Neglected Tropical Diseases in Indonesia

An Integrated Plan of Action Ministry of Health Indonesia 2011-2015

World Healthn Organization

World Healthn Organization

An Integrated Plan of Action to successfully achieve elimination and sustained control of 5 of the mostimportant neglected tropical diseases in Indonesia: Lymphatic Filariasis, Schistosomiasis,Leprosy, Yaws and Soil-Transmitted Helminths.

NEGLECTED TROPICAL DISEASES Neglected Tropical IN INDONESIA Diseases in Indonesia

An Plan of of Action Action AnIntegrated Integrated Plan Ministry of Health Indonesia Ministry of Health Indonesia

2011-2015 2011 - 2015

World Healthn Organization

An Integrated Plan of Action to successfully achieve elimination and sustained control of 5 of the most important neglected tropical diseases in Indonesia: Lymphatic Filariasis, Schistosomiasis, Leprosy, Yaws and Soil-Transmitted Helminths. 1

Contents Foreword by WHO Representative Foreword by Director General Disease Control & Environmental Health Executive Summary Neglected diseases in Indonesia Plan of Action for NTD control/elimination General objectives Summary budget Country Profile Geography and demographics Political situation and administrative structure Health care system School Health Programme (UKS) School Immunization Month Programme (BIAS) Background of NTDs & disease control initiatives in Indonesia Leprosy Lymphatic filariasis Schistosomiasis Soil-transmitted Helminths Yaws Overlapping of NTDs endemicity Health, hygiene & nutrition promotion Integrated vector management Integration between disease control initiatives Drug supply and logistics Development of Plan of Action Rationale Benefits Challenges Plan of Action for NTD Control General objectives Expected results ER I Updated strategies based on international guidelines and best practices 2

5 7 11 11 14 14 17 18 18 19 19 21 21 22 22 24 28 30 32 34 34 35 36 38 40 40 40 40 41 41 42 43

ER II Accurate estimation of the burden of the 5 NTDs 43 ER III Successful management of drug donations 44 ER IV Strengthened capacity of health workers and volunteers 45 ER V Integrated social mobilization 46 ER VI Integrated and improved MDA for LF, schistosomiasis, and STH 47 ER VII Integrated and intensified morbidity case detection 49 ER VIII Integrated and intensified case management 49 ER IX Strengthened monitoring and evaluation (M&E) system for the 5 NTDs 50 ER X Establishment of a surveillance system for leprosy, LF, schistosomiasis and yaws after their elimination as public-health problems 51 ER XI Establishment of a national NTD Taskforce 52 ER XII Increased visibility, advocacy and political commitment for NTD control and elimination 52 ER XIII Increased advocacy for comprehensive NTD control linking water, sanitation, hygiene education and chemotherapy 53 ER XIV Integrated health promotion 54 Milestones 56 A. Accelleration Program of Filariasis Elimination, Drug Availability and Distribution 56 B. Program Management, Advocacy, Socialization and Surveillance (MONEV) 57 A. Detailed activities & Times 61

