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Public-Public Mix for DOTS Indonesia’s Experience

Public-Public Mix for DOTS Indonesia’s Experience. By Dr Rosmini Day NTP Manager Dr Firdosi Mehta MO TB WHO (IUATLD conference Paris 29/11/03). Contents. Back Ground Laying the Foundation – 5YSP 2002 – Donor interest & support Catalyst – Ext TB Monitoring Mission Jan ’03

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Public-Public Mix for DOTS Indonesia’s Experience

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  1. Public-Public Mix for DOTSIndonesia’s Experience By Dr Rosmini Day NTP Manager Dr Firdosi Mehta MO TB WHO (IUATLD conference Paris 29/11/03)

  2. Contents • Back Ground • Laying the Foundation – 5YSP • 2002 – Donor interest & support • Catalyst – Ext TB Monitoring Mission Jan ’03 • Involvement of Lung Clinics/Hospitals • Reaching out to other Govt sector health providers • Lessons learnt from the HDL project • The way forward

  3. Map of Indonesia

  4. Health Facilities related to TB Control • Health Center 7.312 • Microscopic Health Center 2.612 • Chest Clinic 34 • Provincial Health Laboratory 26 • HOSPITAL : • Lung Hospital (RSTP) 9 • District General Hospital 340 • Provincial General Hospital 40 • Private General Hospital 600

  5. Health seeking behaviour in Indonesia • Socio economic survey held in 1995 (SUSENAS) • 39% of population went to PPs to get medical care • World Health report 2000 • Private expenditure on Health care – 76.3% • Out of pocket expenditure on Health care – 70.1% • Survey held in 2000 among GPs: • on average each PP treats 20 patients annually • 28% of the diagnosis are conducted by sputum smear test • 72% are conducted by radiological examination • 77% of the TB medication are given by prescription • 82% of the PPs would like to participate in DOTS • 92% of them not expecting profit

  6. N W E S Legend 0 - 24 25 - 49 50 - 99 100 - more Map of Notification Rate (All Forms) 2002 Indonesia – National TB Program

  7. Vision & Mission of the 5YSP Vision TB is no longer a public health problem Mission • To provide a national TB policy and standards, and evaluate the national TB program accurately and comprehensively • To establish strategic alliances and transparencies in the TB program • To improve health service accessibility for TB patients to get appropriate services of high quality

  8. Targets under the 5YSP Cure Rate 85% CDR 75% CDR 70% CDR 60% CDR 50% CDR 40% 2004 2005 2006 2002 2003

  9. Strategies Under the 5YSP • Advocacy-social mobilization-empowerment • Strengthening the quality of the program • Strengthening drug management • Strengthening diagnostic capacity • Strengthening DOT • Providing resources & facilities

  10. Donor Support by Provinces in Indonesia - 2003 = KNCV = CIDA = TBCTA = GFATM = DUTCH GOVT.

  11. North Sumatera East Kalimantan South Sumatera Central Sulawesi South Sulawesi West Java Central Java East Java Provisional CDR 2002 = data not available = 40 – 69% = 0 – 39% =  70% EIGHT PROVINCES REVIEWED

  12. Major Findings • Much progress has been made in 2000-2002; majority of recommendations from earlier missions have been addressed or are being implemented. • Target for treatment success achieved. • Great enthusiasm and commitment of staff observed. • Good examples of DOTS implementation observed in various provinces. • Rapid expansion of DOTS and decentralization continue to pose challenges to ensuring the quality of DOTS in the country.

  13. Case Detection • TB patients detected and treated in three different governmental health systems; Case notifications limited to public health system under DG CDC • Smear microscopy services are widely available

  14. Key Recommendations For the ministry of health: • To issue a common directive from the 3 DG’s to improve co-ordination between the 3 concerned components of the health system, in order to establish standardized quality DOTS implementation with a uniform recording and reporting system. 2. To stimulate local authorities to re-vitalize Gerdunas chapters in order to strengthen DOTS acceptance among clinicians, both governmental and private, and include partner organizations in financial schemes.

  15. Parallel Public Health Systems

  16. Steps taken to involve Lung Clinics Back ground • 34 Lung clinics + 9 Lung Hospitals • Majority located in Java with high pop density • Main morbidity seen is TB • Basic elements of DOTS present, with varying degree of adherence with Nat Guide Lines • Constraint – Functioning under parallel MOH systems with little coordination

  17. Steps Taken To Involve Lung Clinics Jun/July 03 Training of LC staff April/May 03 Development of Implemen- tation guidelines and training curriculum April/May 03 Special data collection and validation exercise in LC 7/3/03 Meeting with Directors of LC & CDC Heads 19/2/03 Minister Calls Meeting with 3 DG’s 7/2/03 Debriefing Ext Monit Mission

  18. TB Data & contribution of LC

  19. Contribution (%) of Lung Clinics In 2002 Data Increase

  20. Involvement of Other Govt sector Health Providers • Ministry of Defense – Army has 54 hospitals in different locations. Cater for defense persons & their families. DOTS Training commenced in Oct ’03 • Prisons – Assessment ongoing. Strategies of involvement under development • Industry – Initial dialogue initiated for involvement of Industries in DOTS implementation • Academia – Involvement of Medical Schools & PH Institutions

  21. Lessons learnt from HDL Project • Involvement of hospitals has greatly increased Case Notification (CNR) in Yogya: more then 300% increase over a period of 3 years. • The HDL experience in Yogyakarta has provided ample evidence and directions for further DOTS expansion through hospital and private sector involvement.

  22. Lessons learnt from HDL Project • Most institutions demonstrated great enthusiasm and good commitment to implement DOTS. • A strong interface between Hospitals and Public Health Services (provincial DOTS committee) is essential for an effective linkage .

  23. Lessons learnt from HDL Project • In general hospitals are good in diagnosis of cases • Hospitals have strong potential for direct smear microscopy • However their performance with regard to case holding and treatment supervision is inferior compared to health centres.

  24. Public-Public mix as one step in many to reach “undetected/unreported” TB cases. estimated TB cases Partnerships PP collaboration all true TB cases IEC cases presenting to health facilities Patient convenience, enablers cases presenting to public health facilities cases presenting to DOTS facilities Quality facilities, services cases correctly diagnosed by DOTS facilities Lab. QA Training, Supervision diagnosed cases reported by DOTS facilities

  25. * ( * = data extrapolated from Q1 and Q2 )

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