abrief history oftb in indonesia eng

A brief history oftuberculosis control

in Indonesia

IA brief history oftuberculosis control

in Indonesia

WHO Library Cataloguing-in-Publication Data

A brief history of tuberculosis control in Indonesia.

WHO/HTM/TB/2009.424

1.Tuberculosis prevention and control. 2.Tuberculosis transmission. 3.Indonesia.

I.World Health Organization.

ISBN 978 92 4 159879 8 (electronic version) (NLM classification: WF 200)

World Health Organization 2009

All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: [email protected]). Requests for permission to reproduce or translate WHO publications whether for sale or for noncommercial distribution should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: [email protected]).

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Design & layout by Blue Infinity, Geneva, Switzerland

III

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .IV

Abbreviationsandglossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V

Executivesummary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .VII

1. Tuberculosis control before 1995 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

2. The health system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

3. Laying the foundation partnership & training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

4. Scaling up - the first strategic plan - the DOTS era (20022006) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 4.1 Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 4.2 Humanresources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 4.3 Drugsupply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 4.4 Pilotprojects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

5. Monitoring programme performance and TB epidemiology & measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 5.1 Casedetection,notificationratesandtreatmentsuccess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 5.2 Measurementofprevalenceandincidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 5.3 Measurementofmortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 5.4 Otherhealthindicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

6. Temporary cessation of the Global Fund grant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

7. The way forward - the 2nd strategic plan - maintaining DOTS while implementing the new Stop TB strategy (20062010) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

7.1 Pursuehigh-qualityDOTSexpansionandenhancement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 7.1.1 Laboratories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 7.1.2 Trainingandhumanresources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 7.1.3 Monitoringandevaluationsystems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 7.1.4 Aneffectivedrugsupplyandmanagementsystem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

7.2 AddressTB/HIV,MDR-TBandotherchallenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 7.2.1 TB/HIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 7.2.2 Drugresistancesurveillanceandtreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

7.3 Contributetohealthsystemstrengtheningbasedonprimaryhealthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

7.4 Engageallcareproviders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

7.5 EmpowercommunitiesandpeoplewithTBthroughpartnership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 7.5.1 Advocacy,communicationandsocialmobilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 7.5.2 Remoteareasandvulnerablegroups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

7.6 Enableandpromoteresearch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

8. Funding needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

9. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Table of contents

IV

Y AnanditaNational Tuberculosis Control Programme (NTP) Indonesia (Advocacy, communication and social mobilization [ACSM] Unit and Tuberculosis [TB] Unit)

Carmelia BasriExpanded Programme for Immunization (EPI) Indonesia

BesralUniversity of Indonesia (ARI surveys)

FX BudionoNTP Indonesia (Partnership and planning coordinators)

Franky LoprangWHO Indonesia (WHO Country Office)

Firdosi MehtaWHO Indonesia (WHO Country Office)

Tri Yunis MikoUniversity of Indonesia (annual risk of infection (ARI) surveys)

Nigor MouzafarovaWHO Regional Office for South-East Asia

Servatius PareiraWHO Indonesia (WHO Country Office)

Sri PrihatiniWHO Indonesia (WHO Country Office)

Ari ProbandariGajah Mada University, School of Medicine (hospital evaluation) Indonesia

Erwin SasangkoWHO Indonesia (WHO Country Office)

Jane SoepardiNTP Indonesia (Manager, sub-directorate)

Jan VoskensKNCV Tuberculosis Foundation, Country Office, Indonesia

Nadia WiwekoNTP Indonesia

YudariniUniversity of Indonesia (ARI surveys)

The World Health Organization (WHO) gratefully acknowledges the contributions of the individuals listed below, who assisted in the preparation of this document.

This work was carried out as part of a project supported by the Bill & Melinda Gates Foundation, and we thank the Foundation for its support.

Acknowledgements

VAIDSacquired immune deficiency syndrome

ACSMadvocacy, communication and social mobilization

ADBAsian Development Bank

ARIannual risk of infection

Askeskinasuransi kesehatan orang miskin (health insurance for the poor)

ATSAmerican Thoracic Society

AusAIDAustralian Agency for International Development

CIconfidence interval

CIDACanadian International Development Agency

DFIDDepartment for International Development (United Kingdom)

DOTSThe basic package that underpins the Stop TB Strategy

EPIExpanded Programme for Immunization (Indonesia)

FDCfixed-dose combination (drugs in the form of a tablet)

Abbreviations and glossaryGDFGlobal Drug Facility

GDPgross domestic product

GERDUNASGerakan Terpadu Nasional Penanggulangan TB (Indonesian Stop TB Partnership)

GLCGreen Light Committee

Global FundThe Global Fund to Fight AIDS, Tuberculosis and Malaria

GNIgross national income

HDLhospital DOTS linkage

HIVhuman immunodeficiency virus

IMAIndonesian Medical Association

IMAIintegrated management of adult illness

INHisoniazid

ISTCInternational Standards of TB Care

JICAJapan International Cooperation Agency

A brief history of tuberculosis control in Indonesia

VI

KNCVKNCV Tuberculosis Foundation

KuISCoalition for Health Indonesia

MDGMillenium Development Goals (United Nations)

MDR-TBmultidrug-resistant TB

MoHMinistry of Health (Indonesia)

MSHManagement Sciences for Health (Indonesia)

NGOnongovernmental organization

NIHRD National Institute of Health Research and Development (Indonesia)

NTPnational TB control programme

PASpara-aminosalicylic acid

PCRpolymerase chain reaction

PERSIIndonesian Hospital Association

PIPKRAPertemuan Ilmiah Pulmonologi dan Kedokteran Respirasi

PMTCTprevention of mother-to-child transmission

PuskesmasPusat Kesehatan Masyarakat (community health centres)

SCCshort-course chemotherapy

SCVT Stichting Centrale Vereniging ter Berstrijding van de Tuberculose

STPStop TB Partnership (international)

TBtuberculosis

TBCAPTB Control Assistance Programme

TBCTATuberculosis Coalition for Technical Assistance

THEtotal health expenditure

TORGTB Operational Research Group, NTP

UNITAIDthe international drug purchase facility

USAIDUnited States Agency for International Development

WHOWorld Health Organization


VII

This report summarizes the history of tuberculosis (TB) control in Indonesia, assesses the impact of the countrys National TB Programme (NTP) on the epidemiology of TB in Indonesia, and outlines barriers to future progress. It was prepared as part of a World Health Organization (WHO) project, with contributions from the KNCV Tuberculosis Foundation (KNCV) and the NTP, and was funded by the Bill & Melinda Gates Foundation. The target audience is the Government of Indonesia, its partners, the community at large, donors and other NTPs, all of whom can learn from the experience described here of investment in TB control the approaches used, the outcomes achieved and the challenges faced.

Indonesia is ranked as having the third highest TB burden in the world, with 244 prevalent (active) TB cases per 100 000 population, which, in 2008, equated to an estimated 565 614 people living with TB. The prevalence of infection with the human immunodeficiency virus (HIV) among the adult population nationally is estimated at 0.16%, and HIV infection is characterized as a concentrated epidemic; however, in Indonesias Papua province, the prevalence is 2.5%, which is considered a generalized epidemic. Twelve provinces have been identified as priority areas for HIV interventions, and an estimated 193 000 people are living with HIV in Indonesia (1). Among incident (new) TB cases, the estimated prevalence of HIV is 3.0% nationally (2). Multidrug-resistant TB (MDR-TB) is estimated to account for 2.2% of all TB cases nationally; this is lower than the estimated South Asian regional average of 4.0%. Given the high burden of TB in Indonesia, the 2.2% represents 12 209 MDR-TB cases emerging every year (3).

