Field Oversight Visit

Gorontalo

5-8 March 2014

TWG Field Oversight Visit Report This report summarizes a joint Field Oversight Visit to Gorontalo, conducted by members of the GF Country Team (CT) for Indonesia, member from WHO country office in Indonesia; MOH Indonesia representative, representatives from PR NU, and CCM Indonesia/TWG members. The group was divided into two teams to facilitate a wider range of site visit opportunities. The findings and recommendations described below were compiled from site visit notes provided by each team, and from notes of end-of-day discussions between team members.

I. Team members

Dra. Psi. Wenita Indrasari, MPH, MSi (CCM/TWG Chair HIV), Dr. Thomas Suroso, MPH (CCM/TWG Chair HSS), Dr. Ferdinand J Laihad, MPHM (CCM/TWG Chair Malaria), Drs. Hisyam Said, Msc (CCM/TWG Chair TB), Tiara Nisa Mahatmi (WHO), Abdur Rachim (HIV MOH), Nurul, CCM Secretariat; Prawita Yani (NU), Sri Rahayu (NU), Doungkamon Vongin (GF CT), Shahid Khan (GF CT)

II. Sites visited

Date and city Specific offices, facilities and CSOs

Kota Gorontalo

March 5, 2014 • Meeting with CSOs Malaria • Meeting with CSO HIV-Refocusing NU

March 6, 2014 • Meeting with Vice Governor of Gorontalo Province • Meeting with Mayor of Gotontalo City • Meeting with District AIDS Commission Gorontalo • Team 1 : HIV/TB

Site visit to Puskesmas Limba B Site visit to Puskesmas Wongkaditi

Kab. Gorontalo

• Team 2 : Malaria Site visit to Village Malaria Post/Posmaldes Site visit to Breeding Place

Kota Gorontalo

March 7, 2014 • Meeting with Provincial Health Office • Site visit to Prof. DR. Aloei Saboe Hospital • Site visit to Provincial Warehouse • Team 1 : HIV/TB

Meeting with Key Affected Population HIV Kab. Gorontalo

• Team 2 : Malaria Meeting with District Health Officer of Kab. Bone Bolango

• Site visit to Hot Spot - Cafe Valentine at Kab. Bone Bolango

Kota Gorontalo

March 8, 2014 • Debriefing team Field Oversight Visit to SR

Kab.

Gorontalo

• Team 1 HIV/TB : Site visit to Dr. M.M Dunda Limboto Hospital

• Team 2 HSS: Site visit to Puskesmas Tibawa

III. Findings

Gorontalo consists of 1 city and 5 districts with total population of 1,094,544. There are 12 hospitals and 92 Health Centers. Regarding the question on availability of funds, the Global Fund has clarified that Indonesia is eligible to apply for continued funding for all 3 diseases and HSS. Priority provinces and districts within the country will be proposed by the CCM, based on various factors including disease burden. Since Indonesia is a middle-income country, evidence of domestic contributions is a requirement to access available funding. Therefore, it is encouraged that provinces and districts contribute to the health funding as well. NGO / outreach services in Gorontalo:

• HIV: There are three communities which are doing a good outreach in Gorontalo. The issues of MSMs and TGs are appropriately addressed, as well as for female sex workers. There is a need to include more females in the community group aiming at providing more confidence to the females. There are anti-ARVs campaign to marginalize ARVs and replacing it with an herbal treatment through internet. This misunderstanding should be properly addressed as some of the patient died without taking ARVs.

• Malaria: there are 3 NGOs doing the outreach work for Malaria. These are NU, Aisyiyah and

Muhammadiyah. The carders visit only 20 households per month which is not enough. The carders also only find patients and refer to HCs for testing. Lacking treatment practice is a challenge as there are too much time lag in between, sometimes patients do not wait for the result of the diagnostics. Health carders should be trained for doing the test and the drug should be given to midwife to ensure patient receive treatment.

• TB: No formal community organization involved for outreach support, the Health office

creates their own community activities by having meetings and socialization to create communities awareness.

