Challenge TB - Indonesia

Year 4

Annual Report

October 1, 2017 – September 30, 2018

Submission date: November 5, 2018

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Cover photo: “TB education and Information Synergy”, an event organized by the MOH, NTP and the department for Health Promotion, facilitated by CTB. The department of Health Promotion is now firmly active for TB awareness raising amongst secondary school children throughout Indonesia. From left to right: dr. Rizkiyana Sukandhi Putra, M.Kes as Director of Health Promotion and Community Empowerment, MOH; dr. Wiendra Waworuntu, M, Kes, Director of Communicable Diseases, MOH; Dr. Anung Sugihantono, Director General of Disease Prevention and Control of the Ministry of Health, Indonesia; Seno Hartono, the Communication and the Public Affairs Bureau, Ministry of Education and Culture; Maman Wijaya, head of the Film Development Center, Ministry of Education and Culture; Rosyad Burgan, Indonesian Boy Scout representative; Tjia Candyana, Challenge TB Project Coordinator.

This report was made possible through the support for Challenge TB provided by the United States Agency for International Development (USAID), under the terms of cooperative agreement number AID-OAA-A-14-00029. Disclaimer The authors’ views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

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Table of Contents

1. Executive Summary .......................................................................................................... 7

2. Introduction ..................................................................................................................... 9

3. Country Achievements by Objective/Sub-Objective ............................................................. 13

4. Challenge TB Support to Global Fund Implementation ......................................................... 33

5. Challenge TB Success Story ............................................................................................. 36

6. Operations Research ....................................................................................................... 38

7. Key Challenges during Implementation and Actions to Overcome Them ................................. 43

8. Lessons Learnt/ Next Steps ............................................................................................. 43

Annex I: Year 4 Results on Key Performance Indicators including Mandatory Indicators (see PDF file attached) ............................................................................................................................. 46

Annex II: Status of EMMP activities ......................................................................................... 47

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List of Tables

Table 1. Challenge TB 16 Intervention District Profile and national comparison ............................... 12 Table 2. Main roles and responsibilities of CTB partners .............................................................. 12

List of Figures

Figure 1. Geographical distribution of CTB supported 6 provinces and 16 districts .......................... 11 Figure 2. Trend proportion of presumptive TB tested by Xpert, TB patients screened for DM and childhood TB notification in 43 Puskesmas receiving DPPM intervention for 5-6 months. ................. 14 Figure 3. Comparison of notification of TB patients in 2018 and 2017 in 43 Puskesmas receiving DPPM intervention for 5-6 months. ................................................................................................... 14 Figure 4. Trend notification from private providers in 16 CTB districts year 2104-2018. .................. 15 Figure 5. Xpert expansion and utilization in CTB provinces and non-CTB provinces in Oct 2017 – Sep 2018. .................................................................................................................................. 17 Figure 6. Xpert Testing Among Presumptive DR-TB Patients in 6 CTB Provinces (2015-2018). ......... 18 Figure 7. Geographical mapping of C/DST laboratory nationwide ................................................. 19 Figure 8. Percentage of TB patients who know their HIV status and Percentage of TB treatment facilities with onsite HIV testing in 16 CTB districts, January 2015 – September 2018 ..................... 21 Figure 9. Percentage TB/HIV Patients receiving ARV in 16 CTB districts, January 2015 – September 2018 ................................................................................................................................... 22 Figure 10. TB Patients who know their HIV Status, JSD Sites, 2017-2018 ..................................... 24 Figure 11. TB/HIV patients receiving ART during TB treatment, JSD Sites, 2017-2018 .................... 25 Figure 12. Treatment enrollment of DR-TB patients and Loss to Follow-Up (LFU) in 2016-2018 as MICA has been routinely implemented in 13 CTB districts ................................................................... 26 Figure 13. Expansion of STR treatment sites, and patients enrolled on STR, BDQ and conventional regimens (Sep 17 - Sep 18). .................................................................................................. 27 Figure 14.District budget allocation for TB (in USD) in 16 CTB districts (in DKI Jakarta combined of 5 administrative cities) ............................................................................................................. 29 Figure 15. The graphics of TB knowledge on the vehicle wraps, launched during the World TB Day on 24 March 2018. .................................................................................................................... 31

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List of Abbreviations and Acronyms APA AnnualplanofactionAPBD AnggarandanPendapatandanBelanjaDaerah(LocalGovernmentBudgetPlan)ART Anti-retroviraltherapyATM AIDS,Tuberculosis,MalariaATS AmericanThoracicSocietyBBLK/BLK Balai Besar Laboratorium Kesehatan/Balai Laboratorium Kesehatan (Provincial Health

Laboratory)BPJS BadanPenyelenggaraJaminanSosial(NationalHealthInsuranceProvider/Agency)BPOM BadanPengawasObatdanMakanan(NationalDrugandFoodControlAgency)BPPM BinaPelayananPenunjangMedik(MedicalLaboratorySupportServices)BPPSDMK BadanPengembangandanPemberdayaanSumberDayaManusiaKesehatan(TheAgency for

DevelopmentandEmpowermentHumanResourceofHealth)BSC BiologicalsafetycabinetC/DST Culture/drugsensitivitytest(ing)CBO Community-basedorganizationCCM CountryCoordinatingMechanismCEPAT CommunityEmpowermentofPeopleAgainstTuberculosisC-GAT CountryGeneXpertAdvisoryTeamCME ContinuingMedicalEducationCPT Co-trimoxazolePreventionTherapyCSO CivilsocietyorganizationDAP DistrictActionPlanDitjenBUK DirektoratJenderalBinaUpayaKesehatan(DirectorateGeneralofHealthEfforts)Ditjenpas DirektoratJenderalPemasyarakatan(DirectorateGeneralofCorrections)DM DiabetesmellitusDOTS DirectlyObservedTreatment–ShortCourseEPT ExpertpatienttrainerEQA ExternalqualityassuranceFAST FindingTBcaseActively,Separatingsafely,andTreatingeffectivelyFBO Faith-basedorganizationFLD FirstlinedrugGF GlobalFundGP GeneralPractitionerHCW HealthcareworkerHDL Hospital-DOTSlinkageHIV HumanimmunodeficiencyvirusHRD HumanresourcesdepartmentIAI IkatanApotekerIndonesia(IndonesianPharmacistsAssociation)IC InfectioncontrolIMA IndonesianMedicalAssociationINH IsoniazidIPT IsoniazidPreventionTherapyISTC InternationalStandardsforTuberculosisCareJATA JapanAnti-TuberculosisAssociationJKN JaminanKesehatanNasional(NationalHealthInsuranceSystem/Scheme)KARS KomiteAkreditasiRumahSakit(NationalCommitteeofHospitalAccreditation)LMIS LogisticsManagementInformationSystemLQAS LotqualityassurancesamplingsystemM&E MonitoringandevaluationMDR Multi-drugresistant

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MIFA ManagementInformationForActionMoH MinistryofHealthMOLHR MinistryofLawandHumanRightsMSH ManagementSciencesforHealthNAP NationalAIDSProgramNGO Non-governmentorganizationNRL NationalReferenceLaboratoryNSP NationalStrategicPlanNTP NationalTuberculosisProgramNTPS NationalTBPrevalenceSurveyOR OperationalresearchP2PL Pengendalian Penyakit dan Penyehatan Lingkungan (Department of Disease Control and

EnvironmentalHealthPCA Patient-centeredapproachPDPI PerhimpunanDokterParuIndonesia(IndonesianPulmonologistsAssociation)PHC PrimaryHealthCenterPLHIV PeoplelivingwithHIVPMDT ProgrammaticManagementofDrug-ResistantTuberculosisPNPK PedomanNasionalPelayananKedokteran(NationalGuidelinesforMedicalPracticeStandards)PPK PedomanPelayananKlinis(ClinicalPracticeGuidelines)PPM Public-privatemixPSM ProcurementsupplymanagementPuskesmas Pusatkesehatanmasyarakat(Publichealthcenter)QA QualityassuranceSEA SouthEastAsiaSITT SistemInformasiTuberkulosisTerpadu(IntegratedTBInformationSystem)SLD Second-linedrugSOP StandardoperatingprocedureSRL SupranationalReferenceLaboratorySSF SingleStreamFundingSUFA StrategicUseofARTs(HIVprogramprioritydistricts)TA TechnicalassistanceTB TuberculosisTBCAP TuberculosisCoalitionAssistanceProgramTORG TuberculosisOperationalResearchGroupTOSSTB TemukanObatiSampaiSembuhTBUGM UniversitasGadjahMadaUHC UniversalhealthcoverageUI UniversityofIndonesiaUSAID UnitedStatesAgencyforInternationalDevelopmentWGS WholeGenomeSequencingWHO WorldHealthOrganization

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1. Executive Summary During the current five-year planning period, the Ministry of Health (MOH) is focusing on access to and quality of essential and referral health care services. Important developments are: a) Universal Health Insurance (JKS), in 2018 covering 75% of the population and funding 44% of income of the public and private health sector, thus making it an important tool for regulation; b) The MOH’s a strong focus on Family Based Medicine Approach (PIS-PK), in which TB is included as one of the presidential indicators for health; c) in 2018, the MoH included the acceleration of TB elimination as one of the three top priorities for health toward universal health coverage. In the last 2 years, Indonesia managed to increase the number of notified TB patients by 35%, from approximately 330,000 (2015) to 446,000 (2017); and currently the TB treatment coverage rate is 53%. The 16 CTB supported districts contributed 21% of the total national increase, while covering only 11% of country population. Based on the nationwide 2018 drug resistance survey, conducted by the MOH, with support from CTB and WHO, the MDR-TB prevalence is estimated at around 2.4% among new patients and 13% among previously treated patients. Further analysis of the survey is ongoing, including WGS (whole genome sequencing), which is co-funded by the TB Alliance. The CTB coalition for Indonesia (WHO, FHI, IRD and ATS, with KNCV in the lead) focussed in Year 4 on CTB objective 1: “Improved access to quality patient centered TB, TB/HIV and MDR-TB services”, case notification being the highest priority indicator, with a secondary focus on Objective 2: “Prevention of transmission and disease progression” and objective 3: “Strengthened TB platforms and health systems strengthening”. Included in objective 3 is the CTB support to the Global Fund PRs on TB control systems and overall health systems development, especially infection control, the Xpert platform, PPM and strengthening community systems. In the 4th year of implementation, Challenge TB key results are as follows:

Expansion and utilization of GX testing: By the end of Year 4, a total of 559 GeneXpert machines with 2,258 modules are operational nationwide. CTB provinces contributed about 70% of GeneXpert testing with a utilization rate of 38% in August 2018; the reported utilization of Xpert machines in non-CTB supported provinces is slowly increasing from 11% at the start of Year 4 till 18% in August 2018.

Case notification: The national acceleration in case notification in 2017 was the result of more complete and more timely reporting, the inclusion of TB cases lacking a recorded laboratory test, more intensive use of diagnostic tests and better engagement of hospitals, especially private sector hospitals. Over 2017, in CTB districts, notification by primary health centers (PKM) increased 9%, by public hospital 27% and by private hospital 48%, bringing the private sector contribution up from 24% in 2016 to 28% in 2017.

