SCALING UP PPM IN INDONESIA

Seventh Meeting of the Subgroup on Public-Private Mix for TB

Care and Control

23-24 October 2011, Lille, France

Dyah Erti Mustikawati NTP Manager MOH Indonesia

Content

• Background

• Situation

• Strategy

• Challenges

• Conclusion

•Background • Situation

• Strategy

• Challenges

• Conclusion

INDONESIA

General Information

Total Population 234.181.405 (Projection 2009, BPS)

Islands 17.000

Number of Districts 399

Number of Cities 98

Number of Sub Districts 6.652

Number of Villages 77.012

Type of Health Care Facilities

TOTAL DOTS

Health Centre 9.549 9.161

PRM/PPM/PS 1.914/2.746/4.467

Chest Clinic 28 28

Lung Hospital 9 8

Hospital 1.627 639 (39,27%)

- Public Hospital 533 315

- Parastatal/Own State Hospital

63 22

- Military-Police Hospital 155 73

- Private Hospital 867 221

5 Country with TB Burden

(Global Tuberculosis Control, 2011)

1. India (2,300,000)

2. China (1,000,000)

3. South Africa

(490,000)

4. Indonesia (450,000)

5. Pakistan (400,000)

400.000-500.000 New Cases per

year , 61000 Died by years (Global Tuberculosis Control 2011)

Global report 2011: Rank 9

MDG’s Indicator Achievement for TB

Incidence, Prevalence & Mortality TB, 1990, 2007*) & 2009**)

*) Global Report TB, 2009 page 282

**) Global Report TB, 2010 page 171

***)Global report 2011

Per year

Per

100.000

pop

Per day Per year

Per

100.000

pop

Per

day

Per

year

Per

100.000

pop

Per

day

Per

year

Per

100.000

pop

Per

day

Incidence all

type TB

626.867 343 1.717 528.063 228 1.447 430 189 (45%) 1.178 430 189

(45%)

1.178

Prevalence all

cases

809.592 443 ~ 565.614 244 ~ 660 285 (36%) ~ 660 289

(35%)

~

Incidence new

smear + cases

282.09 154 773 236.029 102 647 NA NA NA NA NA NA

Mortality 168.956 92 463 91.369 39 250 61 27 (70%) 167 61 27 (70%) 167

TB cases

1990 2007 2009 2010

BACK GROUND INFORMATION

PPM in Indonesia has involved various health providers such as hospitals, prison, workplace/ industry, PPs, Health insurance, Ministry of Defence, Police but not yet in systematic approach

PPM initiated first in hospitals and Lung Clinics/hospitals (Hospital DOTS Linkage) because the greater potential role played by the hospital in providing better outputs (institutional approach) in 2000

In coordination with JAMSOSTEK since 2010 provided TB DOTS services to 159.811 companies with about 13 million workers and families in the country, but until 2011 implementation still limited in 2 big provinces (DKI Jakarta & West Java)

PT ASKES is also involved in procurement of standard national TB Drugs

JAMKESMAS and JAMKESDA provided the treatment cost for poor TB patients

BASIC TOOLS OF PPM IMPLEMENTASION ENGAGEMENTOF SPESIFIC TYPES OF

CARE PROVIDERS

TOOLS ACCEPTABLE/ USEFULL

8. Engaging private practitioners

v

9. Engaging Hospitals v

10. Engaging NGO’s v

11. Engaging Workplaces

v

12. Engaging Social Security Organizations

v Esp : Health Insurance

schemes (HIS)

13. Engagement for TB/HIV collaboration

v

14. Engagement for PMDT

v

PPM TOOL-KIT FOR SCALE-UP PPM IN INDONESIA

TOOLS ACCEPTABLE/ USEFULL

1. Rationale & generic approach

v

2. National situation assessment

v

3. Operational guidelines

v

4.ACSM v

5. M & E v

6. ISTC v

7. Resources & budgeting

v

• Background

•Situation • Strategy

• Challenges

• Conclusion

1.4 4.6

7.5 12

19 20 21

30.6

37.6

54

68

75.7

69.8 72.8 73.1

78.3

41.3

91

81

54 58

73.8

87 86 86.1 86.7 89.5 91 91 91 91 91.2

88.4

0

10

20

30

40

50

60

70

80

90

100

year

CASE DETECTION AND TREATMENT SUCCESS RATE, INDONESIA 1995-2011*)

