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A brief history of

tuberculosis control
in Indonesia

A brief history of
tuberculosis 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


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Design & layout by Blue Infinity, Geneva, Switzerland

Table of contents
Acknowledgements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IV
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 (20022006). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.1 Funding. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.2 Human resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.3 Drug supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.4 Pilot projects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6
6
8
8
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 (20062010) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
7.1

Pursue high-quality DOTS expansion and enhancement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

7.1.1
7.1.2
7.1.3
7.1.4

Laboratories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Training and human resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Monitoring and evaluation systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
An effective drug supply and management system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

16
16
17
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
III

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

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)

FX Budiono
NTP Indonesia (Partnership and planning coordinators)

Jan Voskens
KNCV Tuberculosis Foundation, Country Office,
Indonesia

Franky Loprang
WHO Indonesia (WHO Country Office)

Nadia Wiweko
NTP Indonesia

Firdosi Mehta
WHO Indonesia (WHO Country Office)

Yudarini
University of Indonesia (ARI surveys)

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)

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.

IV

Abbreviations and glossary


AIDS
acquired immune deficiency syndrome

GDF
Global Drug Facility

ACSM
advocacy, communication and social mobilization

GDP
gross domestic product

ADB
Asian Development Bank

GERDUNAS
Gerakan Terpadu Nasional Penanggulangan TB
(Indonesian Stop TB Partnership)

ARI
annual risk of infection

GLC
Green Light Committee

Askeskin
asuransi kesehatan orang miskin (health insurance for
the poor)

Global Fund
The Global Fund to Fight AIDS, Tuberculosis and Malaria

ATS
American Thoracic Society

GNI
gross national income

AusAID
Australian Agency for International Development

HDL
hospital DOTS linkage

CI
confidence interval

HIV
human immunodeficiency virus

CIDA
Canadian International Development Agency

IMA
Indonesian Medical Association

DFID
Department
Kingdom)

for

International

Development

(United

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)

IMAI
integrated management of adult illness
INH
isoniazid
ISTC
International Standards of TB Care
JICA
Japan International Cooperation Agency

A brief history of tuberculosis control in Indonesia

KNCV
KNCV Tuberculosis Foundation

Puskesmas
Pusat Kesehatan Masyarakat (community health centres)

KuIS
Coalition for Health Indonesia

SCC
short-course chemotherapy

MDG
Millenium Development Goals (United Nations)

SCVT
Stichting Centrale Vereniging ter Berstrijding van de
Tuberculose

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

VI

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

A brief history of tuberculosis control in Indonesia

Executive summary
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

VII

A brief history of tuberculosis control in Indonesia

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.

TB cases successfully treated


160000

143937

140000
115478

120000
100000
80243

80000

65724

60000
40000
20000

2738

9592

11635

1996

1997

23144

23139

1998

1999

45730

46260

2000

2001

0
1995

2002

2003

2004

2005

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.

VIII

A brief history of tuberculosis control in Indonesia

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.

IX

A brief history of tuberculosis control in Indonesia

1. Tuberculosis control before

1995

The information in this section is taken from an


unpublished history of Indonesias National Tuberculosis
(TB) Programme (NTP) (5).

After Indonesian
independence in 1949,
diagnosis and treatment of TB

relied primarily on radiography


and hospitalization

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 mid1980s (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, fullysupervised regimen (HR/5H2R2). The study showed cure
rates of more than 90% and, in 1977, a short-course

The years 1969 and 1970 marked


the start of modern
TB control;

guidelines were revised and


the NTP was established

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

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

A brief history of tuberculosis control in Indonesia

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.

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

From 1977 to 1995 there were

two national
TB regimens,
the conventional course
and the SCC

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)

with the former being


gradually phased out

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.

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

120000
347,576 deaths averted
100000
80000
60000
40000
20000

0
2000

2001

2002

2003

2004

2005

2006

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

A brief history of tuberculosis control in Indonesia

2. The

health system
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,

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.

has been successful


in some respects, but has also led to
undesirable effects.

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).

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

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

MoH investment

in private hospitals, laboratories,


medical schools and health insurance

A brief history of tuberculosis control in Indonesia

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.