3

Abbreviations

ALB

- Albendazole

AusAID

- Australian Agency for International Development

DC & EH - Disease Control & Environmental Health DEC

- Diethylcarbamazine

DG

- Directorate General

DoE

- Department of Education

DHO

- District (or city) Health Office

GSK

- GlaxoSmithKline

IEC

- Information, Education and Communication

LF

- Lymphatic Filariasis

MB

- Multi-bacillary

MDA

- Mass Drug Administration

MDG

- Millennium Development Goals

MF

- Microfilariae

M&E

- Monitoring and Evaluation

MOH

- Ministry of Health

NTD

- Neglected Tropical Diseases

PHC

- Primary Health Centre

PHO

- Provincial Health Office

PoA

- Plan of Action

SAE

- Serious adverse events

UKS

- School Health Programme

STH

- Soil-transmitted Helminthiasis

UNICEF - United Nations Children Education Fund

4

USAID

- United States Agency for International Development

WFP

- World Food Program

WHO

- World Health Organization

Foreword

H

ealth is recognized as an essential component of human development. In collaboration with Ministry of Health, World Health Organization and other development partners created several opportunities for improving the health of people, enhancing quality of life and ensuring a better future. In spite of various constraints, tangible progress has been made by governments, communities and partners towards improved health outcomes; nevertheless, many challenges lie ahead. These includes, weak health system, an increasing burden of communicable and noncommunicable diseases, high child and maternal mortality, recurrent epidemics and humanitarian crises aggravated by disaster and limited financial resources. In accordance with WHO’s mandate, vision and collaboration and coordination with other partners, we have pledged to continue to focus on partners role in the provision of normative and policy guidance; strengthening of partnerships and harmonization of support to the country, supporting health systems strengthening based on the primary health care approach; putting neglected tropical disease at top of the agenda and intensifying the prevention and control of communicable and non-communicable diseases; and accelerating response to the determinants of health. Indonesia is endemic for neglected tropical diseases (NTDs) for which chemotherapy is available: lymphatic filariasis, soil-transmitted helminthes and schistosomiasis, leprosy and yaws are among the major. Different studies have indicated that there are a number of provinces and districts, where these diseases are co-endemic. Control programs for these diseases are managed vertically and the potential benefits of integration of the programs have not been explored. The country is uniquely positioned to make major advances to reduce, and in some cases eliminate NTDs as public health problems given the demonstrated commitment and strong programmatic experience of the government, and a number of development partners working in NTD control. The NTDs form group diseases are strongly associated with poverty, and these disease agents thrive best in tropical areas, where they have very favorable conditions for the breeding and further development. These diseases are largely silent, as the people affected or at risk have little recognition in the communities and rarely have any political voice. At present, the neglected tropical diseases have their breeding grounds in the places left furthest behind by socioeconomic progress, where substandard housing, lack of access to safe drinking water and poor sanitation, filthy environments, and abundant insects and other vectors contribute to efficient transmission of infection for these diseases. Close companions of poverty, these diseases also anchor large populations in poverty. In developing countries like Indonesia the leprosy and lymphatic filariasis deform in ways that hinder economic productivity and cancel out chances for a normal social life. The infectivity of soil transmitted helminthic infection disrupts school attendance, contributes to malnutrition and impairs the cognitive development of children. 5

The consequences are costly for societies and for health care such as rehabilitation for leprosy and lymphatic filariasis. Fortunately, in the country these problems are now much better documented and much more widely recognized. Good medicines are available for many of these diseases, and research continues to document their safety and efficacy when administered individually or in combination. Generous drug donations by pharmaceutical companies have helped relieve some of the financial barriers and allowed programmes to scale up coverage. A strategy of preventive chemotherapy, which mimics the advantages of childhood immunization, is being used to protect entire at-risk populations and reduce the reservoir of infection. The fact that many of these diseases overlap geographically has practical advantages preventive chemotherapy regimens are being integrated so that several diseases can be tackled together, thus streamlining operational demands and cutting costs. An integrated approach to vector management likewise maximizes the use of resources and tools for controlling vector-borne diseases are practical and feasible. While the report highlights a number of remaining challenges, the overall message is overwhelmingly positive. It is entirely possible to control neglected tropical diseases.Aiming at their complete control and even elimination is fully justified, and this integrated action plan sets out the solid evidence needed to achieve control. Even though each Disease Control Sub-directorate at the MOH DG CDC & EH has its own plan including some level of integrated activities for different diseases, this Plan of Action was needed in light of recent announcement of enhanced drug donations for NTD by pharmaceutical companies globally, renewed donor interest in funding NTD activities for accelerating elimination and control, review and evaluation of schistosomiasis program in Central Sulawesi (October-November 2010), finalization of LF plan for 2010-2014 (May 2010), and need to revitalize MOH integrated disease control strategy developed in 2007 that integrates some activities in the LF, leprosy, yaws and STH program. This single document with key activities about a number of NTD in Indonesia is illuminate synergies between NTD programs that enhance cost-effectiveness. This document can help refine activities for accelerated control of NTD in light of recent international and national developments and could be used as a tool to promote funding at national level in the country and external funding for activities implementation. I would like to express my sincere thanks to the Joint Mission Members from World Health Organization, USAID, and AusAID for the technical support and helping in the process of the development of integrated action plan on neglected tropical diseases to promote NTD Control in the Republic of Indonesia

Khanchit Limpakarnjanarat WHO Representative Indonesia

6

Foreword

T

he neglected tropical diseases (NTDs) are a group of infectious diseases which primarily affect the poorest sectors of society, especially the rural poor and the most disadvantaged urban populations. More than 1 billion people are affected with one or more neglected tropical diseases, yet these diseases remain neglected at all levels. Although some of NTDs affect Indonesia, over the past five years three of them in particular – leprosy, lymphatic filariasis, and yaws – have been targeted for elimination. These diseases not only affecting large number of population also carry high mortality and morbidity; they also affect people’s productive and social lives. Moreover, most of them are feared and are the source of strong social stigma and prejudice and as a result, these diseases are often hidden- out of sight, poorly documented and unmentioned. Strategic steps taken by the international community have contributed to such progress: the World Health Assembly passed resolutions for the global elimination of leprosy and lymphatic filariasis in 1991 and 1997, respectively. In 2006, the WHO South-East Asia Regional Committee passed a resolution calling all Member States to intensify efforts towards achieving the goals of eliminating selected NTDs including yaws. The Ministry of Health has targeted to decrease the diseases transmission, to prevent diseases related disability, especially for leprosy and lymphatic filariasis and to diminish the social stigma toward the diseases. Early case detection and early treatment with MDT (Multi Drug Therapy) are the important strategy to be carried out to reduce leprosy burden. Yaws elimination programme has been started out in hyper-endemic provinces and has completed active case finding and treatment with benzathin penicillin, while the elimination strategy for lymphatic filariasis relies on the mass administration of diethylcarbamazine and albendazole to all individuals living in endemic areas. Minimizing public stigmatization on leprosy and lymphatic filariasis patients are also an important role to be conducted. We should push for integrating these programmes with other sectors by implementing this developed integrated national action plan. We should act rightly and promptly, working in teams which have high integrity, transparent and accountable. NTD control requires an integrated approach with chemotherapy being backed up by a range of supplementary interventions, along with inter-sectoral cooperation by Ministry of Health, education, agriculture and other development related ministries. 7

