Country Perspective: Indonesia

Dyah Erti Mustikawati NTP Manager, Indonesia

Ninth Meeting of the Subgroup on Public-Private Mix for TB Care and Control and Global Workshop on Engaging Large Hospitals, 28-30

August 2013, Bangkok, Thailand

Basic principles for PPM Indonesia Aim:

– to reach the remaining 30-40% patients (unreached currently) – Ensuring the protection of access toward quality TB care – Reducing/ Preventing more severe epidemi: TBMDR/XDR

By: – Increase coverage of TB program to:

Close the gap (CNR increase 5%/yrs, Mandatory notification) Early detection and early access to PMDT for every TBMDR/XDR Maintaining High Standar of quality TB care

– But not sacrifice the quality of services to: Protect the right of patients Reduce mortality and morbidity

Key approach: – Regulatory – System strengthening To Provide stromg Foundation for TB Control Program

The size and the role of, and contribution to TB control, of the identified provider group

Health Providers:

Indonesia Total DOTS

# % Primary Health Care 8875 8875 100% Lung Clinics / Hospitals 37 37 100% Public Hospitals 533 458 86% Private Hospitals 867 314 36% Military/ Policy Hospitals 181 95 53% Para-Statal Hospitals 63 29 46% Prisons 270 168 62% Private Practitioners >80.000 315 0.3% NGOs 11 - Workplace 29 -

PPM Contribution 2012 Country Provider Group

including large hospitals

No. of cases contributed by non-NTP public providers

No. of cases contributed by non-NTP private, corporate and voluntary providers

% of contribution from non-NTP providers to total case notification

Indonesia •PHCs: 8875 •PPs: 315 •Prisons: 168 •Hospitals:

a.Private Hosp: 314 b.Public Hosp: 458 c.Parastatal Hosp:

29 d.Military/ Police

Hosp: 95 •Lung Clinics/ Hosp: 36

•Prisons: 451 •Hospitals: 68,397 cases •Lung Clinics: 8,528 cases

•PPs: 4971 •Workplace: 345 •NGO: 116

25%

Pillar 1: Basic DOTS at Primary Health Care (Puskesmas)

Challenge Action Way Foward TB Service Quality: • Limited coverage of

Labs EQA in PHC (50%)

• No Real time information system

• Lack of funding for TB Health promotion and tracing

• Only focused on New Smear Positive cases

• Limited supervision from district

Improving quality of TB services at PHC: • Expand new TB EQAS system to

cover more than 5000 microscopic centers at PHC level.

• Expand Implementation of electronic TB information system to PHC level.

• Utilization of PHC operational budget (BOK) to support health promotion and patient tracing activities, including activities to reach the unreached population

• Case finding intensification for all forms of TB in PHC level.

• Increase budget available for supervision and improve quality of supervision.

• 100% of EQA coverage by 2016

• SITT phase 2 implementation (including for PHC), will be started on January 2014

• Revise guidance for PHC budgeting tools to support TB control program

• TB supervision tools has been updated.

Low coverage of TB HIV services, only focused in hospitals

• Collaboration strengthening with NAP for “test and treat” initiation

• New policy of CoC decentralized up to Puskesmas level

Started for 10 high burden districts in 2013 and expands gradually to 75 district

Pillar 2: Public/ Private Hospital Services

Challenge Action Way Foward • Lost to follow up rates in

hospital still high, it has decreased, from 48% to 15% in the last 10 years.

• Hospital currently contributed approx. 25% of TB cases in the country. But only 58% of hospitals has been engaged since 2001.

• JEMM 2013 found under reporting of TB cases in all hospitals visited, especially for paediatric, smear negative and extra pulmonary TB

• Financing issues for service fees and operational cost

• Newly updated SPM (Minimum Service Standards) guides local government and public hospital to implement standard TB control.

• Development of New Hospital Accreditation which include TB control requirements

• Development of PNPK (National TB Medical Services Guideline) as reference for Hospital SOP and Clinical Pathway as mandated by health regulation and hospital law to assure quality of services.

• New Managerial Guidance for Hospital Manager/owners.

• Updated supervisory tools for Hospital DOTS implementation

• Integration of TB Surveillance system (SITT) into National Health Information Systems (NHIS) mandated for hospitals.

• Take momentum for TB financing through new Health financing system schemes (BPJS).

• Implementation of new SPM in the next fiscal years.

• Support to National hospital accreditation committee.

• Implementation and monitoring of the new PNPK and managerial guidance

• Ensuring the component for standard TB care are covered by BPJS scheme.

Pillar 3: Private Practitioners and Specialists

Challenge Action Way Foward • Only 0,3%

(315/>80.000) of Private practitioners (stand alone doctors) are reporting to NTP.

• Estimated 30% of TB cases goes to private practitioners

• Preparation for Mandatory Notification. • Transformation of ISTC ver.2 to PNPK as

required by Health regulation for strong impact.