HIV:

• Harm reduction in practice is still a problem. The local police whose operation is not under the province still reach out the IDUs.

• SR NU provided operational funds for the support group in 2013. There is no available funding in 2014 and the local government has also cut funding due to alleged fraudulent cases. There is clear evidence that the support groups are in need of funding.

• Gorontalo has not been trained for LKB (Continuum of Care), however some activities related with coordination, linkage between communities/CSOs with facilities, decentralization are happening. LKB training will strengthen the practise that is already there.

• Dedicated staffs conducting mobile VCTs extra office hour in the night to hotspots, making HIV testing available and accessible for people who wants to be tested. Gorontalo identified that dormitory (“kos-kosan”) is one of the target for HIV testing.

Puskesmas Limba B and Wongkaditi

• At Puskesmas, it was found that none of the IDUs were referred. Meeting at the municipality has also informed that the NGOs are working with police to reach IDUs which is not a good approach because, due to fear, the targets will not be willing to cooperate.

• The report on number of FSWs and Waria reached is on track without any major concern. There seems a potential problem with regards to the prevention at the level of massage centres as these centres now offer services.

• All the relevant staff at Puskesmas are aware that there is policy to test HIV in pregnant

women and TB patents. They started to test more pregnant women and TB patients, it is a written policy, but there are not enough RDTs to do the testing in reality.

• Patients with positive HIV test result are accompanied to hospital for ARV treatment. Time

laps is not long which demonstrates that Puskesmas has been managing this well.

• The MARPs outreached by NU will have a referral card to help them have access to Puskesmas in which, both side will record each as one of their achievements. The next route is to refer back the patient to NU's implementing unit to receive psychosocial support, from Puskesmas to NU. However, NU's SSR staffs were not aware that his process is also one of the recording activities NU needs to report to SR. Coordination among SSRr should be better addressed by the Provincial and/or City AIDS Commission.

• There is substantial funding for Provincial AIDS Commission amounting to Rp 600m. One of the areas to be covered with this funding is to support Puskesmas staff to operate mobile clinics. This is the additional money and it needs to be ensured that the required amount is invested in the proper area.

Prof. DR. Aloei Saboe Hospital

• There have been some TB/HIV Collaboration activities. HIV patients are screened for TB and all TB patients are tested for HIV.

• There are two pediatric HIV cases and they are eligible for treatment, however, the treatment has not yet started. The doctor apparently does not have the confidence for HIV child treatment. An urgent intervention from the national level to remove the bottleneck and provide counseling is required.

Malaria

• Gorotalo municipality has done a commendable job combatting malaria. Gorontalo municipality received eliminated status as there is no malaria case for 5 years consecutively. High case of Malaria at the district level - District Gorontalo: 525 cases (38%) SPR=6,9%; Kab. Boalemo 238 cases (17,6%) , SPR= 13.2% and Kab. Pohuwata 368 cases (27.2%), SPR=24.6%. Most of the case at Kab. Bone Bolango district but most of the case are from illegal mining. There should be a special intervention at the mining site. Challenges will be transportation and the cost. Puskesmas Limboto Barat

• There were 20 positive case found in 2013, with 3 lost patients. Medicine only can be requested at the HC to warehouse and only by health personal. According to the policy,

pharmacy can do it. LPLPO should be filled out by the pharmacy at HC and sent to district (program).

• Illegal mining have spread in all districts and more case are found in this group. Case control

and blood test should be conducted in mining area. • NGOs and FBOs have good collaboration from HC, district and the village. For efficiency, the

activities should be conducted with other related disease at the village level. • There is a stock-out of Artemisinin injections at Provincial Health Office. These have been

requested from other provinces but all are not available. In July, all provinces/districts are stock out due to the high malaria season. 3 patients of severe case die because of no drug. Their performance is better and the staff is very dedicated. 1 district report 60% to the PHO, the rest is more than 90%.

Village Malaria Post: Village Daenaa

• There are only 1 LLINs per household even though there are more than 2 family members per house. There are 2 carders who visited 40 houses each month, out off 900 houses in the village. The village also organized maternal/child health discussion every month, venue changes from area to another to cover all populations. The carders do not do RDT test at VMV but refer the suspect to sub-health center.

