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ROUND 10

R10_CCM_IND_THSS_PF_s1-2_2Sep10_En.doc 1/17

Deadline for submission: 20 August 2010, 12 Noon CET

Applicant Name CCM Indonesia

Country Republic of Indonesia

Income Level Refer to Annex 1 in the Roxund 10 Guidelines Lower-middle income

Applicant Type X CCM Sub-CCM

Non-CCM

If your country is also part of a Round 10 multi-country proposal, indicate for which disease(s)

HIV

X Tuberculosis Malaria

Currency X USD Euro

Disease Title

Does the proposal include cross-cutting

health systems strengthening interventions?

Indicate yes or no and Include sections 4B and 5B

in one proposal only

Is this being submitted as a consolidated

disease proposal?

Indicate yes or no

HIV

Choose either Regular or MARPs reserve

Regular

___

Cannot submit request for cross-cutting health

systems strengthening with a MARPs reserve proposal

MARPs Reserve

Tuberculosis Accelerating progress toward universal access to quality DOTS

YES

YES

PROPOSAL FORM – ROUND 10 SINGLE COUNTRY APPLICANT SECTIONS 1-2

ROUND 10


MANDATORY SECTIONS OF THE PROPOSAL FORM:

A) Complete sections 1-2 only once per applicant1

Section 1 Funding Summary and Contact Details Section 2 Applicant Summary and Eligibility

Membership Details (CCM or Sub-CCM) Eligibility Form (if applicable)

B) Complete sections 3-5 once for each disease proposal2 Section 3 Proposal Summary Section 4 Program Description

Performance Framework or Consolidated Performance Framework Pharmaceutical and Health Products List (if applicable) Work Plan

Section 5 Funding Request

Detailed Budget OPTIONAL SECTIONS OF THE PROPOSAL FORM: If relevant, complete sections 4B and 5B only once per applicant and include with only one disease proposal Section 4B Cross-cutting health systems strengthening interventions

Section 5B Cross-cutting health systems strengthening funding

1 The applicant only needs to submit a single section 1-2 as part of the application, even when applying for multiple diseases. 2 The applicant needs to submit a section 3-5 for each disease proposal submitted.

INDEX OF ALL PROPOSAL SECTIONS

IMPORTANT NOTE:

We strongly recommend applicants use the information below as an essential reference while

completing the Proposal Form and other application documents. It is very important to carefully read each section in the Round 10 Guidelines at the same time as filling out the proposal and other application documents in order to submit a complete application. All other Round 10

documentation is available on the Global Fund’s website.

ROUND 10


SECTION 1: FUNDING SUMMARY AND CONTACT DETAILS

1.1 Funding summary

Disease Round 10 Funding Request

Year 1 Year 2 Year 3 Year 4 Year 5 Total

Tuberculosis $15,143,949 $20,176,564 $29,714,493 $28,208,334 $26,409,376

$ 119,652,716

Cross-cutting HSS interventions

Insert disease name

$ 4,015,863 $ 8,390,895 $ 10,386,726 $ 9,792,728 $ 5,305,752 $ 37,891,964

Total Round 10 Funding Request $157,544,680

1.2 Contact details

Primary contact Secondary contact

Name Dr Tine Tombokan MHA Ms Nancy Fee

Title Executive Secretary of CCM Indonesia

UNAIDS Country Coordinator Indonesia

Organization CCM Indonesia UNAIDS Secretariat Indonesia

Mailing address

Ministry of Health,Blok A,9th

floor Jakan H.R.Rasuna Said Blok X-5, kav 4-9,Kuningan,Jakarta Selatan,12950

Menara Thamrin 10th Floor

Jl. M.H. Thamrin Kav 3

Jakarta 10250, Indonesia

Telephone

+62 21 5290 6560

+62 21 5292 2021

+62 21 5296 4286

+62-21-3141308 ext: 116

Mobile: 0815-9202915

Fax +62 21 5292 2023 +62-21-3907569

E-mail addresses

[email protected]

[email protected]

[email protected]

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1.3 List of Abbreviations and Acronyms used by the Applicant

Acronym/ Abbreviation

Definition by Disease Component TB

ACSM Advocacy, communication and social mobilization

AIDS Acquired Immuno Defficiency Syndrome

APBN Anggaran Pendapatan Belanja Negara (national revenue and expenditure budget)

ARV Anti Retro Viral

Askes Asuransi Kesehatan (Health insurance company)

BPOM Badan Pengawasan Obat dan Makanan (Food and Drug Administration)

CBO Community Based Organization

CCM Country Coordinating Mechanism

CDES Center for Data, Epidemiology and Surveillance

CDR Case Detection Rate

CIDA Canadian International Development Agency

CNR Case Notification Rate

CPT Cotrimoxazole Preventive Therapy

CSS Community System Strengthening

DHO District Health Office

DIPA Daftar Isian Pelaksanaan Anggaran (national budget for government institution)

DOT Directly Observed Treatment

DOTS Directly Observe Treatment Shortcourse

DST Drug Sensitivity Test

DRS Drug Resistant Surveillance

EQA European Quality Assurance

FBO Faith Based Organization

FDC Fixed Dose Combination

FHI Family Health International

FLD First Line Drugs

GDF Global Drug Facility

Gerdunas Gerakan Terpadu Nasional (National integrated movement for TB)

GIS Geographic Information System

GLC Green Light Committee

HDL Hospital DOTS Linkage

HIV Human Immunodeficiency Virus

HSS Health System Strengthening

IMA Indonesian Medical Association

ROUND 10


INH Isoniazid

ISTC International Standard of Tuberculosis Care

IWAPI Ikatan Wanita Pengusaha Indonesia (Indonesian women entrepreneur association)

Jamkesmas Jaminan Kesehatan Masyarakat (National community health insurance scheme)

Jamkesda Jaminan Kesehatan Daerah (Local community health insurance scheme)

Jamsostek Jaminan Sosial Tenaga Kerja (Social insurance scheme for employees)

JEMM Joint External Monitoring Mission

KAP Knowledge, attitude and practice

KNCV Koninklijke Nederlandse Centrale Vereniging tot Bestrijding der Tuberculose (Royal Netherlands Tuberculosis Association)

KOWANI Kongres Wanita Indonesia (Indonesian women cooperative)

LQAS Lot Quality Assurance Sampling

MCH Maternal Child Health

MDG Millennium Development Goals

MDR-TB Multi Drug Resistant Tuberculosis

MICT Management Internal Control Team

MoH Ministry of Health

MSH Management Science for Health

NGO Non-Government Organization

NTP National TB Program

OR Operational Research

PEPFAR President’s Emergency Plan for AIDS Relief

PAMALI Persatuan Masyarakat Peduli (TB patient NGO)

PHO Provincial Health Office

PITC Provider Initiated Testing and Counseling

PKK Pemberdayaan Kesejahteraan Keluarga (Family Welfare movement)

PLW-HIV People Living With Human Immunodeficiency Virus

PMDT Programmatic Management Drug Resistant Tuberculosis

PPs Private Practicioners

Pramuka Praja Muda Karana (Indonesian Boys scout Organization)

PPM Public Private Mix

QA Quality Assurance

RDU Rational Drug Use

SDA Service Delivery Area

SEAR South East Asia Region

SIKNAS Sistem Informasi Kesehatan Nasional (National health information system)

SIKDA Sistem Informasi Kesehatan Daerah (District health information system)

SLD Second Line Drugs

ROUND 10


SPM Standar Pelayanan Minimal (minimum standard of service)

TB Tuberculosis

TBCAP Tuberculosis Control Assistance Program

TBCTA Tuberculosis Coalition for Technical Assistance

TORG Tuberculosis Operational Research Group

ToT Training of Trainers

UNDOC United Nations Office on Drugs and Crime

UNDP United Nation Development Programme

USAID United States Agency for International Development

VCT Voluntary Counseling and Testing

WHO World Health Organization

XDR-TB Extensively Drug Resistant Tuberculosis

1.3 List of Abbreviations and Acronyms used by the Applicant of HSS proposal

Acronym/ Abbreviation

Definition by Health System Strengthening (HSS) as cross cutting intervention

ACSM Advocacy, communication and social mobilization

AIDS Acquired Immuno Defficiency Syndrome

APBN Anggaran Pendapatan Belanja Negara (national revenue and expenditure budget)

ARV Anti Retro Viral

Askes Asuransi Kesehatan (Health insurance company)

BPOM Badan Pengawasan Obat dan Makanan (National Authority of Food and Drug Control)

BINFAR & ALKES Bina Farmasi & Alat Kesehatan (Directorate of General Pharmacy and Medical Devices)

CBO Community Based Organization

CCM Country Coordinating Mechanism

CDES Center for Data, Epidemiology and Surveillance

CDR Case Detection Rate

CIDA Canadian International Development Agency

CNR Case Notification Rate

CoEs Center of Excellence

CPT Cotrimoxazole Preventive Therapy

ROUND 10


CSO Civil Service Organization

CSS Community System Strengthening

DHO District Health Office

DIPA Daftar Isian Pelaksanaan Anggaran (national budget for government institution)

DOT Directly Observed Treatment

DOTS Directly Observe Treatment Shortcourse

DST Drug Sensitivity Test

DRS Drug Resistant Surveillance

EQA European Quality Assurance

FBO Faith Based Organization

FDC Fixed Dose Combination

FHI Family Health International

FLD First Line Drugs

GDF Global Drug Facility

Gerdunas Gerakan Terpadu Nasional (National integrated movement for TB)

GFATM the Global Fund for AIDS TB and Malaria

GIS Geographic Information System

GOI Government Of Indonesia

GLC Green Light Committee

GTZ Gesellschaft fuer Technische Zusammenarbeit

HDL Hospital DOTS Linkage

HIO Health Information Officer

HIS Health Information System

HIV Human Immunodeficiency Virus

HMN Health Metrics Network

HSS Health System Strengthening

ICD-10 International Statistical Classification of Diseases and Related Health Problems (the 10th revision)

ICT Information and Communication Technology

IMA Indonesian Medical Association

IMR Infant Mortality Rate

IMRSSP Indonesian Mortality Registration System Strengthening Project

INH Isoniazid

ISTC International Standard of Tuberculosis Care

IT Information Technology

IWAPI Ikatan Wanita Pengusaha Indonesia (Indonesian women entrepreneur association)

Jamkesmas Jaminan Kesehatan Masyarakat (National community health insurance scheme)

Jamkesda Jaminan Kesehatan Daerah (Local community health insurance scheme)

ROUND 10


Jamsostek Jaminan Sosial Tenaga Kerja (Social insurance scheme for employees)

JEMM Joint External Monitoring Mission

JICA Japan International Cooperation Agency

KAP Knowledge, attitude and practice

KNCV Koninklijke Nederlandse Centrale Vereniging tot Bestrijding der Tuberculose (Royal Netherlands Tuberculosis Association)

KOWANI Kongres Wanita Indonesia (Indonesian women cooperative)

LQAS Lot Quality Assurance Sampling

MCH Maternal Child Health

MDG Millennium Development Goals

MDR-TB Multi Drug Resistant Tuberculosis

MICT Management Internal Control Team

MMR Maternal Mortality Rate

MoH Ministry of Health

MPVT Medical Products, Vaccines and Technologies

MSH Management Science for Health

NGO Non-Government Organization

NIHRD National Institute of Health Research and Development

NTB Nusa Tenggara Barat (West Nusa Tenggara)

NTP National TB Program

NU Nahdatul Ulama (Islamic FBO)

OR Operational Research

OTC Over The Counter

PEPFAR President’s Emergency Plan for AIDS Relief

PAMALI Persatuan Masyarakat Peduli (TB patient NGO)

PHC Primary Health Care

PHP Pharmaceutical and Health Products

PHO Provincial Health Office

PITC Provider Initiated Testing and Counseling

PKK Pemberdayaan Kesejahteraan Keluarga (Family Welfare movement)

PLW-HIV People Living With Human Immunodeficiency Virus

PMDT Programmatic Management Drug Resistant Tuberculosis

PPs Private Practicioners

Pramuka Praja Muda Karana (Indonesian Boys scout Organization)

PPM Public Private Mix

PUSDASURE Pusat Data dan Surveilans Epidemiology (Center for Data and Epidemiological Surveillance)

PUSKESMAS Pusat Kesehatan Masyarakat (Public Health Center)

QA Quality Assurance

ROUND 10


RDU Rational Drug Use

SDA Service Delivery Area

SEAR South East Asia Region

SHI Social Health Insurance

SIKNAS Sistem Informasi Kesehatan Nasional (National health information system)

SIKDA Sistem Informasi Kesehatan Daerah (District health information system)

SLD Second Line Drugs

SPM Standar Pelayanan Minimal (minimum standard of service)

SRS Sample Registration System

TB Tuberculosis

TBCAP Tuberculosis Control Assistance Program

TBCTA Tuberculosis Coalition for Technical Assistance

TORG Tuberculosis Operational Research Group

ToT Training of Trainers

UNDOC United Nations Office on Drugs and Crime

UNDP United Nation Development Programme

USAID United States Agency for International Development

VCT Voluntary Counseling and Testing

VPN Virtual Private Network

WHO World Health Organization

XDR-TB Extensively Drug Resistant Tuberculosis

ROUND 10


SECTION 2: APPLICANT SUMMARY AND ELIGIBILITY

2.1 Members and operations

2.1.1 Membership summary tick the relevant box

Sector Representation Number of members

x Academic/educational sector

x Government 10 (ten)

x Non-government organizations (NGOs)/community-based organizations

6 (six)

x People living with the diseases 1(one)

People representing key populations3

x Private sector 1(one)

x Faith-based organizations 2 (two)

x Multilateral and bilateral development partners in country 5 (five)

Other specify

Total Number of Members: Must equal the number of members in the Membership Details form4

25 members

3 See the definition of key populations found in the Round 10 Guidelines.

CCM applicants

Complete sections 2.1 & 2.2 Delete sections 2.3 & 2.4

Sub-CCM applicants

Complete sections 2.1, 2.2 & 2.3 Delete section 2.4

Non-CCM applicants

Complete section 2.4 Delete section 2.1, 2.2 & 2.3

ROUND 10


2.1.2 Broad and inclusive membership

Since your last eligible application to the Global Fund:

(a) Have there been any changes in members since the last time the CCM (or Sub-CCM) was determined eligible?

No

go to section 2.1.2 (c)

Yes

go to section 2.1.2 (b)

(b) If ‘Yes’ in part (a), please describe in the space below how those new members were selected.

Answer for 2.1.2.(a) is YES and the Answer for 2.1.2.(d) is YES

CCM Indonesia Period 2007 -2009 ends at December 2009.and each constituency GOVERNMENT ---CIVIL SOCIETY and DEVELOPMENT PARTNERS were requested to select their members in each constituency for the new period of CCM Indonesia January 2010 –December 2011.

The Government Constituency was coordinated by Dr Arum Atmawikarta MPH, the Civil Society constituency was coordinated by Prof Dr Sudijanto Kamso Kamso SKM and the Development Partners was coordinated by Nancy Fee.

The total members are 25 members, from Government 10, Civil Society 10 and Development Partners 5

Some members are new selected and some are reselected from formerly period by their own constituency

(c) Is there continuing active membership of people living with and/or affected by the diseases?

No

Yesx

(d) Is there continuing active membership of both males and females and/or any improvement toward gender balance among members?

No

Yesx

ROUND 10


Clarified Section 2.1.2

2.1.3 Member knowledge and experience in cross-cutting issues

(a) Health Systems Strengthening: Describe the capacity and experience of the CCM (or Sub-CCM) on health systems strengthening issues

Health System is recognized among CCM members as an issue which need to be strengthening and CCM members are aware of the WHO six pillars or building blocks for HSS. CCM members agree to adopted HSS as a cross cutting issue in the Indonesia Round 10 TB proposal.

CCM Indonesia has formerly experienced in submitting HSS proposal as only for one building block, which is Health Information System(HIS) but unfortunately the proposal was too broad and was not endorsed by CCM members.

Follow up in Indonesia Round 9 Proposal with Technical Assistance from WHO put as the cross cutting issue in AIDS Proposal the HSS the Blood Safety but only the disease proposal HIV-AIDS was approved for Round 9 while the Blood Safety was not approved by the TRP of The Global Fund.

Ministry of Health Indonesia, Data and Surveillance Center proposed to CCM to have a Health Information System and Pharmaceutical Supply and Chain Management as cross cutting issue of HSS in the TB Round 10 disease proposal and CCM has approved to be submitted to The Global Fund in Indonesia Round 10 TB & HSS proposal.

(b) Gender: Describe the capacity and experience of the CCM (or Sub-CCM) in gender and also issues concerning sexual orientation and gender identities.

Expertise and skills in methodologies to assess gender differentials in disease burdens and their consequences (including differences between men and women, boys and girls), and in access to and the utilization of prevention, treatment, care and support programs; and

Comprehensive knowledge of the factors that make women and girls and sexual minorities vulnerable such as harmful gender norms, behavior, attitudes and practices that underlie the differentials in the spread of HIV (e.g. gender based violence, discrimination and stigma, sexual female mutilation, early marriage, masculinity, etc).

The Vice-Chair of CCM attended the GF-WHO meeting in Phattaya (June 30-July 1, 2010) in which gender mainstreaming was discussed extensively. The Vice-Chair also attended the WHO SEARO Mock Review in New Delhi (July 26-30, 2010) in which gender mainstreaming was discussed substantially during plenary sessions and the mock review process. CCM is also aware of the GF concept notes on gender main streaming available on the website

(c) How many members of the CCM (or Sub-CCM) have considerable expertise in one or both of the areas described in section 2.1.3 (b)?

Nearly all CCM members have knowledge about Gender due the various discussion in CCM meetings and other events e.g. Workshop on Gender issue in country.

(d) Multi-sectoral planning: Describe the capacity and experience of the CCM (or Sub-CCM) in multi-sectoral program design.

CCM members consist of various stakeholders, Government, Civil Society Constituency and Development Partners who take part in the CCM Technical Working Group on disease ATM. CCM TWG developed the Proposal with inviting Non CCM members from Academic, Experts and other related parties to the disease such as NTP for TB (NAC for Aids and CDC Malaria for Malaria) and also Civil Society Organization for their inputs

ROUND 10


2.2 Eligibility

2.2.1 Application history

Recently applied for funding in Round 8, or Round 9, or RCC Waves 5-8 and was determined eligible

Complete sections 2.2.2 to 2.2.8

Last applied for funding before Round 8 or RCC Wave 5

Complete Eligibility Form


Do not complete sections 2.2.2 to 2.2.4

Determined ineligible at last application

Complete Eligibility Form


Do not complete sections 2.2.2 to 2.2.4

2.2.2 Proposal development process

(a) Describe the process used to invite submissions for possible integration into the proposal from a broad range of stakeholders including civil society and the private sector, at the national, sub-national and community levels, as well as from key populations, where applicable.

Explain the process for each disease proposal in the application

TB Round 10 Proposal Development The formal call for PRs and proposals for Round 10 TB component was circulated by the CCM on June 10, 2010. The chair of the TB Technical Working Group chaired the Proposal Development Team (List of proposal development team members attached). The proposal development process was preceded by development of the National Strategy for Tb control 2010-2014. The first internal meetings of the writing team of the national strategy for TB control were conducted between March 22-27, 2010 (Participant list and MoM attached). These meetings produced the outline of the national strategy. The outline was then used to guide a consensus workshop on key challenges for TB control in Indonesia which was held on April 14-15, 2010 (Participant list and MoM attached). The inventory of challenges identified from this workshop was used by the writing team to elaborate a first draft of the National Strategy which was developed during internal meeting between April 28-29, 2010 (Participant list and MoM attached). The first draft was then consulted with the Expert Committee and Technical Working Groups on May 7, 2010 (Participant list and MoM attached). The writing team revised the draft national strategy based on input from this consultative meeting. The revised draft national strategy, along with information received regarding GF R10 call for applications, were used by the R10 proposal development team to develop preliminary concept notes for the R10 TB proposal. These preliminary concept notes were disseminated through a meeting organized in June 22, 2010 attended by NTP focal points and partners (Participant list and MoM attached). This meeting was followed by another dissemination meeting in June 24, 2010 for stakeholders within MoH (Participant list and MoM attached). On June 25 a meeting was held to finalize the inputs from the stakeholders to be incorporated into the R10 TB proposal (Participant list and MoM attached). The proposal development team subsequently developed a preliminary draft incorporating the inputs from the meeting. The proposal development team participated in a proposal development workshop in June 30-July 1, 2010 organized by WHO in Thailand. The proposal development team organized in July 12, 2010 a national consultation with representatives from a broad range of stakeholders, including NGO, provincial health offices, donor agencies and relevant government

ROUND 10


ministries to review gaps and possible interventions. Gaps, goal, objectives, SDAs and performance framework were established upon review of inputs (Participant list and MoM attached). The proposal development team elaborated further the draft proposal based on the inputs. The revised proposal was presented in the CCM-TWG meeting on July 23, 2010 (MoM attached). The proposal development team further revised the draft proposal based on inputs received during the CCM-TWG meeting. The revised proposal was brought by the team to WHO SEARO New Delhi, for Mock Review (July 26-30, 2010). The proposal was extensively revised during the Mock Review. The revised proposal was presented during a CCM-TWG extraordinary plenary meeting organized on August 5, 2010.

HSS Round 10 Proposal Development

To develop HSS proposal, preliminary meetings were held with CCM and development partners in May 2010, followed by extensive consultation with stakeholders in July and August 2010. A three-day workshop was conducted in Bogor, Indonesia in July 2010 to accelerate proposal development – it involved key departments in the MoH, and was facilitated by national and international consultants. Gender equality was observed in the development of the proposal with almost equal participation from males and females; this will be sustained all through program implementation. A visit to Lombok Tengah district, NTB Province (underperforming district) was conducted where meetings were held between proposal development team and Puskemas, district hospital and DHO staff (including TB supervisor). Discussions held with key partners including GTZ, AUSAID, WB and USAID to ensure integration of development programs, minimize overlap and prepare the grounds for better monitoring of HSS activities.

Presentations on proposed HSS made via video conferencing to 16 regional health information managers to solicit input/feedback (meeting held in Medan, North Sumatra on 08 July) and 17 regional health information managers in Surabaya, East Java on 29 July 2010. Consultation with CSOs and private sectors (including those providing TB services) was held on 12 August 2010 to identify constraints to information sharing and solutions to address the problems. Discussion with TB proposal team was held to identify and prevent potential overlap activities and seek synergies between both component.

(b) Describe the process used to transparently review the submissions received for possible integration into the proposal.


All inputs and proposals for possible integration into this proposal were discussed at the CCM TB Technical Working Group meetings conducted on July 23, 2010 (MoM attached) and August 5, 2010. and CCM TB Technical Working Group members reviewed the development of the proposal

(c) Describe the process used to ensure the input of people and stakeholders other than CCM (or Sub-CCM) members in the proposal development process.


TB Proposal Development team invited all those who are interested to contribute in proposal development to participate at the meetings and to provide inputs.. Stakeholders representing all regions of Indonesia (Java, Bali, Sumatra, Kalimantan, Sulawesi, Nusa Tenggara, Maluku, Papua) participated during the meetings on April 14-15, 2010 and July 12, 2010 (see 2.2.2. a and see List of participants attached). International Partners ( WHO, USAID, KNCV); .CBOs (e.g. Aisyiyah, Muhammadiyah, NU, Perdhaki) and Universities (e.g. University of Indonesia, Gadjah Mada University), NGOs (e.g. PPTI, FHI), Patient organization (i.e. Pamali) participated in the various meetings organized between April 14-July 12, 2010 described in section 2.2.2. (a) (see list of participants attached). The proposal development team also invited inputs via email for all interested parties.

ROUND 10


(d) Attach a signed and dated version of the minutes of the meeting(s) at which the CCM (or Sub-CCM) members decided what to include in each disease proposal.

Annex number

( 2.2.2.d)

MoM 5 August 2010 CCM Plenary meeting and signed of attendance list

2.2.3 Process to oversee program implementation

(a) Describe the process used to ensure the input of stakeholders other than CCM (or Sub-CCM) members in the ongoing oversight of program implementation.

The Process used to ensure the input of stakeholders other than CCM members in the ongoing of program implementation is :

CCM Technical Working group in the review of Program updates and Disbursement Request (PUDR) by PR’s usually invites non CCM members, such as experts in the disease (ATM) from development partners, academic and professional association to get their inputs.(Gov Manual p.9 III.7 Composition)

CCM Oversight Committee in problem solving issues usually invites non CCM members, LFA and other related parties regarding the disease problems.(Gov.Manual p.12 III.7.3 Composition)

Annex Number (2.2.3.a) – Governance Manual p.9 III.7 and p.12.III.7.3

(b) Describe the process used by the CCM (or Sub-CCM) to oversee program implementation.

The Process used by the CCM to oversee Program Implementation is as follows :

CCM Technical Working Group on each disease review Principal Recipient’s reports as PUDR on regular base, before quarterly base but recently six month based.

Might there be found problems which can’t be solved by the CCM TWG than it will be referred to CCM Oversight Committee to find a solution and will reported in a CCM Plenary meeting.

CCM members conduct field monitoring together with inviting non CCM members, experts in ATM diseases to oversee the implementation of programs funded by GFATM

2.2.4 Process to select Principal Recipient(s)

(a) Describe the process used to make a transparent and documented selection of each of the Principal Recipient(s) nominated in this proposal.

Explain the process for each Principal Recipient for each disease

Call for Round 10 Proposal was followed by Call for Principal Recipient through

web which was upload on 30 July 2010 : www.tbindonesia.or.id

and www.depkes.go.id as well as printed media on 29 July 2010, Indonesian country wide newspaper KOMPAS as attached of 2.2.4.(a) Annex Number ( 2.2.4.a)

Two institution applied for PR Round 10 TB proposal and only one for PR HSS Round 10 which are :

ForTB PR from : Government, MoH CDC Sub Directorate of TB and Nahdatul Ulama (NU) a Faith Based Organization.

HSS PR only one application which is from MoH Center for Data and Surveillance (PUSDASURE)

ROUND 10


CCM Oversight establish a PR Selection Team consist of 6 members, which are 2 from Government,2 from CSO and 2 from Development Partners who has reviewed the written applications.

(b) Attach the signed and dated minutes of the meeting(s) at which the CCM (or Sub-CCM) members nominated the Principal Recipient(s) for each disease.

Annex number 2.2.4. MoM of CCM Plenary Meeting on 18 August 2010 and signed attendance list .

2.2.5 Non-implementation of dual track financing

Dual track financing means that at least one government sector and one non-government sector Principal Recipient have been nominated for each disease in this proposal. If relevant, provide an explanation below as to why dual track financing has not been applied for any of the disease proposals in this application.

As been explained in 2.2.4. Two institution applied for PR Round 10 TB proposal which are from : Government, MoH CDC - TB and Nahdatul Ulama (NU) a Faith Based Organization After the CCM Selection Team review the CDC TB from MoH got a high rating while the FBO –NU was low rated and in their presentation in CCM plenary on 5 August 2010 they were not quite ready and given a follow up presentation in CCM Plenary 18 August 2010 where many of CCM Members are not convinced of their capability as PR and recommended to be SR, which was one of the decision taken in CCM Plenary 18 August 2010.

2.2.6 Managing conflicts of interest

(a) Are the Chair and/or Vice-Chair of the CCM (or Sub-CCM) from the same entity as any of the nominated Principal Recipient(s) for any of the disease proposals in this application?

Yes

go to (b) and then section 2.2.8

No

go to section 2.2.8

(b) If yes, attach the plan for the management of actual and potential conflicts of interest.

insert annex number

2.2.7 Proposal endorsement by members

The Membership Details form has been completed with the signatures of all members of the CCM (or Sub-CCM)

Membership Details form, with signatures, is attached to the application - Annex C

ROUND 10


Section 2: Eligibility List annex name and

number

CCM and Sub-CCM applicants only

2.2.2(a) Process used to invite submissions for possible integration into each disease proposal

2.2.2(b) Process used to review submissions for possible integration into each disease proposal

2.2.2(c) Process used to ensure the input of a broad range of stakeholders in the proposal development process

2.2.3(a) Process to oversee grant implementation by the CCM (or Sub-CCM)

Gov.Man p.9.III.7

Gov.Man p.10 III.7.1

2.2.3(b) Processes used to ensure the input of a broad range of stakeholders in grant oversight process

Gov.Man.p.9.III.7.Composition

Gov.Man p.12 III.7.3

2.2.4(a) Process used to select and nominate the Principal Recipient(s) for each disease proposal

(1)-Call for PR in news paper Kompas

(2) Selection Team MoM

(3) CCM Plenary 18 August 2010

2.2.6 Conflict of Interest policy

2.2.7 Minutes of the meeting at which the proposal was finalized and endorsed by the CCM (or Sub-CCM)

MoM CCM Plenary 18 August 2010

2.2.7 Endorsement of the proposal by all CCM (or Sub-CCM) members

Membership Details Form – ANNEX C

PROPOSAL CHECKLIST: SECTIONS 1 AND 2

[Type text] [Type text] [Type text]

R10ProposalFormSection3‐5

Acceleratingprogresstowarduniversalaccessto

qualityTuberculosiscontrolinIndonesia

8/19/2010

CCM Indonesia

ROUND 10 – Tuberculosis

R10_CCM_IND_T_PF_s3-5_23Aug10_En.doc 2/79

3. PROPOSAL SUMMARY

3.1 Transition to a single stream of funding

(a) Select only one of the three options:

Option 1: Transition to a single stream of funding by submitting a consolidated disease proposal

go to section 3.1 (b)

Relevant sections are marked in RED throughout the proposal form

X Option 2: Transition to a single stream of funding during grant negotiation

go to section 3.1 (b)


Option 3: No transition to a single stream of funding in Round 10


(b) For options 1 or 2, list the grant numbers.

Round 5: Equitable quality DOTS for all (INO-506-G05-T)

Round 8: Consolidating progress and ensuring quality DOTS for all (INO-809-G11-T)

3.2 Duration of Proposal Planned Start Date To

Month and year: 01-07-2011 30-06-2016

3.3 Alignment to in-country cycles

Describe:

(a) how the proposal duration was selected in section 3.2 and how it contributes to alignment with the national fiscal cycle(s), programmatic reporting, or in-country program reviews; and

(b) the systems in place for regular national program reviews and evaluations (including Operations and Implementation research).

The start date of R10 grant is expected around July 2011, while the Indonesian fiscal cycle is from January to December. The annual planning of the National Revenue and Expenditure Budget (APBN)

PROPOSAL FORM – ROUND 10 SINGLE COUNTRY APPLICANT SECTIONS 3-5: Tuberculosis



starts in April 2011. Therefore the start date of the grant can be easily accommodated in the planning process of the national program and both budgets can be easily adjusted. The Government of Indonesia has made a regulation to improve harmonization between external grant funding and national planning budgets in order to improve transparency and efficiency of funding disbursements. All funds available including external funds (e.g. Global Fund, USAID/ TBCAP) and other sources are now officially registered and included in the National Budget for Government Institutions (DIPA). The current Global Fund (GF) grants round 5 and round 8 are already registered and are incorporated in the DIPA of the Ministry of Finance.

The NTP at district, provincial and national level report and review on a quarterly basis, thus the R10 is expected to start at the third quarter of the reporting and review cycle. Additionally, at national level the NTP conducts a mid-term review in December-January and an annual review in June-July, thus the R10 is expected to commence around the annual review in 2011. Additionally, during the proposed R10 period independent Joint External Monitoring Missions are scheduled to be conducted in 2011, 2013 and 2015. The R10 GFATM proposal is entirely based on the new National Strategy for TB control 2010-2014 (see annex), which includes a financial gap analysis for TB control program for the next five years and on some of the recommendations of the latest Joint External Monitoring Mission (JEMM) report (2007). The National Strategy for TB control 2010-2014 provides the roadmap to achievement of the MDG for TB and identifies the gaps in government- and other source funding in order to accelerate TB control program in Indonesia as part of the global stop TB plan strategy. This National Strategy is also fully embedded in the Medium Term National Development Plan 2010-2014 which includes specific targets for TB control. This is crucial since inclusion in the National Development Plan ensures fixed government budget lines for core NTP activities including funding for drug procurement. Furthermore the National Strategy for TB control 2010-2014 is fully in line and part of the Strategic Plan of The Ministry of Health 2010-2014.For summaries of the Medium Term National Development Plan and the National Health Plan we refer to the annex of this proposal.

3.4 Summary of Round 10 Proposal Provide a summary of the tuberculosis proposal.

Current situation of the TB Problem in Indonesia Indonesia had been ranking third in the world for the highest Tuberculosis (TB) burden for many years, but very recently (WHO update to Global Report 2009) the country has moved to fifth rank, with an estimated annual prevalence of all TB cases mounting to 244 per 100.000 population and an estimated incidence of new cases reaching 228 per 100.000 population (WHO, 20091). This can be considered as a major achievement of the program. Estimated prevalence of HIV among incident TB cases in various provinces is between 3-8 %. High defaulter rate and irrational use of second-line drugs (SLD) in hospitals and private sector are contributing to the increase of MDR/XDR. Among 388 MDR-TB suspects examined, 126 (32%) have been confirmed as MDR-TB. In consideration of the planned future expansion to all provinces across the country through this proposal, we expect that the number of MDR-TB patients detected and treated will reach over 5000 by 2014. Out of existing 482 districts in Indonesia, 138 are officially recognized by the government as underserved districts, mostly in remote areas. These districts have been designated as priority areas for accelerated development. In fact most populations in Papua (>42%) and West Papua provinces (27-41%) are still not fully covered by DOTS program. Out of 105 prisons that have been sensitized for TB control, 1865 suspects have been notified of which 324 were smear positive. During the same period, TB contributed to 15% of all deaths in the prisons. National response and progress In the initial phase of DOTS expansion (1995-2005) the NTP prioritized implementation of DOTS mainly in the Community Health System (Puskesmas).The rapid expansion phase of TB control program in Indonesia (2006-2010) reached wider communities, including the poor and vulnerable population, expanding the types of health facilities implementing DOTS strategy (hospitals, clinics, etc.), implementing DOTS-plus strategy, and integrated TB-HIV services. The number of relapses and failures is still below 2 % suggesting that the overall rate of TB drug resistance of patients treated in the general health services is relatively low. Notification of sputum smear Negative cases is increasing over the last

1 WHO Global Tuberculosis Control Report, 2009



few years as result of increased notification by hospitals since every year more and more hospitals and clinics are being involved in the national TB program. These are major accomplishments of the NTP Indonesia, however, there are still major gaps in the programme including unreached community, such as the urban poor (11.1 million in 2010). The National Strategy for TB control covering the period 2010-2014 NTP aims to consolidate progress and address a series of new challenges guided by the newly developed National Strategy for TB control covering the period 2010-2014 titled ‘’breakthroughs for universal access’’. It is based on the Global Plan to Stop TB. The goal of this plan is to sharply decrease the disease burden of TB by the end of 2014 through ensuring universal access to quality diagnosis and patient centered quality treatment. General strategies aim to prevent creation of MDR and to cure existing MDR cases. The plan describes seven key strategies in line with the new Stop TB strategy (elaborated in section 4.1) essential to achieve the MDGs for TB control and is fully embedded in the Medium Term National Development Plan (MT-NDP) for the Republic of Indonesia 2010-2014, providing a strong basis for future sustainability. The MT-NDP states three specific target indicators for TB control: TB prevalence, case detection rate and treatment success . The National Strategy 2010-2014 for TB is also in line with the Strategic Plan of the Ministry of Health covering the same period. Recently (Febr. 2010) the President of the Republic of Indonesia issued an instruction indicating TB control as one of the main priorities of the MT-NDP in national efforts to achieve the MDGs. Main challenges to be addressed through Round 10 support 1. Challenges in TB control strategy implementation

Recent slowing down of progress in TB case detection due to under-notification, barriers in acces to diagnosis and diagnostic delays.

