BOOK: HIV-AIDS Policy and Health System in Indonesia: A Document Review

BOOK: HIV-AIDS Policy and Health System in Indonesia: A Document Review

CHPM. 2016. HIV-AIDS Policy and Health System in Indonesia: A Document Review. Yogyakarta: CHPM UGM

Important Summary:

·      HIV and AIDS Policy Stakeholders in Indonesia: It consists of international development partners, Ministry of Health-Indonesia, The National Aids commission, provincial and municipal AIDS commission, civil society organisation (Non-Governmental Organisation [NGO] and key population communities) and private sectors.

·      The adherence of ARV may contribute to reduction of mortality rate due to AIDs related diseases. The MOH data shows that case fatality rate (CFR) due to AIDs related diseases decrease from 13.51 % in 2005 to 0.35 % in 2013 (MOH, 2013)

·      Two major sources of the funding for ARV procurement are 70 % of total budgets from the State Budget (APBN) at and 30 % from GFATM. ARV request is based on request basis of each region in Indonesia in order to monitor the use and the availability of this specified ARV drugs that should be taken in a timely manner and for a lifetime. However, due to the long chain of the distribution that results in delays and out-of-stock of supplies, in 2011, ARV distribution was delegated to the provincial and district level. (pp 74)

·      Ideally, within decentralisation should create a space for local government to design effective HIV and AIDs strategies based on local approach; however, due to majority of funding is from APBN and international fundings, MOH implement centralised HIV program and there is limitation of community participation for giving suggestion to centralised MOH for better improvement of HIV programs.

·      I observed how HIV managers in provincial level and district level will gather in Jakarta for training, meetings, and evaluation for current update HIV programs in Jakarta, and each representative has obligation to transfer their current update knowledge and program into their lower level public health office till puskesmas.

·      Target based oriented, normative approach to achieve target

·      Achievement of a program based on donor-based approaches, like creating local government regulation (Peraturan Daerah/Perda) on HIV and AIDS; realisation of HIV subjects on Public Health Department; establishment of the Local AIDs Commissions (Komisi Penanggulangan Daerah/KPAD)

·      The drawback of how local government’s response to HIV/AIDs are too much focus on passing local policies to regulate HIV programs and set up local AIDS Commission (KPAD), VCT centres, and other HIV programmes, nevertheless in some point, policy makers in national, provincial, and district level may only focus on normative achievements, regular meetings, regular reports, but neglect to the capacity and quality in HIV program implementation.

·       NGO may depend on international funding or based on membership's payment, however the report of NGO's activities are directly reported to international donors and may lead not to transparency for other Indonesia's agency.

HIV and AIDS Policy Stakeholders in Indonesia

It consists of international development partners, Ministry of Health-Indonesia, The National Aids commission, provincial and municipal AIDS commission, civil society organisation (Non-Governmental Organisation [NGO] and key population communities) and private sectors.

Evolution of HIV and AIDS response policies in Indonesia

Table 6. Actively Reporting HIV and AIDS Service Facilities, 2011-2013

Type of service	Total; by Year
	2011	2012	Up to September 2013
VCT	500	503	889
CST ·      Referral hospital ·      Satellites ·      Total	235 68 303	239 89 338	266 114 380
STIs	643		370
PMTCT	90		113
TB-HIV	223		223

Pp 73

(Find the update one, Ministry of Health of Republic of Indonesia, 2013)

**The adherence of ARV may contribute to reduction of mortality rate due to AIDs related diseases. The MOH data shows that case fatality rate (CFR) due to AIDs related diseases decrease from 13.51 % in 2005 to 0.35 % in 2013 (MOH, 2013)

The number of PLWHA receiving ARV treatment until September 2013 was 36,483 people. A total of 35,178 persons (96.2 %) received the first line of ARV for adults and 3.19 % (1.163 people) received the 2nd line, while 1.27 % was unknown.