In the 1980s, through its Health Sector Development Plan, Indonesia established a public health system using a design founded on primary health concepts (4). The model focuses on extending basic health services to the poor, and relies on providers with modest training; the providers operate at the periphery, but use a five-tier referral system. The NTP is fully integrated and is delivered through the primary health system.

The Health Sector Development Plan made health services more accessible for most of the population, and health outcomes improved consistently from the 1980s until the present (4). In 1999, the Government of Indonesia initiated a process of political and administrative decentralization, whereby districts became the key players in all fields of governmental activities, including health care. Decentralization continues today.

Indonesia was one of the first countries to pilot short-course chemotherapy (SCC) for TB, in 1977. The Indonesian Ministry of Health (MoH) then piloted the internationally recommended strategy for TB control DOTS in 1993, and in 1995 it formally established DOTS as the national policy. Expansion of DOTS after 1995 was initially slow, and case detection rates remained below 30% until the year 2002.

In 1999 and 2000, a foundation was laid for the acceleration of DOTS expansion. First, GERDUNAS (Gerakan Terpadu Nasional Penanggulangan TB) a broad national TB partnership designed to bring wide acceptance of the DOTS strategy and coordinate the activities of all TB partners was officially launched by Indonesias Minister of Health on World TB Day in 1999. Then, in 2000, financial support from the Dutch Government was used to establish a comprehensive DOTS human resource development programme that targeted all levels of the NTP (5). Expansion of DOTS was facilitated by intensive collaboration with KNCV and WHO as technical partners (6).

In 2001, the first five-year strategic plan was developed, and 2002 marked the beginning of an era of increased funding for TB control by external donors, notably from the United States Agency for International Development (USAID) through the Tuberculosis Coalition for Technical Assistance (TBCTA), which was led by the Canadian International Development Agency (CIDA) and KNCV. This funding focused on further capacity building and DOTS expansion in the heavily populated

Executive summary


VIII

provinces of Indonesia. Grants from the Global Drug Facility (GDF) a allowed the country to establish TB drug buffer stocks in the rapid expansion phase. During 2003, Indonesia received additional support from the Global Fund to Fight AIDS, Tuberculosis and Malaria b (referred to as the Global Fund), which increased the funds available for TB control by 40%. Through Global Fund support, the NTP was able to employ more staff, and to stimulate and scale up many of its usual functions.

The TB case detection rate increased rapidly from 30% in 2002 to 76% in 2006. The treatment success rate has been above 85% since the year 2000, and it reached 91% in 2007. Indonesia was the first high TB burden country in the WHO South-East Asia Region to achieve the global targets for case detection (70%) and treatment success (85%).

Two successive nationwide prevalence surveys indicate that the incidence of TB has fallen by about 2.4% per year since 1980; tuberculin surveys used to estimate the annual risk of TB infection carried out between 1972 and 1987 in 10 provinces of the country support this finding (7-9).

As shown in Figure 1, the NTP has been improving case detection and cure for more than a decade (2) successfully treating more than half a million TB patients (567 620) over 10 years. However, the existence of the programme does not fully explain the estimated decline in overall TB prevalence over 25 years. The decline is probably due to the widespread use of SCC, combined with overall socioeconomic improvement as demonstrated by the steady increase in gross national income per capita (10) and other aspects of high-quality TB control, such as improved case detection, better case holding and increased treatment success.

1995

2738

1996

9592

1997

11635

1998

23144

1999

23139

2000

45730

2001

46260

2002

65724

2003

80243

2004

115478

2005

143937

20000

40000

60000

80000

100000

120000

140000

160000

0

TB cases successfully treated

Figure 1. TB cases successfully treated under the Indonesian NTP since the start of the DOTS strategy, 1995-2005

a The GDF, which is part of the Stop TB Partnership, is a mechanism to expand access to and availability of high-quality anti-TB drugs

and diagnostics, to facilitate global expansion or maintenance of DOTS.

b The Global Fund is an international financing institution aimed at saving lives.


IX

Despite administrative and financial decentralization of the health system since 2006, 90% of TB programme operations at the district level are still funded by the central TB programme or by donors (primarily the Global Fund), and few operations are financed by the district or provincial governments. In 2007, due to problems with financial management and oversight, the Global Fund officially restricted funding to Indonesia for all grant components for six months. The restricted funding provided for continuation of life-saving activities during the six months, and for direct purchase of an emergency supply of TB drugs through the GDF. During the restriction period, the NTPs dependency on donor funds and its vulnerability quickly became apparent, as the programme faced severe attrition of staff whose positions had previously been financed by the Global Fund, and cessation of funding for operational activities, such as monitoring and supervision. Case detection and notification rates were reduced during this time, although treatment outcomes remained stable. The long-term effects of the suspension have yet to be evaluated, but have opened a discussion about concerns surrounding financial management, donor dependence and plans for future financial sustainability.

Indonesia is in transition in terms of epidemiological and demographic factors; it is also adjusting to the political and administrative decentralization of the health sector that was initiated in 1999. The government has shown its commitment to improving the performance of the health system by developing universal insurance schemes that target the poor and by increasing the general government health expenditure as a percentage of total general government expenditure from 4.1% in 1995 to 5.3% in 2006. However, the total health expenditure as a percentage of gross domestic product (GDP) remains low, at 2.2% in 2007 (11), and the global economic crisis, which began in 2008, is expected to lead to budget cuts within the health sector.

Following major expansion of DOTS over the last decade, with clear improvements in case detection and treatment success, the NTP has begun to implement a second strategic plan for 200610 (12). This plan is built on a solid DOTS foundation with the aim of strengthening the quality of service delivery and increasing the participation of hospitals in both the public and private sectors. New strategies include creation of hospital DOTS linkages, treatment of MDR-TB, improvement in the laboratory network and strengthening of a quality assurance system; in addition, HIV collaborative activities are poised for expansion.

As with the scale up of DOTS in the past, if the TB programme is to achieve the goals outlined in the second strategic plan, sustained financing will be essential. A sustainable solution will mean dealing with weakness in financial mechanisms and district-level contribution to health. The NTP, in line with objectives of the MoH, has developed strategies to encourage district-based contribution to health budgeting, including contributions for control of TB. The strategies also focus on central and local partnerships, to ensure collaboration and communication among all sectors to attain these goals. If case detection continues to increase and treatment success remains high, the decline in TB incidence is likely to be sustained or be even more rapid.


1

The information in this section is taken from an unpublished history of Indonesias National Tuberculosis (TB) Programme (NTP) (5).

TB control in Indonesia began in the early 20th century with a Dutch initiative to combat TB Stichting Centrale Vereniging tot Bestrijding der Tuberculose (SCVT). By the end of World War II, 20 diagnostic units and 15 sanatoria had been established, mostly on the island of Java. After Indonesia gained independence in 1949, a further 53 additional TB centres and sanatoria were set up, the majority located in large cities. At this that time, diagnosis of TB relied primarily on radiography, and treatment of the disease primarily relied on radiography and hospitalization of TB patients. This was despite the fact that the anti-TB drugs aminosalicylic acid (commonly known as para-aminosalicylic acid, PAS), isoniazid (INH) and streptomycin had recently been discovered, and the World Health Organization (WHO) had begun to recommend TB diagnosis based on sputum smear examination and ambulatory treatment.