Limited success in reaching specific risk groups like TB patients in remote islands, prisons, pregnant women with TB and pediatric TB patients

Continuous generation of MDR/XDR and low proportion of MDR cases notified or treated. Out of 8900 MDR-TB cases estimated by WHO, only 129 patients have been diagnosed by July 2010 of which less than 100 have started treatment.

Limited progress in expanding TB-HIV collaborative activities. Out of 180 ARV sites, only 30% are covered by TB-HIV collaboration.

2. Challenges in health systems Not all care providers have been engaged in TB control and many labs are not yet involved Lab

quality assurance system. Shortage of skilled human resourses due to establishment of new districts and consequences of

decentralization policy leading to high staff turn over, staff shortages, and a considerable training backlog

Inadequate logistic management information system leading to ineffective management of TB drugs/ laboratory supplies and risks of for stock outs

High reliance to donor funding and lack of local ownership resulting in low local financial support to sustain the TB control programme

Routine reporting in general is incomplete, delayed and has not yet completely covered TB in hospitals and private sector

3. Challenges in community systems The main weaknesses in community system are: Poor enabling environment and weak advocacy Weak coordination and linkages with existing NGOs Weak capacity of existing NGOs to address TB Limited monitoring & evaluation and planning capacity among several NGOs Poor access to service delivery for vulnerable communities:

All these weaknesses are elaborated in the proposal according to the Community System Strengthening (CSS) Framework.

Proposed interventions through Round 10; The Global Fund (GF) round 10 proposal is submitted to advance the national TB program towards achieving the MDGs for TB control by accelerating implementation of new strategies that are outlined in the new national strategy for TB control 2010-2014. The goal of the proposal is to improve access to quality DOTS services by strengthening health systems and expanding community networks in order to



reduce morbidity and mortality of TB and MDR-TB. The following main objectives and priority intervention areas have been identified for R10 support: Objective 1: Increased access to quality DOTS services to al TB patients and Programmatic Management of Drug Resistant TB (PMDT) services for all MDR patients, with a focus on vulnerable groups and remote areas. SDA 1.1. High-Quality DOTS: Improve the quality of current DOTS services (improving treatment succes rates and decreasing default, failure and error rates), through mentoring, on-site training and supervision, and periodic review of DOTS teams (in continuation of R5 and R8 activities). SDA 1.2. High-Risk Groups: Narrow the gap of un-detected TB patients focusing on implementing active case finding strategies for vulnerable groups like children with TB, and specific risk groups including the poor, HIV patients, prisoners and people living in urban slums and unreached areas. SDA 1.3. MDR-TB: Supporting implementation of the recently developed a National Programmatic Management of Drug-resistant TB (PMDT) Expansion Plan covering the period of 2010-2014 aiming to prevent the spread of drug resistance in which a total of 5100 drug resistant TB cases will be treated. SDA 1.4. TB-HIV: Accelerating TB-HIV collaboration by increasing coverage and access to quality DOTS for high risk population and people living with HIV increasing coverage and access for TB patients to the HIV services complementary to activities supported by R8 and R9 (National AIDS Program). SDA 1.5. Procurement and supply management: procurement of logistics and equipments including bufferstocks for first line drugs (FLDs), procurement of second line drugs (SLDs) as well as replenishment of broken microscopes. Objective 2: Strengthened health systems with focus on improving quality of service delivery and optimizing TB case management SDA 2.1. Service Delivery: Accelerating public and private hospital involvement from 30% to 80% by 2014. Activities focus on implementation of ISTC; adopting quality DOTS as a criteria for hospital accreditation and networking between hospitals and health centers for more effective referral SDA 2.2. Health Work Force: Increase and enhance the skills of human resourses and solving crucial staff shortages as a result of high attrition and establishment of new districts and decentralization policy as well as to increase capacity for implementation of the new strategies as guided in the TB Human Resources (HR) plan in integration with HR in Health plan. The priority is to address not only the training needs at district and health facility level but also to include ISTC elements in certification criteria for private providers in collaboration with professional associations. SDA 2.3. Medical products, vaccines and technology: Efforts to improve procurement and supply chain management, improve tracking of logistics to prevent stock outs and strengthen existing pharmacovigilance programme (in coordination with DG Pharmaceutical Service, MoH, in coordination with cross-cutting HSS proposal) SDA 2.4. Health Financing: Improve financing of TB control to ensure optimal accountability of funding and embedding planning for TB control in national and local development budgets (APBN, APBD), gradually phasing out external donor support. Other main strategy is to etablish collaboration and coordination with national health/ social security schemes. SDA 2.5 Health Information System: Strengthening the existing TB information system (capturing expansion and disaggregations of contributions by diverse providers, gender, age groups, geographical areas); integrating the current TB information system into the national and local health information systems (SIKNAS/SIKDA); Implementation of this SDA in coordination with the Center for Data and Surveillance, MoH and the cross-cutting HSS proposal, Objective 3: Strengthened community systems to empower communities to support and sustain TB control. SDA 3.1. Monitoring and Documentation of community and government interventions: activities supporting implementation of the amended Indonesian ACSM Framework, including enhanced participation of NGOs in national consultative forums. SDA 3.2. ACSM: supporting local NGO’s to actively engage and advocate with decision makers in district parliaments; Implementation of the recently developed advocacy tools; supporting NGOs in development of advocacy messages and campaigns SDA 3.3. Building community linkages, collaboration and coordination: fostering linkages between NTP and communities by engaging women and youth organisations (e.g. PKK and Karang Taruna) as well as HIV /AIDS NGOs and other local NGOs/FBOs in suspect identification, referral for laboratory examination and treatment monitoring.



SDA 3.4. HR Skill building for service delivery, advocacy and leadership: Further capacity building of FBOs (e.g. Aisyah, NU, Perdhaki etc), NGOs (PPTI) currently engaged in TB control and CBOs (PKK) including leadership training for policy and advocacy roles at national levels and management, planning, monitoring & evaluation, gender auditing. These activities will be integrated with SDA 2.2. SDA 3.5. Financial Resources: NTP under this SDA in collaboration with partners forum (TBCTA, NGOs, WVI, etc.) will assist CBOs/NGOs in development of CSS proposals. PR will issue anual calls for proposals for stimulating innovative, local specific approach for community based TB control. SDA 3.6. Service availability, Use and Quality: interventions under this SDA mainly cover development of general guidelines and protocol for engagement of local NGOs describing the minimum standards for quality DOTS services;development of referral systems between local NGOs and local health services SDA 3.7. Monitoring & Evaluation, Evidence Building: this SDA mainly entails community monitoring and evaluation of their involvement with feedback mechanism, including on linkage, referral systems, and clinical services The Round 10 proposal has been developed with the purpose to maintain efforts undertaken during GF Round 5 and to consolidate Round 8 implementation, complementing some of the under-budgeted new initiatives undertaken with R8 support (i.e. monitoring and evaluation, community TB care, TB-HIV collaboration), and closing the funding gap beyond Round 5 implementation for the period 2012-2014 (refer to financial gap analysis section). All TB-HIV activities included in this proposal are also complimentary to the HIV proposals for Round 8 and 9. The total amount requested through GFATM Round 10 is US$ 119,652,716

Financial gap analysis (US$)

‐

20,000,000.00

40,000,000.00

60,000,000.00

80,000,000.00

100,000,000.00

120,000,000.00

140,000,000.00

2011 2012 2013 2014 2015

GF R10 (proposed)

Private

USAID

GF R8

GF R5

GoI (Expected)*

GoI (Available)

*GoI (expected) include compulsory health allocation from local cigarette tax to be imposed starting 2014 (estimated to reach US$ 350 million per year)

The requested GFATM budget support is considered as an essential additional external contribution. The Government has committed itself to assume full responsibility for financing future drug supply and routine operational activities. During the implementation period the government and partners will gradually take over financing of activities and inputs needed to achieve the objectives.

4. PROGRAM DESCRIPTION

4.1 National program Describe:

(a) current tuberculosis national prevention, treatment, and care and support strategies; (b) how these strategies respond comprehensively to current epidemiological situation in the country;and (c) the improved tuberculosis outcomes expected from implementation of these strategies.

Under a recent Debt2Health arrangement, the Government of Australia has agreed to cancel AUD$75 million of Indonesia's debt. On condition this proposal is approved, Indonesia will receive half of this amount to be invested in the national program to combat TB through GFATM mechanism. The requested budget support from GFATM will not displace government contributions to national TB control, but will fill existing gaps resulting from introduction and rapid expansion of new initiatives as described in the National Strategy for TB control 2010-2014.



TB control in Indonesia has made remarkable progress over the last decade. Acceleration of DOTS implementation since 2002 enabled Indonesia as the first country in South East Asia to achieve the Global Targets in 2006. In 2009, Indonesia maintained this program achievement with case detection rate at 73% and treatment success rate at 90%. If sufficient funding for TB remains available and a sustainable TB program is well managed, it can be realistically assumed that by 2015 Indonesia will have achieve the MDGs targets for TB. The general strategy of TB control program at national level aims to prevent and treat TB and MDR TB through specific interventions to reach wider communities, including the poor and vulnerable populations (children, prison inmates, slum populations), expanding the types of health facilities implementing DOTS strategy (hospital, clinic, private practice, etc.), implementing PMDT strategy, and integrated TB-HIV services. However since 2007 a clear slowdown in acceleration of case detection is visible. This indicates the need to adjust current strategies in order to reach the ‘’unreached’’, while at the same time maintaining the quality of current DOTS services. These new strategies to address current bottlenecks and new challenges are described in the new national strategy for TB control 2010-2014. The plan has been developed in the first half of 2010 through a fully participatory approach involving all stakeholders.

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The plan aims to consolidate the basic DOTS program and to accelerate implementation of new initiatives in accordance with the revised Stop TB Strategy, Toward achieving Universal Access; “access to DOTS service must be available for all TB patients, regardless of their socio-economic background, demographic characteristics, and clinical conditions”. High quality DOTS for vulnerable groups, such as children, urban slum areas, women, poor people, and uninsured, will be put on the list of priorities. In terms of geographic areas, the government of Indonesia through the Presidential Instruction, prioritizes acceleration of public services development for 138 underserved districts (out of the existing 485 districts), The objectives of the new national strategy for TB control have been formulated as follows: (1) Improved and scaled up quality DOTS service ; (2) TB/HIV, MDR-TB, and the needs of poor and other vulnerable groups addressed: (3) International Standards for TB Care implemented by all public, community and private health providers ; (4) Empowered communities and TB patients; (5) strengthened health system and TB control program management; (6) Strengthened central and local government commitment for TB control program; (7) Enhanced research, including development and utilization of strategic information The strategies and activities to reach these objectives have been formulated as follow: 1. Expanding and improving quality of DOTS service: 1.1. Early detection and diagnosis through quality assured bacteriology examination 1.2. Provision of pharmaceuticals, medical supplies through an effective logistic system to ensure continuous supply of drugs.



1.3. Standardized treatment with adequate patient supervision and support. This strategy is expected to contribute toward increased case detection and treatment success of tuberculosis patients as well as prevention of emergence of MDR-TB. 2. Addressing TB/HIV, MDR-TB, and the needs of the poor and other vulnerable groups. 2.1. Expanding TB/HIV collaboration activities 2.2. Deliver MDR TB diagnosis and treatment under proper case management conditions and prevent the emergence of resistance to second-line drugs (PMDT). 2.3. Meeting the needs of poor and vulnerable populations This strategy is expected to contribute towards improving equitability of access to populations that are vulnerable for TB by increasing the proportion of HIV positive TB patients receiving HIV care, support and treatment; increasing the number of confirmed MDR-TB patients put on treatment; and expanding the proportion of TB pediatric cases diagnosed managed in accordance to ISTC 3. Involving all public, community, company, and private providers through Public-Private Mix (PPM) approach and ensure compliance to the International Standard for TB care. 3.1. Accelerating the expansion of Hospital DOTS Linkage 3.2. Promote the International Standards for Tuberculosis Care (ISTC) to all providers. This strategy is expected to contribute toward: improving access of unreached populations and increased proportion of public and private care providers implementing ISTC 4. Community and TB patient empowerment 4.1. Creating demand: increasing the number of TB suspects seeking care and treatment for their disease with DOTS providers or providers implementing ISTC . 4.2. Strengthen ACSM: Increasing the capacity of healthcare providers and outreach workers in ACSM to promote DOTS including patient education and patient-centered approaches. 4.3. Development of community-based DOTS: Enhancing Community partnerships to improve TB case detection and support for DOT in TB treatment, and increasing community-based DOTS service to overcome geographical barriers for access to TB services, to lower treatment cost by providing closer DOTS service to the community. This strategy is expected to contribute toward increased participation of communities in TB control and facilitate enforcement of current regulations relevant for TB control (e.g.. compulsory notification), provide social; support and thus further improving case detection and treatment outcomes. 5. Contribute to health system strengthening and management of TB control program 5.1. Governance: strengthening implementation of existing policies and regulations for TB. 5.2. Health services : improving quality of health care facilities primary health care and acceleration of adequate infection control in health facility and congregate settings. 5.3. Human resources for health: Ensure availability of human resources with adequate skills 5.4 Sustained supply of drugs and other commodities. This strategy is expected to contribute towards a stronger supporting policy environment, improved quality of health services and a sustainable skilled health workforce by integrating TB HR into HR for health . 6. Promote central and local government commitment for TB control program 6.1. Enhancing the level of political commitment to increase budget allocation for TB control program from the local government 6.2. Mobilize government support and resources This strategy is expected to contribute towards improved sustainability of disease control through increased proportion of local government contribution to TB control financing 7. Promote research, development and utilization of strategic information: Indonesia will implement a national research agenda based on priorities of the NTP, involving a wide range of research institutions in collaboration with international institutions and organizations. Priorities for research include program-based operational research and research on new strategy implementation as well as collaboration with international and local initiatives to support new diagnostic test, treatment regiment and vaccine.



The program will also enhance the utilization of strategic information like expanding web based electronic reporting system (e-TB manager, electronic TB register, TB-HIV, and other web-based system, particularly for hospitals and private sector. effective briefings and quarterly feed back to local government and health providers (Health facilities UPK), Conducting a TB prevalence survey in 2013 Policy evaluation: collecting evidences for policy, finance, and human resource barriers that can be solve through advocacy. This strategy is expected to contribute towards increased utilization of operational research and strategic information for program decision-making and policy action. Ultimately, effective implementation of the above mentioned strategies are expected to lead toward achievement of the following targets by 2014:

Baseline (when)

Target (2014)

Number of TB cases per 100.000 population 235 224

Proportion of all estimated new smear positive TB cases being notified (CDR)

73 90

Proportion of new smear positive TB cases cured 85 88

Proportion of province with minimum CDR 70% 15 50

Proportion of province with minimum success rate 85% 80 88

4.2 Epidemiological profile of target populations (a) Describe the current epidemiological profile of the target populations, and how this profile is changingwith respect to tuberculosis.

Indonesia had been ranked third in the world for the highest Tuberculosis (TB) burden for many years, but most recently (WHO update to Global Report 2009) the country has moved to fifth rank, with an estimated annual prevalence of all TB cases mounting to 244 per 100.000 population and an estimated incidence of new cases reaching 228 per 100.000 population (WHO, 20092). Incidence of new smear positive TB is an estimated 102 per 100.000 population. Annual mortality of TB is more then 90.000 deaths per year. National TB Prevalence surveys in 2004 showed men to women ratio of active TB was 1.7 to 1 However it should be noted that the number of active TB cases found in this survey was rather small (82 active TB cases). In 2005 TB case notification of SS+ of men to women ratio was 1.4:1 decreasing to 1.3 :1 in 2008. Percentage of pediatric case was about 11% of all cases in 2008. Estimated prevalence of HIV among incident TB cases is 3.0% nationally. Co-infection rate of TB among HIV patients is around 60%. Out of 3000 TB patients reported by 12 TB-HIV pilot sites, 2393 were tested for HIV and 1007 turned out to be HIV positive. Unknown numbers of TB patients are inadequately diagnosed and improperly treated by hospitals and private sector providers, which are not reported to the NTP. High defaulter rate and irrational use of second-line drugs (SLD) in hospitals and private sector are contributing to the increase of MDR/XDR. Among 388 MDR-TB suspects examined per June 2010, 126 (32.47%) has been confirmed as MDR-TB. In consideration of future expansion to all 33 provinces across the country, we expect that assume the number of MDR-TB patients detected and treated will reach over 5000 by 2014. 138 out of 485 districts are considered to be underserved districts. Out of existing 495 districts in Indonesia, 138 are considered underserved districts, mostly in remote areas. These districts have been designated as priority areas for accelerated development. In fact most populations in Papua (>42%) and West Papua (27-41%) are still not reached by DOTS program. Indonesia also has more than 11. million urban poor facing major obstacles to access health care. Even health services for the poor cannot be accessed due to their un-registered status. Out of 105 prisons which has been sensitized for TB control, 1865 suspects have been notified of which 324 were smear positive. During the same period, TB contributed to 15% of all deaths in the prisons. Despite having this high burden of TB cases, Indonesia, with support from Global Fund and other partners was the first country among the highest burden countries in the WHO South-East Asia region to

2 WHO Global Tuberculosis Control Report, 2009



successfully achieve the global TB target for case detection and treatment success in 2006. In 2009, some 287.469 new TB cases were notified (as of May, 2010) and out of this number, 166.294 cases are smear positive. Therefore, the case notification rate for smear positive TB stands at 71 per 100.000. These are major accomplishments of the NTP Indonesia. The average number of relapses and failures remains below 2 % suggesting that the overall rate of TB drug resistance of patients treated in the general health services is relatively very low. However, most of these data are from health centers only where DOTS has been well established. Drug resistance is likely to be much higher in the hospitals and private sector not yet involved in the NTP, due to non-adherence to DOTS and very high defaulter rates. Unfortunately data from the private provider sector are not captured by the NTP, while TB data from hospitals are only available for around 30% of the hospitals that are linked to the NTP. The proportion of Sputum Smear Positive Cases slightly increased from 56 % in 2008 to 59% in 2009. The number of Sputum Smear Negative Cases has been increasing over the last few years, which is likely the result of increased notification by hospitals since every year more and more hospitals and clinics are being involved in the national TB program. The number of childhood TB cases in 2009 was 29.649, including 1.865 smear positive TB cases. Proportion of childhood TB among all TB cases was 10.31%, however, there’s a general tendency of over-diagnosis of childhood TB. Health seeking behavior: The KAP survey in 2004 also revealed that 66% of families choose health center as their first choice when they have TB symptoms, 49% chooses private practitioners, 42% goes to public hospitals, 14% attends private hospitals, and only 11% that opted for private midwives or private nurses. In urban areas, majority of respondents prefers private practitioners, followed by public and private hospitals, and the rest opts for self medication. In contrast, people living in rural areas prefer to consult public health centers, midwives/nurses and dukun (traditional healers). Analysis on health seeking behavior among respondents with a history of TB treatment showed that the three main health facilities which served as their first choice for diagnosis were hospital, health center, and private practitioners. Further analysis on regional level showed that in the Eastern part of Indonesia the health center is the preferred facility for people with symptoms of tuberculosis, while in the other two regions, hospitals were seen as first choice. Delay in diagnosis and treatment of TB due to obstacles in access to DOTS facilities is still the main challenge for Indonesia which has such a wide geographical area and variation.

(b) Do the activities in the proposal target:

X Whole country Specific geographic region(s) Specific population group(s)

Paste map here if relevant (see Guidelines)

(c) Size of population group(s) If national data is disaggregated differently then type over the categories proposed

Population Groups Population Size Source of Data Year of Estimate

Total country population (all ages)

232517000 United Nations Population Division

2010

Females > 25 years 65816000 United Nations Population

Division 2010

Females 19 – 24 years 10137000 United Nations Population Division

2010

Females 15 – 18 years 10068000 United Nations Population Division

2010

Males > 25 years 63728000 United Nations Population 2010



(c) Size of population group(s) If national data is disaggregated differently then type over the categories proposed

Population Groups Population Size Source of Data Year of Estimate

Division

Males 19 – 24 years 10352000 United Nations Population Division 2010


Females 0 – 14 years 30434000 United Nations Population Division 2010


Other: use "Tab" key

to add extra rows if needed

(d) Tuberculosis epidemiology of target population(s)

Indicators (see the footnote under this table for the

references)

Number or rate or percentage [Calculation]

or (reference) Best estimate

Low estimate

High estimate

TB estimates, 2008 (available on http://www.who.int/entity/tb/dots/table4_2_2_gfatm.xls) a Estimated number of new TB cases (all forms) 429730 343784 515677 (1)

23205 18564 27846

27932 22346 33519

b Estimated number of new TB cases (all forms) per 100 000 population 184 148 222

[a/population*100 000]

c Estimated number of new smear-positive cases

210000 170000 250000 (1)

d Estimated number of new smear-positive cases per 100 000 population

90 73 108 [c/population*100

000]

e Estimated prevalence of TB cases (all forms) 480000 230000 830000 (1)

f Estimated prevalence of TB cases (all forms) per 100 000 population 206 99 357 [e/population*100

000]

g Estimated number of deaths due to TB (all forms) among HIV-negative people

62000 27000 120000 (1)

h Estimated number of deaths due to TB (all forms) among HIV-negative people per 100 000 population

27 12 52 [g/population*100 000]

i Estimated number of HIV-positive new TB cases (all forms)

12032 7563 18564 (1)

j Estimated number of HIV-positive new TB cases (all forms) per 100 000 population 5 3 8

[i/population*100 000]

k1 Estimated % of MDR-TB among new TB cases 2.0 0.5 6.9 (2)

k2 Estimated % of MDR-TB among previously treated TB cases 14.7 0.0 39.6 (2)

Indicators Number or rate or percentage [Calculation]



(see the footnote under this table for the references)

Best estimate

Low estimate

High estimate

or (reference)

TB notifications, 2008

l1 Number of new TB cases (ss+, ss-/unknown, extra pulmonary) notified in 2008 292899 (3)

l2 Number of new TB cases (ss+, ss-, extra pulmonary) and retreatment TB cases (relapse, after failure, after default, other) notified in 2008

298329 (3)

m Number of new TB cases (all forms) notified per 100 000 population 129 [l1/population*10

0 000]

n % of estimated new TB cases (all forms) notified 68.2 85.2 56.8 [l1/a*100]

o Number of new smear-positive TB cases notified 166376 (3)

Male 0-14 871

Male, 15-44 56888

Male, 45 and more 40283

Female 0-14 1015

Female 15-44 43792

Female, 45 and more 23527

p Number of new smear-positive TB cases notified per 100 000 population 72 [o/population*100

000]

q % of estimated new smear-positive TB cases notified - Case detection rate of new smear positive TB

79.2 97.8 66.5 [o/c*100]

r Number of TB cases all forms (new and retreatment) that were tested for HIV 2393

(4)

s % of TB cases all forms (new and retreatment) that were tested for HIV 79.7 [r/l2*100]

t Number of notified TB cases all forms (new and retreatment cases) that were found or known to be HIV-positive

1007 (4)

u % of all estimated HIV-positive TB cases that were found or known to be HIV-positive - case detection of HIV+ TB

- - 42 [t/i*100]

v Number of notified HIV-positive TB cases (new and retreatment) started or continued on CPT

- (4)

w % of all notified HIV-positive TB cases (new and retreatment) started or continued on CPT

- [v/t*100]

x Number of notified HIV-positive TB cases new and retreatment) started or continued on ART

102 (4)

y % of all notified HIV-positive TB cases (new and retreatment) started or continued on ART

10.1 [x/t*100]

z Number of TB cases (new and retreatment) received diagnostic DST

338 (4)

aa Number of multi-drug resistant TB (MDR-TB) cases notified among new and re-treatment cases

126 (per June 2010) (4)

Treatment outcome, 2007



ab Number of new smear-positive cases registered for treatment in 2007 160617 (3)

ac Number of new smear-positive cases notified in 2007 160617 (3)

ad % of all notified new smear-positive TB cases that were registered for treatment 100 [ab/ac*100]

ae Number of new smear-positive TB cases that were successfully treated (2007 cohort) 146197 (3)

af % of all new smear-positive TB cases registered for treatment that were successfully treated (2007 cohort) include TSR?

91.02

[ae/ab*100]

ag Number of new smear positive TB cases that failed their treatment 908 (3)

ah % of all new smear-positive TB cases registered for treatment who failed their treatment (2007 cohort)

0.6 [ag/ab*100]

ai Number of new smear positive TB cases who died while on TB treatment

3133 (3)

aj % of all new smear-positive TB cases registered for treatment who died while on TB treatment (2007 cohort)

2.0 [ai/ab*100]

ak Number of new smear positive TB cases who defaulted 6914 (3)

al % of all new smear-positive TB cases registered for treatment who defaulted (2007 cohort)

4.3 [ak/ab*100]

Other: specify

use "Tab" key to add extra rows

if needed

1. Global tuberculosis control: a short update to the 2009 report. WHO/HTM/TB/2009.426 2. Multidrug and extensively drug-resistant TB (M/XDR-TB): 2010 global report on surveillance and response.

WHO/HTM/TB/2010.3 – See Annex 6: Estimates of MDR-TB, by WHO region, 2008 3. Data from country TB routine recording and reporting system. 4. Data from recording and reporting system of pilot sites



4.3 Major constraints and gaps in disease, health, and community systems

4.3.1 Tuberculosis program

Describe:

(a) the main weaknesses in the implementation of current tuberculosis strategies; (b) existing gaps and inequities in the delivery of services to target populations; and (c) how these weaknesses affect achievement of planned national tuberculosis outcomes. Since 2007 several barriers led to slow down of progress in case detection and as a result considerable numbers of TB patients remain un-notified nor being treated according to DOTS strategy. The NTP has only partly succeeded in reaching specific risk groups for TB; Since 2007 the ‘’gap in case detection’’ remained steady to around 30 % for smear positive cases and around 50% for smear negative patients. Main weaknesses in implementation of TB control are described in the National Strategy for TB Control Indonesia 2010-2014. These include: Expansion of DOTS to hospitals is slower than anticipated. Yet only around 30% of the approximately

1.300 hospitals of the country are linked to the DOTS program. Consequently many TB patients consulting hospitals face barriers in accessing quality DOTS services. Secondly, TB surveillance in hospitals is not yet complete. Inadequate standardized treatment and high default from treatment in hospitals and private sector is evident from several studies, while 40% of TB patients Indonesia seek care from these hospitals and private practitioners. Many of the patients treated in these hospitals and private practices are not notified to the NTP

Urban poor (over 11 million in 2010) and remote communities still face several socio-economic barriers and major lack of access to quality DOTS. In remote areas of the Eastern region distances to health services and lack of infra structure remain a key barrier for many rural communities living far from existing DOTS services (e.g. over >42% population in Papua province is not yet covered by DOTS services) . As a result many TB patients remain undiagnosed and treatment default is high.

Notification of TB in children has recently considerably increased (from 0.6% in 2007 to 11.2% of all TB cases notified) as a result of efforts to improve case notification in younger age-groups. However there is still major quality issue regarding diagnosis due to considerable over diagnosis of pediatric TB in many hospitals and private facilities. Moreover diagnosed children are often not treated according to DOTS guidelines. Problems are aggravated by shortages of diagnostics like tuberculin and pediatric formulations for treatment of children.

There is considerable under diagnosis and treatment delay in pregnant women with TB. Active screening for TB in ANC services is not yet implemented.

DOTS expansion to prisons: TB is among the top 5 diseases in prisons. From 442 prisons, currently only 265 have clinics and health personnel. Despite recent progress, around 118 (40%) of prisons with clinics have been trained by NTP but surveillance is still weak, and consequently data are incomplete or lacking. Majority of prison inmates do not yet have access to TB services and as a result are not screened nor treated for TB. TB-HIV collaborative activities are still limited. Risk for transmission of TB in prison settings is high due to lack of infection control and overcrowding. Several challenges remain including fully integrating prisons in the surveillance system and linking prisons clinics to respective health facilities for screening, diagnosis, treatment. Transfer between prisons and post-release referral to health services have been addressed in the TB in Prisons guidelines but not yet adequately implemented. TB in prison is not yet integrated in the national strategy for HIV control of the Ministry of Justice, consequently not funded with local sources.

Management of TB-HIV co-infection is still limited; though some collaborative mechanisms exist, collaboration at various levels needs to be strengthened. Coverage of TB/HIV collaborative services in TB clinics and HIV/AIDS care settings is still low: out of the existing 180 ARV hospitals, 117 have DOTS units however, only 62 report collaborative TB-HIV activities. Consequently, eventhough 60% out of 16.000 patients on ARV treatment are co-infected with TB, only a minority of these have access to DOTS service on site. Furthermore, Provider Initiated Testing and Counseling (PITC) is not implemented widely yet, Access to Cotrimoxazole Preventive Therapy (CPT) and ART in DOTS setting is still limited due to weak linkage and referral systems. TB screening for people living with HIV (PLWHIV) is not yet done systematically. Isoniazid Preventive Therapy (IPT) is not included yet in the national TB/HIV policy but a plan has been developed to pilot IPT in two selected sites, unfortunately no budget could be secured for this. Provision of essential diagnostic- and treatment supplies is irregular or inadequate. Moreover, confidentiality issues related to HIV status of TB-HIV patients hampers surveillance of TB-HIV, contributing to lack of systematically collected data.

Expansion of PMDT has been slow and is still limited to two pilot sites in Jakarta and Surabaya. Consequently, the majority of DR-TB cases still remain un-notified and untreated. Out of 8,900 MDR-



TB cases estimated by WHO, only 126 has been diagnosed by June 2010 but less than 100 of them have been put on treatment. Around 10% of MDR-TB patients refused to initiate treatment due to inadequate psychological and motivation support to MDR patients. Moreover, there are still problems related to compliance to PMDT guidelines among some physicians.

4.3.2 Health Systems

Describe the main weaknesses of and/or gaps in health systems that affect tuberculosis outcomes.

Related to description of health sector challenges we refer to chapter 4 ‘’strategic issues’’ in the national strategy for tuberculosis control in Indonesia 2010-2014, the JEMM report 2007 and section 4.3.2 in GF TB Round 8 proposal.

1. Challenges in service delivery Initially the DOTS program was established in the Community Health Care system and only

since 2005 the program expanded to the more than 1.300 hospitals. So far around 30% of these hospitals have been linked to the DOTS program and most of the around 60.000 practicing doctors in hospitals and clinics are still unaware of ISTC and do not follow DOTS. Consequently creation of MDR/XDR by these practitioners is still uncontrolled.

The network and quality of laboratory services for smear microscopy and culture / DST are still inadequate, particularly to support expansion of PMDT: After rapid expansion of diagnostic capacity (to more then 5.000 diagnostic units) major challenges still remain related to the quality of these services. Lab Quality Assurance System (LQAS) is not yet systematically implemented. Cross checking by provincial referral laboratories (BLK) is irregular and only cover less than 50% of existing labs. This leads to both under-, as over-diagnosis of TB. Seven new provinces (out of 33) do not have a reference lab. Progress in expansion of quality assured culture and DST is slow but good (now 5 regional laboratories quality assured by Supra-national Reference Lab) and geographic coverage still low particularly for the Eastern region. Much effort remains to be made to expand the network from 5 to 17 quality assured laboratories for culture and DST (of which 8 laboratories will be selected to become regional laboratories and 33 provincial reference laboratories. Equipment and infrastructure in the laboratories is generally still deficient, especially in relation to laboratory bio-safety

2. Weaknesses in human resources: inadequate provider competence, staff shortages, high staff turnover (15-30%), and overstretched management capacity at all levels due to: establishment of new districts after split up (from 405 in 2006 to 495 in 2010) and

decentralization policy resulting in shortages of skilled staff and increased training needs for public health services, public and private hospitals and private health care providers.

Initiation and expansion of new initiatives: shortages of human resources become more evident. Technical as well as managerial capacities at provincial and district TB level (supervisors and management teams) are still inadequate to cope with the increasing workload in monitoring and managing the growing range of program activities.

major challenges in implementation of ISTC. Quality of TB and MDR-TB case management (diagnosis, treatment, patient support and surveillance) is still inadequate. The pre-final draft of the national HRD plan still needs to define strategies in collaboration with professional association for capacity building of the vast number of private providers (more then 60.000 private practitioners spread out over the country).

3. Challenges in logistics and supply management, The program still faces risks of stock outs due to difficulty to obtain timely and reliable logistics reports needed for effective management of the supply systems, and shortage of adequate buffer stocks to mitigate against supply interruptions and unexpected usage patterns. Existing, national governmental regulations and legislation stipulate the upper limit for buffer stocks to be maximum 30%. Efforts are needed to further improve the logistic management information - and supply chain management system.

4. Challenges in health financing. To a large extent the National TB control program still relies on donor funding. Budget deficits for health at district level hamper continuity of routine TB program activities like monitoring and supervision: The autonomous district governments generally allocate only 1-4% of the total local

development budget (APBD) to health, while Government policy stipulates at least 10%. The availability of resources for performance based incentives are limited, leading to poor

staff motivation. In many districts, low contribution to health hampers program sustainability. Only 1/3 of districts have succeeded to establish District Insurance Schemes.

5. Challenges in surveillance and monitoring & evaluation: The surveillance systems for HIV, TB and Malaria are still ‘’vertical’’ and generally not yet



integrated into the national and local health information system. Data reporting in general is delayed, irregular and not yet completely cover all care providers Limited analysis and utilization of data for action and feedback mechanisms at all levels..

4.3.3 Community Systems

Describe the main weaknesses of and/or gaps in community systems that affect tuberculosis outcomes.

