The Role of Health System to Support PMTCT Program Implementation in Jayawijaya Regency

The incidence of HIV and AIDS in Indonesia continues to increase. The possibility of mother to child transmission will be greater if intervention is not performed. The purpose of this study is to assess the role of health systems in health and non-health sector affecting the implementation of PMTCT. This qualitative research took place in Jayawijaya. Primary data collection was conducted through in-depth interviews, and observation. Secondary data was derived from the survey of health facilities conducted in Papua. We interviewed eleven (11) informants. The results of this study confirmed that the implementation of PMTCT was still inadequate, only 64% of the health services in Jayawijaya provide PMTCT services. Considering the vast area and the difficulty of access to health services, local government should undertake expansion of comprehensive PMTCT services, provide antiretroviral drugs for pregnant women, and reagents, as well as psychosocial support to PLHIV.    


INTRODUCTION
Since it was first discovered twenty-five years ago, HIV and AIDS cases in Indonesia continue to increase, especially in the reproductive age of 20 to 39 years. At the end of 2012, there were an estimated 591.823 people infected by HIV, one-third (30%) was women. Sexually Transmitted Infections (STI) contributes the largest in the transmission of HIV virus, in which the possibility of transmission is up to 200 times. Transmission of HIV from mother to infant or child reaches 90% during pregnancy, childbirth, and breastfeeding (MOH, 2013). 1 If the spread of HIV-AIDS, it will become a huge threat for public health, especially on reproductive health resulting in increasing maternal and infant mortality. The National AIDS Strategy 2010-2014 explained that transmission of HIV from mother to child tends to increase along with the increasing number of women positively infected with HIV either from their spouse or as a result of risky behavior. Based on the projection, the number of pregnant women who require Prevention of Mother to Child Transmission (PMTCT) services will increase from 5,730 people in 2010 to 8,170 people in 2014 (National AIDS Commission, 2010). 2 Since 2007, efforts to prevent transmission of HIV through mother to child has been implemented on a limited scale, especially in areas with high HIV epidemic level (National AIDS Commission, 2010). 2 As of 2011, there have been as many as 90 PMTCT services integrated in the MCH services (Antenatal Care). The number of cases served throughout Indonesia in PMTCT program is only 1,862 people (DG & PL, Ministry of Health, 2012). 3 The coverage is still far from the target set by the government.
Based on the results of the Integrated Biological and Behavioral Survey (IBBS) in 2013, HIV prevalence rate in Papua (Papua and West Papua) was 2.3%, belonging to the category of generalized epidemic. 4 HIV prevalence in Jayawijaya District is third in rank after Jayapura and Timika Districts. Comparison on HIV prevalence between urban and rural areas in the province of Papua according to the Integrated Biological and Behavioral Survey Papua or IBBS (2006) was 2.9% for rural areas and 1.5% for urban areas. 5 The high prevalence of HIV-AIDS will affect not only the health sector alone, but also the socioeconomic issues.
The growth of HIV-AIDS cases in Jayawijaya has been increasingly alarming as it ranks the highest (third after Jayapura and Timika) in the number of cases by years. 6 According to the data from the Health Service of Jayawijaya District, in the first quarter of 2013 the number of cases of HIV-AIDS was 3,245 cases, in which 1,458 (45%) of the total cases were women. The number of pregnant women going to counseling and HIV test was only 50%. 6 It is far from the national targets requiring all pregnant women to undergo HIV test as a form of early detection.
Since the implementation of regional autonomy, Jayawijaya has experienced twice proliferation of (administrative) regions, first in 2002 and second in 2008. This condition affects the mobilization of the population to access health services, as new district are not ready in the aspects of infrastructure and resources.
Jayawijaya is a district located in the central mountain where indigenous people inhabit the highlands of Papua or the so-called the Heart of Papua. Historically, the origin of the ancestors of these mountain people came from Wamena, Jayawijaya. It is very influential in how people see the concept of health and sickness. These concepts are also influential in how they access health care services.

