BOOK: KAJIAN DOKUMEN KEBIJAKAN HIV-AIDS DAN SISTEM KESEHATAN DI INDONESIA

Reference:

Tim Peneliti PKMK FK UGM: Ignatius Praptoraharjo, PhD; Drs. M. Suharni, MA; dr. Satiti Retno Pudjiati, SpKK(K); Hersumpana, MA; Eunice Priscilla Setiawan, SE; Sisilya Bolilanga, MSc; dan Eviana Hapsari Dewi, MPH PPH Atma Jaya: Iko Safika, PhD

Kebijakan HIV-AIDS dan Sistem Kesehatan di Indonesia © PKMK FK UGM Perpustakaan Nasional: Katalog Dalam Terbitan (KDT) Kebijakan HIV-AIDS dan Sistem Kesehatan di Indonesia/Tim Peneliti PKMK FK UGM Yogyakarta: Pusat Kebijakan dan Manajemen Kesehatan Fakultas Kedokteran Universitas Gadjah Mada xxvi+179 halaman/17 x 25 cm Cetakan pertama, Oktober 2015 ISBN: 978-602-0857-09-1 1. Kebijakan 2. HIV-AIDS 3. Sistem Kesehatan Indonesia I. JUDUL

http://www.kebijakanaidsindonesia.net/id/hasil-penelitian/1393-kajian-dokumen-kebijakan-hiv-aids-dan-sistem-kesehatan-di-indonesia

Important quotation:

SUMMARY OF THE BOOK

(INDONESIAN)

Masih tingginya epidemi HIV dan AIDS di Indonesia diiringi dengan dinamika respons atau penanggulangan terhadapnya. Penelitian ini menelaah dinamika respons tersebut. Argumen utamanya: respons terhadap epidemi HIV dan AIDS di Indonesia mencerminkan ragam kontestasi yang rumit antara berbagai pendekatan, mazhab, dan aktor dalam sebuah konteks kemasyarakatan yang dinamis.

Kontestasi yang pertama mengemuka antara pendekatan vertikal dan horizontal. Pendekatan vertikal mengandalkan kecakapan teknis pengendalian yang terpusat dan ketat, sedangkan pendekatan horizontal mengutamakan pengendalian yang bersifat multisektoral dan desentralistik. Kontestasi berikutnya ialah soal rujukan pengambilan kebijakan, antara merujuk kepada data teknis/epidemiologis dan pertimbangan politik-ekonomi. Misalnya, jika merujuk kepada data teknis, penggunaan kondom seharusnya bisa dilakukan; tetapi karena pertimbangan politis, kampanye penggunaan kondom menjadi tidak mudah diterapkan. Kontestasi lain ialah soal keterlibatan aktor antara pemerintah pusat dan daerah. Respons oleh aktor pusat tampak lebih dominan secara teknis karena akses mereka yang lebih kuat atas data-data epidemiologi; tetapi secara politis dan operasional, daerah berperan lebih penting. Selain itu, kontestasi juga tercermin dari ragam lembaga yang mengusung masing-masing mazhab (school of thoughts) yang berbeda, misalnya antara USAID dan AusAID (sekarang DFAT), GFATM, berbagai NGO internasional, dan lembaga pemerintah.

Ragam kontestasi itu beriringan dengan dinamika perkembangan kebijakan penanggulangan HIV dan AIDS di Indonesia. Dua hal yang secara substantif me­ mengaruhi dinamika perkembangan kebijakan itu ialah berubahnya relasi antara pemerintah pusat dan daerah (desentralisasi), serta perkembangan epidemi itu sendiri. Sebelum 1999, ketika sistem pemerintahan masih sentralistik, pendekatan vertikal dengan aktor utama pemerintah pusat beserta mitra pembangunan internasional penyokong dana penanggulangan HIV dan AIDS di Indonesia sangat dominan. Kemudian ketika desentralisasi bergulir dengan diberlakukannya UU Nomor 32/2004 tentang Pemerintahan Daerah dan PP Nomor 38/2007 tentang Pembagian Urusan Pemerintahan, Antara Pemerintah, Pemerintah Daerah Provinsi, dan Pemerintah Daerah Kabupaten/Kota urusan kesehatan, termasuk penanggulangan HIV dan AIDS, berubah karenanya.

