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 (