THEORETICAL REVIEW § The Prevention of Mother to Child Transmission
World Health Organization (WHO) and United Nations (UN) have developed a comprehensive four-pronged strategy aimed at integrating key interventions into essential maternal, newborn and child health services 7 : 1. The first prong emphasizes the importance of preventing HIV among women of reproductive age before they get pregnant; 2. The second prong is focused on the prevention of unintended pregnancies among women living with HIV; 3. The third prong focuses on pregnant women who are already infected and demands that HIV test be integrated into antenatal care, that they receive ARVs to prevent transmission of the virus and for their own health and that they are counseled adequately on the best feeding option for their baby; and 4. The fourth prong calls for better integration of HIV care, treatment, and support for women found to be positive and their families. § Healthcare System In 2010, WHO released guidelines to strengthen health system. This guideline aimed to monitor how the health system faced increasing input and evolving process, and how the system improved health indicators consequently. The Six Building Blocks consisted of health services; health workforce; health information systems; access to essential medical products, vaccines and technologies; health financing system; and leadership and governance. 8  care, support, and treatment (CST); prevention of mother-to-child transmission (PMTCT); drug harm reduction; STI diagnosis and treatment services; prevention of transmission through blood donor and other blood products; planning, monitoring and evaluation, as well as epidemiological surveillance at regional referral and non-referral including other health facilities, referral hospital, and people living with HIV in District or city; and the active involvement of the public sector, including families. 10

RESEARCH METHODS
This study included an analysis based on health systems for both the health and non-health sectors causing gap in the achievement of PMTCT program on health care facilities in Jayawijaya. This study involved the perspective of Local Government in formulation of policies related to the implementation of PMTCT, which was evidence-based. The method was qualitative with data collection techniques employing interviews, observation, and documentation. Secondary data was taken from the assessment of health care facilities in Papua in 2012 conducted by the Papua Provincial Health Office and District Health Office, supported by the Clinton Health Access Initiative (CHAI) in 10 hospitals and 160 CHCs in 12 Districts in the province of Papua. Other factors of non-health involved cultural influence in the implementation of PMTCT program.
The study was conducted in Jayawijaya District by visiting several health care facilities conducting the PMTCT program (4 services), Jayawijaya District Health Office, AIDS Prevention Commission, as well as some Non-Governmental Organizations (NGOs) working in the field of health. This research was carried out within two weeks from April to May 2014 in Wamena, Jayawijaya.

RESULTS AND DISCUSSION
Government policy in the implementation of PMTCT program supports to lower the infection rates through early detection. Nevertheless, this cannot be realized when health systems are inadequate. By looking at the number of PMTCT services (4 services) in Jayawijaya, and correlating it with the number of pregnant women as many as 4,100 pregnant women, then those services are still far from enough. This has been made worse by the condition of Jayawijaya as the main District of the newly-formed Districts where the community in those newly-formed Districts still access health services in the main District.
Geographical constraints in mountainous areas such as Jayawijaya will always be a challenge and very influential on the implementation of health programs in general. For example, people have to walk for days to visit health services, so that the rate of lost to follow-up will be higher. This is proven by the dropping number of pregnant women counseled on Antinatal Care (ANC) visit by 50% from K1 coverage. Similarly, in antiretroviral treatment, patients find it difficult to access drug due to geographical factors although antiretroviral drugs and reagents are sufficiently available. Sometimes, the distribution of ARVs and reagents cannot be done because Jayawijaya can only be accessed by air (plane), and bad weather has always been a challenge for such location.
Another challenging factor was stigma. Of the analysis done, stigmas were mostly from families. Frequently, patients do not want to visit health services because they were not convenient to access VCT clinic. This can be minimized through counseling and testing initiated by health workers, involving those in VCT clinics as well as patients in antenatal care units, general practitioners, dentists, and TB or STI clinics.
In general, the number of health resources in Jayawijaya is not sufficient, as compared in ratio with the number of the population served. The ratio of general practitioners is 7.4 for every 100,000 population, which is still far from the target indicator of Indonesia Sehat (Healthy Indonesia), in which the ratio should be 40 per 100,000 people (Pusdatin, 2013). 6 This also happens to health personnel, such as laboratory assistants, who have an important role in HIV test. Although there has been no specific research on the matter, observations made during data collection show that the rate of absenteeism of health workers is also quite high, especially in rural areas. Often the Community Health Center is closed all day, and there are no health workers coming to work. With difficult geographical conditions, patients often find empty health services after traveling for such a long way to the health services. There have been no supportive policies by the Local Government on a system of reward and punishment against health workers.
