RESEARCH PROTOCOL
The Integration of HIV and AIDS Response in the National Health System Framework
April 2014
Table of Content
Page
Table of Content ... 2
A List of Abbreviations ... 5
I. Introduction ... 9
1.1. Situation of HIV and AIDS in Indonesia ... 9
1.2. HIV and AIDS Response in Indonesia ... 9
1.3. HIV and AIDS Response and Health System ... 11
II. Research Questions and Objectives ... 16
2.1. Research Questions ... 16
2.2. Objectives ... 17
2.2.1. General Objectives ... 17
2.2.2. Specific Objectives ... 17
III. Conceptual Model ... 19
IV. Research Method ... 22
4.1. Research Design and Procedure ... 22
4.2. Research Location ... 26
4.3. Informants ... 27
4.4. Instrument ... 27
4.5. Data Management ... 28
4.6. Data Analysis ... 29
4.7. Research Quality Control ... 31
4.8. Reporting format ... 33
V. Research Implementation ... 34
5.1. Research Organization ... 34
5.2. Nasional research advisory board ... 34
5.3. Research Advisor ... 34
5.4. Consultative Group ... 34
5.5. Research Team ... 35
5.6. Administration and Management Team ... 36
5.7. Research Duration ... 36
5.8. Research Ethics ... 37
5.9. Policies on Dissemination and Publication of Research Results ... 38
Risk Management ... 39
VI. Bibliography ... 41
Appendix 1 ... 44
Appendix 2 ... 45
Appendix 3 ... 48
Appendix 4. ... 55
Appendix 5 ... 60
Appendix 6. ... 61
Appendix 7 ... 62
Appendix 8 ... 65
Appendix 9 ... 68
Appendix 10 ... 69
A List of Abbreviations
AIDS Acquired Immunodeficiency Syndrome
AMHP Alat Medis Habis Pakai (Consumable Medical Devices)
ALT Alanine Transaminare
ARV Antiretroviral drugs
AST Aspartate Transaminase
APBN/D Anggaran Pendapatan dan Belanja Nasional/Daerah (State/Regional Budget and Expenditure)
Bappeda Badan Perencanaan Pembangunan Daerah (Regional Development Planning board)
BMHP Bahan Medis Habis Pakai (Consumable Medical Material) CSR Coorporate Social Responsibility
CST Care, Support and Treatment
DBK Daerah Bermasalah Kesehatan (Region with Health Problems) DFAT Department of Foreign Affairs and Trade, Australia Government Dinkes Dinas Kesehatan (Health Department)
Dinsos Dinas Sosial (Social Department)
Dikbud Dinas Pendidikan dan Kebudayaan (Education and Culture Department) Disnaker Dinas Tenaga Kerja (Manpower Department)
Dikcapil/KKB Dinas Catatan Sipil/Kependudukan (Civil Registry Office) Dispora Dinas Pemuda dan Olahraga (Youth and Sports Department) Dispenda Dinas Pendapatan Daerah (Regional Revenue Office)
Dishub Dinas Perhubungan (Transportation Department) Dinpar Dinas Pariwisata (Tourism Department)
Depag Departemen Agama (Religion Department)
DTPK Daerah Tertinggal Perbatasan dan Kepulauan (Disadvantaged Borders and Islands)
FGD Focus Group Discussion
HIV Human Immunodeficiency Virus
Penasun/IDU Pengguna Napza Suntuk (Injecting Drug User)
IMS Infeksi Menular Seksual (Sexually Transmitted Infection) IO Infeksi Oportunistik (OI - Opportunistic Infection)
JKN Jaminan Kesehatan Nasional (National Health Insurance) Jamkesmas Jaminan Kesehatan Masyarakat (Community Health Insurance) Jamkesda Jaminan Kesehatan Daerah (Regional Health Insurance)
KIE/IEC Komunikasi, Informasi, dan Edukasi (Communication, Information and Education)
KPAN/P/K Komisi Penanggulangan AIDS Nasional/Propinsi/Kota/Kabupaten (National/Provincial/City/District AIDS Commision)
KTS/VCT Konseling dan Tes Sukarela (Voluntary Counselling and Testing)
LP Lintas Program (inter-programs)
LSL Lelaki Berhubungan Seks dengan Lelaki (MSM - Men who have Sex with Men)
LS Lintas Sektor (Inter-sectors)
LSM Lembaga Swadaya Masyarakat (Non-government organization)
MDGs Millenium Development Goals
TRM/MMT Terapi Rumatan Metadon (Methadone Maintenance Treatment) ODHA Orang dengan HIV dan AIDS (PLWHA - People Living with HIV and AIDS) OMS Organisasi Masyarakat Sipil (Civil Society Organization)
OBS Organisasi Berbasis Sosial (Social-based Organization)
OBM Organisasi Berbasis Masyarakat (Community-based Organization) Ormas Organisasi Kemasyarakatan (Community Organization)
Pemda Pemerintah Daerah (Regional Government)
PKMK/CPHM Pusat Kebijakan dan Managemen Kesehatan (Center for Policy and Health Management)
PMTS Pencegahan HIV Melalui Transmisi Seksual (HIV Prevention through Sexual Transmission)
Pokdisus Kelompok Studi Khusus (Specific Study Group)
PPH Pusat Penelitian HIV dan AIDS (HIV and AIDS Research Center)
PPIA Pencegahan Penularan dari Ibu ke Anak (Prevention of HIV Transmission of Mother to Child)
PPP Profilaksis Pasca Pajanan (post-exposure prophylaxis).