The first survey of the prevalence of TB in Indonesia was carried out in 1964, and included both rural (Malang regency a ) and urban (Jogjakarta city) areas. Tuberculin surveys, to assess both prevalence and annual risk of

infection, were conducted in 10 provinces over the period 19721995.

The years 1969 and 1970 marked the start of modern TB control the guidelines for the management of TB patients were revised and the NTP was established. The NTP strategy focused on diagnosis and delivery at community health centres (puskesmas), with hospitals and TB centres serving as referral units for complex cases. Diagnosis was based on direct sputum smear examination, and treatment consisted of a two-year anti-TB drug regimen (HS/11H2S2/12H2 b ) supervised by the TB centres and sanatoria. The regimen was revised in the late 1970s (2HS/10H2S2) and again in the mid-1980s (2HSZ/10H2S2), when pyrazinamide was added. In 1976, the drug rifampicin was introduced, initially through a clinical study that was conducted in six hospitals and lung clinics and involved a six-month, fully-supervised regimen (HR/5H2R2). The study showed cure rates of more than 90% and, in 1977, a short-course

chemotherapy (SCC) regimen containing rifampicin (HRE/5H2R2) was piloted in six provinces. The cure rate in the pilot projects was 88%; based on these results, the short-course regimen was introduced nationally, being implemented in a stepwise fashion over a period

1995Tuberculosis control before

The years 1969 and 1970 marked the start of modern

TB control; guidelines were revised and the NTP was established

After Indonesian independence in 1949, diagnosis and treatment of TBrelied primarily on radiography and hospitalization

1.

a Indonesia is divided into 33 provinces, each of which is subdivided into regencies and cities, which are further subdivided into districts.

b Abbreviations for TB treatment regimens follows standard WHO abbreviations and can be found in Treatment of tuberculosis: guidelines for national programmes, WHO 2003.http://whqlibdoc.who.int/hq/2003/WHO_CDS_TB_2003.313_eng.pdf


2

of several years. During this period, the NTP used rapid village surveys, with fixed targets for each village cohort, to find active cases. Sputum smears were examined through Kinyoun-Gabbett staining (i.e. the method used before the introduction of Ziehl Neelsen staining), without quality assurance, and using loose drugs in full patient packages. Hence, from 1977 to 1995 there were two national TB regimens, the conventional course (2HSZ/10H2S2) and the SCC (HRE/5H2R2), with the former being gradually phased out over several years.

In 1993, the KNCV Tuberculosis Foundation (KNCV) introduced directly-observed SCC in a field trial in four districts on the island of Sulawesi, working within the existing leprosy control programme.

The key elements of the strategy were:

diagnosis by direct smear with Ziehl Neelsen staining following standardized methods

directly-observed SCC treatment (2HRZE/ 4H3R3)

an uninterrupted drug supply

standardized recording and reporting.

The pilots were gradually scaled up to all four provinces in Sulawesi. In 1994, based on the successful Sulawesi

experiences, the NTP piloted the full DOTS strategy in two other districts, one in East Java province, the other in Jambi province. Since 1995, the DOTS strategy has been endorsed and implemented nationwide, again in

a stepwise fashion over a period of several years, and has averted many deaths (Figure 2). However, the DOTS strategy was only expanded to the network of community health centres (basic health services), and not to the hospital sector and lung clinics.

From 1977 to 1995 there weretwo national

TB regimens, the conventional course and the SCC with the former being gradually phased out

2000 2001 2002 2003 2004 2005 2006

20000

40000

60000

80000

100000

120000

0

347,576 deaths averted

Figure 2. TB deaths averted under the Indonesian NTP since the DOTS strategy was introduced


3

In the 1980s, the public sector component of Indonesias health system was put in place under the Indonesian Health Sector Development Plan, using a design founded on primary health care concept (4). The model differed from previous ones in that its focus was on extending basic health services to the poor it relied on providers with modest training and operated at the periphery. By the 1990s, the Government of Indonesia had built and staffed more than 7100 health centres, 19 000 subcentres, 285 district hospitals and 50 special referral hospitals (4). Health services in Indonesia are organized at five levels: central, provincial, district, subdistrict and village. Various facilities are used at the different levels, but at the core of each level is the primary care centre, which forms the basic unit. The system is supported by a referral system consisting of district, provincial and central hospitals, which provide secondary and tertiary care.

Indonesias large private-health sector expanded rapidly, partly as a result of the Ministry of Health (MoH) decision to allow public-sector staff to work part-time in private practice. The MoH saw this as a way to supplement low public-service salaries and allowances, while retaining qualified practitioners in the public sector. Currently,

about 65% of publicly employed health workers have a second job (13). At the same time, the MoH encouraged investment in private hospitals, laboratories, medical schools and health insurance schemes (4). This system has been successful in some respects, but has also led to perverse incentives (i.e. incentives that have an

unintended and undesirable effect), and is thought to have drawn many health workers away from rural areas (13).

The first phase of the Indonesian Health Sector Development Plan made health services more accessible for most of the population, and health outcomes have improved consistently from the 1980s to the present (4). For example, infant mortality fell from more than 125 deaths per 1000 live births in 1980 to less than 34 in 2006 (10), but in 2006 ranged from 77 per 1000 live births among the poorest households to 22 among the wealthiest (13). Contraceptives were used by more than 60% of the sexually-active adult population (4), and total fertility rate fell from 4.35 births per adult female in 1980 to 2.2 in 2006 (10). However, maternal mortality remains high, with four deaths per 1000 live births in 2006; in addition, rates of child malnutrition, which had reduced in the 1990s, have stagnated since 2000 (13). These indicators vary significantly across the country.

By the early 1990s, the number of patients visiting government outpatient facilities was dropping steadily, and the number of patient visits to private health facilities was increasing, although since 2004 this trend appears to have reversed (4). Since the early 1990s, the poor have increasingly relied on self-treatment; their use of government facilities especially hospitals is well below average rates (4). Despite recent efforts to provide health insurance for the poor, this remains true today (13). In 2006, 50% of health care was privately funded, and 66.3% of that was out-of-pocket expenditure; also, only 15% of the population was covered by any form of health insurance (4, 11).

Sociopolitical change at the end of the 1990s was the trigger for fundamental and rapid changes in public systems. In 1999, the Government of Indonesia initiated a process of political and administrative decentralization, whereby districts became the key players in all fields of governmental activities, including health care. The decentralization was implemented abruptly in 2001. The

health systemThe

MoH investment in private hospitals, laboratories,medical schools and health insurance

has been successfulin some respects, but has also led to

undesirable effects.

2.


4

ad hoc introduction of decentralization laws and the short time for preparation had serious consequences for TB control. There was drastic reorganization of public services (including health), as well as restructuring of their funding mechanisms. The centralized budget planning system was replaced by a system of block grants to districts, whereby local governments decided on allocations. Control of communicable diseases, previously seen as the responsibility of the central government, became fully dependent on district budgets. Unfortunately, in many districts, such control was not prioritized; consequently, allocations for activities to control communicable diseases, including TB, were eliminated (14). In addition, government health staff numbers were reduced or staff were transferred.

The process of decentralization was further hampered by the limited organizational capacity at the central and local government level. As a result, lines of decision often still depended on former authority structures and hierarchical relationships. Insufficient financial information and inadequate planning systems caused severe underfunding of public services, including health, at the district level. This situation was aggravated by the lack of implementation guidelines, which led to confusion about roles and responsibilities at all levels. The important achievements made by the public health sector in the first phase of operations were difficult to extend or even sustain over the last decade. Indonesia is in transition in terms of epidemiological and demographic factors; it also faces adjustments to decentralization. Although the general government health expenditure as a percentage of total general government expenditure rose from 4.1% in 1995 to 5.3% in 2006, the total health expenditure (THE) as a percentage of gross domestic product (GDP) remains low, being 2.2% in 2007 (11). Also, overall national public health expenditures as a percentage of GDP remain low, being 1.1% of the GDP in 2007 (11).