The case fatality rate of reported AIDS by year, 2000-September 2013 are fluctuated, the trend of CFR was declining since 2000 to September 2005 to 2013 from 13.51 % to 0.35 %. (pp 74)

Two major sources of the funding for ARV procurement are 70 % of total budgets from the State Budget (APBN) at and 30 % from GFATM. ARV request is based on request basis of each region in Indonesia in order to monitor the use and the availability of this specified ARV drugs that should be taken in a timely manner and for a lifetime. However, due to the long chain of the distribution that results in delays and out-of-stock of supplies, in 2011, ARV distribution was delegated to the provincial and district level. (pp 74)

Since 2005, the procurement of ARVs has been under the oversight of the Directorate General of Pharmacy. Funding for ARV procurement comes from two major sources i.e. the Global Fund and the State Budget (Anggaran Pendapatan dan Belanja Negara/ APBN). In 2010, 70% of funds for came from the State Budget and 30% from GFATM. The annual budget planning was integrated with the annual budgeting process of the Ministry of Health. ARV is distributed directly to health facilities on a request basis. This centralisation of ARV distribution is implemented to facilitate the monitoring of use and availability of drugs at facility level. Given the disease characteristics which require the consumption of specific ARV drugs, ARV should be taken in a timely manner and for a lifetime. However, centralised distribution was often a problem due to the long chain of distribution resulting in delays and out-of-stock of supplies. In 2011, the distribution was delegated to the districts in order to facilitate and simplify the distribution system. In addition, local stakeholders, such as Local KPADs, Provincial/District Health Offices, civil society organisations and PLWHA can monitor the procurement and distribution.  (p 74-75)

Policy on human resources, access and logistic management

At present, there is a wide variation in the types and number of human resources working in HIV and AIDS response. Human resources in HIV and AIDS program may include field level personnel (peer educators, outreach workers, supervisor of field programs, field level program manager), service level personnel (staff counselors, specialists, physicians, laboratory workers, nurses, administrators, nutritionists, midwives, case managers) and personnel at the coordination/ KPA level in districts and municipalities (program managers,

 monitoring and evaluation/surveillance officers, finance administration managers, secretaries/managers).

Nearly all health workers receive compensations (i.e. fees or salaries) from the foreign aid. Only health personnel assigned by the government and some coordinators in some municipalities/districts are funded by the state. While the field level officers are paid using foreign aid, the government also provided provided full support for health workers as stipulated in government regulations. For example, midwives may be hired on a contract basis with an incentive to attract them to work at the village level. ( pp 77)

Logistics

Centralized procurement is also applied to condoms and syringes. To anticipate fraud, which is difficult to control from the central level, it was decided that the procurement of condoms and syringes for supporting GFATM and AusAID programs should be done centrally through the KPAN. Supplies are then distributed directly to KPADs and their NGO partners in program implementations. (p. 79)

Table 7 Shows the pharmacy services at health facilities which provided ARV increases from 180 referral hospitals to 249 referral hospital in 2012 and 284 hospitasl in 2013 with majority of patients are adults and about 4-5 % are children (24, 410 patients in 2011, 31,002 patients in 2012 and 37,871 patients in 2013).

Human Rights

Human rights based policies in HIV and AIDS often encountered challenges because of conflicting values and norms in the society. There are many contradictions between central and local regulations. For example, there is still lack of clarity and contradictions between regulations in condom distribution, prostitution especially those in disguise (entertainment spots such as cafes, bars, discotheques, and night clubs), and extramarital sex. As a consequence, it is difficult to determine the effectiveness of policy and law enforcement within the context of local regulations on HIV and AIDS response.

For example, the Medan Municipality Government Regulation Article 15 (2) letter c stated that only husband-wife couples are allowed to use condom. Such a regulation may prevent access of non-married couples to condoms. Barriers to accessing condoms may result in unsafe sex and increased and STI occurrence (pp 83)

Policy on Multi-sectoral Governance

From 1987 to 2013, there have been 10 international level policies, 66 national level policies, and 55 local regulations (17 Provincial Regulations and 38 District/Municipality Regulations) concerning HIV and AIDS. It can be generally concluded that the policy-making process has been strengthened and improved in responding to social and political circumstances. In particular, the transition in the centralized decision making during the New Order Era (1987-1998) to the decentralised Autonomy Era (2001 to 2013) was quite evident. However, the majority of policies issued during the last two decades focused on the technical aspect of treatment. There has been a gap in the policy which aim to mainstream the HIV and AIDS issues across sectors. The negative impacts of the decentralized governance on HIV and AIDS response have not been adequately assessed and addressed.

