring Measles Oral Polio BCG carrier Refrigerator disable refrigerator + Hepb Index Index line Trained /safety device in Vaccine Vaccine Vaccine with ice syringes temperature Vaccine (mean)” (met all)” box refrigerator pack National Puskesmas Puskesmas-urban 80% 75% 96% 98% 95% 81% 94% 88% 91% 88% 91% 89% 89% 35% 157 Puskesmas-rural 61% 77% 90% 95% 83% 60% 91% 82% 82% 77% 80% 80% 80% 24% 108 All Puskesmas 69% 76% 93% 96% 88% 69% 92% 84% 86% 82% 85% 84% 84% 28% 265 Private Rural 30% 79% 54% 67% 92% 30% 43% 43% 30% 38% 67% 54% 52% 0% 5 Urban 34% 43% 67% 93% 94% 59% 54% 42% 47% 36% 45% 48% 55% 3% 36 BPJS network 36% 50% 62% 88% 93% 49% 55% 40% 46% 36% 45% 47% 54% 4% 31 Not BPJS network 26% 34% 78% 98% 100% 80% 46% 48% 44% 35% 55% 55% 58% 0% 10 All Private 34% 47% 65% 90% 94% 56% 53% 42% 46% 36% 47% 49% 55% 3% 41 Service Readiness: Malaria “Malaria Guideline and Training Diagnostic Items Medicines & Commodities Items Supply Side” Representativeness Index Index Index Number of District/Type of facility Capacity Facilities Rapid Malaria First-line “Readiness “Readiness Guide- Staff to conduct Paracetamol Malaria smear antimalarial Index Index line Trained malaria cap/tab Testing test in stock (mean)” (met all)” microscopy Met Met Mean Met all Mean Mean all all Priority Districts Puskesmas Puskesmas-urban 43% 86% 64% 43% 100% 95% 100% 98% 95% 86% 90% 88% 76% 86% 0% 21 Puskesmas-rural 28% 41% 34% 12% 77% 54% 70% 67% 46% 73% 84% 79% 59% 61% 0% 83 All Puskesmas 31% 50% 40% 18% 82% 63% 76% 73% 56% 76% 86% 81% 63% 66% 0% 104 Private: Single & Multiple Provider Urban 21% 13% 17% 8% 33% 25% 46% 35% 4% 54% 75% 47% 38% 35% 4% 24 Rural 20% 10% 15% 10% 50% 10% 20% 27% 0% 40% 70% 40% 10% 29% 0% 10 BPJS network 17% 8% 13% 8% 25% 25% 58% 36% 8% 33% 83% 44% 17% 33% 8% 12 Not BPJS network 23% 14% 18% 9% 45% 18% 27% 30% 0% 59% 68% 45% 36% 33% 0% 22 All Private 21% 12% 16% 9% 38% 21% 38% 32% 3% 50% 74% 45% 29% 33% 3% 34 National Puskesmas Puskesmas-Urban 47% 47% 47% 26% 39% 70% 92% 67% 26% 28% 96% 62% 26% 60% 7% 111 Puskesmas-Rural 39% 60% 49% 30% 78% 64% 80% 74% 51% 50% 96% 73% 46% 67% 13% 105 All Puskesmas 42% 55% 49% 28% 63% 66% 84% 71% 41% 42% 96% 69% 39% 64% 11% 216 Private: Single & Multiple Provider Urban 19% 6% 12% 4% 4% 13% 33% 17% 4% 21% 66% 43% 21% 23% 0% 59 Rural 14% 10% 12% 3% 3% 0% 16% 6% 0% 14% 59% 37% 11% 17% 0% 15 BPJS network 23% 10% 17% 6% 4% 20% 37% 20% 3% 13% 53% 33% 13% 23% 0% 34 Not BPJS network 13% 3% 8% 1% 4% 3% 23% 10% 3% 25% 75% 50% 25% 21% 0% 40 All Private 18% 7% 12% 3% 4% 11% 30% 15% 3% 19% 65% 42% 19% 22% 0% 74 Assessing HIV, TB, Malaria and Childhood Immunization Supply-Side Readiness in Indonesia 67 68 References Ali, P.B. 2017. “Transitioning externally funded health programmes – country experience: Indonesia.” Technical Working Group on Sustainability, Transition from Aid and Health System Strengthening. 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