I would like to make it clear that to make people healthy, there are four main strategies that should become the guideline of every health worker, as follow: 1. Mobilize and empower people to live clean and healthy 2. Improve the accessibility of people to the qualified health services 3. Improve the surveillance system, monitoring, and information of health 4. To ensure implementation of the activities outlined in this integrated plan of action, additional funding need to be allocated from the government of Indonesia at central, and district levels, as well as external funds from international donors.

Prof. dr.Tjandra Yoga Aditama Director General DC and EH

8

WHO/USAID/AusAID Joint Mission for the Promotion of NTD Control in the Republic of Indonesia 15-19 November, 2010

Aim of the mission is to promote the development of a National PoA for the integrated control of NTD.

Participants International Participants A Montresor, Scientist, Control of NeglectedTropical Diseases,World Health Organization, Geneva, Switzerland M. Brady, Advisor, Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland M. Pacque, GHFP Technical Advisor, USAID/Washington DC M. Linehan, Infectious Diseases Team Leader, USAID Indonesia K. Kopoc, Director or CWW (Children without Worms) M Rebollo, Consultant, World Health Organization, Geneva, Switzerland Ministry of Health Indonesia Tjandra Yoga Aditama, Director General of DC & EH Rita Kusriastuti, Director of Vector Borne Disease Control H. Mohammad Subuh, MPPM, Director Direct Transmitted Diseases Trihono, Director General National Institute of Health Research & Development Saktiyono, Programme Manager. LF, Schistosomiasis and STH Christina Widaningrum, Programme Manager, Leprosy and Yaws Taniawati Supali - Indonesia University World Health Organization: Regional Office A.P. Dash, Regional Advisor for NTD, WHO/SEARO, India World Health Organization: Country Office Khanchit Limpakarnjanarat, WHO Representative, Indonesia Anand B. Joshi, Program Manager for NTD, WHO- Indonesia USAID Indonesia Irene Koek, Director, Office of Health Kendra Chittenden, Senior Infection Disease Advisor Artha Camelia, Emerging Infections Diseases Specialist 9

AUSAID Gerard Cheong, First Secretary Health Australian Embassy Gina Samaan, Consultant AusAID, Jakarta JICA – Indonesia Yurico Egami WHO Indonesia - Neglected Tropical Diseas Working Group • Khanchit Limpakarnjanarat, WHO Representative - Advisor and overall guidance • M.R Kanaga, Administration/Management • Anand B Joshi, Member: NTD focal point • Graham Tallis, Member: Communicable Diseases Expert • Sharad P. Adhikary, Member: Environmental Health Expert • M Sudomo, Member: Schistososomiasis and LF expert • Benyamin Sihombing:, Member: Leprosy,Yaws and other NTD specialist • Nursila Dewi, Member: Information/ Communication • Representative from USAID, Indonesia • Representative from AUSAID - Indonesia • Representative from JICA - Indonesia

10

Executive Summary

T

he Government of Indonesia has demonstrated awareness of the important burden of neglected tropical diseases (NTDs). National plans and policies have been developed to fight leprosy, lymphatic filariasis (LF), schistosomiasis, soiltransmitted helminths (STH) and yaws. Successful experiences have demonstrated the political commitment both at the central and district levels. Community compliance and participation are an important part of the NTD programs, as shown by the example of LF, where mass drug administration (MDA) is carried out with help of community volunteers or school deworming where children receive the drug during immunization days, achieving coverage of almost 90% of school-age children (SAC) in the areas where the program is implemented. However Indonesia faces many challenges to achieve the goal of control of STH and elimination of leprosy, LF, schistosomiasis, and yaws. Lack of coordination between different programs and stakeholders, insufficient and irregular political commitment at the district level, and limited funding to fully implement strategies and achieve sufficient coverage, makes it difficult for Indonesia to succeed in achieving the targets set by WHO for sustainable control and elimination of NTDs. This Integrated Plan of Action (PoA) confronts many of those obstacles and proposes a roadmap for integrated control of 5 of the main NTDs in Indonesia:leprosy,LF,schistosomiasis, STH and yaws. Under the leadership of a national NTD Taskforce, integration will focus on advocacy and social mobilization, use of a common pathway to distribute drugs and detect disease cases, capacity building of health workers, and health promotion at community level. This integrated NTD Program will facilitate cost savings and optimal use of human resources, as well as speed up implementation to find the shortest route to achieve the goals on time. To ensure implementation of the activities outlined in this PoA, additional funding will need to be allocated from Indonesian government at central and district levels, as well as external funds from international donors. Drug donations will continue to play a key role in the success of the plan.