HIV and AIDS Policy Stakeholders in Indonesia are included the Internasional Development Partners, KPAN, Ministry of Health, Civil Society Organisations, Key Population Groups and Private Sector. They may have similar or different roles in involving the processes of planning, preparation, and implementation of policies and programs on HIV and AIDS response in Indonesia. Pp 89

A. The international development partners foccus on funding supports, capacity building and tehnical assistance, pp 89. From 1996 to now, there are some different international partners: 1. World Bank (1996-1999) with work area in Jakarta and Riau with focusing on institutional development and piloting sexually transmitted diseases interventions

2. IHCP (AusAID) with work area in Jakarta, Bali, Makassar, Papua & West Papua that supporting within interventions

3. a) HCPI/AusAID (2008-2015) with work area of Jakarta, Banten, West Java, Central Jawa, East Jawa, Bali, Papua & West Papua with promoting national policy, involvement of government units (puskesmas), budget increase by local government for Harm Reduction, expansion of scale and scope of Harm Reduction (including MMT)

3. b) HAPP, ASA, SUM/USAID in Jakarta, West Java, Central Jawa, East Java, Bali, North Sulawesi, Papua, West Papua focusing on community-based approach and creating condusive environment for STD and HIV and AIDS services (policy, tehnical guidelines, professional development, applied research and surveillance)

3.c) Partnerships Fund, focusing on institutional development of AIDS commissions  at national and local levels (personnel, office operations)

4. GFATM  (2009-2014) (round 8: 12 provinces) & GFATM  (2010-2015) (round 9: 21 provinces), GF New Funding Model (2018-2020): ensuring the interventions to take place in 141 prioritized municipalities/districts, provision of ARV.

Indonesia's partnership with the Global Fund has already contributed to significant impact on HIV, TB and malaria. More than 50 percent of the districts in Indonesia have eliminated malaria. More than 90,000 people are on treatment for HIV and more than 2 million cases of TB have been detected and treated.( https://www.theglobalfund.org/en/news/2018-02-13-indonesia-and-global-fund-unveil-new-grants/)

B. Ministry of Health

Moh of Republic of Indonesia was assigned to assist the President in administering government’s affairs in the heatlh sector. In carrying out these tasks, the Ministry of Health held several functions as following. (pp 92)

1.     Formulation of national policy, implementing policy, and technical policy in health sector

2.     Implementation of government affair in MOH’s respective sectors;

3.     The management of government’s assests under the MOH responsibility

4.     Control over the execution of MOH duties;

5.     Submission of report on evaluation results, suggestion, and consideration in MOH’s duties and functions to the president

As a policy-makers at national level, the MoH has issued a policy on HIV and AIDS prevention, care, support and treatment, as well as community participation. for example, the Decree of Minister of Health No. 1285/Menkes/SK/X/2002 on Manual of Response to HIV and AIDS and STIs, which was updated by Decree No. 21/2013 on HIV and AIDS. The Decree of Minister of Health No. 021/Menkes/SK/1/2011 contained the Ministry of Health’s Strategic Plan for 2010-2013, whic outlined the direction of the policy and strategy of the MoH including HIV and AIds response.

C. The National AIDS Commission

The Presidential Decree No. 36/1994 on AIDS Commission mandated the Establishment of KPAN, which is KPANa cross-sectorial commission responsible to ensure a comprehensive, integrated, and coordinated HIV and AIDS prevention and response in Indonesia. The aims of KPAN are as follows:

a. To conduct activities on AIDS prevention and response under the provisions of the applicable laws and regulations and/or global strategy of HIV and AIDS prevention and response launched by the United Nations;

b. To increase public awareness of the danger of AIDS and improve the cross-sector, comprehensive, integrated, and coordinated AIDS prevention and/or response.

