If Indonesia’s HIV- and TB-program targets are to be reached by 2020, the design of both programs needs improvement, the Office of the Inspector General said, emphasizing shortcomings in the HIV program in particular. This was the second OIG audit of Indonesia’s Global Fund grants since the Global Fund’s investments in the country began, in 2003.

The OIG report, published on 3 January 2020, rated the adequacy and effectiveness of grant design as ‘partially effective,’ and the effectiveness and efficiency of implementation and assurance arrangements as ‘need[ing] significant improvement’.

The OIG highlighted that Indonesia’s HIV grants do not yet include plans to increase the number of facilities offering both testing and treatment, because the finalization of the expansion plan is still underway (see page 14 of the OIG report). Facilities that offer testing as well as treatment are a critical component in rolling out the ‘test and treat’ policy known to improve treatment rates.

The audit covered the period from January 2017 to December 2018, and included all four Principal Recipients and six grants that were active during that time (see Table 1 below). The auditors visited selected health facilities, laboratories and warehouses in Jakarta.

(Editor’s note: The GFO asked the OIG whether Jakarta was sufficiently representative of issues that might affect the whole country, given its island-archipelago geographic structure. The OIG replied that Jakarta, Indonesia’s capital, has the highest prevalence of HIV, TB and MDR-TB in terms of numbers, and while the findings at the facilities visited in Jakarta could not be extrapolated to the whole country, they gave a sense of what the gaps might be in other provinces. The broader issues identified during the audit relate to systems and controls countrywide, the OIG said.)

Key achievements

The OIG report points out three areas within Indonesia’s key achievements and good practices in fighting the three diseases. First, Government financial commitment to fight the three diseases, with Indonesia meeting its 20% co-financing commitment for the 2018-2020 allocation period (the government in any case finances 64% of total funds to fight the three diseases). Government also finances procurement of most HIV, TB and malaria commodities, and the Ministry of Health has decreed it will increase the number of hospitals providing MDR-TB treatment to 260. (Editor’s note: The Government decree does not mention the baseline number from which they are planning to increase.)

Second, the OIG notes good programmatic performance, such as (for example), an increase in the number of HIV tests conducted among key affected populations using mobile clinics, which has bridged the gap between outreach and testing, and strengthened collaboration between health facilities and civil society organizations (CSOs); the introduction of mandatory TB case notification (leading to a 24% increase in case notification outcomes in 2018), and 800 GeneXpert machines installed in health facilities.

Third, there is complementarity between government and CSOs in implementing interventions for key affected populations, for example in outreach and testing of men who have sex with men.

Country context

Indonesia accounts for about 2% of the global HIV disease burden (an estimated 640,000 people living with HIV), with TB also remaining a major issue (an estimated 845,000 people with TB in 2018), and significant TB-HIV co-infection. The majority of districts are malaria-free, with most of Indonesia’s malaria burden persisting in Eastern Indonesia.

Indonesia has a population of 264 million, with 55% of the population living in urban areas, mostly on the island of Java, and the remainder spread over 16,000 islands in the world’s largest archipelago.  Income levels in Indonesia, a G-20 member, have risen steadily in the past 20 years, making it likely that it will reach middle-income status and may be ineligible for future Global Fund allocations. The country launched a universal health care program in 2014, with 74% of the population enrolled by the end of 2018.

Since 2004, the Global Fund has signed grants with Indonesia worth more than $1 billion. The Global Fund is the country’s largest external donor (26%), while Government finances 64% of the funding to fight the three diseases in Indonesia.

Indonesia is considered a ‘high impact’ Global Fund country (very large portfolio, mission-critical disease burden).

Main findings and Agreed Management Actions

The OIG described four main findings from its audit, which we summarize here (see pages 13-19 of the report for full details). The associated Agreed Management Actions (AMAs) follow each finding.

4.1 PLHIV testing and linkage between testing/treatment and monitoring need improvement, to reach the HIV ‘90-90-90’ cascade

Compared to regional or global numbers, and despite progress made since the adoption of a ‘test and treat’ policy, Indonesia’s HIV treatment cascade remains at a low 50-17-7. This low performance poses risks to the success of the grant and the gains made so far, the OIG says. Specific issues are:

• Stagnant testing yield and testing targets among key affected populations (MSM, people who inject drugs, transgender individuals, and female sex workers); low testing coverage among these populations represents a missed opportunity, the OIG says, for early diagnosis and timely initiation of antiretroviral therapy.
• Low linkage to treatment, high loss to follow-up of people on treatment, and inadequate PLHIV treatment monitoring: More than 60% of PLHIV who know their status on are initiated on treatment, and more than 23% are lost to follow-up after 12 months. The OIG identifies contributing factors to low treatment coverage to include gaps in the referral system that links patients to treatment, improvement needed in implementing the ‘test and treat’ policy, and limited central-level oversight on patients lost to follow-up.
• Gaps in monitoring clients on HIV treatment: Indonesia has very limited implementation of viral-load testing to monitor treatment efficacy, though it has adopted the WHO guidelines on viral load testing at six and 12 months – and then annually – after treatment initiation. Viral load testing coverage is less than 7%, but paradoxically the budget line for viral-load testing is underutilized; this is due to confusion around whether the Global Fund or Government finances the cost of testing not covered by social health insurance, which in turn has led to a reluctance of clinicians to prescribe viral load testing, the OIG report said.