PSM Peran Serta Masyarakat (Community Participation) Puskesmas Pusat Kesehatan Masyarakat (Community Health Center) Renstra Rencana Strategis (Strategic Plan)
RPJM Rencana Pembangunan Jangka Menengah (Mid-Term Development Plan) RPJMD Rencana Pembangunan Jangka Menengah Daerah (Regional Mid-Term
Development Plan)
RKPD Rencana Kerja Pemerintah Daerah (Regional Government Work Plan) RSCM Rumah Sakit Cipto Mangunkusumo (Cipto Mangunkusumo Hospital) SRAN Strategi Rencana Aksi Nasional (National Action Plan Strategy)
STBP/IBBS Surveilans Terpadu Biologis dan Perilaku (Integrated Biological and Behavior Survey)
SDM Sumber Daya Manusia (Human Resources)
S&D Stigma dan Diskriminasi (Stigma and Discrimination) SKN Sistem Kesehatan Nasional (National Health System)
SKPD Satuan Kerja Pemerintah Daerah (Regional Government Working Unit) SOP Standard Operation & Procedure
SPM Standard Pelayanan Minimum (Minimum Service Standard) WPS Wanita Pekerja Seks (Female Sex Worker)
WPSL Wanita Pekerja Seks Langsung (Direct Female Sex Worker)
WHO World Health Organization
UA Universitas Airlangga (Airlangga University) UNAIDS Joint United Nations Programme on HIV/AIDS Uncen Universitas Cendrawasih (Cendrawasih University)
Unhas Universitas Hasanudin (Hasanudin University)
Unika Universitas Katolik Atmajaya (Atmajaya Catholic University) USU Universitas Sumatera Utara (North Sumatera University) Unud Universitas Udayana (Udayana University)
Research Personnels and Institutions/organizations involved
Reseacher Team
PKMK FK UGM : Ignatius Praptoraharjo, PhD; Drs. M. Suharni, M.A; dr. Satiti Retno Pudjiati, Sp.
KK (K); Hersumpana, S.Kom, Sisilya Bolilanga, SKM, M.Sc Eunice Priscilla Setiawan, S.E; dan Eviana Hapsari Dewi, S.Si
PPH Atma Jaya : Iko Safika, PhD University Researchers Team
1. Cendrawasih University: Melkior Tappy, SKM, MPH; Yane Tambing, SKM, MPH 2. Papua State University: Afia Tahoba, SP, Msi; Djumiati Mustiah, SP, MSi
3. Udayana University: dr. Luh Putu Lila Wulandari, MPH; dr. Nyoman Sutarsa, MPH 4. Nusa Cendana University: Simplexius Asa, SH, MH; DR. Yohanes G. Tubahelan, SH, MH 5. Hasanuddin University: Shanti Riskiyani, SKM, M.Kes; Sudirman Nasir, PhD
6. Airlangga University: Dr.dr. Windhu Purnomo, MS; drg. Arief Hargono, M.Kes 7. Pokdisus: dr. Anshari Saifuddin Hasibuan; Kurniawan Rachmadi, SKM, MSi 8. Atma Jaya University: Anindita Gabriella, M.Psi; Siradj Okta, SH, LLM
9. North Sumatera University: Lita Sri Andayani, SKM, M.Kes; dr. Juliandi Harahap, MA Research Advisors
PKMK FK UGM: Prof. dr. Laksono Trisnantoro, MSc, PhD.
PPH Atmajaya: Prof. Irwanto, PhD.
Consultative Group
Kemenkes RI Subdit P2PL : dr. Siti Nadia; dr. TrijokoYudopuspito, MSc.PH; dr. Afriana Herlina, M.Epid.
KPAN: dr. Suryadi Gunawan, MPH; Irawati Atmosukarta, MPP.
DFAT: Debbie Muirhead, Adrian Gilbert, Astrid Kartika.
FK UGM: dr. Yodi Mahendradhata, MSc, PhD, dr. Yanri Subronto, SpPD,PhD, dr. Ida Safitri,SpA., dr. Eggi Arguni,MSc, SpA, PhD.
HCPI: Prof. Budi Utomo, MPH.
I. Introduction
1.1. Situation of HIV and AIDS in Indonesia
The HIV and AIDS epidemic in Indonesia is considered one of the fastest growing in Asia Pacific countries. In 2012 estimate number of new HIV cases in Indonesia reached 76,000 with a total of 610,000 cases (UNAIDS 2012). Since the first HIV cases reported in 1987 until 2012, HIV cases have spread to 345 (69.4%) out of 497 districts/cities throughout 33 provinces in Indonesia.
Meanwhile, until June 2013 the largest number of HIV and AIDS cases was found in 10 provinces, namely DKI Jakarta, East Java, Papua, West Java, North Sumatera, Bali, Central Java, West Kalimantan, Riau Islands, and South Sulawesi (MOH, 2013). According to the Ministry of Health, Republic Indonesia (MOH), the estimated number of people living with HIV and AIDS in Indonesia by 2012 might reach 591,000 people, whereas the number of key affected populations (KAPs) reached 8,700,000 people in the same year. These includes 74,000 injecting drug users (IDUs), 230,000 direct and indirect female sex workers (FSWs), 38,000 waria; and 1,100,000 men who have sex with Men (MSM). In addition, the number of sex workers’ clients was estimated to reach more than 7,350,000 people (MOH, 2012). These high figures indicate a high risk of HIV spreads, thus raising long-term healthcare problems for people living with HIV and AIDS (PLWHA) in the future.
1.2. HIV and AIDS Response in Indonesia
The HIV and AIDS programs and policies in the last 20 years have focused on providing a universal access, in which promotive, preventive, curative and rehabilitative health services related to HIV and AIDS service deliveries can possibly be accessed by a minimum of 80% of KAPs. These include behavior change among KAPs (e.g IDU, FSW, MSM), by increasing the use of clean syringes and condom, testing and treatment for sexually transmitted infections (STI) and HIV through series of information, education and communication (IEC) (NAC, 2011).