Situasi ini memunculkan dua tantangan dalam penyusunan kebijakan publik. Pertama, bagaimana kebijakan penanggulangan HIV dan AIDS secara politik-ekonomi bisa sejalan dengan tata kelola pemerintahan yang sebagian telah terdesentralisasi. Kedua, bagaimana mengintegrasikan layanan HIV dan AIDS secara teknis ke dalam program kesehatan yang sudah ada untuk memastikan respons jangka panjang di tengah keterbatasan sumber daya dan kapasitas pemerintah daerah yang beragam.

Salah satu tantangan sekaligus kesempatan penting bagi respons daerah terhadap HIV dan AIDS ialah desentralisasi sebagian kewenangan pemerintah pusat ke daerah. Desentralisasi bukanlah hal yang mudah karena membutuhkan harmonisasi pengelolaan urusan publik secara umum, terutama kesehatan dalam hal ini. Di bidang kesehatan, harmonisasi itu merentang baik dalam hal kebijakan maupun layanan kesehatan. Dalam situasi seperti ini, diperlukan pengembangan sistem kesehatan yang inovatif untuk meningkatkan status kesehatan masyarakat.

Respons kelembagaan (pembentukan lembaga) dan pemberlakuan peraturan/ kebijakan merupakan dua langkah yang paling banyak ditempuh. Kedua langkah ini dianggap akan menjamin keberlangsungan program, karena melalui keduanya pemerintah bisa meneruskan investasi yang telah ditanam oleh donor. Penelitian ini menunjukkan bahwa peraturan/kebijakan dan tata kelembagaan yang terbentuk menyerahkan efektivitas implementasinya kepada sistem kesehatan dan tata kelola pemerintahan yang ada secara umum atau dengan kata lain mengasumsikan kecakapan sektor di luar lingkup HIV dan AIDS serta sektor kesehatan secara khusus dalam memberikan respons yang komprehensif. Banyak kasus di daerah penelitian mengungkapkan bahwa kedua langkah ini lebih mencerminkan aspek-aspek normatif: ada peraturan dan ada lembaga, tetapi tidak berjalan efektif lantaran kualitas implementasinya yang rendah. Hampir semua provinsi membentuk Komisi Penanggulangan AIDS Daerah (KPAD), tetapi dengan berbagai alasan, peran lembaga ini cenderung terbatas pada sekadar memenuhi mandat. Pelaksanaan peraturan daerah (perda) terkait HIV dan AIDS juga tidak efektif karena absennya sumber daya dan sanksi yang memadai, selain karena sering tumpang tindih atau berlawanan dengan peraturan di sektor publik lainnya.

Secara umum, kelemahan mendasar dalam respons daerah terhadap HIV dan AIDS ialah terlalu bertumpu pada “pengadaan” kebijakan (perda, perbup) dan kelembagaan (KPAD), tetapi sedikit perhatian pada kapasitas implementasinya. Kelemahan ini jamak ditemukan di bidang kesehatan secara umum, bahkan sudah menjadi permasalahan klasik bukan hanya di bidang kesehatan dan bukan hanya di Indonesia. Penelitian Prof. Lant Pritchett dari Harvard Kennedy School tahun 2014 mengenai kecapakan dokter di India misalnya, menyimpulkan bahwa permasalahan pokok pembangunan di negara berkembang ialah pada tahapan implementasi. “The problem (often) isn’t either policy or capacity it is the organizational capability for implementation.” Lebih lanjut Prichett menunjukkan suatu pola respons negara-negara berkembang dalam mengelola program pembangunan, yaitu menerapkan teknik “Isomorphic Mimicry” suatu teknik mengecoh musuh yang digunakan seekor ular takberbisa dengan menampakkan diri bak seekor ular berbisa (warna belang-belang). Dengan membentuk lembaga baru, memberlakukan kebijakan, menandatangani komitmen bersama, dan lain sebagainya, seolah-olah pemangku kebijakan sudah mengambil respons dengan baik. Kelembagaan dan kebijakan yang dikeluarkan oleh pemerintah ibarat warna belang-belang pada ular takberbisa. Penampakan ini kurang efektif karena tidak diikuti dengan pemenuhan kecakapan implementasi.