AMA 1: The Secretariat will review implementation arrangements to meet treatment coverage targets of 31 December 2020, and to ensure proper mechanisms for monitoring patient cohorts are in place (owner Head of Grants Management; due 31 January 2021).

4.2 Improvements needed to achieve the desired TB and MDR-TB notification and treatment outcomes

The report identified four specific areas of improvement within this topic, notably:

1. Challenges with the effectiveness of contact-tracing activities: more than 50% of TB cases referred by volunteers are not being tested in health facilities due to the absence of updated guidelines on who qualifies for referral;
2. Limited implementation of ‘Public/Private Mix’ at the district level: the country’s large private health sector is not yet firmly linked to the reporting network of the National TB program; while 74% of initial care sought for TB occurs in private health facilities;
3. Improvement needed in the management of GeneXpert machines (installation delays; idle machines no longer under warranty, delays in replacing broken parts)
4. Improvement needed in the management of MDR-TB: Around 49% of people diagnosed with MDR-TB do not start treatment, and there is no mechanism to track them (Indonesia is one of the world’s 27 high-burden MDR-TB countries.

AMA 2: The Secretariat will work with the Federal Ministry of Health, civil society organizations and development partners to ensure that staff from Global Fund-supported CSOs are instructed to consider all bacteriologically confirmed cases in their lists for contact investigation follow up; and to revisit district public/private mix (DPPM) activities and assess the need to maintain, scale up or scale down this activity (owned by Head of Grants Management Division; due 31 January 2021).

4.3 TB/HIV collaborative activities, including GeneXpert utilization, require strengthening

Alongside several examples of good TB/HIV collaboration, including HIV outreach workers systematically conducting screening for TB symptoms as part of HIV outreach to key affected populations, the OIG noted key challenges in this area:

• Vertical TB and HIV program structure: In Indonesia, TB is diagnosed and treated mainly at the primary health-care level, while HIV treatment is mostly hospital-based, leading to many co-infected patients receiving care in two different facilities, which places an additional burden on the patient. Only 34% of primary healthcare facilities and 26% of hospitals are able to provide HIV testing services; there is no cross-validation of data between the two programs, and there are different reporting systems for TB and HIV.
• Sub-optimal use of GeneXpert machines for viral-load testing: Recent increased distribution of more than 809 GeneXpert machines is designed to increase their use for viral load testing in addition to TB testing, but delays between training and the rollout of viral load testing, plus a prolonged negotiation with a third-party supplier have hampered this scaleup.
• In 2018, a plan to improve TB/HIV collaboration was developed and approved, but at the time of the audit in August 2019, the plan’s budget had not been finalized.

AMA 3: The Secretariat will work with the Ministry of Health and other development partners to finalize the budget for the Acceleration plan of TB/HIV control (owned by Head of Grants Management Division, due by 30 June 2020).

4.4 Gaps in oversight and assurance arrangements

The gaps identified by the OIG seem to focus on oversight and supervision – specifically of planned supervision visits – of sub-recipients. The audit report said that five of the six Principal Recipients do not have a comprehensive supervision plan in place. Some sub-recipients rated as high-risk were not visited, while medium- or low-risk sub-recipients were visited.

The National HIV Program (Ministry of Health as the PR) has eight staff performing supervision across 46 sub-recipients and 240 sub-sub-recipients. The OIG said that “there is no difference in the approach towards sub-recipient reviews and monitoring, despite variations in grant size and risk level”. This, the OIG report said, has contributed to 50% of the PRs exceeding their supervision budgets in 2018, even though they have conducted fewer supervision visits than planned.

The OIG also said that there is no documented evidence that five of the six PRs communicated review findings and recommendations to sub- and sub-sub-recipients, while the PRs said that they communicate findings verbally. Nonetheless, there is no system that tracks findings and recommendations raised during supervision, and no formal mechanism for providing feedback to sub-recipients after supervision.

AMA 4: The Secretariat will ensure that all PRs develop a risk-based sub-recipient supervision plan for the monitoring of their sub-recipients, and to ensure that systemic feedback and follow-up mechanisms are put in place (owned by Head of Grants Management Division; due 30 June 2020).

Further reading:

• This audit report is called ‘Global Fund Grants in the Republic of Indonesia’, 3 January 2020 (GF-OIG-20-001).
• The 2015 report is ‘Audit of Global Fund Grants to the Republic of Indonesia’, 1 December 2015 (GF-OIG-15-021).