Indonesia HIV-HRH Assessment

September 21, 2018

Welcome & Opening RemarksSubdirektorat HIV AIDS dan PIMS / CDC / MOH

USAID/Indonesia

IntroductionsHRH2030 Program

Assessment Objective

▪ Assess the HRH-related barriers at the policy and site levels that may be hindering HIV service delivery

▪ Gather evidence to recommend policy and site level interventions to improve HIV service delivery▪ HRH optimization to achieve Fast-Track targets

▪ Longer-term sustainability planning and HIV mainstreaming

▪ Consideration of differentiated service delivery (DSD) models

Workshop Overview

▪ Methods▪ Policy Assessment

▪ Site-level Assessment

▪ Results▪ Policy Assessment

▪ Site-level Assessment

▪ Preliminary recommendations

▪ Discussion & next steps

Methods

HRH2030 Policy and Site-level Assessment Approach in Indonesia

Policy Assessment Objectives

1. To identify relevant HRH policies, protocols, scopes of practice, and task shifting practices that hinder or support the key health worker types to implement and scale up HIV services

2. To identify policy and advocacy opportunities, challenges, priority actions, and implications for HRH programming to strengthen the implementation of HIV services

Policy research questions

For HIV policy implementation in Indonesia:

1. What are the major policy and regulatory barriers and opportunities in the HRH system for current implementation?

2. What are the policy implementation issues that influence the health workforce in delivering HIV services?

3. Learning from the implementation of SUFA, what HRH policy, regulatory, and legal adaptations will be needed for fully implementing Test and Treat program in the future?

4. What policy or regulatory changes should be prioritized to achieve more effective implementation?

5. What aspects in the policies, protocols, scopes of practice hinder or support the implementation of task-shifting practices in Indonesia?

*Adapted from the Policy

Implementation Assessment Tool:

(http://www.healthpolicyplus.com/a

rchive/ns/pubs/hpi/1155_1_PIAT_P

aper_Taking_the_Pulse_of_Policy_

acc.pdf)

1.Policy analysesa. Policy* search

Website of relevant institutionMLHR, MoH, MORTHE, Ministry of Labour

MLHR websiteValidate status of regulation

b. Policy Inventory

Primary Mainly concerns with

HIV/AIDS and HRH issues

Technical/derivativeFurther describes technical aspects

of a primary policy

Backgroundprovides context for

primary policy

Methods

Google

c. Text analysis

2. Key informant

interviews

HRH2030 Policy and Site-level Assessment Approach in Indonesia

Site-level Assessment Sample

Site District

Volume of all HIV tests

conductedVolume of HIV+ tests

High Medium Low High Medium Low

PKM Kecamatan Tanjung Priok North X X

PKM Kecamatan Setiabudi South X X

PKM Kecamatan Gambir Central X X

PKM Kecamatan Tamansari West X X

PKM Kecamatan Penjaringan North X X

PKM Cengkareng West X X

PKM Cakung East X X

PKM Kecamatan Kramat Jati East X X

Ruang Carlo Central X X

PKM Kelurahan Kramat

(Kecamatan Senen)Central X X

Site-level tools

•Unit manager questionnaire Availability

•Rapid task analysisCompetency(self-reported)

•Client flow mappingAccessibility

Challenge identification

• Health worker focus group discussion

Unit manager questionnaire

▪ Semi-structured interview

▪ HRH Availability▪ Types, number and availability of cadres at facility

▪ Current health worker allocation per HIV service point

▪ Health worker capacity and preparation for providing quality HIV services

▪ Manager perspectives on▪ Reasons contributing to absenteeism, retention, and

productivity

▪ HRH barriers pertaining to service delivery

Adapted from the PEPFAR Rapid Site-level Health Workforce Assessment Tool

https://www.hrh2030program.org/pepfar_tool/

Rapid Task Analysis (1)

Service Areas

1: Examination of HIV, STI and hepatitis

2: ART Enrollment

3: ART Initiation

4: Adherence Counselling

5: Clinical Examination & Consultation

6: Recording and Reporting

7: Health Education

8: Integrated TB-HIV Services

9: Mobile Testing

10: PMTCT

11: Harm reduction

Health Worker Types

Doctor

Nurse

Lab Technician

Recording & reporting

officer

Pharmacy

Midwife

Cadre/community

counselor

“Core team” for site activation

Adapted from HRH2030 Rapid Task Analysis Questionnaire

https://www.hrh2030program.org/wp-content/uploads/2018/06/Rapid-Task-Analysis-Tool.pdf

In your opinion, to what extent is

your knowledge about this task?