Selanjutnya soal pendanaan. Dana penanggulangan HIV dan AIDS sampai saat ini mayoritas masih berasal dari donor luar negeri. Beberapa kebijakan untuk mendorong pemerintah dalam mendanai penanggulangan HIV dan AIDS telah diluncurkan, juga banyak daerah telah mengalokasikan dana dari APBD, tetapi cakupan pendanaan masih terbatas pada aspek biaya administratif. Dana untuk program dan pelayanan masih dinilai kurang.

Di sisi lain, peran masyarakat sipil yang direpresentasikan oleh komunitas populasi kunci masih belum optimal. Kelompok ODHA dan pecandu napza nisbi diterima keberadaannya dalam penyebutan identitas diri sebagai komunitas, sedangkan wanita pekerja seks (WPS), waria, lekaki seks dengan lekasi (LSL), dan gay belum mendapat tempat untuk menunjukkan identitasnya di dalam masyarakat dan sebagai kelompok berkepentingan.

Rekomendasi

Dengan memerhatikan situasi epidemi HIV dan AIDS di Indonesia, kontestasikontestasi yang ada dalam penanggulangan HIV dan AIDS tersebut perlu dikelola supaya tidak saling menegasikan antara satu dan lainnya. Untuk itu perlu disusun sebuah peta-jalan (roadmap) yang mengintegrasikan program HIV dan AIDS dengan sistem kesehatan baik di tahap perumusan maupun implementasi. Mengingat cakupan peta-jalan integratif itu tidak hanya aspek-aspek teknis tapi juga aspek politik-ekonomi, pelaksanaannya akan terbayang tidak mudah. Tetapi, integrasi antara pendekatan vertikal dan horizontal dengan komposisi yang tepat dalam kebijakan penanggulangan HIV dan AIDS merupakan kunci untuk efektivitas dalam meningkatkan cakupan dan kualitas program penanggulangan HIV dan AIDS di satu sisi, serta penguatan layanan dasar kesehatan di sisi lainnya.

(ENGLISH)

Executive Summary In response to the growing epidemic of HIV and AIDS in Indonesia, a wide range of responses and countermeasures has been introduced by the Indonesian health systems. The current study aims to examine changes in the health system responses to curb the HIV epidemic over the last 3 decades. The study revealed that the health system responses to HIV and AIDS epidemic in Indonesia reflect complex contestations between various approaches, principles, and actors operating within a constantly changing sociological context. First, there is discordance between the vertical and horizontal strategies to address the increasing number of HIV and AIDS cases. The vertical strategy relies on a rigid and highly centralized technical intervention. In contrast, the horizontal strategy emphasizes multisectoral and decentralized approaches. Secondly, in policy making processes, political and economical considerations often outweigh epidemiological evidence as the basis for decision making. For instance, evidence has shown that the use of condom in high risk population should be promoted; however political considerations have prevented widespread campaign on condom use. Furthermore, there is often a conflicting role between the central and local governments. With strong access over epidemiological data, there is a predominance of central government actors particularly in technical intervention. However, local government have stronger role given their politically strategic position and autonomy in program implementation. Finally, disagreement is often found between school of thoughts represented by different institutions working in HIV and AIDS, for example USAID and AusAID (now DFAT), GFATM, local and international NGOs, and government agencies. These lacks of alignment and clarity of roles between different approaches, actors and principles characterized the evolution of HIV and AIDS policy in Indonesia. Two main issues substantially influenced changes in the development of HIV and AIDS policy in Indonesia. First is the transformation in the relationship between central and local governments (i.e. decentralisation). Prior to the decentralisation of the health sector in 1999 during which the health system was fully centralized, formulation and implementation of HIV and AIDS strategies were predominantly led by vertical approaches with the central government and funding of international development partners as the main actors. After health sector decentralisation was enacted by Law No. 32/2004 on Local Government and Government Regulation No. 38/2007 on Division of Government Affairs, autonomy was divided between the Central Government, Provincial Government, and the District/Municipality Government. As a consequence, the governance in health including HIV and AIDS also underwent substantial changes. The second issue influencing the evolution of HIV and AIDS policy is the growth of HIV and AIDS epidemic.

