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Present, future and strategic management of TB program
in Indonesia
Dr. Asik Surya, MPPM
• Pendidikan
– Dokter FK Unair Surabaya, 1990
– Master Public Policy and Management, University of Southern California, LA, USA, 1999
• Pekerjaan : Program Tuberkulosis Nasional , Ditjen P2P, Kemenkes
• Alamat Kantor : Subdit Tuberkulosis, Gdg B, Lt.4, Ditjen P2PL, Jalan Percetakan Negara 29 Jakarta
• Alamat Rumah : Jalan Mataram No.6 Taman Yunani, Sentul City, Bogor.
• HP : 08170931310,
• Email : [email protected], [email protected]
Content
• Background
• Present TB Situation in Indonesia
• Milestones toward TB Elimination in Indonesia
• Policy and Strategy to acheive the goal.
• Conclusion
Background
• TB burden is high in Indonesia (high incidens /
cases, low coverage, resistance, comorbidity and
leadership management)
• Global and national commitment:
• MDGs (goal 6 target 6 C) and SDGs
• RPJMN (Midterm National Development Plan)
• Priority program as Pro PN.
• Strategic Plan Ministry of Health
• Family Health approach
• Minimum Standard of Services (SPM)
• Commintment of Goverment.
Global TB BurdensCountries in the three TB high-burden country lists WHO, 2017
258 M Insiden mortality
TB 1.020.00395/100.000
100.000
TB/HIV 78.00010/100.000
26.000
MDR-TB 10.000
7.3 B incidens mortality
TB 10.400.000142/100.000
1.400.000
TB/HIV 1.170.00011/100.000
390.000
MDR-TB
Unnotified TB cases among 10 countries of estimated TB incidence, 2015
6. Bangladesh
7. Kongo
8. China
9. Tanzania
10. Mozambique
1. India
2. Indonesia
3. Nigeria
4. Pakistan
5. Afrika Selatan
Prevalence Estimates (per 100,000 people aged 15 years old and above)
Indonesia National TB Prevalence Survey 2013-2014
Characteristics/domains Positive smear TB Bacteriologically confirmed TB
National 257 (210 - 303) 759 (590 - 961)
Sex
Male 393 (315 - 471) 1,083 (873 - 1,337)
Female 131 (88 - 174) 461 (354 - 591)
Region
Sumatera 307 (208 - 407) 913 (697 - 1,177)
Java-Bali 217 (147 - 287) 593 (447 - 771)
Others 260 (184 - 336) 842 (635 - 1,092)
Urban/rural
Urban 282 (220 - 345) 846 (678- 1,048)
Rural 231 (163 - 300) 674 (512 - 874)
TB Burden in Indonesia, 1990-2014: Before and after TB National Survey Prevalence 2013
Notified TB cases is only 33%
0
200
400
600
800
1000
1200
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
20
14
670.00067%
1.020.000
330.000
Unnotified cases (unreacheable
and under reporting)
TB Incidence per year
New cases 1.020.000
Death 100.000
Treatment coverage (notified)
33%
Situation Burden
TB HIV incidence 78.000
Knowing HIV status 3.523 (5%)
TB HIV on ART 21%
Succes rate 56%
Estimated of TB burden(WHO 2017)
Estimated of DR-TB burden (WHO 2017)
Incidence MDR/RR TB 32.000
Estimated MDR/RR-TB cases
among notified pulmonary TB
cases
10.000
Estimated %of TB cases with
MDR/RR-TB
2.8% (new)
16% (Prev.Tx)
Laboratory-confirmed cases 2.135
Patients started on treatment 1.519
Succes rate 51 %
Treatment outcome 2015
Estimated TB Incidence (rate and absulute), 2017
< 50.000 kasus50.000 – 100.000 kasus> 100.000 kasus
Insidens kasus TB (angka absolut) per tahun
Kejadian pertahunKasus baru = 1.020.000Kematian = 100.000
Insidens kasus TB per 100.000 pendudukn
< 400 400 - 500> 500
Notification rate and Succes rate 2016
39%
23%
14%
8%7%
0%
20%
40%
60%
80%
100%
2009 2010 2011 2012 2013 2014 2015