Improving access to HIV testing in TB patients: There was an increase in the percentage of TB patients who know their HIV status from 35% in 2017 to 47% in 2018, and of TB/HIV patients on ART from 46% in 2017 to 54% in 2018. This is in the 16 CTB supported districts. In the first two quarters of 2018, these 16 districts contribute significantly contribute to available national figures: 24% of all the diagnosed TB-HIV co-infected patients, and 76% of all co-infected patients who are put on ART. This is a result of a combination of several approaches, namely the inclusion of TB-HIV screening in the DPPM approach in 307 health facilities with a referral mecchanism to ART sites, a joint service delivery approach in Jakarta combining efforts of the NTP and NAP in 60 health centers, and an acceleration approach to HIV testing of TB patients in the other CTB supported districts covering 259 out of 280 (93%) kecamatan, 406 out of 485 (84%) Puskesmas, 69 out of 108 (64%) public hospitals (including Lung clinics/hospitals), and 114 out of 321 (36%) private hospitals.

Improving quality of MDR TB by implementing MICA( monthly interim cohort analysis): The implementation of MICA (Monthly Interim Cohort Analysis) in 13 CTB districts (since 2017), has been instrumental in increasing the treatment. The MDR-TB enrollment rate in 13 CTB assisted districts

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increased from 71% in 2016 to 77% in 2017. Lost to Follow Up (LFU) reduced from 23% in 2016 to 7% in 2018. This was a result of the introduction of the Monthly Interim Cohort Analysis (MICA). In CTB districts, MICA, applied by district TB Wasors and patient organizations, resulted in 85% of the Apr-June cohort of Year 3, compared to 62% of the Jul-Sep cohort of APA2.

Strengthening political commitment in CTB supported districts: By the end of Year 4, in the CTB supported districts, local government budget allocation for TB control strategy increased by 76% to IDR 6.8 billion (approx. USD 506,000 in 2018, as compared to USD 287,000 in 2017). This was a result of all 16 CTB-supported districts/cities having finished District Action Plans (DAP), of which 15 have been ratified by the Head of Region. Multi-stakeholder involvement revealed there is funding for TB is available at district level within and beyond the health sector. Building on this, CTB also supported Action Planning in 5 provinces , 4 of which are nearing completion. There are an additional 25 districts in the process of drafting their TB DAP. Engaging more audiences to advocate TB: In Year 4 a total of 22 short films were produced by high school students, 9 from DKI Jakarta, 7 from North Sumatra, and 6 from Papua, which were all uploaded to the Challenge TB YouTube Channel (https://www.youtube.com/channel/UCcHvftsRBZt6i-zsO0RQGag/videos) as a communication strategy for community awareness campaign on TB. This was done in collaboration with the Film Development Center of the Ministry of Education of Republic of Indonesia, culminating in a Tuberculosis Short Film Festival in Jakarta on 23 March 2018. The videos were handed over to the Ministry of Education and Culture, and will be disseminated through 116 mobile cinema units in 34 provinces, and 72 schools that are equipped with cinema facilities.

Other achievements in Year 4 include the following:

CTB assisted the NTP and professional societies in developing the National Strategic Plan for District PPM and developed the secondary and primary care level implementation models. In March 2018 CTB started with its implementation at primary care level, including two-way referral networks with hospitals, establishing 216 out of 485 Puskesmas PPM networks in 280 sub-districts. This resulted in strengthening the role of the Puskesmas as the coordinator in its catchment area ensuring effective engagement with private providers.CTB also supported building the Coalition of Professional Organizations (KOPI TB) at the district level, strengthening their capacity to support the puskesmas PPM networks. Following this, Ministry of Health released a circular in March 2018 to all provincial and district health offices to establish KOPI TB in their respective areas. At the same time CTB continued support to the District health offices (DHO), maintaining 90% linkage of public hospitals, and increasing the linkage of private from 47% at start of Year 4 to 72% at the time of reporting.

CTB contributed considerably to the development of the TB Information System of the NTP, which was one of the contributors to the acceleration of case notification in CTB supported districts. A new version of the current system (SITT) was launched in CTB supported districts, with an improved dashboard preview, and easier data analysis . With these improvements, provincial health information teams in CTB areas have been strengthened, and can use the information during on the job training, supervision and data validation meetings. To improve data quality further, CTB has started the software development of a new TB information system integrating the old system, eTB manager and connectivity data. This is expected to finish in December 2018, and operational by March 2019.

2. Introduction • Country • Indonesia • Lead Partner • KNCV Tuberculosis Foundation • CTB Coalition Partners • ATS, FHI 360, IRD, WHO • International Resource Partners funded

through CTB • Desmond Tutu TB Center, Stellenbosch University,

South Africa

• Local Partners funded through CTB

Atma Jaya Catholic University, Dian Nuswantoro University (UDINUS), IAKMI Surakarta, IDAI, IDI North Sumatera, IDI Semarang, Padjadjaran University (TB TWG UNPAD), PDPI Surakarta, PERSAKMI Jember, PESAT North Sumatera, PPM TB Jember, PPM Tulungagung, PPNI Bogor, SEMAR Central Java, Yayasan KNCV Indonesia, YPAIDS Tulungagung, Yayasan Pejuang Tangguh (PETA) and Yayasan Terus Berjuang (TERJANG).

Indonesia's archipelago consists of around 17,504 islands with a population of 262 million. The country consists of 34 provinces, containing in total 514 districts (including 98 municipalities), 7,217 sub-districts and 83,344 villages1. The health services network consists of 9,767 community health centers (puskesmas), 2,820 hospitals (1,016 public, 1,804 private)2. There are approximately 110,400 licensed general practitioners. With urbanization and economic growth, private hospitals increased more rapidly (7% per year) than public hospitals (3% per year). The network of public health services has a decentralized model of administration and financing. Planning in provinces and districts takes place under the responsibility of the Ministry of Home Affairs. Puskesmas are responsible for the organization of public health programs, including TB diagnosis, care and prevention. Indonesia has a gross national income per capita of USD 3,605 in 2016. About 27.8 million people (10.6%) live under the poverty line3, and an additional 105 million people are categorized as "near-poor” (around 40% of the population (JEMM report 2017)). Indonesia’s current economic plan 2015-2020 includes a focus on social assistance programs for education and health care. Indonesia experiences a demographic shift, with declining fertility rates and an increasing elderly population (7%). Life expectancy at birth in 2017 was 70 years for males and 75 for females. There is a rapid increase in urban populations (currently 57%)3, with 37 cities of over 1 million population and is home of the second largest urban area in the world, consisting of the Jakarta and surroundings, with an estimated population of over 33 million. During the current five-year planning period, MOH is focusing on access to, and quality of, essential and referral health care services. Important developments are: a) Universal Health Insurance (JKS), in 2018 covering 75% of the population and funding 44% of income of the public and private health sector4, thus making it an important tool for regulation; b) The MOH stated a strong focus on Family Based Medicine Approach (PIS-PK), in which TB is included as one of the variables to be assessed and monitored. In the last 2 years, Indonesia managed to increase the number of notified patients by 35%: from 330,000 (2015) to 446,000 (2017). In the Global TB Report 2018, WHO adjusted the total estimate of TB incidence for Indonesia in 2017 to 842,000 patients, using the findings of the Indonesia Inventory Study, which brings the estimated TB treatment coverage rate to 53%; however more than 395,000 patients are still missing from the records, either not identified or not reported. The adjusted estimation of TB incidence placed Indonesia as the third largest country in terms of number of TB patients after India and China.

1 Statistical Yearbook of Indonesia 2018 2 DG Health Services, Ministry of Health, updated April 2018 3 World Bank 2017 4 Health Sector Public Expenditure Review, World Bank, December 2017

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The completeness and accuracy of routine TB surveillance and vital registration (VR) systems in Indonesia give an inaccurate picture of the true TB burden in the country. This in turn challenges the ability to measure progress towards national and for instance GF Grant targets. Greater efforts need to be made to find the “missing” or undetected cases and ensure that they are rapidly diagnosed, treated and reported. Patients who die or are lost to follow up prior to starting treatment, are currently not captured well. The amount of under-reporting assessed through the inventory study in 2017 was around 62% in hospitals and 15% in Primary Health Centers (Puskesmas). In Year 4, three important high-level meetings took place concerning TB. The Global Ministerial Conference in Moscow “A Multi-Sectoral Response to End TB in the Sustainable Development Era” was followed by the Ministerial Meeting to End TB in the South East Asia Region in Delhi, and in September 2018 The United Nations High Level Meeting on TB in New York. Important over the past years is the increasing political commitment in Indonesia to TB care and prevention, as expressed by TB being one of the district level indicators followed up by the President with the endorsement of Minimum Service Standards, the National High Level Meeting on District Action Planning and Inter-sectoral Collaboration, immediately after the Moscow meeting, and the increases in domestic budgets for TB care and prevention. Based on consultation with the NTP and the USAID Mission, the main focus of the CTB project in Year 4 are CTB objective 1: “Improved access to quality patient centered TB, TB/HIV and MDR-TB services”, case notification being the highest priority indicator, with a secondary focus on Objectives 2: “Prevention of transmission and disease progression” and objective 3: “Strengthened TB platforms and health systems strengthening”. Included in objective 3 is the CTB support to the Global Fund PR’s on TB control systems and overall health systems development, especially infection control, the Xpert platform, PPM and strengthening community systems. Based on the National Strategic Plan and taking into consideration the accelerated utilization of Global Fund (GF) funding in the country, the CTB project provides technical assistance to the National TB Program (NTP), on PPM, engaging private and unlinked public sectors (including prisons), laboratory network strengthening, closing the diagnostic-treatment gap for MDR-TB patients and supporting the introduction of new drugs and regimens, patient’s support and community engagement, infection control (IC), increased uptake of TB/HIV collaborative interventions and LTBI treatment for children and PLHIV. CTB supports strengthening TB surveillance systems, new interventions and implementation research. Sustainability is enhanced by the mobilization of the district governance structures and (local) government commitment to fund and implement comprehensive local TB control plans. CTB actively promotes dissemination of CTB mediated good practices and interventions in the framework of national policy making; dissemination is achieved through uptake in national policies and legislation and (Global Fund or domestic) budgets; inclusion in guidelines, capacity building at nation and provincial level in the methodologies, presentations in local and (inter) national forums, study visits, publications etc.. Partners agreed for CTB Indonesia to work under the following 9 CTB sub-objectives:

- Sub-objective 1: Enabling environment - Sub-objective 2: Comprehensive, high quality diagnostics - Sub-objective 3: Patient centered care & treatment - Sub-objective 5: Infection control - Sub-objective 6: Management of Latent TB Infection - Sub-objective 7: Political commitment & leadership - Sub-objective 8: Comprehensive partnerships and informed community involvement - Sub-objective 10: Quality data, surveillance and M&E - Sub-objective 11: Human resource development

Geographical Areas At national level, CTB provided Technical Assistance to the Directorate of CDC of Ministry of Health as the main beneficiary/ partner. Additional recipients of TA include other MoH Directorates such as BUK (Medical Services), KAN/KALK, Binfar (Directorate General of Pharmaceutical and Medical Devices) and Provincial/District Health Offices and local partners in all prioritized provinces. The main

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epidemiological information on the 16 intensified CTB districts is provided in Table 1, as an addition to the information in Annex 1. Figure 1. Geographical distribution of CTB supported 6 provinces and 16 districts