TB

Puskesmas Limba B and Wongkaditi

• Treatment success rate is high for the province of Gorontalo – overall success rate as of 2013 is 87%. The success could also be due to the fact that the population size of the province is not high (less than two million).

• There is no digital TB information system in place in the two PKMs, Even though there is new integrated information system introduced recently that include SITT (TB Integrated Information System). The national health insurance scheme recently kick off in the country has madethe Puskesmas equiped with internet connection; however, as yet there is no computer for TB program, making the SITT is not accessible from the Puskesmas.

• HIV patients are tested for TB and vice versa. However, the old form wherein no column for

TB-HIV collaboration are still in used, thus put us in doubt to how to record TB patients tested for HIV. They promise to use the new form in the near future which will also contain information about HIV. In case of any HIV detection, the facility highlighted that they refer the HIV patient to the central hospital – the facility also provide counseling support. The facility, however, produced record of TB patients having STI and those were subsequently referred to the central hospital.

• The puskesmas were aware of syphillis testing for pregnant women and already tested some with high risk, however there is not enough syphilis testing (RDT and RPR).

• The target to find MDR-TB case in the province is quite high, but health worker at Puskesmas

Limba B found only one suspect for MDR-TB and his sputum is sent to Lab in Surabaya even though Makassar is closer. It seems there is no clear instruction of where to send the sputum. There is no facility available to treat MDR-TB in the provinceso it looks like they do not want

to find MDR TB patient because at the end they do not have budget for transporting the patient to go for treatment in Makassar. However, the PMDT and facility for MDR-TB is in the plan and should be established here soon.

• SITT: in PKM the facility for SITT is not in place. It is still done manually. The supervisor (Wasor) at district will collect the data and pass it to the province Wasor to be uploaded to the system. Since there are many stages, there could cause the error of data input.

Prof. DR. Aloei Saboe Hospital

• DOT is working well at the hospital. There are facilities to check the sputum and have programmatic medication. Procedure is in place including TB/HIV and VCT clinic is in the hospital that the patient can be referred to. There is no arranged place for patient to take out the sputum. The patients are asked to do it in the alley close to the toilet and it is not an open space. This is not considered as a good practice as the TB germs can spread to people close by.

• At the hospital TB/HIV collaboration works well as mentioned in HIV section.

• There are some levels of complication according to the referral system. If the referral comes from PKM, treatments for patients are free. However, If the patient came directly to the hospital, he has to pay some hospital fee as regulated.

• It seems that the hospital needs technical advice for building of MDR-TB ward. They are

wondering if the ward can be built near maternal ward since the hospital has the spaces there.

Dr. M.M Dunda Limboto Hospital • TB/HIV collaboration still has some gaps. TB patients are not tested for HIV and vice versa

because the staff does not aware about the Minister Decree.

• Dr. MM Dunda Hospital in Gorontalo regency as a satellite to serve people living with HIV to ARV treatment is far from the city.

• There are guideline problem causing the delay in treatment. TB patient with negative sputum test at Pukesmas cannot receive treatment even though their symptom obviously shows that the patient has TB. Patient needs to have another test at the hospital to confirm TB before they receive treatment.

Health System Strengthening • HMIS issue – information system for drug supply is used at Health Center level, although it is

under-web, not web-based. With under-web system, health officials have to sit in one office and use only one computer which has the system installed. Suggestion is to have BPGS so that data can be entered from anywhere. There is no LPLPO and no e-report.

• SIKDA is not working yet. In both the facilities - Puskesmas Limba B and Wongkaditi - the integrated information system for HIV (SIHA) is functioning well with the information flow from district to province and to central level.

Warehouse at district of Bone Bolango • The temperature was high (30 degree centigrade) as shown in the thermometer at the ware

house of the district of Bone Bolango. The air-condioners were not operated at the time of visit. Malaria and TB drugs are managed by the program of the district. This warehouse will

be expanded in 2014 – the current capacity does not cater the requirements. The bidding for expansion will be in the district using e-procurement (LPSE) from central level. Administrative process is underway.