Indonesia is
in transition in terms of
epidemiological and demographic
factors; although health
expenditure has risen, it

remains low.

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).

A brief history of tuberculosis control in Indonesia

3. Laying the foundation

partnership & training


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 efficiency and cost-effectiveness of programme


management. KNCV and WHO provided technical
assistance (15).

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.

The objective of DOTS


expansion was to

The objective of GERDUNAS



was to create a

stronger platform
for TB control and declare

total war against TB


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

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

improve quality

of services delivered
by increasing skills and improving

efficiency and cost-effectiveness...


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.

A brief history of tuberculosis control in Indonesia

4. Scaling up - the first strategic plan - the DOTS era

(20022006)
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.

in 2009, the budget


requirements are

projected to
reach USD 80 million

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

9000

3.0

8000

2.5

7000
6000

2.0

5000

1.5

4000
3000

1.0

2000

0.5

1000
0

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

0.0

Private expenditure on health USD


General governement expenditure on health USD
Total expenditure on health (THE) as % of GDP

Figure 3. Trend in public health expenditures, Indonesia,


19952007
Source: World Health Organization National Health Account
Series (11)

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

A brief history of tuberculosis control in Indonesia

90

January - March 2004


(GF 16 Provs)

2009 gap to be covered by Global Fund round 8 grant

80
70
US$ millions

60
50
40
30
20
April - June 2004
(GF 19 Provs)

10
0

2002

2003

Government
Loans

2004

2005

2006

Grant
Global Fund

2007

2008

2009

Gap

Figure 4. Indonesian National TB Programme budget, by


donor, 20022009
Source: World Health Organization (2)
April - July 2005
(GF 21 Provs)

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

November 2006 March 2007


(GF 33 Provs)

Global Fund (GF)


TBCTA/ USAID

DUTCH GOVT.
DFID - MDGs

KNCV + USAID + GF (Q9)


CIDA + USAID + GF (Q9)

Figure 5. Geographic distribution of donor funding in


Indonesia, 20042007
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

A brief history of tuberculosis control in Indonesia

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
35
80
70

25

60

20

50
40

15

30
10

20

5
0

case detection rate (%)

Budget (US$ in millions)

30

10
1998

1999

2000

2001

2002

2003

2004

2005

2006

Donor funding
CDR

Figure 6. Donor funding and TB case detection rate,


Indonesia, 19982006

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

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

DOTS over the six years to 2009...


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

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.

A brief history of tuberculosis control in Indonesia

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
9

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

A brief history of tuberculosis control in Indonesia

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

A brief history of tuberculosis control in Indonesia

5. Monitoring programme performance and

TB epidemiology
& measurement
5.1 Case detection, notification rates and
treatment success

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 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

14.0

the increase in
suspect evaluation rates,

sm+
suspect
& positive

12.0

was much more rapid once support

2000000
1800000
1600000

8.8

1400000

8.0

8.0

was forthcoming from external donors...

11.6

11.3

10.4

10.0

notification rates and the case detection rate

12.5

12.3

12.1

1200000
1000000

6.0

800000

4.0

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

600000
400000

2.0

200000

0.0

2000

2001

2002

2003

2004

2005

2006

2007

Figure 8. Proportion of examined suspects found to be


smear positive for TB, Indonesia, 20002007
Source: National TB Programme data

2500
2005

2004

2006

2000
1500
1000
500
INDONESIA

NORTH SULAWESI

GORONTALO

11

SOUTH EAST SULAWESI

a Source: National TB Programme data

WEST IRIAN

Source: National TB Programme data

NORTH SUMATERA

Figure 7. TB suspect evaluation rate per 100 000 population by province, Indonesia, 20042006

