Setting
Following the political transformation in 1998, Indonesia experienced decentralization reform in 1999. The health services were decentralized to provincial and district governments which operate under the Ministry of Home Affairs [14]. As a result, the Ministry of Health (MoH) decentralized most of the responsibility for planning and service delivery to local governments. At the provincial level, the provincial health office (PHO) is responsible for coordinating health issues within the region across districts, and managing a provincial hospital. The district health office (DHO) organizes the health services at district level through a network of PHCs (primary health centres) and one or more district hospitals depending on the size of the population. DHO is also responsible to manage health programs through the PHCs [26]. However, the relationship between MoH, PHO and DHO is not a hierarchical one. The district government is not a sub-ordinate of the provincial government as most of the power is decentralized to the district government. Each level has its own mandates and areas of authority. These arrangements create coordination challenges for coordinated inter-district collaboration particularly for bordering districts between two different provinces.
The study was conducted in three districts in the Menoreh Hills Region: Kulon Progo District in Yogyakarta Province, Purworejo and Magelang Districts in Central Java Province, Indonesia. These areas consist of 14 malaria-affected sub districts located in the bordering area, with total of 18 PHCs serving approximately 1.1 million people in the region [27].
Design
This was a mixed-methods study combining secondary data collection and participatory action research methods involving four sets of participants from different levels of the health system (village, district, provincial, and national). These participants were key stakeholders who play essential roles in malaria control programmes. This includes the national and subnational malaria control programmes (i.e. communicable disease and malaria control programme managers from MoH, PHO, DHO and PHC), health service providers (i.e. head of PHCs), other government bodies (i.e. district planning agencies) and representatives of the local communities (i.e. head of malaria endemic villages, village malaria workers). The government stakeholders were identified from the organogram and discussion within the research team. One of the co-authors was the disease control program manager at Kulon Progo District Health Office (TBR) who liaised the research team with the government stakeholders in other districts. Each DHO sent invitation letters to head of PHCs in endemic subdistricts to participate in the FGD. The head of PHCs sent invitation letters to head of endemic villages in their catchment areas.
This study was conducted in seven phases as follows: (1) scientific literature and administrative data review, (2) FGDs (focus group discussions) using nominal group techniques with malaria managers and head of PHCs to identify priority problems in malaria control, (3) joint consultation with DHO staff to prioritize problems and formulate intervention, (4) costing study for the strategic and operational plan involving representatives from villages, PHCs and DHO (5) joint consultation with national and provincial stakeholders about the operational plan including the results of the costing study, (6) finalization of joint strategic and operational plan with costing study, and (7) dissemination to stakeholders. We consulted the district and provincial malaria control program managers to identify implementation strategies while national stakeholders were consulted to define the technical strategies according to the national malaria strategic plan. Table 2 summarizes the study phases and the stakeholders involved in each phase.
Prior to primary data collection, two key malaria control stakeholders from each health office (three DHOs and two PHOs) were selected as facilitators and intensively trained on how to systematically facilitate each step of the joint strategic and operational planning and costing for malaria elimination. One facilitator from Kulon Progo District also involved in the data analysis and manuscript writing processes. During the consultations (Phase 2 to 6), the FGDs, nominal group techniques (NGT), and brainstorming were performed by these trained facilitators with guidance from study investigators. The NGT was used to elicit priority issues as this method ensure relatively equal participation, a time-saving technique, and relatively produce a large number of ideas while avoiding unnecessary conflict.
Data were collected using pre-structured worksheets and interview guidelines, voice recorders and additional typed-written notes documented the proceedings. The pre-structured worksheets were used to guide the planning and budgeting exercise. The worksheets consisted categories of technical strategies taken from the national malaria strategic plan. Additionally it also consisted budget categories that were used in disease control program planning. The interview guidelines were used to explore the acceptance and adoption of the action plan among participants. In addition, administrative data (from present and previous years), price quotations from suppliers, guidelines and policy documents were also collected to approximate the monetary value of the identified needs for the joint plan for collaborative malaria control activities. Data collected from scientific literature in cross-border malaria abroad were used as complements to guide the initial draft of the strategic, operation, and costing plan.
Analysis
Softcopies of the voice recordings of the consultations were transcribed verbatim using InqScribe Software and then translated to English. The thematic coding of the transcripts was done by AF and TRS. Themes were discussed within the group. Descriptive and summary statistics were done to process the quantitative data for the costing activities in Phase 5.
Findings
Problems priority and strategy
Problems priorities identified by stakeholders in malaria control during FGDs included 1) community aspects: low community awareness and participation in malaria prevention, high mobility of residents between districts; 2) health service aspects: lack of financial and human resources, lack of inter-district coordination between PHCs and DHOs and 3) policy aspects: poor endorsement of migration surveillance policy, limited role of local government. Table 3 summarizes the problem priority identified by stakeholders at PHCs level in each district.