Additionally, Care, Support, and Treatment (CST) programs have also been implemented to reduce barriers in accessing health services by PLHIV, including stigma and discrimination. The main objectives of these HIV and AIDS related policies are to reduce HIV prevalence by 0.5% in
2015 (NAC, 2011). The National AIDS Commission (NAC) has determined 137 districts/cities in 33 provinces as the priority areas, in which 80% of KAPs are expected to be reached in the these areas and they have access to available HIV and AIDS services (NAC, 2010). In addition, NAC has developed many policies to promote HIV response. These include the following strategies; strengthening the coordination among the key stakeholders from planning, implementing, monitoring and evaluation; ensuring the civil society’s engagements; ensuring commitment and continuing funding supports from national and local government, as well as international donors; and strengthening provincial/districts/cities AIDS commission.
As the leading sector in HIV and AIDS response programs, the Ministry of Health (MOH) has developed various programs and services to address this epidemic. For instance, there are Methadone Maintainance Treatment (MMT) in 83 hospitals, Community Health Centers, prisons, and Needles & Syringes Programs (NSP) in 194 Community Health Centers and Society Organizations (CSOs), CST programs in 378 referral hospitals and satellite hospital, and prevention from mother to child (PMTC) programs in 113 hospitals and Community Health Centers (MoH, 2013). The Ministry of Health has also put various efforts into improving capacity building for health care providers, ensuring good working environments, effective referral systems and logistic and procurements, improving strategic information, developing financing plans, as well as a coordination mechanism to provide better access to HIV and AIDS services.
An external review conducted by WHO in 2012 indicates that the current HIV and AIDS policy and program development have resulted in positive results by significantly increasing the number of interventions. However, this improvement is not evenly distributed yet in various areas, including its types of interventions (WHO, 2012). The efforts for prevention, treatment, support and medication remains a challenging task to reduce HIV prevalence among KAPs and to improve the quality of life of PLHIV as indicated from the high risk behavior and HIV prevalence among key populations. The Integrated Biological and Behavioral Surveillance (IBBS) in 2011, for instance, reported that HIV prevalence among IDUs, direct FSWs, indirect FSWs, waria, and MSM, are as follows; 42%, 10%, 3%, 22%, and 8%, respectively (MOH, 2012b). This prevalence was similar to the IBBS result in 2007, even it tended to double or triple in MSM
populations (MOH, 2012b). The high HIV prevalence especially among transgender groups and MSM is worrying since most (81%) transgender groups and nearly half (49%) of MSM are also sex workers (MoH, 2012b). By the end of September 2013, 36,582 PLHIV have taken anti- retroviral therapy (ART) out of 132,755 PLHIV reported (MoH, 2013). PLHIV still experience high stigma and discrimination in the society and in the health care (Butt et al. Jothi & BPS, 2010, Spritia, 2005).
The expansion of HIV and AIDS program in the last decades in Indonesia has brought about several consequences. For example, in addition to continuing services for KAPs and low-risk population, the future of HIV and AIDS response efforts also faces challenges, particularly in providing long-term healthcare services for PLHIV as the more effective ARV treatment can reduce the mortality rate of PLHIV. These two continuous challenges need a sort of integration in both upper and lower courses of healthcare services. The integration in the upper course lies on the integration of HIV and AIDS policies and programs into the health system; whereas, the integration in the lower course is directed to the development of healthcare services and operational system to ensure high quality healthcare which is in line with the continuum of care of HIV and AIDS response including prevention, CST (care, support, and treatment) and also impact mitigation.
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.
II. Research Questions and Objectives
2.1. Research Questions
Based on the above, the main issue in this research is:
‘To what extent has the integration of HIV and AIDS response efforts into the health system in Indonesia?’
Specific research questions:
1. How are the context, process and substance of policies and programs on HIV and AIDS response at the national level within the framework of the existing health system?
2. To what extent is the consistency between the regulations and policies of HIV and AIDS both at central and regional levels, as well as among regions and sectors?
3. To what extent is the synergy, functions and roles of KPA, health department, inter- sectors, and NGOs in HIV and AIDS response at the national and regional levels?
4. How big is the proportion, suitability, distribution and sustainability of existing funding (e.g. foreign donors, state budget /regional budget and public funds) against HIV and AIDS response at the national and regional level)?
5. To what extent are the work relationship, manpower and capacity building between non- government Human Resources (HR) for AIDS with the health human resources at the central and regional levels?
6. To what extent is the integration of HIV and AIDS reporting system into the strategic information system at the regional and national levels and the use of 'evidence' to develop and execute the policies and programs?
7. How are procurement, distribution chain, and portability of prevention materials, diagnostics and therapy at the regional and central levels within the context of national health insurance policy?
8. To what extent is the active participation of affected communities in HIV and AIDS response?
9. How is the correlation between the university and the needs for HIV and AIDS response at the national and regional levels in the provision of knowledge sources and human resources?
2.2. Objectives
2.2.1. General Objectives
To analyze the integration level of HIV and AIDS response policies into the Health System in Indonesia so that the recommendations for HIV and AIDS response for medium-term can be made.