The main weaknesses in community system are: limited implementation of existing TB regulations due to lack of community pressure groups demanding local authorities (mayors/governors, parliament members) to enforce laws and regulations related to TB control; limitations in community participation due to lack of advocacy on the impact of TB disease and the potential of communities to avert it;’ and limited involvement of women/youth organizations and patient NGOs in TB control.These weaknesses are elaborated further below according to the Community System Strengthening (CSS) Framework. 1. Poor enabling environment and weak advocacy Lack of informed demand for quality TB services due to limited community sensitization on the

Patients Charter for TB care (outlining patient rights, role and responsibilities of TB patients). Partial implementation of communication strategies for TB. There is poor access to proper

information on TB, including limited distribution, shortage and poor variation of IEC materials. Existing communication channels for communities are not utilized optimally like primary and secondary education and local media. Branding of DOTS in prevention and treatment of TB is still insufficient. This results in many TB suspects and patients seeking care and treatment in the private sector, consulting private doctors and hospitals/clinics who do not provide DOTS.

Inadequate implementation of existing regulations relevant to TB control (e.g. national Minimum Standards of Care for public services, standards for minimum budget allocation for health, obligatory disease notification) partly due to weak community capacity to negotiate (‘’watchbody’’)

2. Weak coordination and linkages with existing NGOs Collaboration and coordination between local government and non-government organizations and/or

facilities at local (district) level is in general improving, but still lacking in many districts. This despite formation of the National Stop TB Movement (Gerdunas) in 2000, establishment of the TB Partnership Forum at national level in 2002 (as partnerships between national government and NGOs), followed by the establishment of the CCM (Country Coordinating Mechanism) in 2003. Though several good exceptions exist, it yet leaves a huge potential for community involvement and service delivery untapped. Moreover the National Stop TB Partnership Movement (Gerdunas) is not functioning optimally and recent efforts to move Gerdunas direct under the Coordinating Minister for Social Welfare have not yet succeeded.

The level of community mobilization is still low: Many NGOs (including HIV NGOs) have not yet , or only partially been engaged in TB control. The national partnership forum linking NGOs active in TB control at national level is not functioning effectively and still lacks a permanent secretariat. This results in poor coordination between these organizations and NTP.

3. Weak capacity of existing NGOs to address TB (including human and material resources and organizational capacity)

Large NGO’s like Aisyah (30 million members) and NU (60 million members) are increasingly involved in supporting DOTS services (GF R8) but still consider TB services as a ‘’project driven’’ activity and their capacity to expand their role in TB is still constrained.

Some other NGOs under Perdhaki and Pelkesi and NGO related to HIV/AIDS own health facilities in slums and in the eastern part of Indonesia that do not yet provide DOTS services or are not linked to the NTP due to limited capacity or lack of local coordination mechanisms. Weaknesses often relate to inadequate internal management including human resources, coordination and planning for activities.

TB patient organizations like PAMALI and other patient organizations lack organizational capacity resulting to limited contribution to the program. Informed demand of TB patients whereby (ex-) patients speak-up to local decision makers in district governments, to insist on quality services, is still scarce.

Several NGOs like PPTI lack capacity to expand DOTS through their organizations. Weaknesses often relate to limitation in management and shortages of human resources and funding.

4. Limited monitoring & evaluation and planning capacity among several NGOs: Most NGOs involved in TB control have weak monitoring and evaluation capacity resulting in poor program achievement and lack of feedback mechanism. Documentation and sharing of best practices between NGOs are still limited due to inadequate functioning of the TB partnership forum.

5. Poor access to service delivery for vulnerable communities: Until now many isolated



communities in remote areas with poor infrastructure and no access to health services have not been empowered to take up their own responsibility to address TB, including suspect identification, referral for laboratory examination and treatment monitoring. As a result morbidity and mortality in these areas are very high. This leaves community TB care and patient involvement as one of the feasible alternatives. Local NGO’s could play a major role in empowering local communities.

4.3.4 Efforts to resolve weaknesses and gaps

Describe what is being done, and by whom, to respond to health and community system weaknesses and gaps that affect tuberculosis outcomes, as outlined in sections 4.3.2 and 4.3.3.

Weakness Efforts being done By whom

Weaknesses in health service provision

1. Hospital DOTS Linkage has been scaled up, now covering 30% of public and private hospitals

2. A National plan for Laboratory Network Development for 2010-2014 has been developed under leadership of the Microbiology Laboratory Department in the MoH.

3. Microscopy Reference Laboratories in 7 new provinces are in a well advanced stage of development

4. 8 Regional labs are being selected to be upgraded to regional reference lab for culture / DST and rapid drug resistance detection.

5. Cumulative Five Regional Reference laboratories have succeeded to achieve quality assurance for culture/DST by SRL during 2008

NTP, GFR8 KNCV/ TBCAP, IMVS, WHO

Weaknesses in human resources:

1. A new HRD strategic plan 2010-2014 is in its final stage of development based on analysis of human resource and training needs.

2. All TB trainings, Curricula and training materials have recently been reviewed in collaboration with the PPSDM (The Human Resource Unit within the MoH) and are now fully accredited and certified. This is important for staff carreer development and sustainability of HRD in future

3. Curriculum and training materials for private practitioners based on ISTC have been developed and being field tested.

4. Indonesian Medical Association is fully involved in capacity building for medical professionals. ISTC Task forces in branches of professional societies were established in 32 provinces.

NTP, GFR5 KNCV/ TBCAP, Indonesian Medical Association

Weak logistics and supply management

1. Preparations are made to move physical logistics operation for TB medicines and commodities outside a direct governmental undertaking, into contracted service with a national (parastatal) pharmaceutical distributor

2. The e-TB manager software for MDR-TB drug management has been implemented.

3. Logistic management trainings have been rolled out to cover all districts

4. Monthly alert system for buffer stock has been implemented

NTP, DG Pharma Service, USAID/TBCA, MSH, GF R1

Weakness in surveillance and monitoring evaluation

1. Development of web based MIS system is in preparation 2. National reporting system revised to include TB –HIV data and PPM. 3. TB has been included in the SPM (Minimal Service Standards) and

TB case notification is being included in the Hospital Reporting System (under the Directorate of Medical Services, MoH)

4. Positioning of Surveillance Technical Officers for hospital DOTS in 12 district clusters

5. Modeling to attain regional adjusted incidence and prevalence figures

NTP, USAID/ TBCAP, GFR5, YanMed

Weak implementation of

1. The Department of Medical Services of the Ministry of Health has developed management guidelines for TB control in hospitals.

2. The Department of Medical Services is in the process to develop certification and accreditation standards for hospitals, which will be included in the licensing requirements.

Directorate Medical Services, NTP,



regulations 3. Similarly the Indonesian Medical Association is in the process of preparing certification standards for medical practitioners, based on ISTC.

4. Regular coordination established between DG of Medical Services, DG of community health and DG of CDC and environment,

TBCAP

Poor political commitment

1. TB control has been included in the National Development Plan 2010-2014 with secured budget lines

2. TB is priority in the Strategic Plan of the Ministry of Health, reaffirmed by the recent Instruction of the President RI 2010 on accelerating and intensifying all efforts including TB control to achieve the MDGs

3. In December 2009 the Indonesian Government reinforced these interventions through the Ministerial Decree of Health no 1278 on integrated TB/HIV interventions. This policy has now been followed by National Aids Strategy 2010-2014 which lists integrated TB/HIV interventions as key to widening universal access for people living with HIV

MoH, NTP

Lack of patient involvement and Community TB Care to reach vulnerable populations

1. Technical support to NGOs and community organizations, including empowering of PPTI, to support DOTS expansion mainly in the Eastern part of Indonesia

2. Building partnerships with an increasing number of NGOs and other institutions

3. DOTS expansion to remote areas in combination with activities for TB-HIV

4. TB activities have been incorporated in the national ’’Desa Siaga’’ initiative (= village preparedness), as an effort to increase outreach at village level.

NTP/ USAID/

TBCAP, R5, R8

Aishyah, NU, PPTI and other NGOs

Weak capacity and suboptimal involvement of NGOs

1. Appointment of a large NGOs like Aisyiah as PR R8 GF, and a number of other NGOs as SR.

2. Patient charter endorsed and disseminated 3. Pamali has been established as an association of patient

organizations 4. Large NGOs have been effectively involved in DOTS expansion 5. Some large corporations (e.g. KPC, Mandiri Bank) support operations

of local NGOs

Aisyiah, NU, NTP, TBCAP, corporations

Weak financing

1. Formal agreements with Jamsostek (national social security system) 2. Presidential decree no 1 and 3 year 2010 to accelerate MDG including

TB 3. Improvement of recruitment system for financial management staff

NTP. Jamsostek

4.4 Proposal strategy

Complete this version of section 4.4.1 if the applicant selected option 2 or 3 in section 3.1 of the Proposal Form

Option 2 = Transition to a single stream of funding during grant negotiation Option 3 = No transition to a single stream of funding in Round 10



4.4.1 Interventions

This section should be completed in parallel with the Performance Framework and detailed budget and work plan

Describe the objectives, service delivery areas (SDA), and activities of the proposal. The description must be organized in that exact order and the numbering system must match the Performance Framework, detailed budget and work plan. The description must identify: (a) who will implement each area of activity (e.g. Principal Recipient, Sub-recipient or other

implementer); and (b) the targeted population(s).

All interventions in this section are focused on tackling constraints in access to quality TB services to address the stagnation in case notification evident since 2007, and on solving bottle necks in program implementation, health systems and community systems resulting in poor access and program quality. Solving these bottle necks is essential to advance the national TB program towards achieving the MDGs for TB control and facilitate implementation of the new Strategic Plan 2010-2014 (‘’breakthrough to universal access’’). For description of these bottlenecks see the new Strategic Plan (SP) 2010-2014 and sections 4.3.1 to 4.3.3. Goal of this ambitious strategic plan is to sharply decrease the disease burden of TB by the end of 2014 through ensuring universal access to quality diagnosis and patient centered quality treatment. In general strategies aim to prevent creation of MDR, to cure existing MDR cases and expanding TB/HIV with a focus on vulnerable and high risk groups including prisoners and populations with concentrated HIV epidemics. The consolidated goal of this proposal is: Improved access to quality DOTS services by interventions for specific regions, expanding community networks and strengthening health systems in order to reduce morbidity and mortality of TB and MDR-TB. Objectives of this R10 proposal: 1. Increased access to quality DOTS services for all TB patients and to PMDT services (Programmatic

Management of Drug Resistant TB) for all MDR patients, with a focus on unreached populations, vulnerable groups and remote areas

2. Strengthened health systems with focus on improving quality of service delivery and optimizing TB case management by solving current bottle necks in human resources, health information systems and PSM systems.

3. Strengthened community systems and empowered communities to support and sustain TB control Strategies in this proposal are nationwide with special focus on specific geographic areas with low case detection and poor performance and/or case holding that are prioritized by NTP. This prioritization is in line with the list of 139 districts that have been prioritized for accelerated development, which are part of the “districts with major health problems’’ (DBMK) or 35 “remote and border districts” (DTPK) as defined by Presidential Instructions 1 and 3 (2010). All SDAs in this proposal are in line with the seven main strategies of the national strategy for TB control in Indonesia 2010-2014, essential to achieve the MDGs for TB control. This plan is fully embedded in the Medium Term National Development Plan (MT-NDP) for the Republic of Indonesia 2010-2014. The development plan provides a strong basis for future sustainability since it includes two specific targets for TB control. The SP 2010-2014 for TB is also in line with the Strategic Plan of the Ministry of Health covering the same period.

Objective 1 :Increased access to quality DOTS services for all TB patients and to PMDT services (Programmatic Management of Drug Resistant TB) for all MDR patients, with a focus on unreached populations, vulnerable groups and remote areas:

SDA 1.1. High-Quality DOTS Indicators:

1. Number of new smear positive TB cases notified 2. Number of new smear positive TB cases successfully treated

This SDA aims to ensure that every symptomatic TB patient is detected and put on treatment early, adhere to treatment and followed up systematically. The activities under this SDA encompass provision of



transportation costs required for sputum collection and the transportation of the sputum slide from satellite centers (Puskesmas Satelit) to the referral microscopic centers (Puskemas Rujukan Mikroskopis) and hospital laboratories, including transport costs for defaulter tracing. During home visit health education and counseling are provided to the patient, their family and surrounding community. The main activities proposed to be supported through R10 are thus: 1.1.1 Enhanced sputum collection, transportation, smear-preparation and examination 1.1.2 Strengthening default tracing and education and counseling for patient, family and community 1.1.3 Supporting Monitoring and Supervision at central, province and district level. Implementer: NTP in collaboration with provincial and district health offices Target Population: TB patients SDA 1.2 High Risk Groups Indicators: 1. Number of children with TB among all TB cases notified 2. Number of new Smear Positive TB patients reported in prisons This SDA aims to narrow the gap of un-detected TB patients focussing on active case finding strategies in specific risk groups (like children with TB, pregnant women with TB and women at risks for HIV) and in other vulnerable groups including underserved populations like urban poor in slum areas, inmates in prisons etc. 1.2.1 TB in children activities include:

Active casefinding in young age groups by implementing systematic contact screening and systematic examination of house household contacts of all TB patients.

Assessing cost-effectiveness and operational feasibility of tuberculin testing as one of the tools to be considered in the diagnostic process and Isioniazid Preventive therapy for children, Based on the results the NTP will define a national policy and guidelines

Dissemination of ISTC among Indonesia pediatricians in order to improve quaility of diagnosis and access to standardised treatment for TB in children, to prevent overdiagnosis and address underreporting.

Development of management and technical guideline for pediatricTB. Establishment of TB pediatric secretariat and regular meetings of the pediatric TB working

group

1.2.2 Step-wise expansion of active case finding among high risk groups to improve early case detection. This includes several activities including piloting of active case finding activities e.g. TB symptom screening of selected risk groups (poor people in urban slum areas with high incidence of TB and poor populations in underserved districts).

1.2.3 Acceleration of TB Control in Prisons: Stepwise expansion of TB and TB-HIV services to the prison system in Indonesia, ensuring

adequate screening for TB and HIV of all inmates, and ensuring proper treatment for TB cases identified. This also incorporates strengthening of referral systems for successful transfer of TB patients (pre-release between prisons, and post-release to health services).

Advocacy for implementation of regulations regarding minimum standards for TB infection controls in prisons. Serious overcrowding, lack of administrative, environmental and person protection measures in prisons result in high risk of TB transmission, in particular in narcotics detention centers where HIV rates are steeply increasing due to IDU. Policy and guidelines for TB-IC in prisons are currently being developed by the Department of Community Health Services in collaboration with the Prison department witin the Ministry of Justice and Human Rights but still remain to be implemented. Activities include capacity building in the prison system and introduction of IC interventions in prisons.

Assistance to Ministry of Justice and Human Rights for development of a national strategic plan for TB in prisons. This strategy should be annexed to the national strategy for TB and the strategic plan for HIV control in prisons, including TB IC in prisons. Models for TB control in prisons that do not have their own health facility will be piloted.

1.2.4 Promotion of gender responsiveness: piloting interventions for ensuring timely detection and treatment of pregnant women with TB and early detection of TB in women with high risk of HIV such as female sex workers, female IDUs, female partners of male IDUs and transgenders. These activities will be in collaboration with HIV-NGOs involved through GF R 8 and 9 and the NGO network under NTP in R 10 (see objective 3 under CSS).



Implementer: NTP, NAP

SRs: DepHukHam (Ministry of Justice and Human Rights), IMA (Indonesian Medical Association), Provincial and district health offices

Target Population: Specific high risk groups like children with TB, women, pregnant women in specific

areas, PLHIV, prisoners and people living in urban slums SDA 1.3. TB-HIV Indicator: Number of TB-HIV patients enrolled in HIV Care Major Activities Activities in this proposal are focused on accelerating TB-HIV collaboration by increasing coverage and access to quality DOTS for people living with HIV and increasing coverage and access for TB patients to existing HIV services by strengthening TB-HIV coordination between the two programs at the national and province/district levels and within health facilities i.e. hospitals and selected community centers and other health services where VCT services exist. These TB-HIV activities are complementary to activities that are currently supported through GFATM TB R8 and GFATM HIV/AIDS R9. R9 covers efforts to decrease TB burden among HIV patients (Intensified case finding among PLHIV, TB Infection Control, ART for TB/HIV co-infected patients). The main activities proposed to be supported under R10 are as follow: 1.3.1. Expanding TB/HIV services (in collaboration with PRs of HIV Round 8 and 9) and accelerate

expansion of TB-HIV collaborative activities to more VCT designated hospitals and selected health centers, then currently supported by R8 and R9 HIV proposals. This also includes:

a. implementation of Provider Initiated Testing and Counseling (PITC) in hospital DOTS units which are designated ARV hospitals

b. provision of Cotrimoxazole preventive therapy (CPT) c. provision of TB-HIV IEC materials d. strengthening TB-IC in HIV care facilities

1.3.2. In close collaboration with NAP (R9 HIV).Strengthening of referral networking between hospitals and health centres in geographic areas that are now covered under R5 in order to improve continuity of care.

1.3.3. Developing and piloting a national IPT policy; INH Preventive Therapy is not yet included in the national TB-HIV policy. This activity consists of IPT piloting in some HIV sites as a first step to develop a national policy and guideline for IPT.

1.3.4. Strengthening TB-HIV surveillance through implementation of the Law on Medical Practice addressing the issue of confidentiality: guideline for handling confidentiality in medical record keeping, based on this Law, will be disseminated and implemented in order to enable adequate data collection and reporting on TB-HIV.

1.3.5. Ensuring access of HIV patients to existing PMDT services: This will be achieved through integration of PMDT and TB/HIV services: HIV positive MDR suspects will be tested by culture /DST and provided MDR treatment if resistant. (In the 2 PMDT pilot sites HIV positive patients with MDR have until now been excluded from SLD treatment).

1.3.6. Strengthening coordination and joint TB-HIV planning, monitoring and evaluation meetings at national, provincial and district levels

1.3.7. Update management and clinical guideline and training modules for TB-HIV.

Implementer: NTP in collaboration with related stakeholders (WHO, NAP, Ministry of Justice, FHI, UNODC, etc.) , Provincial and district health offices

Target Population: TB patients, PLHIV, risk groups SDA 1.4 MDR-TB Indicator: Number and percentage of lab confirmed MDR TB patients enrolled in SLD treatment In response to the call from the Ministerial Meeting of the High M/XDR-TB Burden Countries in Beijing China in 2009, the NTP Indonesia has recently developed a National PMDT Expansion Plan covering the period of 2010-2014. Goal of the plan is to prevent the emergence of drug resistance. Objectives are to deliver MDR TB treatment under proper case management conditions and to prevent the emergence of resistance to second-line drugs. The plan targets to: diagnose and treat at least 80% of the estimated DR TB cases (target= 6400) by 2014, establish at least one diagnostic and one or more treatment centers at provincial level in each



province. establish PMDT linkages with public and private sector hospitals and NGO/INGO During 2010 – 2014 a total of 5100 DR TB cases will be treated. During this period PMDT will be expanded to all 33 provinces. Culture facilities will be established at all Provincial laboratories and Drug Sensitivity Testing at selected regional levels. For expansion plan see table below:

Year

Suspects in the catchment area

(Districts/ municipalities)

Catchment area (Province)

MDR‐TB patients identified and placed on treatment

%

Number of Labs

conducting Cultures

Number of Labs Conducting First‐

line DST

2010 300 4 100 0.6 4 5

2011 2,100 14 700 11 14 5

2012 4,800 21 1600 25 21 7

2013 10,200 27 3400 53 27 11

2014 15,300 33 5100 79 33 17

The sub strategies outlined in the PMDT expansion plan are: stepwise expansion of PMDT services to ensure universal access for MDR-TB patients by implementing the National Expansion Plan for PMDT 2010-2014 (see annex); Strengthening and expanding the microscopic laboratory network including EQA capacity for culture and DST to new areas (as described in the National Plan for TB Laboratory Network Development (RenJa Lab 2010-2014, see annex); Establishment of MDR surveillance, either by repeated DRS or implementing sentinel surveillance for MDR-TB in the network of quality assured labs; Involvement of all care providers (PPM / ISTC - Public-Public, Public-Private Mix (PPM) approaches; (refer to HSS and CSS). The main activities proposed to be supported through R10 are as follow: 1.4.1. Revision and improvement of guidelines and training modules 1.4.2. MDR TB Working Group Meetings 1.4.3. Finalization of MDR TB Response Plan 1.4.4. Developing Regulation of SLD Usage 1.4.5. Expansion of network of culture DST Laboratories 1.4.6. Develop IEC Materials for TB MDR 1.4.7. Site Preparation 1.4.8. Scaling up diagnostic, treatment and follow up 1.4.9. Supervision of PMDT expansion Implementer: NTP and YanMed (Directorate of Medical Services), BPPM (Directorate for Medical

Service Support), Provincial and district health offices Target Population: MDR patients SDA 1.5 Procurement and supply management Expansion of activities and geographical coverage (due to newly established districts) and replacement of broken equipment requires procurement of logistics and equipments as follow: 1.5.1. Procurement of bufferstocks for FLD (30% of annual FLD needs) and procurement of SLD (see

section 4.8) 1.5.2. Procurement of microscopes (fo new labs, replacement of old/ broken ones), lab supplies and

reagents 1.5.2. Procurement of PPD test materials



Objective 2: Strengthened health systems with focus on improving quality of service delivery and optimizing TB case management by solving current bottle necks in human resources, health information systems and PSM systems. SDA 2.1. Service Delivery Indicator: 1. Number of hospitals involved in PPM/ISTC 2. Number and % of new smear-positive TB patients notified by hospitals among the new smear positive

TB cases 3. Number and percentage of laboratories showing adequate performance among those that received

external quality assurance for smear microscopy Activities under this SDA aim at accelerating hospital involvement in order to achieve universal access to DOTS services, linking up 80%of all general (public and private) hospitals to the NTP by 2014.Activities focus on strengthening collaboration with Private Hospital Associations (PERSI, YARSI), and FBOs owning health facilities in remote areas, with the purpose to expand and strengthen internal and external networks including proper referral systems between community health centers and public hospitals. Activities include: 2.1.1 Implementation of the new Minimal Service Standards for Health where DOTS has been inserted

as one of the minimal standards for health facilities, in particular for hospitals. TB Minimal Services Standards related to diagnosis and treatment will be included in

certification and accreditation criteria for health facilities as mentioned in the Hospital Decree 2009. This activity is expected to enhance nationwide service delivery for TB and TB/HIV at all health facilities including hospitals.

Strengthening internal and external networking for Hospital DOTS Linkage (HDL) Supporting attendance in international PPM meetings/workshops.

2.1.2 Strengthening professional societies (under the . Indonesian Medical Association ) to enhance implementation of International standards for TB care in hospitals and private providers. Actions include: incorporating ISTC as one of the mandatory criteria for certification of private providers

managing TB patients. Medical doctors providing TB care will need to comply to binding criteria regarding diagnosis, treament and notification of TB. This certification is obligatory in the process of licensing by the Indonesian medical Association. – Establishing joint TB secretariat in the Indonesian Medical Association (e.g. IMA). – Strengthening networking between PPs, health facilities and district health offices by

linking local IMA representatives with provincial-/cluster/dictrict- DOTS teams – Facilitating continuous professional ecucation and participation in international

conferences/workshops. Improving access to quality assured diagnosis by strengthening laboratory networks including

strengthening of QA for sputum smear microscopy. Recently the Directorate of Laboratory Services (BPPM) of the MoH developed a National Plan for expansion of the TB Laboratory Network. R10 will support selected activities of this plan that were not covered by R8. – panel testing: Implementing EQA for provincial reference laboratories. – expansion of LQAS and intensifying supervision in the laboratory system – updating laboratory guideline for microscopy and culture / DST.

Implementer: NTP, SR professional Society (IMA), DG Medical Services, Directorate for Medical

Support Services (BPPM), Provincial and district health offices. Target Population: All TB patients and suspects. SDA 2.2 Health Work Force Indicator: Number and percentage of districts with TB staff trained on DMIS out of all districts Interventions under this SDA are to increase and enhance the skills of human resourses and solving crucial staff shortages as a result of high attrition and splitting of districts into new units (from 340 in 2002 to almost 500 in 2010) and to increase capacity for implementation of the new strategies. Priority is to address the training backlogs at district and health facility level (due to high turn over at community health centers level, expansion beyond community health centers) but also for the large number of private



providers working in private or NGO facilities. This SDA supports the implementation of the HRD Plan 2010-2014 (see annex) and focusses on: 2.2.1. Cascade training by expanding the group of mastertrainers and strengthening teams of trainers at

provincial level for training in districts. 2.2.2. Acceleration of recently standardised and accredited training for NTP supervisors (managerial and

technical aspects), DMIS and financial management, planning, budgeting and for introduction of the new initiatives, e.g.: MDR-TB: PMDT TB-HIV (Training TB staff on HIV/AIDS): risk assessment, PITC, IPT HRD for culture and DST new diagnostic technologies. Establishment of 2 national training laboratories

2.2.3. Certification/accreditation of training Implementer: NTP, SR professional Societies under IDI (IMA), Health Workforce Unit, MOH Target Population: Technical and supervisory staff at province-, district and facility level and members of

professional societies SDA 2.3 Medical products, vaccines and technology Indicator: Number and percentage of district that reported no stock out in first line drugs on last day of the quarter Objectives / outputs 1. Improve Quality Assurance and Quality Control 2. Improve drugs and health commodity Management Information System 3. Improve forecasting and quantification of medicines and commodity requirements 4. Improve storage and inventory management 5. Improve Distribution to other stores and end uses 6. Improving rational drug use and patient safety 7. Commence pharmacovigilance program Activities 2.3.1. Technical assistance for pharmaceutical management of SLD 2.3.2. TA for all medicines for: sampling and QA testing to meet GF QA compliance requirements; 2.3.3. Develop revised reporting system for medicines and commodities after contracting out of physical

distribution services. 2.3.4. Develop training plan including ToT, and training at Province and District levels in new system. 2.3.5. Develop system and procedures for quantifications of new products –. 2.3.6. Develop contracts, monitoring, reporting formats, audit control and management for

subcontracted physical logistics service.. 2.3.7. Develop system for supply into approved private sector operators. 2.3.8. Assist the National Drug Regulatory Agency (BPOM) to develop national pharmacovigilance

system to incorporate TB and develop training program and ToT (this activity is in coordination with the cross-cutting HSS proposal).

The activities under this SDA will be in coordination with DG Pharmaceutical service, Food and Drug Administration and the cross-cutting HSS proposal Implementers: PR with provincial and district health offices and engaging external consultants,

SR: Directorate of Pharmaceutical Services, Target Population: TB Patients, Food and Drug Administration, district and provincial drug/logistic

warehouse. SDA 2.4 Health Financing Improve financing to ensure optimal accountability of funding and embedding planning for TB control in national and local development budgets (APBN, APBD), gradually phasing out external donor support. 2.4.1. Activities to ensure budegetlines for TB control in local government budgets (APBD): refer to

ACSM. This activity relates to SDA 1 under Objective 3 2.4.2. Establishing collaboration and coordination with national health/ social security schemes like

AsKes (National Health Insurance) JamSosTek (Social Security for workers/labour), JamKesMas (Community Health Insurance system), Jamkesda (Local Government Health Insurance). Objective is to develop regulations under the Ministry of Finance for incorporating TB in national and local insurance schemes and establish reimbursement systems for health workers providing care to TB patients. This intervention is essential to sustain operational activities for TB control



after donor funding stops. Seed money is required to link the national program with national insurance schemes like JamkesMas, and AsKes and linking district TB programs will local insurance schemes under JamKesDa.

Implementer: NTP, SR Planning bureau MoH, National Planning Board. Target Population: Local members of parliament, insurance company companies. SDA 2.5 Health Information System This SDA intents to address the constraints in the national and local health information systems including the poor quality of TB surveillance in hospitals and private sector. Proposed activities are complementory to activities initiated under R5 and R8. 2.5.1. Improving TB surveillance by incorporating TB notification in the hospital reporting system,

establishment and maintenance of a web-based TB information system and incorporate TB data to the the National Health Information System (SIKNAS) under the CDES (Center for Data and Surveillance Epidemiology) and Provincial / District Health Information system (SIKDA) under the Prov/District Health Authority.

2.5.2. Improving data collection to disaggregate case notification and treatment data by age and sex, analyze and adjust DOTS plan accordingly.

2.5.3. Coordination meetings at provincial / district level for monitoring and data validation. 2.5.4. Implementation of a nationwide prevalence survey, mortality and other impact studies. 2.5.5. Implementation of DRS: establishing health facility based DR sentinel surveillance. A proposal on cross cutting HSS is being developed, addressing weaknesses in the general HIS. The proposal focusses on developing an integrated HIS in Indonesia including establishing 5 centres of excellence for health informatics, integrated data management including data quality assurance and mortality registration. Implementer: NTP, SR Provincial and district health offices, National Institute for Research and

Development. Target Population: All TB patients in Indonesia. Objective 3: Strengthened community systems and empowered communities to support and sustain TB control. Interventions under this objective aim at increased awareness on TB disease in the community, at preventing patient delay through involvement of mass community organisations and increased local demand for quality TB control services to local governments. Existing community mass organisations with country wide social networks will be involved in prevention and care of TB patients. Activities are centered on engagement of existing woman and youth organisations like the PKK (Family Welfare Movement), that have the potential to inform and mobilize large populations including those in remote areas. Objective is to involve these organisations and other CBOs/NGOs in suspect identificationsuspect referral for laboratory examination and treatment monitoring. This proposal also seeks to integrate TB control into the existing village health initiative (‘’Desa Siaga’’ = Village Preparedness and Response’’). These are local communities linked to a village health post (PosKesDes) which is lead by a health worker (ususally village midwife) and supported by community cadres. Desa Siaga promotes social and community health responses and offers an unique opportunity to expand community involvement in TB in Indonesia. During the extensive consultative process for situational analysis and prioritization of stragegies during development of the StraNas (National Stratregic Plan 2010-2014) several NGOs, community organizations and large FBO including Nahdlatul Ulama, Aishyah (Muhamamadiah) and Perdhaki participated in the situational analysis. Consecutive meetings were held to identify areas and geographic regions where strengthening of community system interventions were most needed. The SDAs for this objective have been formulated in accordance to the Community System Stregthening (CSS) framework as elaborated in the GFATM concept note. We aim to comprehensively adopt six core components of the CSS framework, the fifth core element of the framework however for reasons of efficiency (minimising duplication of activities) organisational and leadership strengthening has been integrated in this proposal into the third core component (resources and capacity building). Core Component 1: Enabling environment and advocacy SDA 3.1 Monitoring and Documentation of community and government interventions



Indicator 1. Number of community based organisations that documented feedback meeting with the

community reviews or evaluations in the last 12 months Activities under this SDA are supporting implementation of the amended Indonesian ACSM Framework . So far implementation of this framework has resulted in several positive achievements, including enhanced participation of local NGOs in national consultative forums. Additional activities are needed in the following areas: 3.1.1. Accelerating dissemination of the patient charter to providers, local parliaments and communities. 3.1.2. Involve HIV/AIDS NGOs in advocacy activities for TB control and strengthen local patient

organisations to speak out on behalf of patients to local parliaments, as ‘’Patient Watch’’. 3.1.3. Documenting best practices, lessons learnt and evidence gained during implementation of the

ACSM Framework (through OR), publish and disseminate nationwide. 3.1.4. Production and channeling of local specific IEC and communication materials for specific

audiences e.g. children, women, community based organisations and community leaders (e.g. Tuha Peut di Aceh).

Implementer: NTP,

SR National, provincial, district TB committees, NGOs, CBOs providing care to TB patients.

Target Population: Community and local parliaments.

SDA 3.2 ACSM Proposed activities include : 3.2.1. Supporting local NGO’s to actively engage and advocate with decision makers in district

parliaments (DPRD) in the effort to ensure implementation of the new SPM regulation in local health facilities (especially hospitals) and to increase local budget (APBD) allocations for TB control;

3.2.2. Establishing a national TB ambassador to promote local government buy-in for TB Control. 3.2.3. Implementation of the recently developed advocacy tools, to strengthen lobbying and advocacy

capacity of local TB teams / NGOs aiming to address the poor local government support for TB. 3.2.4. Supporting NGOs in development of advocacy messages and campaigns 3.2.5. Collaboration with Department of Education (DikNas), and the Religious Department (Depag) for

development of educational materials on TB and TB-HIV for each level of education (e.g. primary, secondary schools, islamic boarding schools (pesantren/madrasah).

3.2.6. nhancing media relations (develop network and linkages) and capacity building for communication strategies through media – radio, television, print.

3.2.7. Participation of representatives from NGOs in International meetings and policy dialogue of the Stop TB Partnership and other forums and exchange/study visits to learn and compare best practices for NGO engagement in TB control.

Implementer: NTP, SR Center for Health Promotion MoH Target Population: TB patients, CBOs and local parliaments Core Component 2: Community network, linkages partnership and coordination SDA 3.3 : Building community linkages, collaboration and coordination Indicator: Number of community based organisations that deliver services for prevention, care or treatment and that have a functional referral and feedback system in place This SDA focuses on fostering coordination and linkages between NTP and local NGOs by: 3.3.1. Engaging women and youth organisations like the PKK (Family Welfare Movement), KOWANI

(Indonesian Women Cooperative), IWAPI (Indonesian Women Entepreneurs), Pramuka, HIV/AIDS NGOs and other local NGOs/FBOs (like Karang Taruna etc) to involve these organisation in suspect identification, referral for laboratory examination and treatment monitoring. Activities include technical capacity building of these NGOs through the provincial and district health services. Inputs may include provision of small grants to local women organization to test model interventions.

3.3.2. Support integration of TB into the existing village health initiative (‘’Desa Siaga’’). NTP in collaboration with BinKesMas and Promkes will carry out situational assessments in



selected and representative provinces, in order to identify needs for community system. strengthening and to develop a national system for inclusion of TB control in Desa Siaga. Criteria for representativeness in the assessment include geographic characteristics and program specific issues. Objective is to involve Desa Siaga in TB control program and build capacity on TB control prevention and care.

3.3.3. Reinforcement / revitalization of the existing National Partnership Forum o Support for joint secretariat of the partnership. o Regular meetings for the partnership at central and provincial level.

