Indonesia

The Republic of Indonesia, a country of more than 227 million people as of 2005, is still in a phase of socio-economic and political instability, complicated by huge natural disasters. The number of people living under the poverty line was 48 million in 1999 and 38 million in 2002. Most of the poor live in rural areas. The adult literacy rate averages 88 percent.

Despite major progress in DOTS expansion over the past few years, Indonesia still ranks third on the list of high-burden TB countries in the world. TB incidence (all cases) is estimated to be around 540,000 new cases per year, including 240,000 new smear-positive cases. About 100,000 people die of TB every year, and it is the third leading cause of death. The disease burden varies widely within the country: incidence of TB in the remote and poor eastern parts of the archipelago were found to be 3-4 times higher than in Java.

The magnitude of suffering and death caused by the tuberculosis epidemic in the country is still high. The estimated prevalence of TB is around 600,000 smear positive cases and yearly in Indonesia around 100,000 people die of the disease. Indonesia has made rapid progress towards reaching the global targets; case detection rates (CDR) have steadily increased to from 21% in 2002 to 67% in 2005, while the success rate (SR) has remained steadily above the national target of 85%.

TB CAP Highlights Indonesia

Improving Technical Capacity
TB CAP support focuses on the building and strengthening of local technical and management capacity through increased technical assistance. Objective is to improve access to quality TB services provided by government as well as non-government health providers. The assistance is not limited to geographical areas as before, but is in principle nation-wide, though it focuses on priority areas. Since 2006 TB CAP assistance concentrates on five major bottlenecks to DOTS expansion in Indonesia:

1. Weak or wavering local political commitment.
2. Poor access to DOTS for patients due to geographical, socio-economic and cultural barriers.
3. Slow progress in engagement of private practitioners, other public-private providers including NGOs and other institutions and the lack of interventions to prevent further spread of MDR.
4. Absence of effectively coordinated TB-HIV/AIDS activities and ineffective program coordination.
5. Shortage of qualified staff and inadequate management skills at various levels. Limitations in technical and management capacity at provincial and district levels (in particular in the Eastern part of Indonesia) including diagnostic capacity, drug management, planning, and M&E capacity.

TB CAP successfully addresses constraints in technical capacity of the NTP in Indonesia through a wide scope of human resource development activities and inputs: This includes capacity building of local technical staff (assistance in training of 1183 medical doctors and other staff in hospitals- 464 male and 719 female) and positioning of an additional 30 well trained senior and junior technical officers at strategic positions spread over four large provinces in Java, Sumatra, South Sulawesi and Papua. These technical officers are all directly supervised by national and international experts from TB CAP and other international organizations including IMVS and UAB. These experts train and provide continuous coaching of the local technical staff on their particular field of expertise. For example, assistance to strengthen the laboratory network is provided through technical assistance by three local laboratory specialists coached by an international laboratory expert from a Supra National Laboratory. As a result, in 2008 three reference laboratories have achieved EQA status after successfully completing panel testing for culture and DST by a WHO acknowledged Supra National Laboratory (IMVS Adelaide). These laboratories are the Provincial Laboratory in Surabaya, the department of Microbiology of the University of Indonesia and the NEHCRI Laboratory in Makassar. This achievement is conditional for implementation of DOTS Plus in Indonesia.

With support from TB CAP the Indonesian program has achieved to establish internal networks in 75 large Indonesian hospitals, and external referral networks with health centers in 10 clusters of districts (DKI Jakarta, West-, Central and East Java, South Sulawesi). Consequently the notification of patients diagnosed in hospitals according to DOTS guidelines has doubled over the year. Establishment of hospital DOTS networks are conditional for improved TB/HIV collaboration. However, expansion of DOTS to hospitals requires strong support from health professionals, in particular from specialists. Much progress has been made with mobilization of professional societies through the establishment of local Task Forces for implementation of ISTC: The Central Task Force within the Indonesian Medical Association (IDI) is now very pro-active and has successfully established local ISTC task forces in 13 of the largest provinces in the country. The situation analysis on the current status of ISTC implementation has been done in all these provinces using ISTC assessment tool. 108 Facilitators have been trained in 3 batches (for 12 provinces). The training curriculum combines ISTC with Hospital DOTS linkage. The taskforces are very instrumental for acceptance of ISTC (and DOTS) among specialists and other providers. This will expectedly facilitate expansion of DOTS in hospitals all over the country.