Indonesia is in transition in terms of epidemiological and demographic factors; although health

expenditure has risen, it remains low.


5

Although DOTS became the official strategy of Indonesias NTP in 1995, few health staff in the country responsible for TB service delivery had been trained in DOTS at that time. In addition, delivery of such services through the NTP was limited to the puskesmas (community health centres) and specialized TB centres; it did not cover either public or private TB hospitals, which traditionally provided services to a large proportion of all TB patients.

The decentralization process of the Indonesian health system had considerable impact on the TB control programme: much of the financial responsibility, as well as prioritization of TB control, was devolved from the central to the local governments (15). In 1999, in the presence of the President of Indonesia, the MoH launched a new initiative GERDUNAS (Gerakan Terpadu Nasional Penanggulangan TB) a local equivalent of the global Stop TB Partnership. The objective of GERDUNAS was to create a stronger platform for TB control by coordinating all partners and sectors hospital and private sectors, and all other stakeholders, including patient and community representatives in the delivery of TB services (6). The aim was to declare total war against TB, by promoting and accelerating TB control measures.

In 2000, financial support from the Dutch Government was used to lay the foundation for accelerating DOTS expansion, through implementation of a plan for national capacity building in TB control. The three-year plan, funded with US$ 4 million, involved a systematic review of all levels of health personnel involved in TB service delivery. The primary objective was to improve the quality of the services delivered to TB patients, by increasing the skills of health workers at all levels and improving

the efficiency and cost-effectiveness of programme management. KNCV and WHO provided technical assistance (15).

Thirty master trainers were placed in four regional centres, where they trained more than 1000 provincial and district level supervisors in about 40 batches. These

supervisors then trained 10 000 of 22 000 health facility level supervisors, using standardized training modules developed for each level of health service delivery. The method involved active learning in small groups. Training of health facility staff at all levels took more than two years. The comprehensive training efforts nationwide laid the foundation for scaling up DOTS. After 2002, human resource development activities were rapidly scaled up to other provinces in Indonesia, with support from the United States Agency for International Development (USAID) through the Tuberculosis Coalition for Technical Assistance (TBCTA), supplemented with support from the Canadian International Development Agency (CIDA), and the Royal Netherlands Tuberculosis Foundation (KNCV). During implementation of this project, structure and reporting mechanisms for management of funding down to the district level were developed; these proved to be crucial when the Global Fund to Fight AIDS, Tuberculosis, and Malaria (referred to as the Global Fund) began dispersing funds in Indonesia in 2003.

The objective of GERDUNAS was to create a stronger platform for TB control and declare

total war against TB

The objective of DOTS expansion was to improve quality of services delivered by increasing skills and improving efficiency and cost-effectiveness...

3.

partnership & trainingLaying the foundation


6

The first part of the Indonesian Health Sector Development Plan (200206) was aimed at DOTS expansion. It was based on the assumption that decentralization would initially draw resources away from public health programmes and, as such, would weaken the NTP. Donor funding for the plan was targeted at securing core operations for nationwide DOTS implementation, including provision of finance directly to the district. At that time, the level of funding contribution to health by the district government was not known, but was expected to be less than the amount needed to scale up DOTS. This suspicion was later confirmed in a district health financing survey undertaken by the University of Indonesia (16). The strategic plan foresaw a gradual shift from donor funding to local government sources over a period of five years.

Due to the governments focus on primary health care, the distribution of health centres providing TB diagnosis and treatment in Indonesia generally matched the population served, except in some remote areas. Through the initiatives funded by the Netherlands and USAID, noted above, by 200102, health staff in 95% of all centres had been trained in the delivery of DOTS, and implementation of DOTS had started in most provinces. However, the country still lacked sustainable funding for core activities and regular supervision, needed to ensure quality and routine reporting.

4.1 Funding

In 2006, Indonesia spent approximately USD 7 billion on health care, which was about twice the amount spent in 1995, although the total health expenditure (THE) as a percentage of GDP remained low, being 2.2% in 2007 (Figure 3). About half of THE was from the government

and half from private expenditure. In terms of general government expenditure, the proportion spent on health increased from 4.1% in 1995 to 5.3% in 2006, but remained far below the target of 15% (11).

In 2002, the estimated budget requirement for TB control was approximately USD 34 million, but only about one third of that was available USD 6.7 million from the government and USD 3 million from donors (Figure 4). By 2005, the estimated budget requirements had increased to more than USD 50 million, and they are projected to reach almost USD 80 million by 2009 (2). The government contribution to the TB budget increased from USD 6.7 million in 2002 to USD 24 million in 2005, and is projected to grow to USD 34 million in 2009. The government contribution to the total TB budget increased from just under 20% of the total TB budget in 2002 to over 40% in 2009. Actual government expenditure as a percentage of the NTP budget in recent years has varied, being 100% in 2004, 77% in 2005, 56% in 2006 and 83% in 2007. Thus, actual expenditure has recently been

(20022006)Scaling up - the first strategic plan - the DOTS era 4.

General governement expenditure on health USD

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Figure 3. Trend in public health expenditures, Indonesia, 19952007

Source: World Health Organization National Health Account Series (11)

in 2009, the budget requirements are projected to reach USD 80 million


7

much lower than the planned government budget for TB control.

In 2007, due to the world economic crisis and increases in the prices of food and oil, the government cut funding in all public sectors, including total TB expenditure, which was reduced by 15%. A reduction of 50% is expected in 2009 (NTP, personal communication, 5 November 2008).

Since the early 1990s, Indonesias NTP has successfully secured donor funding from the Asian Development Bank (ADB), the Australian Agency for International Development (AusAID), CIDA, the Dutch Government and KNCV, the Global Fund, the Japan International Cooperation Agency (JICA), the United Kingdom Department for International Development (DFID), USAID and World Vision. The donor contribution to TB, excluding the Global Fund, ranged from USD 3 million in 2001 to USD 12 million in 2006. The most substantial increase in funding one that allowed the budget gap to be closed between 2004 and 2008 was from the Global Fund. The initial dispersal of funds from the first round of the Global Fund at the end of 2003 added more than USD 13 million to the TB budget in 2004. Support from the Global Fund represented almost 40% of the total available budget, on average, over the following five years.

Donor funds are dispersed mainly at the district level (Figure 5). Donor funding, including that from the Global Fund, was coordinated to provide complementary coverage of the country until 2005, after which the Global Fund became the primary donor for funding the

operational activities of the NTP. Other donors then phased out their support for operational activities and focused primarily on supporting new strategies and providing technical assistance.