CENTRAL SULAWESI

WEST KALIMANTAN

WEST NUSA

NAD

JAMBI

SOUTH KALIMANTAN

EAST NUSA TENGGARA

BENGKULU

WEST SULAWESI

PAPUA

SOUTH SULAWESI

MALUKU

WEST SUMATRA

BANGKA BELITUNG

CENTRAL KALIMANTAN

BANTEN

EAST JAVA

WEST JAVA

CENTRAL JAVA

DI YOGYAKARTA

EAST KALIMANTAN

SOUTH SUMATERA

LAMPUNG

BALI

RIAU

DKI JAKARTA

NORTH MALUKU

RIAU ISLANDS

A brief history of tuberculosis control in Indonesia

Number of TB cases per 100 000 population

140.0

new ss+ rate


all forms rate

120.0

51

new smnew EP

100.0

49

80.0

48

60.0

47

40.0

46

20.0

45

0.0

Average age of TB patients Indonesia


National - male

50

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Figure 9. Notification rates for TB, Indonesia, 19952007


Source: National TB Programme data

National - female

44

2001

2002

2003

2004

2005

2006

Figure 11. Average age of TB patients by gender,


Indonesia, 20012006
Source: National TB Programme data

Notification rate among males all age groups 2001 - 2006

1000

100

100

10

10

2001
0 - 14

2002

2003

15 - 24

2004
25 - 34

2005
35 - 44

Notification rate among females all age groups 2001 - 2006

1000

2001

45 - 54

2002

2003

55 - 64

2004

2005

65+

Figure 10. TB notification rate by age group per 100 000 population, Indonesia, 20012006
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 followup. 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.

%
100
80
60
40
20
0

1997

1998

1999

Not evaluated
Died

2000

2001

2002

Transferred out
Completed

2003

2004

Defaulted
Cured

2005

2006
Failed

Figure 12. Treatment outcomes expressed as a


percentage, Indonesia, 19972006

12

A brief history of tuberculosis control in Indonesia

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 smearpositive 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,
600

Progress towards MDGs: Prevalence rate fell 4% / years 1980-2004

500
% fall cf 1990

400
300

28%
35%

200

Sumatra
1980 survey

Java - Bali
1990

KTI (East)

125

217

321

246

342

67

146

255

203

311

422

54%

433

42%
100

National

2004 survey

Figure 13. Prevalence of smear-positive TB in 1980 and


2004 prevalence surveys, Indonesia
Source: Soemantri et al, 2007 (7).

13

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

In 2007, tuberculin surveys


carried out by the University of Indonesia.

complemented previous
surveys of 1985

and the nationwide survey of 2004

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.

A brief history of tuberculosis control in Indonesia

Two projects have been launched to strengthen the allcause-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, cause-of-death
reporting mechanisms
were put in place at sentinel sites,

to help assess progress


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

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.
1600

GNI per capita in Indonesia 19802006

1400
1200
1000
800

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

600
400
200
0

Asian market crash


1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006

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
100000 population, which is less than half of the
mortality rate estimated for 1990.

Figure 14. Gross national income (GNI) per capita in


Indonesia, 19802006
Source: The World Bank Key Development Data & Statistics (10).
35

Birth and Death rate in Indonesia 19802006

30

Birth rate, crude


(per 1000 people)

25
20
15

Death rate, crude


(per 1000 people)

10
5
0
1979

1984

1989

1994

1999

2004

Figure 15. Birth and death rate per 1000 in Indonesia,


19792004
Source: The World Bank Key Development Data & Statistics (10).

14

A brief history of tuberculosis control in Indonesia

6. Temporary cessation of the

Global Fund grant


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

The effects on TB
activities from the cessation of the

Global Fund grant impacted on TB surveillance,

monitoring and supervision at


DOT centres

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 smearpositive cases detected was greatly reduced, being
15000 less than the previous year. This was partly
balanced by an increase in smear-negative notification
rates, which increased by 10000, 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,

15

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

...new mechanisms must be explored


to ensure TB programme sustainability

of when donor funding


is phased out.

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.

A brief history of tuberculosis control in Indonesia

7. The way forward -the 2nd strategic plan -maintaining


DOTS while implementing the new Stop TB strategy

(20062010)

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.

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

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


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 drugsusceptibility 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

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

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

16

A brief history of tuberculosis control in Indonesia

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

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.

suboptimum areas of
human resource development

7.1.4 An effective drug supply and management


system

include management and


supervision skills

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 MDRTB. 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

17

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

A brief history of tuberculosis control in Indonesia

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

better surveillance
data are required
to estimate the
true magnitude
of TB/HIV coinfection
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 HIVrelated 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 MDRTB, 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

drug resistance
surveys are planned in
seven provinces

over the next next three years.