Not acquired the basic knowledge

Only the basic knowledge

Necessary knowledge to perform the

task

Advanced knowledge

Rapid Task Analysis (2)

Is this

task

assigned

to you?

No

Yes

In your opinion, how confident

are you in performing the task? Need more opportunity to apply

knowledge

Can apply knowledge but still need help

Confident performing task, but not to

teach others

Confident performing task and teaching to

others

Have you

been trained

for this task?

No

Yes• Informal, on-the-job training

• Clinical mentoring

• Formal in-service training

• Pre-service training

How often do you perform

this task? Never

Seldom

A few times a month

A few times a week

Almost every day

Client flow mapping

▪ For ART refill patients with undetectable viral load

▪ Participatory observation▪ Where do they go?

▪ How long does it take?

▪ With which health workers do they interact during the visit?

▪ Where are the service delivery bottlenecks, if any?

▪ For reasons of ethics and confidentiality, CSCs were trained to use tablets to conduct client flow mapping

Health worker Focus Group Discussion (FGD)

▪ Client and health worker flow mapping from HW perspective▪ Who is involved at each service area?

▪ What are challenges at each service area?

▪ Root cause analysis by HRH category type:

Adapted from HRH2030 Optimizing Health Worker Performance and Productivity to Achieve the 95-95-95 Targets

https://www.hrh2030program.org/prodperftoolkit/

Health

worker

competency

gaps

Low

engagement

Poor

allocation of

staff or tasks

Inefficient

work

processes

Other

health

systems

issues

Results

HRH2030 Policy and Site-level Assessment Approach in Indonesia

Evolution of Policies for HIV Service Delivery

HRH Quantity & Quality HRH Management

Medical Practices

Law, HRH Law Competency, Registration,

Licensing

UU 17/2007,

RPJP HRH Development

UU 5/2014 ASN Legal foundation for ASN

management – PNS &PPPK

UU 23/2014 on

Regional Government Role of regional government in HRH

planning & development

PP 43/2016 SPM Quantity & quality standard of HRH

PP 11/2017 on Civil

Servants Managementmanagement of human resources for civil

servant)

PP 18/2016 on

Local Apparatus Offices & Technical Implementation Unit

perform the HRH planning)

HRH Procurement HRH Planning

PMK 26/2017Procurement of HRH by agreement

PMK 33/2015 Manual to determine HRH needs

PB 61/2014HRH planning and equity

Law or regulation

established by the House

of Representatives with

President's consent.

Law set by the President

to implement the act as it

should.

Based on certain content

for the purpose of the

administration of certain

affairs in government.

UU: Undang-undang

Act/Law

PP: Peraturan

Pemerintah

Government regulation

PMK: Perat uran

Menteri Kesehatan

Minister of Health

Regulation

HRH Regulation : Hierarchy of Legislations

UUD 1945 Constitutional Foundation

Ministry of

Research &

Higher

Education

Health

Professional

Education

Institutions

Health

Professional

Graduates

Ministry of Health Ministry of

Civil

Apparatus Empowerment

Ministry of

Home Affairs

BPPSDMPlanning

overall HRH

needs (#)

DG of Health

ServicesQuality of Care

(Accreditation)

DG of

CDCTechnical

Competence.

Technical Policies &

Program PlanningLocal

Government/

PHO / DHO

Puskesmas

&

Hospitals

Planning & Technical DirectionEducation Procurement

HRH Stakeholders in Policy Implementation

Management

Employed

Health

ProfessionalsCommand

Coordination

Professional

Councils

Regulation

Policies on HRH Education

▪ HIV competencies are integrated into pre-service education policies for doctors, nurses, midwives▪ Standar Kompetensi Dokter Indonesia – SKDI, 2012