In 2017 Indonesia (with approximately 1 million incident TB cases) notified 446,732 patients, a national TB case detection rate of 53%, a significant increase by 44% as compared to 360,565 TB cases notified in 2016. Over the total project period, with a baseline in 2014, overall notification in 16 CTB-supported districts increased by 44% while notification in the other 498 districts increased 36%. The 16 CTB supported districts contributed 21% of the total national increase, while harboring only 11% of the population (see geographical distribution in Figure 1) and an estimated 9% of the estimated Indonesian TB burden. In 2017, the 16 CTB supported districts contributed 19% to the national notification, compared to 14% in 2014. Important contributors to this acceleration in CTB supported districts are more complete and more timely reporting, the inclusion of TB cases lacking a recorded laboratory test, more intensive use of laboratory tests for diagnosis and more engagement of hospitals, especially private sector hospitals: over 2017 notification by primary health centers (PKM) increased 9%, by public hospital 27% and by private hospital 48%, bringing the private sector contribution to case notification up, from 24% in 2016 to 28% in 2017. Table 1 shows that in the year 2017, in CTB provinces, in total 3.051 patients were diagnosed with Rif Resistant/Multi Drug Resistant TB (RR/MDR TB) and 2.213 (72%) started treatment, compared to an enrolment rate of 71% in 2016 (1454 enrolled/2059 diagnosed). In 2017, the enrolment in CTB areas accounted for 70% of national enrolment. Overall data harbor large differences between districts: TB notification in 2017 ranged from 104 in Tulung Agung district in East Java to 756 per 100,000 population in Mimika district in Papua province. Overall in 2017 In Mimika district, 53% of the TB cases were notified by private facilities (down from 71% in 2016, due to better functioning of the PKM level which has doubled its contribution), versus 1% in Jember district in East Java. In Jakarta, private sector contributions varied between 18% and 43%. In 2018 the analysis of the Indonesia Inventory study (IVS) was made available, showing overall 41% underreporting during the first quarter of 2017; 62% under-reporting in hospitals, 15% in puskesmas and around 96% among general practitioners, laboratories and primary care clinics; 21% under-reporting among bacteriologically confirmed patients and 55% among clinically diagnosed patients.

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Delays in NTP reporting in Indonesia remain a major problem, with quarterly reports only being completed 1-2 quarters later, with often significantly more patients added to the records; taking that into account would reduce the overall proportion of underreporting found by the IVS. The findings of IVS, however, give an indication of the type of facilities where underreporting is most prominent. The IVS findings support the choices made by the NTP for a rapid response focused at improved notification at hospitals and improving the reporting system of clinically diagnosed patients, while developing a model for engagement of general practitioners and other primary care providers. Table 1. Challenge TB 16 Intervention District Profile and national comparison

Lead and collaborating partners During APA 4, CTB interventions in Indonesia were implemented through KNCV with assistance from two in-country coalition partners (FHI360 for TB/HIV and prisons, with 4 staff hosted in the KNCV office, and WHO for national level policy and guidelines). IRD provides one local long term technical staff in Indonesia, hosted by the KNCV office and working in support of the e- and mHealth interventions. KNCV was getting support as needed, by short-term technical assistance from two external coalition partners, ATS and IRD. The coalition continues to speak with one voice to the NTP, USAID/ Mission, and dialogue among stakeholders, through the lead coalition partner, KNCV.

Table 2. Main roles and responsibilities of CTB partners

Partners MainRoles&responsibilitiesKNCV Lead the overall technical assistance to NTP and other stakeholders, ensuring a comprehensive program. Lead the project

management,including:developmentandimplementationofagreedworkplansandbudgets,supervision,reviewprogressandreporting

FHI360 ThroughanationaltechnicalteamwillprovideTAintheareaofTB-HIVandprisons,includingTB/HIVsurveillance,includingTAintheseareastodistricts,asperagreedworkplans.AspecialfocuswillbethecollaborationwithLINKAGESinthisfieldinJakartaandPapua.FHI360leadandimplementtheoverallCTBeffortinPapua,withTAfromKNCVandothercoalitionpartnersasrequired.Therefore,FHI360hasanestablishedprovincialCTBofficeinJayapura

WHO ActivelyengageinandensuredevelopmentofpoliciesinlinewiththeWHOEndTBstrategy,globalguidelinesandstandardsandlatestscientificevidence.Assistinfacilitationoftrainings,workshopsetc.andprovideTAtotheoverallimplementationoftheCTBworkplanasrequired.WHOhasnodirectimplementationresponsibilities.

ATS TechnicalAssistancefordevelopingexcellenceinPMDTandthedevelopmentofdistantclinicalconsultationamongcliniciansandnurses in Indonesia. Technical assistance for engagement of professional societies in CTBprovinces and distance support forfurtherdevelopmentofcontactinvestigation(revisionofSOPs,forms).

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IRD TechnicalassistanceforfinalizationofalandscapeanalysisandstrategicframeworkforanewnationalTBHISstrategyandwholedatasolution;supportforimplementationandchangemanagementofe-Healthandm-Healthasappropriate.IRDleadsthesmartphoneapplicationinsupportofimplementationofmandatorynotification.

3. Country Achievements by Objective/Sub-Objective

Objective 1. Improved Access

Sub-objective 1. Enabling environment1. Enabling environment During Year 4, CTB assisted NTP and professional societies in developing a National Strategic Plan for District PPM and developed the model for implementation. CTB also contributed to the development of an enabling environment for the District PPM model to function and ensure engagement of all providers. The components includes the Coalition of professional organization, and primary and secondary health care providers. 1.1 The establishment of Coalition of Professional Organizations (KOPI TB) This is essential for the implementation and continuous support to the functioning of the DPPM model at primary and secondary care levels, which is underpinned by a close collaboration between the District Health Office and the local professional societies.

The roles of KOPI TB at the district level, as part of the DPPM district team are: 1. As clinicians, lead by example by implementing the National TB Standards of Care 2. As clinicians in their respective hospitals, encourage the establishment of a well-functioning

internal TB services network 3. In the district as a whole, KOPI members are resource persons, co-facilitate the improvement

of capacities of all health service providers in both the primary and secondary care levels, through training, guiding, supervising and mentoring.

Key Results - On 1st March 2018, the Ministry of Health released a circular to provincial and district health

offices to support the establishment of TB coalitions of professional organizations (KOPI TB) in their respective geographic areas.

- Following the formation of KOPI TB at National level, KOPI TB at Provincial level has been established in 7 provinces: DKI Jakarta, Kepulauan Riau, South Kalimantan, Bangka Belitung, North Sumatera, Central Java and East Java. Furthermore, KOPI TB at District level has been established in total 15 districts including 12 CTB supported districts. This number is expected to increase under the GF catalytic funding, for which the CTB experience will be used.

1.2. The establishment of Public-Private Mix networks at sub-district level In Year 4, CTB supported the NTP in operationalizing the role of the sub district health centers, Puskesmas (PKM), in increasing and coordinating primary care level diagnosis and treatment of TB in their catchment area through engagement of general practitioners (GPs), clinics, laboratories, pharmacies and Civil Society Organizations (CSOs) in their respective roles in managing tuberculosis in their communities and linking them to National TB program including diagnostic services, medicine supply and patient socio-economic support.

Key Results - The establishment of Public-Private Mix networks at sub-district level started with TB update

workshops at Primary Health Centers (puskesmas) including the establishment of TB teams in the health facilities and the introduction of health network mapping tools.

- CTB team facilitated self-assessment of TB services and NTP performance at the puskesmas, using a benchmarking tool.

- CTB supported DHOs with the establishment of Puskesmas PPM networks, strengthening the role of the puskesmas as the coordinator in its catchment area concerning the engagement with private providers. In total, 216 out of 485 puskesmas PPM networks were initiated (in 280 sub-districts). In these 216 puskesmas, internal networks between the various units were

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established, hospital linkages were forged, and a start was made in 133/216 puskesmas with external networking, engaging GPs and clinics.

- The DPPM approach to strengthen internal (the various health center departments) and external network (the GPs in the catchment area) of sub-district Puskesmas shows promising improvement which still need to be closely monitored and guided for a functioning PPM network. The interim results show that more diabetes patients are screened, a slight increase in childhood TB notification, and a surge in Xpert tests (Figure 2 and 3 below).

Figure 2. Trend proportion of presumptive TB tested by Xpert, TB patients screened for DM and childhood TB notification in 43 Puskesmas receiving DPPM intervention for 5-6 months.

Figure 3. Comparison of notification of TB patients in 2018 and 2017 in 43 Puskesmas where DPPM was implemented for 5-6 months.

40%45% 42%

38% 41% 38%

55%61%

72%75%

64%

82%77%

73%78%

97%

80%

100%

7% 9% 9% 7% 9% 10% 8%12% 12%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18

% presumptive TB tested by Xpert % TB patients screened for DM

% Childhood TB notification

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*DatainSeptember2018isincomplete.- As part of strengthening internal network in hospitals, CTB supported the NTP in notifying

unreported TB patients from hospitals in 6 CTB provinces, through on-the-job training of the GF-funded data officers. In Year 4, this activity has yielded more than 20,000 TB patients who are now reported in SITT.

- By engagement of the private sector (which was first focused on private hospitals), TB notification by the private sector in the 16 CTB districts has increased from 13,116 patients in 2015 to 24,287 in 2017, an increase of 85% (see figure 4).

- As part of the DPPM approach, CTB strengthened the capacity of local Civil Society Organizations (CSO) through sub-awards, training and mentoring, while assisting them to develop other sources of finance, supporting the DHOs expanding the PPM approach at primary and secondary care level in their respective districts. CSO linkages, coordinated by puskesmas, were established in 240 (out of 280) sub-districts in 5 out of 6 CTB provinces.

- In supporting mandatory notification reporting by the clinic and general practitioners, a new version of the WiFi-TB mobile application for reporting of patients by clinics and GP’s has been released in March 2018 and implemented in 13 CTB districts.

- The adjusted WiFi-TB v2 includes new functions like recording of presumptive TB patients, sending reminders for treatment and monitoring for the patient using SMS system, and automatic data linkage to the SITT (Sistem Informasi Tuberkulosis Terpadu) to avoid double data entry by TB staff.

- Following the activities to find unreported TB patients in hospitals (Dec’17-Jan’18), CTB continue supported NTP to completed data validation and careful consideration of the results. The notification data in 2017 was corrected to 446,732 cases.

Figure 4. Trend notification from private providers in 16 CTB districts year 2104-2018.

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Next Steps - In Year 5, CTB will support and build capacity of DHO and KOPI TB to ensure the functioning of the

DPPM district teams including supportive supervision and mentoring on implementation of DPPM approach in primary and secondary care levels.

- Full scale up of PKM-PPM network to the 280 puskesmas in 16 districts that were engaged in Year 4. No new puskesmas will be engaged by CTB staff itself, so that a full focus can be on completing the full DPPM approach that was started in the various puskesmas during Year 4.

- CTB will support POP TB Indonesia (national coalition of patients organizations) to develop a roadmap of patients’ organization sustainability in supporting TB patients.

- CTB will support PHO and DHO in supervising the active role of health community cadres in active case-finding and case holding of DR-TB. This is done together with Aisyiyah, LKNU and patient organizations.

- CTB will provide opportunity for DHO and KOPI TB to organize workshops to engage the remaining 269 puskesmas in the CTB supported districts, including small start-up package for puskesmas that will initiate the DPPM process. CTB will merely play a coaching role in this. CTB will ensure quality documentation of results and good practices.

- CTB will support NTP, PHO, professional societies and CSOs to establish the dissemination mechanism for expansion to other provinces/districts. Support will be provided through: • Supervisory and mentoring visit together with NTP, professional societies and other national

stakeholders will be conducted to CTB supported districts to guide and document the DPPM implementation.

