Indonesia

Indonesia ranks third on the list of 22 high-burden tuberculosis (TB) countries in the world. According to the World Health Organization’s (WHO’s) Global Tuberculosis Control Report 2009, there were an estimated 528,063 new TB cases and an estimated incidence rate of 102 new sputum smear-positive (SS+) cases per 100,000 population in 2007. Based on WHO disability-adjusted life-year calculations, TB is responsible for 6.3 percent of the total disease burden in Indonesia, compared with 3.2 percent in the Southeast Asian region. In 1992, DOTS (the internationally recommended strategy for TB control) was first piloted in Sulawesi and, according to WHO, had expanded to 98 percent of the country by 2005; DOTS coverage reached 100 percent in 2007. Indonesia has exceeded WHO’s target of 85 percent for DOTS treatment success, reaching 91 percent. The DOTS case detection rate has more than doubled over the past six years, from 30 percent in 2002 to 68 percent in 2007 (in 2006, Indonesia surpassed WHO’s target of 70 percent for DOTS case detection for the first time, reaching 73 percent). This was due to the collaboration of both public and private health care providers and the expansion of community-based TB care. The national adult HIV prevalence is low, at around 0.6 percent; however, 3 percent of all new TB patients are HIV positive¹. There is currently no national policy of counseling and testing TB patients for HIV, but training modules for TB and AIDS health providers have been developed.

A major challenge to TB control in Indonesia is the containment of multidrug- resistant (MDR) TB. Though the MDR-TB rate is still relatively low, the total number of MDRTB cases is considerable due to the large numbers of TB patients. According to WHO, there were an estimated 6,427 new SS+ MDR-TB patients in 2007, or 2 percent of all new cases, but 20 percent of all re-treated cases are MDR-TB. MDR-TB is generated mainly due to the large numbers of TB patients who are inadequately treated. The private sector also provides TB treatment, but the treatment outcomes are not captured by the National TB Control Program (NTCP) surveillance system. Default on treatment and the misuse of second-line drugs in hospitals are contributing to the increase of drug-resistant TB. The first representative drug resistance survey in Java is currently being completed, with support from USAID. Ninety-eight percent of 1,226 samples have been tested for drug resistance. Preliminary results of this survey indicate that the level of MDR-TB is around 1.5 percent among new patients and 14 percent among re-treatment cases in Java.

The treatment of MDR-TB patients has begun, and USAID is helping Indonesia improve the management of second-line drugs. As of March 2009, extensively drug-resistant TB has not been found in Indonesia.

USAID Approach and Key Activities

USAID works closely with the Indonesian Government, the NTCP, and the Tuberculosis Coalition for Technical Assistance to implement the USAID-funded Tuberculosis Control Assistance Program (TB CAP). The goal of TB CAP is to expand quality DOTS and increase technical and management capacities. USAID provides assistance nationwide and continues to have an increased focus on specific high TB-burden areas, including urban areas and selected remote provinces (Java/Bali region and large provinces in Sumatra, Sulawesi, and Papua).

Assistance includes the strengthening of diagnostic services, human resources, drug management, local government commitment, and operations research. USAID funds for TB programming in Indonesia totaled $5.9 million in fiscal year 2008. USAID provides support for the following activities:

• Addressing the challenge of MDR-TB by training laboratory staff in culture and drug susceptibility testing, introducing innovative diagnostics for MDR-TB, and building capacity of health staff in MDR-TB activities
  
• Building management capacity to improve planning, reporting, evaluation, and coordination of TB activities
  
• Developing advocacy toolkit
  
• Developing quality assurance networks for all diagnostic service
  
• Facilitating laboratory accreditation for both smear and culture and drug sensitivity testing
  
• Providing direct technical assistance (TA) with the strengthening of hospital DOTS linkage systems and establishing International Standards for Tuberculosis Care (ISTC) nationwide
  
• Strengthening monitoring capacity at the national, provincial, and district levels
  
• Enhancing the capacity of the national program through support to general and laboratory staff at the district and health center levels
  
