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 : kingasik@yahoo.com, asiksurya@yahoo.com

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

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400

600

800

1000

1200

19

90

19

91

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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

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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