Donor funds were prioritized for DOTS implementation at the district level, anticipating that the shift from central to district level funding of TB control through decentralization would leave gaps in operations funding at the district level. In general, financial support for TB at the district level following decentralization was low, and it did not increase substantially in the following years. For

Loans Government Grant

Global FundGap

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902009 gap to be covered by Global Fund round 8 grant

02002 2003 2004 2005 2006 2007 2008 2009

Figure 4. Indonesian National TB Programme budget, by donor, 20022009

Source: World Health Organization (2)

January - March 2004(GF 16 Provs)

April - June 2004(GF 19 Provs)

April - July 2005(GF 21 Provs)

November 2006 March 2007(GF 33 Provs)

Global Fund (GF)TBCTA/ USAID

DUTCH GOVT.DFID - MDGs CIDA + USAID + GF (Q9)

KNCV + USAID + GF (Q9)

Figure 5. Geographic distribution of donor funding in Indonesia, 20042007


8

example, a study of seven districts in four provinces in 2004 found that, on average, districts allocated only 4.6% of public funds to the district health office much less than the target of 15% (16). On average, less than 2% of this district health funding is spent on TB. However, over a three-year period, most districts reviewed in the study showed decreasing expenditures on TB control, with local district planners diverting funds from TB control to curative and other preventive health services that lacked funding. The study also found that only 10% of TB operational activities were financed by districts, with the remaining 90% funded by donors at the central level (16) (Figure 6). The Strategic Plan for Tuberculosis Control 20022006 outlined a gradual shift from donor funding to local government sources over this period; however, local district planners facing resource deficits for other health services deviated resources from TB control, which had stronger donor support. While the National TB Programme had succeeded in attracting donor support

with a positive impact on TB control, the dependency of the TB programme on donor contributions for normative operations has left the programme extremely vulnerable if donor support is withdrawn.

4.2 Human resources

Development of human resources in the NTP laid the foundation for the rapid expansion of DOTS over the

six years to 2009. Technical and management capacity were strengthened in a stepwise and systematic approach to human resource development. In 20002001, the NTP made an initial assessment of training needs and human resource development, with support from KNCV and WHO. After assessing skill gaps for all levels of staff, the NTP developed training curricula, modules and methodologies. A core group of 26 master trainers was created; this group then trained more than 1100 provincial and district level staff at four regional training centres. In turn, these provincial staff

trained district level staff. Initially, funding for the initiative came from the Dutch Government (from 2000 to 2002), subsequently from CIDA and USAID, and later from the Global Fund.

Programme management structures at the provincial level were further strengthened by appointing provincial project officers and financial assistants; structures were later expanded to include provincial technical officers and provincial training coordinators. The number of staff positions at the central unit grew from 13 in 2001 to almost 50 by 2007. Capacity building at the central unit was supported by partner organizations (the KNCV and the WHO), and donors and operational costs were mainly covered through Global Fund resources (NTP, personal communication, 28 April 2008).

4.3 Drug supply

Until 2003, the Government of Indonesia was committed to providing 100% of the TB drug stock for Indonesia. It always paid for 50% of first line anti-TB drugs excluding a buffer stock and procured these drugs from local manufacturers. In 2003, the Global Drug Facility (GDF a )provided a 30% buffer stock through a grant, in the form of fixed-dose combination drugs (FDCs). This was the first time that FDCs had been used in the country, and it encouraged the state-owned drug companies to begin production of FDCs in 2004; however, local manufacturers were unable to expand production to match the rate of DOTS expansion. From 2005, funds from the Global

CDRDonor funding

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Figure 6. Donor funding and TB case detection rate, Indonesia, 19982006

Development of human resources in the NTP laid the foundation for the rapid expansion of DOTS over the six years to 2009...

a The GDF, which is part of the Stop TB Partnership, is a mechanism to expand access to and availability of high-quality anti-TB drugs and diagnostics, to facilitate global expansion or maintenance of DOTS.


9

Fund have been used to finance the additional 50% of drugs required and the buffer stock, all of which have been procured directly from the GDF.

Locally-purchased drugs and kits, procured by the Ministry of Health, are sent directly to districts, except for 20% of the buffer stock, which is equally divided between the central and provincial levels. The manufacturers are responsible for distributing drugs and are asked to inform the NTP on distribution and stock positions in provinces; however, this is not done routinely. Drug management in Indonesia has been fraught with problems, even before decentralization, because the drug management information system needed to obtain accurate data on stock levels in provinces and districts functions poorly. This results in an oversupply in some areas and an undersupply in others. The lack of information on stock positions and expiry dates adversely affects the planning process and drug management.

In 2007, there was almost a major drug shortage when the government had insufficient resources for the purchase of drugs, and local manufacturers were unable to produce the drug supplies in quantities sufficient for expansion of DOTS. In addition, the buffer stock was allocated at 20%, rather than the 100% required during an expansion phase. At the same time, the Global Fund grant was suspended, making it difficult to renegotiate funding to cover the additional drugs needed. Ultimately, the NTP negotiated with the Global Fund to make an exceptional release of funds under an emergency order, (NTP, personal communication, 4 November, 2008). Although considerable efforts are being made to improve drug supply management, the NTP is still concerned about the possibility of future interruptions in drug supply in Indonesia, given the lack of local manufacturing capacity and further budget cuts that are anticipated as a result of the possible prolonged global economic crisis.

4.4 Pilot projects

A substantial number of tuberculosis cases are diagnosed and cared for outside the community health system (puskesmas), and therefore outside the direct line of authority of the NTP (17, 18). No comprehensive information is available on the numbers of patients who are managed in the private sector and in government hospitals and clinics, apart from some quantification obtained in a knowledge, attitude and practice survey. This accompanied the tuberculosis prevalence survey in 2004 and found that 3050% of TB patients receive TB care in hospitals (7). A more recent survey found

that chest hospitals manage relatively large numbers of TB patients (19). Chest radiography is the most commonly used diagnostic tool in hospital and private practice. Sputum smear is underused or not performed at all on TB suspects, and sputum culture is uncommon. Additional diagnostic methods, such as serology and polymerase chain reaction (PCR), are commonly used, but often inappropriately; the predictive value of these tests is unknown and quality assurance is lacking. The quality of treatment performance is unknown in much of the private sector. Treatment regimens in hospitals and private sector vary considerably, and adherence and patient follow-up is poor. For these reasons, involvement of the private sector, as well as of both public and private hospitals, has widely been considered a crucial and important aspect of increasing case detection and improving treatment success.

The DOTS programme was initially established in the community health centre network, under the Directorate of Community Health. This excluded almost 400 public hospitals, which fall under a different directorate (Medical Services), and more than 800 private hospitals. In 1999, the Ministry of Health began an initiative to introduce DOTS into public and private hospitals, and link these hospitals to the national TB programme through the Indonesian Hospital Association (PERSI). The initiative consisted primarily of raising awareness and providing hospital doctors with training in DOTS (15). In 2000, KNCV, in collaboration with the Gorgas Foundation at the University of Alabama in the United States, provided technical and financial support to initiate a hospital DOTS linkage (HDL) pilot project in Jakarta, under the guidance of the NTP. The project had four major components: human resource development, recording and reporting, referral and tracing, and an integrated laboratory network. During the pilot project, it became clear that establishment of a coordinating body at provincial level was vital to the success and long-term sustainability of the project (20). This coordinating unit was formed and was also made responsible for overseeing the implementation of DOTS in the public sector, which ultimately resulted in a uniform surveillance, monitoring and evaluation system that operated across the province (20). Since 2003, systematic efforts have been made to involve non-NTP facilities and clinicians in delivering DOTS services through the HDL strategy. By 2008, nearly one third of the hospitals in four provinces were implementing DOTS. However, according to a recent review (19), few staff in these hospitals have had the appropriate training, and many components necessary


for a successful programme are lacking for example, standardized recording and reporting, default tracing and effective referral links to the puskesmas. Given that an estimated 3050% of TB cases are managed in the private sector, building partnerships with both the public and the private sector will continue to be a critical area of focus for the NTP in the years to come. Achieving optimal case management and assuring quality care for TB patients will depend on setting criteria for certification of providers, expanding the notification system to the hospital and private sector, and building effective referral networks between public health services and the hospital sector.