• Capacity building workshop for national and provincial stakeholders to guide and support the expansion.

• Provide implementation tools including job aids and video tutorial/instruction. Regional provincial workshops to disseminate documentation of CTB implementation approach for DPPM. Priority will be given to the provincial teams in 8 provinces supported by GF Catalytic Funding (Banten, Kepri, Riau, Lampung, NTB, Sumbar, SulSel, SumSel)

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# patients notified by privateproviders 11,802 13,116 16,433 24,287 16,172

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Sub-objective 2. Comprehensive, high quality diagnostics2. Comprehensive, high quality diagnostics The CTB Lab team has been involved in Xpert expansion planning and preparation, updating the Xpert manual, developing materials for workshops/trainings, being facilitators, and preparation the installation schedule. In Year 4, CTB provided TA and expansion of eTB manager access for all Xpert sites in CTB districts to improve timely reporting. The NTP is focusing attention on increasing uptake and reporting in other provinces as well. Overall the proportion of new patients, as well as children tested is increasing, showing progress on the implementation of the new algorithm. The utilization and reported testing among PLHIV is still low, and CTB with the NTP is working on improving recording and reporting, intensifying the sample transportation network from non Xpert sites, improving the linkage with HIV treatment sites, and ensuring implementation of the new algorithm.

Key Results

2.1 GeneXpert expansion and utilization By the end of Year 4, a total of 559 GeneXpert machines with 2,258 modules were installed and are operational nationwide. An additional 358 machines will be distributed by the end of 2018. The implementation of the new diagnostic algorithm with GeneXpert testing as the primary diagnostic test for TB, resulted in 265,165 GeneXpert tests in Jan-Sep 2018 (more than doubled as compared to year 2017). As can be seen in Figure 5, CTB provinces contributed about 70% of GeneXpert testing with a utilization rate of 38% in August 2018 as compared to 16% utilization rate in non CTB provinces (we use the WHO definition of utilization (3 test/module/day * 240 days per year)).

The introduction of the national (TB) laboratory specimen transportation system SITRUST with tracking of the specimens by the Yayasan KNCV Indonesia (YKI), through CTB sub-award, has started in 16 CTB districts. In total 18,972 specimens were transported in Year 4, against 2639 in the year before. The system has the potential to become a universal laboratory specimen transportation system, used not only for sputum samples. The contribution of this system to improve the Xpert testing among presumptive DR-TB patients in 6 CTB Provinces may not be visible yet, as shown in Figure 6. The evaluation of SITRUST implementation will be done quarterly in Year 5.

GxAlert software pilot implementation at CTB provinces has been conducted, including an additional pilot of “Data to Care” software with collaboration from PSM – Chemonics Project as was requested by NTP.

Figure 5. Xpert expansion and utilization in CTB provinces and non-CTB provinces in Oct 2017 – Sep 2018.

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*DatainSeptember2018isincomplete.

Figure 6. Xpert Testing Among Presumptive DR-TB Patients in 6 CTB Provinces (2015-2018).

*DatashownforperiodJan-Sep2018withincompletedatainJul-Sep2018.

2.2 Laboratory Quality Improvement and Sputum Smear diagnostic

In Year 4, GLI standards in TB lab network accreditation have been socialized to Sub-directorate of Quality Control and Accreditation MoH, and also KAN (National Accreditation Committee) & KALK (Health Laboratory Accreditation Committee). CTB conducted an introduction workshop of integrated

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11 GLI standards for the National Laboratory Accreditation System, and was reported to NTP and each Accreditation Committee.

The introduction of eTB12 to facilitate EQA participation was conducted nationwide. As a results, Sputum Smear EQA participation reached ≥ 95% in 4 CTB districts. Good quality performance by laboratories have reached 80% in 3 CTB districts, indicating that still a lot has to be done. LQMS has been disseminated to all 21 culture/DST laboratories in Indonesia.

Progress summary of C/DST laboratory expansion in Year 4 (see Figure 7 below): - 13 out of 21 standardized culture labs are located in CTB Provinces - 8 out of 11 certified 1st Line DST Labs are located in CTB Provinces - 7 out of 9 certified 2nd Line DST Lab are located in CTB Provinces

In Year 4, 3 out of 7 targeted SL LPA laboratories (Microbiology UI, BBLK Surabaya and Persahabatan hospital) are operational to support STR implementation. The sputum referral network has covered all 34 provinces. The accreditation for these labs are obtained gradually since July 2018 which makes the labs are ready to provide the service.

Figure 7. Geographical mapping of C/DST laboratory nationwide

2.4.1. Sample transportation networks between HIV treatment sites and Xpert sites

In Year 4, CTB completed TA activities related to GeneXpert for PLHIV with presumptive TB in 16 CTB districts. In collaboration with PHO and DHO, CTB disseminated the new TB diagnostic algorithm where all TB presumptive patients (including PLHIV with presumptive TB) will be diagnosed using GeneXpert. The project also established a sputum transportation network to support GeneXpert testing and disseminated information on the GeneXpert network to all HIV treatment sites.

As a result, use of GeneXpert and the sputum transportation system has improved at HIV treatment sites in 16 districts. From October to December 2017, 425 PLHIV with presumptive TB were tested with Xpert, finding 105 MTB cases with Rifampicin sensitivity (RS) and 16 MTB with Rifampicin Resistance (RR). From January-March 2018, 583 PLHIV with presumptive TB were tested, resulting in 122 RS and 16 RR. From April to June 2018, 505 PLHIV with presumptive TB were tested with Xpert,

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resulting in 100 RS and 11 RR. From July-September 2018, 617 PLHIV were tested, resulting in 130 RS and 5 RR. The decrease in number due to fasting month and long Idul Fitri holiday.

Next Steps - In Year 5, CTB will support NTP and National Reference Laboratory in GeneXpert expansion and

the implementation of the GeneXpert distribution plan, through supervision and supported by connectivity solutions (DataToCare pilot and consequent NTP decision).

- CTB will support the PHO/DHO in increasing GeneXpert utilization and expansion through integrated provincial GeneXpert & PMDT M&E meeting and strengthening the GeneXpert referral network (including SITRUST implementation), the early engagement of provincial Health Services (Yankes) in GeneXpert expansion in the province, and advocacy to local government to secure budget in the district action plans for GeneXpert logistic procurement.

- CTB will support NTP and National Referral Laboratory (NRL) in further strengthening NRL and Intermediate Referral Laboratories (IRL) in cascade capacity building for the EQA system and discuss solutions to the human resources needed to do that, and specimen transportation network.

- CTB will support NTP to finalize the integration of 11 GLI Standards into the National Accreditation System for laboratories, which will be disseminated to the surveyors/assessors.

- CTB will support the NTP and the National Reference Laboratories to maintain quality and expanding culture/DST labs.

Sub-objective 3. Patient-centered care and treatment3. Patient-centered care and treatment

3.1.1. Childhood TB: Strengthening good childhood TB practices and new innovations

Key Results: In Year 4, the Childhood TB guideline and benchmarks are already included in the district PPM tool and training materials, with focus on case finding, contact investigation (CI), and LTBI treatment. The SOP for implementation of CI by community cadre has been finalized, and can be used by SRs to the GF grant. The number of children diagnosed with TB in the CTB supported districts remained stable at 13% of all new patients, whereas relatively in the DPPM health centers this slightly rose from around 9% to 12% (see fig.2).

The study protocol and SOPs for piloting GX testing using stool sample were finalized and approved by NTP, the Indonesian Pediatric Society, and the Expert Committee (KOMLI). Ethical clearance is under review by University of Indonesia. Site preparation workshops will start in October 2018.

In addition, the chapter for childhood DR-TB management is included in the national PMDT guidance and has been disseminated to Clinical Expert Teams from 34 provinces.

Next Steps: In Year 5, the stool sample study will be completed in the first quarter of 2019. CTB will support the implementation of childhood TB and DR-TB management at national level through TWG and at district level through the DPPM approach.

CTB will support NTP to evaluate the implementation of CI scale up and possibly review the training module and tools for CI implementation. The focus will be on documentation and recommendation on lessons learnt and good practices on cadre engagement under the DPPM approach and collaboration with GF supported activities for community (Aisyiyah and LKNU).

3.1.2. TB-HIV: Ensure HIV testing for TB patients In Year 4, CTB integrated the TB/HIV provider-initiated testing and counseling (PITC) approach into DPPM Puskesmas’ technical updates to ensure HIV testing is conducted either on site or through referral. To facilitate this integration, CTB conducted workshops on internal linkage strengthening for TB

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management in 216 Puskesmas where HIV testing for all TB patients had been identified as a priority. A key component of the workshops was ensuring functioning TB/HIV patient referral networks from TB units at Puskesmas to ART sites. This was in addition to the Joint Service Delivery approach in Jakarta described in paragraph 3.2.5. Key Results: In Jakarta, CTB supported TB/HIV acceleration through on-going clinical mentoring and data quality assurance of HIV testing among TB patients in Joint Service Delivery (JSD) sites with a total of 15 Kecamatan Puskesmas (sub-district level) and 45 Kelurahan Puskesmas (sub-sub district level). The DPPM approach at sub-district level was started in 216 Puskesmas that had also prioritized HIV testing for all TB patients and a functioning referral network to ART sites. In the 16 CTB districts, there was an increase in the percentage of TB patients who know their HIV status from 35% in 2017 to 47% in 2018, and of TB/HIV patients on ART from 46% in 2017 to 54% in 2018 (also fig.9). In the first two quarters of 2018, these 16 districts contribute significantly contribute to available national figures: 24% of all the diagnosed TB-HIV co-infected patients, and 76% of all co-infected patients who are put on ART. This is a result of a combination of several approaches, namely the inclusion of TB-HIV screening in the DPPM approach in 307 health facilities with a referral mechanism to ART sites, a joint service delivery approach in Jakarta combining efforts of the NTP and NAP in 60 health centers, and an acceleration approach to HIV testing of TB patients in the other CTB supported districts covering 259 out of 280 (93%) kecamatan, 406 out of 485 (84%) Puskesmas, 69 out of 108 (64%) public hospitals (including Lung clinics/hospitals), and 114 out of 321 (36%) private hospitals (also fig.8). Analysis from the 16 CTB districts, shows that in the districts where almost all TB treatment sites have HIV testing available, the TB patients have a high rate of HIV testing. This also applies to ART coverage among TB/HIV patients. The challenge is in referring these patients to designated facilities. During initial steps, the institution of “navigators” to help ensure all those with HIV reach CST sites for HIV initiation was suggested. CTB will be piloting this approach in Year 5, for DKI Jakarta provinces under Joint Service Delivery in collaboration with LINKAGES. Figure 8. Percentage of TB patients who know their HIV status and Percentage of TB treatment facilities with onsite HIV testing in 16 CTB districts, January 2015 – September 2018

Source: Data Collection Tools APA 4, Oct 12th, 2018 *incomplete data

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Figure 9. Percentage TB/HIV Patients receiving ARV in 16 CTB districts, January 2015 – September 2018

Source: Data Collection Tools APA 4, Oct 12th, 2018 *incomplete data 3.1.4. TB in prisons: TB control program strategy for a sustainability CTB had to revise the Year 4 workplan due to the six-month vacancy in the position for TO TB in Prison (January to June 2018), which delayed the national level workshop to develop a TB control program strategy for correction facilities. Key Results: CTB collaborated with MoH supported the Ministry of Law and Human Rights (MoLHR) to finalize the TB Control Program Standard Guideline for Correction facilities, which has been signed by DG of Correction in an official decree endorsing implementation of the guideline. This guideline includes sections on human resources, facility and budget needs, SOPs, and performance indicators for TB case finding and case holding in correction facilities. It will be used by prisons/detention centers and MoLHR at the provincial and national level to plan the TB control program. After several consultations with KNCV and MoLHR, CTB and partners decided to cancel the national and provincial workshops on the sustainability of the TB control program and instead focus on developing a district level sustainability plan for the TB control program for correction facilities in Year 5. This plan will clarify the support needed from DHO and nearby health facilities as well as national insurance (BPJS). The support for screening in prisons received less attention, resulting in a decreased notification of 409 patients in the first 3 quarters of Year 4 as compared to 824 in the same period in Year 3. In August 2018, CTB supported MoLHR to review the achievements from the National Action Plan for Correction Facilities, 2014-2019. This review and subsequent analysis will be used develop the Action Plan for 2020-2024 in Year 5 and will support the handover of TB activities in prisons, in this way helping to create a more sustainable approach by the prison services itself.