Neglected diseases in Indonesia Neglected tropical diseases (NTDs) blight the lives of a billion people worldwide and threaten the health of millions more. These ancient companions of poverty weaken impoverished populations, frustrate the achievement of health in the Millennium Development Goals and impede global development outcomes1. Indonesia has one of the heaviest burdens of NTDs globally, with one of the largest populations at risk. The country is endemic for five of the NTDs for which chemotherapy is available: leprosy, LF, schistosomiasis, STH, and yaws.

11 1

Working to overcome the global impact of neglected tropical diseases. WHO 2010

Leprosy In 2000, Indonesia eliminated leprosy at the national level, with a prevalence rate of less than 1 case per 10,000 populations. However, the number of new leprosy cases, approximately 20,000 per year, has remained stable for ten years. In 2009, 14 provinces and 160 districts, mostly in the east and central and west Java, still reported a prevalence rate of >1 per 10,000 population. Epidemic indicators such as the proportion of grade-2 disability (10.5%), the proportion of child cases (12.01%) and the proportion of multi-bacillary (MB) cases (82.43%) indicate that ongoing support is needed to reduce the leprosy burden. The leprosy program aims to reduce disability from 10% to 5% by 2015, through rapid index-case finding in high endemic areas. The National Programme for Leprosy’s strategy consists of four main activities i.e., case finding, case detection, case management and mitigation of the impact of leprosy. Comprehensive case finding and detection efforts are important initial activities to identify and detect cases in a leprosy service area unit. Case management emphasizes accurate diagnosis and treatment. Counseling is an integral activity in case management to ensure treatment compliance and to overcome stigma. Mitigation of the impact of leprosy includes improving the quality of life of for people affected by leprosy through disability care and rehabilitation and psychosocial and economic support. The leprosy program estimates a cost of $60,000 per district for active case finding, for a total of $3 million for 50 districts. The Novartis Foundation supplies free drugs through WHO. The Netherlands Leprosy Relief and Sasakawa Foundation provide operational and technical assistance to the MOH program. Lymphatic Filariasis (LF) LF is one of the major public health problems in Indonesia. All three types of lymphatic parasites namely Wuchereria bancrofti, Brugia malayi and Brugia timori are prevalent in Indonesia, but B. malayi is the most dominant. Twenty-three species of mosquitoes are vectors for LF in Indonesia as of 2009, an estimated 125 million people are at risk of filariasis infection, in 337 endemic districts, which function as the LF program’s implementation units. The highest prevalence rates were in Maluku, Papua,West Irian Jaya, East Nusa Tenggara and North Maluku provinces (all in east Indonesia). A total of 11,914 chronic cases have been reported nationally between 2000 and 2009. The Government of Indonesia has decreed filariasis elimination as one of national priorities to combat communicable diseases in line with Presidential decree number 7, 2005, and agreed to participate in the international goal launched by WHO to eliminate LF as a public health problem by 2020.The LF program’s objectives are to reduce and eliminate transmission of LF by MDA, and to reduce and prevent morbidity in affected persons. In 2009, MDA with diethylcarbamazine (DEC) + albendazole covered more than 19 million people in 30% of the endemic districts, with an average program drug coverage rate of 66.5% of the at-risk population in those districts. Albendazole is donated by GlaxoSmithKline (GSK) through WHO and DEC is purchased locally. According to the 2011-2014 National Plan for LF, the central government is responsible to ensure the procurement of drugs and provide 12

routine budget, while the local government is expected to contribute the operational and maintenance budget. External funding is required to achieve the goal of elimination by 2020. The cost of distribution per person calculated in the National Plan is US $0.23. Schistosomiasis Schistosomiasis, due to Schistosoma japonicum, is endemic in the Lindu, Napu and Bada valleys in Central Sulawasi province, with an at-risk population of 25,000 to 50,000.Although control activities ended in 2005, 2010 surveys showed a resurgence of transmission with an average prevalence of infection of 9.6% among 5 villages in Napu Valley. These areas have restricted access to potable water and sanitation, with few families having latrines. The program has limited resources for control operations and praziquantel for treatment of those infected has not been readily available. A detailed and budgeted plan (2011-2014) for schistosomiasis elimination was developed by the Vector-Borne Disease Control Directorate (VBDCD) within MOH. The total cost of the programme in the draft plan is US $4,838,760 for the period. The unfunded gap is equivalent to 65% of the total amount. Soil-transmitted helminths (STH) In the last 15 years, hundreds of districts have been surveyed in Indonesia to assess the STH prevalence. Over 40,000 individuals (mostly children) were involved. Results show that STH infection is widespread in the country and, according to WHO guidelines, most of the areas surveyed need at least one treatment/year. Preliminary predictive mapping for areas for which data are not available suggests that STH are intensively transmitted through the entire country. In 2009, more than 19 million individuals were treated with donated albendazole through LF MDA; this treatment resulted in deworming of 1 million preschool children and 3.6 million school-age children. An additional number of children were dewormed through the school system by local authorities and international partners such as the World Food Programme (WFP); however exact treatment figures are not known at national level. Twenty-one and a half million children live in districts where LF is not endemic and therefore do not benefit from the impact of albendazole distribution through LF MDA.As some of these districts are highly endemic for STH, they would benefit from a donation of mebendazole. Yaws Currently 18 of the 33 provinces are believed to be affected with yaws, with five classified as high burden. In 2009, 8,309 cases were reported (mostly from 6 districts in Nusa Tenggara Timur province), and numbers have been increasing steadily since 2001 (when 2,112 cases were reported). From the remaining provinces, no information is available. The MOH strategy is designed to eradicate the disease by 2013. The strategy includes active casefinding of cases and their contacts, mobilization of community support, capacity building of health staff for detection and management of cases, and establishment of partnerships with other disease control programs and external partners. Active case finding, or annual ‘search and treat’ missions, is planned to scale up from 10 districts in 2010 to 18 districts in 2011, using an island-by-island approach.Technical assistance, monitoring, supervision and 13 2

