HIV/AIDS in Indonesia

Course: International Public Health Date: 2-4-2013 By: Muhammad Rizki Febrianto Maud Raaymakers Robel Afeworki Martine van Zoest

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Index
1. Introduction 3

2. Demographics

3. Determinants of HIV/AIDS in Indonesia a. Biology b. Demographic transitions c. Poverty d. Awareness e. Behavior f. Stigma g. Insufficient supply of treatment

5 5 5 5 6 7 7

4. Bibliography 5. Attachment

8 9

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Introduction
HIV is a virus that causes AIDS (Acquired Immunodeficiency Syndrome) by destroying the ability of bodys immune system to protect against infections. The virus binds to CD4 -T-cells, which are crucial for cellular immunity, uses them for replication and destructs them in the process. Failure of the immune system associated with a low number of CD4 cells leads to a threat of opportunistic infections and other life-threatening diseases like malignancy. HIV is a retrovirus, which means that it can turn its RNA in DNA once it is inside the host cell. This viral DNA is subsequently integrated in the DNA of the host. Within cells, the retrovirus replicates at a high speed: this results in a great viral diversity. HIV is distinguished in two types; HIV-1 has caused a global pandemic that has infected altogether 57.9 million people since the onset, while HIV-2 is mainly restricted to West-Africa. Both types are closely related and both eventually lead to AIDS. Prevalence, incidence and mortality The estimated number of HIV-infected people worldwide is no less than 34,2 million, among which are 3,4 million children. In the year 2011 alone 2,5 million people have died from AIDS-related causes. The epidemic lasts for over 30 years now and each day 7100 individuals are newly infected. The overall growth of the epidemic is stabilizing, yet in many parts of the world the incidence is continuing to expand. There is a big gap between our resources and what is needed.

Symptoms There are four clinical stages of HIV: The first stage occurs one to six weeks after the infection and is much like a short flu episode. Symptoms are for example fever, lymfadenopathy, pharyngitis and malaise. During this period, large amounts of virus are being produced in the body. As a result, the CD4-T-cell count is falling rapidly, until a relatively stable level of cells remains. At that moment, the disease moves to a stage that is called clinical latency. The virus replicates at very low levels and there are no symptoms, but it is still possible to infect another person. This stage can last for more than 10 years. The level of HIV in the blood is very low, but antibodies are detectable. The third stage starts when the viral load begins to rise again. Consequently, the amount of CD4-Tcells drops and symptoms start to appear. Opportunistic infections like tuberculosis and fungal and parasitic infections occur and also unexplained anemia and weight loss are frequently seen. When the number of CD4-T-cells has been decreased until 200 cells/l, the stage AIDS is reached.

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Severe and deadly complications occur, for instance the Kaposi sarcoma, cervical carcinoma and encephalitis. Transmission The virus enters the body through four body fluids: sperm (including pre-ejaculatory fluid), blood, vaginal discharge and breast milk. Thus, routes of transmission are unsafe sex, blood-blood contact like sharing needles or blood transfusion and transmission from mother to child. Therapy The fact that HIV is not curable does not mean that it is not treatable. Since 1996, there is a combination therapy available called HAART (Highly Active Antiretroviral Therapy). This treatment consists of two or three different HIV-inhibitors that all inhibit the replication of the virus inside cells, and in doing so, suppress complications and prolong life.

Demographics of HIV/AIDS in Indonesia

There are currently 238 million people living in Indonesia. The first case of AIDS was reported in 1987 in Bali and the number of cases is growing rapidly ever since. In the year 2000 itself, 225 cases of AIDS were reported. During the first years of the new century this number was rising rapidly. Already in 2009 333.000 people were infected with HIV.1

Although the overall prevalence of HIV in Indonesia is only 0,2%, in certain populations the percentage is much higher. 50% of all infections are caused by sharing needles. Especially young, high-educated men are infected this way2. HIV is mainly found in key populations, for instance sex workers, transgender, clients of sex workers, men who have sex with men and injecting drug users. There is one area in which HIV is categorized as a low-level epidemic, with a prevalence of 2.4% among 15-49 year-olds in the general population; this area is Papua.1

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Determinants of HIV/AIDS in Indonesia

HIV transmission is profoundly influenced by the surrounding social, economic and political environment, including factors such as poverty, oppression, discrimination and illiteracy. Biology A number of significant biological factors affects the risk of sexual transmission of HIV. The risk of HIV transmission per sexual contact is increased substantially if either partner is experiencing a sexually transmitted disease (Rttingen et al, 2001). Countries in which access to treatment for sexually transmitted diseases is poor are thus especially vulnerable to HIV. Women are also biologically more susceptible to HIV infection than men (Nicolosi et al, 1994), and the risk of HIV transmission per sexual contact is thought to be highest among younger women (Gray et al, 2001); this partly explains the high HIV prevalence levels observed in young females in purely heterosexual epidemics. It has also been shown that circumcised men are less likely to be infected with HIV than uncircumcised men (Weiss et al, 2000), and that women who use hormonal contraceptives are at a high risk of HIV infection (Wang et al (1999), Martin et al (1998). Differences between cultures and beliefs in terms of contraceptive use, circumcision practices and access to treatment for sexually transmitted diseases can therefore explain much of the observed variation in HIV prevalence levels. Demographic transitions HIV related risk behaviors seem to increase with social, economic and political changes throughout the country and are markedly associated with sexual transmitted diseases (USAID, 2001). In the 90s, Indonesia saw political upheavals overthrowing the authoritarian regime of Suharto which ushered the transition to democracy; however, it was accompanied by rising unemployment and increasing poverty. It was at this time that intravenous drug use became a widespread social phenomenon which propelled the HIV/AIDS epidemic in the country onwards. Poverty AIDS disproportionally affects people with limited economic and social resources. It deepens poverty and increases the number of poor at risk of infection, since people with few resources have the least access to health care related information and services. The emergence of poverty over the past two decades accompanied by the political and economical instability turns out to lead into an increased incidence of HIV/AIDS in Indonesia. Awareness Due to low understanding of the symptoms of the disease and the high social stigma attached to it, only 5-10% of HIV/AIDS sufferers in Indonesia actually get diagnosed and treated. Awareness is especially low in Papua and West-Papua. 48% of Papuans are unaware of HIV/AIDS, an even higher number, up to 74%, is found among uneducated populations. Unawareness plays a major role in the rapid evolution of the HIV/AIDS epidemic in Indonesia. People that are unaware of the big problems they might be facing will not try to prevent infection by, for example, using sterile needles or using condoms.

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Picture 2.1: Map of AIDS epidemic in Indonesia

A new group of patients is formed by housewives (60% of new patients in Bogor, West Java). In some parts of Indonesia they now outnumber prostitutes when it comes to the percentage of new HIV infections.3 This is also an important development because patients are not aware of possible vertical transmission and therefore could infect their children. Awareness should thus be raised, especially among the common population, in order to prevent more cases. Behavior In certain populations in Indonesia there is a much higher prevalence of HIV compared to other populations. Of all sex workers for instance, 15% is infected, and among men who have sex with men there is a prevalence of HIV of 5,2%. Besides, the number of HIV infections resulting from heterosexual contact is also rising. It is estimated that 90% of the HIV-infected women in Indonesia is infected by their husband. The highest percentage however exists among injecting drug users: no less than 52% of these people is infected. The modes of transmission vary much across Asia, but the pandemic is generally driven by unsafe sex and sharing of contaminated needles.4 Injecting drug users tend to gather up in groups with an average of 7-15 persons and use the same needles. A survey reported that only 12-15% of drug users in such groups always use their own equipment. In addition, from several other studies appeared that they often do not clean or do not know how to adequately clean the needles, and most of them share their needles despite knowing that HIV is possibly transmitted this way. In fact, even when the injecting drug users received needles from the needle exchange program, a survey reported that the needles were still being shared. The sex business is still growing rapidly in Indonesia. The industry has become more commercially and organized. More and more men, even married, are involved with sex workers, which is one of the causes for the rise in HIV cases among heterosexual couples.5 Among men who have sex with men, it is relatively common to sell and buy sex. From a survey appeared that 32% of all sex workers reported to not have used a condom with their most recent client, and very few use them consistently. Resistance from clients of sex workers regarding the use of condoms happens often; sex workers who do not use them could earn on average 20% more money.6