3.3.4. Linking local NGOs to provincial DOTS team ensuring integration of NGOs in this coordinating bodies.

3.3.5. Establish patient network to improve access to TB care. 3.3.6. Enhancing capacities of provincial and district health offices for partnership building and

collaborating with NGOs. 3.3.7. Rapid assessments by provincial health offices to identify potential organisations. 3.3.8. Establishment of Provincial partnership forums in minimally 7 provinces, focussing on provinces

with with a low CDR. Implementer: NTP, SR: Women-, Youth-, and patients Organisations. Target Population: Communities all over Indonesia, CBOs and TB program staff. Core Component 3 : Resources and capacity building (including core component 5: organisational and leadership strengthening) SDA 3.4: HR Skill building for service delivery, advocacy and leadership: Indicator:

1. Number of community health workers and volunteers currently working in community based organisations who received training or re-training in TB service delivery according to national guidelines in the last 12 months

2. Number of community based organisations that received training for institutional strengthening

Activities are aimed at increasing integrated service delivery at community level: 3.4.1. Capacity building of NGOs currently engaged in TB control (e.g. Aisyah, NU, PPTI):

leadership training for policy and advocacy roles at national levels and management, planning, monitoring & evaluation and implementation of TB electronics).

3.4.2. Capacity building of local HIV-AIDS NGOs to: o Leverage their potential for referring TB suspects to NTP, monitoring of treatment adherence

and using support networks for TB and MDR-TB patients co-infected with HIV; o Strengthen leadership and advocacy to influence local policies and enhance local advocacy

initiatives supportive of TB control. o Improve M&E capacity at NGO level for analysis and use of available data such as surveys of

high risk populations . 3.4.3. Study visit to compare best practices in NGO engagement in TB control, e.g. BRAC in Bangladesh. 3.4.4. Small grants for NGOs to model intervention. 3.4.5. Technical assistance for CSS, including gender auditing. Implementer: NTP , SR: NGOs Target Population: CBO staff SDA 3.5. Financial Resources NTP will facilitate competitive grants for modelling of innovative community-based TB control model through following procedures: 3.5.1. Annual calls for proposals by CCM/TWG TB. 3.5.2. Development of proposals by interested CBOs/NGOs. NTP in collaboration with technical partners

will provide technical assistance (local Universities, NGOs, TB CARE) through coordination under the partners forum.

3.5.3. Review of submitted proposals by the CCM TWG to asses the potential contribution of the proposal to the objectives and targets outlined in the performance framework.

3.5.4. Capacity building of the selected NGOs to strengthen financial and project management, implementing internal accountability systems, acquisition and use of accounting software including oversight of resources and budgets etc.

Core Component 4 : Community activities and service delivery SDA 3.6. Community-based activities - service availability, use and quality



Complete this version of section 4.4.1(a) (b) and (c) if the applicant selected option 1 in section 3.1 of the Proposal Form

Option 1 = Transition to a single stream of funding by submitting a consolidated disease proposal

4.4.1 Interventions

This section should be completed in parallel with the Consolidated Performance Framework and detailed budget and work plan

(a) Overview of programmatic activities Describe the objectives, service delivery areas (SDA), and activities of the consolidated disease application. The description must be organized in that exact order and the numbering system must match the Consolidated Performance Framework, detailed budget and work plan. The narrative description of the Round 10 interventions should reflect all objectives, service delivery areas (SDAs), and activities in the Round 10 consolidated disease proposal, but distinguish between what programming is being continued from existing grants versus new programming for Round 10.

The description must identify: (1) who will implement each area of activity (e.g. Principal Recipient, Sub-recipient or other

implementer); (2) the targeted population(s); (3) what changes in implementation and/or the targeted population(s) have occurred, if any, for

those elements which are from existing grants and continuing in this consolidated disease proposal;

(4) any links between the existing grant activities to be continued in the consolidated disease proposal, as these activities previously existed in separate grants;

(5) any links between the proposed activities and existing Global Fund grants for other diseases or HSS; and

(6) how duplication will be avoided if there are linkages identified in points (4) and (5) above.

Not applicable

(b) Changes to existing SDAs, programmatic activities, indicators and targets

Activities under this SDA include: 3.6.1. Developing a general guideline and protocol for engagement of local NGOs describing the

minimum standards for quality DOTS services and dissemination of these guidelines through partnership forum.

3.6.2. Situational analysis / mapping of needs and gaps in community based service delivery in selected provinces with low CDR, and identification of potential community organizations.

3.6.3. Developing referral systems between local NGOs and local health services to ensure access to TB care for TB suspects, and back-referral to community systems for ongoing support for treatment and patient care.

Implementer: NTP, SR: NGOs, CBOs Target Population: TB patients, community organisations. Core Component 5: Organisational and leadership strengthening The activities for this core component has been integrated into Core Component: Resources and capacity building (see above). Core Component 6 : Monitoring, evaluation and planning SDA 3.7: Monitoring & Evaluation, Evidence Building This SDA will be implemented in the form of community monitoring and evaluation of service quality, including linkage and referral systems, and clinical services, Main activities proposed to be supported through Round 10 include: 3.7.1. Supporting regular community monitoring and evaluation meetings. 3.7.2. Facilitating technical assistance from provincial and district health office/DOTS team.



In the table below, list the SDAs and activities of existing grants consolidated within the Round 10 consolidated disease proposal. Explain whether each SDA and activity from an existing grant will be included in the Round 10 consolidated disease proposal by indicating an increase in scale, decrease in scale, continuation without change, or discontinuation. Provide justification for any proposed changes or discontinuation.

The proposed changes should be clearly and systematically reflected in the Consolidated Performance Framework

Round # Service

Delivery Area (SDA)

Activity Proposed change Justification for change

use “Tab” key to add extra rows

(c) Changes to existing impact or outcome indicators and targets

Describe any major changes in indicators and targets that may have occurred due to the programming described above in sections (a) and (b) and that is supported by the Consolidated Performance Framework. In particular, if there has been discontinuation or change in indicators or if targets have been changed between previous grants and the Round 10 proposal, describe why this has occurred.

Not applicable

4.4.2 Addressing weaknesses from a previous category 3 proposal

If relevant describe how the weaknesses identified in the TRP Review Form of a previous category 3 proposal have been addressed.

Not applicable

4.4.3 Lessons learned from implementation experience

How do the implementation plans and activities described in 4.4.1 above draw on lessons learned from program implementation (from either Global Fund financed or non-Global Fund financed programs)?

Indonesia is the first country in the South East Asia Region to achieve the global targets (70/85% CDR/SR respectively) and now fifth among high burden countries globally. Improvement of case detection has progressed consistently with the increase of external donor support. Global Fund support contributed significantly to the achievement of the global targets with treatment success rate steadily around 90% over the last four years and a case detection rate that sharply increased from 19% in 2000 to 74% in 2006. The NTP is being supported by a complex but transparent partnership of several technical- and donor agencies, and it succeeded to secure sufficient funding for the realization of this plan following approval of round 5 and round 8 of the Global Fund and USAID/TBCAP project support. Notwithstanding, there are still major gaps in the control program that need to be filled to adequately address the epidemic particularly in term of MDR-TB, TB-HIV, High-Risk Groups, Health system strengthening and community system strengthening. Experiences in the previous years also underline lessons for future implementation. Lessons for management and administration Lessons from management and administration of Round 1, Round 5 and Round 8 also provide a wealth of experience for implementation of the proposed Round 10 grant. 1. Lessons from previous grant restriction highlights the importance of:

a. Management Internal Control Team (MICT): the grant restriction underline the need to



revamp the Financial Internal Control Team (FICT) which only oversees financial matters to become a cross-cutting Management Internal Control Team (MICT) since July 2010. MICT encompass broader involvement of all management aspects (e.g. legal framework, assets, work force, planning, financing). Support will be allocated in R10 – for oversight meetings and supervision to address management issues (e.g. harmonizing state regulation with GF regulation).

b. Development and implementation of a Risk Management System encompassing risk identification, risk assessment and risk monitoring to ensure adherence to the Project Implementation Manual and proper implementation of the program by SRs. This is done in common understanding between PR and SRs, Government and GFATM secretariat.

2. Additional lessons from previous rounds a. Experiences from Round 1 highlight the importance of: proper forecasting, continuous

monitoring of implementation to adjust activity planning based on output/outcome indicators; step-wise expansion; compliance to standard terms and conditions as attached to the grant agreement.

b. Round 5 is still ongoing and administrative challenges documented are related to overspending (e.g. due to miscalculation of unit costs); under/delayed spending (e.g. due to delayed claims), need for reprogramming, weaknesess in the procurement system. Delayed claims has been attributed to the fact that GF contracted staff have only been allocated at provincial level, due the threshold of maximum proportion of administrative costs. This has lead to considerable work overload of a limited number of staff at provincial level. Based on this observation, efforts are currently being made to delegate administrative tasks to staff at district level supported by GF grants for HIV/AIDS and Malaria. Districts not covered by staff with salaries through these other grants would be proposed to be supported through local government funding. Implementation of PMDT was delayed due to several legal and procedural factors outside control of the NTP which were not foreseen.

c. Round 8 has just started and implementation set off smoothly. Preliminary observations suggest disparity between regions in they capacity to respond to problems Furthermore various SR face difficulties in achieving CDR targets due to extrapolation of national estimates of TB incidence to provincial level. (Hence the need to increase the study population for the next prevalence survey in order to enable obtaining regional prevalence figures). Activities for round 8 also has to be reduced due to shortage of budget because of significant currency exchange loss (from 11.000 IDR -> 9.000 IDR per 1 US$).

Lessons for program interventions NTP has made major efforts to expand the link to the public and private hospital sectors. HDL Guidelines have been developed, and ISTC have been introduced and endorsed by all professional associations under the Indonesian Medical Association since 2006. Training material for hospital DOTS linkage which includes ISTC, has been developed and are now being used in an accelerated training program supported by GFATM. Additional technical surveillance officers have been employed by USAID/TBCAP, posted in strategic hospitals to monitor and guide the expansion of the hospital DOTS, and ISTC Task Forces have been established in 32 out of 33 provinces. The progress in Hospital DOTS Linkage (HDL) is obvious: most hospital managements show a strong commitment to join the DOTS strategy however the progress of implementation is slower then expected. So far less then 400 hospitals are regularly reporting to the NTP. However HDL expansion is still hampered by lack of support from the majority of health professionals, in particular specialists rejecting DOTS for a variety of reasons. One of the lessons learnt from the slow progress in HDL was related to the limited involvement of YanMed (Department of Medical Services in MoH) as a major stakeholder responsible for hospital services. Recently NTP, with support of TBCAP, has stepped up efforts to involve YanMed to fully utilize its regulatory responsibility and functions. This proposal will harness the potential role of DG Medical Service, not only to accelerate hospital DOTS linkage but also to incorporate TB control in the hospital accreditation system. The introduction of performance based incentives in previous years has raised concerns over data validity and undermining other activities not linked to incentives. This has led to recruitment of additional salaried staff and realignment of the existing performance based incentives. Since several years NTP has increased engagement of local and international NGO’s like PPTI, Hope International, large Faith Based Organizations like Muhammadiyah, Aisyiah, Perdhaki (Catholic), Pelkesi (Protestant) and large Community Based Organizations like PKK (Woman Welfare Organization) and NU (Nadatul Ulama). However contributions and outputs of these NGOs are still relatively limited. Based on



this experience, the proposed activities will target strengthening partnerships as well capacity building of these NGOs and provincial/district health offices to collaborate with NGOs.

4.4.4 Enhancing TB/HIV collaborative activities

Describe: (a) how the proposal will contribute to strengthening TB/HIV collaborative activities; and (b) the collaboration between the National TB program and the HIV services of your country. Indonesia is classified as a country with a concentrated HIV/AIDS epidemic but with alarming increase of among high risk populations (sexual and drug use). In some parts like Papua Island, the HIV epidemic is considered to be generalized. NTP and NAP jointly developed a National TB/HIV Strategy in 2007 though on small scale TB/HIV collaborative activities had been implemented even before. In 2007, NTP and NAP jointly developed a national policy and guidelines, SOPs, training curricula and tools for TB/HIV. Through GF R 5 and 8 both NTP and NAP jointly implement TB/HIV activities by strengthening coordination between two programs at the national level, province/district level and within health facilities i.e. hospitals and selected VCT health centers . The key activities to address TB – HIV are based on the interim policy on collaborative TB-HIV activities and include intensified TB case finding among PLHIV, TB infection control, and free HIV testing, treatment, care and support for TB-HIV co-infected patients. INH Preventive Therapy is not yet included in the national policy. A plan for IPT piloting has been developed for two selected sites with the objective to incorporate this intervention in the national TB-HIV policy. Activities to decrease HIV burden among TB patients include HIV counseling and testing of new TB patients with risk of HIV (implemented in DOTS setting managed by NTP with GF R8 TB) and provision of Cotrimoxazole Preventive Therapy, and ART for co-infected patients (GF HIV R8). NTP and NAP work collaboratively on improvement of M&E and supervision. R 8 TB/HIV activities are implemented in 12 HIV priority provinces (concentrated of general epidemic) out of 33 provinces. Through GF R9 HIV, National AIDS Commission, NAP and NGO PR are implementing HIV prevention and care including TB/HIV in the remaining 21 other low HIV prevalence provinces. However, most of these provinces are high TB Burden areas, particularly the Eastern Islands. Recent data from some cities in these islands showed a dramatic increase of HIV among new TB patients. NTP proposes GF R 10 to bolster support for TB/HIV activities covering the areas in GF HIV R 9 in close collaboration with NAP. The main activities in GF R10 include:

1. Piloting gender responsive TB-HIV interventions: Women with high risk of HIV i.e. female sex workers, female IDUs, female partners of IDUs, and transgenders (who perceived themselves as women) in the pilot sites will be educated and referred for TB screening in nearby health facilities.. The PR TB R10 will seek collaboration with HIV NGOs supported by GF R 8 and 9.

2. TB screening and promotion for HIV counseling and testing wit a focus on marginalized groups: urban migrants (in slum areas), MSM, male sex workers, and prisoners are the targets for. These activities are also in collaboration with NAP complementary to GF R 5 and 9.

3. PITC: Provider Initiated Testing and Counseling will be promoted in TB DOTS setting in R 10. 4. Promotion by NTP to implement The Three I’s in collaboration with NAP. This activity includes

piloting of IPT in selected HIV settings and integration of PMDT and TB/HIV. 5. Strengthen structured coordination bodies in the new provinces and districts covered under R9

HIV. These activities are accommodated under SDA 1.3 TB-HIV

4.4.5 Enhancing social and gender equality

Using specific references to objectives, SDAs, and activities included in section 4.4.1, explain how the Round 10 interventions address issues related to social and gender equality and confirm that these items have been properly costed in the budget.

DOTS services in Indonesia are in line with the “Pro-Poor Strategy” of the government. Majority of DOTS is currently been provided in health centers where lower socio-economic people have access to free services. Because of the large size of the country with 17,000 islands, some parts of the country with different density of population have un-equal access to TB DOTS service. This inequality has been addressed in GF R 5 and 8 by DOTS in remote area activities. Although the DOTS program previously



had no special focus on gender equality the access to DOTS services for women compared to men is considered to be acceptable. The National TB Prevalence surveys in 2004 showed a Male-Female ratio of active TB of 1.7. However it should be noted that the number of active TB cases found in this survey was rather small (82 active TB cases). In 2005 the Male- Female ratio was 1.4 which decreased to 1.3 in 2008.Analysis of M:F ratio in various age groups reveals a lower access to service among elder age groups of women from 55-64 and 65 and older. NTP plans to conduct a quick assessment to understand the factors affecting this lower access for older women and address these factors through GF R 10. Regarding TB in children the NTP is collaborating closely with IDAI (the Indonesian Pediatric Association) to improve quality of diagnosis and treatment of TB among children through GF R 8. In 2008 around 11% of all TB cases were children below the age of 15. However, with increasing of HIV among new born and children, there is need to continue to improve the quality of diagnosis and treatment of TB among the young age groups, particularly, among children with HIV and TB. There are several population groups with relatively poor access to DOTS services due to social and gender imbalance, including migrants in slum areas in big cities, HIV high risk populations (particularly women), marginalized groups and prisoners. Because of poverty, people from rural areas migrate to urban areas and most of them stay in squatter areas. Since they are ‘illegal’ and ’unregistered’ these poor migrants are usually not covered by local insurance mechanisms for the poor and as a consequence do not have access to free TB care. HIV high risk groups i.e. female sex workers, female IDUs, female partners of IDUs, MSM and male sex workers and transgenders (who perceived themselves as women) also have limited access to DOTS due to stigmatization. In prisons and detention centers , the Prison department in the Ministry of Justice and Human Rights has formulated a policy and strategy for HIV and TB prevention and care in the prisons, however implementation is at limited scale due to lack of capacity and resources. In GF R 10, NTP will address the issue of gender and social imbalance by: 1) Improving data collection to disaggregate case notification and treatment data by age and sex,

analyze and adjust DOTS plans accordingly (SDA 2.5. Health Information System). 2) Improve the quality of TB diagnosis and treatment among children with TB and TB/HIV including

intensified contact examination (SDA 1.2. High-Risk Groups). 3) Work collaboratively with PRs and NGOs of HIV R 8 and 9 to pilot TB screening among high risk

populations even before HIV status is known (these include female sex workers, female IDUs, female partners of IDUs, transgenders, MSM and male sex workers) and refer suspect cases to local DOTS services (SDA 1.2. High-Risk Groups).

4) Increase collaboration with local community organizations (NGOs and FBOs ) through GF R 10 to promote TB screening among urban poor migrants and refer suspect cases to local DOTS facilities (SDA 1.2. High-Risk Groups and SDA 3.3 : Building community linkages, collaboration and coordination).

5) Intensify collaboration with the Prison department of the Ministry of Justice and Human Rights , review current implementation of the national strategy for TB in prisons and assist with development of a 5 year Strategic Plan for TB in prisons with the objective to strengthen TB service delivery. This plan should include TB capacity building of the prison workforce, building linkages between prisons and local health facilities and include a plan for pre-post release referral system (SDA 1.2. High-Risk Groups).

For costing of the interventions related to social and gender equality and we refer to the detailed workplan in the Attachment

4.4.6 Partnerships with the private sector

Describe how contributions related to: (i) co-investment from the private sector, and (ii) donated goods or services, will add value to the planned outcomes of the proposal. Make specific reference to the associated objectives, SDAs, or activities to which they are linked.

1. In line with government commitment for universal coverage, NTP will intensify efforts to engage insurance organizations and private health insurance companies to integrate DOTS into their standard insurance packages. The main two health insurance companies are PT Jamsostek (Social insurance company for employee and PT Askes (National Health Insurance Company), details



of envisaged engagement are as follow: a. Recently Directorate General for Disease Control and Environmental Health, Ministry of Health,

Indonesia has signed a Memorandum of Understanding with PT Jamsostek (Social insurance company for employees ) to collaborate with the National TB program. Implementation of the DOTS strategy TB is among the top five diseases in Jamsostek health facilities and the disease contributes to 35% of all outpatient consultations in some of these facilities. Jamsostek currently covers 159,811 companies with 13 million employees. The insurance scheme also covers family members of employees, thus the total coverage is approximately 39 million participants, roughly 18% of the total population in the country. The total number of TB patients in the country per year is around 520,000. Thus, we can assume that 93,600 (18%) could be covered by Jamsostek. The estimated cost per patient treated in Indonesia is approximately US$ 180. Thus, the annual contribution of Jamsostek, assuming 100% coverage, would potentially reach US$ 16,848,000. Step-wise scale up of Jamsostek coverage during the proposed R10 is as follows: 2011 (20%); 2012 (30%); 2013 (40%); 2014 (50%); 2015 (60%), and total contribution of Jamsostek could be equivalent to US$ 33,696,000.

b. PT Askes (National Health Insurance Company) is currently covering 40% of the population (approximately 88,000,000). The total number of TB patients in the country per year is around 520,000. Thus, we can assume that 208.000 (40%) is covered by PT Askes. The estimated cost per patient treated in Indonesia is approximately US$ 180. Thus, the annual contribution of Jamkesmas with 100% coverage of its 208.000 participants would potentially reach US$ 37,440,000. Thus assuming PT Askes compensates for all costs related to diagnosis and treatment of TB according to DOTS (stepwise as follows: 2011 (20%); 2012 (25%); 2013 (30%); 2014 (35%); 2015 (40%), the total contribution of PT Askes could be equivalent to US$ 56,160,000.

Total potential contribution of health insurances would thus be equivalent to US$ 89,856,000 (16% of estimated total need over the proposed R10 period). This contribution is linked to SDA health financing.

2. Other co-investment from private sector contribute and add value to the outputs and outcomes of this

proposal eventhough it is not possible yet to quantify these contributions in financial terms. These co-investments would contribute to achievement of SDA 1.1, 1.3, 2.1 and 2.2. a. Professional associations under the Indonesian Medical Association are increasingly

supporting the NTP, contributing to dissemination and training activities for ISTC. Their involvement is crucial in adopting ISTC in the private sector and further prevent MDR. Private health facilities are also increasingly involved in TB service provision for adult and children using DOTS strategy. Those activities are expected to increase the number of adult and pediatric TB cases detected and treated.

b. Involvement of large companies (such as oil- and mining companies, large factories and plantations) for TB in work place initiative is still relatively low, however is gradually expanding, particularly in the remote areas: e.g. Timika TB Control Project is a successful partnership between the District Health Department, district-level tuberculosis (TB) control program in Papua Province and a private company (PT Freeport Indonesia). The mining company supports TB services through a local NGO. Another example is the National Coals Mining Company KPC in Kalimantan supporting a community health programs collaboration with PPTI (Indonesia TB Association), the Indonesian Doctor Association (IDI) and the Indonesian Red Cross (PMI). The activities carried out during this program are training and supervision and supporting Tuberculosis cadres. The steel company Krakatau Steel provided a permanent clinic supporting the DOTS program. A local NGO, YKB in collaboration with HOPE, works with International companies like has Pfizer and Johnson, Nike, Levi Strauss, Panasonic, Krakatau Steel, BP and others. YKB also agreements with five insurance companies that provide health coverage to factories in Indonesia with focus on MCH and infectious disease control including TB and hopes to replicate this with other companies.



Only complete section 4.4.7 if the applicant selected Option 2 or 3 in section 3.1 of the Proposal Form, DO NOT COMPLETE section 4.4.7 if the applicant selected Option 1 in section 3.1 of the Proposal Form

Option 1 = Transition to a single stream of funding by submitting a consolidated disease proposal Option 2 = Transition to a single stream of funding during grant negotiation Option 3 = No transition to a single stream of funding in Round 10

4.4.7 Links to other Global Fund resources

Describe in the table below the linkages between this Round 10 proposal and existing Global Fund resources. It is important to list the SDAs and activities as outlined in the current proposal in the left hand column, add a description as to how they relate to previous grants in the middle two columns, and then outline how the Round 10 proposal specifically addresses this in the right-hand column.

Key SDA and activity as proposed in the Round 10 proposal

Existing grants

Round 10 Proposal Round 5 Round 8

SDA 1.1. High Quality DOTS

Supporting diagnosis and treatment of new TB cases

Yes Yes Filling the gap after expiration of Round 5 and Round 8

SDA 1.2. High Risk Groups

TB in children

Yes No Active case-finding in household contacts and improvement of diagnosis

TB in prisons

Yes No Expansion of TB in prisons, IC in prisons and strengthening TB control capacity in Ministry of Justice

Gender responsive TB control program

No No Developing Guideline for TB Screening among Pregnant Woman, Piloting TB Screening Surveillance among Pregnant Woman

1.3. SDA TB HIV

Decrease the burden of HIV/AIDS in TB patients

Development of Guideline, Training Module and Training Piloting Implementation

Promotion of HIV screening among TB patients in 12 provinces

Expansion to other provinces and

Implementation of PITC, Focus on high risk,-and vulnerable groups including women and MDR TB patients, collaboration with HIV NGOs

Decrease the burden of TB in people living with HIV/AIDS

Development of Guideline, Piloting, training, establishing TB-HIV collaboration in selected areas

Infection Control and promotion of TB screening among HIV/AIDS patients in 19 provinces

Expansion of TB-HIV collaborative activities to cover all high prevalence HIV provinces, Piloting of INH Prophylaxis, Therapy,



SDA 1.4. MDR-TB

3.1 TB MDR services Piloting and Initial implementation of 2 sites

No Expansion coverage to all 33 provinces

SDA 1.5. Procurement and su

Procurement of buffer stocks FLD, SLD and microscopes

SLD procurement, Buffer stocks for FLD

Buffer stocks for FLD

Procurement FLD buffer, microscope replacement, PPD, SLD for expansion

SDA 2.1. Service Delivery

Hospital DOTS Linkage

Development, Review of Guideline and also Training Module

Training and building networks between NTP and hospital

ISTC and HDL trainings for hospitals

Incorporation of TB in minimum service standards and accreditation standards for hospitals

TB in Private Practitioners (PPs)

Initiation of involvement of PPs

No Incorporating ISTC for certification private practitioners, strengthening professional association, Training and CME for PPs

SDA 2.2. Health Workforce

Training

Yes (mainly for Hospitals)

Yes (DMIS, TB-IC, DOTS Plus)

Training for new districts, staff turn-over and nationwide expansion of new strategies

SDA 2.3. HSS: Medical Products, Vaccines and Technology

Quality assurance and quality control for medical products

No No Yes

DMIS

Training for district TB coordinators

Training for district TB coordinators and pharmacists

Development and implementation alert system for TB drugs

Pharmacovigilance

No No Implementation of surveillance Adverse Effect on TB drugs

Improve drugs distribution No No Contracting out

SDA 2.4. HSS: Health financing

Strengthening Health Insurance scheme

No No Developing linkages and collaboration with National Health Insurance schemes

SDA 2.5.HSS: Information System

Integration to general health information system

No No Integration of TB surveillance with National and district health information



4.4.8 Links to non-Global Fund resources

Describe whether the Round 10 interventions (e.g. goals, objectives, SDAs, and activities) listed in section 4.4.1 have linkages to programs financed through non-Global Fund resources. If such linkages exist, list the non-Global Fund financed programs and their activities, and explain how the proposal complements those programs and activities. In addition, explain how the Round 10 interventions do not duplicate existing programs and activities supported by non-Global Fund resources.

system (linked to cross-cutting HSS proposal)

SDA 3.2. ACSM

ACSM activities

Informed demand, improve patient education and community participation, strengthening political commitment with focus at central level

No Informed demand, improve patient education and community participation, strengthening political commitment with focus at district level

SDA 3.3. CSS : Building community linkages, collaboration and coordination

Engaging large NGOs

Linking NGOs to NTP as SRs

Large NGO as PR implementing community TB care

Expand involvement of NGOs with focus on women and youth organizations; include TB in Village health initiative (Desa Siaga)

SDA 3.5. CSS: Financial Resources

Empowering small NGOs/CBOs

No No Competitive grants for NGOs/CBOs to pilot innovative community based TB control



KNCV Tuberculosis Foundation remains the coordinating partner of Stop TB Partnership for Indonesia, providing technical assistance to the NTP in several priority areas. Over the last 10 years KNCV has been the leading agent in the Coalition for Technical Assistance (TBCTA), assisting the NTP Indonesia in its efforts to accelerate DOTS expansion, based on the objectives and strategies of the Five Year Strategic Plans through TBCTA and TBCAP mechanisms. KNCV also supports smaller projects from own funding sources and channeled funding from CIDA (ISAC) to support DOTS expansion in selected provinces from 2003-2006. All support is complementary to resources provided through GFATM. The work plans for KNCV/TBCAP support are always prepared after consensus and in close consultation involving all partners. Close collaboration and regular coordination with NTP and partners avoids overlap in any of the support areas and allows readjustment of planning if necessary. USAID: One of the key mechanisms for supporting USAID’s TB care and prevention strategy over the last 5 years has been the TB CAP project. The project will end in September 2010, however a no-cost extension for priority activities has recently been granted until March 2011. Support focused on technical assistance to the NTP through local capacity building in the following areas: increased political commitment, building of public-private partnerships for DOTS focusing on hospital DOTS linkage; strengthened TB drug management; improved management of MDR-TB; strengthened TB/HIV coordinated activities; improved human and institutional capacity; and strengthened TB care and support. TB CARE is the expanded follow-on mechanism to the TB CAP program. All support is complementary to GFATM support. For the coming 5 years TB CARE will be one of the main global mechanisms for implementing USAID’s TB strategy as well as contribute to TB/HIV activities under the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). TBCARE will complement existing and planned projects in the Bureau for Global Health to provide global leadership and support to National TB Programs (NTPs) and other in-country partners. Technical approaches under TBCARE will be: Improving and expanding TB care and treatment (DOTS expansion and strengthening), Strengthening Leadership and Management for TB, supporting quality National TB Laboratory Networks and universal and early access to Quality Diagnosis and Treatment, National Access to Quality TB Commodities, Effective TB monitoring, evaluation and surveillance. Furter TBCARE will support expansion of Programmatic Management for Drug Resistant TB (PMDT) focusing on diagnosis, treatment, care and surveillance of MDRTB, TB/HIV care and treatment, intensified TB case finding, TB screening and treatment within HIV settings and Isoniazid Preventive Therapy. Support to Health Systems Strengthening includes enhancing political commitment for TB, HRD, TB Information and Surveillance Systems, Infection Control (IC) and Engaging all Care Providers. All above technical approaches are priority areas for NTP and GFATM support Overarching elements (key issues that cut across the TB technical areas ) are ‘’CARE ‘’: C - Coordination: leveraging Country resources, strong partner coordination A – Access: gender and vulnerable groups R - Responsible and Responsive: efficient, financial vigilance and country based implementation E - Evidence Based: strong M&E and evidence based project interventions WHO Indonesia supported the NTP through technical assistance, and assistance through funding from DFID expired in March 2009). WHO has supported tuberculin surveys, a TB mortality study, Hospital assessment studies, strengthening surveillance using GIS and provision of TA. All TA is complementary to that provided by GFATM and TBCAP. The ISAC support concentrating on TA for surveillance, building of management capacity, training in TB supervision/monitoring and evaluation, laboratory strengthening, advocacy and communication, partnership building and information, and community-based TB coalitions has now also expired. WHO now get support through TBCAP, assisting NTP with implementation of the National TB control strategy and GF R 8 implementation The key areas WHO is currently providing support to NTP include quality DOTS program, PMDT and DRS, TB/HIV (training), PAL and TB in children. UNITAID: in collaboration with GDF, Stop TB, GFATM and GLC Global Fund to Fight AIDS, TB and Malaria (GFATM) , promoting the scale-up of MDR-TB diagnosis using new rapid diagnostic tests, has committed to funding these tests until 2011, with the aim of facilitating the response to 15% of the global MDR-TB burden. Indonesia is mentioned as one of the potential countries (Category 3) to receive complementary support in 2011 for Liquid culture, rapid immunoassay, and DST – 100% in Category 1,2, and 3 countries and for line probe assays.



4.4.9 Strategy to mitigate unintended consequences of additional program support on health systems

Describe:

(a) the potential risks and unintended consequences on health systems that may result from the implementation of the proposal; and

(b) the proposed strategy for mitigating these potentially disruptive consequences.

During the preparation of the proposals the TB team had repeated consultations with all stakeholders including NAP to discuss and decide on roles and responsibilities of both programs, based on the strategies of the TB-HIV collaboration interim policy document. It is expected that this productive collaboration will subdue any potential disruptive effects. The proposal is also written in coordination with the HSS proposal development team. Reflections from these exercises highlighted the following issues:

1. Unintended consequences on the general health system

a. Since HSS is one of the main components of this proposal it is expected that there will be no significant unintended consequences on the health system: In fact the second objective concentrates on solving several serious constraints in the Indonesian health system, in particular related to limitations in human resources, monitoring and evaluation, and availability of essential supplies, including strengthening the financing system and the basis for sustainability of TB control program activities through linking to the national and local insurance systems. Substitution of external (donor) funding for TB control interventions by reimbursements through national and local insurance schemes (e.g. JamSosTek, JamKesmas, JamKesDa) will strengthen future resourcing of the health system.

b. Though most of the health systems weaknesses are general and are also applicable to the other two disease control programs for HIV and malaria, the majority of the proposed health strengthening interventions in this proposal are specifically related to TB control. Overlap of health systems related issues with other disease control programs relate mainly to leadership and governance, health finances and partly in management of drug supply and information systems.

c. The TB- epidemic and the steadily spreading HIV epidemic are increasingly overlapping, and so do health system strengthening interventions: HRD, surveillance, drug and supply management and the building of referral systems are increasingly combined and integrated: NAP and NTP collaborate in training at local level, M&E systems of the community health systems are being synchronized with the M&E system of the Directorate of Medical Services (YanMed), contracting out of the TB drug distribution system follows the same system as NAP program has implemented etc. Collaboration between TB and HIV programs is increasing since 2006 during the development of the TB-HIV policy document, training materials for TB-HIV and development of TB-HIV surveillance materials.

2. Unintended consequences on program management:

a. The management of a large amount of approved funding would potentially impose additional burden on the existing management capacity. To anticipate this NTP will continuously strengthen management capacity at all levels.

b. Expansion of initiatives such as HDL can create significant extra burden on the existing program capacity. To anticipate this NTP will work with key partners (e.g. the Indonesia Hospital Association) to manage these additional activities.

c. Embarking on areas beyond current reach of the program may lead to adoption of ineffective interventions through trial and error. To minimize this NTP will promote step-wise approach of new initiatives (commencing with small-scale pilots before expanding) and collaborate with other relevant partners, including universities to facilitate evidence based decision making for policy and guideline development.

3. Potential consequences of natural disasters: Indonesia is prone to a wide range of disasters (e.g. flood, earthquake, land slide, tsunami). Years of experiences however has led to development of disaster management capacity including in the health sector, for instance through development of district disaster plans and hospital disaster plans. These recent capacity build up would minimize impacts of disasters on health program, including activities proposed under this R10.



4.5 Program Sustainability

4.5.1 Strengthening capacity and processes in tuberculosis service delivery to achieve improved health and social outcomes

Describe how the proposal contributes to overall strengthening and/or further development of public, private and community institutions and systems to ensure improved tuberculosis service delivery and outcomes. If available, refer to country evaluation reviews

Support explanation with excerpts from documents that the country has adopted, identifying the source, such as a National Disease Strategy

The activities in this proposal have been selected based on a consultative process with key stakeholders involved. They include representatives of civil society organizations, academic institutions, government sectors, international development partners and program implementers. The proposal recognizes the importance of capacity building for various components of TB control program to achieve improved outcomes. Health system strengthening and community system strengthening activities are thus very prominent in the proposal. Within health system strengthening, activities are geared toward strengthening of health workforce (including in the private sectors), enhancing quality of lab networks and supply chain management. Within the community system strengthening, activities are geared toward capacity building of NGOS at central and local level for leadership and management.