Treatment Outcome RR/MDR TB
On Treatment Cured Completed
Failed LFU Died
Died before treatment Initial Defaulter Rejected to receive treatment
Transferred out Others *Data per Dec 2016
MDR/RR TB
Implementation of DOTS Strategyin Health Facility
Health Facility Total DOTS
n %
Lung Clinic 26 25 96%
Lung Hospital 9 5 55,5%
Hospital
- Public Hospital 633 510 80,6%
- Military-Police Hospital 162 97 59,8%
- Private Hospital 828 362 43,7%
Health Center 100%
TB Patients health seeking behavior on TB treatment
Survei Prevalensi tahun 2004
Region
Hospital
and Lung
Clinic
Puskes
mas
Private
Practitioner
Sumatera 44% 43% 12%
KTI 31% 51% 16%
Jawa 49% 21% 29%
Proportion of TB Patients seekingHealth from Private Practitioners*
39,9
48,243,9
36,5
19,2 31,3
4,814,2 10,8
8,5 13 8,8
9,7 3,62,6
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Jawa Bali Kalimantan Papua Sumatra Sulawesi
Lain-lain
RS khusus paru
Praktik swasta
Puskesmas
RS swasta
RS pemerintah
*Riskesdas 2010, Balitbangkes (2011)
Care-seeking pathways and current behavioral incentives
TB treatment and notificationIf hospitals are engaged in notifying patients, total TB case notification will increase significantly
Place of treatment Participants reported under TB treatment
NPS Found in SITT
Public health center 34 11
Public hospital 34 8
Private hospital 26 1
Others 31 4
total 125 24 (19%)
SITT = integrated TB information system (National TB electronic register)
Place of treatment Participants reported under TB treatment
NPS Found in SITT
Public sectors 68 19
Private sectors 57 5
total 125 24 (19%)
Challenges of TB Program1. Leadership:
1. Centralistic approach, low ownerships from sub-national levels2. Highly donor dependence raised concern over sustainability3. Too many players, but lack of synergy4. Weak synergistic of project exit strategy
2. Management1. Low case detection, only 32% reached by NTP2. PPM networking is on going implementation3. High turn over, weak of distribution of competence staff4. Weak of planning, distribution, and evaluation of supply chain
management5. Under reporting, weak of utilization of strategic information, and
mandatory notification is on going implemented6. Rapid molecular test is about starting to be accelerated7. New diagnostic algorithm on progress implemented
Strengths and Opportunities of TB Program
1. New government regulation of SPM (minimum standard of service), RPJMN (Midterm National Development Plan), Renstra (Strategic Plan MOH)
2. Desentralisation at Distric level improved and strengthened
3. Steady expansion of National Health Insurance coverage
4. Increasing of percentage of health allocation against GDP
5. Stronger collaboration and integrated approach at MOH among units and programs
6. Multi sectoral approach coordinated by BAPPENAS (National Plan and Development Body)
7. Health family approach and community movement (Germas) has been launched by MOH to be National integrated public health
8. Increasing laboratory system and diagnostic capacity with rapid molecular test expansion
Updating strategic approach
• Utilize new baseline data of TB burden prevaileing from new TB
prevalence survey thay more sensitive, representative.
• Changging passivecase finding to more accelerative through,
active, intensify and massif.
• More decentralized system and approach. More focus on case
finding and treatment.