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(For a clearer view: see attachment)

Stigma There are 3 phases of an HIV/AIDS epidemic: HIV epidemic, AIDS epidemic, and the last is the epidemic of stigma, discrimination and denial7. The third phase is the most crucial one where all the problems arise and needs immediate action to be tackled, yet stigma is still poorly understood by the society.8 The existence of stigma is more likely to be the main factor that hampers any actions to tackle HIV/AIDS epidemic. Stigmatization of HIV/AIDS firstly came from the fear of the society who thinks that suffering from this disease is just like being sentenced to death penalty. Risk behaviors involved in the transmission of this disease emphasizes the stigma even more. The transmission via unsafe sexual behavior, sharing needles among drug users, homosexual and transgender causes society to consider this disease as a punishment to these groups of people, especially in Indonesia where those behaviors are still regarded as immoral or improper. This causes the society to unintentionally marginalize People Living With HIV/AIDS (PLWHA). Stigma negatively affects PWLHA as well as its spreads.9 Stigma causes disclosure of HIV infection status, therefore creating higher chance for the person to spread the disease. Moreover, perceived stigma also lowers compliance towards Anti Retroviral Therapy (ARV), therefore it can lower the cure rate and make the person vulnerable to spread the disease. Insufficient supply of treatment HIV treatments in Indonesia focus on the use of antiretroviral regimens which prolongs the life of people living with HIV/AIDS. In spite of the governments free policy in provision of ARV supply in many Indonesian health centers, there were only 39% of people with advanced HIV who had been receiving ARVs in 2009.10,11 PLWHA are mainly susceptible to contract opportunistic infections, which exacerbates the health status of HIV/AIDS patients, but the availability free ARV treatments for these infections in HIV referral hospitals plays a pivotal role in reducing morbidity of a disease. The limited disease awareness of Indonesian people and insufficient supply of treatment contribute to the burden of HIV/AIDS in Indonesia.

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Bibliography
1. 2. 3. 4. National HIV and AIDS strategy and action plan, National AIDS Commission. Igor van Laere et al., Indonesi pakt hiv en drugs aan, Nr. 23 - 10 juni 2011 Surabaya Aids Prevention Commission http://www.ilo.org/wcmsp5/groups/public/---ed_protect/---protrav/--ilo_aids/documents/legaldocument/wcms_173075.pdf 5. http://www.thejakartapost.com/bali-daily/2013-03-11/hiv-cases-sex-workers-fallingrisky-behavior-persists.html 6. http://www.aidsdatahub.org/dmdocuments/sex_work_hiv_indonesia.pdf 7. Mann, Jonathan. 1987 8. HIV/AIDS-related Stigma and Discrimination : A Conceptual Framework and an Agenda for Action, 2002. 9. The effects of HIV stigma on health, disclosure of HIV status, and risk behavior of homeless and unstably housed persons living with HIV. Wolitski, et al. 1987 10. HIV/AIDS in Indonesia (https://sites.google.com/site/hivaidsinindonesia/home/prevention-and-treat) 11. The National HIV/AIDS Strategy 2007-2010 (Indonesia)

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Attachment

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Health System

HIV/AIDS in Indonesia

Course: International Public Health Date: 9-4-2013

By:

Muhammad Rizki Febrianto Maud Raaymakers Robel Afeworki Martine van Zoest

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Index
1. Introduction 2. Building Blocks of Health System a. Health service delivery & Workforce b. Information c. Medical products and Technology d. Financing e. Governance & Leadership 3. Conclusion 4. Bibliography 12

12 14 15 15 16 18 19

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Introduction
Indonesia is the largest archipelago in the world comprising approximately 17.508 islands. With almost 249 million people, Indonesia is the 4th biggest country in the world in terms of population. With its demographical and geographical characteristic, Indonesias health system faces difficult challenge. Indonesias health system was hampered due to political chaos in 1998. The new government introduced decentralization politic in 2000 where every province is given its own autonomy, resulting in heterogeneous health system in several provinces in Indonesia. However, it is slowly going back to the right track to pursue a national health system, which is currently based on Presidential Order number 72/2012. Its main goal is to implement health development by all components of the nation to promote community health status as high as possible1 Indonesias health challenges mainly comes from 2 aspects.2 Ongoing demographic and epidemiological transitions are causing problems such as double burden of disease and financial inequalities. This will cause an increased need from society resulting in more diverse and more costly health care. Moreover there is an additional pressure coming from newly emerging diseases and epidemics such as Human Immunodeficiency Virus (HIV)/Acquired Immuno Deficiency Syndrome (AIDS), avian influenza (H5N1) and swine flu (H1N1), which are still prevalent in Indonesia. Policy to implement universal health income coverage as mandated by Law number 40/20043 forces Indonesia to do health reform especially in terms of health infrastructure and human resources inequity and distribution. This paper will asses Indonesian health system and its impact toward management of HIV/AIDS cases in Indonesia in accordance with building blocks of health system from World Health Organization (WHO).

Building blocks of Health System

A. Health service delivery & workforce
The Indonesian health care workforce and service delivery is an area with great potential for improving health outcomes, although is it very complex as well. Important gains have occurred over the past decade, yet at the same time Indonesia is dealing with serious shortcomings in number, distribution and quality of its health workers. Also, the service delivery is lagging behind. For example, the number of hospital beds per 1000 people is one of the lowest in the East Asia, even lower than those of countries with much lower income, such as Vietnam. On a worldwide scale, Indonesia has significantly fewer beds than other countries of a similar income level.4 Several challenges play a part in the slow progress concerning health workforce and service delivery in Indonesia. Firstly, Indonesia has a shortage of health workers, although the number has been increasing in the last 10 years. At this moment, Indonesia has a rate of 6 health workers per 10.000 inhabitants5. According to the WHO, the minimum health workforce needed to achieve 80% coverage of essential health interventions is 23 health workers per 10.000 people. Besides, inequitable distribution between urban and rural areas is a huge problem. Indonesia has recently set up a policy which obligates newly graduated physicians to work in a remote area; they receive financial and nonfinancial incentives for this service. This initiative has led to more young physicians starting posts in rural areas, but still the countrys remote areas are seriously underserved. This can partly be explained by the fact that deployment policies do not prioritize distribution concerns sufficiently. In 2001, a rapid decentralization of government functions and finances to the district level took place in Indonesia. Since then, the local governments have been focusing on the construction of new health centers in order to increase the availability of health care. The average number of physicians per health center has increased over the last ten years, but at the same time more and more health centers have no doctor at all, especially in rural areas. Thus, the gap of the physicians to population rate between urban and rural regions is widening.