Competence of health personnel poses another problem, especially in supporting the implementation of the PMTCT program. Currently, technical support in capacity building from international institutions has been stopped since two years ago. However, until now the regional government does not have adequate funds for PMTCT program. With the cessation of international support, local funds should be able to continue funding and replicating the PMTCT program. That way, the competence of health professionals in the field of PMTCT will always be up to date based on guidelines set by the Government and international standards.
The central government has issued a policy in terms of logistics funding for HIV-AIDS control program through Circular Letter of the Director General of Disease Control and Environmental Health (P2 and PL) No. HK.02.03/D/III.2/823/2013 stating that there is division of authority between central and regional governments. For HIV Rapid Test, the reagent CD4 and Viral Load (VL) by 45% is provided by the Central Government and the rest by the Local Government. 4 As for ARVs, 100% is funded through the Central Government budget since 2013. Thus, the availability of logistics associated with HIV should not face any obstacles. Yet again, the competency of health workers in supply chain management is not maximized. This requires attention from the local government to allocate funds for capacity building in terms of the supply chain management does as to avoid stock out on ARV and reagents.
From the afore-mentioned analysis, the researchers conclude that the lack of funding on PMTCT program will greatly affect its implementation. Although Jayawijaya receives considerable international financial support, yet little is allocated specifically for PMTCT program and UNICEF even suspended its support two years ago. Cross-sectorial cooperation and coordination is needed to build commitment on HIV prevention. Efforts to improve health services are closely related to governance. How a program is implemented based on the plan is also dependent on valid and reliable data. The unsynchronized data between health services make planning in the Health Department rely alone on information from previous years, and the policy is not evidence-based. In addition, PMTCT is not included as a priority issue for local government, that socialization on the importance of PMTCT program is insufficient.
Money is not an issue for the people of Papua as they have abundant funds, including Special Autonomy funds from natural resource allocation by the Central Government. In terms of the policy, the Governor has allocated 15% for the health sector by. However, it is still referring to the priority of each District. Other health sector funding policy, namely Papua Health Security (Kartu Papua Sehat/KPS), guarantees free cost of health care on referral and health facilities for all indigenous Papuans and non-Papuan citizens who meet the criteria. Yet again, it was the competence of local government in terms of planning and budgeting that matters and coupled with unreliable data hindering the process. The monitoring function is still not running, especially in the implementation of health programs. The role of the community in monitoring was especially important in ensuring the quality of health services.
Of the various health system problems in the implementation of PMTCT program mentioned above, culture is also an important factor to consider in planning health programs. As already discussed, the people of Papua are of various tribes and languages. Cultural constraints will affect the achievement of PMTCT program. Thus, community empowerment through community organizations, religious organizations, and through health volunteers to improve the knowledge on the importance of healthy living and on preventing HIV transmission is indispensable. Prevention programs that adapt the local content or local cultural conditions is what the community requires. § PMTCT Services Availability of health care services is the key to health development and utilization of health care services by society. Based on the basic data collection in Jayawijaya, it turns out that the number of health care services provided is not ideal. For HIV-AIDS HIV test services, it is provided only in nine (9) health care services (64% of the total health care services), among which there are eleven (11) Sexually Transmitted Infection services and eight (8) Antiretroviral services.