• Integrated system : public-private mix for TB servics networking
• Strengthening program leadership and regulation especially at
distric level. (govenor, moyor regent decree on TB elimination)
• Multisectoral approach (what could be roled by the other sectors,
and ministerial)
• Accereated the acces to quality services and patient and
community : Utilize new diagnostic tool (example Xpert mechine)
not merely microscopic; Updated referral flow and alghorithm to
include new tool of diagnostic; Integrated to Health family and
community approach
Milestone 2015 - 2020• Strengthening PPM networking and active case finding• Utilize Molecular Rapid Test (Xpert) and microscopic• Decentralized program activities to Districts• Strengthening regulation and program leadership• Trantitioning exit strategy strangthenig domestic
resource• Implementing risk factor control of TB transmission• Implementing shorter treatment regimen for MDR-TB • Strengthening Implemention of shorther regiment for
latent TB and risk group• Case finding Acceleration for >70% CDR and maintaning
succes rate for >85%.
Milestone 2020 - 2025• Maintaining CDR for more 70% and treatment success > 85%.
• Optimalize decentralization of program activites to Districts.
• Avoiding catastropic cost of TB treatment.
• Strenthening risk factor activity : prophilaxis and TB latent treament
• Optimalized Xpert diagnosis and microscopic
• Optimalize decentralization of program activites to Districts.
• Implementing shorter regiment of sensitive TB
• Accelearting the use of shorter regiment of laten TB
Milestone 2025 - 2030• Maintaining CDR for more 80% and treatment success > 90%.
• Achieving universal coverage for TB treatment.
• Avoiding catastropic cost of TB treatment
• Accelearting the use of shorter regiment of laten TB
• Innovation of TB diagnoses
• Implementing TB vaction
• Strengthening case surveilance especially cross border and migration
• Akselerasi shorter regimen untuk laten TB
• Accelaerating shorter regiment of sensitive TB
Milestone 2030 - 2035• Strengthening case surveilance especially cross border
and migration
• Promote innovation on TB risk factor control
• Maintaining CDR for more 90% and treatment success > 95%.
• Maintaining universal coverage for TB treatment.
• Avoiding catastropic cost of TB treatment
• Maintaning high coverage of prophylaxix and latent TB treatment
• Accelarating the use of TB vaction
Milestones of NTP strategy towards TB eliminationVision: Indonesia free TB by 2050”
Goal: “TB elimination in Indonesia by 2035”
1,000,000
800,000
500,000
200,000 110,659
90% 90% 90% 90% 90%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
-
200,000
400,000
600,000
800,000
1,000,000
1,200,00020
14
201
5
201
6
201
7
201
8
201
9
202
0
202
1
202
2
202
3
202
4
202
5
202
6
202
7
202
8
202
9
203
0
203
1
203
2
203
3
203
4
203
5
insiden success rate (SR) case treatment
2035
Target dampak pada 2035:
• 90% penurunan insiden
TB
• 95% penurunan kematian
TB dibandingkan tahun
2014
2016
Peluncuran Strategi TOSS-TB
PPMIntensif, Aktif, massifSTR MDRFaktor risiko
Faktor RisikoSTR TB MDRSTR TB SOSTR LTB
Faktor RisikoVaksin TB Faktor Risiko
Vaksin TB
Milestones
35% 75% 90% 95%
20% 50% 80% 90%
Modelling toward Elimination by Interventions
Penemuan Aktif
Pencegahan
Pendekatan Keluarga
Pendekatan Pasif Intensif
Year 2015 2016 2017 2018 2019 2020
Incidence per 100.000 395 389 379 364 344 319
New TB case (incidence) 1.009.119 1.006.237 992.441 964.533 922.059 864.702
Case detection rate/CDR 33% 33% 40% 55% 65% 80%
Case notification per
100.000 population 129 128 152 200 224 225
Indicator and target
NTP Strategies (2015-2019)TOSS: Comprehensive Strategies for TB Control
2. Increase access of
qualified TBservices
1. Strengthen
program leadership
3. Control Risk Factor of TB transmission
5.Increase
community self-reliance
6.Synergize program
management
Decentralization in District level
Leadership Approach
Contributing to health system strengthening
Community and TB patient centered
Inclusive, proactive, effective, professional and accountable
4. StrengthenPartnership
Strengthen TB Program leaderships
• District health approach
• Clear Plan, Roadmap and regulation.
