Located between Australia and the South China Sea are the fifteen thousand Indonesian islands that make up the fourth largest nation in the world. Indonesia’s 258 million population make it the largest Muslim nation in the world, and home to Java, the most populous island in the world. The national motto ‘Unity in Diversity’ seems appropriate as the Indonesian Archipelago is home to hundreds of ethnicities, linguistic groups and religions. Since its independence, Indonesia has become the largest economy in Southeast Asia, mainly through the export of raw materials, hydrocarbons and agricultural products. The Indonesian capital Jakarta is the second largest metropolitan area in the world and is home to roughly 30 million people. The sheer size and diversity of the country has brought with it significant corruption and inadequate healthcare with only 0.9 hospital beds per 100.000 people and only 0.2 physicians per 1000 people.
Tuberculosis in the country
As the fifth largest cause of death in Indonesia, Tuberculosis claimed 100.000 lives in 2015. Indonesia is in the list of six countries that account for sixty percent of all new TB cases and, together with Nigeria and India, accounts for almost half of the 4.3 million gap between incident and notified cases globally. MDR-TB is a significant problem in Indonesia, with low enrollment for this dangerous drug-resistant variation of tuberculosis putting the country in the list of five countries that account for sixty percent of the global gap between MDR-TB notification and treatment.
TB has now been made a notifiable disease in Indonesia, with Challenge TB support. This means that all health providers delivering TB services are now obliged to report TB cases to the National TB control Program (NTP). Consequently, information on the large numbers of TB patients diagnosed in private hospitals, private clinics, and individual practitioners is now also being included in the national TB surveillance system. This helps to improve our understanding of the TB epidemic.
KNCV Activities in the country
In 2015, the National Peer Educators Association (Perhimpunan Organisais Pasien TB Resistan Obat) was launched to represent all drug-resistant TB patients’ groups in Indonesia and empower patients and ex-patients through psychosocial support and advocacy.
Indonesia is a country where the Challenge TB program is active. Challenge TB is USAID’s flagship global mechanism for implementing USAID’s TB Strategy and is led by KNCV Tuberculosis Foundation, who also led USAID’s previous TB Control projects TB CARE I, TB CAP and TBCTA.
KNCV Tuberculosis Foundation’s work in Indonesia covers all areas of TB control, but our largest investment is in patient-centered care and treatment specifically for people with MDR-TB and or TB/HIV co-infection.
For example, patient support groups give essential support to patients on treatment for multidrug-resistant TB (MDR-TB).
KNCV has joined forces with a number of national and international partners to combat this epidemic. In Indonesia we are leading the largest of all the Challenge TB projects. We do so together with our coalition partners World Health Organization, FHI 360, MSH and ATS.
Our five technical areas of intervention are:
- Ensuring there is universal access to services by integrating TB in the National Health Insurance System (JKN), and securing increased local government funding for TB;
- Increasing TB case detection using an intensified case finding approach to address the current gap in the notification of TB cases;
- Ensuring the quality of treatment and care is up to standard for people with TB, drug-resistant TB and TB with an HIV co-infection;
- Expanding and improving the network of TB diagnostic services;
- Strengthening TB monitoring and evaluation, TB surveillance and operations research.
We work at national level in support of the National TB Control Program, but also in nine provinces in Indonesia. In five of these provinces we give intensified assistance in ten priority districts, in the form of an intensified package of measures which include all components of TB control. In these districts we are working to design “best models of practice”, for the purpose of learning from these models and sharing the best practices for wider implementation.
Our focus in the other four provinces is on supporting the expansion and quality assurance of the most essential components of TB control.
KNCV is also assisting the agencies that are principal recipients of Global Fund (GFATM) support in order to address specific TB technical and managerial issues. Other areas we work in include support and guidance for the introduction of new technologies, such as LED diagnostic microscopy and new drugs to treat MDR-TB (Bedaquiline).
Last year, the number of GeneXpert machines increased by 735% (from 82 to 603) to be able to find more TB patients faster.
We helped to strengthen the voice of TB patients, by supporting the establishment of POP TB, a national association of 8 patient-support groups.
In Indonesia, great progress was made with the development of district ownership and funding for TB control. This way TB care and prevention is further integrated into the healthcare system, working towards sustainable TB control. In order to get district funding, districts are now obliged to produce a TB action plan. We helped develop a national guideline for district planning, as well as to develop a tool to estimate the TB burden at both district and provincial levels. These tools are now used for planning nationwide.
To be able to identify and timely treat more TB and MDR-TB patients, the number of available GeneXpert machines for diagnosis increased from 82 to 603. This year 132 machines were installed throughout 34 provinces, with another 471 machines procured and awaiting installation in early 2017. The accelerated scale-up is funded by the Global Fund (320 machines) and domestic sources (201 machines), with KNCV providing technical advice and funding for procurement, placement, installation, and training for laboratory technicians and regional GeneXpert teams on support and troubleshooting.
Prisoners are a key population at-risk of contracting TB. We therefore worked together with the Directorate General of Correction Ministry of Law and Human Rights and FHI 360 to create the ‘Prisoners Action Plan’. This work plan, which was signed by all participating parties in April, aims to provide all inmates with access to effective TB, DR-TB, and TB/HIV services, and to develop a post-release program.
In 2016, we helped to establish two important Indonesian TB organizations. The first, POP TB, follows in KNCV’s footsteps as an association of local TB organizations. The second, the Yayasan KNCV Indonesia, is a local NGO, working under the umbrella of the KNCV quality network.