WHO. Preventive chemotherapy in human helminthiasis. Geneva, World Health Organization, 2006.

training are integrated with the leprosy programme. The program estimates a budget of $80,000 per district, not including technical assistance and monitoring, for a total cost of $9 million over 5 years.

Plan of Action for NTD control/elimination The Government of Indonesia is committed to intensify its efforts to control and eliminate five of the most important NTDs affecting the country and causing suffering and impoverishing millions of people. This Plan of Action (PoA) was developed to improve the management of each disease and make the programs more efficient by integrating some of the activities in a way that will save human resources, time and money. This integrated approach should obtain better health results and help achieve the final goal of sustained control of STH and elimination of leprosy, LF, schistosomiasis, and yaws from Indonesia. General objectives i)

to strengthen the Indonesian health system through improved training, advocacy and coordination at all levels of the health system,

ii)

to strengthen multi-sectoral collaboration within the MOH, Ministry of Education, Ministry of Internal Affairs and Ministry of Religious Affairs among others, and

iii) to strengthen the national capacity for successful management of international cooperation funding (USAID, AusAID, WHO and other international agencies) and drugs donations (DEC, albendazole, mebendazole, benzathine penicillin, praziquantel, leprosy multidrug combination). The main expected results of this PoA are: i)

Updated strategies based on international guidelines and best practices

ii)

Accurate estimates of the burden of these 5 NTDs to improve macro and micro planning, monitoring and evaluation.

iii) Successful management of drug donations. Lack of timely access to drugs constitutes a barrier for success of most of the programs. However, there are companies willing to donate their drugs to countries which can demonstrate their capacity to forecast and distribute the drugs to those in need. iv) Strengthened capacity of health workers and volunteers through integrated training at all levels. Activities which strengthen the knowledge, abilities, skills and behavior of individuals (MoH, health workers, school teachers and communities) and improve institutional structures and processes help the program more efficiently meet its mission and goals in a sustainable way. v)

Integrated social mobilization activities, key for the success and sustainability of the plan.

vi) Integrated and improved MDA for LF, schistosomiasis, and STH including scaling up and increasing coverage to achieve the individual program goals. 14

vii) Integrated and intensified morbidity case detection for leprosy, LF and yaws through MDA campaigns and field visits of health care workers (index case contacts study). Intensified case-finding during LF MDA campaigns and IEC activities is a unique opportunity for leprosy and yaws elimination efforts to screen communities. viii) Integrated and intensified case management for leprosy, LF and yaws through field visits of health workers and support to self-care groups. Improving case management is one of the best ways to fight stigma and discrimination of chronic patients, win the trust of the community, and increase self declaration by suspected patients. ix) Strengthened monitoring and evaluation system for the 5 NTDs. x) Establishment of a surveillance system for leprosy, LF, schistosomiasis and yaws after the elimination of these diseases as public health problems. ‘Supporting’ expected results are: xi) Establishment of a national NTDTaskforce. By joining all national and international stakeholders in a single network, the program will improve coordination among the different programs, integrate of activities, share results, facilitate solutions, and maximize impact. xii) Increased visibility, advocacy and political commitment for NTD control and elimination. Having one PoA for 5 different NTDs will increase their visibility and will facilitate political and financial commitment by maximizing results with minimum cost. xiii) Increased advocacy for comprehensive NTD control which links water, sanitation, hygiene education and chemotherapy. A long-term solution to fight and eliminate diseases related to poverty is to fight poverty itself, by improving living conditions and enabling people to change their behavior by having access to water, sanitation and hygiene education. xiv) Integrated health promotion and hygiene education. Every opportunity will be used to promote health and hygiene in the community. Social mobilization campaigns, MDA, school deworming days, self-care groups as well as every contact with the health system will be use to promote hygiene and health habits.