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

18

A brief history of tuberculosis control in Indonesia

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 MDRTB. 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
Practices for diagnosis and management of

drug resistance
have not yet been
standardized

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.

or regulated in Indonesia.

Poor commitment of
local governments
has been demonstrated through

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).

19

decreasing financial
contributions
to health and TB control

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 to address the unrealized central
budget allocation for drugs. The NTP and the central
GERDUNAS committee are advocating for allocation
of additional budget for drugs, and an emergency GDF
grant application has been initiated to fill the gap. In
addition, the NTP has been actively assisting local
manufacturers to become prequalified and included

A brief history of tuberculosis control in Indonesia

in the WHO approved list (whitelist), so that they can


expand production. To address the critical area of
DOTS expansion within the hospital sector, the NTP
is continuing to roll out the International Standards
of TB Care (ISTC) (28). TB officers have been placed
in designated clusters of hospitals to support and
expand hospital DOTS linkages, and the NTP is
committed to continued and improved collaboration
with other departments, such as the Directorate
of Medical Services and provincial and district
authorities.

7.4 Engage all care providers


Given that an estimated 3050% of TB patients
are managed outside of the NTP, engaging all care
providers is one of the highest priorities of the NTP
over the next five years (19). Pilot projects for hospitals
and private practitioners have largely been successful,

Indonesias NTP has


been working to develop a
comprehensive strategy
to address health system weaknesses
adversely affecting TB control.
and DOTS coverage of hospitals is estimated at
approximately 37%. The key issue in scaling up the
HDL, and in engaging the private sector, is the poor
quality of DOTS services provided in these institutions,
which results in high default and low treatment success
rates. Performance will need to improve in this sector
to improve success rates and limit the emergence of
drug-resistant TB.
Scaling up DOTS to a diverse private sector requires
acceptance and adoption of the International Standards
of TB Care (ISTC). These standards are a powerful tool
to build awareness and enable DOTS implementation
by private practices, workplaces, prisons and police
and army health services (28).
The Indonesian NTP, through strategic partnerships,
gained acceptance from key opinion leaders early on in
the process of rolling out the ISTC. Introduction of the
ISTC started in 2004, through technical support from
the American Thoracic Society (ATS) and KNCV. With
support from USAID and TBCTA, KNCV undertook a
wide variety of activities to disseminate and implement

the ISTC. KNCV participated in several national


congresses for professional organizations, including the
first National TB Congress in Jakarta (November 2004),
the National Congress for Lung Specialists (PIPKRA
Congress) and several other seminars. In these fora,
TBCTA experts presented the ISTC for discussion to
a large audience of lung specialists and other medical
specialists. The standards were generally welcomed
and accepted. The NTP, professional organizations
and technical partners, in collaboration with KNCV,
developed a work plan to gain endorsement of the
ISTC by the professional societies and other relevant
organizations. During the ceremony on World TB Day
in 2005, the strong commitment of the Indonesian
Medical Association (IMA) and six other medical
professional organizations to approving the ISTC as a
national standard of TB care was clear. Six professional
organizations officially signed endorsements of the
ISTC in the presence of Indonesias Minister of Health
and Minister of Social Welfare.
A central task force within the IMA has established
local task forces to implement the ISTC in 13 provinces.
The local task forces comprise IMA members, and
their primary purpose is to encourage all medical
professionals to disseminate and implement the ISTC.
The current status of the ISTC implementation has been
analysed in all 13 provinces using an ISTC assessment
tool. More than 100 ISTC facilitators have been trained.
The training curriculum combines ISTC with HDL.
The task forces have been instrumental in gaining
acceptance of the ISTC (and DOTS) among specialists
and other providers. It is expected that these task forces
will facilitate expansion of hospital DOTS linkages in the

engaging all care


providers is one of
the highest priorities

of the NTP over the next five years.


country. It seems that the standards are more readily
accepted than NTP guidelines, because of their clinical
orientation and strong evidence base.
In concert with these ISTC activities, the NTP and the
private sector are jointly working to implement, monitor
and evaluate the impact of DOTS, to help facilitate a
seamless process of patient diagnosis, treatment,
surveillance and follow-up.