10


5.1 Case detection, notification rates and treatment success

The objectives of Indonesias first Global Fund grant was to scale up DOTS, increase the case detection rate, and improve recording and reporting. The TB suspect evaluation rate increased from 293 per 100 000 suspects examineda at the start of the Dutch training initiative in 2001, to 693 per 100 000 in 2006; the increase

was consistent across all provinces (Figure 7). By 2006, just over 1.5 million suspects had been examined for TB (Figure 8). The case detection rate of smear-positive TB increased from less than 30% to 76% in four years (Figure 6). Notifications of all TB cases increased from 44.5 per 100 000 in 2001 to 124.6 per 100 000 in 2006 (Figure 9). A similar increase was evident across all age groups (Figure 10) and, between 2001 and 2006, the

average age of TB patients nationally was also increasing (Figure 11). In 2001 and 2002, suspect evaluation rates, notification rates and the case detection rate began to increase; however, the increase was much more rapid once support was forthcoming from external donors such as USAID (through KNCV and TBCTA) and later the Global Fund (Figure 6).

the increase in suspect evaluation rates, notification rates and the case detection rate was much more rapid once support was forthcoming from external donors...

& measurementMonitoring programme performance and TB epidemiology

5.

a Source: National TB Programme data

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11


The proportion of cases treated successfully, including those with documented cure and those that have completed treatment, has consistently been above 85% since the year 2000, and reached 90% in 2004 (Figure 13). From 2000 to 2006, the proportion of cases having completed treatment was replaced with cure, meaning that follow-up laboratory diagnostics were being conducted more consistently to confirm cure, which indicates improvement of patient follow-up. The proportion of cases that were not evaluated decreased, and the relapse rate fell from 4.5% in 2000 to 2.4% in 2006, indicating that both reporting and the quality of TB treatment were improving.

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Figure 9. Notification rates for TB, Indonesia, 19952007


Figure 11. Average age of TB patients by gender, Indonesia, 20012006


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Figure 12. Treatment outcomes expressed as a percentage, Indonesia, 19972006


13

5.2 Measurement of prevalence and incidence

The increasing notification rate for TB (Figure 9) reflects improvement in TB case detection and patient notification; therefore, these data do not yet reflect trends in incidence in Indonesia. To estimate the underlying trend in incidence and prevalence, data from prevalence of disease and infection surveys carried out in the 1970s and 1980s can be compared with more recent surveys.

Between 1979 and 1982, prevalence surveys were carried out in 15 of the 26 provinces of Indonesia, with the aim of estimating the prevalence of smear-positive TB in selected provinces (7). The coverage of surveys was wide in Sumatra (4 of 8 provinces), Java-Bali (all 5 provinces) and the eastern region (5 of 12 provinces). From these surveys, the national prevalence was estimated to be 317 smear-positive TB cases per 100 000 population, with regional variations showing a higher prevalence in the Eastern region, followed by the West, and a lower prevalence of TB in the Central Java-Bali region (Figure 13). The first nationwide prevalence survey was carried out in 2004. In this survey, the prevalence was found to be 104 TB cases per 100 000 population, a three-fold reduction, which equates to a 4% annual decrease in prevalence. The 2004 survey saw a regional variation similar to that observed in the earlier regional prevalence surveys, with the highest prevalence in the East, followed by the West, and the lowest prevalence in the Central Java-Bali region. Methods for suspect and diagnostic criteria differed from the earlier surveys, where sites were selected based on proximity to a laboratory and the number of smears examined was lower; however,

even when data were adjusted, the reduction in prevalence was significant (7). Based on the findings of the prevalence survey, the reduction in incidence was estimated at 2.4% per year.

In 2007, tuberculin surveys used to estimate the prevalence of TB infection were carried out by the University of Indonesia at the request of the Ministry of Health in three provinces of Indonesia. The surveys were designed to complement the previous tuberculin surveys carried out in 1985 (8, 9) as well as the nationwide prevalence survey carried out in 2004 (7). The provinces selected were West Sumatra, Central Java and Nusa Tenggara Timur, and the objective was to estimate the

provincial prevalence of infection among schoolchildren aged 69 years, and then use these data to compute the annual risk of TB infection (21, 22). Coverage of registered children ranged from 85% to 94%, and similar frequency distributions of reaction sizes were seen across the provinces. The prevalence of infection across all three provinces was estimated at 7%, and the estimated annual risk of infection estimated at about 1%. Similar tuberculin surveys carried out in 1985 indicated an average annual risk of TB infection of 3%, suggesting a 5% average annual decline since 1985, and supporting the findings of the prevalence survey (8, 9, 22, 23).

5.3 Measurement of mortality

Reliable mortality statistics are best derived from a valid vital-registration system that is cause-of-death specific. Accurate measurement of mortality by cause of death is important for planning, but also for measurement of progress towards certain targets such as the United Nations Millennium Development Goals (MDGs). Although the Ministry of Home Affairs developed new guidelines for vital registration in Indonesia in 2003, there are no specific instructions for reporting cause of death. The main shortcomings of the existing mechanism in Indonesia are a lack of instruments to aid in data collection, a lack of training in data collection and analysis, and poor integration of different elements of the registration system.

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Figure 13. Prevalence of smear-positive TB in 1980 and 2004 prevalence surveys, Indonesia

Source: Soemantri et al, 2007 (7).

In 2007, tuberculin surveyscarried out by the University of Indonesia.

complemented previous surveys of 1985

and the nationwide survey of 2004


Two projects have been launched to strengthen the all-cause-of-death reporting system and to generate better TB-specific mortality estimates. In 2006, the National Institute for Health Research and Development (NIHRD) in collaboration with the NTP and supported by WHO and DFID launched a pilot project to strengthen the mortality and cause-of-death registration system in Indonesia. A working group comprising different ministries and stakeholders was set up to advise on a streamlined mechanism for notifying deaths and compiling mortality statistics. The approach developed paid particular attention to maximizing accuracy of TB death registration, and was piloted in three sites on Java Island. A study on the accuracy of a verbal autopsy tool was conducted in conjunction with this project; results are being analysed (15).

In 2007, sentinel sites for special surveillance of TB mortality were established to complement the routine registration system.

Cause-of-death reporting mechanisms were put into place at these sites, following WHO guidelines, with the ultimate aim of helping to assess progress towards MDG targets. In the first phase of the project, two sites were set up in four provinces covering a population of 1.6 million. New cause-of-death instruments were developed and put into place, together with operational guidelines for cause-of-death reporting, and training was undertaken to improve skills in data management and analysis. Results are being analysed and will be used in developing a baseline against which progress towards the MDG targets can be measured (15). The current WHO estimate of TB mortality rate is 39 per 100 000 population, which is less than half of the mortality rate estimated for 1990.

5.4 Other health indicators

Both prevalence of smear-positive TB and annual risk of infection have been substantially reduced; however, the cause of the decline cannot be firmly established nor can it be attributed solely to the efforts of the NTP. One hypothesis is that the decline in TB is linked to the early introduction of rifampicin-containing regimens, which has

reduced the prevalence of smear-positive disease (7). Another explanation (which has not been tested) is a link to the growth of the economy. From 1980 to 2006, Indonesias real GDP grew at an average rate of 5.5% per year, with a rapid increase in gross national income per capita in the years following the Asian economic crisis that started in 1997 (Figure 14) (10). The average life expectancy at birth increased by 13 years over a 25-year period, increasing from 55 to 68 years for both men and women a level that is only slightly lower than China, Thailand and Turkey (10, 22). In Indonesia, the birth rate fell by one third and the death rate was almost halved during this period (Figure 15) (10). Social and economic improvements may have contributed to better nutrition, reducing the transition from infection to disease; they may also have reduced transmission due to better housing and ventilation.