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3.2.5. TB-HIV: Joint Service Delivery in Jakarta, Clinical Mentoring and Access to Care In the five DKI Jakarta districts, CTB, LINKAGES, and PSM supported a special Joint Service Delivery (JSD) approach to accelerate the provision of TB/HIV services. JSD efforts focused on 15 selected Puskesmas kecamatan and 45 of their feeder Puskesmas kelurahan. PHO, with support from CTB and LINKAGES, conducted a workshop for these 60 Puskesmas where they introduced four testing amplification strategies: (1) mobile testing through DOKLING5 application, (2) patient referral with support from cadres, (3) specimen/blood transportation, (4) R-zero (prick test). Furthermore, all Puskesmas kelurahan received on-the-job training, TA, and clinical mentoring during the workshop. During the on-the-job training, CTB found that data validation is an important component in the JSD approach due to under reporting and erratic recording of testing and treatment data by the Puskesmas. During data validation, CTB found that some Puskesmas continue to use their routine strategy rather than the prick test because of not having received any official letter from PHO about it. Nineteen (32%) Puskesmas have an HIV testing laboratory available, 34 (57%) refer patients for HIV testing, 6 (10%) use blood transportation, and 1 (2%) uses the prick test R-zero. DHO leads most activities at Puskesmas. Key Result:

- CTB-supported health facilities saw an increase in the proportion of TB patients who knew their HIV status. In Jakarta, at the Joint service Delivery sites, between July to September 2018, 84% of TB patients knew their status compared to 62% in the previous year (Figure 10).

- Also in Jakarta, there was an improvement in the percentage of TB/HIV patients initiating ART – 54% were on ART between July to September 2018, compared to 30% in the year before (Figure 11).

- ART initiation in Q2-Q3 2018 was not as high as Q1 2018 due to delays in initiating some TB/HIV patients on ART. We expected a very high percentage starting on ART, but there is often a 2 month delay which is in line with national guidelines (wait 2-8 weeks after TB treatment start).

- PHO Jakarta asked CTB and LINKAGES to expand TA efforts to all Puskesmas Kecamatan facilities and selected provincial level hospitals in Jakarta in an effort to improve TB/HIV cascade performance. The DHO, supported by CTB and LINKAGES, has scaled up to 14 additional Puskesmas Kecamatan and 49 more Puskesmas Kelurahan through two rounds of workshops between July and August 2018, and to seven selected provincial level hospitals in September 2018.

- During clinical mentoring and on the job training, all Puskesmas Kelurahan under these 14 Puskesmas Kecamataan were invited and received the update. In total, the approaches reached 29 Puskesmas Kecamatan and 243 Puskesmas Kelurahan. This scale up led to better overall achievement within DKI Jakarta (see figure 10 and 11).

- CTB began scaling up the JSD approach to seven selected provincial level hospitals out of total 180 hospitals (55 public and 125 private). Currently, due to limited funding, CTB and partners have not determined whether the JSD approach will be expanded beyond these seven hospitals or not.

- CTB will begin documenting good practices in Q1 of Year 5 for dissemination to other CTB underperforming districts.

5 DOKLINGisanonlineschedulingandtrackingsystem,shortfordokter(doctor)pluskeliling(mobile),whichisslangfor“mobiletesting”inthefield.Featuresincludeaschedulingdatabase,anauto-sendrequestlettertoreplacethepreviousschedulingrequestsbyemailandhardcopy,andarecord-keepingfeaturetodocumentthenumberofpeopletestedandhowmanytestedpositiveduringmobileVCT.AGeo-tagfunctioncreatesavisualoflocationswiththehighestHIVprevalence,whichcanbeusedtoidentifyfuturemobileHIVtestingsites.

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Picture: Dra. Khafifah Any, Apt, MARS, interim Head of PHO DKI Jakarta accompanied by Dr. Widyastuti, MKM, Head of Disease

Control Division, PHO DKI Jakarta; and Dr. Anna Uyainah, Sp.PD, KP, MARS, FINASIM, Head of KOPI TBC/Professional

Organization Coalition for TB DKI Jakarta giving opening remarks during the TB/HIV Acceleration Workshop for Hospitals on

September 2018 (Photo credit: Merry Samsuri)

Figure 10. TB Patients who know their HIV Status, JSD Sites, 2017-2018

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Figure 11. TB/HIV patients receiving ART during TB treatment, JSD Sites, 2017-2018

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3.2.1 MDR treatment enrollment and implementation of New Drugs and Regimen

Implementation of Monthly Interim Cohort Analysis (MICA) Following the introduction of MICA to all 34 provinces during a National workshop on STR (attended by PHO Wasor) in Sept 2017, in Year 4, socialization of MICA to the districts was done at the provincial level, also inviting non-CTB districts within CTB supported provinces.

Key Results - The implementation of MICA in 13 CTB districts (since 2017), has been instrumental in increasing

the treatment enrollment rate of diagnosed patients to 78% as compared to 71% in 2016. The use of MICA has contributed to reducing Lost to Follow Up (LFU) from 23% in 2016 to 7% in 2018 (Figure 12). The impact of MICA to improve enrollment rates at the provincial level is not noticeable yet until the expansion of MICA beyond CTB districts is implemented and more reliable notification data are available.

- In CTB districts the application of MICA by the district TB Wasor and patient organizations, facilitated by CTB, resulted in an increase of MDR-TB treatment adherence at 6 months of treatment from 62% among patients from the last cohort of APA2 to 85% among the patients of the third cohort of Year 3.

- In Medan city, MICA has been regularly conducted and facilitated by the initiative of DHO with minimal technical support from CTB technical team.

- CTB provided TA to scale-up and decentralization of MDR TB care, improvement of the linkage to care and quality of PMDT through benchmarking and interim cohort assessments.

- In Year 4, in CTB provinces, there are 42 functional PMDT hospitals (treatment initiation centers) out of a total of 97 designated hospitals. At national level this is 159 out of 360.

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Figure 12. Treatment enrollment of DR-TB patients and Loss to Follow-Up (LFU) in 2016-2018 as MICA has been routinely implemented in 13 CTB districts

Next Steps In Year 5, CTB will support the NTP in the expansion and mentoring of PMDT hospitals including improving capacity of teams of DR-TB nurses and clinicians (PMDT treatment initiation and continuation site) on side-effect management. The latter will be done through a national training of and by the Indonesian Nurse Association (PPNI), nursing faculty, DR-TB clinicians, and the Directorate General medical and nursing care in MOH. The nurse case manager model documented during ATS STTA in July 2018 will be introduced during the training. In addition, clinical mentoring will be done also through improving already existing WhatsApp groups amongst clinicians and public health staff, and organizing regular online discussions.

3.2.2 MDR treatment adherence and quality of care

In Year 4, a combined clinical audit and training for MDR-TB clinicians was completed in 6 PMDT sites including non-CTB district, involving clinicians from 21 PMDT sites. The use of PMDT Benchmarking Tool (all 10 hospitals where this was done modestly improved, although there is still much improvement needed in patient-related indicators), a self-assessment tool, in 5 referral hospitals (Persahabatan, Hasan Sadikin, Moewardi, Soetomo, Adam Malik Hospital) in 5 CTB provinces have facilitated its use in 7 other sub-referral hospitals.

Key Results:

The implementation of STR started in September 2017 with enrolling 32 MDR-TB patients in 6 treatment sites. Towards the end of June 2018, STR access increased to 89 treatment sites in 31 provinces (Figure 13), enrolling 1746 (61%) MDR-TB patients on the STR regimen out of a total of 2876 enrolled on treatment (all regimens) since September 2017. BDQ access has expanded from 9 to 22 PMDT hospitals in 5 CTB provinces and 2 other provinces. Total accumulative BDQ enrolment is 353 patients for the period 2015-2018. The revised PMDT guideline has been finalized in May 2018, which includes the guideline for Delamanid (DLM) implementation. DLM is available to be used by DR-

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TB patients and currently enrolling 12 patients in 3 PMDT hospitals. With the WHO rapid communication further adjustments are expected in the PMDT guidelines at the end of 2018.

Figure 13. Expansion of STR treatment sites, and patients enrolled on STR, BDQ and conventional regimens (Sep 17 - Sep 18).

*Data in Jul-Sep 2018 is not available yet

In support of patient triage and treatment follow-up, CTB also supported the development of SL LPA capacity of culture laboratories and restructuring and the strengthening of the national TB reference laboratory network, by providing TA to 3 new regional reference laboratories and introducing LQMS (laboratory quality management systems) in 7 regional reference laboratories.

Next Steps • At the national and provincial level CTB will continue to focus on improving capacities and

capabilities concerning the quality of MDR-TB care by applying and helping PHO/DHO to apply quality improvement methodologies (benchmarking, interim cohort analysis with action for improvements, nursing job aid, and clinical mentoring), the routine monitoring tool (Monthly Interim Cohort Analysis-MICA). As part of the project transition plan, a set of documentation, tools and good practices will be provided to all relevant stakeholders (SOPs, instruction videos, and interactive tutorials).

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• At the district level, in the context of DPPM, CTB will help training Puskesmas staff on the management of side-effects using nursing job aid.

• CTB will assist NTP to expand the use of STR and BDQ/DLM according to NTP expansion plan, including aDSM implementation, and preparation for the introduction of the announced new WHO DRTB guidelines in November 2018

• Together with NTP focal person, CTB will evaluate the implementation of STR and new drugs, focusing on documentation of lesson learnt.

• CTB will continue to support the NTP and the National Reference Laboratories for maintaining quality and expanding culture/DST labs, and implementing and expanding SL LPA

Objective 2. Prevention

Sub-objective5.Infectioncontrol5.InfectioncontrolIn Year 4, CTB expanded the promotion of using the self-assessment tool for PMDT sites which includes infection control (IC) assessment as one of the standards which was developed in Year 3. The tool has been used in 10 PMDT sites and socialized to all PMDT sites nationwide. The strategy of TB IC, in particular FAST strategy (TemPO – Temukan, Pisahkan dan Obati pasien TB) and TB screening among HCW, was integrated to DPPM approach.

In Year 5, CTB has no specific additional plans in the area of infection control.

