Dyah Erti Mustikawati

Transcription

1 SCALING UP PPM IN INDONESIA Seventh Meeting of the Subgroup on Public-Private Mix for TB Care and Control October 2011, Lille, France Dyah Erti Mustikawati NTP Manager MOH Indonesia

2 Content Background Situation Strategy Challenges Conclusion

3 Background Situation Strategy Challenges Conclusion

4 INDONESIA General Information Total Population (Projection 2009, BPS) Islands Number of Districts 399 Number of Cities 98 Number of Sub Districts Number of Villages Type of Health Care Facilities TOTAL DOTS Health Centre PRM/PPM/PS 1.914/2.746/4.467 Chest Clinic Lung Hospital 9 8 Hospital (39,27%) - Public Hospital Parastatal/Own State Hospital Military-Police Hospital Private Hospital

5 5 Country with TB Burden (Global Tuberculosis Control, 2011) 1. India (2,300,000) 2. China (1,000,000) 3. South Africa (490,000) 4. Indonesia (450,000) 5. Pakistan (400,000) New Cases per year, Died by years (Global Tuberculosis Control 2011)

6 Global report 2011: Rank 9

7 MDG s Indicator Achievement for TB Incidence, Prevalence & Mortality TB, 1990, 2007 *) & 2009 **) TB cases Incidence all type TB Prevalence all cases Per year Per pop Per day Per year Per pop Per day Per year Per pop Per day Per year Per pop (45%) (45%) ~ ~ (36%) ~ (35%) Per day ~ Incidence new smear + cases NA NA NA NA NA NA Mortality (70%) (70%) 167 *) Global Report TB, 2009 page 282 **) Global Report TB, 2010 page 171 ***)Global report 2011

8 BACK GROUND INFORMATION PPM in Indonesia has involved various health providers such as hospitals, prison, workplace/ industry, PPs, Health insurance, Ministry of Defence, Police but not yet in systematic approach PPM initiated first in hospitals and Lung Clinics/hospitals (Hospital DOTS Linkage) because the greater potential role played by the hospital in providing better outputs (institutional approach) in 2000 In coordination with JAMSOSTEK since 2010 provided TB DOTS services to companies with about 13 million workers and families in the country, but until 2011 implementation still limited in 2 big provinces (DKI Jakarta & West Java) PT ASKES is also involved in procurement of standard national TB Drugs JAMKESMAS and JAMKESDA provided the treatment cost for poor TB patients

9 PPM TOOL-KIT FOR SCALE-UP PPM IN INDONESIA BASIC TOOLS OF PPM IMPLEMENTASION TOOLS 1. Rationale & generic approach 2. National situation assessment ACCEPTABLE/ USEFULL v v ENGAGEMENTOF SPESIFIC TYPES OF CARE PROVIDERS TOOLS 8. Engaging private practitioners ACCEPTABLE/ USEFULL 9. Engaging Hospitals v 10. Engaging NGO s v v 3. Operational guidelines 4.ACSM 5. M & E v 6. ISTC v 7. Resources & budgeting v v v 11. Engaging Workplaces 12. Engaging Social Security Organizations 13. Engagement for TB/HIV collaboration 14. Engagement for PMDT v v Esp : Health Insurance schemes (HIS) v v

10 Background Situation Strategy Challenges Conclusion

11 CASE DETECTION AND TREATMENT SUCCESS RATE, INDONESIA *) SR Q CDR Q year *) Q- 2 CDR SR Target CDR RPJMN 73%, Global 70% Target SR RPJMN & Global 85%

12 % CONTRIBUTION TO TB CASE DETECTION by HEALTH FACILITIES % 80% 60% 40% 20% 0% NSS (+) NSS (-) EP retreatment NGO PPs Workplace Prisons Lung clinic Hospital PHC Health facilities PHC Hospital Lung clinic Prisons Workplace PPs NGO