Informants from Asolokobal Health Center say that the society can accept PMTCT services. There has been no denial of pregnant women to be examined and counseled on HIV, yet it must be done with a simple approach and good understanding about HIV. Here is an excerpt: "First, we do the counseling to them, as these days we face many major diseases. We inform them using simple language and help them understand; this step is important if you want to check. After counseling, we tell them not to worry to tell us their problems or the symptoms they have; we tell them that there is a cure now. That way, they will be willing to tell their problems.  (5), seven (7) doctors, and seven (7) nurses, four (4) non-health counselors, and eight (8) laboratory trained personnel on VCT. In the hospital (Wamena Hospital), there are five (5) doctors, twelve (12) nurses, six (6) midwives, two (2) laboratory assistants, and non-health counselors trained on VCT. In Kalvari Clinic, there are only two (2) nurses, one (1) laboratory, and three (3) non-health counselors trained on VCT (Papua Provincial Health Office, 2013). 6 To increase coverage of HIV test services, procedures are exercised. The first mechanism performed is by offering voluntary counseling and continued with training on HIV Test initiated by Health Workers. The existence of HIV test is followed by an increasing number of Services, Support, and Treatment (SST) and PMTCT services. Jayawijaya District has SST services offered in seven health centers with four (4) trained doctors, six (6) trained and skilled nurses, and five (5) midwives. As for the program PMTCT services, it is dominated by the fifteen (15) trained midwives as compared to other health professionals namely three (3) trained physicians and 1 (one) nurse (Papua Provincial Health Office, 2013). 6 Most of the health workers with PMTCT skills are midwives. The Health Department of Jayawijaya confirms that they held PMTCT training in cooperation with UNICEF involving facilitators and coordinators of midwives.
In the implementation, Wamena CHC has quite various VCT personnel. Asolokobal CHC has midwives trained with PMTCT skills, as stated by one of the informants:

"Health workers in charge of PMTCT are those in charge of Mother and Child Care in Asolokobal. The Mother and Child Care has three (3) midwives, and one of them has been to PMTCT training by the Health Department in cooperation with UNICEF in 2013." (A staff Responsible for Mother and Child Care Program at Asolokobal Heath Centre) § ARV Drugs
In support of ARV treatment, Jayawijaya already carries out the expansion of ART services to the primary care level. In Jayawijaya, there are 7 health centers that serve HIV test and 7 HIV test laboratories have, 6 of them serve antiretroviral drug administration (Papua Provincial Health Office, 2013). 6 HIV services are also carried out in nearly all health care facilities in Papua, including hospitals and clinics. Jayawijaya District has Wamena General Hospital and Kalvari Clinics that provide HIV services such as HIV test and antiretroviral treatment. Sufficient availability of ART services can contribute to the prevention of AIDS and even death. Until 2013, the number of HIVpositive pregnant women receiving antiretroviral drugs in Jayawijaya were 49 people, in which 32 of them were treated in health centers and the remaining 17 received ARV drugs from Wamena Hospital (Papua Provincial Health Office, 2013). 6 The availability of ARV is important for PMTCT program. During this time, Wamena General Hospital (Anggrek Clinic) claimed to never experience unprecedented vacancy antiretroviral drugs. An informant from Jayawijaya District Health Department revealed that there was an increase in ARV recipients in Jayawijaya, as follows: In practice, there are some problems in the provision of ARVs in Jayawijaya among others high lost to followup, not all health centers serve ARV, and the difficulty of access to the services, as expressed by the informant.
To finance the procurement of ARVs, during 2012 to 2013, the program is fully funded by the central government budget. At the time of the study, the researchers did not find any stock outs of drugs. There were, however, some cases in which drugs were late delivered; drugs remained remains available in minimal amount. It appears that the distribution chain was weak. The capacity of health workers in terms of supply chain management has been minimal not to exclude large transport constraints. § Reagent Related to places that serve HIV test, an informant from Health Department of Jayawijaya said that there were some places, which need HIV test, and only 64% of the total health centers, as follows: However, Asolokobal health center admitted that sometimes there was a delay of supply of reagent from the District Health Department causing some patients to miss the examination.