Sub-objective6.ManagementoflatentTBinfection6.ManagementoflatentTBinfection

Key Results In Year 4, a draft plan for a 3HP pilot was made and guidance for the use of Lfx-E for eligible DR-TB contacts was finalized. LTBI treatment is promoted through community-based CI activities. The SOP for implementation of CI by community cadre has been finalized, and can be used by GF-SRs.

Next Steps In Year 5, as soon as the drugs are made available by NTP, CTB will support implementation of LTBI management among priority risk groups (using 6H or 3HP for drug-sensitive TB, and Lfx-E for DR-TB) through:

• Early initiation of 3HP in 6 districts; • Evaluation of latent DR-TB treatment; • Documentation, in particular how LTBI treatment is implemented through CI.

This will lead up to and accelerate the start of the IMPAACT4TB project of UNITAID.

Objective 3. Strengthened TB Platforms

Sub-objective 7. Political commitment and leadership7. Political commitment and leadership The development of District Action Plans (DAP) for TB is a potential source of sustainable funding for TB programming in the post-Global Fund era. In Year 4, CTB expanded the support to develop DAP beyond CTB districts and provinces.

Key Results - The signing of a joint commitment for inter-sectoral collaboration in TB care and

prevention by the Minister of Health, Minister of Home Affairs, DG Representatives of Ministry of Villages, National Planning Agency, Local Government Representatives throughout Indonesia, Partners and Non-Government Organizations.

- All 16 CTB-supported districts/cities have finished preparing DAP documents and 15 of those have been ratified by regulation of the Head of Region.

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- Local government budget allocation for the TB control strategy in 16 CTB supported districts increased by 76% to IDR 6.8 billion (approx. USD 506,000 in 2018, as compared to USD 287,000 in 2017) as shown in Figure 14.

- Five provinces are already in the process of drafting a Provincial Action Plan where 4/5 provinces are nearing completion of document preparation.

- The District Health offices in Surakarta and Jember committed operational funds, as was reported in the second quarter of Year 4.

- On the expansion of DAP beyond CTB areas, there are 25 districts/cities in the process of drafting the document with technical assistance from CTB, where 1 city, Cirebon city, has completed the preparation of documents and legalized it by regulation of head of region.

- In 2018 some districts have allocated special costs for tuberculosis but the amounts are still low because the new DAP document has been passed so it has not been proposed in the 2018 regional budget cycle. DAP will be ready to be part of the local budget cycle in 2019 and 2020.

Figure 14.District budget allocation for TB (in USD) in 16 CTB districts (in DKI Jakarta combined of 5 administrative cities)

Next Steps - In APA 5, CTB will provide support to DHO and DAP teams to monitor and advocate the

translation of DAP into local budget in CTB-supported provinces/districts. - The expansion of DAP approach to other districts and provinces will be done through:

• Capacity building and mentoring of provincial team of PHO; • Stimulating the provincial team (PHO) to expand DAP to other districts as part of

Provincial Action Plan; • Facilitation of a platform among districts to share experiences.

- CTB will hand over a set of documentations and guidelines to NTP, provincial and district governments. CTB will provide specific recommendation related the good practices,

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results to date, and lesson learnt on advocating the use of specific available budget scheme in districts (i.e. village fund, BOK funds, puskesmas’ capitation, etc.).

Sub-objective 8. Comprehensive partnerships and informed community involvement8. Comprehensive partnerships and informed community involvement In APA 4, CTB focused on local use of the national communication strategies. Media messages were developed by 10 schools in Jakarta to raise awareness on Tuberculosis through short films and video blog. The short films produced were reviewed by a panel Jury consisted of:

1. The Film development center, Ministry of Education and Culture, Republic Indonesia 2. Health Promotion Directorate, Ministry of Health, Republic Indonesia 3. Sub-directorate Tuberculosis, Ministry of Health, Republic Indonesia 4. Challenge TB Indonesia

CTB contributed to effective GF grant implementation by participation in GF Country Team visits and TWG meetings.

Key Results - In Year 4, CTB has increased advocacy efforts to engage with youth and partnerships

through other sectors, which in this case is the Film Development Center of the Ministry of Education of Republic of Indonesia. The partnership between Ministry of Health and Ministry of Education and Culture was strengthened during Tuberculosis Short Film Festival in Jakarta on 23 March 2018. A total of 22 short films were produced by high school students, 9 from DKI Jakarta, 7 from North Sumatra, and 6 from Papua were submitted and uploaded to Challenge TB YouTube Channel on https://bit.ly/1Qy1YOK

- On World TB Day at the National Monument in Jakarta, CTB contributed to the TBGRAPHY exhibition during which the winners of the Festival Film were announced.

- On August 8, 2018. CTB facilitated the hand-over event between Ministry of Health to Ministry of Education and Culture. The short films produced by high school students will be disseminated through 116 mobile cinema unit in 34 provinces, and 72 schools that equipped with cinema facilities.

- The results of a survey to measure the improvement of TB knowledge gained after short films viewing was presented during The 2018 International Social and Behavior Change Communication Summit featuring Entertainment Education in Nusa Dua, Bali, on 16-20 April 2018.

- CTB supported a blogger workshop as part of the World TB Day activities which was held on 19 March 2018 in coordination with the Public Communication Bureau, MOH and attended by more than 30 bloggers.

- CTB received a Charter of Acknowledgment for its participation in TB control program in Bandung city. The Charter was given by the Assistant for Governance and Welfare Affairs representing the City Mayor on World TB Day event at the City Hall on 28 March 2018, and followed by TBGRAPHY the next day.

- In partnership with CTB, DKI Jakarta Provincial Office launched TB messages on five vehicles including electric bikes (see Figure 15 below): 2 funded by CTB and 3 funded by DKI Jakarta. The event took place during the World TB Day and was launched by Anung Sugihantono, the Director General of Disease Prevention and Control (P2P) Ministry of Health.

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Figure 15. The graphics of TB knowledge on the vehicle wraps, launched during the World TB Day on 24 March 2018.

Next Steps - In Year 5, at the district level, desktop software that enables to customize promotional

materials with local content which has been initiated in Year 4, will be finalized. The communication strategy and software will be rolled out in 6 supported provinces together with the provincial health promotion units.

- At the provincial level, CTB will showcase good practices and lessons learned to other districts in CTB provinces. The overall showcase will be delivered in the form of seminars and also booths in specific technical areas, where participants can ask questions to technical officers from the implementing districts, PHO, CTB, and other implementing stakeholder.

Sub-objective10.Qualitydata,surveillanceandM&E10.Qualitydata,surveillanceandM&E10.1 Patient-based electronic recording and reporting system In Year 4, CTB supported the dissemination, training and troubleshooting of SITT version 10.4 in 6 CTB supported provinces, which is now better capable of capturing all forms of TB. SITT version 10.4 was enhanced with a dashboard preview, allowing easier data analysis and presentation of areas of interest. CTB also supported intensified data collection in selected under-reporting hospitals. CTB also assisted the NTP to organize the transition of the SITT server from a hired private company to the Central Data and Information Body (Pusdatin) of the Ministry of Health.

Key Results - CTB assisted in the training for the migration from SITT (Sistem Informasi Tuberkulosis

Terpadu) 10.3 to SITT 10.4 and in trouble-shooting for difficulties in the web platform. - New version SITT 10.04 developed, including giving training and migration process,

trouble shooting and enhance SITT dashboard in offline and online version (web version), allowing easier data analysis and presentation of areas of interest.

- Provincial health information team in CTB areas have been strengthen, using on the job training, supervision and data validation meetings.

- On e-TB Manager Software, CTB developed a new function on how to “track” the sites that have updated the stock positions and transactions at all levels for second-line TB drugs and Xpert cartridges.

- On lab connectivity software, the team provided the NTP with a summary and recommendations from the evaluation of the GxAlert pilot. On request of the NTP and in collaboration with the PSM Project, CTB facilitated the development of plan for

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implementation of a new pilot study with Savics who developed Data to Care software, to enable an informed choice about which system to use in the future

10.2 Development of new surveillance system SITB (Sistem Informasi TB)

In APA 4, CTB finished the Final Report of Master Plan Technical Document of SITB. In discussion with GF and WHO, CTB has taken over the procurement of the SITB development process from WHO. Approval from USAID and PMU has been granted. The software development is expected to be completed and tested by May 2019.

Key Results - Technical master plan document has been finalized and share to all parties i.e. NTP and

Pusdatin. - CTB has signed an agreement with an IT Company who will develop the software,

including TA to make sure software development are in-line with technical master plan document and provide good quality software.

10.3 Operational Research

In Year 4, CTB started the fieldwork of the study “Tuberculosis case yield of risk group screening using optimized screening and diagnosis algorithms in Indonesian community health centers: a cluster-randomized study (ICF Study)”. In addition, CTB supported NTP in the development of the Roadmap for TB elimination in 2030.

Key Results

- Fieldwork of the ICF study is completed with 5,960 out of 6000 target participants are recruited in 10 target puskesmas.

- The interim results have been accepted for presentation at the 49th Union World conference on Lung Health in The Hague.

- On request of the national planning committee (Bappenas), the application of TIME in Indonesia will be combined with OneHealth for cost effectiveness modeling, based on the (revised) NSP and decentralization, to inform tailored interventions and development of TB Elimination Roadmap in Indonesia 2030.

Next Steps In APA 5, CTB will continue the improvement of recording and reporting at district, hospital and PKM level, which contributed significantly to the reported CTB achievements on case notification. CTB will support a structured management approach by DHOs on various aspects of TB care and prevention. In collaboration with DHOs, CTB will adjust its own management tool “the district dashboard” and provide technical support to DHO’s on its use for “data analysis for action” and promote “data analysis for action” by Puskesmas and Hospitals. TA will be given to NTP and a selected IT company for development of SITB software, to make sure product of the software are in line with the “Master Plan Technical Document”. Regular monthly coordination meeting will be conducted, for close monitoring software development progress. Beta version pilot implementation will be conducted at CTB provinces to test functionality, durability, server setting functions, collecting bugs information, and recommendations from stakeholders. SITB beta version will be available in January 2019 and pilot implementation at CTB provinces will be conducted on Jan-March 2019.

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CTB will provide TA to support operational research at national level and scientific publication on Bedaquiline study. The development of TB Elimination Roadmap in Indonesia 2030 will be supported by CTB through STTA for the costing of the roadmap. The ICF algorithm for TB screening and diagnosis among PKM attendants is expected to be completed by December 2018. The study protocol of phase-2 will be finalized based on results of phase-1, to be picked up by other funding mechanisms. The analysis of Phase-1 ICF study data and development of manuscript for publication in peer-reviewed International Journal will be supported by Local Universities through a Sub Award mechanism. UNPAD, UNS and UI will be engaged for qualitative assessment and cost analysis.

Sub-objective11.Humanresourcedevelopment11.HumanresourcedevelopmentIn APA 4, CTB supported the formation of KOPI TB and provide capacity building to the professional societies in support of implementation of the district PPM approach. In Year 4 almost 5000 staff were trained, as compared to 300 in Year 3. The increase was due to the implementation of DPPM, the expansion of PMDT, and various efforts in the area of data improvement.

Key Results - At national level, KOPI TB which consisted of PAPDI, PDPI, IDAI, IMA and other

professional organizations was formed and trained with support from CTB, including the role as secondary and primary care level (public-private) interface with the DHO - and to initiate implementation in other districts through Global Fund and domestic resources.