2.2.2. Specific Objectives
1. To analyze the context, process and substance of policies and programs on HIV and AIDS at national and regional level within the framework of the existing health system;
2. To measure the consistency between the regulations and policies of HIV and AIDS both at the national and regional levels, as well as among regions and sectors;
3. To identify and measure the synergy, functions and roles of the KPA, health department, inter-sectors, and NGOs in HIV and AIDS response at the national and regional levels;
4. To measure the proportion, suitability, distribution and sustainability of existing funding (e.g. foreign donors, APBN/D - state/regional budget & expenditure and public funds) against HIV and AIDS response at the national and regional levels;
5. To identify the work relationship, manpower and capacity building between the non- goverment Human Resources (HR) for AIDS with the health human resources at the national and regional levels;
6. To measure the integration of HIV and AIDS reporting system into the strategic information system at the regional and national levels and use of 'evidence' to develop and execute the policies and programs;
7. To measure procurement, distribution chain, and portability of prevention materials, diagnostics and therapy at the regional and national levels and in the context of national health insurance policy;
8. To measure the active participation of affected communities in HIV and AIDS response;
and
9. To measure the correlation between the universities and the needs of HIV and AIDS response at the regional and national levels and in the provision of knowledge sources and human resources.
III. Conceptual Model
Basically the research is meant to measure to what extent has the integration of HIV and AIDS response into the health system by focusing on the performance exploration of functions of the health system in HIV and AIDS response contextually. Hence, the research uses a conceptual model and an analytical framework as developed by Atun et al (2010a) and Coker (2010) to measure the integration of a spesific intervention to address a specific issue in the health system.
According to Atun et al (2010), integration is defined as a rate of adoption and assimilation of specific health interventions in a variety of basic functions of the health system. The concept of adoption or assimilation used as an indicator of the integration level is based on the assumption that a specific health intervention (in this case HIV and AIDS) is believed to be an innovation in health efforts in the terms of perspectives, practices or institutional management considered different from other health efforts. When viewed from the health system aspect, the integration of various functions indicates to what extent the various basic functions in the health system is used together to support the innovation to address specific health issues by building a commitment amongst the actors in the health sector system and utilizing available technology and resources (WHO, 2007). In the context of Indonesia, these various health system functions include management and health regulations ; financing; Human Resource;
strategic information; service delivery, and community empowerment (Presidential Decree No.72 of 2012).
To what extent the integration of HIV and AIDS response efforts into the health system will be affected by ( 1 ) the characteristics of problems, policies, and HIV and AIDS program (prevention, CST – care,support,treatment and impact mitigation) , (2) the interaction of various stakeholders in health system and HIV and AIDS response efforts, (3) characteristics of the health system and the interaction amongst principal functions in the health system, and (4) political, social and cultural contexts where HIV and AIDs response is developed and implemented, including decentralization (Atun et al., 2010, Coker et al., 2010). Based upon this
idea, the conceptual model for this research is developed by assuming that the four components interact together and it affects the integration level and determine the performance of the health system which includes coverage, accessibility, equity, quality and sustainability in HIV and AIDS responses. The conceptual model is illustrated in figure 1 below.
Figure 1. Conceptual Model
The issues on HIV and AIDS in Indonesia are basically a part of a global epidemic which stimulates various global health initiatives developed by various international institutions. How these issues are addressed through various policies and programs on HIV and AIDS is believed to be a dynamic process among the stakeholders (actors) in the health system and HIV and AIDS response itself. The interaction among stakeholders will affect how HIV and AIDS are perceived and how to address these issues at the national and regional levels, either positively or negatively. This interaction takes place not only within the framework of the health system but also in the social, cultural, and political contexts, including decentralization and its politics in the government. The interaction between HIV and AIDS response as an innovation in health
response and the key actors in the dominant social, political and cultural contexts will in turn determine the integration level of HIV and AIDS response into the health system as well as the health system performance levels in HIV and AIDS response. The integration of HIV and AIDS response into the health system is expected to improve the performance of the health system in addressing HIV and AIDS issues so as to improve the health status of the society. This integration is also expected to maintain the sustainability of HIV and AIDS response in the future.
The aforementioned conceptual model is expected to explore the integration of HIV and AIDs response into the health system holistically based on the functions or sub-health system and to identify various factors influencing the level and nature of integration that have occurred.
Although the conceptual framework tries to see the integration level holistically, there are several contextual factors that cannot be understood or elaborated in this model. Similarly, the dynamic interaction of the various components is not linear and can result in various responses from the unexpected system, including various negative consequences that might arise.
IV. Research Method
4.1. Research Design and Procedure
The research on "The Integration of HIV and AIDS Response into the National Health System Framework" will be conducted with a cross-sectional design, qualitative method, and inductive approach. It will also use a research principle on theory building and explanatory research (Gilson & Raphaely, 2008; Walt et al., 2008) as well as the principle grounded research (Glaser
& Strauss, 1967; Strauss & Golbin, 1998).
This approach assumes that the various abstractions or a deep understanding on the research will be produced at the end of the research. The conceptual model used in this research (see diagram 1), will be used as a reference to develop a list of questions and analysis, whereas the inductive approach will be used to develop a grounded understanding to what extent the HIV and AIDS is integrated into the national health system framework, based on patterns or themes which arise in the research results. The inductive approach will be based on the framework taken from Creswell, 2003 "The inductive Logic of Research in a Qualitative Study" (See Figure 2).
Figure 2. The logic framework of inductive approach in the research of “The integration of HIV and AIDS response efforts into the national health system framework.”
Stage III: Researchers im[plement triangulation proses by combining the results of primary and secondary data to get a descriptive picture about
condition of the sub-system at each research location.
Stage V: Researchers draw conclusions on the integration level based on the previous stages so as to get an idea on what and how the integration of
HIV and AIDS into the national health system in each level (district/city, provincial and national).
Stage IV: Researchers extract information to identify the integration level based on key words in each sub-system dimension. Subjective scoring will be used to determine the integration degree of each individual sub-system
in accordance with HIV and AIDS response efforts.
