Present, future and strategic management of TB program in Indonesia [PDF]

Pendidikan. – Dokter FK Unair Surabaya, 1990. – Master Public Policy and Management, University of. Southern Califor

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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 : [email protected], [email protected]

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 7.3 B

incidens

mortality

TB

10.400.000

1.400.000

WHO, 2017

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 10/100.000

MDR-TB 10.000

26.000

Unnotified TB cases among 10 countries of estimated TB incidence, 2015

1. 2. 3. 4. 5.

India Indonesia Nigeria Pakistan Afrika Selatan

6. 7. 8. 9. 10.

Bangladesh Kongo China Tanzania 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

Male

393

(315 - 471)

1,083

(873 - 1,337)

Female

131

(88 - 174)

461

(354 - 591)

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

282

(220 - 345)

846

(678- 1,048)

Rural

231

(163 - 300)

674

(512 - 874)

(590 - 961)

Sex

Region

Urban/rural

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

800

TB Incidence per year New cases Death

600

400

Treatment coverage (notified)

1.020.000 100.000

Unnotified cases (unreacheable and under reporting)

670.000 67%

33%

200 330.000

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

0

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 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%

- Public Hospital

633

510

80,6%

- Military-Police Hospital

162

97

59,8%

- Private Hospital

828

362

43,7%

Hospital

Health Center

100%

TB Patients health seeking behavior on TB treatment Region

Hospital Puskes and Lung mas Clinic

Private Practitioner

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% 90%

8,5

13

9,7

3,6

80%

19,2

70% 60%

8,8 2,6 31,3 Lain-lain

36,5

RS khusus paru Praktik swasta

50% 40% 30%

48,2

Puskesmas 43,9

RS pemerintah

39,9

20% 10%

0%

4,8 Jawa Bali

RS swasta

14,2

10,8

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 Public health center Public hospital Private hospital Others total Place of treatment

Participants reported under TB treatment NPS Found in SITT

34 34 26 31 125

11 8 1 4 24 (19%)

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.

2. 3. 4. 5. 6. 7. 8.

New government regulation of SPM (minimum standard of service), RPJMN (Midterm National Development Plan), Renstra (Strategic Plan MOH) Desentralisation at Distric level improved and strengthened Steady expansion of National Health Insurance coverage Increasing of percentage of health allocation against GDP Stronger collaboration and integrated approach at MOH among units and programs Multi sectoral approach coordinated by BAPPENAS (National Plan and Development Body) Health family approach and community movement (Germas) has been launched by MOH to be National integrated public health 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

90%

90%

90%

90%

90%

100% 90%

1,000,000

1,000,000

800,000

2016

800,000

Target dampak pada 2035: • 90% penurunan insiden TB • 95% penurunan kematian TB dibandingkan tahun 2014

80% 70% 60% 50%

600,000

500,000

2035

insiden

success rate (SR)

case treatment

110,659

10%

2035

2029

2028

2027

2026

2025

2024

2023

2022

2021

2020

2019

2018

2017

2016

2015

2014

-

30% 20%

200,000 Faktor Risiko Vaksin TB 2034

Faktor Risiko Vaksin TB

2033

Faktor Risiko STR TB MDR STR TB SO STR LTB

2032

200,000

PPM Intensif, Aktif, massif STR MDR Faktor risiko

2031

Peluncuran Strategi TOSS-TB

2030

400,000

40%

0%

Milestones

35%

75%

90%

95%

20%

50%

80%

90%

Modelling toward Elimination by Interventions Pendekatan Pasif Intensif

Penemuan Aktif

Pencegahan

Pendekatan Keluarga

Indicator and target

Year Incidence per 100.000 New TB case (incidence) Case detection rate/CDR Case notification per 100.000 population

2015 395 1.009.119 33%

2016 389 1.006.237 33%

2017 379 992.441 40%

2018 364 964.533 55%

129

128

152

200

2019 2020 344 319 922.059 864.702 65% 80% 224

225

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

1. Strengthen program leadership

2. Increase access of qualified TB services

3. Control Risk Factor of TB transmission

4. Strengthen Partnership

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

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 Road Map of TB Elimination Long Term Local Development Plan Midterm Local Development Plan Strategic Plan Health Office TB Local Action Plan Local Government Work Plan

2015 - 2020

2020 - 2025

2025 - 2030

Guide/ Describe/ Notice/ Refer

2030 - 2035

TB in National Planing System National Road Map TB Elimination

National 5 years plan TB Control

Central Government

Strategic Plan MOH

National Annual Plan TB Control

Guide

Guide

Refer

refer

Midterm National Describe National Government Work Plan Development Plan Notice Workshop

Long Term Local Development Plan Guide

Midterm Local Local Government Development Plan Describe Work Plan

Long Term National Development Plan

Guide

Work Plan MOH

Local Government Local Road Map TB Elimination

Guide Strategic Plan Health Office Local 5 years plan TB Control

Refer Guide

Work Plan Health Office Local Annual Plan 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

Clinic

Private Lab

Pharmacy

IPA District Hosp

Lung Hospital

District HO

PHC Coverage 60%

Lung Clinic

Intermediate Laboratory

Coverage 40% Active Case Finding through family and community based • Cadre, • Integrated services post, • TB village post

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

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 rifampicinresistant-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 (

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