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 Burdens
Countries in the three TB high-burden country lists WHO, 2017

7.3 B incidens mortality

TB 10.400.000 1.400.000
142/100.000
TB/HIV 1.170.000 390.000
11/100.000
MDR-TB

258 M Insiden mortality

TB 1.020.00 100.000
395/100.000
TB/HIV 78.000 26.000
10/100.000
MDR-TB 10.000
Unnotified TB cases among 10 countries of estimated
TB incidence, 2015

1. India 6. Bangladesh
2. Indonesia 7. Kongo
3. Nigeria 8. China
4. Pakistan 9. Tanzania
5. Afrika Selatan 10. Mozambique
 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%
1200
1.020.000

1000 TB Incidence per year

New cases 1.020.000

800 Unnotified cases
670.000
(unreacheable
Death 100.000 67%
and under
600 reporting)
Treatment
coverage 33%
400 (notified)

200
330.000

2012
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011

2013
2014
 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 10.000
among notified pulmonary TB
cases
Estimated %of TB cases with 2.8% (new)
MDR/RR-TB 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

Insidens kasus TB per

100.000 pendudukn
< 400
400 - 500
> 500

Kejadian pertahun
Kasus baru = 1.020.000
Kematian = 100.000

Insidens kasus TB (angka

absolut) per tahun

< 50.000 kasus

50.000 – 100.000 kasus
> 100.000 kasus
Notification rate and Succes rate 2016
 MDR/RR TB

Treatment Outcome RR/MDR TB

100%
7%
8%
80%
14%
60%
23%
40%

20% 39%

0%
2009 2010 2011 2012 2013 2014 2015
On Treatment Cured Completed
Failed LFU Died
Died before treatment Initial Defaulter Rejected to receive treatment
Transferred out Others *Data per Dec 2016
Implementation of DOTS Strategy
in 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
Hospital
Puskes Private
Region and Lung
mas Practitioner
Clinic

Sumatera 44% 43% 12%

KTI 31% 51% 16%

Jawa 49% 21% 29%

Survei Prevalensi tahun 2004

 Proportion of TB Patients seeking
Health from Private Practitioners*
100%
8,5 13 8,8
90% 2,6
9,7 3,6
80%
19,2 31,3
70%
Lain-lain
36,5
60% RS khusus paru
50% Praktik swasta
Puskesmas
40% 48,2
43,9 RS swasta
30%
39,9 RS pemerintah
20%
10%
14,2 10,8
0% 4,8
Jawa Bali Kalimantan Papua Sumatra Sulawesi

*Riskesdas 2010, Balitbangkes (2011)

 Care-seeking pathways and
current behavioral incentives
TB treatment and notification
If 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%)

Place of treatment Participants reported under TB treatment

NPS Found in SITT

Public sectors 68 19
Private sectors 57 5
total 125 24 (19%)

SITT = integrated TB information system (National TB electronic register)

 Challenges of TB Program
1. Leadership:
1. Centralistic approach, low ownerships from sub-national levels
2. Highly donor dependence raised concern over sustainability
3. Too many players, but lack of synergy
4. Weak synergistic of project exit strategy
2. Management
1. Low case detection, only 32% reached by NTP
2. PPM networking is on going implementation
3. High turn over, weak of distribution of competence staff
4. Weak of planning, distribution, and evaluation of supply chain
management
5. Under reporting, weak of utilization of strategic information, and
mandatory notification is on going implemented
6. Rapid molecular test is about starting to be accelerated
7. 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 elimination
Vision: Indonesia free TB by 2050”
Goal: “TB elimination in Indonesia by 2035”
1,200,000 100%
90% 90% 90% 90% 90%
90%
1,000,000 1,000,000 Target dampak pada 2035: 80%
• 90% penurunan insiden
TB 70%
800,000
2016 800,000 • 95% penurunan kematian
TB dibandingkan tahun 60%
2014
600,000 50%

500,000 40%
400,000 Peluncuran Strategi TOSS-TB
30%
PPM Faktor Risiko 2035
Intensif, Aktif, massif STR TB MDR Faktor Risiko 20%
200,000 200,000
STR MDR STR TB SO Vaksin TB 110,659
Faktor Risiko 10%
Faktor risiko STR LTB
- Vaksin TB 0%

2034
2014

2015

2016

2017

2018

2019

2020

2021

2022

2023

2024

2025

2026

2027

2028

2029

2030

2031

2032

2033

2035
insiden success rate (SR) case treatment
Milestones

35% 75% 90% 95%

20% 50% 80% 90%
Modelling toward Elimination by
Interventions
Pendekatan
Pasif
Intensif

Penemuan Aktif

Pendekatan
Pencegahan Keluarga
 Indicator and target

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
 NTP Strategies (2015-2019)
TOSS: Comprehensive Strategies for TB Control

2.
1. 3. 5. 6.
Increase 4.
Strengthen Control Risk Increase Synergize
access of Strengthen
program Factor of TB community program
qualified TB Partnership
leadership transmission self-reliance management
services

Decentralization in District level

Leadership Approach
Contributing to health system strengthening
Community and TB patient centered
Inclusive, proactive, effective, professional and accountable
 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 TB Guide/ Describe/ Notice/ Refer

Elimination

Long Term Local

Development
Plan

Midterm Local
Development
Plan
Strategic Plan
Health Office

TB Local Action
Plan

Local
Government
Work Plan
 TB in National Planing System
National Road Map National 5 years National Annual
TB Elimination plan TB Control Plan TB Control

Strategic Plan Guide

Work Plan MOH
Central Government MOH
Guide Refer
Long Term National Guide Midterm National Describe National Government
Development Plan Development Plan Work Plan
refer Notice Workshop
Long Term Local Midterm Local Local Government
Development Plan Guide Development Plan Describe Work Plan
Guide Refer
Strategic Plan Guide Work Plan Health
Local Government
Health Office Office

Local Road Map TB Local 5 years plan Local Annual Plan

Elimination TB Control TB Control
 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
Passive Case Finding through network of health service (PPM)
Intensify using collaboration with HIV, DM, PAL, MCH, H&N, EH
Mandatory
notification GP IMA
Private Hosp Private Lab
Pharmacy
Clinic IPA
District Hosp
Lung
Hospital District HO
PHC
Lung Clinic Intermediate
Coverage 60% Laboratory

Coverage 40% Active Case Finding through family and community based
• Contact investigation: 10 – 15 people per one index case
Cadre, • Active Case Finding in specific population: dormitory,
Integrated prison, detention center, refugees, work place, school
services post, • Active Case finding in community integrated with other
TB village activities
post
 Permenkes no.67 tahun 2016
Penanggulangan Tuberkulosis
 RPP SPM
orang 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 microscopy
and 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
 Multisectoral approach
Priority National Project

Kementerian/lembaga dan
dinas terkait
•Lembaga Swadaya
•Kemendagri, Kemenkeu,
Masyarakat, umum maupun
Bappenas/da,
berbasis agama
Kemendikbud, Kemendes

Sektor Swasta, CSO, Institusi Litbang dan

Org. Internasional
TB Perguruan Tinggi
Sekolah dan
Akademi
Masyarakat, kader dan
pasien TB Org.Kesehatan/
Profesi

Provider layanan
Kemterian Kesehatan
kesehatan
Dinas Kesehatan
 Financing TB Program 2008-2017*
(in billion rupiah)
1200

1000
GF
800

600
Hibah Lain

400

200 APBN

0
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
GF 137 152 206 166 174 174 190 222 407 230
Hibah
58 62 66 62 85 107 165 144 106 102
Lain
APBN 97 103 107 135 133 87 163 205 485 365
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