- CTB support the formation of KOPI TB at provincial and district level were facilitated by Master Trainers (KOPI TB at National level) to ensure effective implementation of the DPPM approach in CTB and non-CTB supported areas.

Next Steps In Year 5, CTB will continue to support PHOs in the formation of KOPI-TB chapters in non-CTB districts in the context of the DPPM approach.

4. Challenge TB Support to Global Fund Implementation

CurrentGlobalFundTBGrantsName of grant &

principal recipient (i.e., Tuberculosis NFM

- MoH)

Average Rating*

Latest Rating

Total Approved/ Signed Amount**

Total Committed

Amount

Total Disbursed to

Date

IND-T-MOH 2018 B1 B2 38,499,843 17,295,358 9,929,965 IND-T-AISYIYA 2018 B1 B2 5,820,634 14,768,458 2,486,725

Source: CCM secretariat * Since 2012

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** Current NFM grant not cumulative amount; this information can be found on GF website or ask in country if possible.

In-countryGlobalFundstatus-keyupdates,currentconditions,challengesandbottlenecks- In Year 4 CTB contributed to finalization of the detailed GF budgets and the performance

framework and answering Technical Review Panel questions in preparation of the Grant Allocation Committee (GC) review, and consequent grant making. In December 2017 the new TB/HIV grant was signed.

- Overall grant absorption by Primary Recipient Ministry of Health (MoH) was approximately 80% (pending final reports); that of Primary Recipient Aisyiyah over 90%. While CTB support contributed to the overall 80 – 90% absorption rate by the end of the grant period, the weak financial management system is expected to lead to a downgrading of the performance rate.

- The country under-performed on some key indicators, like HIV testing among TB patients, despite recent improvements like expansion of HIV testing of TB patients at PKM level, which is based on CTB experiences. CTB continues to provide grant management support mostly on technical and strategic issues, as well as the development of forecasts and preparation of orders for drugs and laboratory supplies, especially Xpert cartridges.

- In collaboration with WHO, and global fund PR/SR (Aisyiyah and LKNU), CTB supported the training of trainers to facilitate training of Cadres in 26 Provinces.

- CTB has actively supported Country Team Global Fund mission to Indonesia in June 2018, especially on supply chain management on Xpert cartridges and second line TB drug analysis. Using the Quant TB software to determine which drugs that predicted will be stock out in the coming month, including the recommendation to anticipate it.

- In the effort to ensure the availability of Xpert cartridges, CTB will support NTP to accelerate Global Fund procurement using budget allocation year 2018-2019. The acceleration on procurement budget year 2019, will be conducted this year as a back-up plan if the procurement process using APBN budget is delayed or cancelled.

- CTB initiated active surveillance of notification, being the data collection in hospitals by the GF data officers who were supported by CTB provincial teams, leading to immediate action to maintain the gains in notification made in 2017.

ChallengeTBinvolvementinGFsupport/implementationandanyactionstakenduringYear4- In Year 4, CTB supported the dissemination of SITT version 10.4 in 6 CTB supported

provinces, which is better capable of capturing all forms of TB. CTB also supported intensified data collection in selected under-reporting hospitals.

- At the national, provincial and district level, CTB supported MoH, Provincial and District Health Offices to implement GF supported TB-HIV activities through co-facilitating a TOT on PITC for the national trainers group.

- CTB continued TA to Xpert expansion, strengthening of MDR diagnosis and treatment; facilitated a workshop for dissemination of the District Public Private Mix concept to 34 provinces, which was held in Jakarta on 11-12 December 2017. The District PPM approach is the main component of the GF catalytic funding.

- CTB supported the MoH during a field visit to monitor GF support to TB-HIV collaborative activities in Medan.

- CTB assisted the MoH in the national prevalence survey of HIV among TB patients, which was funded by the GF. Support was provided concerning data collection and analysis in five CTB provinces (North Sumatera, DKI Jakarta, West Java, Central Java and East Java) by coordinating with the provincial teams and field visits to two of the 20 districts sampled. The results have not yet been published.

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- In preparation of contact investigation by CSO’s under the GF grant, CTB finalized the pilot on contact investigation. In January 2018 results were shared with the NTP and CSO’s to inform further planning and discussions with the GF Country Team.

- CTB supported the NTP during a GDF mission and Global Fund visits to provide necessary data and information on quantification of second-line TB drugs using Quant TB software. Using eTB manager, CTB also assisted the NTP to monitor drug availability and use as the basis of drug monitoring, forecasting and procurement.

- CTB also provide assistance to the NTP in drafting responses on GDF&GF mission action points, including involvement in routine CCM/TWG TB meetings and Global Fund teleconferences.

- CTB also provide capacity building to GF technical officers and data officers to ensure sustainability and uptake of CTB approaches (DPPM, PMDT, GX utilization and DAP), including the TB surveillance system.

- TB/HIV National Acceleration Plan Development In November 2017, CTB supported MoH to develop a TB/HIV National Acceleration Plan, which was requested by the Global Fund. To support the writing process, CTB supported 2 field visits to Medan (North Sumatera) and Jember (East Java) to conduct a situation analysis. Finalizing the document has been a lengthy process requiring several rounds of input from the Global Fund. As of September 2018, the document is still being finalized.

- TB/HIV Joint Planning In March 2018, CTB supported MoH to facilitate a TB/HIV joint planning workshop in Jakarta, for representatives from all 34 provinces. For this workshop, CTB supported the development of discussion material/guidance and introduced the clinical mentoring manual that was developed in Year 3. CTB also facilitated the DKI Jakarta TB/HIV joint planning workshop. At this workshop all DHOs agreed to scale up the implementation of TB/HIV acceleration plan to all Puskesmas and selected hospitals.

- IPT Dissemination CTB supported PHO DKI Jakarta to disseminate the IPT guideline to 44 Puskesmas Kecamatan and Puskesmas Kelurahan in Medan city, North Sumatera

- HIV National Action Plan Development In August 2018, CTB, together with NAP, supported a field visit to North Jakarta and Kota Medan to get input on development of an HIV National Action Plan.

- TB in Prison In August 2018, CTB supported MoLHR and MoH to review and revise the existing TB infection control guidelines for correction facilities as well as develop a self-assessment check list.

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5. Challenge TB Success Story Keep Fighting

The shorter treatment regimen for drug-resistant tuberculosis (TB) is transforming lives wherever it is introduced. The number of people being diagnosed with TB that is resistant to standard drugs is increasing with each passing year. In 2017, there were an estimated 12,000 people with drug-resistant TB in Indonesia, but troublingly only 1,597 were actually diagnosed and put on appropriate treatment.

To make matters worse, the number of patients who were treated successfully was on the decline. The normal treatment is painful, packed with side effects, and long, so long that around a third of patients just quit.

The USAID-funded Challenge TB project has overseen the introduction of the shorter course of treatment that takes 9 months instead of 24, this alone is having an impact on a disease which brings pain, poverty, and devastation to all who get it.

Twenty-four-year-old Anjar, from Central Java, lives at home with her family. Her father is a farmer, and her stepmother sells clothes at the local market.

Anjar was working in a shop when she got tuberculosis (TB). She started coughing, and instead of getting better, it got worse, and she started coughing up blood. This a classic symptom of TB as the blood vessels inside the lungs are eroded by the disease and begin to bleed.

She was put on treatment, and six months later she was cured. She thought that was the end of it, but it wasn’t, within half a year, she was sick again, the cough was back, and so was the disease.

In the hospital, she was tested with a new GeneXpert machine purchased by Challenge TB. This technology diagnoses TB and resistance to the key TB drug rifampicin in a couple of hours. The news was not good, she had developed drug-resistant TB, and her life fell apart once more.

She was one of 14 patients to be put on the newly introduced shorter treatment at the Hasan Sadikin hospital, in West Java. She quit her work to focus on her treatment, and she kept away from her family as she feared she would infect them too. So for nine long months, she was alone, only speaking to her family on the phone, and enduring the side effects on her own

In July 2018 she successfully completed her treatment making her the first person in Indonesia to do so. She said: “I am so grateful – all the hard work and effort to introduce these new treatments have paid off, and I was cured in such a short time.”

Now that she has finished her treatment she is back with her family. Looking back, she remembers now that her late mother also coughed up blood when she got sick. Despite visiting doctors and hospitals she never got a diagnosis and died in 2012. Now she knows her mother probably died of TB and may even have infected her as well, a thought which is unbearable.

Since her recovery, she has realized how important it is to be supported through treatment no matter how long or short it is. So to help others navigate the difficult road, she has joined a group for ex-drug-resistant TB patients called “Terjang” which is short for Terus Berjuang and means - Keep Fighting. The members of Terjang visit TB patients at home or in the hospital to offer much-needed

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support, counseling, and encouragement during treatment. One of the things she always tells them is, “Never give up, keep fighting, and be confident you can be cured.”

It is now a year since Indonesia started its first patients on these new treatments. So far 1,058 patients have been enrolled on shorter and individualized treatments, 63 are already cured, and there are many more to come.

6. Operations Research

Title of OR study Local partners involved in study

Implementation Status Key findings Dissemination

TuberculosiscaseyieldofriskgroupscreeningusingoptimizedscreeninganddiagnosisalgorithmsinIndonesiancommunityhealthcenters:acluster-randomizedstudy(ICFStudy)

- NationalTBProgram- Provincial/DistrictHealthOffice

- NationalandIntermediateReferralLaboratory

- ThelocalTBexpertgroup(KOMLITB)

- UniversitasPadjajaran

- UniversitasNegeriSebelasMaret

- UniversitasIndonesia- Privatelaboratory

- EngagementandownershipofstudybytheNTP

- Datacollectioninall10puskesmasinBogordistrictforICFstudyphase-IhascompletedintheendofAugust2018with6,087puskesmasclientssignedinformedconsent.However,thereisaneedtocollectadditionaldataforeconomicsandqualitativestudycomponentsinfourhealthfacilitiesinWestJavaprovincethathaveGeneXpertmachinesforTBdiagnostic.FourhealthfacilitiesareDistrictHospitalofCiawi(RSUDCiawi),PuskesmasCiranjanginCianjurdistrict,PuskesmasCimahiSelataninCimahicity,andPuskesmasPancoranMasinDepokcity.

- Initialdataanalysisfrom7outof10puskesmashasbeenconductedandithasbeenpresentedonSep12,2018.Theinitialdataanalysiswasnotcompleteyetbecausedatavalidationoftherestthreepuskesmashadnotbeenfinalized.

- ThepreliminaryreportoftheICFstudyphase-Iisexpectedinthemid-ofNovember2018.

Nextsteps:- Tofinalizedatavalidationfor3puskesmas.- Costingdatatobecompleted

- Numberofeligibleclientsfrom10puskesmas:14,920

- Numberofclientsinvitedforthestudy:10,037

- Numberofparticipants:6,090,with:§ Only61%oftheinvitedclientsparticipated.

§ Therearecompletedatafor>90%oftheparticipants.

- Initialdataanalysisfrom7outof10puskesmasfoundthat127participantsshownTBpositivebasedonXperttestand98participantsshownTBpositivebasedonsputumsmearmicroscopy.

- SomeTBriskfactorsthatshowhighTBcasesare:§ ThosewhodidnotcompletepreviousTBtreatment

§ TBdiagnosis<2yrsago§ LivedwithTBpatientinpastyear

§ Quitsmoking<1yrago§ Diabetesmellitus§ BMI<18.5kg/m2§ Wantsfreex-ray

- OnSep12,2018:initialdataanalysishasbeendisseminatedto10puskesmasandBogordistrictoffice.