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Although by means of decentralization a more efficient planning and recruitment system was intended, the impact is limited by a lack of clarity on the division of responsibilities. Also, the central government is still involved in most of the functions, whereby the smaller, local governments do not receive much autonomy. This further impedes efficient planning. Moreover, the number of private practice providers is increasing. The private sector already comprises about 50 % of all health services in Indonesia and is still growing. There is poor oversight over the quality of these services, and dual practice is very common. The fact that dual practice is legal has led to gains in access, but since a large part of many physicians income comes from private services, it might be that the health care workers are spending less time in public services. Subsequently, this leads to inefficiencies in the use of public budgets for health.6 Finally, overall quality of services provided by both public and private facilities has improved over time for prenatal care, child care and adult care. This improvement however is marginal, and the overall quality remains low. From the Indonesia Family Life Survey appeared that health workers gave correct answers only to about half of the standard questions and procedures. These data were representative for all three aforementioned types of care and across regions. Also, the regulatory framework that governs the quality of health service providers is weak, as many providers are graduating from schools that are not or insufficiently accredited. The quality of health professional education is lagging behind in Indonesia. Shortage of health workers is a major barrier to the preventing and treating of HIV; the problem is particularly complex in the regions with high prevalence of HIV, since it makes the health workers themselves vulnerable to disease and death too. Indonesia is one of the countries with the most critical shortage, and the number of HIV infections is rising. A vicious circle arises: already weak health systems are further undermined by poor health workforce, which results in an inadequate response to the HIV epidemic. In Indonesia there are not enough health workers to deliver on the

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target of universal HIV treatment. Expanding the workforce and increasing the skills of existing health workers will help in delivering better services in the context of HIV/AIDS.

B. Information
Health Information Systems (HIS) provide the basis by which evidence-based decisions concerning health improvement are possible. In order to be able to collect, analyse and use reliable data, a good HIS is very important. The National Health Information System established by the Ministry of Health in Indonesia comprises several components, namely health and disease record, disease surveillance, specific programmes like malaria, tuberculosis and tobacco control, health services record and related studies and surveys. Every three years, Indonesia carries out the National Health Survey: one of the main instruments to assess the countrys health status, fair financing and responsiveness. Despite attempts to get accurate data on cause of death, the information is still not close to optimal. Provincial or district health offices often develop their own HIS without coordination of the general government because of decentralization, which leads to disruption of information flow. No data that cover the entire nation exist. This makes development of improvement strategies and monitoring health programmes very difficult. In some programmes though, for instance the specific ones for malaria and tuberculosis, the central government still has the responsibility.7 The NHIS of Indonesia faces some problems, among which are the weak coordination between the many different HIS, the lack of regional capacity and the inadequate use of information for management purposes. This is why the NHIS is attempting to integrate all existing HIS, make the current procedure and mechanism of reporting more efficient and simple, empower the regional capacity relating to HIS and develop HIS human resources, in order to provide accurate and relevant data for decision making. By doing so, the health service management will eventually be strengthened.8 Well-functioning Health Information Systems are important in tracking the HIV/AIDS epidemic. Timely information is essential for determining who is being affected and why; the emphasis of preventive measures and treatment can then be put on where it is most needed. Tracking HIV/AIDS trends is challenging and depends on several factors. Besides how often and which people are tested, factors related to the health information system are also very influential: for example whether and how confirmed cases are reported to health departments and how case reports are shared with the central National Health Information System. These last mentioned factors are particularly problematic in Indonesia because of decentralization. When there is no accurate and representative collection of data, the HIV/AIDS epidemic cannot be adequately followed, which will negatively affect decision making on preventive measures and priorities.9

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C. Medical products, vaccines and technology

There is a significant progress in terms of quantity of health service in Indonesia. It is evident from the amount of new primary health cares being established recently. However there has been concern about lack of quality in health service delivery in Indonesia, especially in primary health care where health providers have limited knowledge of the basic care criteria.10 There has been also problem with standardization in health education in Indonesia. Despite thousands medical doctor graduates annually, their capability to give high quality health service is being questioned.10 Moreover, the infrastructure of primary health cares is sometimes not adequate enough thus needed to refer to higher health service facility.10 In the other hand, Indonesia faces no problem in terms of drug supply. Through programs such as jaminan kesehatan masyarakat (jamkesmas) and jaminan kesehatan daerah (jamkesda), people can reach affordable generic drugs with good quality.11 Indonesia has adopted detailed and clear guideline in diagnosis and management of HIV/AIDS, therefore the risk of misdiagnosed and missed management is minimalised with this guideline. HIV/AIDS patients in Indonesia continue to receive proper management. Indonesias health ministry also has increased amount of health center where VCT test and ARV treatment are available for free and guarantee that Indonesia will not suffer from ARV drugs shortage.12

D. Financing
The amount of financial resources mobilized for health care and how they are used depends on health care financing policy. Financing is the principle instrument by which to determine resource flows, distribution of resources, and incentive structures for health providers. The amount of health system expenditure in Indonesia is very small, it accounted $99 per capita in 2009 according to the WHO (Human Resources for Health Country Profile Indonesia). The overall health financing situation in Indonesia is complex and incompletely documented (WHO report, 2013). In 2008 50,4% of total health expenditure was undertaken by public sector agencies while the remaining 49,6% was by private sector, which is managed by the household out of pocket payment system. Indonesias public health spending remained stagnant over years while out of pocket payments is above average for its income level and has improved quietly. Despite substantial increases in government health expenditures as a share of GDP over recent years, Indonesian governments barely spend 1 percent of GDP on public health, and total health expenditure (meaning including the private sector) is only 2,6% of GDP. The diagram below illustrates Indonesian public expenditure for 2001-2009. 45 IDR Trillions (constant 2007 prices) 40 35 30 25 15 5 0 2001 2002 2003 Province 2004 2005 2006 2007* 2008* 2009** Share of GDP Central District 1.2% 1.0% 0.8% 0.6% 0.4% 0.2% 0.0%

20 10

(World bank: Investing in Indonesias Health Health Public Expenditure Review 2008)

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In 2005, the government introduced the Askeskin/Jamkesmas health insurance program for the poor, and by 2008, some 76 million poor and non-poor Indonesians were projected to have coverage. Through this program, part of the financial barriers to the utilization of health services by the poor was removed. The health insurance coverage of Indonesia showed that in 2010, 59,07% of the population has access for use upon public and private sectors supported by jamkesmas (Civil Health Insurance for the poor), jamkesda (District level Health Insurance for the poor), askes (Indonesia Health Insurance), and jamesostek (Workforce and Social Insurance) schemes. The coverage, cost of payment and target population involved are listed on table below.16

Table1. Health Insurance coverage for Indonesia reported 2009. In July 2004, the government committed to provide access to subsidized antiretroviral therapy to everyone needing treatment, with the ultimate goal of ensuring universal access. A total of 59 hospitals in all provinces have been identified as HIV care, support and treatment sites under the National AIDS Programme. The first line antiretroviral regimen therapy cost is estimated to be about US$ 420 per person per year. The Ministry of Health has committed funds to fully subsidize the provision of antiretroviral drugs, including reagents (WHO,2005). By the end of 2006, Indonesias Ministry of Health had established over 100 voluntary counseling and testing (VCT) sites and provided ART at 75 selected hospitals. Antiretroviral drugs (ARVs) are provided free of charge to patients. However, PLHIV pay for other services including VCT, medical consultations and examinations, laboratory monitoring and other opportunity costs associated with HIV care, including time spent away from work and travel costs.14 As for the end of 2007, there were 296 VCT clinics throughout Indonesia and 153 hospitals which provide free ART.15

E. Governance and Leadership

In a recent report of the National AIDS Commison , it was recognized that HIV/AIDS is a problem that threatens the improvement in quality and productivity of Indonesian citizens. Therefore a strategy and action plan was developed. Goals of this action plan: I) Increase the coverage of prevention; 2) increase availability of care, support and treatment; 3) reduce negative impact from the epidemic by improving access to social mitigation, as needed; 4) strengthen partnership, as well as health systems and community systems as related to HIV; 5) improve coordination and mobilization of financial resources; 6) increase application of structural interventions; 7) use an evidence-informed approach in planning, priority setting, and program implementation.

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The government is planning on tackling the major rise (for projections see figures 1 and 2) in HIV infections by using the following strategies: A. Prevention of HIV infection transmitted through use of contaminated needles/ syringes: needle/syringe exchange programs, methadone substitution, referral to health services for treatment of STIs and addiction recovery therapy. B. Prevention of HIV through unsafe sexual contact: promoting condom use. C. Development of comprehensive program for MSM: a program is yet to be developed. D. Prevention of Mother to Child Transmission: increase the number of pregnant women that get HIV testing, expend the current availability and integration of PMTCT services.