15

n

ariasis

an integrated actions

MDA

Albendazole Mebendazole & PZQ

Logistics

Coordination Budgeting Planning Case detection

Hygiene Maps

Wat & San

Training Social mobilization AMR Health education

Guidelines

DEC Surgery

Rehab & palliative care Hygiene

Advocacy SAE Support groups Surveillance Fight stigma M&E MD and BP Case management

“Index case detection”

Summary budget

Integrated Neglected Tropical Disease Budget Estimation in USD 2011 Estimated Operational government gaps 16 commitment (External funds required) 10,000,000

5,000,000

2012 Estimated Operational government gaps commitment (External funds required) 10,000,000

5,000,000

2013 Estimated Operational government gaps commitment (External funds required) 10,000,000

5,000,000

2014 Estimated Operat government gap commitment (Exter fund requir 10,000,000

5,000,

17

1,000,000

150,000

11,650,000

Schistosomiasis

Grand Total

500,000

Soil Transmitted Helminthic Infection (STH)

Leprosy and Yaws

10,000,000

6,000,000

100,000

700,000

200,000

5,000,000

Operational gaps (External funds required)

2011

Estimated government commitment

Lymphatic filariasis

Description

11,650,000

150,000

1,000,000

500,000

10,000,000

Estimated government commitment

6,000,000

100,000

700,000

200,000

5,000,000

Operational gaps (External funds required)

2012

11,650,000

150,000

1,000,000

500,000

10,000,000

Estimated government commitment

6,000,000

100,000

700,000

200,000

5,000,000

Operational gaps (External funds required)

2013

11,650,000

150,000

1,000,000

500,000

10,000,000

6,000,000

100,000

700,000

200,000

5,000,000

Operational gaps (External funds required)

2014 Estimated government commitment

Integrated Neglected Tropical Disease Budget Estimation in USD

11,650,000

150,000

1,000,000

500,000

10,000,000

6,000,000

100,000

700,000

200,000

5,000,000

Operational gaps (External funds required)

2015 Estimated government commitment

Summary Budget: Integrated Neglected Tropical Disease Budget Estimation in USD

Country Profile

Geography and Demographics

I

ndonesia is the largest archipelago country in the world with 17,508 islands of which 6,000 are inhabited3 . It is located in Southeast Asia between the Indian Ocean and the Pacific Ocean, and spans a total area of 1,919,440 sq km (land 1,826,440 sq km & water 93,000 sq km). Indonesia has a number of natural resources including petroleum, tin, natural gas, nickel, timber, bauxite, copper, fertile soils, coal, gold, silver. Various islands periodically face natural disasters such as floods, severe droughts, tsunamis, earthquakes, volcanoes and forest fires4. In 2008, the population was estimated at 228.8 million, of which 168.3 million are ≥15 years old. The gross income per capita was estimated at USD 3,310 (Box 1). The major religion in Indonesia is Islam with 88% of the population, followed by Protestant 5%, Roman Catholic 3%, Hindu 2%, Buddhist 1%, other 1% (1998 data)4. Infant mortality rate (IMR) nationally is 26.8, ranging from 8.2 in DKI Jakarta province to 43.2 in West Nusa Tenggara province3. Box 1: Demographic statistics in Indonesia5 Statistics: Total population: 228,864,000 Gross national income per capita (PPP international $): 3,310 Life expectancy at birth m/f (years): 66/69 Healthy life expectancy at birth m/f (years, 2003): 57/59 Probability of dying under five (per 1 000 live births): 34 Probability of dying between 15 and 60 years m/f (per 1 000 population): 231/192 Total expenditure on health per capita (Intl $, 2006): 87 Total expenditure on health as % of GDP (2006): 2.2

Based on Bureau of Statistics 2008 data,3 mean years of schooling is higher for males than females (8 years vs. 7.1 years) nationally. The National Socio-economic Survey (SUSENAS), a household survey conducted by the Indonesia Bureau of Statistics (BPS), found that 96.1% of children 7-12 years old were enrolled in school, compared to 79.2% for children 13-15 years old, and 49.8% for children 16-18 years old. School enrollment varies from 99.52% in Jogjakarta province to 83.38% in Papua province. The percentage of households using an improved drinking water source, such as a pump/ well/spring water (that are at least 10m away from a septic tank), was 52.72% nationally.This varied widely from 69.21% in Jogjakarta province to 34.86% in West Papua. Importantly, the regional variation did not necessary correlate with urbanization since city provinces such as Jakarta also had low rates (44.33%). 18 3 4 5

Bureau of Statistics: www.dds.bps.go.id/eng/download_file/booklet_leaflet/booklet_okt2009.pdf Asian Center for the Progress of Peoples 2007: www.acpp.org/uappeals/cprofile/Indo%20Country%20Profile.pdf World Health Statistics: http://www.who.int/healthinfo/statistics/en/

Political situation and administrative structure Indonesia is a democratic republic with 33 provinces encompassing 397 districts and 98 cities3. Indonesia’s governance was decentralized to the level of district/city on 1 January 2001. The 495 districts and cities have become the key administrative units responsible for providing most government services including health but excluding defense and national security, foreign affairs, fiscal policy and religion. Since 2001 the situation has evolved and currently decentralization in Indonesia has entered a new phase of consolidation; however local institutions in many districts and cities still lack the capacity to fulfill their new mandates effectively. Further, development indices, poverty rates, and proneness to crisis (conflict or natural disasters) vary across different provinces. Coupled with the diversity in culture, terrain and population, these have made implementation of interventions a challenging task6 . The Ministry of Interior Affairs (Dalam Negeri) is the key ministry responsible for decentralization and the funding of regional governments.