D. Provincial AIDS Commission and District/Municipality AIDS Commission

The Provincial KPA is chaired by the Governor. This entity has the tasks of formulating policies, strategies, and measures that are needed for HIV and AIDS response in the province according to the policy, strategy and manual stipulated by the KPAN. P.98

District/Municipality KPA is chaired by the Regent/Mayor. District/Municipality KPA is assigned to formulate policies, strategies, and measures necessary for HIV and AIDS 100 response in the district/municipality according to the policy, strategy and manual stipulated by the KPAN. District/Municipality KPA is to report regularly to the Chairman of the KPAN. The provisions concerning working procedures of District/Municipality KPA are regulated by the Regent/Mayor based on the working procedures established by the Chairman of the KPAN. P. 99

D. Civil Society Organisation (CSO)

NGO

NGOs play an important role in HIV and AIDS response in Indonesia. They initiated the outreach work to marginalized and unknown groups. NGOs also help key populations to be able to access services, establish peer support groups, and conduct policy advocacy. (p 101)

Key population communities

In addition to the national NGOs that have long established such as PKBI, Spiritia and YPI, there are currently six networks of communities affected by HIV, including Jangkar, IPPI, GWL-INA, PKNI, JOTHI and OPSI. These networks represent hundreds of community-based activists throughout Indonesia. The Indonesia UNGASS AIDS Forum consists of JOTHI, IPPI, PKI, GWL-INA, OPSI, MAP, JSG, IKON, Our Voice, LP3Y, PITA, KPI, Gerbang, Pantura Plus, Rempah, Bina Hati, Stigma, and Solidaritas Perempuan. (p.103)

While other community organisations in general typically rely on membership fees to fund their activities, GWL-INA, OPSI and JOTHI depend more on international partners as their funding sources. International funding is usually disbursed directly to the organisations or through the KPAN. However, these organisations also have their own challenges. For example, JOTHI and OPSI are still dealing with the organisation's internal management issues, while GWL-INA is overwhelmed by the involvement from international partners.39 (p. 103)

Some Challenges:

There have been many important advances in CSO activities, however, more attention should be addressed on the following issues:

1. Most CSOs depend on donors or projects for funding and design of programs. Financial contribution from governments and communities is lacking. This situation puts them in a vulnerable position, particularly when the main source of funding is terminated or withdrawn. 2. The majority of these CSOs perform specific activities focusing on HIV and AIDS. Only a few CSOs deal with broader and cross-cutting issues such as gender, poverty, access to justice and human rights. Therefore, they are often isolated from the country’s economic, social, cultural, and political development.

3. Field studies also showed that the most CSOs reported only to donors. There is a lack of transparency and accountability to their community constituents.

There are at least three service providers for human resources in HIV and AIDS response, namely the government, CSO/CBOs and the private sector. The existing human resources policies related to HIV and AIDS response have not clearly regulated human resources issues in CSO/CBO and private sector. The 2010-2014 National Strategic Action Plan for HIV and AIDS has determined the following personnel needed for managing CSO/ CBO: field level personnel, peer educators, outreach workers, field program supervisor, and field level program managers. Meanwhile, the availability of human resources at the private sector is very limited. (pp 78)

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.

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

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.

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. 

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.

UU No. 32 tahun 2004

http://www.dpr.go.id/dokjdih/document/uu/33.pdf

**

7. Desentralisasi adalah penyerahan wewenang pemerintah oleh Pemerintah kepada daerah otonom untuk mengatur dan mengurus urusan pemerintahan dalam sistem Negara Kesatuan Republik Indonesia

President of Indonesia; October 2004

** Ideally, within decentralisation should create a space for local government to design effective HIV and AIDs strategies based on local approach; however, due to majority of funding is from APBN and international fundings, MOH implement centralised HIV program and there is limitation of community participation for giving suggestion to centralised MOH for better improvement of HIV programs.

**I observed how HIV managers in provincial level and district level will gather in Jakarta for training, meetings, and evaluation for current update HIV programs in Jakarta, and each representative has obligation to transfer their current update knowledge and program into their lower level public health office till puskesmas.

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. 

**Target based oriented, normative approach to achieve target

**Achievement of a program based on donor-based approaches, like creating local government regulation (Peraturan Daerah/Perda) on HIV and AIDS; realisation of HIV subjects on Public Health Department; establishment of the Local AIDs Commissions (Komisi Penanggulangan Daerah/KPAD)

** The drawback of how local government’s response to HIV/AIDs are too much focus on passing local policies to regulate HIV programs and set up local AIDS Commission (KPAD), VCT centres, and other HIV programmes, nevertheless in some point, policy makers in national, provincial, and district level may only focus on normative achievements, regular meetings, regular reports, but neglect to the capacity and quality in HIV program implementation.

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. 

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.