I. Introduction
1.3. HIV and AIDS Response and Health System
The HIV and AIDS response in Indonesia cannot be separated from global health initiatives through various programs and funding schemes (e.g. Global Fund, aids from the U.S.
government and the Australian government through USAID and DFAT, etc.). The presence of global health initiative in Indonesia since the beginning of the AIDS in Indonesia is proved to have been able to increase the program funding. Consequently, it managed to increase the coverage of HIV and AIDS related services. Despite the fact that the financing from the global initiatives tend to decline from year to year, at present most funding for HIV and AIDS response mainly depends on bilateral and multilateral grants with government funds covering only 40 % of the total financing (Najib , 2013). This pivotal role of global health initiatives in HIV and AIDS response in developing countries has resulted in various positive and negative consequences on
health systems. Various studies have recorded negative consequences on the health system such as the development of a dual system, namely the HIV and AIDS response system and the health system in general, weak incentives of health system to support the HIV and AIDS control efforts and the lack of integration between HIV and AIDS services and other health services (Atun et al., 2010a, b; Conseil et al., 2013; Desai et al., 2010; Dongbao et al., 2008; Kawonga et al., 2012; Shakarishviliet al. 2010). Likewise, HIV and AIDS response tends to develop mechanism of service delivery, planning, financing, monitoring and evaluation separated from general health system. It also sparks a worry that this situation will worsen the health system as it will absorb the resources available for addressing other health problems. Various efforts to strengthen health systems have been recommended by experts through integration of HIV and AIDS response into the health system (Atun et al., 2010; Coker et al. , 2010; Kawonga, 2012) . Integration is generally associated with efforts to adopt and assimilate the HIV and AIDS response efforts into the basic functions of the health system. At the service delivery level, this integration can be conducted, for instance, by integrating special AIDS services into general health services, engagement of inter-programs and other sectors in AIDS response, integrating the financing system in AIDS response into the general health financing, etc.
A study on the integration of AIDS programs and TB in Indonesia indicates that both programs are not integrated yet into the health system functions in general such as in health management, Monitoring and Evaluation system, planning, financing, and provision of services (Desai et al., 2010; Coker et al., 2010). Furthermore, the study on the documents on HIV and AIDS programs in Indonesia from 1987 to 2013 conducted by Centre for Health Policy and Management Team, Faculty of Medicine, Gadjah Mada University (UGM) suggests that the policies and programs on HIV and AIDS response during this period strengthened all findings of the previous studies. First, the HIV and AIDS response is a vertically-oriented policy initiated and developed by the central government with full supports from global health agencies. However the integration process into the existing health system is weak since it is built on different system from the national health system in the country. Second, in a decentralized era, the present local governments has not played a significant role in the HIV and AIDS response to
develop policies and programs for prevention, CST (care, support, treatment) and the impact mitigation. In addition to the desk review, the result of field observations in 6 provinces presents several problems in institutional, resources, and financing aspects as follows: a) the dominant central government and international development partner agencies tend to place local governments as program implementer. Hence, the commitment and financial support for HIV and AIDS response tend to be minimum; b) local funding for HIV and AIDS programs tend to be very limited and used to finance provincial AIDS commision secretariat ; c) the problems on access to HIV and AIDS related services by key populations (e.g. limited hours of service, numbers and qualifications of health workers specifically for AIDS service, payment systems , stigma and discrimination, etc.) still exists in community health centers, hospitals and other VCT clinics; and d) there are overlapping functions between provincial AIDS commission and Health Offices in HIV and AIDS programs at the local level.
As a health issue, HIV and AIDS responses cannot be separated from the existing health system in a country. WHO (2007) defines a health system as the whole of organizations, institutions and resources whose primary objective is to achieve a good health degree in the community.
This health system includes various health measures undertaken by the government and non-government sectors (civil society organizations and private sectors) both at the national and sub-national levels. On one hand, a strong health system will allow responses of HIV and AIDS response to be sustainable and integrated into other health efforts. On the other hand, if the health system is weak, then the whole efforts for the HIV and AIDS response should be able to integrate themselves into the existing system so as to strengthen the various functions of the existing health system.
The integration of HIV and AIDS response programs into the health system is not an easy task to do since it involves a lot of players (each with their own agendas), infrastructures, policies and resources. The integration of HIV and AIDS response into the health system requires significant efforts to improve the effectiveness and accessibility of HIV and AIDS services by maximizing available resources and infrastructures (Dudley and Garner, 2011).
The integration put both systems at risk because the result achieved by AIDS response as a vertical intervention could not be sustained by the weak health system. Conversely, the available resource in the existing health system could be absorbed by the needs of AIDS response. Additionally, the fact that the health system is not yet established at the local level tends to push policy makers to continually use a vertical approach (Godwin and Dickinson, 2012).
However, no clear conclusions are drawn about the impacts of specific intervention integration into the health system to the public health status due to the limited studies on the integration and lack of adequate methodologies (see Kawonga et al., 2012 and Coker et al., 2010). Thus, the basic issue is not to select a certain approach rather than the others or the second integration of that approach because of the variability of the context of diverse policies, but rather to see that each approach complements one to another and need to be integrated into the portion in line with the complexity of an integrated and sustainable health care delivery based upon planning, coordination and effective management (Dudley and Garner, 2011; Atun et al., 2010). Formulating degree of integration between AIDS response and existing health system is the biggest challenge and it requires very careful consideration.
The policy issues that should be taken into account when studying integration between HIV and AIDS response and health system in Indonesia are as follows; (1) how to develop a public health response to address the increasing complexity for HIV and AIDS response in the long run; and (2) how far degree of integration between AIDS response and health system could be achieved in the proper combination despite the fact that the existing health system performance is currently not optimum due to political, economic and socio-cultural aspects. A comprehension of these two policy issues will be beneficial to design an effective and sustainable HIV and AIDS response program through adjustment efforts from the health system strategy and HIV and AIDS response, setting up the priorities and mobilizing resources to the operational and service level (Atun and Bataringaya, 2011)
To address to these two aforementioned policy issues, CHPM supported by the Australian Government through the Department of Foreign Affairs and Trade (DFAT) and in collaboration
with nine (9) universities in eight provinces in Indonesia will conduct a research on how "The integration of HIV and AIDS Response Efforts into the National Health System Framework in Indonesia" is. This research is intended to map out various strengths and weaknesses of the health system in Indonesia to support or address issues in HIV and AIDS. Hence, it is expected to be able to identify various potentials and opportunities to integrate HIV and AIDS response efforts into the existing health system.