CDR SR Target CDR RPJMN 73%, Global 70%

Target SR RPJMN & Global ≥ 85% *) Q- 2

CDR Q -2

SR Q- 2

NSS (+) NSS (-) EP retreatment

NGO 37 0 0 0

PPs 705 568 47 9

Workplace 78 154 12 4

Prisons 88 35 9 12

Lung clinic 3725 5416 449 276

Hospital 15869 18152 3246 1151

PHC 162864 76922 7896 5137

0%

20%

40%

60%

80%

100%

%

Health facilities

CONTRIBUTION TO TB CASE DETECTION by HEALTH FACILITIES 2010

PHC Hospital Lung clinic Prisons Workplace PPs NGO

ENROLLMENT For PPs PILOT PROJECT by PDPI (OCT 2010 – SEP 2011)

Total TB cases from 23 pulmonologists in private hospital/clinic

Total 1314 patients 200

400

600

800

1000

TB Program Drugs

Prescribed Drugs

427

887

*)From total 1314 patients= 1130 Pulmonary TB patients (adult) (+) 146 Extra pulmonary TB 38 TB on children

Number of patients underwent sputum examination (for diagnosis)

Area Number of

Pulmonary TB patients (Adult)

Number of patients with sputum smear examination

(+) result (-) result

Central Jakarta 391 356 (91%) 164 (46%) 192 (54%)

East Jakarta 304 232 (76%) 77 (33 %) 155 (67%)

South Jakarta 435 312 (72%) 144 (46%) 168 (54%)

• Background

• Situation

•Strategy • Challanges

• Conclusion

INDONESIA

Scaling up engagement of all care providers

STRATEGIES

• To enhance expansion of quality DOTS

• To address TB/HIV, MDR-TB, Childhood TB, the needs of poor population and other vulnerable group

• To engage all public and private care providers in implementation of ISTC

• To empower TB patients and communities

• To strengthen health system and TB control program management

• To increase commitment of national and local government

• To enhance research, development and utilization of strategic information

-

100'000

200'000

300'000

400'000

500'000

600'000

97 98 99 00 01 02 03 04 05 06 07 08 09

Nu

mb

er

of

pati

en

ts

Challenges of National TB Control Program in Indonesia

Estimated ALL TB cases

TOTAL notified TB cases

New Smear Positives

New Smear Negatives

Re-treatment

Extra Pulm

‘ GAP ’

1

7

HEALTH SEEKING BEHAVIOUR TB PATIENT

*NIHRD (2011)

TB Drugs Consumption at Private Market/Sectors*

Country Incidence Consumption of TB

drugs 1st line at

private market (%)

Proportion

of loose TB

drugs (%)

India 1,982,628 117 23

Indonesia 429,730 116 91

Filipina 257,317 86 16

Pakistan 409,392 65 36

China 1,301,322 23 98

Thailand 92,087 17 94

Russia 150,898 13 100

Vietnam 174,593 7 90

Bangladesh 359,671 7 11

Africa Selatan 476,732 3 34

*Wells et al (2011)

6.Community System Strengthening

-Function as advocator raise fund and commitment,

- Increase public awareness, function as public watch to ensure deliveries of quality services,

-increasing awareness of right and responsibility of the patients (patient's charter).

-Social Mobilization, suspect identification, increasing demand creation, intensifying the services of TB in

slum areas and prison -Leading: NGO, FBO, CSO -TA: FHI, other partners

4.Qualified TB Diagnostic

-Approach: Strengthening lab network and Quality Assurance

(public and private) DST, Culture and Microscopic -Leading: Directorate of

Medical Support - TA: KNCV and JATA

2.Public/Private Hospital Services

- Approach: Hospital

Accreditation, Implementation TB DOTS as Minimum Standard

requirement for accreditation of Hospitals

- Leading: Directorates of Referral Health Services

-TA: KNCV

3.Quality DOTS services by Private Practitioners and

Specialist

- Approach: Implementation of ISTC for

all TB care and treatment from all care providers, increasing professional responsibility to cure TB patients,

rewarding through cumulative credits mechanism for licensing/certification

-Leading: IMA -TA: ATS,

5.Quality of anti TB Drug Dispensing and rational

Use of Drug

-Approach: law enforcement, establishment of networking and

monitoring system, WHO prequalification

-Leading: Indonesian Pharmacist Association, DG of Pharmaceutical

Services, Indonesian FDA -TA: USP and MSH

1.Basic DOTS Services At Puskesmas

-Approach: Surveillance System Strengthening and MIFA, Improving

quality of care, increasing coverage of TBHIV, reaching un-reach pop at

remote are (DTPK), increasing referral to Quality DOTS Services

-Leading: NTP -TA: WHO, FHI and other partners

PROGRESS IMPLEMENTATION OF INDONESIAN

COMPREHENSIVE PPM MODEL (1) Pilar 1: Basic DOTS Services at

PHC (PHC) 1. Shifting paper based surveillance system to electronic/web based system