Stage II: Researchers categorize (e.g. coding) the research results of primary data, secondary data, and stakeholder analysis in each location
in sort of summary. The primary data grouping is based on issues/success arising in three HIV and AIDS response efforts (e.g.
prevention, CST: care,support, treatment and impact mitigation) against the seven sub- systems, as well as trends based on coverage and access.
Whereas the stakeholder analysis will identify the actors on HIV and AIDS response in terms of their roles, interests and resources
Stage I: Researchers collect two types of data (primary and secondary data) on the performance of health sub-system against HIV and AIDS response. Researchers will also conduct a stakeholder analysis
in each region
Figure 2 illustrates the research stages based on a logical framework of inductive approach.
Starting from the bottom of the figure the research procedures will be conducted in five stages as follows:
The first stage, the local research team will perform a primary data and secondary data collection, and stakeholder analysis.
The primary data collection will be conducted through focus group discussions in workshops and in-depth interviews by using instruments and guidelines developed by the core team of CHPM, local researchers, and consultative group appointed in this collaborative research program. The two-day workshop will be held separately in two selected districts and cities. The researchers from the selected universities will facilitate the workshop and record the process.
The informants who will get involved in the Regional Government Working Unit (SKPD), community organizations, stakeholders, health workers, representatives of key population groups, and civil society organizations which are located in each district and municipality.
Informants will be divided into groups to discuss the assigned sub-systems concerning the three HIV and AIDS services (Prevention, CTS – Care, Treatment, and Support, and impact mitigation).
The grouping will be based on the correlation between the tasks and basic functions of informants on the required the sub-system.
The in-depth interviews will be conducted at the national and provincial levels to some informants as follows: 1) the national level (e.g. Ministry of Health, Subdit P2PL; NAC;
Bappenas; Menkumham, Menkokesra; networks of key populations (e.g. GWL-INA, OPSI , etc.), and RSCM); and 2) the provincial level (e.g. Health Department; provincial AIDS commision, Bappeda, and hospitals).
The secondary data collection as the supporting data covers the data for each sub-system that will be collected with the indicators developed and prepared by a core team of CHPM, local researchers and "consultative group". The sources and secondary data collection mechanism can be agreed with the informant. The list of informants based on seven sub-division of health system can be seen in Appendix 8.
The stakeholder analysis will also be conducted, which may be done through observation and interview the informant during in-depth interviews. This analysis is to observe which actors that play a major role in HIV and AIDS response, both the ones who support and the ones who hamper.
The second stage, the researchers will categorize the data based on thematic codes in a form of summary. The summary resulted from the primary data collection will be presented in matrix and grouped by issues or success identified from all seven sub-systems to HIV and AIDS responses (e.g. Prevention, Care-treatment-support and impact mitigation). These will be detailed in the analysis section and appendix 5 in the table containing a summary of field results of primary data). The summary of stakeholder analysis will be writen in terms of roles, interests and its resources (See Appendix 1).
The third stage, the researchers conduct a triangulation to verify and validate the results of primary and secondary data. At this stage, the picture of the condition and the interaction of each sub- system in each location will be obtained.
The fourth stage, the researchers draw a conclusion on the integration level for each dimension of the sub-system to HIV and AIDS response (e.g prevention, Care-treatment-suppot and impact mitigation) based on a scoring system previously done. The description of the integration level will be referred to definitions used in researches on integration issues and health system conducted in Indonesia and other countries (Conseil et al., 2010; Desai et al., 2010). In brief, the seven sub-systems on health will be classified based on 26 dimensions, in which key words will be determined for each dimension (See appendix 2). Subjectively the scoring will be used and then the integration level is determined based on three categories as follows: "not integrated",
"partially integrated", and " fully integrated" (see the analysis section and appendix 6 and 7 for scoring table and the integration level of sub-system based on dimention, administratin level and HIV and AIDS response efforts).
The fifth stage, the researchers draw a conclusion based on the available results to get the picture as to what and how the integration HIV and AIDS response efforts into the national
health system at each level (district/city, province and national) is. What are the implications of the outcomes towards HIV and AIDS policies and program will be discussed during this stage.
There will be eight reports, each representing the research locations and another report that reprepresents the result at the national level. All reports will be compiled into one final report before being disseminated at the national, provincial, and district/city level.
4.2. Research Location
There are nine research locations including the capital territory of Jakarta that is considered as the national government of Indonesia. The provinces are: North Sumatera, Jakarta, East Java, Bali, East Nusa Tenggara, South Sulawesi, Papua, and West Papua. The research locations are selected based on the following criterias: 1) having a degree of variation in the epidemiology of HIV and AIDS (low, concentrated, and generalized); 2) the HIV and AIDS program has been running; and 3) there is a university research institute with adequate quality researchers. The research will be conducted by researchers from universities in each of the research location previously determined. In each of the locations there are selected partner universities to be involved: North Sumatra University, Atma Jaya Catholic University, Airlangga University, Udayana University, Nusa Cendana University, Hasanuddin University, Cenderawasih University, Papua University, and the working groups on AIDS at the Cipto Mangunkusumo hospital (Pokdisus RSCM).
In each province, two districts/cities have been selected from a list of 137 districts/cities priorities according to the National AIDS Commission (NAC, 2010). The districts/ cities to be used for research locations are as follows:
North Sumatra: city of Medan and Deli Serdang district
East Java: city of Surabaya and Sidoarjo district
Bali: city of Denpasar and Badung districts
NTT: Kupang and Belu districts
Papua: city of Jayapura and Merauke district
West Papua: city of Sorong and Manokwari district
South Sulawesi: city of Makassar and Pare-Pare district
The data collection at the national level will be conducted by the working group on AIDS – University of Indonesia, and at Special Capital Teritory (similar to provincial government level) will be conducted by PPH Atma Jaya Catholic University.