Figure 1: Shows two different scenarios for all provinces in Indonesia

Figure 2: Scenarios for (West-)Papua

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Conclusion
Indonesia is struggling to make progress addressing HIV/AIDS, where HIV prevalence was 0.2% in 2009.1 Condom use at last high risk sex is low (10.3% for women and 18.4% for men in 2007) and access to treatment remains low (38.4% of population with advanced HIV infection in 2009). Indonesia has made considerable progress in building a national health system but is now facing some difficult challenges to continue progress to achieving universal coverage. A particular challenge is the stewardship, financing and management of a health care system in a highly decentralized country where districts are assuming new responsibilities for health care funding and management but lack the capacity to effectively discharge these responsibilities. It has a mixed public and private health delivery system. The public health system expanded significantly in the 1970s and 1980s and in 2005 Indonesia had 7,700 Puskesmas with 22,000 health sub centers. The private health sector has seen a significant expansion of private hospitals and private hospital beds, almost doubling between 1990 and 2005 to 626 hospitals and 52,300 beds, equaling the number of public sector beds. The total number of beds per population is increasing but is still significantly lower than other south East Asian countries. Puskesmas are the backbone of primary health care in Indonesia. There is considerable variation in the size of population served by the Puskesmas with an average of 100,000 people served by 3.5 Puskesmas. However in most remote areas there are less than one Puskesmas per 100,000 populations. Indonesia has a strong foundation for effective regulation of the safety and quality of medicines where national manufactures meet most of the countrys needs for medicines. According to WHO report 2008, almost 30% of health spending in Indonesia is on medicines, equivalent to US$12 per capita per year. In Indonesia, national production of ARV is done by Kimia Farma, an Indonesian Governmental Pharmaceutical Company contracted by the Ministry of Health. First line medications produced in the country are Zidovudine, Nevirapine and Lamivudine. ARV is free of charge in the universal access spirit since the end of 2004 where the government is committed to achieving universal coverage of health insurance. In 2005 health insurance coverage was an estimate 85.9 million people, approximately 41% of the population (this assumed full coverage of the poor through Jamkesmas which was not the case). Almost 60% of the population therefore does not have health insurance and is at risk of the catastrophic cost of health care. The government is enacting a number of policies and financing streams to move towards universal coverage, therefore, the Indonesias health system is highly decentralized; provincial and district health services have significant autonomy to determine policies, priorities and financing. However, the major source for the national budget for HIV/AIDS is the Global Fund to Fight AIDS, Tuberculosis and Malaria, through which activities in 17 provinces are supported. The National AIDS Commission coordinates the multisectoral approach. The National HIV/AIDS Strategy identifies the following programme priorities HIV/AIDS prevention, care and treatment and support for people living with HIV/AIDS, surveillance, operational research, multisectoral coordination and a sustainable response with fundamental seven objectives: promoting condom use in every high-risk sexual activity; reducing harm among injecting drug users; providing antiretroviral therapy for people living with HIV/AIDS; reducing stigmatization of and discrimination against people living with HIV/AIDS; establishing and empowering provincial and district AIDS committees; developing laws and regulations conducive to HIV/AIDS prevention, care and support programmes; and scaling up efforts for information, education and communication, including religious instruction, to prevent the spread of HIV/AIDS

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Bibliography
1. 2. 3. Peraturan Presiden Nomor 72 Tahun 2012 [Internet]. Jakarta : Perundangan RI; 2009. [Cited April 10, 2013]. Available from : http://perundanganri.bantulkab.go.id Indonesias Health Sector Review *Internet+. Jakarta : World Bank; 2010. *Cited April 10, 2013+. Available from : http://sitesources.worldbank.org Undang Undang Nomor 40 Tahun 2004 tentang Sistem Jaminan Sosial Nasional [Internet]. Jakarta : Perundangan RI; 2004. [Cited April 10, 2013]. Available from : http://perundanganri.bantulkab.go.id The World Bank: New insights into the provision of health services in Indonesia a health workforce study http://www.nationsencyclopedia.com/WorldStats/WHO-systems-indicators-no-workersper10k.html [Cited : April 15, 2013] The World Bank: New insights into the provision of health services in Indonesia a health workforce study. http://www.who.int/healthmetrics/library/countries/HMN_IDN_Assess_Draft_2007_08_en.pdf [Cited : April 15, 2013] http://www.ino.searo.who.int/en/Section4/Section36.htm [Cited : April 14, 2014] http://www.cdc.gov/hiv/topics/surveillance/index.htm [Cited : April 15, 2013] Strategies that Promote High Quality Care in Indonesia. Barber, Sarah L and Gertler, Paul J. 88, s.l. : Health Policy, 2008, Vol. II. ISBN Indonesia's Health Sector Review; Pharmaceuticals: Why Reform is Needed? Jakarta : World Bank, 2009 Pengadaan dan Distribusi Obat Anti Retroviral. [Online] [Cited: April 14, 2013.] http://sehatnegeriku.com/pengadaan-dan-distribusi-obat-anti-retroviral-arv/ World Bank. 2008. Investing in Indonesias Health: Health Public Expenditure Review 2008 The financial burden of HIV care, including antiretroviral therapy, on patients in three sites in Indonesia. Sigit Riyarto, Budi Hidayat; Health Policy and Planning 2010;25:272282. Country Report on the Follow up to the Declaration of Commitment on HIV/AIDS 2006-2007, National AIDS Commission, Republic of Indonesia. Ministry of Health of Indonesia, Report 2009.

4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.

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Global initiatives

HIV/AIDS in Indonesia

Course: International Public Health Date: 16-4-2013 By: Muhammad Rizki Febrianto Maud Raaymakers Robel Afeworki Martine van Zoest

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Index
Introduction Global Fund to fight AIDS, tuberculosis and malaria AUSAID USAID DFID UNAIDS 22 22 27 28 29 29

Bibliography

31

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Introduction
Since the epidemic of Human Immunodeficiencey Virus (HIV) infection and Acquired Immuno Deficiency Syndrome (AIDS) in Indonesia is among the fastest growing in Asia, there is increased attention for halting and reversing the spread of infections, both by organizations in Indonesia and international agencies. In 2010, the funding on HIV/AIDS in Indonesia amounted $69,146,880, of which the Indonesian government spent $27,779,280. The rest of the money was disbursed by international organizations. Of the total expenditure on the disease in Indonesia, the countrys government has been spending an increasing percentage, namely from 27% in 2006 to 40% in 2010.1 Domestic government funding is allocated through the national budget and through local budgets at provincial and district levels. The principal agency responsible for the implementation of the national strategy on HIV/AIDS is the National AIDS Commission (NAC). It is part of the office of the Coordinating Minister for Peoples Welfare and it has governmental, non-governmental and international partners. The Commission coordinates the implementation of many programmes concerning prevention and treatment, especially in key populations, for example by methadone substitution therapy programmes, prison-based programmes, prevention of sexual transmission programmes and prevention of mother to child transmission programmes. Many development partners help the Commission by funding and managing. Since the major organizations are the Global Fund to Fight AIDS, Tuberculosis and Malaria, Australian Agency for International Development (AUSAID), United States Agency for International Development (USAID), Department for International Development (DFID) and Joint United Nations Programme on HIV/AIDS (UNAIDS), these are the agencies that we are going to discuss in detail.