20

A brief history of tuberculosis control in Indonesia

In larger provinces, provincial and district DOTS teams


are being established to facilitate the building of networks
with the private sector and hospitals. These activities are
being conducted in several phases. In larger hospitals,
internal networks are established to ensure that all
TB patients who access hospitals through the various
entry points are diagnosed, notified and treated
according to DOTS guidelines and the ISTC. To date,
37% of approximately 1300 hospitals in Indonesia have
established an internal network with a hospital DOTS
unit. External linkages are established to ensure proper
referral of TB patients to other facilities, to prevent
disruption of treatment after diagnosis or during the
course of treatment. Hospital DOTS coordinators are
appointed to facilitate contact and default tracing,
patient referral, surveillance and supervision activities.
The public health system takes responsibility for
ensuring adherence to guidelines and implementation of
supervision, laboratory quality control and an effective
referral system.

7.5 Empower communities and people with


TB through partnership
7.5.1 Advocacy, communication and social
mobilization
The goal of patient education and social mobilization is
to increase community participation and create demand
for high-quality diagnosis and treatment services
for TB. A knowledge, attitude and practice survey in
2004 found that 76% of Indonesians knew about TB
and 85% knew that it is curable, but only 16% knew
three or more correct symptoms. Moreover, there were
significant misconceptions about how one is infected
with Mycobacterium tuberculosis, and only 19% of
Indonesians knew that TB drugs are free (15). A similar
survey is planned in 2009.
The NTP has developed advocacy, communication
and social mobilization (ACSM) guidelines and an
operational plan to develop the capacity to implement
activities and training modules at provincial and district
levels. The ACSM framework is in line with Indonesias
National Strategic Plan 20062010 (12). There are
also plans to scale up mass media campaigns, and
develop new health education materials, including
materials for patients and health-care providers.
The NTP has developed a national TB campaign to
raise general awareness about TB, and address stigma
and discrimination. Although communities are being
involved in many different parts of the country, the

21

need for a focused approach that involves patients


and communities in TB control at all levels was
highlighted in a recent monitoring review. Many of
the community-based initiatives are being taken up
by grassroots nongovernmental organizations (NGOs)
such as the Coalition for Health Indonesia (KuIS); these
organizations have been active in the development of
community health volunteers and in raising awareness

A survey in 2004 found that 76% of


Indonesians knew about TB,

85% knew that it is curable, but


only 16% knew three or
more correct symptoms.
7.5.2 Remote areas and vulnerable groups
Indonesia is the worlds largest archipelagic nation
state, with an uneven population distribution and several
remote areas, often with low population densities.
Papua and Maluku are the most remote provinces,
with only five persons per square kilometre in Papua.
An estimated 17.7% of the Indonesian population
lives below the poverty line (1), which translates to a
population of 36 million poor (13). Those living below
the poverty line are proportionally the largest vulnerable
population group; other vulnerable groups include
prisoners, migrant workers and injecting drug users,
who are at increased risk of contracting HIV. These
groups have less access than the general population to
high-quality TB care.
There is an encouraging environment for the
development of outreach programmes for remote areas
and vulnerable groups. The Government of Indonesia
is committed to reducing poverty and, within the health
sector, strategies have been developed to improve
services for those people who are underserved;
however, some policies have been implemented more
successfully than others. In 2005, a basic health
insurance scheme Askeskin, initially offered to the
estimated 36 million poor and then expanded to
76.4 million was established to ensure free health
services at the puskesmas and free treatment in
hospitals to all poor (13).
Incentive schemes have been introduced to encourage
doctors and nurses to work in rural and remote areas.
For example, public sector salaries for health workers