4.3. Informants
Primary data collection will be obtained from:
1. Members of AIDS Response Commission at each location (1 province and 3 districts /cities);
2. Relevant regional government office (SKPD) with main duties and functions deals with HIV and AIDS response;
3. Civil Society Organizations (CSOs) supporting or hampering HIV and AIDS responses, and Community-based Organizations (CBOs) working as peer support groups (Kelompok Dukungan Sebaya), and other organizations of key populations; and
4. Representatives of key populations (e.g. IDU, FSW, MSM and transgender) reached by CSO.
The criteria to select CSO and CBO are as follows:
1. Registered as a partner of District / City KPA;
2. Involved in HIV and AIDS response, even though with a different approach.
Types of informants based on groupings by sub-health system are listed in Appendix 8.
4.4. Instrument
Primary data will be collected for each of the seven sub-systems e.g. management and health regulations; service delivery; health financing; human resources (HR); strategic information;
pharmaceutical preparations, medical devices, and food; and community empowerment. In each sub-system, all dimensions to be observed will be defined. Instruments for primary data
collection which consists of a list of questions based on the seven sub-systems and its dimensions will be adapted from "The Health System Assessment Approach: how to manual"
developed by WHO SEARO and USAID in 2012 (www.healthsystemassestment.org). This instrument is already utilised in several countries including Indonesia to test specific interventions related to MDG such as mother and child health, AIDS, TB and Malaria in 2011.
Prior to primary data collection, the adapted instrument will be tested and revised accordingly.
The secondary data collection will be conducted to evaluate between what should be done and what actually occur on the field. The secondary data will consist of: 1) national documents (e.g.
Presidential Decree No. 75 of 2006 on the National AIDS Commission; strategies and national action plans on HIV and AIDS response (SRAN) 2010-2014 issued by the National AIDS Commission, and Minister Regulation No. 21 of 2013 on HIV and AIDS response issued by the Ministry of Health); 2) Standard operating procedures (SOP) for the prevention component, CST (care, support, and treatment), and impact mitigation used in each area; 3) regional laws and other documents which can describe the level of program coverage and services at the regional level; and 4) profiles of the district/city and epidemic situation and the already conducted HIV and AIDS response efforts.
As previously elaborated, the dimensions and keywords are listed in appendix 2, whereas the instrument of primary data, secondary data, and guideline for instrument are in Appendix 3, 4, and 10.
4.5. Data Management
The results of the workshops and in-depth interviews will be recorded and transcribed. At each research location e.g. 8 provinces and 1 national level a data manager will be recruited. He or she will be responsible for coordinating the process of recording the results of primary and secondary data collection conducted by the researchers. The results of data collection will be descriptively written in MS-Word or MS Excel programs. The summaries in the form of data tabulation and matrixes will also be done.
4.6. Data Analysis
As previously elaborated, the analytical framework will use a logical framework of Inductive approach (Creswel, 2003) and the principle of grounded theory (Glaser & Strauss, 1967; Strauss
& Corbin, 1998) which focuses on the development of themes and categories that arise in the research. The verbatim results from the forum group discussions and in-depth interviews will be classified, coded, and analyzed in accordance with the themes that arise in each dimension of sub-systems. The coding process will be conducted continuously when the analysis process is in progress.
In addition, to determine the integration level will refer to the principles used in previous researches (Conseil et al.,2010; Desai et al., 2010). It will consider these four points:
The seven sub-systems of national health: Management & Health Regulation ; Health Financing; Human Resources ; Strategic Information ; and Community Development ;
Twenty-six dimensional integration based on seven sub-systems (See appendix 2 for dimensions and appendix 6 and 7 for analysis);
Three levels of administration: national, provincial, district/city; and
Efforts for HIV and AIDS response: Prevention, CST (care, support, and treatment), and impact mitigation.
The stages for data analysis and result presentation will be made by referring to the logical framework of inductive approach previously elaborated (see diagram 2) with the following process:
The first stage is to summarize the results of the primary data and stakeholder analysis.
Appendix 1 illustrates the stakeholder analysis based on roles, interests and its resources.
Appendix 5 presents Table 1 which describes a summary of research results from the primary data. The summary will describe an interaction among sub-systems towards HIV and AIDS responses at all levels of administration researched. This summary serves as the first step to understand the results of data collection and understand the results that arise in the sub-
system interaction. This summary of primary data and stakeholder analysis will be conducted at each research location in the district/city and province, as well as at the national level.
The second stage is to combine the results of primary and secondary data descriptively and to begin classifying the existing results based on the dimensions of sub-systems and key words. A list of dimensions per sub-systems and key words can be seen in appendix 2.
The third stage is to determine the integration level. To determine this level will cover several stages and require a detailed and long process. Here are the stages to determine the integration:
1. Researchers will make a subjective scoring for each dimension per sub-system at every level of administration (district/city, provincial, and national). The scoring will be made by each dimension based on key words. Table 2 illustrates a scoring example of integration level for sub-system 1 (management, information and regulation) for regulation dimensions (See Attachment 6). The condition scoring is 0 if there is no appropriate keyword and 1 if there is any. The total scoring will be determined for each HIV and AIDS response effort whose value may vary, depending on the number of keywords agreed per dimension. The definition of integration (e.g. fully integrated, partially integrated and not integrated) will be based on the total scoring. To determine whether or not there are key words per dimension can be taken from primary and secondary data on the second stage of the above analysis.
2. The results of integration per dimension at all levels of research administration (district/city, provincial and national) will be concluded and extracted into Table 3 (see Appendix 7). Hence, the picture of the integration in the health system on HIV and AIDS response at the three levels of administration can be determined. There will be 8 tables which will describe those 8 research areas and 1 table of integration at the national level. As previously mentioned, the definition of the integration level will refer to three types of integration (Conseil et al., 2010; Desai et al., 2010) as follows:
Fully Integrated: the intervention is fully managed and controlled through the existing health system.