• Logistic information with the warehouse should be connected with the information system of the health center.

Heath Information System at district of Bone Bolango • SIKDA installed at the central level is not integrated with the information system at the district

level as there are two separate systems. DHO proposed for establishment of a system at district level compatible to the central level so that the information can be accessed by one click.

Provincial Warehouse • Presently, there is a temporary storage facility. The new warehouse is under construction. The

temperature of the current warehouse (27 degree centigrade) was not adequate . There was no thermometer. With respect to the security, there are two personnel who have keys of one main lock.

• The logistics information system has two types of reporting - one certain number of reporting about availability and the second is for dynamic of drug logistic which is called e-logistic. This issue is related to LPLPO for Puskesmas to district. There should be one system to be used for both the reporting on quarterly basis.

• Drugs are potentially to be expired– the drugs should go out before one year of their expiry

date. In this respect, the drugs should go out in couple of months’ time to avoid any potential expiration.

• Malaria RDTs was found to be kept together with insecticide in a separate building which is

not a good practice. Health Information System in Province • ICD 10 reporting system works in hospital but not at the health centres because the doctors

diagnose medicines listed other than ICD list. No follow-up training.

Warehouse at Puskesmas Tibawa • The e-system for Malaria cases works well at the Puskesmas Mapping of malaria stratification

based on Annual parasite incidence (API) was establised. There is only one village classified as high case incidence area (HCI). All essential and emergency drug are stored.

IV. Recommendations

Health System Strengthening • NU is a strong community organization but only do work for HIV. There should be

consideration of expansion to cover other diseases and the province has Rp 1 billion to use for HSS support.

• Available funding needs to be utilized properly. Fund at every level should be used separately and effectively. e.g. mini workshop monthly

• A web-based one drug reporting system should be established instead of using several systems that are not compatible and without system data transferred. There should be more coordination between health center and district warehouse on information system.

HIV

• The limited number of IDUs identified is because the IDUs are still afraid they will be arrested by the police. There should be a better cooperation with the police including the local police who are not under the province to reach the IDUs to address the problem.

• National guideline including the available decree and circulars needs to be socialized to all facilities, and advocacy on cost-sharing for provision of HIV and STI reagents is needed. Facilities need to ensure the availability of reagents inclding for syphilis, and the treatment and other supporting medication (such as epinephrine) for all who are found positive.

• There is a need for technical assistance from national/regional mentors in the area of pediatric

treatments, therefore Gorontalo can start providing treatment for children. • There should be more efforts in finding early cases of HIV, given that more AIDS cases are

found in Gorontalo compared with HIV cases. Of those might includes providing more HIV testing centers, as well as adding more ARV sattelites in some districts.

• LKB training will strengthen the LKB practises that have been implemented partly. • There is a need to have a few simple program indicators that can be used by the districts to

monitor their progress. MDG indicators is not always easy to be monitored. • Need to look at the data specifically for TB-HIV to see the progress and challenges of TB-HIV

collaborative activities Malaria • Severe case management and drug supply chain management should be strengthened. This can

be seen as the evidence of the stock- out of the Artemisinin injection drug that caused 3 deaths. Action should be taken from national level.

• The district health office should train health carders to be able to perform testing and giving treatment to patient. This is to reduce time lag from identifying suspect and starting the treatment.

• Strengthened surveillance of city municipality and mapping of case at village level is needed.

Mapping is required related to the transmission. Also, there is a need for mapping at village by household showing the case and breeding site to identify and classification of disease imported cases.

TB • The training and technical assistance should be provided to the health centers on identifying

and treating MDR-TB patients, given only one MDR-TB suspect found in 2013 in the province.

• The NTP should advocate with provincial and district level health facility to ensure that national guidelines are followed by all clinicians treating TB and TB/HIV patients, given the

fact in some health facility old reporting form of TB without TB-HiV collaboration is still in use.