IMPACT OF GLOBAL FUND INVESTMENTS:

MAKING A DIFFERENCE IN INDONESIA

The tuberculosis (TB) burden in Indonesia is among the top 5 in the world. Despite still facing high TB burden, the national TB control program in Indonesia, with strong financial and technical supports from Global Fund and other partners, shows significant progress in the last decade: Indonesia is the first country among the highest burden countries in the WHO South-East Asia region to successfully achieve the global TB target for case detection and treatment success in 2006.

The Joint External Monitoring Mission (JEMM) 2013 confirmed that NTP Indonesia has made excellent and sustained progress toward the Millennium Development Goal targets for tuberculosis, enabling Indonesia to enter into the next phase of activities beyond 2015 when, with intensive and sustained application of new policies and strategies, tuberculosis will steadily decline as a public health problem in Indonesia’’

gf-progress-chart

Impact of Global Fund support

Global Fund support to Indonesia has made a significant contribution to the reduction of TB infections, illness and death thereby mitigating the impact caused by tuberculosis. Since the start of Global Fund support in 2002, almost 3 million TB cases have been notified by NTP and 90 % of these notified cases have been successfully treated. Besides prevention of morbidity and mortality the program has averted TB infection of large population numbers.

Prevention of transmission and avoidance of disease and mortality in large population numbers have played a significant role in socioeconomic development of the country.’

Program approach and strategies were well designed and implemented: data available from 2 large Drug Resistance surveys indicate that the level of primary drug resistance is still acceptable (estimated around 2% ) and secondary drug resistance around 12%.

Recently NTP with support from partners developed a TB economic burden model ; The model includes treatment costs and household costs, as well as lost productivity due to disability and premature death.  The total burden resulting from TB, from 2007 to 2011, is calculated as USD 8.5 billion withóut GF funding) and USD 6.3 billion wíth external funding. The modeling indicates that external support for the TB program has resulted in benefits of USD 2.2 billion, i.e., a reduction in the total cost associated with Indonesia’s TB burden.

Increasing TB control program performance:

Over the last 10 years there has been a consistent increasing trend of case notification rates for both ‘’all forms’’ of TB, from 74 to 138 per 100,000.

gf-indonesia-roadmap

The trends are also consistently observed in almost all provinces across the country. The data shows that Indonesia is in the right direction to close the gap in TB case finding. Since the year 2002 national treatment success rate has been consistently above the intended target of 85%, maintaining around 90% up to 2012.

Progress towards impact

Due to improved case detection and good treatment results the national TB control efforts are achieving major impact and the decrease in mortality due to TB is consistent:

tb-mortality

Source: WHO

DOTS expansion over the last 10 years, supported by GFATM and other partners, has resulted in significant improvement of access to quality DOTS services, not only in the general population but also for various risk groups e.g. prison populations, children and TB patients that were treated in non-DOTS hospitals.

The exemplary performance of the National TB control program has recently received global recognitions from the Secretary General of the United Nations, USAID Global Health and other international organizations. The Joint External Monitoring Mission conducted in February 2013 concluded that Indonesia achieved important progress toward the 2015 Stop TB and Millennium Development Goal targets, despite several major challenges still remaining.

Remaining Challenges

The deceleration and stagnation of case notification since 2007 is likely due to considerable numbers of TB and also MDR-TB patients being managed by private sector providers including larger public and private hospitals, that are not yet engaged with the NTP ( despite good progress in hospital linkage over the last 7 years). The large size of the private sector (estimated between 80.000 – 100.000 private providers) and the challenges regarding engagement of such large number of practitioners, is one of the critical negative contextual factors influencing the performance of the disease response in the country.

Addressing the gap in TB, MDR-TB and TB-HIV case-notification, while maintaining good treatment results, is the main challenge for the next Phase of the SSF Grant.

Towards sustainability: the Exit Strategy

The MoH Indonesia has recently developed an “Exit strategy for Global Fund grants financing” which outlines strategies for long term financial sustainability on AIDS, TB and Malaria control. The strategy is based on four elements including 1) increased funding from insurance schemes, 2) increased involvement of Corporate Sector (CSR), 3) increased government funding at both central and local level, and 4) efficient allocation and use of funding.