– Develop 5 year District TB Plan, Roadmap of TB elimination
– Strengthening budgeting and financing
– Sinergistic implementation
– Regulated as Govenor, Mayor, Regent Decree
– Stipulated in midterm local development plan (RPJMD)
• Strengthening TB services through Public Private Mix and
Mandatory notification.
• Active Cese Finding : Family and community based, Contact
Investigation
– Screening/Chase survey at the specified place, high-risk
population, Community based Health Innitiative, etc
– Maintaning treatment succes rate high
• Innovative diagnostic and treatment
– Rapid diagnostic : Xpert machine, qualified laboratory
– New and simple diagnosis algorithm
Framework of TB Regulation Development at Local Government
Regulation 2015 - 2020 2020 - 2025 2025 - 2030 2030 - 2035
Road Map of TBElimination
Long Term Local Development Plan
Midterm Local Development Plan
Strategic Plan Health Office
TB Local Action Plan
Local Government Work Plan
Guide/ Describe/ Notice/ Refer
Long Term Local Development Plan
Midterm Local Development Plan
Local Government Work Plan
Long Term National Development Plan
Midterm National Development Plan
National Government Work Plan
Strategic Plan Health Office
Work Plan Health Office
Strategic Plan MOH
Work Plan MOH
National Road MapTB Elimination
National 5 years plan TB Control
National Annual Plan TB Control
Local Road Map TB Elimination
Local 5 years plan TB Control
Local Annual Plan TB Control
Central Government
Local Government
WorkshopNoticerefer
Guide Describe
DescribeGuide
Guide Refer
Guide Refer
Guide
Guide
TB in National Planing System
Improving access and quality of TB Service • Strengthening networking of District based Public-Private Mix (PPM)
– Mandatory notification to all providers treated TB patients
– Intensified case finding through service collaboration: TB-HIV, TB-DM,
TB-Nutrition, IMCI, IMAI, etc;
• Active and massive case finding based on family and communities approach
– Contact investigation to all TB patients’ close contact (10-15 close
contacts)
– Special place, such as dormitory, prison, detention center, refugees’
camp, work place and school is conducted by doing systematic mass
screening.
• Integrated to Universal Health Coverage (JKN-BPJS)
• Decentralized TB services to Health Center, referral system, etc
• Innovated diagnosis and treatment
– Expert machine
– Strengthening network and microscopic laboratory
– New diagnostic algorithm
– Shoter treatment regiment of MDR-TB, SD-TB and LTBI
– Patient adherence
TB Case Finding Strategy
District HOPHC
District Hosp
Private Hosp
GP
Lung Hospital
Lung Clinic
Clinic
Private Lab Pharmacy
Passive Case Finding through network of health service (PPM)
IntermediateLaboratory
IMA
IPA
Active Case Finding through family and community based
• Contact investigation: 10 – 15 people per one index case
• Active Case Finding in specific population: dormitory,
prison, detention center, refugees, work place, school
• Active Case finding in community integrated with other
activities
Mandatory
notification
Coverage 60%
Coverage 40%
Cadre,
Integrated
services post,
TB village
post
Intensify using collaboration with HIV, DM, PAL, MCH, H&N, EH
Permenkes no.67 tahun 2016
Penanggulangan Tuberkulosis
RPP SPMorang dengan terduga tuberkulosis
Pelayanan Kesehatan Orang terduga TB
Support from Ministry Home Affair
Support from Govbnor
TB Action Plan Kota Solo
Regent Decree on TB elimination
Message from Ministry of Health
Indonesia
Call for Action
Akselerasi Penemuan Kasus
Pemanfaatan Diagnostik
International Standard for TB
Care
PERATURAN MENTERI KESEHATAN REPUBLIK INDONESIA NOMOR 13 TAHUN 2013 TENTANG
PEDOMAN MANAJEMEN TERPADU PENGENDALIAN TUBERKULOSIS RESISTAN OBAT
Rekor Dunia MURI “Ketok Pintu”
Within 2 weeksu :• 565.798 household visited• 1.590.529 houeseholds ve been educated• 91.049 suspected TB • 4.950 T confirmed TB cases
• Positivity rate 5%, • incidence 331/100.000 pop,
Edukasi TB melalui transportasi publik
RTL Kesepakatan
Contolling TB risk factors
• Promotion of environment and healthy living
– Behaviour, nutrition, hygene, cough etiquet
• Implementation of prevention and TB infection control
• Treatment of TB prevention and immunization
– Immunisation : providing BCG for child , TB vaccion
(under research and development)
– infection control at health facility
– Prophilaxis treatment for TB latent : child under 5
years contacted with pulmonary TB and PLWHA
• Maximize the TB intensify case finding and maintaining
coverage of high treatment success.