13 ENROLLMENT For PPs PILOT PROJECT by PDPI (OCT 2010 SEP 2011) Total TB cases from 23 pulmonologists in private hospital/clinic TB Program Drugs Prescribed Drugs Total 1314 patients *)From total 1314 patients= 1130 Pulmonary TB patients (adult) (+) 146 Extra pulmonary TB 38 TB on children Number of patients underwent sputum examination (for diagnosis) Area Number of Pulmonary TB patients (Adult) Number of patients with sputum smear examination (+) result (-) result Central Jakarta (91%) 164 (46%) 192 (54%) East Jakarta (76%) 77 (33 %) 155 (67%) South Jakarta (72%) 144 (46%) 168 (54%)

14 Background Situation Strategy Challanges Conclusion

15 Scaling up engagement of all care providers INDONESIA

16 STRATEGIES To enhance expansion of quality DOTS To address TB/HIV, MDR-TB, Childhood TB, the needs of poor population and other vulnerable group To engage all public and private care providers in implementation of ISTC To empower TB patients and communities To strengthen health system and TB control program management To increase commitment of national and local government To enhance research, development and utilization of strategic information

17 Number of patients 1 7 Challenges of National TB Control Program in Indonesia 600' ' ' '000 GAP Estimated ALL TB cases TOTAL notified TB cases New Smear Positives 200' '000 New Smear Negatives Re-treatment Extra Pulm

18 HEALTH SEEKING BEHAVIOUR TB PATIENT *NIHRD (2011)

19 TB Drugs Consumption at Private Market/Sectors* Country Incidence Consumption of TB drugs 1 st line at private market (%) Proportion of loose TB drugs (%) India 1,982, Indonesia 429, Filipina 257, Pakistan 409, China 1,301, Thailand 92, Russia 150, Vietnam 174, Bangladesh 359, Africa Selatan 476, *Wells et al (2011)

20 2.Public/Private Hospital Services - Approach: Hospital Accreditation, Implementation TB DOTS as Minimum Standard requirement for accreditation of Hospitals - Leading: Directorates of Referral Health Services -TA: KNCV 1.Basic DOTS Services At Puskesmas -Approach: Surveillance System Strengthening and MIFA, Improving quality of care, increasing coverage of TBHIV, reaching un-reach pop at remote are (DTPK), increasing referral to Quality DOTS Services -Leading: NTP -TA: WHO, FHI and other partners 3.Quality DOTS services by Private Practitioners and Specialist - Approach: Implementation of ISTC for all TB care and treatment from all care providers, increasing professional responsibility to cure TB patients, rewarding through cumulative credits mechanism for licensing/certification -Leading: IMA -TA: ATS, 4.Qualified TB Diagnostic -Approach: Strengthening lab network and Quality Assurance (public and private) DST, Culture and Microscopic -Leading: Directorate of Medical Support - TA: KNCV and JATA 6.Community System Strengthening -Function as advocator raise fund and commitment, - Increase public awareness, function as public watch to ensure deliveries of quality services, -increasing awareness of right and responsibility of the patients (patient's charter). -Social Mobilization, suspect identification, increasing demand creation, intensifying the services of TB in slum areas and prison -Leading: NGO, FBO, CSO -TA: FHI, other partners 5.Quality of anti TB Drug Dispensing and rational Use of Drug -Approach: law enforcement, establishment of networking and monitoring system, WHO prequalification -Leading: Indonesian Pharmacist Association, DG of Pharmaceutical Services, Indonesian FDA -TA: USP and MSH