Two main challenges in the formulation of HIV and AIDS policy emerged from these circumstances. First, from the political and economic standpoint, it is important to align the HIV and AIDS policy and strategies with the government administration which has been undergone decentralization including the health sector. Second, it is crucial to find strategies for HIV and AIDS services integration into the existing health programs to ensure sustainable response given the limited resources and different capacitycity of local governments. Decentralisation of policy making and authorities from the central to local government does not only present unique challenge but also opportunities to design effective HIV AND AIDS policies and programs. Decentralisation requires an enormous effort in order to synchronize the management of public services across government sectors, including the health sector. In the health sector, this process of synchronisation occurs both in the sphere of health policy and health services. This situation mandates the development of innovative approaches in health systems in order to improve the health status of the community. Institutional responses (e.g. establishment of entities and institutions) and enforcement of the regulations/policies are the two most widely adopted measures in HIV AND AIDS strategies. These measures are considered to ensure sustainability of the programs because they will enable the government to continueinvestments made by donors. The current study shows that the effective implementation of newly developed policies and regulations as well as institutional structures heavily relies on the existing health systems and governance. In other words, the development of HIV AND AIDS strategies often use too much assumption that the health sector and other sectors outside HIV AND AIDS area would have sufficient capacity to deliver comprehensive response. Through case studies in the study location, it was apparent that institutional responses and development of regulations were more of a normative basis against which performance in HIV AND AIDS response will be measured and therefore be made in place. However, institutional structures and regulations are ineffective due to inadequate implementation. For instance, almost all provinces have established the Local AIDS Commissions (Komisi Penanggulangan AIDS Daerah/ KPAD). However, for various reasons, the role of these institutions tends to be confined to merely fulfill their institutional mandates. The implementation of local government regulations (Peraturan Daerah/ PERDA) on HIV and AIDS was also ineffective due to the absence of adequate resources and punishment. In addition, overlapping or disagreement with other public regulations was not uncommon. In general, the weakness of local government’s response to HIV/AIDS is in fact the overdependence on the "procurement" of policies (PERDA and Peraturan Bupati/ PERBUP) and institutions (KPADs), and the lack of attention to the capacity in implementation. This is a common problem in the health sector in general, and even have become a classic problem in the health sector across the world. For example, Lant Pritchett of Harvard Kennedy School in 2014 through a study on the proficiency of doctors in India concluded that the bottlenecks of development in most developing countries are mostly found in the implementation stage. "The problem (often) isn’t either policy or capacity – it is the organisational capability for implementation." Furthermore, Prichett’s study showed a unique pattern in the response of developing countries in managing development programs. This pattern refers to a phenomenon called "Isomorphic Mimicry" technique – a technique used by a non-poisonous snake to deceive their predators by mimicking the appearance of other snake species that are poisonous (i.e. adopting mottled skin). By establishing new entities and institutions, enforcing policies, signing mutual commitments and so forth, policy makers will appear to have delivered a good response. The mottled skin of non-poisonous snake represented the institutions and policies issued by the government described above. Such an attempt is in fact ineffective because it was not followed by adequate implementation capacity within the municipality. The other important issue was funding sources. At present, the majority of funding for HIV/AIDS is contributed by foreign donors. Government policies to encourage the local government to procure funding for HIV and AIDS response have been issued. A number of local governments have allocated funding from local budget (Anggaran Pendapatan dan Belanja Daerah/APBD), however, the allocated budget may only finance the administrative costs. Therefore, funding to sustain HIV and AIDS programs and services are still considered insufficient. Lastly, the role of civil society represented by the key population has not been optimal. Although the identities of existing communities such as people living with HIV and AIDS (PLWHA) and Intravenous Drug Users (IDUs) are quite well accepted by the society, however, this is not the case for Female Sex Workers (FSWs), transgenders, Men who have Sex with Men (MSM), and homosexuals. Recommendations Given the alarming situation of HIV/ AIDS epidemic in Indonesia, the contestations in HIV and AIDS response should be better addressed to prevent contradictions. It is necessary to develop a health system and policy roadmap that integrates HIV and AIDS programs into the existing health system at formulation and implementation stages. This roadmap will encompass not only the technical but also political economy aspects of HIV and AIDS program that will guide programs towards better implementation. An integration of vertical and horizontal approachesin HIV and AIDS policies is the key to improve effectiveness and strategies to scale up the coverage and quality of HIV and AIDS programs and at the end of the day strengthen the basic health services.  