Intensified Research and Innovation
• New diagnostic, drugs and regiment, vaccines, (global priorities), innovation
• National TB research Action Plan (research priority)
• National TB Research Commission
• National TB Research Network (JetSet = Jejaring Riset TB)
• Integrating M&E and operational research
• The use of OR and data for action
An overview of progress in the development of molecular TB diagnostics, 2016
Gaps :tests for the diagnosis of TB in children, rapid drug susceptibility
tests of new treatment regimens, tests predict progression from latent TB
infection (LTBI) to active TB disease, and alternatives to TB microscopyand culture for treatment monitoring.
The global development pipeline for new anti-TB drugs, 2016
THE SHORTER MDR-TB REGIMEN REGIMEN COMPOSITION
• 4-6 Km-Mfx-Pto-Cfz-Z-Hhigh-dose-E / 5 Mfx-Cfz-Z-E
• Km=Kanamycin; Mfx=Moxifloxacin; Pto=Prothionamide; Cfz=Clofazimine; Z=Pyrazinamide; Hhigh-dose= high-dose Isoniazid; E=Ethambutol
FEATURES OF THE SHORTER MDR-TB REGIMEN • Standardized shorter MDR-TB regimen with severe
drugs and a treatment duration of 9-12 months• Indicated conditionally in MDR-TB or rifampicin-
resistant-TB, regardless of patient age or HIV status • Monitoring for effectiveness, harms and relapse will
be needed, with patient-centred care and social support to enable adherence
• Programmatic use is feasible in most settings worldwide
• Lowered costs (<US$1,000 in drug costs/patient) and reduced patient loss expected
• Exclusion criteria: 2nd line drug resistance, extra-pulmonary disease and pregnancy.
The development pipeline for new TB vaccines, 2015
Kemandirian masyarakat dan Patient’s Charter
for TB Care
TBSektor Swasta, CSO,Org. Internasional
Masyarakat, kader danpasien TB Org.Kesehatan/
Profesi
Institusi Litbang danPerguruan Tinggi
Sekolah danAkademi
•Lembaga SwadayaMasyarakat, umum maupun
berbasis agama
Kementerian/lembaga dandinas terkait
•Kemendagri, Kemenkeu, Bappenas/da,
Kemendikbud, Kemendes
Multisectoral approach
Priority National Project
Kemterian KesehatanDinas Kesehatan
Provider layanankesehatan
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
GF 137 152 206 166 174 174 190 222 407 230
HibahLain
58 62 66 62 85 107 165 144 106 102
APBN 97 103 107 135 133 87 163 205 485 365
0
200
400
600
800
1000
1200
Financing TB Program 2008-2017*(in billion rupiah)
GF
Hibah Lain
APBN
TBGRAPHY
Conclusion
• Several strategic efforts has been placed to make the dream come true in any aspects of leadership, managerial and technical.
• Indonesia believe and committed to support Global End TB Strategy to eliminate TB in the entire country by 2035.
Our future
TERIMA KASIH