• Strengthening research capacity in the NTCP and supporting the NTCP in developing a national system for drug-resistance surveillance
  
• Mobilizing professional societies and establishing local task forces to facilitate and expedite the implementation of ISTC
• Improving and increasing reporting of TB-HIV/AIDS and strengthening TB-HIV/AIDS referral systems
  
• Expanding TB-HIV/AIDS activities to reach high-risk groups, particularly prisoners and intravenous drug users
  
• Increasing international TA for drug resistance and management of second-line drugs
  
• Facilitating the design, field testing, and implementation of information, education, and communication strategies and materials for TB control, including TB-HIV/AIDS and MDR-TB
  
• Improving collaboration among the Prison Department, the Department of Justice and Human Rights, and the NTCP and developing a national strategic plan and guidelines for DOTS implementation in prisons
  
• Engaging a variety of other health care providers, including nongovernmental and faith- and community-based
  organizations
  
• Empowering the Indonesian Tuberculosis Association to take up a more coordinating function in the involvement of local partners, including public and private hospitals and nongovernmental organization facilities
  
• Strengthening government capacity in drug management

USAID Program Achievements

USAID support has led to a number of measurable achievements and includes the following:

• Contributed significantly to increased DOTS case detection, which increased from 20 percent in 2000 to 73 percent in 2006
  
• Increased the notification of infectious SS+ TB cases fourfold in East Java from 5,500 in 2001 to 22,900 in 2007, and threefold in Central Java from 5,200 in 2001 to 16,481 in 2007; and helped the national case notification rate for new SS+ cases (100,000 population/year) reach 77 in 2008
  
• Improved the national treatment success rate from 50 percent in 1999 to 91 percent in 2006
  
• Strengthened the function of project management units at the provincial level
  
• Trained 1,183 medical doctors and other staff in hospitals and supported an additional 30 well-trained technical officers at strategic positions spread over four large provinces
  
• Trained more than 13,600 TB program staff, including 5,000 medical professionals, in nine provinces in DOTS implementation
  
• Increased access to quality laboratory services, which enabled 89 percent of new SS+ pulmonary TB patients to be treated and cured
  
• Provided TA to establish international MDR-TB quality control standards for three reference laboratories
  
• Supported, in collaboration with the Ministry of Health and WHO, the development of guidelines and training modules for culture and drug sensitivity testing
  
• Supported the development of a national TB-HIV/AIDS strategy and guidelines to improve case finding and management of TB-HIV co-infected patients
• Developed surveillance of TB-HIV co-infection and TB drug resistance
  
• Began implementation of a drug resistance survey in Java
  
• Established a “One Gate policy” for TB drugs management, which was implemented in all provinces, and developed training modules for the management of drugs logistics
  
• Increased political commitment through development of a planning and budgeting tool, which is being pilot tested in 15 districts in three provinces
  
• Established internal hospital DOTS networks in 75 large hospitals and external referral networks with health centers in 10 districts, greatly enhancing TB case detection and TB-HIV/AIDS coordination
  
• Developed guidelines and training modules for TB-HIV/AIDS and established TB-HIV services in 20 provincial general referral hospitals and five health centers
  
• Trained 900 hospital doctors, specialists, and nurses in Hospital DOTS Lingage

Case Detection and Treatment Success Rates Under DOTS

Note: DOTS treatment success rate for 2007 will be reported in the WHO Report 2010. Source: Global Tuberculosis Control WHO Report 2009

Partnerships

WHO and the KNCV Tuberculosis Foundation primarily lead the external technical partnerships with the Indonesian Government. The Global Fund to Fight AIDS, Tuberculosis and Malaria approved an $18.3 million grant in 2006 to increase access to DOTS. In addition to contributions from the Global Fund, Indonesia receives assistance from the Netherlands Government for staff training and from the Canadian International Development Agency for DOTS expansion. The Asian Development Bank provides support for overall health systems strengthening, while the Global TB Drug Facility focuses on drug support. Netherlands Leprosy Relief also assists Indonesia’s TB control activities.

1 Source: USAID/Indonesia

May 2009

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Related Links

• USAID Overview of Indonesia