Indonesia is entering a phase of rapid and comprehensive acceleration of its TB activities thanks to a substantial increase in funding for 2004 and 2005. With a fully-funded budget, many opportunities are being taken to improve surveillance, case detection and laboratory services, to extend the involvement of other health-care providers in DOTS and to improve TB/HIV coordination. A population-based TB prevalence survey was carried out in 2004; the data will provide a more accurate estimate of the national burden of TB, and provide a basis for assessing the future impact of the NTP on the TB epidemic. Although Indonesia has achieved a high level of DOTS coverage (98%), this has not yet been matched by high levels of case detection because of several factors, including a backlog of staff to be trained, suboptimal laboratory support and the lack of effective links with the hospital sector and private practitioners. Substantial improvements in the weaker areas of the programme should accrue from the greatly increased investment in the NTP.
System of TB control
In the decentralized primary health-care system, TB control is offered through the district health services. District populations range from under 10 000 to more than 2 million, with the majority between 50 000 and 150 000.
Indonesia does not yet have a designated NRL for TB. A fully functioning national TB laboratory network is currently being developed. The existing laboratory network, which is not formally linked with the NTP, consists of microscopy health centres and independent health centres where trained laboratory staff carry out smear diagnosis. Provincial health laboratories provide some assessments of the quality of smear microscopy, and perform culture and drug susceptibility testing on request.
Surveillance and monitoring
Since the burden of TB has been estimated from old (>20 years) and possibly unreliable data, Indonesia carried out an important national disease prevalence survey during 2004. Analysis of the survey data was still in progress in January 2005, and it is not yet clear whether the best estimate of smear-positive prevalence for 2003 will be significantly different from the WHO estimate of 295 per 100 000 population. Because TB cases have been reported with variable effort and consistency since 1980, the notifications over time give no indication of the underlying trend in incidence. However, the higher notification rates among older men suggest that the epidemic could be in slow decline. The national HIV infection rate remains low (0.1% in adults aged 15–49 years in 2003), but HIV appears to be generating more TB cases among young adults in some parts of Java and Papua.
The very high reported DOTS coverage (98% since 2000) has not been matched by high rates of case detection, although the smear-positive case detection rate has increased markedly between 2000 (19%) and 2003 (33%). Optimizing the functional capacity of health centres plus improved collaboration between the NTP, lung clinics and a limited number of public and private hospitals contributed to this success, and further strengthening of these links is needed. The NTP DOTS programme has been recruiting smear-negative and extrapulmonary cases faster than smear-positive cases since 1995. This may be a result of the heavy reliance on X-ray diagnosis in smear-negative patients, particularly in lung clinics and lung hospitals (involvement since 2002). Among new smear-positive patients, treatment success exceeded the 85% target inthe 2002 cohort. Treatment results have been consistently good since the NTP began to evaluate outcomes comprehensively in 2000, although many patients complete treatment without evidence of cure (15% in 2002). There is no evidence yet that DOTS is reducing the burden of TB in Indonesia, but the 2004 prevalence survey data will give a baseline against which performance can be assessed towards the end of the decade.
Improving programme performance
The decentralization of health-care delivery has unfortunately had a negative effect on human resource capacity and development. Constraints include a high rotation of staff and hiring restrictions. As of December 2003, only 34% of health centre staff were adequately trained. Steps are being taken to alleviate this situation, and Indonesia was approved for additional funding through ISAC, which will help to reduce the training backlog by intensifying activities through mobile “master trainer’s teams”. As part of HR development, management capacity has been strengthened at the central and provincial levels during 2004, leading to a considerable improvement in supervision and monitoring by staff at these levels. Closer collaboration between the central, provincial and district health authorities is having a positive impact on TB control activities.
As a result of increased donor support and funding, Indonesia has carried out detailed planning and budgetary exercises at the district level for efficient disbursement of new funds.
Drug resistance surveillance has not yet been instituted in Indonesia. However, laboratory facilities at Surabaya have been upgraded because this laboratory will be used as the reference laboratory for future drug resistance surveys. Limited surveys in Jakarta have found MDR-TB in more than 4% of previously untreated cases; a fully representative survey is needed to determine whether this situation prevails throughout the country (the national WHO estimate is 0.7%). A survey in Central Java is planned for early 2005. There is no national policy for the management of MDR-TB, and pulmonologists treat MDR-TB cases on an individual basis. Some of the second-line drugs are produced in the country.
Diagnostic and laboratory services
The link between TB laboratories and the NTP remains weak but will be made stronger with the establishment of a central laboratory working group and an NRL. A national assessment caried out in November 2004 evaluated the current laboratory services and will be used to guide planning for future improvements. There is also a need to improve and strengthen the EQA system. Priorities should include training of laboratory staff and preparation of a plan and timetable to carry out training and supervision at the provincial level.
Indonesia is classified as a country with low HIV prevalence but with concentrated epidemics, primarily among injecting drug users. A TB/HIV workshop was held in 2002 to consider experiences from central and provincial levels and to develop an action plan for tackling the dual epidemic. A national TB/HIV coordinating body was established and a situation analysis undertaken to assess the linkages between the HIV and TB control programmes in four provinces with high HIV burdens. Guidelines on the management of TB in PLWHA have been published and a pilot project on collaborative TB/HIV activities at the district level is in progress, with funding from WHO.
Links with other health-care providers
Indonesia has developed a national strategy for PPM DOTS, focusing primarily on the involvement of public chest clinics and public and private hospitals. Several small-scale pilot projects have been started, and the hospital DOTS linkage project in Yogyakarta has shown a dramatic increase in case detection (>400%) since it began in 2000. Countrywide, very few general hospitals, medical colleges or prison health facilities are involved in DOTS, and there are no treatment providers outside the NTP that notify cases. However, plans are under way to scale up the successful pilot projects and to start involving private medical practitioners in DOTS.
KNCV and WHO are the lead technical partners in Indonesia and support all aspects of DOTS expansion activities. Other technical partners include Kuis/Johns Hopkins, MSH, NLR, TBCTA and World Vision. Major financial partners are the ADB, CIDA, the Dutch Government, GFATM and USAID. A national TB Partners forum meets three to four times a year to share information with partners and donors and to strengthen collaboration between the various participants in TB control.
Budgets and expenditures
Funding for TB control has improved substantially since 2002, when the NTP reported a funding gap exceeding 50% of the total budget requirement, and expenditures amounting to US$ 18 million. Available funding more than doubled between 2002 and 2003, although a small funding gap remained. The 2004 budget was fully funded, as is the projected budget of US$ 43 million for 2005. If the funds are fully disbursed, spending by the NTP in 2005 will more than double that in 2002. This impressive growth in funding is primarily because of a large grant from the GFATM, which will provide 34% of the NTP budget in 2005, in addition to the increase in government funding. The additional funds allow for an increase in the anti-TB drug budget, as well as more spending on initiatives to improve case detection and cure rates. As projected total case detection and total spending increase, the NTP budget and total TB control costs (i.e. the NTP budget plus estimated spending on health clinic visits not covered by the NTP budget) are expected to remain relatively constant per patient, at about US$ 150–160 and US$ 180, respectively. It remains to be seen whether the increased funding can be absorbed, and whether increased expenditures result in improved case detection.