Additionally, the proposed mechanism to supply standard first line medicine, FDC, TB treatment kits to approved private sector social insurance scheme providers could greatly facilitate improved health outcomes as many TB patients are being treated by private providers. The growth of multiple social medicine insurance schemes in Indonesia in the last 5 years has been such that they are now estimated to account for more than 25% of public health spending.

www.healthsystems2020.org/.../2355_file_Indonesia_PSA_Consolidated_Findings_FINAL.pdf -

At present there is little control on the treatment provided and medicines used for TB treatment within these diverse schemes, which whilst using government funding, are nevertheless operating in the private sector. Supply of standard first line medicine, FDC, TB treatment kits to approved private sector social insurance scheme providers, could have an immediate impact on the situation by ensuring affordable medicines for patients ( free of charge), and promoting RDU and STGs – ( the FDC kits effectively do not permit any variations, since the dosage and regimen is ‘fixed’ within the FDC formulation). Further developments to engage private sector providers through the social insurance schemes could then be developed.

4.5.2 Alignment with broader developmental frameworks Describe how the proposal’s strategy aligns with broader developmental frameworks such as:

Poverty Reduction Strategies; The Highly-Indebted Poor Country (HIPC) initiative; The Millennium Development Goals; An existing national health sector development plan; Any other important initiatives.

This proposal is in line with broader developmental frameworks such as the Millennium Development Goals (MDGs), MDG target 8, and indicators 23 and 24.

The National Strategic Plan for TB control 2010-2014 (‘’breakthrough to universal access’’) is embedded in the National Medium Term Development Plan (Rencana Pembangunan Jangka Menengah) 2010-2014. This Medium Term Development Plan includes specific targets for TB control which is essential since inclusion of these targets in this plan ensures fixed budget lines for core NTP activities from the National Development Budget, including funding for drug procurement and other routine activities.



Furthermore the National TB Strategic Plan 2010-2014 is aligned with and part of the National Health Plan (Rencana Stratejik Kementrian Kesehatan) 2010-2014. The draft National TB Strategic Plan 2010-2014 provides the roadmap to achievement of the MDG for TB and identifies the gaps in government- and other source funding in order to accelerate TB control program in Indonesia as part of the global stop TB plan strategy. Furthermore the Ministry of Health has highlighted the need for healthcare reform to respond to public health problems which is outlined in the Roadmap on Healthcare reform. The blueprint of the plan was stated in the healthcare reform document.

The President of the Republic of Indonesia recently released Presidential Instructions number 1 and 3 year 2010 which call for acceleration of progress toward achievement of MDGs targets, including TB control, which this proposal is also in line with. This proposal is in line with the priorities and targets stipulated in the newly launched National Medium Term Development Plan 2010-2014 and the Strategic Plan of the Ministry of Health 2010-2014.

For a detailed description on alignment of this proposal within broader developmental frameworks: see section 2.3 in the National Strategic Plan for TB control 2010-2014 (‘’breakthrough to universal access’’) in the annex.

Indonesia does not qualify for the Highly-Indebted Poor Country (HIPC) initiative as our country is not considered to be highly indebted.

However, under a recent Debt2Health arrangement, Australia has agreed to cancel AUD$75 million of Indonesia's debt. On condition this proposal is approved, Indonesia will receive half of this amount to be invested in the national program to combat TB through GFATM mechanism.

More than half of Indonesia’s 230 million population lives on less than US$2 a day. Activities in the proposal will benefit vulnerable and poor people in accessing services so that they can avoid economic losses at family and household level in line with the Poverty Reduction Strategy.

4.5.3 Improving value for money Explain how the program that the proposal contributes to represents good value for money. Specifically, given the context of the epidemic in the country and the definition of value for money provided in the Guidelines, describe how the key interventions in the proposal represent the best balance of costs and effectiveness, with consideration to the desired achievement of both short and long term impacts.

Efficiency of NTP over the years: Costs per patient treated under DOTS in Indonesia is less than 200 US$. This represents one of the best values for money compared to other lower middle countries such as Thailand and the Philippines (WHO, 2009). Moreover, decreasing NTP expenditures per patient in the period from 2004 to 2007 indicate improved efficiency over the years (Figure X). The sudden increase of expenditure as of 2007 is mainly due to major efforts of the government to absorb the substantial budget funding gap s due to GF restrictions and the drop in TB patients notified during and after the restrictions. Expenditure is also expected to increase in the subsequent years as new initiatives are being rolled out or scaled up (e.g. PMDT).

Figure X. Per patients’ costs, budgets and expenditures (WHO, 2009)



Despite the fact that central government commitment for health finance has gradually increased over recent years, the program has not fully succeeded to close the funding gaps through increased local government allocations. In 2009, total government budget for operation of the TB program was 145 billions rupiah, an increase of 7.1% compare to the previous financial year, which was 135 billions rupiah. Despite the increase, government contribution covered only 23.4% of the total national budget needs for TB control equaling 621.5 billion rupiah. International donors funding, e.g. Global Fund, USAID, could partially close this funding gap, adding up to 269.36 billions rupiah in 2009, a 45% increased compared to the previous year. Local budget allocation for TB control program in Indonesia has been triggered by stronger commitment of the highest level in the government in order to accelerate achievement of the Millennium Development Goals. Hence existing financial gaps are expected to be narrowed by increasing budget contributions from local and central governments. This proposal contributes to good value for money and includes several interventions with low costs but high expected returns: Inclusion of TB in minimal service standards and in accreditation standards for hospitals and

providers. Strengthening of the regulatory environment related to the latest Presidential Instruction to include

MDG related programs including TB control in district development plans (new regulations to ensure 15% budget allocation for Health (Law UU 36) whereby 10% is allocated from district development budgets (APBD) and 5% from central development budget (APBN). Fiscal space for TB control program budget improvement from the local government is still available. Through accurate budget allocation and local economic growth of 6-7% (National Statistic Bureau) it is expected that the current gap in the health budget for TB control program will be decrease from 31% in 2010 to 13-15% in 2014, by strengthening local capacity and local commitment to achieve target indicators of MDGs in 2015. Thus, the proposed GF R10 grant would actually be an additional funding source to narrow the gap.

In order to decrease donor dependency the Minister of Health has recently instructed Bappenas (the National Planning Bureau) to prepare scenarios for transferring budget lines, currently proposed to GFATM into central and local government sources This pertains mainly to drug supply and human resource development but other budgtlines wil also be considered.

Inclusion of TB in local insurance schemes (ASKES, JamKesMas and JamKesDa etc). The Government of Indonesia has committed funding through Jamkesmas (National community health insurance scheme) to cover 76 million population (approximately 30% of total population). The total number of TB patients in the country per year is around 520,000. Thus, we can assume that 156.000 (30%) would be covered by Jamkesmas. The estimated cost per patient treated in Indonesia is approximately US$ 180. Thus, the annual contribution of Jamkesmas with 100% coverage would potentially reach US$ 28,080,000. Thus assuming step-wise coverage scale up of Jamkesmas during the proposed R10 as follow: 2011 (40%); 2012 (50%); 2013 (60%); 2014 (70%); 2015 (80%), the total contribution of Jamsostek could be equivalent to US$ 84,240,000. This amount would be part of the government contribution to TB control, on top of the earmarked budget allocations for TB control,

Expanding and involving more community / women organizations and shifting certain TB control tasks (suspect identification, suspect referral, treatment monitoring) to communities through the Desa Siaga Initiative, will ultimately decrease the financial burden of government and increase the sustainability of TB control, in particular in hard to reach areas and populations.

Pricing, waste prevention and program integration: Almost all medicines listed in this application are included in the WHO and national TB program essential medicines lists. Some second line medicines are not yet included in the Indonesian public health essential medicines lists but it is expected that at the next update, the second line TB medicines will be included. All GF funded medicines and commodities are NOT subject to specialist GOI procurement requirements, and are procured using internationally recognized systems, at standard prices, through recognized international procurement organizations and sources (GDF/GLC/IDA). The bulk – around 70%-, of the first line medicines are to be procured with GOI funding and are subject to different procurement conditions and prices, governed by GOI pharmaceutical and financial regulations. Moreover, NTP will continue to lobby central government and seek to engage the services of other organizations such as USP, WHO and USAID funded support agencies – TBCAP - to advocate for a review of in-country pharmaceutical pricing, and especially taxation levels. The strengthening of supply chain management including implementation of logistic management information system is expected to minimize expenses due to waste. Integration of interventions with existing interventions delivered by the national AIDS control program as described in the previous sections is also expected to contribute toward better efficiency.



4.6 Monitoring and Evaluation System

4.6.1 Impact and outcome measurement systems Describe the impact and outcome measurement systems, including strengths and weaknesses, used to measure achievements of the program at impact and outcome level.

Measurement of outcome of TB control interventions is Indonesia is based on the revised Reporting and Recording system. The system is gradually being transferred to an electronic system, facilitating validation and data analysis. Recently the e-TB manager has been introduced in the PMDT piloting area, which will be gradually expanded to the new sites. NTP is strongly considering to shift to a web based integrated data information system to enable real-time monitoring of program performance and avoid the problems with reporting delays.

STRENGTH OF OUTCOME measurement system:

Application of an electronic Excel based TB register for district level that also can be applied at health facility level. Electronic and/or paper based reports are compiled at provincial level and on a quarterly base transferred to national level. The data can be entered into a software program, automatically calculating indicators and graphic displays for seven program indicators which can be used for feed back and advocacy.

In collaboration with HIV program, the HIV status of the TB patients including information on management of TB-HIV co-infected patients has been included in the revised TB treatment card, TB register (TB03) and electronic software. The revised data recording system has been field tested and is now being implemented. The issue of confidentiality of HIV status has considerably delayed the implementation of TB-HIV surveillance and as a result until recently only limited data have been available to monitor progress and constraints in TB-HIV implementation

STRENGTH OF IMPACT measurement system:

Sentinel sites for collecting mortality data (from all causes of death including TB) are stepwise being established supported by national budget. It will allow to generate community based mortality data on TB which will enable the program to measure progress towards reaching the TB related MDG indicators.

A draft protocol, work plan and budget for a nationwide prevalence survey, scheduled for 2013, has been developed by the NIHRD ( National Institute of Health Research and Development, Ministry of Health). General objective of this survey is to determine not only national but also regional differences in TB prevalence rates including factors related to TB in Indonesia. Sampling design of the survey will be multistage cluster random sampling with a total of 3,867 census blocks, from each census block 20 selected household: The survey will also assess risk factors and TB (socio-economic status, crowding, ventilation or housing conditions, smoking and TB cases detected by the survey) including knowledge, attitude and practices on TB in the population. The survey will be supported by various institutions (NTP, TB Expert Committee, TORG, Central Statistic Bureau, Experts, University, International Organizations and Provincial and District Health Offices).

A series of Tuberculin surveys in various regions have been carried out in 2007 which enabled the program to estimate trends of ARTI and measure the trends in disease transmission. The result of the survey indicated an ARTI of around 1%, which is considerably lower than ARTI measured through surveys in the 80s (1-4%).



WEAKNESSES of the systems:

Implementation of TB electronic register is not yet countrywide: 24 out of total 481 districts have not yet implemented the electronic system due to limited availability of computer hardware at health facility level

Though a strong en standardized TB surveillance system has been established nationwide, timeliness, consistency and completeness of data in many districts is still poor. This applies also to reporting on drug stocks and expiry dates and laboratory quality assurance for smear microscopy. Problems and delays in information flow hamper planning (work plan adjustments) but also timely reporting to GFATM

Hospital- and private providers/NGOs’ adherence to the national recording and reporting system is still low. As a result there is considerable under-reporting by hospitals and other providers’ contribution towards TB case detection and treatment. Through this grant efforts will be undertaken to align the hospital reporting system with the NTP surveillance system.

Limited analysis and use of data, not all supervisors at province levels are familiar with data validation and data analysis due to inadequate skills caused by lack of training on data analysis and interpretation. Intensification of training is needed to upgrade the skills of supervisors.

Inadequate frequency of supervision due to shortage of local budgets for transport

Many districts and provinces fail to secure local budgets for M&E and coordination meetings which has a severe impact on the quality, timeliness and completeness of reports from those districts.

Unavailability of funding in national budgets for impact measurement activities

Lack of area specific prevalence/incidence estimates: Due to the wide variation of TB incidence in the various regions, the national estimate, based on the National prevalence survey in 2004, is not fit to set more local (provincial) targets. As a result many low prevalence province SRs fail to meet the national CDR target and are ‘punished’ as ‘’poor performers’’. Consequently the proposed study population size in the next prevalence survey plan been considerably increased to allow for local prevalence estimates and realistic targets.

All weaknesses above contribute to reporting delays and/or limited availability of quality data, difficulties in data analysis and hamper decision making in particular for drug management and the monitoring of laboratory quality. All weaknesses are currently being addressed by NTP with assistance of partners (WHO, KNCV USAID/TBCAP including MSH, FHI etc). Budget gaps for these activities are proposed for support through GF R10.

4.6.2 Impact and outcome measurement

(a) Has impact and/or outcome data been collected in the last 2 years?

Yes answer section 4.6.2 (b)

XNo go to section 4.6.2 (c)

(b) What was the source(s) of the measurement?

insert source (large scale surveys, demographic surveillance, vital registration systems, other)

(c) It is important to guarantee that there are systems in place to measure all impact and outcome indicators in the performance framework. In order to do this, fill in the table below, fully describing all planned surveys, surveillance activities and routine data collection in country used to measure impact and outcome indicators relevant to the proposal. Add rows as needed.



Data Source Funding Years of Implementation Impact/Outcome Indicators

relevant to the proposal to be measured by data source 2011 2012 2013 2014 2015

Source 1 Prevalence survey

Total cost 6.000.000 TB prevalence rate Secured funding amount and funding source - Funding gap 6.000.000 Round 10 funding request for Source 1 6.000.000

Source 2 Impact study

Total cost 100,000 100,000 All indicators (including estimations of cost-effectiveness and service delivery costs)

Secured funding amount and funding source - Funding gap 100.000 100,000- Round 10 funding request for Source 2 100,000 100,000

Source 3 Data triangulation

Total cost 50,000 50,000 All indicators Secured funding amount and funding source - - Funding gap 50,000 50,000 Round 10 funding request for Source 3 50,000 50,000

Source 3 Analysis of mortality register

Total cost 250,000 TB mortality Secured funding amount and funding source - Funding gap 250,000 Round 10 funding request for Source 4 250,000



4.6.3 Links with the National M&E System

(a) Describe how the monitoring and evaluation (M&E) arrangements in the proposal (at the Principal Recipient, Sub-recipient, and other levels) use existing national indicators, data collection tools and reporting systems including reporting channels and cycles.

Monitoring and evaluation for this proposal is based on the M&E system described in the National Strategic Plan for TB Control in Indonesia 2010-2014. Objectives and SDA of this proposal are in line with the impact, output and outcome indicators of the national strategy for TB control 2010-2014. NTP Indonesia implements the unified WHO monitoring and evaluation (M&E) system applying a standardized recording format consisting of 13 forms (TB01 – TB13) and a clear mechanism for the reporting system. This is supported by regular M&E coordination meetings at all levels and M&E officers posted at provincial and national levels. The same M&E system will be applied by all PRs and SRs in the implementation of this round10 proposal, with the district level as the basic TB management unit. Achievement of most SDAs in this proposal can be measured with the current uniform reporting system and for each level the reporting is integrated in the existing M&E system. This proposal will specifically support efforts to improve the performance of the surveillance system by provider: incorporating TB notification in the hospital reporting system, establishment and maintenance of a web-based TB information system and adjustment to facilitate measurement of contributions by NGOs and Private Practitioners and other providers engaged in TB control. Further TB data will be incorprated into the the National Health Information System (SIKNAS) under the CDES (Center for Data and Surveillance Epidemiology) and Provincial / District Health Information system (SIKDA) under the Prov/District Health Authorities. Data collection will be improved to disaggregate case notification and treatment data by age, sex and provider type, analyze to enable adjustment of DOTS plans accordingly. Patient forms (TB01) have recently been modified to allow measurement of contributions from various providers and to monitor effectiveness of TB suspect referral, including TB-HIV status. Referral slips will be given to the TB suspects when visiting the designated provider (e.g. village clinics or community health centers). One copy will be retained by the person who refers suspects or patients. At the health facility level, the referral slip will be kept by the health facility and the source of referral (such as community or cadre, village clinics, private doctor, private nurse, private midwife, etc) will be recorded in the existing TB suspect register (TB06) and the lab register (TB04). If diagnosed as TB patient the source of referral will be indicated in the modified TB treatment card (TB01). This information will enable the health facility to measure contribution of community, cadre, village clinics or private practitioners or other providers in case finding and case holding. NGO clinics delivering TB care will apply all existing recording and reporting forms relevant for that health facility (TB01, TB02, TB03 health facility unit, TB04, TB06). The reporting system from the providers follows the existing system of reporting to the district health office as the basic TB management unit. Consequently the district TB register has to be revised (adding a column on ‘’source of referral’’. Quarterly monitoring evaluation meeting at the district level will be attended not only by staff of community health centers, but also representatives of other providers engaged in TB control in the district.

(b) Are all of the M&E arrangements planned for the proposal using the national M&E system?

X Yes

go to section 4.6.4

No

continue to section 4.6.3 (c)

(c) If no, explain why not and list any service delivery areas (SDAs) and/or activities that will not be monitored through the national M&E system.

ONE PAGE MAXIMUM

4.6.4 Strengthening monitoring and evaluation systems



(a) Has a multi-stakeholder national M&E assessment been recently conducted (in last 2 years)?

X Yes

continue to section 4.6.4 (b)

No

go to section 4.7

(b) If yes, has a costed M&E action plan been developed or updated to include identified M&E strengthening measures?

X Yes

continue to section 4.6.4 (c)

No

go to section 4.7

(c) Describe whether the proposal is requesting funding for any M&E strengthening measures. These strengthening measures may have been identified through a national M&E assessment or any other relevant evaluation or review process.

M&E strengthening in this proposal is addressed in SDA 2.5 (Health Information System) and SDA 3.1 (Monitoring and Documentation of community and government interventions).

The M&E assessment conducted in 2008 revealed several weaknesses. These include:

- Current national M&E plan not covering all components of the national strategy (PSM, HRD, ‘’new’’ interventions (i.e. TB/HIV, MDR TB Infection control etc). The current M&E Plan is embedded in the new TB Strategic Plan 2010 – 2014.

- Not all indicators for GF are supported by sound M&E frameworks (i.e. TB/HIV, MDR TB) - Not all SRs have adequate capacity for optimal functioning of M&E. - Incomplete reports and delay in submission of reports from SRs is one of the main bottle-neck in

M&E.

In addition to weaknesses identified above, the M&E system is not yet covering the private providers and NGOs. Most of these weaknesses are currently being addressed through interventions supported by R5 and R8 and assistance form partners (UNDP, TBCAP). As a result NTP overall monitoring and evaluation capacity has considerably been strengthened over the last few years. Specific M&E staff at central and provincial level were recruited and trained, Implementation of the TB electronic system has expanded, and provincial and district supervisors have been trained in monitoring, evaluation and periodic supervision. These activities have considerably improved M&E quality and performance nationwide. Despite this good progress there are still deficiencies in the M&E system and several funding gaps have been identified. Funding support through GFATM R10 is proposed to support following M&E activities:

Monitoring and evaluation coordination meetings at national, provincial and district levels in areas without local government support for this quarterly activity.

Conducting a national Prevalence Survey in 2013 and a Mortality Survey.

Establishment of Drug Resistance Surveillance through DRS survey in Sumatra and the Eastern part of Indonesia, or alternatively, establishment of a national Sentinel Drug Resistance Surveillance system including activities to monitor and supervise establishment of this DRS sentinel surveillance system

Studies to measure the impact of TB control activities in Indonesia.

Activities to improve the quality of surveillance including sufficiently disaggregating data by age and sex, and by key populations to enable districts / provinces areas to undertake gender sensitive programming.

Activities to support the Integration of TB surveillance into the National (SIKNAS) and Regional (SIKDA) Health Surveillance systems.

Maintenance and updating of the national TB surveillance website: TB surveillance will be linked to the TB website (www.TBIndonesia.or.id) including updating of provincial and district profiles regarding the TB and TB-HIV situation.

Strengthening surveillance system for Private providers and NGOs in reporting TB cases.

Coordination meetings with NGOs at provincial level to maintain networking and improve M&E.

Activities to monitor and evaluate NGO involvement and program implementation including technical assistance to NGOs for improvement of M&E.

Documenting best practices, lessons learnt and experiences/ evidence gained during



implementation of the ACSM Framework (through OR) and sharing with other organisations

The budget proposed in this Round 10 proposal for M&E cost is considerable and around 18 % of the total proposed budget. A separate HSS cross cutting proposal has been prepared to address limitations in the national HIS in order to achieve improved integration, quality and management of data and better use for decision making, policy guidance and service delivery.



4.7 Implementation Capacity

4.7.1 Principal Recipient(s) Describe the technical, managerial and financial capacities of each Principal Recipient (PR) to manage and oversee implementation. Include any anticipated limitations to strong performance and refer to any existing assessments of the PR, other than Global Fund reporting mechanisms. Copy and paste tables below if there more than three Principal Recipients

PR 1 Name

National TB Program, Directorate General of Communicable Disease Control and Environment, Ministry of Health

Sector Health

Street Address Percetakan negara 29, Jakarta Pusat

Technical capacity

The capacity of NTP Indonesia has improved considerably over the past years as reflected by the accelerated progress over the latest decade. In 2006, the case detection rate and treatment success has surpassed the global target. In 2009, Indonesia maintained this program achievement with case detection rate 73% and treatment success rate 90%. The rapid expansion phase of the national TB control program in Indonesia (2006-2010) reached wider communities, including large large parts of poor and vulnerable populations, expanding the types of health facilities implementing DOTS strategy (from the network of community health centers to hospitals, chest clinics, etc.), implementing DOTS-plus strategy, and integrated TB-HIV services.

During the last decade the technical capacity of NTP has much increased at all levels. This has, amongst others, been achieved through intensified technical assistance from TBCTA Partners through the USAID Technical Assistance Program (TBCAP) see section 4.4.8. Technical assistance focussed on: strengthening of public-private partnerships for DOTS with a focus on hospital DOTS linkage and implementation of ISTC, strengthened TB drug management, laboratory strengthening, initiation and implementation of PMDT to address MDR-TB; strengthened TB/HIV coordinated activities, and improving human and institutional capacity in all technical areas including drug research. This enabled the NTP to become self-sufficient in several though not all technical areas. Moreover the NTP has established close collaboration with several local Universities and national research institutions (in particular University of Indonesia, University of Gajah Mada in Jogjakarta) , adding to the technical capacity. Notification of Sputum Smear Negative Cases is increasing over the last few years as result of increased notification by hospitals since every year more and more hospitals and clinics are being involved in the national TB program. Ultimately, Indonesia has moved down the rank of high-burden countries from the third to the fifth place. These are major accomplishments of the NTP Indonesia,

Managerial capacity

The NTP, Ministry of Health, with its vast network of local health services in 33 provinces and 482 districts, has proven the capacity to manage the grant using the existing surveillance system, financial regulation, and program management. Human resources in the ministry have been strengthened through recruitment of additional staff in the central PMU to improve the capacity at the central level. The Central Unit now has 22 government officers and 29 GF contracted full-time staff.

NTP-MOH as Principal Recipient has demonstrated its management capacity through administering three GFATM grants, i.e. the round 1, round 5 and round 8 grants. Many lessons have been learnt during implementation of these grants (See section 4.4.3). A capacity gap assessments conducted by UNDP in collaboration with UI and three PRs at the time of temporary restrictions of the GF grant in 2007 indicated several weaknesses in management and organization. Consequently PR and CCM have taken several measures to strengthen the management capacity: A Project Implementation Manual (PIM) and a CCM Governance Manual were implemented during 2007. UNDP provided



management assistance and problem solving in the same year. OGAC provided assistance on legal aspects of contracting between PRs and their SRs and delegation of authorities within the framework of Indonesian laws, assisted in training for GF key program staff on Monitoring and Evaluation plus Program management and assisted CCM with development and operation of the CCM Governance Manual.

To improve local project management, trainings were conducted for all provincial project officers in early 2008, based on the new PIM. This PIM, has been revised in 2010 and was endorsed by CCM. An important element of this revised PIM is the establishment of the Management Internal Control Team (MICT) to strengthen management capacity.

The Management Internal Control team (MICT) has the function to assist PR in improving management monitoring for GF implementation. A new policy has been developed to ensure that all expenditures and disbursements at PR and SRs (province) level are counter-signed by the head of Finance Division of the Directorate General of Disease Control. Furthermore all management staff in PMU are trained on internal control, risk assessment and procurement. Training is facilitated by professional accountants. In addition, UNDP has been contracted to assist capacity building in program management, financial management and procurement & supply management (PSM).

MoH operates mainly through its Central Unit and infrastructure of Provincial and District health service levels. Additionally It has developed close collaboration with International and National NGO. This ensures reaching and involving the targeted populations, acknowledging that this is best done though non-government organizations. Other collaborators are health professional networks (including the Medical Association), the Patient Network, academic and other institutions.

MoH has legal status to enter as PR into the grant agreement with the Global Fund as it also did in previous rounds of GF support.

The CCM has recently been revamped and its functioning has much strengthened.

Financial capacities

The PR for TB in Directorate General of DC and EH has strong Financial Management capacity and accounting systems in place, as demonstrated in Global Fund Round 1 and Round 5. After the restriction period in 2007 the financial system has considerably been strengthened. GF grants are registered with the Ministry of Finance to assure transparency and accountability of the funding support. The Inspectorate General implements routine internal control. BPK implements annual external auditing of the PR.

The system has proven to be able to:

correctly record all transactions and balances, including those supported by the Global Fund;

disburse funds to sub-recipients and suppliers in a timely, transparent and accountable manner;

support the preparation of regular and reliable financial statements;

safeguard the PR’s assets and

Procurement and Supply Management Systems:

Though some good progress in procurement and supply management has been made over the last few years, the system is not yet strong enough to prevent occurrence of stock outs for drugs and other supplies including quality issues of laboratory supplies. Therefore the NTP is considering to contract out drug procurement, simultaneously strengthening the capacity of the DG Pharmaceutical services. Technical assistance for improvement of procurement and supply management systems is provided by MSH through a medium term resident expert. Recently a team of PQM (Promoting Quality of Medicines Program, USAID support) made an assessment of the three national local pharmaceutical companies that produce TB drugs, with the objective to assess their capability and future potential regarding compliance with the WHO Good Manufacturing Practices main principles for pharmaceutical products. The assessments revealed that Kimia Farma, Indofarma, and Phapros facilities all appear to have the appropriate systems in place to provide a level of assurance that they can operate in a state of control regarding compliance with the WHO Good Manufacturing Practices for pharmaceuticals. Additional support is currently considered. The procurement supply and management (PSM) plan outlines how the PR will adhere to the Global Fund’s procurement principles, which include, among others, competitive and transparent purchasing, adequate quality assurance, compliance with national laws and international agreements, appropriate use of health products, mechanisms for the monitoring of the development of



drug resistance where necessary, and accountability safeguards; Objectives are to:

Deliver adequate quantities of quality products to the end-user in a timely fashion (especially in the area of health products) Provide adequate accountability for all procurement conducted.

All aspects above are available at the Sub Directorate and being documented in the attached PSM plan and PIM as guidance for current PSM implementation in R5 phase 2 and R8 phase 1.

Monitoring and Evaluation capacity

PR has established a nationwide monitoring system down to district level and health facilities; Re-training of staff has already been conducted and further re-training is planned to counter staff attrition. Some provinces receive additional support through direct technical assistance.

While the Ministry of Health as the Principal Recipient for all three diseases faced enormous difficulties in 2007 resulting in a restriction of funds disbursement for all Global Fund grants, many improvements have been made by PR and CCM, assisted by technical partners. The CCM and the PRs now have clear guidelines on project management through the Project Implementation Manual and guidelines on program oversight and governance through the CCM Governance Manual.

4.7.2 Sub-recipients

(a) Will Sub-recipients be involved in implementation?

X Yes go to section 4.7.2 (c)

No go to section 4.7.2 (b)

(b) If no, why not?

HALF PAGE MAXIMUM

(c) If yes, how many Sub-recipients will be involved? 1-6 X 7-20 21-50 50+

(d) Are all Sub-recipients already identified? Yes go to sections 4.7.2 (e) and (f)

No

go to section 4.7.3

(e) List the identified Sub-recipients and describe:

The work to be undertaken by each Sub-recipient; Past implementation experience of each Sub-recipient; Any challenges that could affect performance of each Sub-recipient as well as a mitigation

strategy to address this.

Proposed SRs for Objective 2 ( HSS): 1. Directorate for Medical Support Services (Direktorat Bina Penunjang Pelayanan Medik -BPPM)

will be the Sub-recipient for improving access to quality assured diagnosis by strengthening laboratory networks including strengthening of QA for sputum smear microscopy. Recently the Directorate has developed a draft National Plan for expansion of the TB Laboratory Network. R10 will support selected activities of this plan that were not covered by R8.

2. Directorate for Specialized Medical Service (Dit Bina Yanmedik Spesialistik) will be the Sub-Recipients for activities involving hospital engagement, e.g. implementation of the new Minimal Service Standards for Health where DOTS has been inserted as one of the minimal diagnosis and treatment standards for hospitals to be included in certification and accreditation criteria for health



facilities, as mentioned in the Hospital Decree 2009. This SR will also collborate with PR on expansion of PMDT services through their hospital network.

3. Indonesian Medical Association (IDI):

IDI is the Professional Organization for Medical doctors (IDI= Ikatan Dokter Indonesi) Under its umbrella it has 33 Medical Specialist Associations, including 33 Collegiums, 37 Medical Society Associations. The organisation is established in 31 Provincial Offices and 325 District offices and has around 50.000 registered members. The objective of the IDI is to assist the Government in a variety of national healthprograms to improve health status of the Indonesian population, promote development of new technologies and support continuous professional development (CPD) by accreditation of training. The organisation also provides recommendation for certification in the process of medical licensing of all medical doctors. The role of IDI in TB control program is to disseminate ISTC (International Standard for Tuberculosis Care) to all doctors in Indonesia. IDI will be the Sub-recipient for activities to lead implementation of International standards for TB care including incorporating ISTC as one of the mandatory criteria for certification of private providers who manage TB patients.

Proposed SRs for Objective 3 ( CSS): 4. Nahdlatul Ulama (NU) is the largest moslem organization in Indonesia. Established in 1926 as a

faith-based organization in Surabaya, Nahdlatul Ulama has networks in 33 regions through, 2.339 branches, 12 special branches, 2.630 Branch Representative Councils and 37.125 Sub-Branch Representative Councils. NU has more then 60 million members.NU provides vast and strategic health infrastructure reaching grass root level. It has 58 clinics and 600 health care facilities (puskestren) within the Islamic Boarding Schools (pesantren). NU’s health department (LK NU) is responsible for work on health programs. Main activities related to health include amongst others: development of regulations and policies related to public health, managing special health centres such as clinics, health consultations,maternity hospitals and special clinics for narcotics and drugs, HIV and rape victims. The organization also organizes training for improving community empowerment and improving health services and establishes health posts and drug stores at Islamic Boarding Schools. NU has experience in managing funding contributions from many sources such as the Ministry of Religious Affairs, the Ministry of Health and international development partners such as the Colombo Plan, the Ford Foundation, Millennium Development Corporation, AusAID, USAID. NU has been involved in the fight against TB since 2004, by becoming a sub-recipient for GFATM TB grant and also PR for R9 HIV implementation. NU Secretariat has financial management, procurement, M&E, and technical units in place to ensure effective program implementation. The NU Secretariat provides technical and management support to ensure that program implementers will achieve the intended outcome of the program.

5. Pamali TB: PAMALI is a community, patients and ex-patients organization. PAMALI was established in February 2007, initiated by community partners at a meeting hosted by PPTI Samarinda, East Kalimantan. PAMALI objectives are to improve patient and Community education and social mobilization in order to increase community participation and demand for quality diagnosis and treatment services for TB, and in the implementation of the TB control program. One of activities conducted by PAMALI is adaptation and dissemination of the Patient’s charter International in Indonesian’s settings. Now they plan to disseminate the Indonesian Patient Charter’s in several provinces of Indonesia. PAMALI will be the Sub-recipient for activities for empowering TB patients.

6. Woman Welfare Organization (PKK): PKK is a large national movement supervised by the Ministry of

home affair (Kementrian dalam negeri), PKK is a community-based organization for empowering and improving the welfare of society through the family. At present the coverage of PKK movement is practically nationwide. The success of the PKK movement in the efforts to improve family welfare has been recognized by society, and even gained recognition from international agencies (WHO, Unicef, Unesco, etc.). PKK has been involved in TB control in GF TB Round 1 but the scale of involvement was limited. In this GF Round 10 proposal PKK will be Sub-recipient for community empowerment activities enabling community members to be involved in suspect identification, referral for laboratory examination and treatment monitoring.



(f) If the private sector and/or civil society are not involved as Sub-recipients in implementation, or only involved in a limited way, explain why.

Not applicable

4.7.3 Sub-recipients to be identified Describe:

(a) why some or all of the Sub-recipients are not already identified; and

(b) the transparent, time-bound process that the Principal Recipient(s) will use to select Sub-recipients and not delay program performance.

One of the main purposes of this proposal is to scale up involvement of existing NGO’s and community based organizations in DOTS expansion. The NTP, with technical support from partner organizations, will assist the NGO’s in planning and implementation. This implies capacity building, improved coordination at central and at provincial level, provision of inputs like equipment and supplies, anti-TB drugs and coordinated monitoring and supervision. Several sub-recipients have already been identified (please refer to 4.7.2). The process of identifying other SR is based on the priority areas selected for this proposal. In order to enlarge NGO involvement and increase the number of SR’s the CCM is still encouraging other community organizations to submit a proposal through calls for proposals and announcements in the TB web site. By using both the TB official website and local newspapers, the information is expected to be more transparent and to reach a broader audience of TB partners in Indonesia including local HIV/AIDS NGOs and other NGOs/FBOs. Moreover meetings of the National TB Partnership Forum (attended by TWG, CCM, NGOs, and academic institutions) will be increased and held periodically to inform local partners on progress and needs. In these meetings all partners are encouraged to submit a proposal to CCM. The selection team, consisting of NTP and TWG representatives, developed general and specific criteria for selecting the SRs: The general criteria are legal status, organization profile, coverage, past experience in health

program or more specifically in TB, project scale, financial report, networking and willingness for cost sharing.

The specific criteria are for selection are similar to the ones applied in R8 and include: o Address priority SDAs and clearly describe the link to these SDAs o Clearly describe strategies, implementation, monitoring and evaluation of planned

activities in detail, including a Performance Monitoring Plan with indicators. o Explain the linkages with the Tb services at central or local levels o Explain the logic, continuity, and linkages to existing activities carried out by the

organization or other stakeholders o Demonstrate organizational competence in relation to the planned activities o Incorporate work plans, detailed budgets and time schedule for the activities

Applying these criteria, the selection team reviews additional applications.

