Indonesia

After rapid progress towards reaching the global targets the Case Detection Rates (CDR) in Indonesia have more or less stabilize around 70% over the last 3 years. CDR in 2008 reached 72% with a Case Notification rate for sputum smear positive patients at a rate of 71%. Treatment success rates for smear positive patients remain constant around 90% which is well above the global target of 85%. (2007 cohort: cure rate 82% and treatment completion rate: 9%). External donor support from USAID, GFATM and intensified technical assistance from partner organizations including KNCV Tuberculosis Foundation, WHO, ATS, MSH has contributed much to the achievements of the NTP.

During 2008 more than 298.329 TB cases were notified of which more than 166,376 were found to be infectious cases (Sputum Smear Positive). Case notification of sputum smear negatives is steadily increasing, but the proportion is still below 40%. The number of relapses and failures remains low (2 % of new cases) suggesting that the overall rate of TB drug resistance for patients diagnosed at general health facilities is still relatively low. This is supported by preliminary data of the DRS (2008) suggesting primary multiple drug resistance of around 2%. However, these data refer mainly to health centers where the TB program has been well established. Drug resistance is likely to be higher in the hospitals and private sector due to poor adherence to DOTS and high defaulter rates.

During 2009 progress in DOTS expansion in Indonesia was seriously hampered by shortages in TB drug-, and laboratory supplies in several provinces [Core indicators: to be obtained from the country data, WHO global report on TB and UNDP statistics.(http://www.who.int/tb/publications/global_report/en/index.html)

Role of KNCV Tuberculosis Foundation

Describe in maximum 200 words the role of KNCV Tuberculosis Foundation: What did we actually do in the country. Focus of KNCV assistance to the NTP Indonesia is strengthening local human resources to address the major challenges in TB control. Support includes amongst others assistance to link hospitals (including private sector- and non-government institutions) to the program, strengthening capacity of drug management, expanding and improving the laboratory network including external quality assurance for culture and DST, expanding TB-HIV collaboration, prevention and management of TB drug resistance, operational research etc. KNCV heads a coalition of various technical organizations, its main partners being WHO, FHI, MSH and ATS; Experts of these international organizations provide technical assistance to the NTP, training and coaching of local senior and junior technical staff, enabling them to deliver continuous quality technical support at central and local level.

Achievements

Describe in maximum 200 words what KNCV achieved (in terms of SMART). Good progress has been made with laboratory network strengthening: 5 local reference laboratories have now been quality assured for culture and drug sensitivity testing (DST) for first line drugs and two of these laboratories for DST on second line drugs. 3 Other laboratories are in the process of achieving EQA for SL-DST. 2 Pilot sites have been established for management of Drug Resistant TB. Staff in the pilot sites were trained with support from Tropical Disease Foundation (Manila): Treatment enrolment of the first MDR-TB patients has successfully started in 2 referral hospitals (Persahabatan and Sutomo Hospital) linked to a network of health centers. The Hain test has been successfully validated and is now field tested at the PMDT sites in order to enable speeding up expansion of PMDT.
 
TBCAP Indonesia expanded its partnership and intensified collaboration with the Directorate of Medical Services (Yanmed), to accerate and scale up implementation of DOTS in hospitals (HDL) and to develop a National Laboratory Plan. DOTS  is being expanded to 162 hospitals (from 91 hospitals in 2008) referral links and networks between these hospitals and health centers (Puskesmas) are being established in 12 district clusters. Consequently the notification of patients diagnosed in hospitals supported by TBCAP contributes to around 8-10% of the total number of TB patients notified in these provinces. However quality issues with regard to treatment results remain a major concern.

Progress has been made in mobilizing the Indonesian Medical Association (IDI) through establishment of task forces for implementation of ISTC in almost all provinces. Guidelines and training modules on ISTC implementation for private practitioners have been finalized. TB-HIV collaborative activities are progressing slowly in five priority provinces (Jakarta, East Java, Papua, West Papua, and Riau Islands). Policies, guidelines, modules, IEC materials, and supervision tools for TB-HIV have been developed. An electronic database for TB and HIV is currently being piloted. Good progress in implementation of DOTS in prisons was achieved in collaboration with Ministry of Justice and Human Rights. National Guidelines and training modules have been developed for DOTS in prisons with KNCV/TBCAP support. Staff from 36 prisons in 14 provinces  have been trained during 2009.

Further a curriculum and a set of 5 training modules for ACSM were drafted in bahasa Indonesia including a facilitators guide and implementation guidelines. The fourth Advanced Course for DOTS Acceleration (ACDA) was conducted with 20 participants from 7 provinces. 2 Trainings for TB Infection Control were conducted in Jakarta.

The organization and staffing of TBCAP Indonesia was further strengthened through recruitment of a new KNCV Country Representative Officer and 20 additional technical officers. The overall organization and management of TBCAP-Indonesia at country office level was strengthened by appointing HDL -, and MDR Coordinators, as well as recruiting a Program Support Officer, a Monitoring & Evaluation Officer and a Communication/PR Officer. Furthermore provincial coordinators and finance officers were appointed.

Next steps

Describe in maximum 200 words what the future looks like; what are KNCV’ concrete plans.

The focus of KNCV assistance to Indonesia will be expansion of the prevention and management of drug resistant tuberculosis including all related technical areas, amongst others expanding laboratory capacity for culture and drug resistance testing and drug resistance surveillance. KNCV will continue to support expansion of the DOTS plus pilot projects in Jakarta and Surabaya, later to be expanded to other areas in Indonesia (West and Central Java). Other priority areas are expansion of DOTS implementation and quality improvement in hospitals, prisons and other institutions, including strengthening the involvement of non government organization and faith based organizations with special focus on remote areas in Papua are other priority areas. Likewise more attention will be given to bolstering of drug management for first and second line drugs, implementation of e-TB manager and the expansion of TB-HIV collaboration in the areas with concentrated and generalized HIV epidemics.

To this end KNCV will review the scope of work developed in collaboration with local NGO’s and concentrate on harnessing the potential coordinating function of these organizations. KNCV will intensify its assistance to other government departments (Department of Medical Services, Justice and prison services) with the objective to increase capacity for TB control in prisons and hospitals with special attention to regulatory functions like certification and accreditation of facilities and integrating essential TB program indicators in its reporting system. Research capacity will be increased trough the TB operational research group to build a strong evidence base for all new initiatives.