Health care system The overall health financing situation in Indonesia is complex and incompletely documented7. In 2003, around 34% of total health expenditure was undertaken by public sector agencies, while 66% was private. By far the largest single source of private expenditure was direct out-of-pocket payments by households, accounting for nearly half of the total expenditure. Insurance coverage has been increasing since the advent of the new social insurance scheme for the poor7.

The general decentralization process implemented in 2001 has had many impacts on the health system, even though it was not designed specifically with the health sector in mind. In particular, health financing, health information system, human resources for health and service provision have been affected. Under decentralization, responsibility for health care provision is largely in the hands of district/city governments. Despite this, the central government continues to set the national agenda, targets for health and along with the provincial governments, provides a supervisory, support and monitoring role for district/city governments. The Ministry of Health (MOH) in Indonesia, situated in the capital Jakarta, has 4 Directorate-Generals, 2 Institutes, an Inspectorate-General and a Secretariat-General under which there are 14 Centers and Bureaus (Figure 1).A number of these structures are critical for the control of NTDS under consideration in this PoA. Primarily, the DirectorateGeneral of Disease Control & Environmental Health (DG DC & EH) has five directorates, where the Directorate of Vector-Borne Disease Control oversees LF, schistosomiasis & STH control and the Directorate of Directly-Transmitted Diseases oversees leprosy and yaws control. Under the DG DC & EH, there is a planning unit, finance unit and a regulation unit that are involved in the overall management of the business of the Directorate-General.

19 6

Government of Indonesia and UNDP Country Programme Action Plan, 2006-10 www.undp.or.id/pubs/docs/CPAP%202006-2010.pdf 7 World Health Organization Indonesia Country Office www.searo.who.int/indonesia

Figure 1: Organizational structure of Ministry of Health, Indonesia*

STRUKTUR ORGANISASI DEPARTEMEN KESEHATAN INSPEKTORAT JENDERAL INSPEKTORAT JENDERAL

SEKRETARIAT JENDERAL SET

STAF AHLI MENTERI

INSPEKTORAT

BIRO PERENCANAAN DAN ANGGARAN DIREKTORAT JENDERAL BINA KESEHATAN MASYARAKAT

DIREKTORAT JENDERAL BINA PELAYANAN MEDIK SET

SET DIREKTORAT

DIREKTORAT

BADAN PENELITIAN DAN PENGEMBANGAN KESEHATAN

BIRO KEPEGAWAIAN

DIREKTORAT JENDERAL PENGENDALIAN PENYAKIT DAN PENYEHATAN LINGKUNGAN

PUSAT KESEHATAN HAJI

BIRO HUKUM DAN ORGANISASI

BIRO UMUM

DIREKTORAT JENDERAL BINA KEFARMASIAN DAN ALAT KESEHATAN

SET

SET DIREKTORAT

DIREKTORAT BADAN PENGEMBANGAN DAN PEMBERDAYAAN SDM KESEHATAN

SET

SET

PUSAT

PUSAT DATA SURVEILANS EPIDEMOLOGI

BIRO KEUANGAN DAN PERLENGKAPAN

PUSAT

PUSAT PROMOSI KESEHATAN

PUSAT PENANGGULANGAN KRISIS

PUSAT PEMBIAYAAN DAN JAMINAN KESEHATAN

PUSAT KOMUNIKASI PUBLIK

PUSAT SARANA, PRASARANA DAN PERALATAN KESEHATAN

PUSAT PEMELIHARAAN

PUSAT PENINGKATAN, DAN KERJASAMA LUAR PENANGGULANGAN NEGERI INTELEGENSIA KESEHATAN

*Menteri kesehatan = Minister of Health, Direcktorat Jendral Pengendalian Penyakit dan Penyehatan lingkungan

= DG DC & EH, Direktorat Jendral Bina Kefarmasian dan Alat Kesehatan = DG Pharmacy and Health Supplies, Pusat Promosi Kesehatan = Centre for Health Promotion, Pusat Kerja Sama Luar Negeri = Centre for International Collaboration, Direktorat Jendral Bina Pelayanan Medik = DG General Medical Services, Direktorat Jendral Bina Kesehatan Masyarakat = DG Community Health.