4.7.4 Coordination between or among implementers Describe:

(a) how coordination will occur between multiple Principal Recipients if there is more than one nominated Principal Recipient for the proposal; and

(b) how coordination will occur between each nominated Principal Recipient and its respective Sub-recipient to ensure timely and transparent program performance.

For this proposal only one PR will be proposed, which is the Ministry of Health. Since this proposal aim to be consolidated with earlier rounds (R8) the same coordination mechanism will be applied. In round 8,



MoH is requested by all PRs to coordinate the grant implementation across PRs. The number of SRs will increase to include NGOs and other potential partners.

Since the lifting of the previous GF restrictions, many efforts have been made to improve grant management and oversight functions of CCM, e.g. implementation of the new Project Implementation Manual and Governance manual. Standardized procedures (e.g. financial management and procurement system, finance control team) are outlined in the PIM and implemented by all PS and SR. These efforts and instruments will serve as a basis to ensure optimal coordination and collaboration between PR and SRs.

The link between PR and SR’s will be established at all levels. For example local NGOs clinics will receive their TB drugs from district or provincial health offices in exchange of quarterly TB reports. Coordination between PR and SR’s at local level is assured under stewardship of the provincial / district health offices. All surveillance activities at district and health facility level will be coordinated by provincial and district health offices. Team members comprise of representatives of the respective PR/SR’s.

Further coordination and monitoring mechanisms will be undertaken through:

quarterly meeting between PRs and SRs, appointment of focal points within the SRs for financial, M&E, and PSM activities standardization through development of templates for monitoring, reporting, measuring

achievements and financial management.

Technical assistance:

The existing national partners will provide technical and management assistance to the PR Coordinating Unit to help solve technical issues and strengthen financial and management capacity of the PR’s.

The partners will help to identify TA needs and suggest solutions and assist in identification of technical agencies or consultants.

4.7.5 Strengthening implementation capacity (a) The applicant is encouraged to include a funding request for management and/or technical assistance to achieve strengthened capacity and high quality services, supported by a summary of a technical assistance (TA) plan based on the indicative percentage range in the Guidelines. In the table below provide a summary of the TA plan. Refer to the Strengthening Implementation Capacity information note for further background and detail

TA Surveillance, DRS, Impact measurement

Management and/or technical assistance need

Management and/or technical assistance activity

Intended beneficiary of management and/or technical assistance

Estimated timeline

Estimated cost

same as proposal currency

Accelerating Capacity building

Training and management support to NGOs

NTP Women Welfare Organizations and other NGOs, Patient organizations like Pamali, PPTI Year 1- 5

Expanding capacity building in PMDT, TB-IC and other new initiatives

NTP, DG Medical Services Professional Associations (IDI) etc



Total budget for TA is set on 3% of total proposed R10 budget.

A complete TA plan will be developed during grant negotiation, in close coordination with TB CARE.

Expanding Laboratory capacity and training for Culture and DST + QA

NTP, Directorate of Medical Support services (BPPM), Private laboratory

Improving M&E

and expanding

Research

TA for:

Prevalence survey Impact surveys

including measurement of Service Delivery costs

Mortality survey Drug Resistance

Surveillance Improving surveillance

system including MIS for hospitals and private sector

Improving M&E capacity of NGOs

Expanding Operations Research

NTP, NIHRD, Directorate of Medical support services, CDES, Directorate of specialized Med Service

Throughout first 4 years

Strengthening Health Systems

Strengthening program management and administration

PR

SRs: Professional organizations, NGOs including PKK, Pamali and others

Throughout first 4 years Expansion of private

sector collaboration

Health Insurance Institutions

Medical associations

CSS: Piloting innovative community based TB control

NGOs, CBOs (e.g. PKK)

Strengthening PSM

PSM: Improving pharmaceutical and health commodity management

Quality Assurance and Quality Control,

PR

BPOM

DG Pharmaceutical Services




DMIS, forecasting and

quantification, Distribution to other

stores and end users rational drug use and

patient safety,

setting up pharmaco-vigilance program

Strengthening Monitoring and Evaluation

Improving NTP surveillance system

SR (provincial Health Services and NGOs


Establishing DRS

PR University of Indonesia, NTP,

Directorate of Medical Support services (BPPM),

Year 1-5

Impact measurement NIHRD Year 3-5

Imroving management and implementation

Addressing High Risk Groups

Active case finding in urban slums, remote areas; household contacts. Gender auditing; Improving capacity for pediatric TB

PR

Professional Organizations (IDAI)


Supporting accelerating TB-HIV collaboration including expansion of IPT

NTP

NGOs

Prov & District Health Services

Year 1-5

Supporting expansion of PMDT

NTP

MDR Working group.

Prov & District Health Services

Directorate of Med Support Services

Year 1 - 5

(b) Describe the process used to identify the assistance needs listed in the above table.

1. The next External Monitoring and Evaluation Mission for Indonesia is scheduled for the first quarter of 2011: This mission will assess progress and constraints since the last EMM mission in 2007and expectedly identify further technical and management assistance gaps and needs. In the process of development of the current Strategic Plan 2010-2014 and de GFATM R10 proposal specific information on needs and gaps in technical assistance areas was obtained from technical reports delivered by visiting WHO and KNCV/TBCAP consultants, from GDF and GLC monitoring reviews and USAID mission, TBCAP quarterly progress reports and work plans, monitoring reviews, and inputs from the various technical working groups discussions (e.g MDR technical working group, Laboratory working group, NTP logistics working group etc.



2. In order to improve effectiveness of TA the CCM is strongly considering to establish a TA Coordination Unit for all technical assistance to be delivered related to implementation of GFATM support. This Unit will have the tasks to oversee technical assistance needs of the various programs, monitor the TA plan and improve coordination for technical assistance between the various stakeholders. A small working group will draft terms of reference for such a TA coordinating unit

3. Currently NTP is collaborating with a range of partners and active players who have a proven track record in provison of assistance in various technical areas: International organizations currently providing external technical assistance include WHO, KNCV and other TBCTA partners under TBCAP (including MSH, FHI, ATS), GDF, and GLI etc. Increasingly local institutions are involved and providing technical assistance including Universities (Gajah Mada University, University of Indonesia but also other Indonesian organizations. As stated before the TBCAP program will end in September 2010, though USAID has granted a No-Cost Extension for priority interventions until March 2011. In the last quarter of 2010 the USAID, under President Obama’s Global Health Initiative (GHI), will enter in a new agreement (Cooperative Agreement for the implementation of Tuberculosis CARE -TB CARE). The tendering process is currently under way. The focus of TB CARE support is described in section 4.4.8. The USAID mission in Jakarta has agreed with the Ministry of Health Indonesia to collaborate under this mechanism. A work plan for TB CARE assistance, involving all major stakeholders, will be developed during the last quarter of 2010.

(c) If no request for management and/or technical assistance is included in the proposal, provide a justification below. Or, if the funding request is outside the indicative percentage range, provide a justification below.

Not applicable

4.8 Pharmaceutical and Other Health Products

4.8.1 Scope of Round 10 proposal

Does the proposal seek funding for any pharmaceutical and/or health products?

X Yes go to section 4.8.2

No skip the remainder of section 4.8

4.8.2 Table of roles and responsibilities

Function Name of the organization(s) responsible for this function

Role of the organization(s) responsible for this function

Does the proposal request funding

for additional staff or technical assistance?

indicate Yes or No

Procurement policies, systems, and planning

PR/NTP

GOI/Ministry of Finance

NTP has overarching responsibility for ensuring full observation of GF procurement policies.

GoI/MoF for overall governmental

GoI/MoF – No



Ministry of Health/ DG Pharmaceutical service

NTP

procurement policies and systems

MoH for specific health procurement policies and general health commodity planning

NTP for specific TB commodity planning and medicines procurement

MoH- No

NTP - No

Intellectual property regulations

GOI

DG Pharmaceutical service

BPOM

Overall national regulations

Public sector medicines and health commodities

Health Commodity and medicines

No

Quality assurance and quality control

PR/NTP

BPOM – national regulatory authority for drugs


NTP has overarching responsibility for ensuring full observation of QA QC requirements

Role of national medicines regulatory authority

Provides import permission after verification of CoA

Monitors and verifies quality of imported medicines, jointly samples imported products and ensures secure custody through to analysis.

Monitors quality of public sector health commodities. Jointly samples products for analysis

NTP - Yes for technical assistance especially for MDR second line medicines

BPOM - Yes for technical assistance to start in-country QA analysis of imported products


– Yes for sampling procedures and secure chain of custody

Management and coordination more details required in section 4.8.3

NTP


NTP has overall responsibility for management and coordination of TB medicines.

DG Pharmaceutical service provides coordination for GoI funded medicines

No

Product selection NTP

NTP has overall responsibility to ensure product selection

No



KOMLI – Expert Committee on TB


complies with KOMLI recommendations and GF procurement regulations.

KOMLI – a national level, independent, expert committee for TB - has overarching authority to determine all aspects of diagnosis and treatment including detailed treatment regimens and thereby the products required.

MoH to ensure products are contained in National Essential Medicines List (DOEN) and National formulary

Management Information Systems (MIS)

NTP

Provincial Health Office (PHO)

District Health Office (DHO)

NTP has overall responsibility to ensure reporting of TB medicines and commodities.

NTP has direct responsibility for Central level commodity reporting and collation of national data.

PHO reports on Province level logistics functions

DHO reports on District level logistics functions

NTP yes

Forecasting

NTP

Ministry of Health/DG Pharmaceutical services

NTP has overall responsibility to undertake forecasting for TB medicines and commodities

MoH/ DG Pharmaceutical services monitors forecastings to assist in coordination with GoI funded procurements and overall GoI medicines activities.

NTP- yes – especially for MDR second line medicines

Storage and inventory management more details required in section 4.8.4

NTP



NTP has overall responsibility to ensure satisfactory storage and inventory management.

NTP has direct responsibility for Central level storage and distribution.

PHOs maintain buffer stocks ( for Province)

NTP – Yes, directly and also for ToT Yes and to provide training to PHOs and DHOs



DHOs hold main stocks and distributes to Health centers

Distribution to other stores and end-users more details required in section 4.8.4

NTP



NTP has overall responsibility to ensure satisfactory distribution

NTP has direct responsibility for Central level distribution.

PHO distributes buffer stocks (if there are any District shortages)

DHO either distributes to health centres or health centers collect from DHO.

NTP - Yes directly and also for ToT Yes and to provide training to PHOs and DHOs

Ensuring rational use and patient safety

NTP


BPOM

NTP has overall responsibility for rational use and safety of TB medicines

DG Pharmaceutical service operates the national rational use of medicines program

BPOM has national responsibility for patience safety in use of medicines

Yes to DG Pharmaceutical service

BPOM

Pharmacovigilance BPOM

BPOM have national responsibility for pharmacovigilance

BPOM – yes to increase program

Drug resistance Surveillance

NTP

NTP has overall responsibility for drug resistance surveys for TB medicines.

Yes

4.8.3 Past management experience Describe the past experience of each organization that will be involved in managing pharmaceutical and other health products.

Organization name Short description of management experience

Total value procured during

last financial year same currency as proposal

NTP Over 10 years of managing nationally funded and Donor Funded TB commodities; including over 5 years of major GF grants.

US $ 8 million

DG Pharmaceutical Service

DG Pharmaceutical Service (Binfar) is a relatively new government Unit which grew out of the previous Department of Pharmacy (Yanfar) two years ago. As the previous Yanfar there is over 10 years experience. DG Pharmaceutical service procures all GOI funded central level funded medicines, for the MoH and manages their distribution (through contracted private sector delivery) to all

All medicines US $ 40 million

TB medicines US $ 3 million



Districts in the country.

BPOM

As the national regulatory authority of medicines BPOM has over 15 years experience of managing medicines regulatory affairs.

BPOM does not directly procure medicines.

use the ‘Tab’ key to add extra rows

4.8.4 Alignment with existing systems

Describe how the proposal uses existing country systems for the management of the additional pharmaceutical and health product activities that are planned, including pharmacovigilance and drug resistance surveillance systems. If existing systems are not used, explain why.

The national responsibility of the implementation of pharmacovigilance in the country is under by BPOM (Food and Drug Administration). Activities to strengthen the pharmacovigilance function of BPOM, particularly in regard to TB drugs, are proposed to be supported under GF R10.Facility-based drug resistance surveillance system will build on the established referral labs network. As NTP is able to satisfactorily integrate the currently independent vertical delivery systems and contract out delivery requirements to a pharmaceutical distributor the need for government provision of distribution will be removed entirely and can be provided by the parastatal/private sector.

4.8.5 Storage and distribution systems

(a) Which organization(s) have primary responsibility to provide storage and distribution services under the proposal?

tick the corresponding

boxes to the right and enter the name of the organization(s)

X National medical stores or equivalent

specify Currently, for GF funded commodities, NTP operates a central/national store using a dedicated store room within a grouping of national medical store rooms, and distributes using contracted commercial transport from there to Provinces and Districts.

Sub-contracted national organization(s)

specify

Sub-contracted international organization(s)

specify

X Other: National pharmaceutical distributor

specify: Currently dual systems are in use. For GOI funded commodities storage and distribution is undertaken by a contracted national pharmaceutical distributor. GF funded commodities have been handled separately through a NTP central store. NTP wishes to integrate systems a.) within TB commodities; and have all TB commodities, regardless of funding source, handled by a national pharmaceutical distributor: b.) within disease programs; as HIV/AIDS already uses the national pharmaceutical distributor for all commodities regardless of funding source.



(b) For storage partners, what is each organization's current storage capacity for pharmaceutical and health products? If the proposal represents a significant change in the volume of products to be stored, estimate the relative change in percent, and explain what plans are in place to ensure increased capacity.

The bulk of the first line TB medicines – around 70% - will be funded by GOI and procured from in-country manufacturers by NTP. No central level storage is required.

Around 20% of the first line medicines are expected to be funded by GF and will be procured through GDF. These medicines will be imported and will help to serve as the national buffer stock. These medicines will (initially) be held centrally, to act as the national buffer stock, and require storage provision.

NTP is currently using a storage area within a cluster of MoH stores, for imported medicines. This is around 1,200 sq m. This area has adequate space capacity for envisioned imported stock holding, but is in relatively poor physical condition and not really suitable for medicines storage.

NTP wishes to integrate the current multiple, vertical, storage systems, and is in the process of contracting out storage to a national pharmaceutical distributor ( a system which is already used for GF financed HIV/AIDS medicines) to store medicines in the same way as used for the GOI funded TB procurements.

Second line medicines are currently stored in the Central Store of MoH. Current storage space is inadequate for the envisioned increase in second line medicine supply and NTP also intends to contract out storage to a national pharmaceutical distributor who can provide GSP and cold chain storage conditions.

National commercial pharmaceutical distributors are considered to have adequate storage volumes (though not necessarily at a single national store – more likely at diverse regional/Provincial level stores) for the volume of TB medicines required – the envisioned imported (GF funded) supply would represent less than 20% by value of an individual distributor’s turnover and only 30% of the volume of GOI procured TB medicines the distributors are already currently handling.

The predicted GDF funded medicines throughput represents a significant DECREASE in the central level physical storage volume requirement. Although the TOTAL TB medicines usage is increasing at around 5% per year, the plan is that much more of this requirement – around 70% for years 2012/13 - will be funded by GOI and delivered by in-country manufacturers directly to Provincial and District level, thereby reducing the physical volume of central storage required.

As NTP is able to satisfactorily integrate the currently independent vertical delivery systems and contract out storage requirements, the need for government provision of central level physical storage will be removed entirely and can be provided within the parastatal/private sector pharmaceutical distributors.

(c) For distribution partners, what is each organization's current distribution capacity for pharmaceutical and health products? If the proposal represents a significant change in the volume of products to be distributed or the area(s) where distribution will occur, estimate the relative change in percent, and explain what plans are in place to ensure increased capacity.

There is no directly operated government distribution service for TB medicines. For GOI funded medicines, distribution by the in-country manufacturers to District level is included as part of the procurement process (by Government regulation). For GF funded medicines which are imported, commercial distributors are contracted to undertake the distribution.

The bulk of the first line TB medicines – around 80% - will be funded by GOI and procured from in-country manufacturers by Directorate of pharmaceutical services (Binfar). This procurement process



includes direct delivery from the manufacturer to every Province and District in the country. Around 20% of the first line medicines are expected to be funded by GF and procured through GDF. These medicines will be imported and will help to serve as the national buffer stock. These medicines will be distributed through contracted commercial distributors to Districts.

NTP is in the process of integrating the current multiple vertical distribution systems and is in the process of contracting out distribution activities to a national pharmaceutical distributor (a system which is already used for GF financed HIV/AIDS medicines) to distribute medicines in the same was as used for the GOI funded TB medicine procurements.

Second line medicines: NTP will also contract out distribution to a national pharmaceutical distributor who can provide GDP distribution services.

National commercial pharmaceutical distributors are considered to have adequate distribution volumes for TB medicines – the envisioned imported supply would represent less than 20% by value of an individual distributor’s turnover and only 30% of the volume of GOI procured medicines they are already currently distributing.

The predicted GDF funded medicines throughput represents a significant DECREASE in the distribution volume requirement. Although the TOTAL TB medicines usage is increasing at around 5% per year, the plan is that much more of this requirement – around 70% for years 2012/13 - will be funded by GOI and delivered by in-country manufacturers directly to Provincial and District level, thereby reducing the physical volume of distribution required for GF funded medicines.

4.8.6 Pharmaceutical and health products for initial two years

Complete the Pharmaceutical and Health Products List and list all of the products that are requested to be funded through the proposal.

If the pharmaceutical products included in the Pharmaceutical and Health Products List are not included in the current national, institutional or World Health Organization Standard Treatment Guidelines (STGs), or Essential Medicines Lists (EMLs), describe below the STGs that are planned to be utilized, and the rationale for their use. Applicants are invited to justify the prices based on either the range provided in the Unit Costs for Selected Key Health Products information note or with another published international reference source. If the provided price is out of range, provide justification. Also, if local legislation is preventing access to low cost prices through local manufacturers or similar mandates, clarification should be provided as well as a plan for addressing such barriers over the life of the proposal.

All medicines listed in this application except amoxicillin/clavulanate are included in WHO and National standard treatment guidelines. Amoxicillin/clavulanate has been included for possible pilot scheme use with pediatric patients in year two. All medicines listed in this application are included in the WHO and national TB program essential medicines lists. Some second line medicines are not yet included in the Indonesian public health essential medicines lists (Daftar Obat Essensial Nasional - DOEN). This list is only reviewed and updated every four years and it is expected that at the next update, the second line TB medicines will be included. In the meantime permission from the national pharmaceutical authorities has been granted for the use of the necessary second line medicines for MDR treatment purposes.

All GF funded medicines and commodities are NOT subject to specialist GOI procurement requirements, and are procured using internationally recognized systems, at standard prices, through recognized international procurement organizations and sources (GDF/GLC/IDA).



The bulk – around 80%-, of the first line medicines are to be procured with GOI funding and are subject to different procurement conditions and prices, governed by GOI pharmaceutical and financial regulations.

The first line medicines treatment kits in use in Indonesia are of a slightly different configuration to the standard kits contained in the Unit Costs for Selected Key Health Products information note and the GDF on-line Product catalogue. For GDF funded supplies the price of the last purchase of these commodities through GDF ( in 2009) has been used. The required kits are similar and priced slightly less than the benchmark price for GDF kit types I/III C and IIB.

Sputum smear diagnostic test reagents cost have been taken from in-country procurement costs from 2009.

Hain test costs, have been taken from the FIND country list, prices:

http://www.finddiagnostics.org/programs/find-negotiated-prices/mtbdrplus.html

Delivery, storage and distribution costs have been estimated using actual costs from 2009 GDF supplied medicines.

For GOI funded supplies the price of the last GOI funded purchase has been used, corrected for current exchange rates from Indonesian Rupiah to US dollars. GOI prices include delivery to Health District level.

In August 2010 a massive rise in the price of GDF TB kits has been noted, occasioned largely by the world shortage of streptomycin. This situation will adversely effecting all countries including Indonesia. The Price of Category II kits was US $ 63.33 and has very recently increased to US $ 102. Since around 3,000 GDF kits are required each year this will need a budget increase of $ 120,000 EACH year ONLY for the GDF supply. The impact on locally GOI procured in-country manufactured kits is yet unknown, but if it is assumed that the same level of increase an ADDITIONAL US $ 250,000 per year will be required for the GOI Cat II kits supply. This price increase has not yet been included in the proposal, and the budget needs should be reconsidered in a later phase when the impact of the price increase is known. Bottom line- an extra US $ 800,000 for drugs is likely to be needed (for the first two years) – and the price situation on streptomycin is not yet stable – there may well be further price rises.

Prices for Second line medicines are taken from the last purchase price paid through GLC/IDA supply.

Access through local manufacturers.

NO GF funded pharmaceuticals are procured through local/Indonesian manufacturers.

Current GOI central level governmental pharmaceutical procurement regulations require all GOI funded pharmaceutical products to be procured only from national State Owned Enterprise (SoE) pharmaceutical manufacturers.

Current SOE prices for first line TB medicines are around 40% higher than world market prices. (GDF assessment October 2009).

The reasons for the high prices of TB medicines are complex and still not fully documented, but are known to include import duties on APIs, federal taxes on production activities, and environmental protection legislation which results in very high taxes and hence prices of artificial (non-indigenous plant material) packaging materials ( blister strips/hot foil seals/plastic seal kit boxes) required for FDC TB medicines.

NTP will continue to lobby central government and seek to engage the services of other organizations such as USP, WHO and USAID funded support agencies – TBCAP - to advocate for a review of in-country pharmaceutical pricing, and especially taxation levels.



Quantity estimates for all commodities are calculated on the basis of being used; for year 1 in 2012 and for year 2 in 2013. That is commodities will be ordered, and funding will be required in year 2011, but the commodities are not likely to arrive and be available for use before 2012.

The TOTAL medicine/commodity requirement has been shown in the Excel table TB ATTACHMENT B to enable tracing of calculations and comparisons with patient numbers.

NOTE that the bulk of the first line medicines are NOT funded by GF.

GOI funded items are shown in blue.

4.8.7 Multi-drug resistant tuberculosis

Is the provision of treatment of multi-drug resistant tuberculosis included in this tuberculosis proposal?

X Yes include USD 50,000 per year over the full proposal term to contribute to the costs of Green Light Committee Secretariat support services

No

do not include the Green Light Committee costs



5. FUNDING REQUEST

The Round 10 Guidelines contain different guidance for sections 5.1 and 5.2 depending on whether the applicant selected Option 1, 2 or 3 in section 3.1 of the Proposal Form

Option 1 = Transition to a single stream of funding by submitting a consolidated disease proposal

Option 2 = Transition to a single stream of funding during grant negotiation

Option 3 = No transition to a single stream of funding in Round 10

5.1 Financial Gap Analysis

Section D and H of the Gap Analysis table below must be completed differently depending on whether applicant selected Option 1, 2 or 3 (see above)

Summary Information provided should be described further in sections 5.1.1 – 5.1.3 Currency must be the same as identified on the proposal cover page Adjust the years as necessary in the table from calendar years to financial years to align with national planning and fiscal periods

Financial gap analysis

Actual Planned Estimated

2008 2009 2010 2011 2012 2013 2014 2015

SECTION A: Funding needs for the full national tuberculosis program

LINE A Provide annual amounts $ 69,169,182 $ 80,348,563 $ 90,972,038 $95,911,204 $101,524,896 $ 116,265,036 $122,592,370 $128,464,181

LINE A.1 Indicate the amount of the funding need for the full national tuberculosis program over the full term of the Round 10 proposal $ 564,757,688

SECTIONS B, C AND D: Current and planned resources to meet the funding needs of the full national tuberculosis program

Section B: Domestic

Domestic source B1:

Loans and debt relief

Domestic source B2 National funding resources $15,465,359 $ 18,299,428 $ 22,663,450 $28,902,720 $ 36,436,032 $ 31,741,656 $ 36,296,815 $ 63,470,005





2008 2009 2010 2011 2012 2013 2014 2015

Domestic source B3 Private sector contributions

(national) $10,857,600 $ 14,414,400 $ 17,971,200 $21,528,000 $ 25,084,800

LINE B: Total current & planned DOMESTIC resources

Total of Section B entries $15,465,359 $18,299,428 $ 22,663,450 $ 39,760,320 $50,850,432 $49,712,856 $57,824,815 $88,554,805

Section C: External (non-Global Fund)

External source C1 USAID $13,000,000 $13,000,000 $13,000,000 $13,000,000 $13,500,000

External source C2

provide source name here

External source C3 Private sector contributions

(International)

LINE C: Total current & planned EXTERNAL (non-Global Fund)

resources

Total of Section C entries

$13,000,000 $13,000,000 $13,000,000 $13,000,000 $13,500,000

Complete this version of Section D if the applicant selected Option 2 or 3 in section 3.1 of the Proposal Form:

Section D: External (Global Fund) Insert additional lines below if there are more than two existing tuberculosis Global Fund grants

Grant D1 INO-506-G05-T $ 11,318,555 $ 18,734,338 $11,890,034

Grant D2 INO-809-G11-T $ 11,989,350 $16,116,901 $ 17,497,900 $ 23,837,687 $ 23,559,221

LINE D: Total current & planned EXTERNAL (Global Fund) resources

Total of Section D entries

$11,318,555 $30,723,688 $28,006,935 $17,497,900 $23,837,687 $23,559,221

Complete this version of Section D if the applicant selected Option 1 in section 3.1 of the Proposal Form:

Section D: External (Global Fund) Insert additional lines below if there are more than two existing tuberculosis Global Fund grants





2008 2009 2010 2011 2012 2013 2014 2015

Section D1: Grants not included in consolidated disease proposal

Grant D1-A

provide grant number here

Grant D1-B


Section D2: Grants included in consolidated disease proposal and

listed in section 3.1(b)

Grant D2-A


Grant D2-B


LINE D: Total current & planned EXTERNAL (Global Fund) resources

Total of Section D entries

LINE E : Total current and planned resources

Line E = Line B + Line C + Line D $15,465,359 $29,617,983 $53,387,138 $80,767,255 $81,348,332 $86,550,543 $94,384,036 $102,054,805

Calculation of gap in financial resources and summary of total funding requested in Round 10 must be supported by detailed budget

LINE F: Total funding gap Line F = Line A – Line E $ 53,703,822 $50,730,579 $37,584,899 $15,143,949 $20,176,564 $29,714,493 $28,208,334 $26,409,376

LINE G: Round 10 tuberculosis funding request must be same amount as requested in tables 1.1, 5.3, 5.4

and detailed budget for this disease $15,143,949 $20,176,564 $29,714,493 $28,208,334 $26,409,376



Part H – Cost Sharing calculation for Lower-middle income and Upper-middle income applicants

In Round 10, the total maximum funding request for tuberculosis in Line G is:

(a) For Lower-Middle income countries, an amount that results in the Global Fund's overall contribution (all grants) to the national program being not more than 65% of the national disease program funding needs over the proposal term; and

(b) For Upper-Middle income countries, an amount that results in the Global Fund overall contribution (all grants) to the national program being not more than 35% of the national disease program funding needs over the proposal term.

Line H = Cost Sharing calculation as a percentage (%) of overall funding from Global Fund

Complete this cost sharing calculation if the applicant selected Option 2 or 3 in section 3.1 of the Proposal Form: Cost sharing = (Total of Line D amounts for proposal period + Total of Line G amounts) X

100

Line A.1

Complete this cost sharing calculation if the applicant selected Option 1 in section 3.1 of the Proposal Form:

Cost sharing = (Total of Line D1 amounts for proposal period + Total of Line G amounts) X 100

Line A.1

38%



5.1.1 Explanation of financial needs and additionality of Global Fund financing

Describe how the annual amounts were:

(a) developed; (b) budgeted in a way that ensures that government, non-government and community needs were

included to reflect implementation of the country's tuberculosis program strategies; and (c) developed in a way that demonstrates the funding requested in the proposal will contribute to

the achievement of outputs and outcomes that would not be supported by currently available or planned domestic resources.

The costing of the national TB control program has been done based on needs analysis. Resource needs have been calculated based on the total planned TB control activities in Indonesia required to achieve the MDG targets and TB control targets in Indonesia. All strategies are detailed in the National TB control strategy 2010-2014. The strategies are comprehensive and cover government, non-government and community needs as these were developed based on intensive stakeholders consultations. The strategies have been translated into operational activities. These activities have then been costed based on the components needed to carry them out. The total cost from the compilation of these activities is the total program budget. We then identified funding sources for this program budget, e.g. national resources, private contributions, donors. This exercise resulted in identification of financial gaps.

Proportion of GFATM contribution to total need for

National TB Control Program 2011‐2015 = 38%*

35%

16%11%

38% GoI

Private

USAID

GFATM

*GFATM contribution includes R5,R8,R10 (proposed); GoIcontribution includes available and expected budget

The recent Presidential Instruction related to achievement of the MDG will press local governments to increase budget allocation to health. Increased local economic growth is also expected to narrow the current gap in the health budget for TB control program. by strengthening local capacity and local commitment to achieve target indicators of MDGs in 2015. Thus, the proposed GF R10 grant would actually be an additional funding source to narrow the gap. Recently the Minister of Health RI has instructed the national planning bureau to prepare scenarios for transferring budget lines to central and local government sources budget items currently proposed to GFATM.

[The identified financial gaps are expected to be narrowed firstly by increasing budget contributions from the local and central government. Fiscal space for TB control program budget improvement from the local government is still available since current budget allocation to health in districts is still far below the expected level of 10% of local health development budgets, as defined in the health law no 36, 2009. Additionally the law stipulates that 5% budget from the National development budget will be allocated to support health programs. This scheme will be applied from 2011 onwards.



5.1.2 Domestic funding

corresponds to LINE B in Table 5.1

Describe the processes used in country to:

(a) prioritize domestic financial contributions to the national TB program including HIPC [Heavily Indebted Poor Country] and other debt relief, and grant or loan funds that are contributed through the national budget; and

(b) ensure that domestic resources are used efficiently, transparently and equitably, to help implement treatment, prevention, care and support strategies at the national, sub-national and community levels.

As stated above the local (district) government contributions for TB control are still limited. Therefore, within the domestic funding, central budget (APBN) is allocated for national but also for provincial level activities in addition to the provincial funding (APBD I). The budgeting process for APBN was proposed by TB sub-directorate to the Directorate General level (DG of Communicable Disease Control and Environmental) and budgets proposed from within the MOH was then summarized and aggregated by the Planning Bureau, MOH (DIPA Depkes). The total budget for the MOH was discussed at the Ministry of Finance, and revisions were forwarded to the MOH through the Planning Bureau. In the revision process, each Directorate General negotiated and revised the budget. Loan and debt relief were not available for TB control program. Debt Swap: Under a recent Debt2Health arrangement, Australia has agreed to cancel AUD$75 million of Indonesia's debt. On condition this proposal is approved, Indonesia will receive half of this amount to be invested in the national program to combat TB through GFATM mechanism.

The president has established a monitoring unit which monitors implementation of the presidential instruction no. 3 at all level using a dashboard approach indicating performance toward achieving MDGs targets, including TB control targets. This will assure that domestic resources are used effectively to achieve MDGs. Moreover the National planning bureau has embarked on performance-based planning and budgeting focusing on accountability and cost-effectiveness.

To ensure transparencies, the planning process involves all key stakeholders and refers to set performance measures and targets, i.e. performance-based budgeting. To ensure efficient and equitable use of domestic funding resources, all levels (central, provincial, district) have discussed and agreed upon activities planned and budgeted for each level. Joint planning also enables the provinces and districts to identify poorly resourced provinces/districts needing more resources from the higher government level. Activities that are considered non-value added were omitted in the program.

To ensure accountability, MoH Inspectorate General has a well-established internal audit mechanism in place for all government health program activities. In addition, financial audit will be specially conducted by BPK (Badan Pemeriksa Keuangan or Government Financial Audit Bureau). BPK acts as external financial auditor for all program funding, which are already registered and included in the DIPA.



5.1.3 External funding

corresponds to LINE C in Table 5.1

Describe:

(a) any changes in contributions anticipated over the proposal term and the reason for any identified reductions in external resources over time; and

(b) any current delays in accessing the external funding identified in Table 5.1 that should be explained, including the reason for the delay, and plans to resolve the issue(s).

TB CAP will be closing out in September 2010 and still in the process of no cost extension up to May 31, 2011 (pending for approval). The project will end in September 2010, however a 3.5 Million US$ no-cost extension for priority activities has recently been granted until March 2011. TB CARE is the expanded follow-on mechanism to the TB CAP program. All USAID support is complementary to GFATM support. Meanwhile, the call for bidding of the second phase of TB partnership program has been launched by USAID and proposals are being processed at USAID HQ. The next phase USAID will provide support for five years covering interventions described in section 4.4.8. The total amount of USAID support for the coming 5 years will be around 13 Million US$ This will be co-financing of GF Round 10.