The Global Fund to tuberculosis and malaria

fight

AIDS,

The Global Fund was started in 2002 by world leaders, with the aim of turning the tide on the pandemics malaria, tuberculosis and HIV and achieves the related millennium goals. It has become a large multilateral agency and has established programs in 151 countries. The organizations works are2 : - Financial contributions and Marketing campaigns - Pro bono services and core competency partnerships - Support for advocacy and governance, globally and locally - In-country co-investments and operational contributions Donors The Global Fund is a public-private-partnership. It receives voluntary contributions from many different sectors, namely governments, the private sector, philanthropic foundations, corporations and companies, non-governmental organizations and individuals. The largest source for the organization is the funding by governments through bilateral channels: since the start of the Global Fund it has received $24 billion from the public sector, and 54 governments have promised to pay in total $28,8 for 2002 up to 2015. This amount represents 95% of all pledges to the Global Fund. The remaining part is constituted by the private sector and non-governmental organizations.2 The

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countries that have contributed the most are Japan, Canada, the US, France, Italy, the UK and Germany. Apart from donor governments, the European Commission has an important role as well: so far they paid $1,476 billion.

Figure 1 (Global Fund Results Report 2012)

Private funding has been relatively small, but is increasing, partly by large donations by philanthropic foundations like the Gates foundation, which has already disbursed $1,250 billion, and the RED initiative. The latter actor gets participating companies to contribute a percentage of their sales to the fund and has donated $206 million so far (Pledges and contributions, April 2013)4. Other private partners and non-governmental organizations are Chevron, the Coca Cola Company, Takeda Pharmaceutical Company Limited, United Methodist Church and Lutheran Malaria Initiative, United Nations Foundation, Gift From Africa, United Against Malaria and the Standard Bank. The Global Fund also uses innovative financing mechanism in order to raise additional, nontraditional resources. They have partnerships with Dept2Health, which swaps debts on condition that the country uses the money to improve public health, UNITAID, which provides funding for the treatment of malaria, tuberculosis and HIV, and the Dow Jones Global Fund 50 Index, which tracks companies that support the mission of the Global Fund.

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Figure 2 (Global Fund Results Report 2012)

Actions on the HIV/AIDS epidemic The Global Fund comprises one fifth of all international financing of HIV.5 Since 2002, $10,6 billion has been disbursed on HIV/AIDs programs by the Fund. The most recent results, that is to the end of 2012, show important gains: five years ago only 1,4 million people received antiretroviral therapy, while currently the number of treated people through the Global Fund programs is 4,2 million (The Global Fund: Update on results and impact, April 2013).6 The purple line in the graph below represents the share of the Global Fund in the total progression.

Figure 3. Growth of Global Fund Investments in HIV Intervention

Besides, the Global fund has provided treatment to prevent vertical transmission to 1,7 million HIVinfected pregnant women, it has established over 19 million basic care and support services and it has provided the distribution of 4,2 billion condoms and 250 million sessions of HIV testing and counseling (The Global Fund, end 2012). Moreover, the organization fights for the rights of affected people through certain programs, and they are implementing tools for prevention, for example by large-scale circumcision campaigns.

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Cumulative grant expenditure 2002-2011

Figure 4. (Global Fund Results Report 2012)

Programs concerning HIV/AIDS in Indonesia The Global Fund has invested millions of dollars over the past ten years in programs to fight the HIV/AIDS epidemic in Indonesia, and this has lead to significant gains. Until 2011, every year the organization disbursed more money on this problem:

Figure 5 (www.theglobalfund.org)

Programme title

Principle recipient

Total signed amount in US$

5,400,174

Aim

Phase and status

Duration

Performan ce rate: A1(=best), A2, B1, B2, C(=worst)

B1

Prevention and alleviation of HIV impact

Ministry of Health of Indonesia - Dir. of Disease Control & Environmental Health

Indonesia HIV/AIDS Comprehensive Care

Ministry of Health of Indonesia - Dir. of Disease

43,446,781

Providing ART, preventing motherto-child transmission, establishing voluntary counseling and testing centers, training of health care staff, distributing condoms, education Financing key pillars of HIV treatment and prevention in 17 provinces: a massive

Phase II - In Closure

01 July 2003 - 31 December 2007

Phase II - In Closure

01 April 2005 - 31 March 2010

A1

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Control & Environmental Health

Indonesia Response to HIV: Government and Civil Society Partnership in 12 Provinces

National AIDS Commission of Indonesia

4,149,747

scale-up of antiretroviral therapy and prevention activities among the key populations Implementing prevention and care activities in 69 selected districts in the 12 most affected of Indonesias 33 provinces, targeting the key populations: providing male and female condoms and lubricants, promoting the use of condoms and conducting operational research on the role of male circumcision in HIV prevention in Indonesia

Phase I Closed

01 July 2009 - 30 June 2011

A2

Indonesia Response to HIV: Government and Civil Society Partnership in 12 Provinces

Ministry of Health of Indonesia - Dir. of Disease Control & Environmental Health

13,942,038

Indonesia Response to HIV: Government and Civil Society Partnership in 12 Provinces

Indonesian Planned Parenthood Association

11,879,377

Government and Civil Society Partnership in Thirty-three Provinces

Ministry of Health of Indonesia - Dir. of Disease Control &

36,579,651

Reducing HIV-related illness and death in twelve priority provinces: providing methadone treatment for injecting drug users and treatment for sexually transmitted infections, providing testing and counseling services to the most-at-risk populations and treatment for opportunistic infections Reducing HIV-related morbidity and mortality in 12 mostaffected province: achieving universal access to HIV and AIDS services by providing prevention, treatment and care and facilitate cooperation between public sector and community-based organizations to expand the reach of HIV/AIDS services Reducing HIV-related illness and death in 33 provinces: diagnosis and treatment of sexually

Phase I Closed

01 July 2009 - 30 June 2011

B1

Phase II - In Progress

01 July 2009 - 30 June 2014

B1

Phase I - In Progress

01 July 2010 - 31 December 2012

B2

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Environmental Health

Indonesia Response to HIV: Government and Civil Society Partnership in Thirty-three Provinces

National AIDS Commission of Indonesia

22,195,417

transmitted infections, methadone treatment, HIV testing and counseling, opportunistic infection prophylaxis and treatment, antiretroviral therapy and HIV/TB coinfection services Providing of prevention services and increasing the meaningful participation of community-based organizations to ensure that social support and interventions are effective

Phase I - In Progress

01 July 2010 - 31 December 2012

A2

Table 1. Global Fund Grant Lists for Indonesia7 Effects on the local health system The Global Fund claims that its principles are supporting programs that match with national plans and priorities, operating in a balanced manner in terms of different regions, diseases and interventions, operating as a financial instrument and not as an implementing entity and operating with transparency and accountability. The Fund is working according to the concept of country ownership, which means that each country is responsible for determining its own needs and priorities, while also being responsible for ensuring the implementation of their program. For the recipient country, it would be a good thing if the organization really applies these principles. This means for example that the government of that country has the same plan on the agenda, and that not only the easier areas are being helped in order to achieve the largest gains8

The AUSAID fund for HIV/AIDS in Indonesia

AUSAID delivered bilateral 100 million aid for HIV/AIDS between the partnership of Australia and Indonesia (AIPH).9 This eight year fund is mainly intended to prevent and limit the spread of HIV, improve the quality of life of people living with HIV, and alleviate the socioeconomic impacts of the epidemic parallel to the national HIV goals. The $100 million program, which spans from 2008 until 2015, currently operates in nine provinces (DKI Jakarta, West Java, Banten, Central Java, Jogjakarta, East Java, Bali, Papua and West Papua) under the Australian assistantship.9,10 AIPH uses various aid modalities to implement a range of activities: managing contractor (private sector and international non-government organization); pooled funding and specific contributions to multilaterals or civil society. The main components of AIPH are listed below :9 HIV Cooperation Program for Indonesia (HCPI) ($45 million 2008-2013) Aims to strengthen Indonesian leadership on HIV and reduce HIV transmission among injecting drug users, in prisons, the general population in Papua and West Papua and most at risk groups in Bali.