For NTD control, the DG DC & EH also coordinates with the Centre for Health Promotion, the Bureau of Planning & Budgeting (under the Secretary-General), as well as the Directorate-General for Pharmacy & Medical Services and the National Institute for Health Research & Development. In addition to lateral coordination, the DG DC & EH also coordinates with the provincial and district health authorities. Structures for disease control such as vector-borne diseases and directly-transmitted diseases are replicated on a smaller scale in provincial governments. The general division of mandate between national, provincial and district/city governments can be seen below: • Central MOH: prepare national strategy, guidelines & regulations for disease control and provide a supervision, monitoring and support role to provincial and district/city authorities • Provincial Health Office (PHO): adopt national strategies to develop provincial strategy based on local situation, provide training, funding support, supervision & monitoring for district/city level health offices • District/City Health Office (DHO): develop district/city level plans, directly implement disease control activities, supervise lower health structures such as primary health care centers. 20

School Health Programme (UKS) There are about 175,000 public, religious and private schools in Indonesia, all of which are eligible to participate in the School Health Programme (UKS - Upaya Kesehatan Sekolah). There are about 27 million students in primary school, about one quarter of whom are in religious schools (Madrasah Ibtidaiyah). Education is compulsory and provided free of charge in public schools for children from 7 to 15/16 years of age, corresponding to all 6 classes of primary school and 3 classes of secondary school. The number of teachers working in primary schools is 1.38 million. The three major UKS programmes include health education, health service delivery through schools, and a healthy school environment. In addition to immunization, the health services delivered include health and nutrition screening for new students; height and weight monitoring; health education, dental care; iron and iodine supplementation; and de-worming in some areas. Booklets and materials have been developed for UKS, which provide the objectives of the program, health information, how to conduct health promotion in schools and monitoring/evaluation procedures. Content includes information about good nutrition and how to build latrines and water pipes. The MOH Child Health Directorate coordinates activities relevant to the UKS. Four ministries (MOH, Ministry of Education, Ministry of Internal Affairs and Ministry of Religion) are involved in UKS.The implementation is mandated by teachers and supported by primary health care staff in all schools, including religious schools. There is also a ministerial decree about minimum standards in schools for ensuring health (KepMenKes 1429/MENKES/SK/ XH/2006).

School Immunization Month Programme (BIAS) In 1998, the Ministries of Health, Education (MoE), Religious Affairs (MRA), and Internal Affairs launched Bulan Imunisasi Anak Sekolah (BIAS), School Immunization Month Programme. BIAS was designed to be a sustainable routine activity to eliminate tetanus and provide diphtheria boosters. In 2000, measles campaigns for 6-12 year olds were included in provinces that had funding. Since 2003, reported vaccination coverage in schools through BIAS has been about 95% each year. The MOH has the responsibility for policy, service delivery and evaluation, while the MoE and MRA handle social mobilization. The Ministry of Internal Affairs, through its local government and municipality offices, is responsible for covering operational costs. The UKS team leader at each level coordinates and monitors implementation of the overall integrated school health programme, including BIAS. Within the MOH, the staff in charge of health promotion at each level looks after UKS overall; however, the Expanded Programme on Immunization (EPI) is given responsibility at each level to implement BIAS. The UKS guru(s) oversees BIAS within the school. BIAS is managed, supplied and implemented without the technical or financial involvement of multilateral or bilateral partner agencies. While BIAS was integrated within the existing UKS structure, most respondents at lower levels indicated that the existence of the UKS structure was helpful but not in fact required for the adoption of BIAS, since the health workers felt they were able to forge good relations with local schools on their own. 21

Background of NTDs & disease control initiatives in Indonesia

Leprosy Leprosy is a disease caused by Mycobacterium leprae, a bacterium which primarily affects the skin and peripheral nerves. main mode ofcontrol transmission is considered to be air-borne, Background of The NTDs & disease initiatives in Indonesia through droplets discharged from the respiratory tract of untreated infectious cases, who form Leprosy 10 100,000 data from the MOHdata show from thatthat prevalence remains above the elimination levelelimination in 160 (35%) out of 460 districts. Further the MOH show prevalence remains above the level in 160 (35%) out of stratification of new case detection from 2007 suggests that from the heaviest burdenthat is the 460 districts. Further stratification of newrates case detection rates 2007disease suggests in 125 (27%) out of the 460 districts. Figure 2 indicates the burden of disease by province in heaviest diseaseIndonesia. burden is in 125 (27%) out of the 460 districts. Figure 2: Indicates burden ofindisease province in 2009, Indonesia Figure the 2: Leprosy burden Indonesiaby as of 31 December by province Leprosy Burden in Indonesia (31 Desember 2009) Total number new cases 17,260 (Rate:7,49/100 000) Population 2009 : 230.473.991 Aceh

Sumatera

Kalimantan

Gorontalo

North Sulawesi

North Maluku

West Papua

Papua

480(11)

878(2.1)

602 (4.82)

193 (19.08)

425 (18,79)

391 (14.43)

247 (33.01)

887(40.06)

High burden (CDR>10/100000) Or new case> 1000 Low burden CDR