DYNAMICS OF HIV AND AIDS EPIDEMIOLOGY AND RESPONSE

 The first AIDS case in Indonesia was identified in Bali in 1987, during which was no HIV test available. Experts in this field immediately and repeatedly announced the potential spread of HIV and AIDS across the country. The potential of HIV and AiDS transmission in Indonesia was particularly high given the prevailing risk factors, such as the widespread availability of commercial sex industry, the high prevalence of Sexually Transmitted Infections (STIs), poverty, and the high rate of population mobility (Kaldor, 1999). Twelve years after the first case was identified, there was no significant increase in the number of cases despite the persistence of these risk factors. Interestingly, a number of risk factors that were perceived to accelerate increase in the number of cases have instead become prohibitive factors. For instance, poverty has in fact reduced the demand for commercial sex, although it might increase the number of commercial sex workers. However, increasing number of sex workers is not associated with increase in the turnover of customers. 

The Ministry of Health reported that over the period of 1991 to 1995, approximately 40,000 females sex workers (FSWs) were annually tested for HIV. This number was nearly one-fifth of the total FSWs throughout the country. It was found that the annual HIV prevalence was always below 0.03%. It might be inferred that despite the the high rates of population mobility and STI prevalence, the spread of the virus would not take place if the HIV virus was not present in the population.

This situation changed dramatically in the late 1990s, during which the number of young Injecting Drug Users (IDUs) rapidly increased especially in large cities. In 1997, there was no HIV case found among participants of rehabilitation program at the Drug Dependence Hospital (Rumah Sakit Ketergantungan Obat/ RSKO) in Jakarta. However, within four years, it was found that one in two IDUs in Jakarta was infected with HIV.5 Within the next five years, IDUs became the major hub of HIV and AIDS spread in Indonesia. Thus, the main factor driving the spread of HIV and AIDS epidemic was not the size of sex industry or the high prevalence of STIs, but the influx of IDUs into the epidemic network (Family Health International/ FHI, 2002).

Nonetheless, the close relationship between IDUs and the commercial sex industry need to be considered because these two factors might work synergically and result in the rapid expansion of HIV and AIDS epidemic in Indonesia. The 2002 Behavioural Survey Surveillance (BSS) among IDUs in three major cities in Java showed a high number of IDUs practicing unprotected sex with non-IDUs. Approximately 20%-75% of IDUs reported unprotected sex with sex workers. Nearly one in ten IDUs also reported that they provided sex for money. This "synergy" has in fact accelerated the increase of HIV and AIDS prevalence among commercial sex workers. The 2004 BSS in Surabaya showed that the prevalence of HIV and AIDS among commercial sex workers brothel complex had tripled to 3.8% between 2001 and 2004. Among street-based sex workers, the prevalence of HIV and AIDS increased from 4.4% to 12.2% within a period of two years. In Jakarta, the HIV prevalence rose from 1.1% in 2000 to 6.4% within three years. Without the influx of IDUs into the sex industry, the prevalence rate would have been increasing at a slower pace. Figure 1 shows that the the rate of HIV and AIDS prevalence among IDUs increases in parallel with the prevalence among sex workers. It is also apparent that the prevalence among sex workers increases as the IDUs population entered the sexual networks (i.e. IDUs as commercial sex consumers or workers). Previous studies (MoH, 2005; Riono and Jazan, 2004) identified factors that associated with the increase of HIV prevalence as follows: 1. Proportion of people who had been infected in a population; 2. Size of the population; 3. Level of high risk behaviour in a population (e.g., the use of condoms among sex workers, frequency of commercial sex transaction etc.); 4. Interaction between high risk populations (e.g., sexual contacts between IDUs and sex workers). 