The major challenge for the program is containment of multi drug resistance (MDR) in Indonesia in the wake of an HIV epidemic. Though the MDR rate is still relatively low (recent DRS data in Central Java indicate a level of 1,4% for new cases), the total number of MDR cases is considerable due to the large numbers of TB patients: It is estimated that yearly there are at least between 5,000 – 10,000 new smear positive MDR patients. MDR is generated mainly because there are large numbers of TB patients being inadequately treated in hospitals and by the large private sector that are currently not captured by the NTP surveillance system. Consequently this number is unknown: The high defaulter rate and the wide-spread misuse of available second-line drugs in hospitals are contributing to the increase of MDR/XDR. Uncontrolled spread of MDR/XDR is potentially fuelled by the increasing HIV co-epidemic; there is also a large prison population at high-risk for MDR-TB and other co-morbidities such as TB-HIV. Incidental hospital based drug-resistance data indicate a high proportion of drug resistance among TB patients. Indonesia has been confirmed the first case of XDR-TB. The existing reservoir of MDR cases, already resistant to the Quinolones (Ofloxacin), forms a major risk factor for further spread of XDR. The health system still has poor capacity to address MDR-TB, i.e., laboratory facilities, availability of drugs for MDR-TB, and facilities to deliver DOTS-Plus. On the other hand, weak regulations (and a prolific drug marketing industry) have caused second-line drugs to be freely available on the market, and currently many specialists use these second line drugs in first-line regimens.

Management of MDR TB is a major priority in the draft strategic document of USAID and one of the main components of the TB CAP work plan APA4. Addressing this challenge will be achieved through the launching of the first DOTS plus project in Indonesia, involving a comprehensive spectrum of interventions and inputs: development of culture and DST capacity including introduction and validation of innovative diagnostics for MDR (HAIN test), capacity building of health staff in DOTS plus, establishing decentralized treatment services and strong surveillance. For APA4 the target has been set on 75 MDR patients.

Though there are still major challenges, good progress has been made in implementation of DOTS in prisons: Strong collaboration between the Prison Department within the Ministry of Justice and Human Rights and NTP has been established with support from TB CAP: a national strategic plan and policy document for DOTS implementation in prisons has been endorsed by both Ministries. National Guidelines for DOTS in prisons have been developed and will be the basis for development of training modules. DOTS surveillance is now established in 10 large prisons. A plan for implementation has been developed, with full support of the Prison department.

Of highest priority is the expansion of DOTS to all hospitals in Indonesia (totaling more than 1200 facilities) and assuring quality of DOTS implementation in all these hospitals. The same applies to prisons (more then 440 prisons in Indonesia) and the large contingent of private providers. Another challenge is to increase the capacity and commitment from other Directorates to implement the TB CAP supported strategies like Hospital DOTS, ISTC and DOTS in prisons. Support from, and coordination with the other directorates like BPPM (Directorate of Medical Services), the Directorate of Pharmaceutical services is still weak, resulting in slower then expected progress in technical areas.

TB CAP Project Period (2005-2010)

Expected output(s)

1. Increased political commitment
2. Strengthened & expanded DOTS
3. Increased Public-Private & Public-Public Mix
4. Expanded TB-HIV activities
5. Improved Human & Institutional Capacity

KNCV Tuberculosis Foundation as a member of the Tuberculosis Coalition for Technical Assistance (TBCTA), with support from USAID, will continue to assist the NTP Indonesia in its efforts to accelerate DOTS expansion, based on the objectives and strategies of the Five Year Strategic Plan 2006-2010.