Many factors may have contributed to the reduction of TB in Indonesia, and the achievements in TB control over the last five years, if sustained, should continue to reduce the countrys burden of TB.

In 2007, cause-of-death reporting mechanisms were put in place at sentinel sites,

to help assess progresstowards MDG targets.

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14


In 2007, all Global Fund grants to Indonesia were officially restricted for six months due to flaws in financial management by primary and sub-recipients, resulting in the suspension of most of the operational activities in the DOTS programme. The effects on TB activities were

explored through a rapid survey carried out in 11 districts in 6 provinces (24). The study found that the early impacts, from district to central level, included interruption of TB surveillance, monitoring and supervision in DOTS centres and in laboratories. However, the decline in national notification rates of all forms of TB was relatively small, amounting to about 2000 TB cases. The number of smear-positive cases detected was greatly reduced, being 15 000 less than the previous year. This was partly balanced by an increase in smear-negative notification rates, which increased by 10 000, initially due to a decrease in reporting, although final data showed that the decrease was real and not due to reporting alone. Procurement of drugs and supplies had been difficult even before the cessation of the Global Fund grant, but the cessation brought procurement and supply of laboratory reagents to a halt in several of the sites examined. This factor may have contributed to the decline in the diagnosis of smear-positive cases and the increase in notification of smear-negative cases (24). Attrition of contractual staff supported through the Global Fund led to the dismissal of 11 staff at the central level, 80% of contracted accountants at the project management unit and 30% of contracted project staff at the provincial and district level. Honoraria were discontinued, and almost all training for 2007 was postponed. Several initiatives were halted, including the planned scale up of pilot projects,

such as the TB HIV seroprevalence survey, integrated recording and reporting for TB and HIV, and HDL.

The declining notification and case detection rates are some of the most obvious consequences of the restrictions on Global Fund grants. Monitoring the notification rate over the next year will be important for determining the impact of the cessation on case finding. The treatment success rate remains high, and no additional default from treatment has been reported, indicating that quality of treatment has not been affected. The loss of staff and the lack of capacity to conduct training and supervision may have affected the morale of the NTP staff, and the credibility and reputation of the programme, but this is difficult to measure. Funding gradually resumed from November 2007, but resumption of several programme activities took more than half a year.

The Global Fund suspension has highlighted the risks of donor dependence. Although the NTP appears to have preformed adequately during this significant interruption

in funding, it is difficult to anticipate the consequences of a longer term cessation or termination of the grant. Increasing commodity prices are putting a strain on government financing, and have led to budget cuts across all public sectors, including health. Therefore, it is unlikely that financing of gaps in health budgets will shift from donors to the government in the near future. However, new mechanisms must be explored to ensure sustainability of the TB programme when donor funding is phased out.

The effects on TB activities from the cessation of the Global Fund grant impacted on TB surveillance, monitoring and supervision at DOT centres

...new mechanisms must be explored to ensure TB programme sustainability of when donor funding is phased out.

Global Fund grantTemporary cessation of the 6.

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7.1 Pursue high-quality DOTS expansion and enhancement

Indonesias plan for TB control is described in the Framework for the Indonesian Strategic Plan for Tuberculosis Control: 20062010 (12). This second strategic plan builds on the achievements of the NTP over the five years to 2006, and responds to the new emerging challenges to TB control, in line with the Global Plan to Stop TB 20062015 (25). The goal is to consolidate gains from the first strategic plan, in terms of maintaining high-quality DOTS, but to expand the reach of the programme to increase the case-detection rate and scale up the pilot programmes initiated over the previous five years. Some of these plans have been delayed due to the temporary suspension of the Global Fund grant.

7.1.1 Laboratories

Indonesia has a network of 4855 microscopy centres, 7748 sputum collection points and 41 culture laboratories, of which 11 are conducting drug-susceptibility testing using nonstandardized methods, (according to 2006 data from the public sector, collected by the NTP) (15). Currently there is no designated national reference laboratory, although three laboratories have successfully participated in quality assurance exercises in 2008, and have been certified by the Supranational Laboratory at the Institute of Medical and Veterinary Science, Mycobacterium

Reference Laboratory, in Adelaide, Australia. These three laboratories have been designated to cover three complementary roles of a national reference laboratory: quality assurance, laboratory training and drug resistance surveillance. Seven regional reference laboratories will be designated to establish culture capacity over the next few years. These laboratories are already in existence and have been identified, but will require upgrading, staff training and accreditation.

Important priorities for the NTP are improvement in the overall quality of diagnosis for all TB cases and, in particular, access to quality diagnostic services in remote areas (12). A TB laboratory working group has been developed, and Indonesia is on the UNITAIDa list for diagnostics, which will facilitate the rapid integration of new technologies, such as liquid culture and molecular diagnostics (26).

Accreditation systems for TB laboratories will enable private and hospital laboratories to be linked to the NTP, enabling public use free of charge. Development of an accreditation system is a major undertaking; however, this is a designated priority area for laboratory network strengthening and expansion.

7.1.2 Training and human resources

A strong training infrastructure, based on a sound human resource development plan, has been crucial to the successful scale up of DOTS in Indonesia. External monitoring reviews have noted consistently that training activities have improved human resource capacity in provinces and districts; several reviews praised the competence and motivation of staff at the level of the puskesmas (15). In a growing number of provinces, all health centres and hospitals that have been involved are trained in the DOTS strategy. Work on curriculum strengthening in basic training programmes is ongoing. However, specific areas of human resource development have been highlighted by the Joint

(20062010)The way forward - the 2nd strategic plan - maintaining DOTS while implementing the new Stop TB strategy

7.

a UNITAID is a drug and diagnostic purchase facility (see http://www.unitaid.eu/).

The goal is to consolidate gains from the first strategic plan,increase case-detection rate and scale up the pilot programmes of the

previous five years

16


External TB Monitoring Mission as persistently weak and requiring attention (15). Areas noted as suboptimal include management and supervision skills at the district and provincial level, drug management skills, training for hospital staff and private practitioners, capacity for HIV and MDR-TB interventions, and overall

management of training in remote areas (15). The NTP, with support from partners, is actively working to adapt the training structure and address these weaknesses. The human resource development plan has been updated, based on information provided by provincial training coordinators. Also, the training materials for health facility staff and supervisory staff have been revised to include building competence on international standards for TB care, TB/HIV and MDR-TB. Training materials for drug management are being reviewed in collaboration with the Sub-Directorate of Pharmaceutical Services. Recently, major efforts have been focused on reducing the training backlog among hospital staff.

The capacity of existing TB laboratory staff has been reviewed, and a number of initiatives are supporting improvement of the laboratory human resources. The NTP is updating TB laboratory guidelines on standardized direct microscopic examination, culture and drug susceptibility testing of the TB bacterium, Mycobacterium tuberculosis, and management of the TB laboratory. These guidelines will be disseminated to all public sector laboratories conducting culture and drug susceptibility testing. In addition, laboratory management training has been conducted for all provincial laboratories.

7.1.3 Monitoring and evaluation systems

The NTP collects data through a paper register that consists of 13 forms, but it is in the process of moving to an electronic (Microsoft Excel-based) system that will make the capture of data faster and more reliable, and will facilitate analysis (15). Although data are routinely validated and analysed at the provincial and central levels, data analysis happens infrequently at the district

level, and staff training has been recommended for building capacity in this regard (15). Special attention will be given to the hospitals, to improve adherence to the reporting and recording standards of the NTP, especially the use of the NTP register, reporting of paediatric and extrapulmonary cases, and provision of complete information.