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 Clinton Health Access Initiative (CHAI) Phase 2 ($2.6 million 2010-2012) Improve procurement and supply chain management of anti-retroviral drugs (ARV) and HIV test reagents, build capacity for better care, support and treatment in Papua and strengthen policy implementation for HIV services by health agencies, managed by the Clinton Foundation. Indonesia Partnership Fund for HIV (IPF) Phase 2 (up to $1 million annually2010-2011) It is an important source of financial support for AIDS Commissions at national and sub national levels. Funds are managed through UNDP and implementation is managed NAC. MSM initiative ($1.5 million 2011-2013) Supports the development of the national Men have Sex with Men (MSM) action plan and piloting MSM outreach programs in 10 locations. The initiative is a collaboration of HCPI and the NAC. HIV mainstreaming within AUSAID programs (no funding implications for AIPH) Current focus is in the infrastructure and education sectors through provision of technical inputs from the HIV Unit. The AIPH has contributed significantly to the Indonesian HIV response and its major functional roles are as follows :9 Injecting drug users have improved access to a comprehensive package of harm reduction services. HCPI supported harm reduction services. The number of condoms distributed to IDU clients by HCPI supported services. AIPH also supports the national program on condom distribution to Most at Risk Population (MARP). Increasing number of prisoners having access to a broad range of HIV services. AIPH is also supporting the communication strategy for behavior change in Papua. The initiatives emphasis on promoting HIV testing and STI treatment is particularly important in terms of trying to halt the epidemic through sexual transmission. AIPH seeks to meet three long-term program outcomes: 1) Strong Indonesian leadership of an effective and sustainable HIV response; 2) An increased and qualitatively good HIV response; 3) A strategic partnership between Australia and Indonesia that supports the national HIV response. The Aid Activity of Australia Indonesia Partnership for HIV (AIPH) is summarized on the table below. Aid Works initiative number commenced Implementation Completion date Total Australian $ Total other $ Delivery organizations INH 251 April,2008

31 December 2016

AUD 100,000,000 Nil GRM International in consortium with Burnet Institute Clinton Health Access Initiative (CHAI)

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National AIDS Commission (NAC) for Men who have Sex with Men (MSM) Initiative and Indonesia Partnership Fund for HIV and AIDS (IPF) Implementing Partners GoI - AIDS Commissions at national level and in targeted provinces and districts GoI - Ministry of Law and Justice GoI - Ministry of Health at national and sub national level Diverse range of civil society organizations and academic institutions

Table 2. The AUSAID implementation structure for HIV program in Indonesia.9

United States Agency for International Development (USAID)

USAID, once formed in the era of former president John F Kennedy in 1961, is a United States government independent agency that provides economic, developmental and humanitarian assistance around the world in support of its foreign policy.11 In Indonesia USAID works in 5 main program areas, one of them is improving individual health. HIV/AIDS is one of the main focuses of USAID, as it identifies Indonesia as a country whose HIV/AIDS epidemic is among the fastest growing in the region. USAIDs main goals are to stem the transmission of the disease among most-at-risk populations by providing technical support to government agencies and civil society to scale up integrated programs for HIV/AIDS prevention, care and to develop activities that lead to substantial, measureable behavioral change. In 2011 USAID contributed US$ 13 million to bilateral assistance. In addition, USAID also contributed approximately 30 percent in the US$ 27 million Global Fund grant for HIV/AIDS in Indonesia.12

Department of International Development (DFID)

The DFID leads the fight of the British government against world poverty. It was set up in 1971 and runs long-term programs to help stop the underlying causes of poverty and respond to humanitarian emergencies.13 In Indonesia the DFID has run a program, whose goal was to increase capacity to halt and begin to reverse Figure 6. HIV/AIDS grant in Indonesia14 HIV/AIDS infection in concentrated areas and core transmissions groups. The program ran from 2005 to 2010 and DFID invested 28,000,000 (bilateral funding) in the program to control STDs including HIV/AIDS.14

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Joint United Nations Programme on HIV/AIDS (UNAIDS)

This UN departments goal is to lead and inspire the world in achieving universal access to HIV prevention, treatment, care and support. Their main targets are:15 Reducing sexual transmission Preventing HIV among drug users Eliminating new HIV infections among children 15 million accessing treatment Avoiding TB deaths Closing the resource gap Eliminating gender inequalities Eliminating stigma and discrimination Eliminating travel restrictions Strengthening HIV integration UNAIDS fulfills its several missions by:15 Uniting the efforts of the United Nations system, civil society, national governments, the private sector, global institutions and people living with and most affected by HIV; Speaking out in solidarity with the people most affected by HIV in defense of human dignity, human rights and gender equality; Mobilizing political, technical, scientific and financial resources and holding ourselves and others accountable for results; Empowering agents of change with strategic information and evidence to influence and ensure that resources are targeted where they deliver the greatest impact and bring about a prevention revolution; Supporting inclusive country leadership for sustainable responses that are integral to and integrated with national health and development efforts. UNAIDS is guided by the PCB (Program Coordination Board), which consists of representatives of 22 governments from all geographic regions, the UNAIDS Cosponsors, and five representatives of nongovernmental organizations (NGOs), including associations of people living with HIV.15

Financing Funds are raised by the Resource Mobilization Division (RMD) which strives to ensure voluntary financial commitment from governments, multilateral institutions, foundations, the private sector and individuals. Annex 1 shows the core contributors. The RMD also plays a very important role in the connection of donors to various actors and communities in the field of global response to the epidemic. Figure 7 shows the regional 15 breakdown for investments needed. Figure 7 (ww.unaids.org)

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Indonesia: In Indonesia the UNAIDS has played an important role in supporting the NAC by technical coordination and program management support. The table below shows country reports of domestic and international AIDS spending by service categories and financing sources:

Table 3. Country Report of HIV/AIDS Spending15

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Bibliography
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Funding for HIV/AIDS Initiatives [internet]. [cited on April 19, 2013]. Available from : www.citizen.org/funding-for-Indonesian-HIV/AIDS-programs The Global Fund [internet]. [cited on April 19, 2013]. Available from : www.theglobalfund.org/en/donors Global Fund Results Report 2012 [internet]. [cited on April 19, 2013]. Available from : www.theglobalfund.org The Global Fund; Pledges and Contribution [internet]. [cited on April 19, 2013]. Available from : www.theglobalfund.org The Global Fund: Philanthropy brochure [internet]. [cited on April 19, 2013]. Available from : www.theglobalfund.org The Global Fund: Update on results and impact, April 2013 [internet]. [cited on April 19, 2013]. Available from : www.theglobalfund.org Global Fund Grant Lists for Indonesia [internet]. [cited on April 19, 2013]. Available from : http://portfolio.theglobalfund.org/en/Grant/List/IND The Global Fund Principle [internet]. [cited on April 19, 2013]. Available from : www.theglobalfund.org/en/about/principles Report for AUSAID; Review of Australia Indonesia Partnership for HIV (AIPH). 2011. Report for AUSAID; Independent Evaluation of the Australia Indonesia Partnership for HIV (AIPH) management response. 2011. USAID Indonesia [internet]. [cited on April 19, 2013]. Available from : http://indonesia.usaid.gov Indonesia and America Building on Success in Fighting HIV AIDS [internet]. [cited April 19,2013]. Available from : http://indonesia.usaid.gov Department for International Development [internet]. [cited on April 17, 2013]. Available from : https://www.gov.uk/government/organisations/department-for-international-development DFID; HIV/AIDS Project in Indonesia [internet]. [cited on April 20, 2013]. Available from : http://projects.dfid.gov.uk/project.aspx?Project=108261 UNAIDS [internet]. [cited on April 17, 2013]. Available from : www.unaids.org

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Primary Health Care

HIV/AIDS in Indonesia

Course: International Public Health Date: 16-4-2013 By: Muhammad Rizki Febrianto Maud Raaymakers Robel Afeworki Martine van Zoest