Partially Integrated: the intervention is partly managed by the existing health system and the system for a particular intervention.
Not Integrated: the intervention is fully managed and controlled by a specific system for a certain intervention which is different from the prevailing health system.
4.7. Research Quality Control
The control for the research quality will be conducted in several stages as follows:
a. Development process, implementation and research reporting
The control for research quality will be conducted from protocol development stage, data collection, analysis, to reporting stage. As described in the research organization, the research consists of several teams; a core team and university researchers, research advisors, consultative groups, and external reviewers. The personnel in each team consist of experts who will provide feedbacks and review every document collected by the research team. In general, the control towards documents quality will be conducted through: a) an internal review by two research advisors from CHPM and AIDS Research Center (ARC) Atmajaya Catholic University; and b) an external review by the Consultative Group, the donors namely the Australian government through DFAT; and proof reading by external consultants.
b. "Peer review" process
The peer review will consist of a team of experienced experts both from UGM and international universities which have a reputation in the field such as Melbourne University, New South Wales University, and other reputable universities as well as individuals. The peer review will be conducted at the writing stage, especially for international journal publications.
c. Data collection validation
To ensure the quality of qualitative data collection, the validation test will use a
"Cochrane systematic review" concept by Hannes (2011). The principles of data validation used are as follows:
Data credibility
The data credibility will evaluate whether there is an equivalent between respondents’ views and the reconstruction made by the researchers. Several techniques are used as follows: in every research area, two meetings of validation will be held; a) between university researchers and stakeholders; and b) between the university research team and the core team who will discuss the process of data analysis. In addition, the analysis process will be conducted by two different people from the university research team. This process will likely pay attention to possible contradictory and/or the results which need to be clarified.
Data dependability
The dependability of data is conducted to know whether the research process is logical and well-documented. It also serves as a sort of evaluation for the research process in terms of conceptual, logical, and clarity aspects as seen from the conceptual description and the research method used. The technique used in this stage is the literature review by referring to previously conducted similar studies both in Indonesia and other developing countries. In addition, as previously elaborated, the control over research logic and quality are conducted with internal and external reviews.
Data confirmability
To know whether the data confirms the main findings and leads to its implications.
The technique used is to compare the research results with other similar studies found in the literature review. Hence, we will know whether the research results confirm what has been found before, or provide new insights and additional knowledge about the issue studied.
Data transferability
To find out whether the research generates insights that can be transferred to other settings. The technique used in this stage is that the researchers provide information about the contextual situations of the research locations which may include social, political, economic, and cultural factors of the decentralization.
4.8. Reporting format
The report generated at each research location is expected to answer the conceptual model used in this research (see diagram 1). Hence, the report format is as follows:
1. Introduction
Context (characteristics of the region and the decentralization process)
Problem (epidemics and risk behaviors in every research location) 2. Research Method
Research Design and procedure
Research Locations
Informants
Research Duration 3. Research Results
Overview of HIV and AIDS programs in respecteive regions (e.g. prevention , CST (care,support,treatment) and impact mitigation)
Stakeholder analysis on HIV and AIDS response
Overview of sub-health system and the integration level 4. Discussion
Implications of the research results for the pilicy development /improvement
Implications of the research results for HIV and AIDS response program
Implications of the research results for knowledge development
Limitations/weaknesses of the research 5. Conclusions and recommendations
6. Bibliography
V. Research Implementation
5.1. Research Organization
This research will involve researchers and non-researchrers from various institutions and universities, working on and posses’ field experiences on HIV and AIDS in Indonesia. The organizational structure of the research is shown in appendix 9. In brief, the function and roles are organized as following:
5.2. Nasional research advisory board
National research advisory board (NAB) is established to provide a guidance and direction to conduct a series of research to carry out. The members of the NAB consist of representatives from government agencies, policy makers at the national level, international development partners, civil society, and HIV and AIDS-affected groups.
5.3. Research Advisor
Research Advisors consist of representatives from CHPM, Faculty of Medicine, UGM (Prof. dr.
Laksono Trisnantoro, MSc., PhD) and Atma Jaya Catholic University (Prof. Irwanto, PhD).
Research Advisors’ roles are to direct the research concept, to formulate research structure, to build a cooperation with stakeholders at the national and sub-national levels in supporting the development of AIDS policies, to serve as the primary focal point in collaborating with donors (DFAT) and to provide guidance and recommendations on the implementation of activities, including reporting and documentation.
5.4. Consultative Group
Consultative Group (CG) consists of personnels from Ministry of Health, NAC, DFAT, Faculty of Medicine, UGM, and HCPI who are selected based on expertises in one of the following areas:
Policy and regulation on health
Epidemiology
Legal issues related to healthcare
Research Method
Care, Support and treatment
Behavior changes
Economy and health financing
Sexually transmitted infections
CG’s role is to provide direction in the preparation of research implementation and to ensure quality of the research results. CG will provide advices to develop the research protocols, strategies to analyze the data in each study like the recommendations for policy development.
5.5. Research Team
The research team consists of a core team and a local researcher team. The core team are from CPHM FK UGM and ARC Atma Jaya Catholic University with the following responsibilities: 1) to develop and coordinate the development and implementation of protocols to the National Research Advisory Council, research advisors, consultative groups, and local researchers; 2) to prepare training for local researchers; 3) to coordinate and supervise the data collection;4 ) to analyze the reports from local research team; and 5) to write a report which integrate all results from the national and regional levels.