5.2 Detailed Budget Instructions for completion of the detailed budget: For guidance on the level of detail required (or for a template) refer to the budget information available in Section 5.2 of the Guidelines 1. Submit a detailed budget in Microsoft Excel format. 2. Ensure that this detailed budget is consistent in numbering with the Round 10 interventions in

section 4.4.1 of the Proposal Form, the Performance Framework, and the detailed work plan. 3. From the detailed budget, prepare table 5.3, the summary by objective and service delivery

area. 4. From the detailed budget, prepare table 5.4, the summary by cost category. 5. Do not include a request for CCM or Sub-CCM funding in this Round 10 proposal. Requests for

funding are available through a separate application. The application is available at: http://www.theglobalfund.org/en/ccm/



Clarified Section 5.3: 5.3 Summary of Detailed Budget by Objective and Service Delivery Area Use the same objective and SDA numbering as the description in section 4.4.1, the Performance Framework, and the detailed budget and work plan. Annual totals at the end of this table must equal annual totals in the detailed budget and tables 1.1 and 5.4

Objective number

Service delivery area


1 High Quality DOTS $ 356,668 $ 317,224 $ 538,440 $ 3,606,642 $ 3,600,427 $ 8,419,401

1 High-risk groups $ 120,561 $ 328,088 $ 286,081 $ 336,081 $ 180,521 $ 1,251,332

1 MDR-TB $ 491,376 $ 820,196 $ 1,198,215 $ 1,923,950 $ 3,387,987 $ 7,821,724

1 TB/HIV $ 1,511,805 $ 955,624 $ 1,114,115 $ 1,250,760 $ 1,093,437 $ 5,925,741

1 Procurement and supply management (First line drugs) $ 3,142,008 $ 5,305,141 $ 6,862,799 $ 7,129,462 $ 4,139,923 $ 26,579,333

Programme management and Administration cost $ 2,472,256 $ 2,242,591 $ 3,307,036 $ 3,471,275 $ 3,600,658 $ 15,093,816

2 HSS: Medical Products, Vaccines and Technology $ 293,103 $ 560,794 $ 580,306 $ 580,306 $ 400,059 $ 2,414,568

2 HSS: Service delivery $ 823,300 $ 1,078,800 $ 1,320,745 $ 1,510,435 $ 1,294,369 $ 6,027,649

2 HSS: Health Workforce $ 4,209,420 $ 4,881,334 $ 3,492,834 $ 3,754,834 $ 3,659,412 $ 19,997,834

2 HSS: Information System $ 537,354 $ 1,418,716 $ 8,523,077 $ 1,728,633 $ 3,042,627 $ 15,250,407

2 HSS: Financing $ 10,000 $ 12,000 $ 12,000 $ 12,000 $ 10,000 $ 56,000

3 CSS: Advocacy, communication and social mobilization $ 117,996 $ 269,091 $ 281,091 $ 631,091 $ 293,091 $ 1,592,360

3 CSS: Monitoring and documentation of community and government interventions $ 58,000 $ 163,000 $ 36,000 $ 173,000 $ 68,000 $ 498,000



Objective number

Service delivery area


3 CSS: Building community linkages, collaboration and coordination $ 537,902 $ 731,165 $ 900,434 $ 874,545 $ 894,545 $ 3,938,591

3 CSS: Human resources: skills building for service delivery, advocacy and leadership $ 98,000 $ 123,000 $ 123,000 $ 123,000 $ 98,000 $ 565,000

3 CSS: Financial resources $ 146,000 $ 606,000 $ 752,000 $ 716,000 $ 350,000 $ 2,570,000

3 CSS: Community based activities and services - delivery, use and quality $ 95,000 $ 135,000 $ 115,000 $ 115,000 $ 25,000 $ 485,000

3 CSS: Monitoring & evaluation, evidence-building $ 123,200 $ 228,800 $ 271,320 $ 271,320 $ 271,320 $ 1,165,960

Round 10 tuberculosis funding request:

$ 15,143,949 $ 20,176,564 $ 29,714,493 $ 28,208,334 $ 26,409,376 $ 119,652,716



5.4 Summary of Detailed Budget by Cost Category

Summary information provided in the table below should be described further in sections 5.4.1 to 5.4.3 Annual totals at the end of this table must equal annual totals in the detailed budget and tables 1.1 and 5.3

Cost Category Year 1 Year 2 Year 3 Year 4 Year 5 Total

Human resources $ 1,072,367 $ 1,188,818 $ 1,461,942 $ 2,166,127 $ 2,180,620 $ 8,069,874

Technical and management assistance $ 996,000 $ 960,822 $ 1,156,822 $ 610,822 $ - $ 3,724,466

Training $ 6,084,399 $ 7,311,948 $ 6,272,913 $ 6,631,478 $ 6,215,969 $ 32,516,707

Health products and health equipment $ 562,529 $ 530,478 $ 17,136 $ 16,407 $ 19,343 $ 1,145,893

Pharmaceutical products (medicines) $ 2,447,592 $ 4,498,607 $ 5,427,366 $ 5,625,185 $ 4,141,329 $ 22,140,079

Procurement and supply management costs $ 299,198 $ 510,468 $ 1,707,476 $ 1,779,747 $ 277,585 $ 4,574,474

Infrastructure and other equipment $ 610,899 $ 798,073 $ 283,277 $ 398,674 $ 354,396 $ 2,445,319

Communication materials $ 520,000 $ 178,000 $ 118,000 $ 515,000 $ 165,000 $ 1,496,000

Monitoring & Evaluation $ 1,277,212 $ 2,396,623 $ 9,741,301 $ 3,260,283 $ 4,416,658 $ 21,092,077

Living support to clients/target populations $ 523,778 $ 989,326 $ 1,865,909 $ 5,684,215 $ 6,907,191 $ 15,970,419

Planning and administration $ 591,753 $ 656,379 $ 1,042,129 $ 900,174 $ 1,111,063 $ 4,301,498

Overheads $ 158,222 $ 157,022 $ 620,222 $ 620,222 $ 620,222 $ 2,175,910

Other (specify): $ - $ - $ - $ - $ - $ -

Round 10 tuberculosis funding request: $ 15,143,949 $ 20,176,564 $ 29,714,493 $ 28,208,334 $ 26,409,376 $ 119,652,716



5.4.1 Overall budget context Describe any significant variations in cost categories by year, or significant five year totals for those categories.

Proposed budget per cost category (total = US$119,652,716.00)

0 10,000,000 20,000,000 30,000,000

Human Resources

Technical & Management Assistance

Training

Health Products and Health Equipment

Pharmaceutical Products (Medicines)

Procurement and Supply Management Costs (PSM)

Infrastructure and Other Equipment

Communication Materials

Monitoring and Evaluation (M&E)

Living Support to Clients/Target Population

Planning and Administration

Overheads

*Training category includes meetings, workshops; HR category mainly includes salaries, incentives

For Health Product and Health Equipment cost category in year 1 and 2 there are procurement of reagents, microscopes, lab supply and PPD tests and equipments (syringe, cold box) for 93% of total need for 5 years. In year 3,4 and 5, these are expected to be procured by the government using national funding sources, thus no longer proposed to be supported through GFATM. From year 3 onwards there is a significant increase for M&E budget due to the planned prevalence survey and other impact surveys. Costs for the prevalence survey are considerable larger than anticipated due to the increased size of the study population, in order to be able to obtain regional prevalence estimates for adequate target setting at provincial levels. The amount required for this a total of US$ 6 million. Further this budget line will cover the funding gap for surveillance after closure of Round 8. In year 4 there is a significant increase for ‘’living support to clients/target populations’’ cost category as this covers mainly activities under SDA 1.1 High Quality DOTS which in preceding years would still be largely covered by GF TB R8.

5.4.2 Human resources (a) Describe how the proposed financing of salaries, compensation, volunteer stipends, or top-ups will be consistent with agreed in-country salary frameworks, such as national salary or inter-agency frameworks. Attach supporting information as evidence, including draft documents where applicable

Determination of salaries, incentives, training costs and all project management costs will be guided by the Project Implementation Manual (finalized in 2007 for Global Fund grant implementation in Indonesia; revised in 2010). The PRs have agreed on a common standard for personnel and project management costs.

In general, from year 1 to 3, the budget proposed to be covered by Round 10 has been calculated taking into account allocations under Round 5 and 8. A few cost categories such as Human Resources, Pharmaceutical products, M& E, Living Support to Clients/Target Population and Overhead increases variably between year 1 and 5.



(b) In cases where human resources represents an important share of the budget, summarize: (i) the basis for the budget calculation over the initial two years; (ii) the method of calculating the anticipated costs over years three to five; and (iii) to what extent human resources spending will strengthen service delivery.

Attach supporting information as evidence, including draft documents where applicable

The ‘human resources’ category only represent 7% of total five years budget, this is considered relatively small or within the range (below 10%) for implementing the project. The proposed budget for HRD is mainly to cover training needs due to the considerable number of newly established districts, the expected staff attrition and expansion of new initiatives. However, on year one and two, the proposed budget has taken into account that funding for HRD is still being covered by Round 8, to be consolidated with Round 10.

The anticipated HRD costs for year three, four and five (after ending of Round 8) are based on an estimated staff turn over of 10-15 %, and full expansion of new interventions like PMDT, TB-IC, laboratory innovations, etc. to new provinces, ultimately covering the country nation wide. Calculations are made based on the estimated training needs identified in the specific expansion plans for Laboratory development, the MDR expansion plan, the draft HRD plan etc, and the training needs for expansion of CSS to new NGOs / CBOs.

This budget line also includes costs for follow workshops after the training, planning and budgeting workshops, etc.

The investments in human resources for TB control through PPSDM (the Human Resource Unit within the within the Ministry of Health will improve sustainability of HRD, strengthen career development of staff working in TB / TB-HIV control (through accreditation of training) and improve their motivation. All these factors will strengthen quality of service delivery for TB control. Similarly capacity building of private providers though the Indonesian Professional Associations will expand the services into the network of Private Providers who are currently operating outside the NTP.

5.4.3 Other large expenditure items

If ‘other’ cost categories represent important amounts in the summary in table 5.4, (i) explain the basis for the budget calculation of those amounts; and (ii) explain how this contribution is important to implementation of the national tuberculosis program.


No ‘other’ cost category on proposed budget

5.4.4 Measuring service unit cost and cost effectiveness

Provide the following: (a) where available, estimates of recent average service delivery unit costs at the

program-level for key services with an explanation of how the estimates were developed;

(b) estimates of the expected average service delivery unit costs for key services that are included in the proposal; and

(c) a description of how key service delivery unit costs will be measured at the program-level, over time throughout the lifecycle of the grant.

The estimated cost per DOTS patients treated in Indonesia based on WHO calculation is less than US$ 200 (WHO update to Global Report 2009). We expect to be able to generate annual estimates of the costs per DOTS patients treated by dividing the total annual expenditure for DOTS by the total annual number of patients treated under DOTS. The total annual expenditure for DOTS will be calculated based on the total cost of components for delivering DOTS treatment (First line drugs; NTP staff; Program management; Laboratories; PPM/PAL/ACSM/CBC/Other; General health care services). NTP will collaborate with



universities to produce estimates of service delivery unit costs for key services and carry out cost effectiveness analysis as part of the proposed impact studies.

5.5 Funding Requests in the Context of a Common Funding Mechanism In this section, common funding mechanism refers to situations where all funding is contributed into a common fund for distribution to implementing partners

5.5.1 Common funding mechanism

If the country’s response to tuberculosis is through a program-based approach, does the proposal plan for some or all of the requested funding to be paid into a common-funding mechanism to support that approach?

Yes

complete all of section 5.5

X No

do not complete section 5.5

5.5.2 Operational status of common funding mechanism

Describe the main features of the common funding mechanism, including the fund's name, objectives, governance structure and key partners.

Not applicable

5.5.3 Measuring performance

Describe how program performance helps determine financial contributions to the common fund.

Not applicable

5.5.4 Additionality of Global Fund request

Describe how the funding requested in the proposal will contribute to the achievement of outputs and outcomes that would not be supported by current or planned resources available to the common funding mechanism.

Not applicable


PROPOSAL CHECKLIST: SECTIONS 3-5 Tuberculosis

CHECKLIST

Section 3 and 4: Proposal Summary and Program Description

Document attached?

mark an ‘X’ if attached

List document name and number

4.1 Medium Term – National Development Plan 2010-2014 X 1

4.1 Strategic Plan of the Ministry of Health 2010-2014 X 2

4.1 Presidential Instructions No. 1 Year 2010 X 3

4.1 Presidential Instructions No. 3 Year 2010 X 4

4.1 Joint External Monitoring Mission Report 2007 X 5

4.1. Joint Assessment Mission (GF, WHO, KCV, USAID) 2010 X 6

4.1 A brief history of TB control in Indonesia (2009) X 7

4.1 Indonesia GLC Mission Report 2010 X 8

4.1. Report of the DRS Assessment Mission 2010 X 9

4.1. National strategy for TB control 2010-2014 (Pre-Final Draft)

X 10

4.1. National PMDT Expansion Plan 2010-2014 (Pre Final Draft) X 11

4.1. National Lab Development Plan 2010-2014 (Pre Final Draft)

X 12

4.1. TB HR Plan 2010-2014 (Draft) X 13

4.1 National pharmacovigilance policy http://perpustakaan.pom.go.id/KoleksiLainnya/BeritaMeso/0109.pdf

4.1. Indonesian M&E Assessment Summary Report X 14

4.4.1 A completed Performance Framework (mandatory) X 15

4.4.1 A detailed work plan (mandatory) X 16

4.4.2 A copy of the Technical Review Panel (TRP) Review Form from Round 8 or 9, if relevant.

X 17

4.7.2

List of Sub-recipients already identified (including name, sector they represent, and SDA(s) most relevant to their

activities during the proposal term)

See proposal section


PROPOSAL CHECKLIST: SECTIONS 3-5 Tuberculosis

4.7.2.

4.8.6 A completed tuberculosis Pharmaceutical and Health Products List only mandatory if applicant is procuring these

products

X 18

Section 4B: Cross-cutting HSS (only one per country’s application)

Document attached?



4B.2 A completed separate cross-cutting HSS Performance Framework (mandatory, if applicable)

4B.2 A detailed separate cross-cutting HSS work plan (mandatory, if applicable)

Section 5: Funding Request

Document attached?



5.2 A detailed budget (mandatory) X 19

5.2. Prevalence Survey Proposal and Budget X 20

R10_CCM_IND_THSS_PF_s4B5B_24Aug10_En.doc 1/32

4B. Program description

Introduction The health profile of Indonesians has improved over the last 10 years. Growing national wealth and investment in social services have produced major gains for population health. Significant decline in infant and child mortality have contributed to raising life expectancy from 66 years in 2004 to 71 years by 2008 (under-5 mortality rate has fallen from 91 per 1,000 live births in 1990 to 41 per 1,000 in 2008).1 More residents have access to health care today than was the case 5 years previous, thanks to the expansion of social health insurance scheme to the poor (Jamkesmas). Despite these gains, Indonesia’s health indices lag behind those of her regional neighbors. At 229 per 100,000 live births in 2008, Indonesia’s maternal mortality ratio (MMR) contrasts unfavorably with those of Malaysia (42), Thailand (47) and the Philippines (84).2 Indonesia’s 238 million people are spread over 17,000 islands grouped into 33 administrative provinces. The provinces are subdivided into 497 districts. Significant variations exist in socio-economic indices and health profile across provinces. Access to basic services in some regions is very difficult, especially, in the 2 provinces that make up Papua. Travel between outlying districts and the major cities (Jayapura and Sorong) could take several days. Inclement weather, mountainous terrain and scattered populations over numerous islands raise the cost of infrastructure development disproportionately. Not surprisingly, it is difficult to attract health personnel to districts in Papua. Development Outlook Sound macroeconomic policies and fiscal management have produced robust growth and propelled Indonesia into the lower middle income category. Per capita GNI was US$1,800 in 2008 up from US$1,170 in 2005. Powered by manufacturing and mining (especially oil and gas), the economy grew by 6.3% in 2007 and 4.5% in 2009, making Indonesia “one of the best performers within a global recession”.3 The major indices look good – inflation, unemployment, and Debt-to-GDP ratio all posted significant decline from 2007 to 2009. The medium term outlook is promising – GDP growth in 2010 is forecast to grow at 5.5%. Despite these gains, 14% of Indonesians lived below the national poverty line in 2009. Income distribution is skewed – it will take some time before the effects of pro-poor programs initiated by the government become palpable.

1 Ministry of Health. Strategic Plan of the Ministry of Health, the Republic of Indonesia for the Year 2010-2014, Jakarta, 2010. 2 Hogan M, Foreman K, Naghavi M, et al. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goals. Institute for Health Metrics and Evaluation. Seattle, WA, April 2010 3 Asian Development Bank and Indonesia: Fact Sheet. Manila, April 2010.

PROPOSAL FORM – ROUND 10 CROSS-CUTTING HEALTH SYSTEMS STRENGTHENING INTERVENTIONS

SECTION 4B (OPTIONAL)


Health System Challenges Indonesia reflects a health system in transition. Communicable diseases remain major sources of ill-health. TB prevalence is high, accounting for 6.3% of the total burden of disease in the country.4 Even so, the mortality profile is dominated by non-communicable diseases. Strokes, cardiovascular diseases and diabetes now emerge as leading causes of death,5 attributed in part to changing diet and lifestyle. Simply put, Indonesians are consuming more high-calorie, high fat foods and are smoking more. The public sector health network comprises 667 hospitals with 90,000 beds and 8,200 community health centers (Puskesmas) but wide disparities exist in the distribution of health care resources with concentration in metropolitan areas. The central and eastern parts of the country tend to do slightly worse in terms of resources and health indicators. The private-for-profit sector is large and diverse. In 1999, fifty percent (50%) of health care was delivered in private facilities. That changed in 2004 when Jamkesmas was launched. The scheme, which currently covers 76 million people (30% of the population) offers beneficiaries free health care in Puskesmas and hospitals, and includes drug coverage. By 2006, private sector visits had shrunk to just 30%.6 Regulation of the private sector is inadequate but improving. Accreditation and monitoring of providers by health insurance funds are helping to enforce quality standards. There are few NGOs operating in the country. These are mainly faith-based organizations (FBOs) – the largest of them are Muhammadiyah and Nahdhatul Ulama (Islamic FBOs working in Java, Sumatera and NTB (Western/Central part), and YAKKUM and Perdhaki (Christian FBOs active in Papua) in the Eastern part of the country. Organizational capacity is weak and involvement in direct provision of health care is limited. Spending on health is trending upwards, from US$25 in 2005 to US$42 per capita in 2007. About 54% of this comes from the government. The growth is in part fuelled by expansion of SHI. Besides Jamkesmas, there are several risk pools. PT Askes for public sector workers covered 17.1 million people; Jamsostek for the (formal) private sector, 3.9 million; and others, 8.6 million. In total, health insurance covered about 116 million people, roughly 50% of the population as at 2009. Even so, the level of expenditure on health standing at 2.2% of the GDP in 2007, is comparatively low by regional standards – spending in Thailand was 3.7% and Vietnam, 7.1% of the GDP over the same period.

The supply of human resources for health presents a constant challenge. An estimated 60-70% of the health workforce holds dual jobs in public and private sectors. Prior to decentralization, health workers were mandated to serve for 3 years in rural and underserved areas. This evened-out the ratio of health workers (doctors, nurses, midwives, other) to population across regions. While overall numbers have improved, quality lags behind. Accreditation standards for health training institutions are weak and trainers in many private institutions lack clinical or field experience. Whereas access to care has improved with additional infrastructure and human resources, capacity to plan and manage health services remain weak at practically all levels. Information support is weak though improving. Policies are infrequently reviewed and the roles of different actors in the system remain blurred almost one decade after decentralization. Strengthening the Health System Various aspects of the health system in Indonesia warrant strengthening. The disease part of the proposal attempts to address some of these including health workforce. The selection of cross-cutting HSS interventions is guided in part by the priorities outlined in the national health sector strategy, 2010-2014. It also takes into consideration the potential to complement other strategic initiatives aimed at eliminating bottlenecks in the delivery of primary health care (PHC) services, including those targeting

4 Source: http://www.usaid.gov/our_work/global_health/id/tuberculosis/countries/asia/indonesia_profile.html 5 Ministry of Health. Health profile 2008. Jakarta, 2009 6 World Bank. Investing in Indonesia’s health: challenges and opportunities for future public spending. Health Public Expenditure Review 2008. Washington, DC, June 2008


AIDS, TB and Malaria. The GoI is promoting measures that enhance responsiveness of public health services and a management culture that embraces use of evidence for decision-making. The capacity of HIS units across the country is being strengthened via investment in IT and human resources. Video conferencing sessions are also conducted by the central MoH with PHOs and DHOs to seek input to and provide feedback on national health programs. Though currently done on ad-hoc basis, the intent is to use this avenue more effectively for dissemination of information. The Center for Health Data and Epidemiological Surveillance (Pusdasure) is coordinating this effort with assistance from GTZ and the WHO. Support from GTZ runs till the end of 2011 and is focused on strengthening policies and standards to sustain a national health information system (HIS) based on electronic technology. One of the tools recently adopted to enhance the monitoring of health programs is the “StatPlanet”. This is a web-based electronic dashboard that displays key health indicators for all 33 provinces. Presently, input data are derived from population surveys that are conducted every 3 to 5 years. This limits its use for planning and management functions. The intent is to feed data from the provinces through the HIS to a central repository that interfaces with StatPlanet. This will permit quarterly update of key indicators and make them widely accessible to stakeholders. The pharmaceutical sector is another area of strategic focus. An independent entity, the National Agency of Food and Drug Control (Badan POM), regulates the industry. It maintains a network of 30 laboratories across the country and ensures conformance to international standards of Good Manufacturing Practices (GMP) and Good Distribution Practices (GDP). Badan POM assures the efficacy, quality and safety of drugs manufactured and/or marketed in the country. It has emerged a regulatory agency of international repute. Responsibility for monitoring distribution channels is shared with the Directorate-General for Pharmaceutical Services and Medical Device (BINFAR). A division of the MoH, BINFAR coordinates planning and budgeting for drugs and medical supplies in public health facilities, and monitors the performance of public sector distribution channels. BINFAR also operates a national warehouse that maintains buffer stock of drugs and supplies for districts, as well as vaccines and drugs for national disease control programs. The market for Pharmaceuticals and Health Products (PHP) in Indonesia is growing. Demand is driven by population growth and higher spending on health care. In 2007, market size was estimated at US$2.7bn.7 There are more than 100 pharmaceutical companies in the country and one vaccine manufacturer, which is pre-qualified by the WHO. Although, spending on pharmaceuticals is low at US$12 per capita, demand has risen in recent years following the expansion of SHI to cover the poor. Domestic production is up but so also are imports. A recent assessment of the pharmaceutical sector in eight developing countries, noted that “… Indonesia has made the most progress in building up credible regulation of manufacturing and product registration, but faces major challenges in a decentralized environment to regulate retail pharmacy, dispensing doctors and prescription patterns.”8 Decentralization offers provinces and districts the opportunity to procure pharmaceuticals independently and to better tailor supply to demand. However, planning and budgeting for drugs in the public sector is still done annually. Capacity to forecast drugs needs is limited at all levels including the central MoH. There are no software to aid forecasting, inventory and supply management. The result – high holding costs for some items and stock-outs for others. In 2001, competitive bidding was introduced at district level as a means to improving transparency and efficiency in the procurement of pharmaceuticals. The impact of this measure particularly in is yet to be evaluated.

7 World Bank. Pharmaceuticals: why reform is needed. Indonesia health Sector Review (Policy Note Series), Washington, DC, Mar. 2009 8 Diack A, Seiter A, Hawkins L and Dweick I. Assessment of governance and corruption in the pharmaceutical sector: lessons from low and middle income countries. World Bank, Washington, DC, Jan. 2010


Goal of HSS Consistent with overarching need to improve population health and quality of life, the HSS seeks: “To contribute to reducing morbidity and mortality from infectious diseases including AIDS, TB and Malaria.” Objectives of HSS:

1. Reinforce the national health information system for better integration, data management and use of information for decision-making

2. Scale-up the Sample Registration System (SRS) to capture vital events and population-based information

3. Improve pharmaceutical and supply chain management, drug safety and pharmacovigilance Target Area The Presidential Decree Nos. 1 and 3 of 2010 identifies 138 underserved and remote districts as priority areas for targeted intervention within the framework of the national development plan. The selected districts are situated in 22 provinces and cover a total population of 42 million or 21% of the population in those provinces. For the purpose of prioritization, the target area can be subdivided as follows: Category A Province: Good infrastructure/access but weak health profile (32 districts) Category B Province: Moderate infrastructure/ access but weak health profile (71 districts) Category C Province: Remote and weak health profile (35 districts) The HSS will ride on the wave of popular (political) support to strengthen health services and improve access to health care among some of Indonesia’s most disadvantaged populations. Effort will be made in each phase of program implementation to ensure that no district is left behind.


4B.1 Description of cross-cutting HSS intervention

If including more than one intervention, copy this table (4B.1) - up to a maximum of five times - directly below, just before the following question (4B.2)

Title: Intervention 1 Reinforcing the national health information systems for better integration, data management and use for decision-making

Beneficiary Diseases: E.g. HIV, tuberculosis,

and malaria

HIV, TB, Malaria and other diseases

Identify the HSS SDA from the HSS Performance Framework

Health Information

(a) Description of rationale for and linkages to improved/increased outcomes in respect of HIV, tuberculosis and/or malaria

List the overall objective of HSS support, what specific interventions and/or activities will be undertaken during the program term to achieve these outcomes, and which Principal Recipients will be responsible for overall implementation and achievement of outcomes and impact

Rationale:

Indonesia’s national HIS is slowly evolving. A Virtual Private Network (VPN) connects 472 district health office (DHOs) and 33 provincial health offices (PHOs) across the nation so that data on health services can be captured from Puskesmas up to the national level. Health Information Officers (HIOs) have been trained and posted to DHOs while at Puskesmas level, clinical and allied health workers have been cross-trained to enter data electronically. Investment in IT has been significant – the MoH hosts a functional website with server capacity that is 2-4 times its current use. It would permit storage, analysis and dissemination of information from currently untapped sources. Despite these measures, data transmission in most districts is still manual rather than electronic. Reporting formats are not standardized, and in the wake of decentralization, districts have adopted different formats and IT solutions.

In 2007, the MoH conducted an assessment of the HIS using the HMN framework. It showed relative strength in the area of ”Indicators” (composite score of 61%)9 while “Data Management” was very weak (35%). An average score of 51% suggested that for many components in the HIS, the required functionality was “present but not adequate”. The following specific observations were made:

HIS capacity at central, provincial and district levels is limited – IT skills are in short supply, few opportunities exist for technical skills update and only a handful of districts budget for IT support

Timeliness and completeness of reporting varies markedly among districts – in 2008, only 45% of “underserved” districts reported basic health indicators in contrast with 89% for the other districts10

Information where available is not adequately used for decision-making – in many instances, managers simply do not know to interpret health information and use effectively for planning and management

The private/NGO sector is largely excluded for the national HIS development

In a special session with CSOs, participants decried the lack of feedback and prompt follow-up action from government to justify their continued reporting of health data. Simply put, they did not perceive that their organizations derived meaningful benefit from “helping” government.

Activities

Strengthening the health system will require significant additional investment in HIS. The aim is to optimize

9 Ministry of Health. 2007. Indonesian Health Information System Review and Assessment. Jakarta, August. 10 Source: Pusdasure, Ministry of Health, Jakarta, Aug. 2010


use of existing channels for data transmission, facilitated by standards, policies and guidelines that promote uniform reporting and adoption of interoperable IT systems. Activities to this effect are expected to be completed by the end of 2011 - the GTZ is supporting Pusdasure in this regard. Priority will be given to connecting remote and underserved districts, and improving bi-directional flow of information. The following activities will be executed:

Development of health data and metadata dictionary to ensure consistency in the analysis and reporting of health statistics

GIS mapping expanded to cover all the 138 districts in the target area – currently only 10% of districts (52 out of 497) are mapped

Capacity of HIS units at national, provincial and district levels improved via training, technical assistance and procurement of ICT

For Papua which has disproportionately large numbers of underserved districts – appointment of trained HIOs to complement critical health workforce recently deployed to the districts so that reporting and use of information for planning and management are strengthened

Conduct of Data Quality Self-assessment at Puskesmas, hospital and DHO levels to improve data accuracy and reliability

Feedback sessions (via video-conferencing) with policy-makers and program managers will hold twice yearly to enhance use of information for decision-making; these will be facilitated by CoEs and will involve both public and private sector organizations

Research to identify bottlenecks in the flow of information from community to provincial level will be conducted – quality improvement measures identified from this study will be implemented

Outcome

Adoption of new standards for electronic data exchange will enhance bi-directional flow of information between the central repository in the MoH, the provinces, and the districts. Improved reporting by outlying and underserved districts, as well as the private/NGO sector will enhance completeness and timeliness of health information. GIS mapping of communities and resources will permit more equitable allocation of resources. District health profiles and key indicators will be available online and updated quarterly. Ultimately, these will feed into the StatPlanet, the dashboard for monitoring progress towards the MDGs.

PR: Secretary General, MoH

(b) Using a very short sentence, indicate below the planned outputs/outcomes/impact that will be achieved on an annual basis from support for this cross-cutting HSS intervention during the proposal term.

Year 1 Year 2 Year 3 Year 4 Year 5

Percent of districts submitting HIS report within 30 days of end of the month

[N/A]

Percent of districts conducting two feedback sessions with Puskesmas, Private and NGOs per year

[N/A]

Data Accuracy – Error Rate

[N/A]

50%

30%

5

60%

50%

3

70%

60%

3

80%

70%

3


(c) Describe below other current and planned support for this action over the proposal term

In the left hand column below, please identify the name of other providers of HSS strategic action support. In the other columns, please provide information on the type of outputs

Name of supporting stakeholder

Timeframe of support for HSS action

Start date to end date

Amount of financial support provided over proposal term same currency indicated as

part of the Proposal Form

Expected outcomes/impact from this support

Government

2009 – 2014

US$11 million

Use of information for decision making strengthened at national, provincial and district level

Other Global Fund Grants (with HSS elements

if applicable

Round 8:

Round 9:

US$5.5 million

US$5.5 million

Strengthening strategic Information System on HIV/AIDS

Strengthening strategic Information System on HIV/AIDS


WHO

GTZ:

AusAID Indonesia

USAID

JICA

World Bank

2010 – 2011

2008-2011:

GTZ Consolidation Programme Health/Policy Analysis & Formulation in the health sector (PAF)

2011-2015

2012–2016

(Proposed by MoH RI)

Not yet determined

US$ 100,000

EUR 5,500,000 (plus EUR 835,000 contribution by AusAID), overall EUR 6,350,000.

US$1.5 million

$50 million/year for tuberculosis, HIV/AIDS, maternal & child health, and avian pandemic influenza, including imbedded health systems strengthening activities.

HSS activities include laboratory strengthening (TB and API), health workforce capacity building (all areas), quality of care improvement (MCH/TB/API), improved case management; and improved surveillance and use of data (API, TB and HIV/AIDS)

US$6 million

(Proposed by MoH RI)

Not yet determined

Strengthening capacity of health workforce in the use of information for evidence-based decision making

Health policy guidelines and implementing regulations are better geared towards the requirements of a decentralized health system. The Ministery of Health is strenghtened in their reform agenda in the folowing areas: Good Governance, Health Information Systems, Health Workforce, Health finance and Service delivery.

Strengthening of the Mortality Registration System in SRS Area

Improved management of health for maternal health, TB, API particularly;

Improved laboratories and increased proportion of labs meeting EQA;

Improved quality of care in facilities;

Improved referral networks

Improved use of health data (number of individuals trained on use of data)

Proportion of organizations ability to achieve quality improvement targets and implement/evaluate programs

Early Warning and Response System is strengthened nationwide based on national expansion plan. (Proposed by MoH RI)

The World Bank will produce a report on the opportunities to harmonize the information system of the health insurance programs to improve efficiencies.




Title: Intervention 2 Scaling-up the Sample Registration System (SRS) to capture vital events and population-based information

Beneficiary Diseases: E.g. HIV, tuberculosis, and malaria HIV, TB, Malaria and other diseases

Identify the HSS SDA from the HSS Performance Framework Health Information



Rationale:

For more than two decades, Indonesia has relied on community-based mortality surveys (typically verbal autopsy) to obtain information on underlying and direct cause death. The surveys are conducted roughly once every 5 years, using non-representative samples. As revealed in the HIS assessment of 2007, data for estimating indicators like Infant Mortality Rate (IMR) and Maternal Mortality Ratio (MMR) are at least 3 years old with a 5-year gap between data collection and publication of results. Mortality statistics are also derived from medical certificates of cause of death issued by hospitals (public and private). These provide incomplete representation since only about 5% of the population uses the service.11 Besides, the mortality registration system presently does not collect information on the level and cause of death. Indeed, the HIS assessment found that less than 20% of mortality was captured and records of verbal autopsy are never validated. Recognizing these weaknesses, the MoH in collaboration with the Ministry of Home Affairs, initiated the Indonesian Mortality Registration System Strengthening Project (IMRSSP). The pilot started in 2006 and covered Jakarta Metropolis and Central Java. It was managed by the National Institute of Health Research and Development (NIHRD), an agency of the MoH. The University of Queensland, Australia provides technical assistance and financial support comes from AusAID and WHO-Indonesia. The project has since expanded to six additional provinces covering a total population of 4 million.12

Activities

The IMRSSP is now being scaled-up to a nationally representative Sample Registration System (SRS). Using stratified sampling technique, 119 districts (rural) and 14 cities (urban) will be selected as SRS sites. A total of 5 million people or 2% of the population will be covered.13 Support from the Global Fund will cover 60 districts in 22 of the 24 provinces in the intervention area. Using semi-structured verbal autopsy instrument, trained Puskesmas staff will visit the home of a deceased person to ascertain the course of illness and treatment received. The health center physician then assigns a cause of death and trained coders will record the event using ICD-10 codes. For deaths occurring in health facilities (especially hospitals), medical certificates showing multiple causes of death will be completed by the attending physician.

Implementation of the SRS will be preceded by social mobilization and entail close collaboration with district authorities. Specific activities will include:

11 National Agency of Statistics. Indonesia 2007 - National Socio-Economic Survey (SUSENAS) 2007. Jakarta 12 The provinces are Lampung, West Kalimantan, Gorontalo, Papua, Bali and East Nusa Tenggara 13 Ministry of Health. 2007. Development of Indonesian Sample Registration System (SRS), Jakarta, August.


Continuing advocacy with policy makers and partners, along with social mobilization and community education

Training of health center-level staff in the conduct of verbal autopsy

Continuous (longitudinal) enumeration of vital events and reporting on the basis of ICD-10 codes

Conduct of independent, semi-annual surveys to match and verify births and deaths

Outcomes

Together with service-based data, population-based information provide more complete representation of community health status, and facilitates planning and resource allocation. Disease burdens attributable to communicable and non-communicable diseases (including AIDS, TB and Malaria) would be more accurately determined. The SRS being a continuous enumeration process will feed data on near real time basis to the national HIS. It will facilitate the construct of Life Tables and computation of impact indicators (like IMR and MMR) – these are vital to monitoring progress towards MDG 4, 5 and 6. Over time, evidence will become available at community level to assess the impact of pro-poor programs established by the GoI.




Number of districts submitting mortality reports

(2)

Percentage of multiple cause of death validated using ICD 10 codes

(60%)

(20)

(65%)

(30)

(70%)

(40)

(75%)

(60)

(80%)




Timeframe of support for HSS

action


Amount of financial support provided over

proposal term same currency indicated as


Expected outcomes/impact from

this support

Government

2011 - 2015 US $ 1,000,000

Obtain outcome indicators for MDG and the establishment of SRS area to monitor morbidity & mortality


if applicable

Other:


AusAID

2011 - 2015

US $ 1,500,000

Strengthening of the mortality Registration System in SRS Area




Title: Intervention 3 Improving Pharmaceutical Supply Chain Management, Drug Safety and Pharmacovigilance

Beneficiary Diseases: E.g. HIV, tuberculosis, and malaria HIV, TB, Malaria and other diseases

Identify the HSS SDA from the HSS Performance Framework Medicines, Pharmaceuticals, Vaccines and Technologies (MPVT)



ONE PAGE MAXIMUM

Rationale:

The World Bank assessment provides a platform for intervening in Indonesia’s pharmaceutical sector. It is supplemented with reports of internal reviews conducted by Badan POM and BINFAR. The findings are consistent – stringent measures in drug manufacturing are not matched with equal diligence in post-market control.

