Lessons from the DOTS Expansion Plan in Indonesia: highlighting human resource development
Carmelia Basria, Petra Heitkampb, Firdosi Mehtab
Indonesia ranks third among the TB high-burden countries. A decade of TB control using the DOTS strategy has facilitated progress towards reaching the 2005 international targets for TB control. Indonesia reported a case detection rate of 68% for 2005 and a success rate of 87% for the 2004 patients’ cohort. The strong political commitment and leadership shown by the Indonesian government from 1999 onwards have led to the development of today’s TB control strategy. This commentary highlights three key pillars towards the achievement of the 2005 targets.
First, a sound and well-budgeted five-year strategic plan,1 following the Global DOTS Expansion Plan as explained in Enarson & Billo’s paper, laid the foundation for implementation and attracted donor funding, including two grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund).
Second, the NTP focused on human resources development and cascaded training through a bilateral donor grant. The cascaded training programme, which started in late 2000, allowed training of different categories of staff. During the biennium 2002–2003, over 5000 (34.7%) doctors and nurses at the health-centre level were trained out of the total pool of trainees estimated at 14 474. The health ministry reports that 98% of TB staff at health centre facilities and approximately 24% of TB staff at hospitals are trained in DOTS. A core of master trainers at the regional level initiated and supervised the planning and coordination of training activities. Training activities were gradually shifted to the districts after a central training group was established to act as catalyst and reference point in accordance with guidelines and curricula.2 Through the Global Fund funding, as part of the overall human resource development plan, teams of mobile master trainers helped clear the training backlog at the health-centre level. In addition, training coordinators are in place at the NTP and in most provinces.
Third, management capacity has been strengthened at all levels, with a key initiative to establish provincial DOTS teams as well as to decentralize the Global Fund management to district level. The Global Fund has acted as a pull mechanism for improving surveillance and information flows.
Indonesia is moving forward in implementing the new 2006–2010 five-year plan for TB control3 in line with the new Stop TB Strategy. The 2004 prevalence survey4 shows a large geographical difference in TB burden, reflecting the need for area-specific planning, including adoption of the International Standards for TB Control (ISTCs) among all health-care providers. This also addresses the challenge of TB/HIV in affected provinces, and prevents multidrug-resistant TB by strengthening laboratory networks and surveillance. The involvement of all health-care providers in Java and Bali prioritizes linkages between hospitals and health-care centres. In eastern Indonesia and remote areas of Sumatra, the main focus is on strengthening the most peripheral health centres, supported by community-based schemes and NGOs. Many inconsistencies remain in translating these TB policies into local plans and budgets; fostering local government commitment is a related challenge. The 2006–2010 strategic plan outlines strategies addressing these issues. The challenge is to sustain momentum and build on the foundations laid in the first strategic plan. ■
- National TB control program strategic plan 2002-2006. Jakarta: Republic of Indonesia Ministry of Health; 2001.
- TB control curricula and modules. Jakarta: Republic of Indonesia Ministry of Health; 2000.
- Framework for TB strategic plan in Indonesia: 2006-2010. Jakarta: Republic of Indonesia Ministry of Health; 2006.
- Tuberculosis prevalence survey in Indonesia. Jakarta: Directorate General of Communicable Disease Control and Environmental Health, Republic of Indonesia Ministry of Health; 2005.
- National TB Programme of Indonesia, Jakarta, Indonesia.
- WHO Indonesia Office, Jakarta, Indonesia.