Funding for the availability of reagents, in addition to coming from the central government budget through the Ministry of Health, there is also support from international donors. According to the Ministry of Health, it has been determined that the procurements are divided proportionally between the central and local governments. For the province of Papua, it has been set up that the central government funds 45% and 55% are by the local government. However, it varies among regions, according to their respective capabilities. Mechanism on logistics distribution of reagents and other HIV drugs are alike, in which the central government distributes it to the provincial level based on the estimated number of patients. Furthermore, it is redistributed according to estimated number of patients at each District. § Data Weaknesses in the collection and use of the data frequently occur at various levels of service. At the District level, recorded information and data (database) in IHP, Village Clinics, health centers, and hospitals are not connected one to another. Reporting is not in accordance with appropriate standards so data is fragmented. As a result, the planning and budgeting process is not based on the data (evidence-based) as presented below: "There are two most problematic factors in Papua. The first is the data and the second is planning capacity, which is based on the data, yet the data is outdated. I am certain that the data is not regularly updated. There is data, yet it is not valid in a way that it is not periodically updated." (Deputy Director Program Decentralization DFAT) Data on PMTCT program on the District level is still lack of accuracy, not all pregnant women are listed, as revealed by a staff of the District Health Department following: "It is a gap, because I have to keep reminding colleagues. If we have 42 pregnant women given antiretroviral drugs, it should be that we have 42 babies, but there has never been any data about it. Where does it go?" (A staff Responsible for HIV/AIDS Program Jayawijaya Health Department). § Community Empowerment Community empowerment involving volunteers has been done by Asolokobal CHC, as stated by the Head of the CHC: "We do regular activities in addition to IHP activities. We have 41 personnel involved, but one has passed way. They collect information and it is very helpful. We did it once in 2013. However, we normally do that twice a year, in the previous years. That would be involving religious leaders, inter-sectorial meetings, the Mayor, the community, and women themselves." (Head of Askolokobal CHC) An inter-sectorial meeting is one of the activities done, as stated by the Head of Askolokobal CHC, as follows: "We have Mother and Child Care Program, immunization, HIV, TB. We have to coordinate for the programs. We need support from the parties concerned. Internal evaluation, then external. That should be done through meetings. Years ago for HIV, we have mobile VCT involving 9 major villages".
To encourage cooperation with IHP volunteers is one of the responsibilities of Askolokobal CHC, as stated in the following excerpt: "IHP is handled not only by a midwife, but also involved a team of 4 people. The midwife provide counseling, and pregnant women are referred to go to the clinic as we do not take the tool to check the blood and the staff have not been trained. We just provide information in IHP." (A staff Responsible for Mother and Child Care Program at Asolokobal Heath Centre).

Contribution of NGOs also plays an important role in PMTCT, as shown by religious organizations and the community itself. § Funding for PMTCT
In Jayawijaya, funding for HIV programs including PMTCT is minimal. HIV-AIDS program funding is one-door mechanism, through the District -Level National AIDS Commission, as a District Health Department official stated: The lack of funding greatly affects the quality of PMTCT program. To that end, Jayawijaya currently is receiving support from several international donors in the form of capacity building and technical support both on for supply, namely strengthening health services, and demand, namely community empowerment. The government of Papua has issued a health policy through Papua Health Card. This secures the release of the entire "It is an issue of decentralization; we need capacity to do that. However, there is not enough political will is not enough so the central government holds it. When it is released to the regional and local levels, there is an assumption of enough capacity. If it turns out that there is no capacity to manage it, the solution must be made. One of them is through immediate capacity building. If there is no improvement in capacity, the policy itself should be reviewed; otherwise, it is just a waste of resource." (Deputy Director on DFAT Decentralization Program) In the previous discussion, it has been explained that health funding especially PMTCT program in the District is not sufficient due to ineffective and inefficient planning and budgeting process of the service unit level up to the Local Government Units (SKPD), in this case the Department of Health. The working plan of each Local Government Unit is repetitive of the previous year, and is not evidence based, and largely depends on the commitment of the Regional Heads. § Culture Most Papuan in rural areas and inland believe that disease was caused by intervention of supernatural or magical powers, demons, or suanggi, and that everything can be resolved back to the traditional system of medicine as well. However, Papuans in urban areas have been able to combine the traditional knowledge with the modern knowledge in tackling health problems. Regardless of how modern the urban society, the issue of stigma and discrimination was still a major problem. 11 HIV/AIDS still poses a stigma for Papuan, even from their own family, as stated in an interview with a staff of Wamena General Hospital, as follows: "Revenge is a culture here.For example, a husband and wife. If one is sick or is experiencing something bad, then the other will be blamed. It once happened and we ended up going to the police. The police demanded information, but the family did not want to tell anything. If it is a HV case on the woman or wife, then the husband is blamed for that, as people will think that the HIV comes from the husband." (A staff at Anggrek Clinic).