A brief history of tuberculosis control in Indonesia

in remote areas are considerably higher than in urban


areas. However, the increased salary may not be
sufficient to offset the potential benefits and higher
revenues obtainable in the private sectors in urban
areas. Incentive schemes may have helped to increase
the numbers of health workers in rural areas, but the
ratio is still very low. There are 13 medical practitioners
per 100 000 population in Indonesia, one of the lowest
ratios in Asia. In Lampung province (Sumatra), the
ratio is as low as six doctors per 100000 (13). National
partners are helping local health services to address
the shortages in human resources by posting technical
officers in the remote districts of Papua.
The urban poor have been highlighted as a group
requiring priority, and better coordination with NGOs
has been suggested as one of the most effective
avenues for addressing this area. Some provinces
have started to implement DOTS in prisons. The NTP
is targeting 20 prisons within 9 provinces to implement
DOTS, in addition to the 11 pilot prisons trained by the
programme in 2004. In 2008, the NTP, with support from

support from the Research Unit of KNCV, supported by


USAID. TORG serves as a national advisory platform
for operational research, promotes exchange of
information and coordination at the national level, and
advises the Ministry of Health on technical soundness
and relevance of submitted proposals (15). The group
helps the NTP to build capacity for operational research
by linking local universities to NTP staff from provincial
and district health services, and implementing action
research at the local level to solve operational problems.
To date, eight operational research studies have been
successfully completed, resulting in two international
publications. The NTP has proposed that a research
agenda be formulated to promote and coordinate
collaboration between research institutions, and
facilitate publication and dissemination of study results.

The Government of Indonesia is committed

to reducing poverty and

strategies have been


developed to improve
health services for people
who are under-served.

the KNCV and the TBCAP, has developed guidance and


training materials to specifically address TB in prisons
(15).
Recently, the International Patient Charter has been
incorporated into the NTP. The charter was endorsed
by Indonesias National Expert Committee for TB. A
national NGO representing TB patients (PaMaLi) has
been established to support further dissemination,
piloting and roll out of the charter to DOTS facilities and
districts in the country.

7.6 Enable and promote research


Indonesia has a strong foundation in research, with
a record of conducting operational research before
implementing a new strategy, such as short-course
chemotherapy, DOTS including MDR-TB and TB/HIV
management and HDL. In 2003, the NTP established the
TB Operational Research Group (TORG) with technical

22

A brief history of tuberculosis control in Indonesia

8.

Funding needs
The total budget required to support the planned
expansion of the TB control programme from 2006
to 2010 is USD 287 247 285, divided almost equally
throughout the five-year period. Currently, the difference
between the total estimated budget requirement and the
budget available (i.e. the funding gap) is USD 69 373 604,
or 24% of the total budget (12).

Although the programme has achieved


important targets and is the

subject of ambitious

plans for expansion, the current

financing system
is not optimal.

Government expenditure on TB control as well


as donor contributions from CIDA, DFID, the Dutch
Government, the Global Fund, USAID and others has
increased since 2000 (2), contributing to the success of
the NTP and enabling Indonesia to achieve the global
targets for case detection (70%) and treatment success
(85%) in 2006. Although the programme has achieved
these important targets, and is the subject of ambitious
plans for expansion, the current financing system is
not optimal. A TB district financing survey has shown
that local contributions to TB funding are very low and
gradually decreasing, with local funding largely replaced
by external resources. Currently, the Global Fund is
providing more than 80% of district budgets for TB
control (16), suggesting that the NTP is too dependent
on donor funding, and vulnerable to donor withdrawal.
In addition, central budget cuts in 2007 and 2008 are
likely to lead to a substantial decrease in government
expenditure on TB.
The temporary restriction of the Global Fund grants in
2007 exposed the NTPs dependence on donor funding.
However, it also presented an opportunity to initiate serious
discussions about, and planning for, more sustainable

23

funding arrangements within the country at national and


local level. One of the priorities of sustainable financing
will be to require local governments to contribute and
support TB control, with a strong emphasis on core
operational activities such as diagnosis, treatment and
surveillance, to build a more sustainable mechanism
in the future. It has been suggested that districts and
provinces develop their own strategic plan that fits
within the national strategic plan, in order to increase
commitment and ownership (15). The NTP is considering
taking into account fiscal capacity at the provincial and
district levels when determining where external financial
assistance would be most appropriately provided. Areas
with low fiscal capacity would be prioritized, and donor
contributions to wealthier provinces would be gradually
reduced. The long-term vision is to phase out external
funding (15).

One of the priorities


of sustainable financing will be

to require local governments

to contribute and support TB control.