Local research team consists of two (2) researchers from the working groups on AIDS who will conduct a national research and two (2) researchers from each of the 8 universities incorporated in a researcher network for AIDS policies that will conduct research in their respective regions in accordance with the stages listed in detail on the research proposal (protocol adaptation, data collection, analysis and reporting).
The followings are 8 universities involved in this research:
1. North Sumatra University (USU), a local researcher in North Sumatra 2. Atma Jaya University, as a local researcher in Jakarta region
3. Airlangga University, as a local researcher in East Java
4. Udayana University, as a local researcher in Bali area
5. Nusa Cendana University, a local researcher in East Nusa Tenggara 6. Hasanuddin University, as a local researcher in South Sulawesi 7. Papua State University, as a local researcher in West Papua 8. Cendrawasih University, as a local researcher in Papua 5.6. Administration and Management Team
Within the period of research project implemention, the management will be supported by an administration and management team from CHPM. The team consists of a research coordinator, a secretary and a financial and administrative staff.
In general, the administration and manegement team’s duties and responsibilities are to implement plans all activities and coordinate technical plans with each university to follow the predetermined schedules. In addition, the team also plays a role to manage financial and administrative aspects which support the project activities.
5.7. Research Duration
The research will be conducted in January-July 2014 with the following detailed agenda:
Research protocol finalization is currently taking place until the end of April 2014. At the same month a training for research method for the researchers will also be finalized. In parallel an ethic proposal is also undergone the process with the UGM. IF al researchers are ready for field collection data, then all data collection will be done in the following month of May. The whole month of May is scheduled for field research and data collection. Afterwards the data will be analysed. The end of the research is writing for publication that will elaborate the desimination of the academic paper.
Description January 2014
February 2014
March 2014
April 2014
May 2014
June 2014
July 2014
August 2014 Designing and
finalizing research protocol Training on research method
Ethics Proposal Data Collection
& Field Research Data analysis
Reporting Dissemination
and
publication of research results
5.8. Research Ethics
Informants in this research are public officials who deal with the development of policies and programs on HIV and AIDS at the national and regional levels. Hence, the data presented by these officials is public data, thus the informants are not expected to represent themselves in the data collection process. Meanwhile, some other informants represent agencies or non- government organizations or groups affected by HIV and AIDS issues.The informant with such categories would be verbally asked to participate before the data collection is conducted.
To ensure that the informants’ rights are not violated and to ensure the welfare of informants in this research process, the team will ask for ethics approval to conduct this research to the Ethics Committee of the Faculty of Medicine, Gadjah Mada University. It is expected that ethical approval from the Ethics Committee of the Faculty can be used at the provincial/district level given that the research will cover areas in 8 provinces (multi - center study). Yet if there is a policy in certain universities which requires an ethics proposal, then it will also be done.
Besides, in conducting this research every team in each region is expected to pursue a research permit from the local government of each province/district.
5.9. Policies on Dissemination and Publication of Research Results
In addition to the supporting material for advocacy works, to follow up the findings and recommendations from the research, the research results can also be published. Since this research is a multicenter study, thus the publication policy will refer to a collective agreement with each university researcher. The main publication will be initiated by PKMK FK UGM and involve all researchers from universities. The publications will include an acknowledgement from Department of Foreign Affairs and Trade (DFAT) as the funder.
The research team is expected to publish the result of the research in national and international journals. Within the period of August 2013 to December 2015 (29 months) there will be 6 publications in international journals and national journals. The publications of the research will refer to the guidelines from the International Committee of Medical Journal Editors (ICMJE).
Terms for publication are as follows:
1. Ownership: ownership of data and research results goes to CPHM FK UGM.
2. Authorship: the author are all researchers involved (core researchers and local researchers).
3. All publications (abstracts, journals, etc.) using data from the research must be endorsed by CHPM, and proved by an official letter from the CHPM and an acknowledgment is given in written form to every kind of publication
4. It is recommended to use the data together with the universities involved in the research
The final results of the research are nine (9) reports consisting of one (1) report from national researchers and eight (8) reports from local researchers. The whole 9 reports will be compiled into one report covering the study at the national and sub-national levels. The research results will be presented and disseminated at the national, provincial, district/city levels and at a
meeting at the international level by inviting the actors in the field of HIV and AIDS, including related government offices and other stakeholders and also DFAT as the funder.
5.10. Risk Management
Risk Risk Sources Impacts Risk Management
Poor supports from stakeholders on process and research results
can not accommodate stakeholders’ various interests in in the scope of the research
Less involvement of stakeholders in the research process
Incomplete coverage of the research
It is difficult to conduct a research at the operational level
The research results are not used for policy development
Developing a participatory research process
Utilizing the stakeholders’
expertise and experience concerning the research themes through a consultation process
Updating the research progress to the advisory groups from the key stakeholders Researchers have
different understandings about focus of the research being conducted
Unclear research protocol used to guide this research
Differences in the data collected, data analysis and various research
recommendations.
Hence, they can not be compared
Developing the protocol is conducted by involving representatives from universities and conducting training to all investigators on the protocol to be used Delays in
completion of the research process
Weak coordination on research activities
Researchers’s tight schedules outside of the the research
Legislative and Presidential Election in 2014
Informants’ busy time
The second stage of the research series based on the results of the first resaerch is delayed.
The delay of the inputs to policy makers at national and regional level for the development of AIDS response strategy in the post 2015
Developing a coordination mechanism via a mailing list of researchers and doing field visits to supervise the implementation of the research
Conducting an informal approach and socializing to the prospective informants from the very beginning
Monitoring local political developments and preparing schedules to match local conditions
Developing a Scope of Work (SOW) and clear time commitment to researchers Low quality Respondents are less The objectives of the Creating the inclusion