• New TB training system for private practitioners: Faculty of Medicine curricula (Pre service training) and Self financing training (In service training).

• Development of the new accreditation and reward systems for private practitioners, also related with new Health financing system schemes (BPJS).

• Best fit models search for effective engagement: a. Expansion of Private practitioners

involvement under collaboration with ATS, Indonesian Pulmonology society and Indonesian Medical association.

b. Social business model under collaboration with TB REACH

• Mandatory notification will started at 2015, preparation needed: legal aspects, ME systems.

• Dissemination of the new PNPK.

• Pool of trainers preparation for independent training.

• Evaluation of new initiatives.

• PPs at 12 top priority provinces will be engaged by 2016

Pillar 4: Qualified TB Diagnostics

Challenge Action Way Foward • Only 6 provinces

implementing new LQAS system

• Dependency to external supra national laboratory

• Private laboratory are not quality assured

• Non standard lab methods are widely available in private sectors

• Ratio of lab: a. Smear: 1 for

55.000 population

b. Culture: 1 for 22 million

c. DST: 1 for 49 million

• Lab strengthening and country wide expansion of LQAS, supported by TB CARE I and GF.

• Development of road map and long term plan for TB lab expansion with targets: a. 1 Supra national lab before 2016 b. Ratio for lab culture and DST meet

with regional target by 2016. • Involvement of Lab association (ILKI) and

Lab technician association (PATELKI) under collaboration with Lab directorate-MoH.

• Ban for non standard serology examination

• Speed up the expansion of LQAS, not sequential as before

• Preparation of BBLK Surabaya as a candidate for supra national lab

• Speed up preparation process for 18 new labs for culture and DST

• Develop regulation for quality assurance

Pillar 5: Quality of ATD and Rational Drug use

Challenge Action Way Foward • Unknown but huge

uncontrolled TB drug available in free market.

• Limited quality assurance for ATD provided by program (pre and post market)

• All FLD TB drugs provided by GoI but it should follow country regulations.

• Collaboration with BPOM to regulate the market to protect TB patient (quality approach).

• Regular pre and post market quality assurance for ATD provided by PPOM.

• Assist local drug manufacturers to obtain WHO PQM, supported by USP/USAID.

• Collaboration with all pharmacist professional organization (IAI) to support TB program in their respective areas such as manufacture, distribution and drug dispensing.

• Establish regular coordination and communication with BPOM

• Secure funding for pre and post market QA

• At least 2 out of 3 potential candidates could pass PQM by end of 2015.

• Encourage Indonesian Pharmacist association to apply for GF SR

Pillar 6: Community Strengthening

Challenge Action Way Foward • Still limited in scope • Mostly on local

advocacy and DOTS implementation (community case finding and holding, treatment support)

• Only few support on TB-HIV,TBMDR, prison works, PLHIV network, TB patient network

• Establishment of Stop TB Partnership forum Indonesia to engage broader CSOs and community .

• Development of National CSO plan which cover broader issues: a. ACSM b. Support service delivery to unreached

population. c. Increase role of specific NGO/ CSO on

specific area to support TB Program, i.e: IMA, IAI, PDPI, PPNI, DPKR, etc.

• Strengthen capacity of CSOs and community on advocacy and community funding mobilization through various resources: CSR, BAZIS, Dompet Duafa, Church association, Budha Tsu Chi, etc.

• Monitoring Progress

• Intensify coordination

• Documenting lesson learnt/ best practices

• Strengthening networking and data base dissemination to ensure prompt and real time public monitoring watch

• GIS mapping of Quality TB Services

A new direction and opportunity

Sustainable Financing for TB in Indonesia

Government Budget

UHC/ BPJS Community Funding

Resources Central, Provincial, District budget

Central Government

Private/Public CSR, Charity, BAZIS (Zakat, Infaq, Shadaqah), etc

Allocations Program operational cost (training, supervision, meeting) , drugs, reagent, etc.

Diagnostic and Treatment service fee

Income generation, shelter/ dormitory, socio-economic supports, patient’s allowance

Mainstreaming TB under Universal Health Coverage (BPJS) 1

Government owned Health Insurance System The initial phase of BPJS will start in 2014-2016, Full implementation from 2019 onwards. Initial phase will cover 111 million population:

– 25 million employees paying their own premium. and

– 86 million poor population covered by government

Stepwise increase to reach Universal Coverage.

Mainstreaming TB under Universal Health

Coverage (BPJS) 2 TB is included but the package and coverage for

TB still needs to be negotiated. Health Providers in the BPJS: Primary Health Care

units , Hospitals (Public/ Private), Private providers (Stand alone), Clinics need to be accredited first

Timeline for TB: – 2014-2016: Transition phase to gain best fit model,

all diagnostic and treatment cost covered by BPJS, minus ATD and reagents (these will be provided directly by MoH).

– After 2016, all cost for ATD and reagent will be topped up to BPJS, while MoH will focus on coverage of Programmatic aspects