7.1.4 An effective drug supply and management system

Although the Indonesian government is committed to funding TB drugs and ensuring their availability, weaknesses in drug and supply management remain an important issue in the NTP. Drug management systems require a timely and accurate information flow between the NTP central unit, central store, provinces and districts in order to avoid interruption of supply, oversupply and expiry of TB drugs. The NTP is developing a standard operating procedures manual defining the roles and responsibilities in the drug management cycle. The sizes of buffer stocks for each level need to be redefined, and additional technical assistance for drug management training is being provided by Management Sciences for Health (MSH), through USAID and the TB Control Assistance Programme (TBCAP). In the past, drug orders were based on local estimates; however, since 2007, orders have been based on stock levels together with information on expiry dates and consumption data, which should improve the accuracy of the orders. In addition, since 2008, a one-gate policy has been enacted, whereby all TB drugs are managed by the pharmacy department in all provinces and districts; this has made it easier to coordinate distribution channels. Plans are underway for prequalification dossiers to be submitted to the WHO for all locally manufactured TB FDC drugs. Most importantly, political action needs to be taken, to ensure capacity of local manufacturers (15).

despite the Indonesian governments commitment

to funding TB drugs, weaknesses in drug and supply management

remain an important issue

suboptimum areas ofhuman resource development include management and supervision skills

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7.2 Address TB/HIV, MDR-TB and other challenges

7.2.1 TB/HIV

By end of 2006, it was estimated that there were about 193 000 people living with HIV in Indonesia. Injecting drug use was the principal route of transmission, accounting for more than half of the infections (53%), followed by heterosexual transmission (42%) (1). The prevalence of HIV varies among different provinces, with most provinces having a concentrated epidemic and the Papua region having a generalized epidemic. Preliminary results from a population-based HIV

survey among the adult population (1549 years) in Papua province indicated a 2.5% HIV prevalence in the general population (1). From 2004, antiretroviral therapy was provided free of charge and, by the end of 2007, Indonesia had 296 centres providing HIV testing and voluntary counselling, 153 hospitals providing HIV testing and antiretroviral treatment, 19 hospitals providing prevention of mother-to-child transmission (PMTCT) programmes and 20 referral networks for the integrated management of adult illness (IMAI) (15). In 2007, 25% of HIV cases were on antiretroviral therapy.

There is no system of national surveillance of HIV among TB patients. The prevalence of HIV among TB patients was 1.9% (95% confidence interval (CI), 1.62.2%) in a survey of TB patients in Jakarta a province with a low prevalence of HIV (27). However, in some provinces, TB/HIV coinfection is reportedly much higher. Better surveillance data are required to estimate the true magnitude of coinfection. The national estimate of HIV infection among incident TB cases is currently 3.0%.

National TB and HIV programmes in Indonesia have developed experience in implementing collaborative TB/HIV activities. Best practices are being converted into national guidelines (15). However, much remains to be done in terms of refining policies and scaling up services. Mechanisms for improved coordination between the NTP and the HIV/AIDS programme at all levels, especially in high-burden provinces, are being

strengthened. A TB/HIV working group has been created; the group is responsible for national policies and strategies for TB/HIV collaborative activities. HIV focal points are now included in DOTS management teams in provinces with high HIV prevalence, and HIV-related topics are being included in advocacy and in the training curricula for TB supervisors and health staff. Ultimately, these efforts should result in service improvement and scale up in service delivery.

7.2.2 Drug resistance surveillance and treatment

Indonesia completed its first drug resistance survey in Central Java in mid-2008. The survey was financially supported by USAID, with technical support from KNCV, WHO and the Supranational Laboratory at the Institute of Medical and Veterinary Science, Mycobacterium Reference Laboratory, in Adelaide, Australia. Preliminary data indicate a level of 1.7% (95% CI, 0.92.9) MDR-TB among new TB cases, and 14.2% (95% CI, 5.428.5) among retreatment cases. Surveys are planned in seven provinces over the next three years (12). WHO estimates that, nationally, 2.2% of TB cases have MDR-TB, resulting in 12 180 MDR-TB cases emerging every year.

Currently, all diagnosis and treatment of drug resistance takes place in the largely unregulated private sector. Practices for diagnosis and management have not yet been standardized or regulated in Indonesia. Over the last year, the NTP and partners have made important progress in preparing a comprehensive programmatic

response to the challenge of MDR-TB and XDR-TB (15). A national MDR-TB committee has been established, and a plan for the programmatic management of MDR-TB has been developed, with support from KNCV and TBCAP. Initially, urban hospital settings where a strong DOTS network is in place including adequate human resources, laboratory capacity, drug availability and treatment for adverse effects have been selected for the first pilot programmes. Culture and capacity for drug-susceptibility testing has been developed in the selected pilot sites, and an application to the Green Light Committee (GLC) has been approved, with an

better surveillance data are required to estimate the true magnitude

of TB/HIV coinfection

drug resistance surveys are planned in seven provinces over the next next three years.

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MDR-TB management project commencing in 2008 in Jakarta and Surabaya. The NTP, with support from TBCAP, is validating the applicability of a rapid molecular line probe assay for detection of MDR-TB in the Indonesian setting. The aim is to rapidly scale up management of MDR-TB. If the assay proves suitable, it will speed up detection and enrolment of MDR-TB patients into the treatment programme. The implementation of MDR-TB management is supported by USAID through TBCAP, with technical assistance from GLC, KNCV and WHO.

7.3 Contribute to health system strengthening based on primary health care

Because the NTP operates through the national health system, the strength of this system directly affects the performance of the TB programme. The key weakness in the overall health system, as identified by the NTP, is the poor political commitment of local governments.

Poor commitment of local governments has been demonstrated through decreasing local financial contributions to health, and in particular to TB control. This has led to limitations in management capacity at the various levels, and to constraints in human resources. The high turnover of staff (>30%) limits the benefits of training (15). Factors identified as weakening the system include restrictions in hiring (zero-growth policy for recruitment of civil servants) and movement of staff and low salaries, coupled with increasing workload due to expansion of the NTP and implementation of new strategies such as those for TB/HIV and MDR-TB. In addition, there is an unfavourable environment for TB control programme management due to poor implementation of regulations affecting the NTP, such as disease notification and surveillance, regulation of essential drug and pharmaceuticals, minimum service standards, constraints in insurance schemes and inadequate local government financial mechanisms (15).

The NTP is committed to working towards a strong health system, within which disease-specific programmes, such as the NTP, operate. To date, the NTP has contributed to health system strengthening in two specific ways:

it has invested in and strengthened both laboratory and human resources capacity that serve other areas of the health services as well as the NTP; and

it has developed innovative and replicable models for hospital and private sector linkages.

Currently, Indonesias NTP has been working to develop a more comprehensive strategy to address general health system weaknesses that are adversely affecting TB control. The priority areas are: low commitment of local governments in terms of financial contribution for TB control, an unrealized central government budget allocation for drugs (due to budget reallocation in all sectors), and lack of linkages between public health programmes and hospitals.

To address the poor financial contribution of local governments to TB control, the NTP is working to:

revitalize local GERDUNAS committees for better advocacy;

use the central GERDUNAS to advocate for increased allocation of central government funds to local governments for TB control; and

promote a matched local budget where external funds have been made available.

The one-gate policy mentioned above was introduced in 2008 t

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