A brief history of tuberculosis control in Indonesia

Conclusions

450
400
2015
target

350

2015
target

300
250
200
150
100
50
0

Prevalence
1990

2007

46

Epidemiological studies indicate that the prevalence of


TB is decreasing at about 4% per year, suggesting that
incidence is falling at about 2.4% per year. Although the
NTP has made enormous progress over the last decade,
some of this decline was probably already underway
when the programme gained momentum. Thus, other
factors are likely to have contributed to the reduction
in TB incidence in Indonesia; for example, the rapid
improvement in the economy and other associated social
and economic factors.

500

39

Fund, has been critical to the scale-up of TB control,


and has supported the rapid increase in the number of
TB cases evaluated, diagnosed and treated. TB case
notifications increased from 44.5 per 100 000 in 2001 to
119 in 2007, and case detection grew from less than 30%
to 76% in four years. The proportion of cases successfully
treated has consistently been above 85% since the year
2000, reaching 90% in 2004. By 2006, Indonesia was
the first country in the WHO South-East Asia Region to
reach the targets for both case detection and cure. These
figures reflect the fact that the programme has expanded
rapidly, while maintaining and improving the quality of
services.

92

since 2000, reaching 90% in 2004.

2 22

TB cases
successfully treated
has consistently been above 85%

Indonesia has already reached the Stop TB Partnership


targets, as well as those for case detection, treatment
success, incidence and mortality; in addition, the target
to halve prevalence by 2015 is on track (Figures 16
and 17). Indonesias NTP is poised for, and capable
of, further expanding high-quality DOTS, particularly
engaging all providers in a comprehensive way, and
rolling out new strategies in line with the Global Plan to
Stop TB 20062015. However, there are some important
challenges that must be addressed if further success is
to be achieved.

2 44

The proportion of

A temporary restriction of the Global Fund grant in


2007 led to the loss of many contracted staff at central
and provincial levels, and a slow down of normative
functions of the NTP. As a result, there was a decline
in TB notification and case detection rates, although
treatment outcomes remained stable. Most importantly,
the restriction highlighted inadequacies in financial
management, the danger of donor dependence and,
ultimately, the need for sustainable funding.

4 43

The structure of Indonesias health system, based on the


puskesmas (community health centres), has facilitated
DOTS delivery of TB treatment at the community level.
The countrys comprehensive training management
structure and human resource development plan proved
to be a critical foundation. This firm foundation made it
possible to rapidly expand DOTS when financing from
external funding sources increased substantially in 2003.
Donor financing, particularly that provided by the Global

TB prevalence and mortality per 100000 population

9.

Mortality
2015 target

Figure 16. Progress towards the Millennium Development


Goals in Indonesia

24

A brief history of tuberculosis control in Indonesia

The NTPs heavy dependence on donor funds must be


addressed by increasing financial contribution at the
district level. The existing drug and supply management
system is still not functioning optimally, and this situation
poses a threat of future drug shortages if it is not
addressed at a high level. Human resource capacity,
although established on a solid foundation, needs
strengthening in some technical areas related to the
implementation of new initiatives such as management
of MDR-TB, laboratory quality assurance and roll out
of TB/HIV collaboration. Further expansion of private
sector and hospital engagement, and improvement in the
quality of care provided, are required for improved case
detection and management.

Indonesia has already reached Stop TB


Partnership targets but there are

important challenges

that must be addressed


if further success is to be achieved
The NTP has been proactive in developing a strategy
to address many of these issues that impede TB
control. Continued financial and technical support will
be required to achieve these ends, as will maintaining
a strong partnership. Sustainable funding, particularly
at the district level, may be the most critical factor in
determining further expansion and long-term success
of the NTP, but if the programme and the national
government remain coordinated and committed, there is
a strong possibility that the programme will succeed.

TB incidence

350
300
250
200
150
100

2006

2004

2002

2000

1998

1996

1994

1992

50

1990

Incident TB cases per 100000 population

400

Figure 17. TB Incidence rate, Indonesia, 19902007

25

A brief history of tuberculosis control in Indonesia

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26

WORLD HEALTH ORGANIZATION


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1211 GENEVA 27, SWITZERLAND
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