tuberculosis control
in Indonesia
I
tuberculosis control
in Indonesia
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)
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Design & layout by Blue Infinity, Geneva, Switzerland
III
Abbreviations and glossary . . . .V Executive summary . . . .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 (2002–2006) . . . .6
4.1 Funding . . . .6
4.2 Human resources . . . .8
4.3 Drug supply . . . .8
4.4 Pilot projects . . . .9
5. Monitoring programme performance and TB epidemiology & measurement . . . .11
5.1 Case detection, notification rates and treatment success . . . .11
5.2 Measurement of prevalence and incidence . . . .13
5.3 Measurement of mortality . . . .13
5.4 Other health indicators . . . .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 (2006–2010) . . . .16
7.1 Pursue high-quality DOTS expansion and enhancement . . . .16
7.1.1 Laboratories . . . 16
7.1.2 Training and human resources . . . 16
7.1.3 Monitoring and evaluation systems . . . 17
7.1.4 An effective drug supply and management system . . . 17
7.2 Address TB/HIV, MDR-TB and other challenges . . . .17
7.2.1 TB/HIV . . . 18
7.2.2 Drug resistance surveillance and treatment . . . 18
7.3 Contribute to health system strengthening based on primary health care . . . .19
7.4 Engage all care providers . . . .20
7.5 Empower communities and people with TB through partnership . . . .21
7.5.1 Advocacy, communication and social mobilization . . . 21
7.5.2 Remote areas and vulnerable groups . . . 21
7.6 Enable and promote research . . . .22
8. Funding needs . . . .23
9. Conclusions . . . .24
References . . . .26
Y Anandita
National Tuberculosis Control Programme (NTP) Indonesia (Advocacy, communication and social mobilization [ACSM] Unit and Tuberculosis [TB] Unit)
Carmelia Basri
Expanded Programme for Immunization (EPI) Indonesia
Besral
University of Indonesia (ARI surveys)
FX Budiono
NTP Indonesia (Partnership and planning coordinators)
Franky Loprang
WHO Indonesia (WHO Country Office)
Firdosi Mehta
WHO Indonesia (WHO Country Office)
Tri Yunis Miko
University of Indonesia (annual risk of infection (ARI) surveys)
Nigor Mouzafarova
WHO Regional Office for South-East Asia
Servatius Pareira
WHO Indonesia (WHO Country Office)
Sri Prihatini
WHO Indonesia (WHO Country Office)
Ari Probandari
Gajah Mada University, School of Medicine (hospital evaluation) Indonesia
Erwin Sasangko
WHO Indonesia (WHO Country Office)
Jane Soepardi
NTP Indonesia (Manager, sub-directorate)
Jan Voskens
KNCV Tuberculosis Foundation, Country Office, Indonesia
Nadia Wiweko NTP Indonesia
Yudarini
University of Indonesia (ARI surveys) 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.
V acquired immune deficiency syndrome
ACSM
advocacy, communication and social mobilization ADB
Asian Development Bank ARI
annual risk of infection Askeskin
asuransi kesehatan orang miskin (health insurance for the poor)
ATS
American Thoracic Society AusAID
Australian Agency for International Development CI
confidence interval CIDA
Canadian International Development Agency DFID
Department for International Development (United Kingdom)
DOTS
The basic package that underpins the Stop TB Strategy EPI
Expanded Programme for Immunization (Indonesia) FDC
fixed-dose combination (drugs in the form of a tablet)
Global Drug Facility GDP
gross domestic product GERDUNAS
Gerakan Terpadu Nasional Penanggulangan TB (Indonesian Stop TB Partnership)
GLC
Green Light Committee Global Fund
The Global Fund to Fight AIDS, Tuberculosis and Malaria GNI
gross national income HDL
hospital DOTS linkage HIV
human immunodeficiency virus IMA
Indonesian Medical Association IMAI
integrated management of adult illness INH
isoniazid ISTC
International Standards of TB Care JICA
Japan International Cooperation Agency
KNCV
KNCV Tuberculosis Foundation KuIS
Coalition for Health Indonesia MDG
Millenium Development Goals (United Nations) MDR-TB
multidrug-resistant TB MoH
Ministry of Health (Indonesia) MSH
Management Sciences for Health (Indonesia) NGO
nongovernmental organization NIHRD
National Institute of Health Research and Development (Indonesia)
NTP
national TB control programme PAS
para-aminosalicylic acid PCR
polymerase chain reaction PERSI
Indonesian Hospital Association PIPKRA
Pertemuan Ilmiah Pulmonologi dan Kedokteran Respirasi PMTCT
prevention of mother-to-child transmission
Puskesmas
Pusat Kesehatan Masyarakat (community health centres) SCC
short-course chemotherapy SCVT
Stichting Centrale Vereniging ter Berstrijding van de Tuberculose
STP
Stop TB Partnership (international) TB
tuberculosis TBCAP
TB Control Assistance Programme TBCTA
Tuberculosis Coalition for Technical Assistance THE
total health expenditure TORG
TB Operational Research Group, NTP UNITAID
the international drug purchase facility USAID
United States Agency for International Development WHO
World Health Organization
VII This report summarizes the history of tuberculosis (TB) control in Indonesia, assesses the impact of the country’s 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 Indonesia’s 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 Indonesia’s 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
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.
bThe 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 NTP’s 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 2006–10 (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.