In 2008 a total of 23,587 drug samples obtained from various points in the distribution channel were assayed. The analysis showed that only 0.56 % did not meet quality standards. The GoI would like to sustain and improve on this performance but there is limited human resource capacity. Laboratory resources are likewise insufficient. The potential for adulterated and substandard products to penetrate the market thus increases as domestic consumption grows and more generics come on to the market as is presently the case with ATM drugs.

There are others problems still:

The physical state of medical stores at district and health facility levels do not meet national standards – the space is cramped, shelving units are inadequate, and temperature control is really poor; only 36% of DHOs met the required infrastructure requirement

There is poor stock control – in 2009, only 15% of districts met the required stock level for essential drugs

Inventory management is weak – at one of the district medical stores visited, log of manufacturing and expiry dates are not kept, supply lead times are long and wastage rates are never monitored (expired drugs are simply discarded)

Wide variations exist in drug pricing – “branded” generics available in hospitals and licensed pharmacies sell at more than 6 times the international reference price or 4-5 times the lowest priced generic substitute in the country.14

Monitoring of adverse drug events (pharmacovigilance) is weak – it relies mainly on voluntary reports from healthcare professionals but the numbers are rising (from 175 cases reported in 2007 to 533 in 2009)

Activities

This intervention will strengthen the “upstream” (manufacturing and quality control) and “downstream”

14 See footnote #7.


(distribution, storage, and pharmacovigilance) segments of the pharmaceutical sector. Measures that enhance pre- and post-market control along with those that enhance the integrity of distribution channels have been proposed by the respective lead agencies.

Accordingly, Badan POM will:

Develop national guidelines for Bio-Availability and Bio-Equivalency study of generic drugs and for quality and product information regarding ATM medicines

Procure laboratory equipment and reagents for sampling and testing of ATM drugs and other medicines (list provided in Attachment B)

Develop communication strategy to enhance dissemination of information on ATM drugs and strengthen surveillance of adverse events – includes establishment of Call Center and use of SMS for consumer information/education

Conduct workshop for industry stakeholders on pre-qualification standards for ATM medicines On its part, BINFAR will: Develop training modules and conduct training in inventory and supplies management Develop, install and train staff in the use software for inventory and supply chain management to

improve forecasting, procurement and distribution of drugs Rehabilitate drug warehouses at district level in Eastern and Western parts of the country – will

involve civil works as well as procurement of equipment and furniture Procure vehicles (delivery trucks, 4x4s, motorbikes and boats) to facilitate drug distribution and

supervision of health workers – the GoI will fund operating and maintenance costs (insert in 5B)

Outcomes

Improved quality, efficacy and safety of drugs at all points in the supply chain

Improved adverse drug event reporting from better informed consumers of ATM drugs

Shortened drug supply lead times; reduced occurrence of stock-out and expired drugs

Greater efficiency in the allocation of resources for drugs and medical supplies




Number of assay conducted

(150)

Number of provinces implementing communication strategy

(0)

Percentage of district medical stores that meet national benchmark for infrastructure

(40%)

(240)

(8)

(50%)

(300)

(14)

(65%)

(360)

(20)

(75%)

(420)

(24)

(85%)


Percentage of districts that have 18 months’ supply of essential drugs

(20%)

(30%)

(45%)

(60%)

(75%)




Timeframe of support for HSS

action


Amount of financial support provided over

proposal term same currency indicated as


Expected outcomes/impact from

this support

Government 2011-14 US$6,000,000

Improved pharmaceutical services


if applicable

Other:

NONE

NONE


4B.2 Engagement of HSS Key Stakeholders in Proposal Development

(a) Briefly describe which important HSS stakeholders (e.g. ministries of planning, finance etc, non-government sectors) have been involved in the identification and development of appropriate cross-cutting HSS interventions for this Round 10 proposal. Explain why these stakeholders were selected and how they are the most relevant to a comprehensive assessment of health system weaknesses and responses in the particular country context?

ONE PAGE MAXIMUM

Preliminary meetings were held with CCM and development partners in May 2010, followed by extensive consultation with stakeholders in July and August 2010.

A three-day workshop was conducted in Bogor, Indonesia in July 2010 to accelerate proposal development – it involved key departments in the MoH and the bureau for health HR, and was facilitated by national and international consultants.

Visit to Lombok, NTB Province (underperforming district) where meetings were held between proposal development team and Puskesmas, district hospital and DHO staff (including TB supervisor). GTZ facilitated the visit.

Discussions held with key partners including GTZ, AUSAID, WB and USAID to ensure integration of development programs, minimize overlap and prepare the grounds for better monitoring of HSS activities

Presentations on proposed HSS made via video conferencing to 16 regional health information managers to solicit input/feedback (meeting held in Medan, North Sumatra on 08 July) and 17 regional health information managers in Surabaya, East Java on 29 July 2010.

Consultations with CSOs (including those providing TB services) to identify constraints to information sharing and solutions to address the problems.

Gender equality was observed in the development of the proposal with almost equal participation from males and females; this will be sustained all through program implementation.

Implementation of HIS and MPVT activities will involve significant collaboration with the private sector – consultants/consulting firms, IT vendors, private TV, and telecom companies

(b) Has the applicant ensured that:

(i) the cross-cutting HSS interventions in the proposal do not repeat any request for funding under any of the specific disease components (section 4.4.1 of each disease)? And

Yes

(ii) the detailed work plan and a Performance Framework for this disease including separate worksheets that clearly identify the cross-cutting HSS interventions by objective, SDA, and activity for the initial two years of the proposal?

Yes


4B.3 Strategy to mitigate initial unintended consequences

If there are some perceived initial disruptive consequences of the planned investment in any or all of the cross-cutting HSS interventions set out in section 4B.1 above:

(a) What were the factors considered when deciding to proceed with the request for the financial support in any event?

(b) What is the applicant’s proposed strategy for mitigating these potential disruptive consequences?

ONE PAGE MAXIMUM

The unintended consequences of the HSS interventions will arise largely from the fact the PR and SRs are new to Global Fund grant management processes. Capacity could be an issue – there is no standing Program Management Unit in the MoH and SWAps are not well established in the Asia/Pacific region. Fortunately, Indonesia has a lot of experience managing GF grants (disease components only). Valuable experience also comes from the implementation of GAVI-HSS and CSO support – strengthening the institutional capacity of PRs and SRs, and ensuring clear disbursement, accounting and reporting channels are pre-requisites for successful implementation.

Additional technical and management staff will be required, supplemented with training of key staff in implementing units (PR and SRs). Implementation will also be outsourced to NGOs and private sector organizations where feasible and efficient to do so – this will require that the PR build-up the needed capacity for contract management. These costs have been factored into the budget for program support. The UNDP is also assisting the CCM to develop a Technical Assistance Framework (TAF) that will streamline TA needs and ensure fair balance between national and international consultants.

The phasing of activities takes into account the need for capacity building in the first two years of implementation and to ensure that equity objectives are preserved. The allocation of budgets reflects these concerns.

A number of activities under HIS strengthening rely on the preliminary work supported by GTZ in 2011. Delay in completing these tasks could negatively impact on Global Fund-supported activities. Provision is made in the TAF to finance additional TA needs as might be required to speed-up implementation. The GoI also commits to mobilizing additional resources to cover gaps as the need arises.


SECTION 5B: –CROSS-CUTTING HSS INTERVENTIONS

Section 5B may only be included in one disease and under the following conditions:

the proposal identifies gaps and constraints in the health system that have an impact on HIV, tuberculosis and malaria outcomes;

the interventions required to respond to these gaps and constraints are cross-cutting and benefit more than one of the three diseases;

an accompanying Section 4B is included in same disease proposal; and

the applicant has not included Section 4B or Section 5B in any other disease in the Round 10 proposal

Copy sections 5B.1 to 5B.4 starting on the second page below into the Round 10 proposal form after Section 5.5 in the same disease proposal as the applicant included Section 4B (once only, in one disease only) 5B.1 Detailed Budget Steps in budget completion: 1. submit a detailed budget of the cross-cutting HSS interventions in Microsoft Excel format using

the same numbering for budget line items as in the description of cross-cutting HSS interventions in section 4B.1. The cross-cutting HSS interventions may be prepared either as a separate Excel worksheet of the disease budget, or as separate file in Microsoft Excel.

For guidance on details required (or to use a template if there is no existing in-country detailed budgeting framework) refer to the detailed budget guidance in section 5.1 of the Round 10 Guidelines

2. from that detailed budget, prepare a Summary by Objective and Service Delivery Area

(section 5B.2).

It is important to note that SDAs for the purpose of cross-cutting HSS interventions are not the same as the SDAs for the disease section - refer to Section 5B.2 of the Round 10 Guidelines for more information

3. from the same detailed budget as in Step 2, prepare a Summary by Cost Category (section

5B.3); and

PROPOSAL FORM – ROUND 10 CROSS-CUTTING HEALTH SYSTEMS STRENGTHENING INTERVENTIONS

SECTION 5B (OPTIONAL)


4. ensure the detailed budget is consistent in the numbering of objectives, SDAs, activities with the detailed work plan for cross-cutting HSS interventions, and the Performance Framework for cross-cutting HSS interventions.


5B.2 Summary of detailed budget for cross-cutting HSS interventions by objective and service delivery area Clarified Section 5B.2

Budget breakdown by SDA

Objective Number

Service delivery area Year 1 Year 2 Year 3 Year 4 Year 5 Total

1.1

HSS: Health Information Systems [Disseminate revised HIS guidelines to Puskesmas Hospital, District, and Provincial level]

150,000 0 0 0 0 150,000

1.2

HSS: Health Information Systems [Adopt ICD-10 classification for puskesmas and hospitals]

300,000 0 0 0 0 300,000

1.3

HSS: Health Information Systems [Conduct HIS Steering Committee (DeSIKNAS) meetings]

3,500 7,350 7,718 8,103 8,509 35,180

1.4 HSS: Health Information Systems [Conduct HIS training needs assessment]

200,000 0 0 0 0 200,000

1.5

HSS: Health Information Systems [Develop standard curriculum for certified shortcourses in national universities (Centers of Excellence of HIS)]

100,000 105,000 0 0 0 205,000

1.6 HSS: Health Information Systems [Provide equipment

0 157,500 82,688 86,822 0 327,010



Objective Number Service delivery area Year 1 Year 2 Year 3 Year 4 Year 5 Total

and other resources (journals, computer labs, information systems, distance learning programs)]

1.7

HSS: Health Information Systems [Organize short courses in health informatics, epidemiology, biostatistics and demography]

0 147,000 308,700 405,169 425,427 1,286,296

1.8

HSS: Health Information Systems [Provide incentive for HIS staff at District Health Office (DHO) and Puskesmas in Papua and Papua Barat provinces (for Data Center)]

0 21,000 220,500 405,169 182,326 828,995

1.9 HSS: Health Information Systems [HIS facilitation for 45 districts]

0 1,008,000 1,323,000 0 0 2,331,000

1.10

HSS: Health Information Systems [Procure ICT equipment for DHOs and Puskesmas]

125,000 262,500 275,625 289,406 0 952,531

1.11 HSS: Health Information Systems [Develop health data dictionary]

0 315,000 0 0 0 315,000

1.12 HSS: Health Information

Systems[Develop database structures and metadata]

0 0 330,750 0 0 330,750




1.13

HSS: Health Information Systems [Adopt protocol for data exchange and interoperability (including data codification)]

0

0

330,750

0

0

330,750

1.14

HSS: Health Information Systems [Procure ICT equipment for data warehouse at central level]

0 0 291,203 0 0 291,203

1.15

HSS: Health Information Systems [Develop manual and modules for Data Quality Self-assessment (DQS)]

200,000 0 0 0 0 200,000

1.16 HSS: Health Information Systems [Train staff on DQS]

0 105,000 220,500 231,525 0 557,025

1.17 HSS: Health Information Systems [Conduct DQS]

0 131,250 165,375 173,644 182,326 652,595

1.18 HSS: Health Information Systems [Develop interface to link data sources]

0 0 0 86,822 91,163 177,985

1.19

HSS: Health Information Systems [Improve dissemination and use of information for decision making]

73,200 153,720 161,406 169,476 177,950 735,752




1.20

HSS: Health Information Systems [Conduct geocoding and mapping of health facilities]

200,000

210,000

220,500

347,288

243,101

1,220,889

1.21

HSS: Health Information Systems [Operation research on data flow in puskesmas, district and provincial level]

0 210,000 0 0 0 210,000

1.22

HSS: Health Information Systems [Disseminate research findings and introduce quality improvement measures]

105,000 110,250 0 215,250

Subtotal 1,351,700 2,938,320 4,048,965 2,203,424 1,310,802 11,853,211

2.1

HSS: Health Information Systems [Hold preparatory meetings at central and district levels]

2,437 2,559 2,687 2,821 2,962 13,466

2.2

HSS: Health Information Systems [Develop survey protocol, instruments and manuals]

35,765 37,553 39,431 41,402 43,473 197,624




2.3

HSS: Health Information Systems [Conduct worskhop on use of survey protocol, instruments and manual]

50,200 52,710 55,346 58,113 61,018 277,387

2.4 HSS: Health Information Systems [Recruit SRS personnel]

55,907 293,512 616,375 323,597 67,955 1,357,346

2.5 HSS: Health Information Systems [Organize training-of-trainers in interview techniques]

16,875 35,438 55,814 78,140 82,047 268,314

2.6 HSS: Health Information Systems [Training of trainers of local personnel in district level]

16,534 34,721 54,686 76,561 80,389 262,891

2.7 HSS: Health Information Systems [Periodic Subdistrict Meetings]

12,700 33,338 42,005 51,456 54,029 193,528

2.8 HSS: Health Information Systems [Monitoring & Supervision]

40,000 105,000 132,300 162,068 170,171 609,539

2.9 HSS: Health Information Systems [Data Processing (Coding, Editing, Entry and Cleaning)]

0 13,650 19,845 23,153 24,310 80,958

2.10 HSS: Health Information 0 7,350 7,718 8,103 8,509 31,680




Systems [Data Analysis]

2.11 HSS: Health Information Systems [External validation]

0 157,500 198,450 243,101 255,256 854,307

2.12 HSS: Health Information Systems [Information dissemination - Annual Seminar in Jakarta]

120,000 147,000 154,350 162,068 170,171 753,589

Subtotal

350,418 920,331 1,379,007 1,230,583 1,020,290 4,900,629

3.1 HSS: Medical Products Vaccines and Technologies [Hold preparatory meeting on guidelines for product specification, Bio Availability and Bio Equivalency study of medicines including ATM drugs]

4,544 0 0 0 0 4,544

3.2 HSS: Medical Products Vaccines and Technologies [Draft guidelines for product specification, Bio Availability and Bio Equivalency study of medicines including ATM drugs]

39,944 0 0 0 0 39,944

3.3 HSS: Medical Products Vaccines and Technologies [Disseminate guidelines on

17,272 0 0 0 0 17,272




product specification, Bio Availability and Bio Equivalency study of of medicines including ATM drugs]

3.4 HSS: Medical Products Vaccines and Technologies [Pharmaceutical industry pre-qualification program for essential medicine supplies in Indonesia]

0 0 120,173 0 0 120,173

3.5 HSS: Medical Products Vaccines and Technologies [Conduct training on laboratory analysis of drugs including ATMs]

257,360 162,137 0 0 0 419,497

3.6 HSS: Medical Products Vaccines and Technologies [Procure equipment and reagents for laboratory analysis of ATM medicines]

368,016 386,417 0 0 0 754,433

3.7 HSS: Medical Products Vaccines and Technologies [Hold preparatory meetings on strengthening monitoring of distribution channel]

0 27,207 0 0 0 27,207

3.8 HSS: Medical Products Vaccines and Technologies [Develop guidelines on

0 133,030 0 0 0 133,030




strengthening monitoring of distribution channel]

3.9 HSS: Medical Products Vaccines and Technologies [Conduct workshop on strengthening monitoring of distribution channel]

0 77,900 122,692 128,826 90,178 419,596

3.10 HSS: Medical Products Vaccines and Technologies [Hold preparatory meetings on improving pharmacovigilance]

0 67,253 0 0 67,253

3.11 HSS: Medical Products Vaccines and Technologies [Develop guidelines on improving pharmacovigilance]

0 0 55,125 0 0 55,125

3.12 HSS: Medical Products Vaccines and Technologies [Conduct training on improving pharmacovigillance]

0 0 0 36,465 0 36,645

3.13 HSS: Medical Products Vaccines and Technologies [Develop communication strategy on drug safety to consumer]

0 560,700 588,735 618,172 0 1,767,607

3.14 HSS: Medical Products Vaccines and Technologies [Develop Call Center]

0 285,833 0 0 0 285,833




3.15 HSS: Medical Products Vaccines and Technologies [Disseminate communication strategy to stakeholders]

0 209,475 219,949 0 429,424

3.16 HSS: Medical Products

Vaccines and Technologies [

Rehabilitate medical stores at district level in West area @300 m2]

416,670 437,504 459,379 964,695 0 2,278,248

3.17 HSS: Medical Products Vaccines and Technologies [

Rehabilitate medical stores at district level in East area @300 m2]

500,000 525,000 551,250 1,157,625 0 2,733,875

3.18 HSS: Medical Products Vaccines and Technologies [Procure equipment for district medical stores]

72,780 76,419 240,720 505,512 530,787 1,426,218

3.19 HSS: Medical Products Vaccines and Technologies [

Procure vehicles for drug distribution]

0 563,732 1,479,798 1,553,787 1,305,181 4,902,498

3.20 HSS: Medical Products Vaccines and Technologies [Procure and install software for Inventory and Supply Chain

100,000 0 0 0 0 100,000




Management]

3.21 HSS: Medical Products Vaccines and Technologies [Procure IT hardware (PC + modem + back-up equipment)]

0 139,986 48,995 154,335 54,017 397,333

3.22 HSS: Medical Products Vaccines and Technologies [Conduct training on use of software for Inventory and Supply Chain Management]

0 191,797 83,911 88,107 0 363,815

Subtotal

1,776,586 3,567,662 4,027,506 5,427,473 1,980,163 16,779,390

Program Management Program management and

Administration cost [Recruit Staff]

413,200 689,733 689,733 689,733 717,322 3,199,721

Program management and Administration cost [Office Management]

7,829 22,404 22,404 22,404 23,300 98,341

Program management and Administration cost [Supervisory Activities]

40,686 77,600 77,600 77,600 80,704 354,190

Program management and Administration cost [Program Implementation Monitoring]

75,444 97,067 97,067 97,067 100,949 467,594

Program management and Administration cost [Annual Audit]

0 22,222 44,444 44,444 50,000 161,110

Program management and Administration cost [Closing Out Program]

0 0 0 0 22,222 22,222




Program management and Administration cost []

0 55,556 0 0 0 0

Subtotal

537,159 964,582 931,248 931,248 994,497 4,358,734

Total funds requested from Global Fund for cross-cutting HSS interventions

4,015,863 8,390,895 10,386,726 9,792,728 5,305,752 37,891,964


5B.3 Summary of detailed budget by cost category Summary information provided in the table below should be supplemented with additional detail in section 5B.4 below

. Breakdown by cost category (same currency as selected by Applicant on face sheet of the Proposal Form)


Human resources 55,907 750,262 1,316,463 1,176,767 963,783 4,263,182

Technical and Management Assistance 839,944 2,667,730 3,299,783 1,457,451 516,590 8,781,498

Training 1,037,206 997,976 1,224,864 1,290,632 705,226 5,255,904

Health products and health equipment - - - - - -

Pharmaceutical products (medicines) - - - - - -

Procurement and supply management costs 368,016 672,250 291,203 - - 1,331,469

Infrastructure and other equipment 1,114,450 2,162,641 3,138,455 4,712,182 1,889,985 13,017,713

Communication Materials - - - - - -

Monitoring & Evaluation 168,830 313,005 348,972 388,191 405,853 1,624,851

Living Support to Clients/Target Populations - - - - - -

Planning and administration 431,510 827,031 766,986 767,505 824,315 3,617,347

Overheads - - - - - -

Other: avoid using the "other" category unless necessary – read the Round 9 Guidelines

- - - - - -

Total funds requested from Global Fund for cross-cutting HSS interventions (Section 4B.1)

4,015,863 8,390,895 10,386,726 9,792,728 5,305,752 37,891,964


5B.4.1 Variations in costs Briefly explain any significant variations in cost categories by year, or significant five year totals for those categories.

HALF PAGE MAXIMUM

The overall budget is estimated at US$37,891,694 (thirty-seven million, eight hundred and ninety-one thousand, six hundred and ninety-four dollars). Thirty-three percent (33%) of this will be spent in Phase 1 (Years 1 and 2). The allocation of budgets takes into account capacity building for the PR and SRs implementing the program. It includes salaries and operating costs for a program management unit in the office of the Secretary-General (the PR) within the MoH. Such a unit does not exist at present. Implementation will be ramped-up in Years 3 and 4 when a lot of procurement activities and infrastructure rehabilitation take place. This period will see 53% of the budget expended.

5B.4.2 Human resources

In cases where human resources represents an important share of the budget, summarize: (i) the basis for the budget calculation over the initial two years; (ii) to what extent human resources spending will strengthen health systems’ capacity at the client/target population level.

Useful information to support the assumptions to be set out in the detailed budget may include: i) a list of the proposed positions that is consistent with assumptions on hours, salary etc included in the detailed budget; and, ii) the percentage of time that will be allocated to the work under this proposal


HALF PAGE MAXIMUM

Human resources constitute 11% (US$4,263,182) of the total budget over the five-year period. This amount will increase annually, reaching a maximum in the third year. During the first phase, national universities designated as Centers of Excellence for HIS will conduct certified short courses in HIS, epidemiology, statistics and demography.

For very remote districts (especially, those in Papua province), provision is made for the recruitment of HIS officers for a period of 2 years. This will complement other cadres of health workforce (doctors, nurses, midwives) already deployed to the area. Advocacy with the local government will continue to ensure that these staff are absorbed into the public service when GF funding ceases. Such guarantees will be requested of local governments prior to deployment of staff. The budget for human resources also includes support for data collection from enumeration sites under the SRS that will start in Year 2. This will be scaled-up gradually until Year 5.

5B.4.3 Other large expenditure items

If other ‘cost categories’ represent important amounts in the summary in table 5B.4, (i) explain the basis for the budget calculation of those amounts. Also explain how this contribution is important to implementation of the national disease program.

1.1.1 Attach supporting information as evidence, including draft documents where applicable

HALF PAGE MAXIMUM

Infrastructure and Equipment emerge the largest category of expenditure (34%), much of which will go towards rehabilitating district and health center medical stores, as well as improving logistics and supply chain management. Priority is accorded to remote districts in the allocation of funds.

Technical and Management Assistance follows, taking-up 23%. The bulk of the spending is for


specialized IT services (development of data repository, GIS mapping of health facilities, ICT equipment for health centers). The expertise required will usually be sourced in the private or international market.

Still under HIS strengthening, on-site technical support will be provided to districts for to facilitate adoption of new (electronic) formats for data transfer and use of information for decision-making. This facilitation will be available to 45 districts for a total period of 6 months each and will be contracted to NGOs, private sector or universities using national procurement rules.

12

value Year Source Year 1Report due

dateYear 2

Report due date

Year 3 Year 4 Year 5

1 253 2006

Specify- Reports, Surveys,

Questionnaires etc.

207 2011 197 2012 188 180 172

2 105 2006


Questionnaires etc.

86 2011 82 2012 78 74 70

3 39 2007


Questionnaires etc.

38 2011 37 2012 36 35 34

4 Please select…


dateYear 2

Report due date


1 67 2007R&R TB system, quarterly reports 75 2011 80 2012 85 90 90

2 69 2007R&R TB system, quarterly reports

75 2011 80 2012 85 85 80



5 1.4 2009R&R TB system, quarterly reports 1.4 2011 1.4 2012 1.3 1.3 1.2

6 Please select…

Objective Number

123456

Value Year Source 6 months 12 months 18 months 24 months Year 3 Year 4 Year 5

1 1

High Quality DOTS Number of new smear positive TB cases notified73%

169,213/231,370

2009R&R TB system, quarterly reports

86562/116990(75%)

173124/233980

(75%)

91806/115866

(80%)

183610/231731

(80%)

193841/229124

(85%)

203791/226163

(90%)

202197/222855

90%)National Program Y - cumulative annually N Top 10

Directorate General of Disease Control and

Environmental Health, Ministry of Health

2 1

High Quality DOTS Number of new smear positive TB cases successfully treated88,4%

147145/166376


74522/84684(88%)

149044/169368

(88%)

76174/86562(88%)

152349/173124

(88%)

170580/193841

(88%)

179336/203791

(88%)

177934/202197

(88%)National Program Y - cumulative annually N Top 10



3 1

High-risk groups Number of children with TB among all TB cases notified30806/2947

31(10%)


16.264 / 162.642

10%

32.528 / 325.284

10%

17.250 / 172.492

10%

34.500 / 344.984

10%

36.421 / 364.208

10%

38.290 / 382.902

10%

37.991 / 379.909

10%National Program Y - cumulative annually N Top 10



4 1

High-risk groups Number of new Smear Positive TB patients reported in prisons

99 2009R&R TB system, quarterly reports

50 100 70 140 400 440 480 National Program Y - cumulative annually N Top 10



5 1

TB/HIV Number of TB-HIV patients enrolled in HIV Care

991 2009


Questionnaires etc.

30 60 60 120 120 120 120 Current grant Y - cumulative annually N Top 10



6 1

MDR-TB Number of lab confirmed MDR TB patients enrolled in SLD treatment

23 2009


Questionnaires etc.

350 700 800 1600 3400 5100 6000GF & other donors

(not national)Y - cumulative annually N Top 10



7 2

HSS: Health Workforce Number of hospitals involved in PPM (Public Private Mixed)/ISTC (International Standard Tuberculosis)


Questionnaires etc.

40 80 140 200 275 425 575 National Program Y - over program term N Not Top 10



Comments Service Delivery Area Indicator formulation Baseline (if applicable)

Targets cumulativeY-over program term

Y-cumulative annuallyTop 10 indicator

Disease:

DTF: Name of PR responsible for

implementation of the

Improved access to quality DOTS and PMDT Services for all TB patients with focus on vulnerable populations

Male to female ratio of all notified case

These targets have been adjusted based on the current Medium Term National Development Plan targets

Case notification rate: all cases

TB prevalence rate

TB incidence rate

Treatment success rate: new smear positive TB cases

TB mortality rate

Indonesia

TB

Program Goals, impact and outcome indicators

WHO Global TB Report

Impact indicator number

Baseline

Improve access to quality DOTS services by expanding community networks and strengthening health systems in order to reduce morbidity and mortality of TB and MDR-TB

Impact indicator formulation

Objectives:

Case notification rate: new smear positive TB cases

BaselineComments*

Goals:

TBAccelerating progress toward universal access to quality Tuberculosis control in IndonesiaProposal ID:

Please select…

Objective Number

Strengthened health systems with focus on quality service delivery, human resource development, MIS and PSM systems


Tied to

Strengthened community systems through mobilization, capacitybuilding and improved coordination with NGOs

Case detection rate: new smear positive TB cases

Indicator Number

Baselines included in

targets (Y/N)

Program Objectives, Service Delivery Areas and Indicators

Targets for years 1 and 2 Annual targets for years 3, 4, and 5

* please specify source of measurement for indicator in case different to baseline source.

Program Details

Comments*


Outcome indicator number

Outcome indicator formulation

Please select…

Targets

Targets

Country:

PROPOSAL FORM – ROUND 10

R10_CCM_IND_T_PerfFW_23Aug10_En.xls Performance Framework 1/2

Value Year Source 6 months 12 months 18 months 24 months Year 3 Year 4 Year 5Comments Service Delivery Area Indicator formulation

Baseline (if applicable)Targets cumulative

Y-over program termY-cumulative annually

Top 10 indicator DTF: Name of PR responsible for

implementation of the

Objective Number

Tied toIndicator Number


targets (Y/N)


8 2

HSS: Service delivery Number and % of new smear-positive TB patients notified by hospitals involved on TB Program (Government, Private, etc) among the new smear positive TB cases

9852/169213

(5,8%)2009

R&R TB system, quarterly reports

4934 9868 5325 10649 11242.79476 11819.85856 11727.44876 National Program Y - cumulative annually N Top 10



9 2

HSS: Service delivery Number and percentage of laboratories showing adequate performance among those that received external quality assurance for smear microscopy

763/5153(15%)


1031/5153(20%)

1288/5153(25%)

1546/5153(30%)

1804/5153(35%)

2319/5153(45%)

2834/5153(55%)

3349/5153(65%)

National Program N - not cumulative N Not Top 10



10 2

HSS: Health Workforce Number and percentage of districts with TB staff trained on DMIS out of all districts

7 2009


Questionnaires etc.

254/48852%

283/48858%

312/48864%

346/48871%

395/48881%

444/48891%

488/488100%

GF Y - over program term N Top 10



11 2

HSS: Medical Products, Vaccines and Technology

Number and percentage of district that reported no stock out in first line drugs on last day of the quarter.

148 2009


Questionnaires etc.

390/48880%

415/48885%

415/48885%

415/48885%

415/48885%

415/48885%

415/48885%

National Program N - not cumulative N Not Top 10



12 3

CSS: Monitoring and documentation of community and government interventions

Number of community based organisations that documented feedback meeting with the community

NA NA Please select… 0 2 4 6 16 18 21 National Program N - not cumulative N Not Top 10



13 3

CSS: Building community linkages, collaboration and coordination

Number of community based organisations that deliver services for prevention, care or treatment and that have a functional referral and feedback system in place NA NA Please select… 0 2 4 6 16 18 21 GF Y - over program term N Not Top 10



14 3

CSS: Human resources: skills building for service delivery, advocacy and leadership

Number of community health workers and volunteers currently working with community based organisations who received training or re‐training in TB service delivery according to national guidelines in the last 12 months

NA NA Please select… 50 50 70 70 75 170 200 GF N - not cumulative N Top 10



15 3

CSS: Human resources: skills building for service delivery, advocacy and leadership

Number of community based organisations that received training for institutional strengthening

NA NA Please select… 0 5 5 10 15 20 25 GF N - not cumulative N Top 10



16 Please select… Please select… Please select… Y - over program term N Please select...



R10_CCM_IND_T_PerfFW_23Aug10_En.xls Performance Framework 2/2

12


dateYear 2

Report due date


1 253 2006 Please select… 207 2011 197 2012 188 180 172

2 105 2006 Please select… 86 2011 82 2012 78 74 70

3 39 2007 38 2011 37 2012 36 35 34


dateYear 2

Report due date


1 67 2007 R&R TB system 75 2011 80 2012 85 90 90

2 69 2007 R&R TB system 75 2011 80 2012 85 85 80

3 119 2007 R&R TB system 125 2011 135 2012 145 155 165

4 89 2006 R&R TB system 88 2011 88 2012 88 88 88

5 1.4 2006 R&R TB system 1.4 2011 1.4 2012 1.4 1.3 1.2

6 Please select…

Objective Number

123456

Value Year Source 6 months 12 months 18 months 24 months Year 3 Year 4 Year 5

1 1.1HSS: Information system Percent of districts submitting routine HIS report within 30

days of end of the month N/A 2008 HMIS N/A N/A 30 50 60 70 80 National Program Y - cumulative annually N Not Top 10 PusdasureProvincial Health Office to verify submission. Baseline will be determined withinthe first 6 months of implementation

2 1.2HSS: Information system Percent of districts conducting two (2) feedback sessions with

Puskesmas, Private and NGOs per year N/A 2009Administrative

recordsN/A N/A 20 30 50 60 70 National Program Y - cumulative annually N Not Top 10 Pusdasure

Provincial Health Office to verify submission. Baseline will be determined withinthe first 6 months of implementation

3 1.3 HSS: Information system Data accuracy - error rate N/A 2009 Health Facility survey

N/A N/A N/A 5 3 3 3 National Program N - not cumulative N Not Top 10 Pusdasure DQS to start in Year 2

4 2.1 HSS: Information system Number of district submitting mortality reports 2 2009 SRS 2 2 10 20 30 40 60 National Program Y - cumulative annually Y Not Top 10 NIHRD

5 2.2HSS: Information system Percentage of multiple cause of death validated using ICD 10

codes 5 2009 SRS 5 60 65 65 70 75 80 National Program Y - cumulative annually Y Not Top 10 NIHRD

8 3.1 HSS: Medical Products, vaccines d t h l

Number of assay conducted 150 2008 Quarterly activity report

150 150 180 240 300 360 420 National Program Y - cumulative annually Y Not Top 10 Badan POM

9 3.2HSS: Medical Products, vaccines and technology

Number of provinces implementating communication strategy0 2009

Quarterly activity report

0 0 4 8 14 20 24 National Program Y - cumulative annually Y Not Top 10 Badan POM


Percentage of district medical stores that meet national benchmark for infrastructure 36 2009 Supervision report 36 40 45 50 65 75 85 National Program Y - cumulative annually Y Not Top 10 Binfar

National benchmark equals minimum score of 70% for adequacy of infrastructure


Percent of districts that have 18 months supply of essential drugs 15 2009 Supervision report 15 20 25 30 45 60 75 National Program Y - over program term Y Not Top 10 Binfar

DTF: Name of PR responsible for

implementation of the corresponding activity

Comments


Tied to

Targets cumulativeY-over program termY-cumulative annually

N-not cumulative


targets (Y/N)Top 10 indicator

Improving Pharmaceutical Supply Chain Management, Drug Safety and Pharmacovigilance

Indicator Number

Objective Number

Service Delivery Area Indicator formulation

Baseline (if applicable)

* please specify source of measurement for indicator in case different to baseline source.

Program Objectives, Service Delivery Areas and Indicators

Objectives:Reinforcing the national health information system for better integration, data management and use for decision-making

Scaling-up the Sample Registration System (SRS) and promote health system research

Treatment success rate: new

Male to female ratio of all notified cases

Please select…

Case detection rate: new smear positive TB cases

Case notification rate: new smear positive TB cases

Case notification rate: all cases

Outcome indicator number

Outcome indicator formulationBaseline Targets

Comments*

Please select…

TB prevalence rate Global TB reports

TB incidence rate Global TB reports

TB mortality rate Global TB reports

Impact indicator number

Impact indicator formulationBaseline Targets

Comments*

Proposal ID:

Program Goals, impact and outcome indicators

Goals:

Contribute to reducing morbidity and mortality from infectious diseases including AIDS, TB and Malaria

Disease: TB - HSS

HSSProgram DetailsCountry: Indonesia

PROPOSAL FORM – ROUND 10SINGLE AND MULTI-COUNTRY APPLICANT

Performance Framework: Indicators, Targets and Periods Covered

R10_CCM_IND_THSS_PerfFW_24Aug10_En.xls Performance Framework 1/1

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