Cultural issues in Papua were related to the diversity of languages in which there are 272 ethnics by language. Language determines or distinguishes identity and culture. Papua is on the crossroad, between traditional culture, modern, and globalization. 11 Some cultural issues in the Papuan that influence sexual behavior and lead to HIV / AIDS transmission of among others are polygamy, multiple partners, high mobility especially from mountainous areas to urban areas, various ethnics and languages, antipathy to immigrants as it is linked with HIV and the issue of "genocide" (extermination), the strong identity of the local people, and society's acceptance on the very influential Christian churches.
Thus, strengthening health systems should incorporate or accommodate local wisdom, as expressed by the Director of Yukemdi NGO in the following interview: "In the past, they could not care for PLHIV at home or in the village. PLHIV are placed in unoccupied homes. However, they are accepted and are helped. That is the impact of the information we deliver. We have to carefully select the approach, and in Yukemdi we just go with the general pattern in which field officers do cartridge, inform, outreach. We started to talk to the indigenous peoples in 2012. We realize that the almost 90.5% to 90.7% of cases happen in Papua." (Director of Yukemdi NGO).

CONCLUSION
The conclusion of this study for the role of health systems (WHO "Six Building Blocks") are as follows: 1. As a district that has a high prevalence and risk of HIV / AIDS, Jayawijaya experienced shortage of health care having PMTCT services, as currently there are only five health centers and one hospital providing PMTCT services. HIV test services also remain inadequate, with only provided by 64% of the total existing health services. 2. Efforts to meet the needs of human resources able to provide PMTCT services have not been adequately performed-from the number, type, and quality of health workers. In addition, health personnel are still not evenly distributed. 5 3. There have been no problems in the availability of ARV Drugs and reagents, but competence in the field of supply chain management needs to be improved. Further, therapy and treatment using ARV was provided relatively little because it has been exercised by few health centers in Jayawijaya. Noncompliance in taking ARV drugs and lost to follow-up also remains a problem due to geographical constraints and the readiness of health services.
4. Collecting, processing, to reporting data on PMTCT was still not performed by health services. The data were often not connected among health centers or is fragmented at many health centers.
The lack of quality control was closely related to the competence of human resources.
5. The funds from the local government for PMTCT program were too little as compared to the amount of coverage of pregnant women needing test and counseling in ANC clinics.
6. Community empowerment in PMTCT and other health services has been done by the health centers and NGOs, although the number of NGOs involved in HIV programs is limited. Health workers, traditional leaders, and religious communities were also involved in the program. Nevertheless, socialization for HIV prevention programs, especially PMTCT, needs improvement.
7. The process of planning and budgeting from the level of service providers up to SKPD units were still far from expectations. SKPD work plans were repetition of the previous year's plans, and were not evidence-based. It was also evident that funding for PMTCT program was insufficient.
8. Planning of PMTCT program has not fully adapted local cultural conditions, although approaches have been attempted through influence of traditional leaders or through religious organizations.

SUGGESTION
Based on the findings, the following recommendations are given: 1. Considering the vast area and difficulty of access to health services, Jayawijaya, in DHO, needs to immediately provide a complete expansion of PMTCT services ranging from HIV test and counseling through VCT and PITC approach (HIV test initiatives by health workers), the provision of ARV drugs for pregnant women, as well as psychosocial support to PLHIV.
2. Improve coordination across sectors to strengthen the implementation of PMTCT program. Therefore, the results are expected to be more comprehensive from planning to evaluation.
3. The DHO should regularly conduct training on PMTCT and supporting fields (such as data management and supply chain management) to health workers across the health centers and hospitals in Jayawijaya.
4. The government should create a special budget strategies and schemes for women and children suffering from HIV and AIDS, especially to reduce the rate of transmission from mother to child.
5. All parties should improve prevention programs by taking into account cultural elements or health anthropology in prevention of HIV/AIDS. This can be done by utilizing a combination between local rules and common norms, individual, historical context and environment, the variation of delivery, as well as sensitivity to different cultures.