21 PROGRESS IMPLEMENTATION OF INDONESIAN COMPREHENSIVE PPM MODEL (1) Pilar 1: Basic DOTS Services at PHC (PHC) Pilar 2: Public/Private Hospital DOTS Services 1. Shifting paper based surveillance system to electronic/web based system 2. Improving TBHIV reporting recording so that it can capture core data 3. Increase demand creation for utilization of Basic DOTS in PHC 4. strengthening linkage with NGO's/FBO's to intensify case finding 5. Improved EQA system for smear microscopic examination 6. Improved format data collection and intensify data validation and feedback mechanism 1. Launching policy for accreditation and indicating TB DOTS services as one of the minimum standard requirement for hospital accreditation (as mandated by Hospital law no 44/2009) 2. Development and publication of standard guideline for hospital accreditation 3. Socialization of SOP for accreditation to all provinces and district 4. Appointing Committee for Acreditation (KARS) and instrument for accreditation 5. Planning for full implementation of accreditation by 2012, and all hospital without accreditation will not be allowed to extend their operational license 6. Directorates of Medical Services as SSF-TB SRs is fully in charge for provision and monitoring of hospital accreditation implementation

22 PROGRESS IMPLEMENTATION OF INDONESIAN COMPREHENSIVE PPM MODEL (2) Pilar 3: PPs DOTS Services Pilar 4:Quality Assured TB Diagostics 1. Implementation of pilot involvement of Pneumologist in DOTS at Jakarta 2. Socialization of ISTC and establishment of ISTC task force in 33 provinces 3. IMA is responsible to ensure the proper involvement of private practitioners in TB treatment in compliance to ISTC. IMA is Srs for SSF TB Indonesia 4. IMA will developed promoting media to remind that the doctor's responsibility is curing the disease not only treating (professional ethical conduct) 5. IMA will develop user friendly reporting recording system for PPs notification and provides scheme for rewarding cumulative credit point for PPs involvent in TB 6. IMA is planning to establish linkage between PPs, private labs and private paharmacyst 1.Establishing External Quality Assurance for Microscopic from 8 Provinces, to national coverage of 33 provinces 2. Improving and stepwise expansion of quality assured DST laboratories 3. Establishing network of QA beyond public services, by including private laboratories services 4.Stepwise Pilot implementation Gene Expert in 17 sites for accelerating the TBMDR confirmation, TB and TBMDR among HIV patients and TB in prisons

23 PROGRESS IMPLEMENTATION OF INDONESIAN COMPREHENSIVE PPM MODEL (3) Pilar 5:Quality of anti TB Drug and rational Use of Drug Pilar 6: Community System Strengthening Conducting Workshop for WHO praqualification to ensure qualified drug distibuted to patients for FLD (2 times), for SLDs (1 time), supported by USP, Directorates of Pharmaceutical services, IFDA Conducting workshop at national level to Enganging Indonesian Pharmacyst Association in TB control and rational drug use I Indonesian Pharmacyst association agreeable role: integrated Pharmacy Care for TB, Certification and license for Pharmacy practice, monitoring rational drug use of TB drugs, introducing TB in curricula of School of Pharmacyst, initiating professional incentives credits for pharmacyst for their engangement in TB control, advocating TB drugs manufactures etc. IFDA: initiating Pharmaciovigilance/ QA of TB drugs Initiation and establishment of National network of TB affected people to echo their voices and mainstreaming their agenda Empowering NGOs involvement for advocacy and public pressure and watch of other 5 pillars implementation Launching small grants for NGO involvement from SSF TB and focusing their involment in intitutional strengthening for PPM implementation

24 Background Situation Strategy Challenges Conclusion

25 MAJOR BARRIERS TO SCALING UP Multiple leading unit for implementation of each pillars complicates the successfull achievement as achievement in each pillars will influence progress in other pillars there should be close coordination and monitoring of each pillars progress. Intensify coordination and collaboration is really needed, however it is sometime very difficult because of each one busy schedule

26 Background Situation Strategy Challenges Conclusion

27 Conclusion The main strategy to prevent the epidemic of TB MDR is providing universal access to qualified DOTS by engaging all care providers achieved NTP has to initiate, facilitate and monitor the engagement of all care providers Multi mix financing mechanism should be introduced to ensure sustainability of TB control

28 THANK YOU