Indonesia is one of the 27 MDR TB high burden countries worldwide, with estimated 6,800 new cases every year. The national MDR-TB estimated 2.8% among new TB Cases and 16% previously treated TB cases. By the end of November 2016, in Indonesia PMDT services have expanded to 35 PMDT referral hospitals, 57 PMDT treatment centres and 1,193 Treatment sites (treatment satellite) in 34 provinces. More than 55,000 TB patients being tested for drugs resistance and 6,000 of DR-TB patients (MDR, Pre XDR and XDR patients) have been treated all over the country since 2009. n 2016 (January to November), 2293 were confirmed as MDR TB/ RR TB and 1420 (62%) new cases were enrolled. (source: Indonesia.etbmanager.org) Treatment success rate for MDR/RR-TB cases registered 2013 in Indonesia was 51%, and Treatment success rate for MDR/RR-TB cases registered 2013 in Indonesia was 40%. ( source: Global Tuberculosis Report 2016).
Patients with MDR-TB and RR-TB (MDR/RR-TB) require radical changes in treatment compared to those with drug-susceptible TB. They need prolonged treatment (often up to two years) with costly, highly toxic and much less effective second-line medicines, of which there is only a limited number. Moreover, once fluoroquinolones and injectable agents – leading components in second-line treatment regimens – are compromised by additional drug resistance (extensively drug-resistant TB, XDR-TB, defined as MDR-TB plus additional resistance to at least the two most important groups of second-line medicines: the fluoroquinolones and the injectable agents kanamycin, amikacin and capreomycin), treatment becomes extremely difficult.
In Indonesia, MDR TB cases also can not be underestimated. Each year there are an estimated 6800 new MDR TB cases, or 2.8% of all new infections. That number also means that 16 percent of TB cases being treated are MDR TB cases. The current treatment in Indonesia for MDR and XDR-TB is accessible in more than 90 hospitals including referral hospitals, and 1,193 puskesmas which are satellite facilities, spread over 34 provinces. Since 1999 more than 55,000 people have undergone drug resistance tests and 6000 drug-resistant cases have been treated. Data from the Global Tuberculosis Report found that the success rate of MDR TB treatment in Indonesia reached 51%, while for XDR TB the figure fell to 40%.
TB and Public Health
TB is a latent challenge for public health systems. The key to preventing transmission (suppressing the growth of new cases) is to improve the health system to enable everyone to be diagnosed quickly and gain access to effective treatment. At the same time poverty must also be overcome, because poverty is closely related to infectious diseases. Poverty increases the risk of transmission and removes access to adequate treatment. TB is an airborne disease, and therefore it is very important to create a healthy environment and reduce the risk of transmission. These are the duties of public and government health experts.
That way is very important because the problem with TB and MDR TB is so far there is no vaccine to prevent it. Faster and simpler therapeutic methods also do not exist. In addition, in Indonesia the ability to diagnose MDR TB is also uneven, especially for TB in children and TB outside the lung. What can be done now is the political will to improve access to diagnosis and treatment, poverty alleviation, and community-based support.
What about adherence to taking medicine? As previously written, non-adherence behaviors or “disobedience” of patients to continue treatment often occurs because the patient feels healed so as to discontinue the drug, or the patient feels a lot of drug side effects (nausea, vomiting, headache, itching), which is not communicated well by the doctor when consulted. As a result, the patient unilaterally stops taking the medicine without fully realizing the risk of germ-resistant resistance.
The patient’s failure to regularly take medication is caused by many factors and actors outside of himself. Doctors should ensure that the information provided is understood by each patient. For that doctors need to be creative in delivering the message because each patient has a unique way to understand his condition. But more than delivering messages and information, doctors also need to understand the situation of patients and identify what problems can be a barrier to adherence patients. Doctors should not simply provide information without checking whether the patient understands it.
In closing, despite the big challenges ahead, we need not worry because there are already experiences that show TB and MDR TB prevention efforts can work well. The main requirement is of course the concern and commitment of the community and related stakeholders.
Indonesia is making strides towards UHC under its NHI programme or Jaminan Kesehatan Nasional (JKN), which was launched in 2014. The system is financed by premiums paid by employers, the employee and, for those with a low income, the national government. Beneficiaries can access a package of health services through public and selected private health-care providers, who are paid by capitation
for primary health-care services and by reimbursement based on disease classification for hospital care. TB services covered include diagnosis and treatment services for drug- susceptible TB. In addition to the insurance scheme, there is also substantial budget-line support, including first-line
TB drugs financed by the central government, and second- line drugs financed primarily by the Global Fund. High demand and costs, particularly in higher- level facilities, are challenging sustainability. Therefore, the government is in the process of reviewing the benefits package, including through cost–e ectiveness analysis. The NTP is working with JKN, via Indonesia’s Centre for Health Financing and Health Security, to create TB service provision guidelines and monitoring tools for JKN.
The government has announced its intention to shift financing of TB care and prevention to the NHI scheme, which is likely to lead to changes in access to TB medications and services. The mechanisms for financing public health functions are also in flux. A significant proportion of TB patients in Indonesia are treated in the private sector, and JKN may enable further leverage in promoting notification and quality care. By increasing investment in primary care, JKN may help to defray pre-TB diagnostic costs for patients
- Sources: Harimurti, Pandu; Pambudi, Eko; Pigazzini, Anna; Tandon, Ajay. 2013. The nuts and bolts of Jamkesmas – Indonesia’s government-financed health coverage program for the poor and near-poor. Universal Health Coverage (UNICO) studies series; no 8. Washington D.C.: The Worldbank. http://documents.worldbank.org/curated/en/430821468044119982/ The-nuts-and-bolts-of-Jamkesmas-Indonesias-government-financed- health-coverage-program-for-the-poor-and-near-poor. Mukti, A. G., D. Mustikawati, D. Collins, F. Hafi, B. Setyaningsih, and H. Utami. Policy Options and Levers for Financing TB Services in Indonesia. USAID TB CARE I, 2013