Despite the high prevalence of HIV and AIDS among IDUs, in 2006 KPAN estimated that the growth rate of new infections among IDUs seemed relatively stagnant. Although the HIV and AIDS prevalence in FSWs, transgender, and FSW clients are lower than in IDUs, these groups have a larger size of population which results in higher number of cases. KPAN estimated that within the following decade, new transmissions will be predominated by heterosexual contacts as it accounted for nearly 70% of new infections (KPAN 2007). Given such trend in HIV and AIDS epidemic, studies on high risk sexual behaviour have become increasingly important in order to gain a comprehensive understanding of the epidemic situation. It is particularly important to ensure effective response and control the impact on other sectors. 

More attention was also addressed to interaction between transgender sex workers and their clients. The majority of clients of transgender sex workers identified themselves as heterosexuals. Many of them also had sex with female sex workers. With the high prevalence of HIV and AIDS in transgender sex workers – nearly 25% of transgender sex workers in most Indonesian municipalities are infected with HIV – their clients become the "bridge" of HIV transmission from transgender sex workers to FSWs and vice versa, and even to the general population (i.e. to their wives). In addition, the growing sex industries among men who have sex with men in several municipalities also need to be considered. Half of the male sex workers identified themselves as heterosexuals and also have sex with female sex partners (FHI, 2002). Sexual networks are closely interlinked and function as a highway for HIV to spread into the general population, as in Figure 2

Figure 2 – Sequence of HIV Transmission (Riono, 2004)

Riono, P. dan S. Jazant. 2004. “The Current Situation of the HIV AND AIDS Epidemic in Indonesia.” AIDS Education and Prevention 16 (Supplement A): 78–90. Trisnantoro, L. ed. 2009. Pelaksanaan Desentralisasi Kesehatan di Indonesia 2000–2007: Mengkaji Pengalaman dan Skenario Masa Depan. Yogyakarta: BPFE.

HIV and AIDS epidemic has been developing in Papua in a slightly different way. The number of IDUs in Papua is relatively lower than in other major municipalities in Indonesia. The main factor of the rapid spread of HIV and AIDS in Papua is sexual contacts especially heterosexual contacts. An anthropological study on Papuans sexuality described that the characteristics of sexual networks in Papua are very different compared to those in other areas. Premarital and intergenerational sex practices are very common (Butt et. al., 2002), which result in different patterns of HIV and AIDS transmissions and become the main pathway of HIV and AIDS spread into the general population. The 2006 IBBS showed that the epidemic in Papua has reached the general population and developed into generalized epidemic), in which at least 2.4% of the adult population (15-49 years) are infected with HIV and AIDS. Patterns of HIV transmission in Indonesia is mainly concentrated in the at risk populations such as injecting drug users, sex workers and men who have sex with men. However, since the populations are not isolated and they have social interaction with the broader population, the threat of transmitting the virus to the broader population is likely to happen. The course of HIV and AIDS epidemic in Indonesia and its link to changes within the society reflect an epidemic situation which is concentrated on certain groups (e.g. IDUs and sex workers) and yet to find structural expanding transmission network condition to threaten the broader populations.

A structural interaction between at risk population and broader population has thus evolved, resulting in an emergent pattern of HIV transmission which different from the previous pattern. For example, the majority of infected IDUs are sexually active groups. They become powerful bridge to spread the virus to other groups, i.e. their sexual partners such as sex workers or housewives through risky sexual behaviour. In addition to individual characteristics, there are also other factors influencing the extent of HIV and AIDS transmission, such as supports of health services providers, poverty, and mobilization of people.