▪ Standar Kompetensi Perawat, 2007

▪ Standar Kompetensi Bidan, 2007

▪ In-service training required for health worker re-registration

▪ Lab technicians, recording and reporting, and pharmacy staff▪ Nurses can perform some pharmacy tasks in the absence of pharmacy

staff

Policy Implementation for HRH Education

▪ Pre-service education standardization of comprehensive

HIV curricula is limited, particularly in private schools

▪ Variant quality of pre-service curricula

▪ Wide range of HIV in-service training programs established

▪ Targeted selection of in-service trainees and post-training

follow-up may not be consistently practiced

▪ In-service training curricula

Policy Implementation on HRH Regulation, Planning and Procurement

▪ Initial licensure/passing competency exams can be challenging for many new health graduates

▪ Registration processes frequently delayed

▪ Limited use and interoperability of local HRH databases for planning

▪ Challenge to coordinate across stakeholders to hire health workers, specifically related to planning and procurement

Policies on HRH Management Remuneration, incentives and benefits

▪ Civil servant, non-civil servant and private health workers

▪ Compensation vs workload, timing incentives payment

▪ Operational incentives for performing activities outside the health facilities (Puskesmas BOK, DHO)

▪ MOH Regulation No. 21/2016 (60% of fees for medical providers and operational costs) - Local Government’s capability (to adapt the national regulation to the local level and manage the funding for the Puskesmas)

Existing Policies• MOH Regulation No. 64/2015 – technical direction/guidance

• Permenkes No. 21/2013 jo. Permenkes No. 87/2014 – monitoring of quality of

HIV care

• The Act on Health (Law of Health No. 26/2009) - drugs can only be prescribed

by physicians (Law of Medical Practices No. 29/2004)

• Article 65 of Law 36/2014 - Delegation of authority/action (the transfer of

medical authority to health professionals/non-medical)

• Article 29, Article 32 of Law 38/2014 - Delegation of medical authority to nurses

(the transfer of medical authority to nurses has a special legal basis/lex specialist)

• Duty of nurses with certain limitations

Policies on HRH Management

Quality of care and performance

Implementation issues

• Variant the monitoring practices, budget availability

• Only about 50% of health facilities in Indonesia are accredited

• Accreditation as an objective vs maintain quality of care, lack of

human resources at the health facilities to apply and meet the

accreditation standards

• Indonesia Medical Association (Ikatan Dokter Indonesia/IDI) rarely

audits and evaluates quality of care including prescribing practices

Policies on HRH Management

Quality of care and performance

Site-level Results

•Unit manager questionnaire Availability

•Rapid task analysisCompetency(self-reported)

•Client flow mappingAccessibility

Challenge identification

• Health worker focus group discussion

Number of health workers by typeof required “core team” for HIV site activation

PKMHIV Services

Q3, to be verified

Core

teamKnowledge Confidence to perform % Training

New positives

Enrolled in ART

Currently on ART

+

=

-

Advanced

Sufficient

Basic

None

Confident, capable to mentor

Confident

Confident but need support

Needs practice

Across all HWs &

tasks

A 8 6 82 + 0% 73% 20% 7% 11% 41% 36% 11% 66%

B 20 15 237 + 5% 73% 19% 3% 57% 8% 27% 8% 79%

C 0 0 61 + 0% 56% 38% 6% 21% 44% 15% 21% 53%

D 10 6 111 + 0% 85% 12% 2% 20% 32% 34% 15% 95%

E 20 11 171 + 0% 68% 32% 0% 16% 60% 12% 12% 88%

F 10 9 265 + 4% 71% 24% 0% 27% 53% 18% 2% 78%

G 2 7 81 + 12% 81% 8% 0% 46% 31% 23% 0% 88%

H 13 12 241 + 34% 47% 19% 0% 38% 53% 9% 0% 75%

Summary dashboard of 8 Puskesmas KecamatanAll health workers across all tasks

Unit Manager Questionnaire: Example site-level results

Rapid Task Analysis: Example aggregate results

Doctors’ self-reported HIV knowledge, training, skills, and frequency by task (n=13)

Nurses’ self-reported HIV knowledge, training, skills, and frequency by task (n=12)

Doctors’ self-reported HIV knowledge, training, skills, and frequency by assigned task

Nurses’ self-reported HIV knowledge, training, skills, and frequency by assigned task

Nurses’ self-reported HIV knowledge, training, skills, and frequency by assigned

task: HIV diagnosis

Of nurses assigned to HIV

diagnosis, (n=3), 1 reported

having no knowledge

S/he had been trained in HIV

diagnosis

S/he reported needing practice

to perform HIV diagnosis

S/he reported performing the task

a few times a month

Nurses’ self-reported HIV knowledge, training, skills, and frequency by

assigned task: PMTCT

Of 12 surveyed, 1 nurse

reported being assigned to ARV

management of pregnant

women, and having basic

knowledge

S/he has not been

trained for PMTCT.