The information in this section is taken from an unpublished history of Indonesia’s 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 1972–1995.
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
1995 Tuberculosis 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 TB
relied 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 were
two 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
In the 1980s, the public sector component of Indonesia’s 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.
Indonesia’s 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 system
The
“MoH investment
in private hospitals, laboratories, medical schools and health insurance
has been successful
in 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 healthexpenditure has risen,
it remains low.”
Although DOTS became the official strategy of Indonesia’s 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 Laying the foundation & training
6 The first part of the Indonesian Health Sector Development
Plan (2002–06) 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 government’s 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 2001–02, 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
(2002–2006)
Scaling up - the first strategic plan - the DOTS era 4.
General governement expenditure on health USD Private expenditure on health USD
Total expenditure on health (THE) as % of GDP 1000
2000 3000 4000 5000 6000 7000 8000 9000
0
0.5 1.0 1.5 2.0 2.5 3.0
1995 1996 1997 1998 1999 2000 20012002 2003 2004 2005 20060.0
Figure 3. Trend in public health expenditures, Indonesia, 1995−2007
Source: World Health Organization National Health Account Series (11)
“ in 2009 , the budget requirements are
projected to
reach USD 80 million…”
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, Indonesia’s 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 Fund
Gap 10
US$ millions
20 30 40 50 60 70 80 90
2009 gap to be covered by Global Fund round 8 grant
0 2002 2003 2004 2005 2006 2007 2008 2009
Figure 4. Indonesian National TB Programme budget, by donor, 2002–2009
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 - MDG’s CIDA + USAID + GF (Q9) KNCV + USAID + GF (Q9)
Figure 5. Geographic distribution of donor funding in Indonesia, 2004–2007
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 2002–2006 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 2000–
2001, 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
CDR Donor funding 5
Budget (US$ in millions) case detection rate (%)
10 15 20 25 30 35
0 0
10 20 30 40 50 60 70 80
1998 1999 2000 2001 2002 2003 2004 2005 2006
Figure 6. Donor funding and TB case detection rate, Indonesia, 1998–2006
“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.
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 30–50% 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 30–50% 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 Indonesia’s 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 ratewas much more rapid once support was forthcoming from external donors...”
& measurement
Monitoring programme performance and
TB epidemiology
5.
a Source: National TB Programme data
RIAUISLANDS NORTHMALUKU DKIJAKARTA RIAU BALI LAMPUNG SOUTHSUMATERA EASTKALIMANTAN DIYOGYAKARTA CENTRALJAVA WESTJAVA EASTJAVA BANTEN CENTRALKALIMANTAN BANGKABELITUNG WESTSUMATRA MALUKU SOUTHSULAWESI PAPUA WESTSULAWESI BENGKULU EASTNUSATENGGARA SOUTHKALIMANTAN JAMBI NAD WESTNUSA WESTKALIMANTAN CENTRALSULAWESI NORTHSUMATERA WESTIRIAN SOUTHEASTSULAWESI GORONTALO NORTHSULAWESI INDONESIA
500 1000 1500 2000 2500
0
2004 2005 2006
Figure 7. TB suspect evaluation rate per 100 000 population by province, Indonesia, 2004–2006 Source: National TB Programme data
2000 8.0
2001 2002 2003 2004 2005 2006 2007 2.0
4.0 6.0 8.0 10.0 12.0 14.0
0.0 0
200000 400000 600000 800000 1000000 1200000 1400000 1600000 1800000 2000000 sm+
suspect
& positive
8.8 10.4
12.1 12.3 12.5
11.3 11.6
Figure 8. Proportion of examined suspects found to be smear positive for TB, Indonesia, 2000–2007
Source: National TB Programme data
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.
12
20.0
Number of TB cases per 100 000 population
40.0 60.0 80.0 100.0 120.0 140.0
0.01995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 new ss+ rate
all forms rate
new sm- new EP
45
Average age of TB patients Indonesia
46 47 48 49 50 51
44 2001 2002 2003 2004 2005 2006
National - male National - female
Figure 9. Notification rates for TB, Indonesia, 1995–2007 Source: National TB Programme data
Figure 11. Average age of TB patients by gender, Indonesia, 2001–2006
Source: National TB Programme data
Notification rate among males all age groups 2001 - 2006
10 100 1000
1
0 - 14 15 - 24 25 - 34 35 - 44 45 - 54 55 - 64 65+
2001 2002 2003 2004 2005
Notification rate among females all age groups 2001 - 2006
10 100 1000
1 2001 2002 2003 2004 2005
Figure 10. TB notification rate by age group per 100 000 population, Indonesia, 2001–2006 Source: National TB Programme data
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 20
40 60 80 100
%
0
Not evaluated Transferred out Defaulted Failed
Died Completed Cured
Figure 12. Treatment outcomes expressed as a percentage, Indonesia, 1997–2006
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 6–9 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.
KTI (East)
Sumatra Java - Bali National
100 200 300 400 500
35%
422 311 203 255 146 67 433 342 246 321 217 12554%
28%
42%
600 Progress towards MDGs: Prevalence rate fell 4% / years 1980-2004
% fall cf 1990
0
1980 survey 1990 2004 survey
Figure 13. Prevalence of smear-positive TB in 1980 and 2004 prevalence surveys, Indonesia
Source: Soemantri et al, 2007 (7).
“In 2007, tuberculin surveys
carried out by the University of Indonesia.