2. Improving TBHIV reporting recording so that it can capture core data

3. Increase demand creation for utilization of Basic DOTS in PHC

4. strengthening linkage with NGO's/FBO's to intensify case finding

5. Improved EQA system for smear microscopic examination

6. Improved format data collection and intensify data validation and

feedback mechanism

Pilar 2: Public/Private Hospital

DOTS Services

1. Launching policy for accreditation and indicating TB DOTS services as one

of the minimum standard requirement for hospital accreditation (as

mandated by Hospital law no 44/2009)

2. Development and publication of standard guideline for hospital

accreditation

3. Socialization of SOP for accreditation to all provinces and district

4. Appointing Committee for Acreditation (KARS) and instrument for

accreditation5. Planning for full implementation of accreditation by 2012, and all hospital

without accreditation will not be allowed to extend their operational

license

6. Directorates of Medical Services as SSF-TB SRs is fully in charge for

provision and monitoring of hospital accreditation implementation

PROGRESS IMPLEMENTATION OF INDONESIAN

COMPREHENSIVE PPM MODEL (2)

Pilar 3: PPs DOTS Services 1. Implementation of pilot involvement of Pneumologist in DOTS at Jakarta

2. Socialization of ISTC and establishment of ISTC task force in 33 provinces

3. IMA is responsible to ensure the proper involvement of private

practitioners in TB treatment in compliance to ISTC. IMA is Srs for SSF TB

Indonesia

4. IMA will developed promoting media to remind that the doctor's

responsibility is curing the disease not only treating (professional ethical

conduct) 5. IMA will develop user friendly reporting recording system for PPs

notification and provides scheme for rewarding cumulative credit point for

PPs involvent in TB

6. IMA is planning to establish linkage between PPs, private labs and private

paharmacyst

Pilar 4:Quality Assured TB

Diagostics

1.Establishing External Quality Assurance for Microscopic from 8 Provinces,

to national coverage of 33 provinces

2. Improving and stepwise expansion of quality assured DST laboratories

3. Establishing network of QA beyond public services, by including private

laboratories services

4.Stepwise Pilot implementation Gene Expert in 17 sites for accelerating the

TBMDR confirmation, TB and TBMDR among HIV patients and TB in prisons

PROGRESS IMPLEMENTATION OF INDONESIAN

COMPREHENSIVE PPM MODEL (3)

Pilar 5:Quality of anti TB Drug and

rational Use of Drug

Conducting Workshop for WHO praqualification to ensure qualified drug

distibuted to patients for FLD (2 times), for SLDs (1 time), supported by USP,

Directorates of Pharmaceutical services, IFDA

Conducting workshop at national level to Enganging Indonesian Pharmacyst

Association in TB control and rational drug use I

Indonesian Pharmacyst association agreeable role: integrated Pharmacy

Care for TB, Certification and license for Pharmacy practice, monitoring

rational drug use of TB drugs, introducing TB in curricula of School of

Pharmacyst, initiating professional incentives credits for pharmacyst for

their engangement in TB control, advocating TB drugs manufactures etc.

IFDA: initiating Pharmaciovigilance/ QA of TB drugs

Pilar 6: Community System

Strengthening Initiation and establishment of National network of TB affected people to

echo their voices and mainstreaming their agenda

Empowering NGOs involvement for advocacy and public pressure and watch

of other 5 pillars implementation

Launching small grants for NGO involvement from SSF TB and focusing their

involment in intitutional strengthening for PPM implementation

• Background

• Situation

• Strategy

•Challenges • Conclusion

MAJOR BARRIERS TO SCALING UP

• Multiple leading unit for implementation of each pillars complicates the successfull achievement as achievement in each pillars will influence progress in other pillars there should be close coordination and monitoring of each pillars progress.

• Intensify coordination and collaboration is really

needed, however it is sometime very difficult

because of each one busy schedule

• Background

• Situation

• Strategy

• Challenges

•Conclusion

Conclusion

• The main strategy to prevent the epidemic of TB MDR is providing universal access to qualified DOTS by engaging all care providers achieved

• NTP has to initiate, facilitate and monitor the engagement of all care providers

• Multi mix financing mechanism should be introduced to ensure sustainability of TB control

THANK YOU