S/he needs support to

perform PMTCT.

S/he performs

PMTCT somewhat

frequently.

Doctors’ self-reported HIV knowledge, training, skills, and frequency by

assigned task: Advanced clinical ART exam

Of doctors assigned to

advanced ART clinical exam

(n=10), 80% reported having

sufficient knowledge

7 of the these 8 have

been trained to do

advanced clinical ART

exams

7 of the these 8 feel

confident to perform

clinical ART exams

Most doctors perform

advanced clinical ART

exams regularly

Client Flow mapping results:

Time spent in waiting rooms / total time spent at facility by ART refill clients (n=18)

Of those observed, clients spent an

average of 53% of their time waiting

versus receiving care.

Health worker FGDs: Challenge identification▪ Health worker competency gaps

▪ PKM management planning and budgeting for staff in-service training

▪ Increase the number and capacity of Counselor

▪ Low engagement▪ Stigma is not only felt by HIV client but also felt by the HIV core team

▪ Puskesmas management's commitment to "see" that HIV services

are as important as other health service units

▪ Poor allocation of staff or tasks▪ Additional task

▪ Tasks distribution between health workers in the HIV team

▪ Inefficient work processes▪ Manual recording system

▪ SIHA

▪ Integration of recording and reporting systems

▪ Other health system issues▪ Almost all Puskesmas doesn’t have a special room for counseling

▪ Some Puskesmas have the equipment for Viral Load test, but are constrained in procuring cartridges

▪ Unclear Reagan allocation for the CATIN (Calon Pengantin) program.

Discussion & Questions

Preliminary Recommendations

▪ Site-level data review and discussion▪ Health workforce challenges and local potential solutions

▪ Review HIV service delivery to identify gaps and take quality improvement approach (HRH2030 Toolkit; see next slide)

▪ Coordinate strategic in-service skills development in consideration of workload, FTE implications, staff rotations and turnover

▪ Determine evidence needs/workload limits to support incremental task sharing or differentiated care;▪ MMS could be considered at high-volume sites (where pharmacy workload high),

especially when monthly refills present hardship for the client

▪ Scale up tools application through capacity building; use locally available data streams to inform

Optimizing Health Worker Performance and Productivity

to Achieve 95-95-95 Targets

www.hrh2030program.org/prodperftoolkit

Future Opportunities

▪ Distribution of HRH management responsibilities

▪ Increased practical, interprofessional learning and supportive supervision

▪ Anticipate and plan for workload increase for lab/pharmacy staff across other (non-HIV) services

▪ Repeat HIV-HRH assessment to inform future workload needs that may required differentiated care models

▪ Consider strategic use of district and site level funds, e.g., capitation funds

▪ Adapt and apply the policy and site-level assessment methodology across all services

Discussion & Next Steps

▪ Conduct local dissemination of site-level results and support development of site-level solutions and/or improvement plans

▪ Build capacity to routinely apply tools at PEPFAR-supported sites (Jakarta, Papua)

▪ Make Power BI dashboard with detailed site-level results available to USAID, MOH, and partners (LINKAGES)

Closing remarksSubdirektorat HIV AIDS dan PIMS / CDC / MOH

USAID/Indonesia

Acknowledgements

Rachel Deussom, Astri Ferdiana, Caroline Francis, Katy Gorentz, Endang Budi Hastuti, Aulia Human, Ciptasari Prabawanti,

Anton Purnama, Tetty Rachmawati, Edhie Rahmat, Elisabeth Rottach, Nanda Sirajulmunir, Revy Sjahrial

Ministry of Health Indonesia | Provincial Health Office, DKI Jakarta | District Health Offices, East, Central, North, South

and West Jakarta | Participating health facilities

Terima kasih!