Additionally, funding mechanism and cycle was considered potential problem for implementation of proposed strategic plan. we conducted the phase 2 to phase 6 between April to September 2017. However the funding planning cycle for 2018 had already been closed before the strategic planned was finished “Although we really would like to execute this action plan as soon as possible to achieve elimination in 2021, but our funding cycle for 2018 has been closed, so we have to propose these activities in the 2019 district budget.” (district manager)
Thus, based on scientific literature and consultations with various stakeholders, three strategies were identified as the pillars of the joint operational plan: 1) strengthening early alert and rapid response systems, 2) addressing malaria focus through local mass approach and vector control and 3) ensuring availability and access of diagnosis and management for malaria cases.
Stakeholders also identified cross-border strategies to address malaria: 1) intensifying population migration surveillance, (2) strengthening networking, governance and advocacy of the implementation of malaria control across borders with relevant stakeholders including cross-sectoral, and (3) development of malaria information system in Menoreh Hills area. They have also agreed to create a working group, composed of representatives from the three districts, that is authorized to make decisions for cross-border issues related to Malaria. Stakeholders were also able to identify four major areas which need to be allocated funding: indoor residual spraying, distribution of long-lasting insecticide-treated nets, diagnosis and treatment, and surveillance and reporting.
Subsequently, outputs from consultations at the district and provincial levels were presented to the national program managers. Inputs gathered during the discussion include: revision of district activities based on effectiveness and relevance, revision of costing based on number of foci, further clarification of roles of district, province and national stakeholders.
Strategic plan
We developed the 5-year Malaria Elimination Action Plan in Menoreh Hills with inputs and feedbacks from various stakeholders covering all level of health systems and was approved by stakeholders from the three districts and the Ministry of Health Indonesia. This joint action plan covers detailed information on the baseline profiles of the settings, strategic issues, vision, mission and goals for malaria elimination in the region, malaria elimination strategies, costing and budgeting, implementation and governance and monitoring and evaluation of the 5 year malaria elimination action plan. The joint action plan document will then be implemented as a local-specific guidance for malaria elimination activities in the region.
As part of the malaria elimination action plan, a joint task force to implement and evaluate the joint operational plan was proposed. This proposal is supported by the national malaria control program via the Ministry of Health Indonesia Decree (KepMenKes RI No HK.01.07/Menkes/498/2017). The joint task force is responsible for: 1) Decision making and inter-districts coordination, 2) Program planning, monitoring and evaluation, 3) Establishing information system in the region, 4) Technical activities planning and implementation, and 4) Data validation and synchronisation. Furthermore, a technical officer will be assigned to assist with three main areas in epidemiology, entomology and community engagement. The technical officer is responsible for 1) Executing decisions related to program implementation made by the joint task force, 2) Acting as information clearing house to accommodate and ensure information are regularly shared between the three districts, 3) Validating and synchronising data for monitoring and evaluation purposes, 4) Ensuring program planning, monitoring and evaluation are regularly performed, 5) Providing technical support for malaria elimination program in the three districts.
Acceptance and adoption
Participants mentioned that the action plan is urgently needed in the light of achieving malaria elimination in the area by 2021. Malaria elimination has been included as one of the development indicators in the district and provincial mid-long term development plan. To be operationalized, the action plan needs to be anchored with the mid-long term development plan of the district and province to allow funding allocation. It was also important to synchronize the action plan with the funding cycle of the district as mentioned in the problem previous finding.
In terms of costing and budget planning for the action plan, it was agreed that all levels should be involved to ensure adherence to the funding guideline. “The national budget has already their own menu items for activities, but some of the activities in this action plan are not listed. So, it is important for the MoH to join the discussion on budget, because they will know what is needed. For local budget it is more flexible.” (provincial manager).
Although most participants recognized the importance of research process in informing the development of action plan, there was difference in the timeline between research process and development milestones. “Academics have to undergo long process – these might indeed be the necessary steps, but as practitioner we wanted a quick result.” (provincial manager). “While developing the mid-long term development plan, we had to develop a strategic plan within one month, so this action plan will not be able to catch up.” (provincial manager).
Participants also agreed that involving stakeholders from other sectors is important, and for this, establishing a legal basis for the action plan execution is very important. “There should be a regulation from the District Head or the Governor to support the action plan, and in there, the roles of each government unit of other sectors will be specified. Each should determine their target. Since this involves more than 1 province, there should be a joint decree from both Governors for the districts.” (Provincial manager).
It was also agreed by participants that to tackle the cross-border malaria, joint commitment and collaboration is very crucial.