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Index
Introduction Primary Health Care in Indonesia Equity Community participation Intersectoral collaboration Conclusion Bibliography 35 35 36 37 39 40 9

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Introduction
Primary health care is essential health care made universally accessible as first level of contact of individuals, the family and the community in acceptable means through their full participation and at affordable cost for both the community and the country. It forms an integral part of the National Health Care Plan, the central function and main focus of which is the overall social and economic development of the community (WHO, 1978). The fundamental role of primary health care represents mainly the global consensus among member nations, that the people have the right to participate individually and collectively in the planning and implementation of their health care and lead socially and economically productive lives at the highest possible level. The definition of this role enclosed in the Alma-Ata Declaration of 1978. The Alma-Ata Declaration of Primary Health Care The Alma-Ata Declaration adopted on 12th September, 1978 explicitly viewed primary health care as the key to attaining the target of health for all as part of the overall development and in the spirit of social justice. The Declaration resolved the following amendments to be practiced in health care systems: All governments are to formulate national policies, strategies and plans of action to launch and sustain primary health care (PHC) as part of a comprehensive national health system and in coordination with other sectors. The need for urgent and effective action to develop and implement PHC throughout the world, and in particular in developing countries with unacceptable health status. The need for political will and the coordinated efforts of the health sectors and relevant activities of other social and economic developments such as education, agriculture and rural development, housing, etc. The support of governments, WHO, UNICEF and other international organizations as well as multi lateral and bilateral agencies. The need for all health workers to support national and international commitment to primary health care and channel increased technical and financial support to developing countries.

Organization of health system in primary health care The health system aims at delivering health services to the beneficiaries. It constitutes the management sector and involves organizational matters and also allocation of resources, translating policies into services, evaluation and health education. The aim of the health system is health development, which includes continuous and progressive improvement of the health status of a population i.e. community. The health system encompasses the promotive, preventive, curative and rehabilitative aspects of health and also caters for the extremely disabled and incurable.

Primary Health Care in Indonesia

The concept of Primary Health Care (PHC), as mandated by Alma Ata Declaration, is integrated in Indonesias National Health System (NHS) and formulated in the form of Puskesmas which stands for Pusat Kesehatan Masyarakat (Peoples Health Centre). NHS defines Puskesmas as a health service unit of Health Department which holds responsibility of health development in its working area with the mission to mobilize health-oriented development, promote independence and healthy living for families in the community, maintain and improve the quality, equity and affordability of health care, maintain and improve the health of individuals, families and communities and their environment.

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This in turn will contribute to achieve the national development goal which is to increase the awareness, willingness and ability of the people to have a healthy live.1 From its definition Puskesmas aims to meet the basic principles of PHC as stated in Alma Ata Declaration which is equity, community participation and intersectoral collaboration. The presence of Puskesmas has a significant effect towards achieving health development. There are 9321 Puskesmas spread over 33 provinces in Indonesia with the average ratio of 100.000 people are served by approximately 4 Puskesmas2, although depends on their geographical location as well as the size of population. In certain condition where the geographical area is too big, there is staellite Puskesmas with the main job is to help the main Puskesmas. There is also mobile Puskesmas to reach very remote areas in Indonesia. Together they provide greater accessibility toward health care facility as 90.7 % of household in Indonesia can reach health facility within 30 minutes. Puskesmas serves as the backbone of health service in Indonesia. It serves as a primary care which aims to provide equity toward health accessibility for all people but also as a driving force for health promotion in its working area, especially by involving the community. The position of Puskesmas in the NHS is as the primary health care for both health service and public health service which sits under Health Department in the municipality level in a well integrated referral system. The programs of Puskesmas are : 1. Primary care including emergency integrated into referral system to secondary or tertiary care 2. Maternal and child health (MCH) and family planning 3. Nutrition improvement 4. Environmental health 5. Public health promotion and education 6. Eradication and prevention of communicable disease 7. Health surveillance 8. School health program 9. Sport health 10. Public health nursing 11. Eyes health 12. Mental health 13. Dental and oral health 14. Laboratory

Equity
Primary health care aims to make basic care affordable and widely available, especially to the poor and rural populations. In the Alma Ata Declaration inequity was one of the major points discussed. Inequity was termed politically, socially and economically unacceptable. In the past 40 years disparity between and within countries has been increasing. Indonesia Urbanization has a big influence on health and its distribution. South-East Asia now houses half of the worlds poor people, and 520 million people of its inhabitants live in urban areas. The Declaration on Health Development in the South East Asia Region reaffirms the commitment to address inequity and the growing gap between the rich and the poor. In urbanization it is important to realize that cities have certain qualities, resources and problems. Not only urbanization is a big problem in Indonesia. There are also several other factors that make the distribution of care unequal. The shortage of health workers for example, makes a good explanation for the low access in rural areas impossible unless something changes.3 In the other hand, geographical characteristic of Indonesia adds another burden as there are some peripheral

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areas difficult to be reached. Government of Indonesia tries to tackle this problem through establishment of Puskesmas by providing health access for all at an affordable cost. However more efforts should be put as health inequities still exist in several provinces in Indonesia. HIV/AIDS Because of the character of the epidemic in Indonesia -contained to key populations-, it is very hard to get a good image of the effects that the inequity within Indonesia has on the current epidemic. Only in Papua and West-Papua there is a general epidemic, which is a rural area where access to health services is already low.

Community participation
Primary Health Care and community participation are twin concepts: community involvements have measurable effects on improvement of several aspects of health. It is a very important part of the development process and it has a direct link with community empowerment. The concept promotes self-reliance and confidence of people, and it enables them to determine their own destiny to a bigger extend. Primary Health Care needs to be delivered as close to the people as possibly, and in order to establish this, maximum use of both professionals and laymen is necessary. Community participation Indonesia The Primary Health Care approach can be promoted by community health workers, since they foster self-reliance and local participation. Besides, they meet more with the needs of the communities than clinics. A tangible example of this community involvement is Posyandu program which stands for Pos Pelayanan Terpadu (Integrated Service Post). Posyandu is integrated in the program of Puskesmas. Its main focus is on child health and sometimes there are certain Posyandu specialized for elderly. It is done by the people and for the people with assistance from Puskesmas. In 1982, reports showed that activity of Posyandu led to significant results: infant mortality dropped by 30% in 7 years and immunization coverage improved many-fold.4 In 2005, the Indonesian government set up the Support for Poor and Disadvantaged Areas Project (SPADA). It addresses governance and policy problems in 51 of the poorest districts across the country and it empowers the districts by a community-based approach. Trained facilitators help local villagers to identify problems and create solutions. The communities propose their ideas to the program and community members make up the management team that coordinates the project. The local government partners with the management team to implement the program. SPADA had funded over 10,631 infrastructure, economic, and social activities across the country in 2011.5 The recent decentralization in Indonesia provides more space for community participation. Before this policy was implemented, the government of villages only had the authority to execute programs and plans, yet nowadays they are able to also plan projects themselves. The power is brought closer to communities and decisions are possible at the lowest level of the government. However, from a study appeared that often the upper level of the government still has the accountability, whereby the community cannot really control the programs.6 In certain parts of Indonesia like Java, many programs do not involve the communities, because they are so-called top down programs.7 This means that a certain influential person or body from a high level of the government makes a decision, which is disseminated to lower levels. The plan is implemented under the authority of that person or body. The governments can improve community participation by using more bottom-up programs as a part of their policies. This approach leads to a

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better understanding of what is needed at the bottom and it requires a large group of people working together, including people from the community. HIV/AIDS The WHO concluded from 17 studies on the role of community health workers in the prevention and control of HIV that those health workers are an important tool for increasing the awareness and knowledge related to HIV/AIDS.8 Community health workers can enhance community uptake of knowledge and can target vulnerable groups much more easily than health workers in clinics. The latter advantage is particularly important for fighting the HIV/AIDS epidemic in Indonesia, since HIVinfections in this country are mainly found among specific populations. Unfortunately, the stigmatization of patients living with HIV in Indonesia remains a problem for accepting help by community health workers and in this way it hampers testing, initiation and adherence to treatment. The awareness of the existence of stigma in populations should be raised, in order to make discrimination decrease. When the effect of stigma will be diminished, community participation will be reached at a larger level and this will have a positive effect on the HIV/AIDS epidemic in Indonesia. Family Health International (FHI), which is partnering with USAID, launched a program called Aksi Stop AIDS in the year 2000. The program has many goals concerning HIV/AIDS in Indonesia, one of which is expanding community involvement in HIV/AIDS programming. It enlarges the local community assistance in injecting drug use interventions, and by doing this, they strengthen the prevention of HIV/AIDS.9 Examples of community-based programs concerning HIV that could be created are groups for youth or other people to discuss their sexuality in a safe environment, gender awareness programs at local levels in order to strengthen women, group meetings for education and support groups for both the patients themselves and the family members.10

Intersectoral collaboration
The World Health Organization (WHO) defines intersectoral collaboration (ISC) as a recognized relationship between part or parts of different sectors of society which have formed to take action on an issue to achieve health outcomes (or intermediate health outcomes) in a way which is more effective, efficient or sustainable, than might be achieved by the health sector working alone *WHO 1997]. Primarily, the ministry of health sets a health program that includes Health service systems, HIV/AIDS prevention program, HIV/AIDS and STI surveillance, coordination of IDU harm reduction program and Healthy lifestyles information program. Besides, there are major intersectoral approaches like educational, financing and information sectors incorporated to the Indonesian national response control for HIV/AIDS. Intersectoral collaboration of HIV/AIDS prevention HIV/ AIDS is both a health problem and a social problem. The spread of HIV/ AIDS is strongly influenced by human behavior; any efforts to prevent consist of improving skills and knowledge using the existing information, education and communication methods (IEC) in accordance to a local religious and cultural norm. Disseminating knowledge through formal and non-formal education as well as through religious channels is achieved by systemically integrating HIV/ AIDS materials into the regular curriculum. This requires capacity building for teachers, tutors, trainers, bureaucrats and leaders of work units, who can pass such information on to their students or subordinates. Proper implementation of an IEC program also needs capacity building for those on the front line-health

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workers, social workers, outreach workers, teachers, and master trainers. The responsible sectors for HIV/AIDS prevention are listed below: The Indonesian ministry of finance plays a major role in the resource allocation, allocation of fund, disbursement systems for HIV/AIDS State Minister of information and communication is responsible for public information, media policies on HIV/AIDS, dissemination of HIV/AIDS information in government/private sector media at both local and international levels. Ministry of education provides prevention education - Health education curriculum (including youth and gender), youth AIDS awareness prevention education policy in schoolbased and non school-based education, HIV/AIDS prevention programs for tertiary education students and HIV/AIDS prevention programs for educators. Ministry of Women's Empowerment - Integration of HIV/AIDS into the development of women's programs, including gender equity, and empowerment of women and girls. Ministry of religious affairs provides faith based approach- HIV/AIDS prevention education curriculum in religious schools and education centers, sermon-based HIV/AIDS prevention program and promote HIV/AIDS prevention through enhancement of spiritual life. National Narcotics involves in drug control- Coordinated response to the impact of HIV/AIDS transmission among IDUs Intersectoral collaboration of HIV/AIDS care, treatment and support One of the most important outcomes of the UN General Assembly Special Session on HIV/ AIDS (UNGASS) in 2001 was the agreement on the need to expand care and support services for PLHA and to ensure protection of their basic human rights (to prevent, reduce and eliminate stigma and discrimination). Care, treatment and support for PLHA is mainly designed to alleviate the suffering caused by HIV/ AIDS and prevent further HIV infections, and to improve the quality of life of PLHA. The Ministry of finance and education plays a crucial role to fulfill the following aspects in the community, and its main responsibilities are listed below: Improvement of education and training for those involved in care, treatment and support for PLHA (counseling training and increase the number of professionals and volunteers-including PLHA-for care, treatment and support), development of infrastructure for health services, voluntary counseling and testing (VCT), prevention of mother-to-child transmission of HIV (PMTCT), care for PLHA and community and home-based care, and provide support for the establishment of PLHA support groups. They also promote the availability of access to high quality of healthcare with affordable price, high quality antiretroviral drugs and medications to treat opportunistic infections for PLHA. Other intersectoral collaborators engaged in HIV/AIDS care, treatment and support include: Ministry of home affairs designs policies on decentralization and resource allocation at central, province and district/municipal level, supports participation in combating stigmatization and discrimination . Ministry of social welfare provides social support for people affected by HIV/AIDS, programs for vulnerable group, and counseling programs.

Conclusion
Puskesmas continues to gain its importance over years. The implementation of universal health care in 2014 clearly put Puskesmas as the main health center in terms of health promotion, prevention, curative and rehabilitative. The national health system with its relliance on Puskesmas is ideallly made to adapt with geographical and demographical characteristic of Indonesia. However more efforts should be put in terms of quality and quantity of health workers in Indonesia in order to achieve national development goal.

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HIV/AIDS as a complex disease requires complex intervention as well. Ministry of Health should rely more on Puskesmas in preventing as well as treating HIV/AIDS cases. Puskesmas is proven to be effective to provide health service in remote areas. In the other hand community involvement is proven to be effective to reduce transmission of HIV.Lastly intersectoral collaboration is needed as HIV/AIDS prevention cannot only be the responsibility of health sector.

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Bibliography
1. Sistem Kesehatan Nasional 2009 [internet]. [cited April 23, 2013]. Available from : http://www.depkes.go.id/downloads/SKN%20final.pdf 2. Profil Kesehatan Nasional 2011 [internet]. [cited April 23, 2013]. Available from : http://www.depkes.go.id/downloads/PROFIL_DATA_KESEHATAN_INDONESIA_TAHUN_2011.pdf 3. Conference on Revitalizing Primary Health Care, Jakarta, 6-8 August 2008 [internet]. [cited April 24, 2013]. Available from: http://www.who.int/management/district/RevitalizingPHC2008SEARO.pdf 4. Uta Lehmann, David Sanders. Community health workers: What do we know about them? [internet]. [cited April 23, 2013]. Available from : http://www.who.int/hrh/documents/community_health_workers.pdf 5. web.worldbank.org/WBSITE/EXTERNAL/COUNTRIES/EASTASIAPACIFICEXT/EXTEAPREGTO PRURDEV/0,,contentMDK:21843840~menuPK:573970~pagePK:2865114~piPK:2865167~theSitePK :573964,00.html [cited April 23, 2013] 6. Community participation in rural development: a case study of three villages in Purbalingga District, Indonesia. Hiroshima University. [cited April 23, 2013] 7. Atik Triratnawati. Underutilization of community health centers in Purworejo Regency, Central Java [internet]. [cited April 23, 2013]. Available from: http://repository.ui.ac.id/contents/koleksi/2/d494c748c6645fe6dc6f111a02f568abb0ba3b 45.pdf 8. Global Experience of Community Health Workers for Delivery of Health Related Millennium Development Goals. Available from: http://www.who.int/workforcealliance/knowledge/publications/alliance/Global_ CHW_web.pdf [cited April 23, 2013] 9. HIV/AIDS in Indonesia and USAID Involvement. Available from: http://komo.padinet.com/free/v01/DEC-USAID/Indonesia/HIV-AIDS-inIndonesia.pdf [cited April 23, 2013] 10.Understanding Barriers to Community Participation in HIV and AIDS Services, Population Council. Available from: http://www.popcouncil.org/pdfs/AP_BarriersFinalReport.pdf [cited April 23, 2013]

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