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§ IncludingcostingXperttestingfrom3puskesmasand1hospital,includingspecimenreferral,

§ IncludingcostingX-raywhenreferringclientstohospital

- Conductanalysesincludingall10Puskesmas§ Furtherdataexplorationneeded,weighingeffectiveness(#casesfound/1000clientsscreened)againstcostforallpotentiallyeffectivealgorithms,

§ Validatethepredictionmodels.

§ Thosewithrespiratoryproblem

§ Maleparticipants.- NumberofTBcases(GXMTB+)foundbyscreeningmethodareincreasedamongthosewhohaveanycoughandhaveCXRabnormalandcostperTBcasedetectedisestimatedIDR1,035,504.

- ThoughCXRisasensitiveandspecificscreeningtool,theaffordabilityandfeasibilitystillneedtobeexploredfurther.Otherwise,symptomsandlowBMIarepredictiveforTB.

VillageroletomobilizefamilyinTBcontrolefforts

- JemberDistrictHealthOffice

- UniversityofJember- NationalTBprogram- ThelocalTBexpertgroup(KOMLITB)

- Theproposalisrejectedasthemethodologyisnotwell-developed.

N/A N/A

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6.1 Publications

Titleofpublication TypeofPublication

Keyfindings Methodofdissemination

CommunityadvocacytoincreaselocalfundingallocationforTBcontrol

PosteratUnion2018

Someallocationfromlocalgovernmentbudgetrelatedtocommunityengagementandcontributionareidentified,howeveritisnotspecificallydocumentedandbecomechallengestodocumentthespecificbudgetforcommunity.Examplesidentifiedin4districts:- Useofoperationalaidbudgetforhealthtofundcommunityhealthworkersactivitiestodocontactinvestigation- OperationalsupportfromlocalgovernmentforTBpatientorganizationtodopatientsupportactivities(peereducation,CI,LTFUtacing)- SpecialallocationforTBpatientsorganization(operational,PE,CI,patientsupport)

PleasescantheQRcodeorgotothelink:http://bit.ly/CTBIndonesia

ContactInvestigationbycommunitycadreinpublicprimaryhealthcareinSurakartacityandJemberdistrictinIndonesia

PosteratUnion2018

- Numberneededtoscreen(NNS)tofind1TBpatientwas273amongscreenedand5amongtestedcontactsinSurakarta.InJember,NNSwas646amongallscreenedand11amongthetestedcontacts.

- CollaborationwithcadressupportedbylocalfundingareeffectiveforCI.

- Toincreaseyield,expansionshouldlimitscreeningtohouseholdandclosecontactsinsteadofthosewithlimitedexposure;andusemoresensitivescreeninganddiagnostictools.

PleasescantheQRcodeorgotothelink:http://bit.ly/CTBIndonesia

Performancemeasurementdashboardfordata-drivenmanagementofTBcontrolprojectinIndonesia

PosteratUnion2018

- Thedashboardabletoshowthedynamicsinperformanceoneachoftheindicatorsineachdistricts.

- Thevisualizationofindicatorsprovidedusefulinformationineachdistrictforprioritizationofinterventions.

- Amajorbarrierforusingthedashboardistheslowreportingtothecurrentsurveillancesystem,hampering“realtime”feedbackoninterventionsandprogress,whichismitigatedthroughtrainingandonthejobsupport.

PleasescantheQRcodeorgotothelink:http://bit.ly/CTBIndonesia

Bedaquilineusefordrug-resistantTBtreatment:interimresultofitsimplementationinIndonesia

PosteratUnion2018

- Themajorityofthepatients(61%)achievedsputumcultureconversionwithin3months

- Thereportedinterimtreatmentresultsareencouraging,especiallytheearlysputumconversioninthemajorityofpatients.However,19.5%LFUpointstowardsproblemsinservicedelivery;thisisbeingaddressedbydecentralizationofserviceprovisiontohealthcenterlevel,ensuringfollow-upofAdverseEventswhileprovidingtreatmentclosetothehomesofthepatients.

PleasescantheQRcodeorgotothelink:http://bit.ly/CTBIndonesia

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EffectivenessofMonthlyInterimCohortAnalysis(MICA)toimproveenrollmentandtreatmentadherenceamongdrug-resistantTBpatientsinIndonesia

PosteratUnion2018

- Inthe13districtswhereMICAisimplemented,thelosstofollowupofMDRpatientsreducedfrom23%in2016to7%in2018.

- Theenrollmentratefrom73%in2016to77%in2017.- MICAallowsdistrictTBprogramcoordinatorstoidentifyDR-TBpatientsintheirareaandeffectivelycoordinatebetweendistricthealthoffices,primaryhealthcare(Puskesmas)andcommunitycadres/CSOstoenableandensurepatientsareenrolledandadheretotreatment.

PleasescantheQRcodeorgotothelink:http://bit.ly/CTBIndonesia

HIVTestingforAllTBPatientsinJemberDistrict,Indonesia:MissionPossible

PosteratUnion2018

- In2017,JemberDistrictachieved100%coverageofHIVtestingatTBsites.ThenumberofTBpatientstestedrapidlyincreased,from1%in2014to74%in2017.

- UniversalHIVtestinginTBclinicsisfeasibleandhighHIVtestingratesarepossibleinIndonesiaonceHIVlaboratoryservicesareavailable.

- TherestillisaneedtostrengthenthecapacityofTBstafftoofferHIVtesting,especiallyforpediatricTBpatients,andtofurthersupportTBrecordingandreportingsystems.

PleasescantheQRcodeorgotothelink:http://bit.ly/CTBIndonesia

ImplementationofPMDTBenchmarkingTooltoImproveQualityofDR-TBCareinIndonesia

Presentationduringsymposium,Union2018

PMDTBenchmarkingtoolisableto:- ShowtowhatextendDR-TBfacilitiesmetthestandard,includingperformanceindicator.

- Monitorprogressmadetoachievethestandard.- Assistsitestodevelopimprovementplans.- ServeastoolsforPMDTsupervisionvisitbyNTP/PHO.

PleasescantheQRcodeorgotothelink:http://bit.ly/CTBIndonesia

DistrictActionPlanning:experiencesfromIndonesia(Workshop:FindandTreatallMissingPersonswithTB)

Presentationduringsymposium,Union2018

- InJemberdistrict,budgetforTBsignificantlyincreasedmorethandoublefromUSD48,200in2017toUSD117,400in2018.

- Morethanhalfofthebudgetallocatedforcasefinding/treatmentandPPMactivities.

- OnecommitmentoftheDistrictHealthOfficeistoensuretheoperationalfundsofthehealthcadrestoconductcontactinvestigation,patientsupportandcommunication-educationrelatedactivitiesarewellfundedbypuskesmas.

- ExperiencefrompilotContactInvestigation:• HighcoverageofCIbycadres• Successfulreferralof37%and68%• CostforCIbycadrefundedbyPuskesmasusingBOK

(OperationalAidforHealthProgram)

PleasescantheQRcodeorgotothelink:http://bit.ly/CTBIndonesia

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ReachingouttoYouth:RaisingawarenessonTuberculosisthroughshortfilmsandvideoblog

Presentationduringcommunityspaceevent,Union2018

- Thisactivitiespursuesthemissionofraisingawarenessontuberculosisbyscreeningshortfilmsandvideoproducedbyyoungpeople.Allthis,withthegoalofentertainingandeducating,stimulatingtheimaginationandcreativityandempoweringyouthtobeagentofchange.

- 21shortfilmswereproducedbyhighschoolstudentsinJakarta,NorthSumatraandPapuausingtheirownfunding.

- Increaseadvocacyeffortstoengagewithyouthandpartnershipsthroughothersectors,whichinthiscase,theFilmDevelopmentCenteroftheMinistryofEducationofRepublicofIndonesia.

PleasescantheQRcodeorgotothelink:http://bit.ly/CTBIndonesia

GeneXpertforall?ExperiencesfromIndonesia Presentationduringcommunityspaceevent,Union2018

- NumberofXperttestin2017increasedfourfoldcomparedto2016

- In2015,XperttestlimitedonlytoDR-TBandTB-HIVpatients;whilesince2017,itisavailableforallpresumptiveTB.

- ImpactofXpertexpansionandnewTBdiagnosisalgorithm:XperttestisdominatedbypresumptivenewTBpatients(52%)

PleasescantheQRcodeorgotothelink:http://bit.ly/CTBIndonesia

Atotalof6abstracts,2presentations(1symposiumand1workshop)and2communityspacepresentationswereacceptedforthe49thUnionWorldConferenceonLungHealth:

- Posterdiscussionsession:o CommunityadvocacytoincreaselocalfundingallocationforTBcontrolo ContactInvestigationbycommunitycadreinpublicprimaryhealthcareinSurakartacityandJemberdistrictinIndonesiao Performancemeasurementdashboardfordata-drivenmanagementofTBcontrolprojectinIndonesiao Bedaquilineusefordrug-resistantTBtreatment:interimresultofitsimplementationinIndonesiao EffectivenessofMonthly InterimCohortAnalysis (MICA) to improveenrollmentand treatmentadherenceamongdrug-resistantTB

patientsinIndonesiao HIVTestingforAllTBPatientsinJemberDistrict,Indonesia:MissionPossible(e-Posterpresentation)

- SymposiumandWorkshop:o ImplementationofPMDTBenchmarkingTooltoImproveQualityofDR-TBCareinIndonesiao DistrictActionPlanning:experiencesfromIndonesia(Workshop:FindandTreatallMissingPersonswithTB)

- CommunitySpace:o ReachingouttoYouth:RaisingawarenessonTuberculosisthroughshortfilmsandvideoblogo GeneXpertforall?ExperiencesfromIndonesia

7. Key Challenges during Implementation and Actions to Overcome Them

Challenge Actions to overcome challenges

Technical The start of the DPPM approach was postponed until the NSP for DPPM was ready

CTB prepared the model and materials for comprehensive TB technical update and self-assessment benchmarking tool for Primary and Secondary health providers

The process of Sub Awarding expansion of the DPPM approach to professional societies threatened to affect the achievement of the project’s DPPM expansion milestones

In the interim the expansion was done by CTB Provincial teams in close collaboration with the intended subrecipients, until the signing of Sub-Award agreements

Administrative

Vacant position of Technical Officer for TB in Prison until mid-Year 4

The role was covered by Director Technical Services

8. Lessons Learnt/ Next Steps In previous chapters, the achievements have been described in detail. in this chapter an overview of major lesson learnt will be given per sub-objective. SO1: Enabling environment We helped establishing various provincial and district level KOPI-TB chapters, which are a pre-requisite for a well-functioning DPPM approach. However, there are limited numbers of candidates to become active in district-level KOPI-TB, making the approach very local-specific. Our experience with this will be used for extra DPPM work by local NGOs in 37 districts under the GF Catalytic Funding mechanism. The rolling out of the DPPM approach accelerated, with the local teams going for the quickest feasible elements first, namely the internal puskesmas network and the linking with the hospitals. Linking with the external network of GPs proved to be labor-intensive and was often done afterwards. Because of this, in Year 5, we will focus finalizing implementation of the GP network linkage in CTB supported districts, and offer our experiences and good practices for TA to local NGOs implementing the DPPM approach under the GF catalytic funding. Under-reporting of diagnosed patients in Indonesia is a long-standing problem, especially from the private sector and non-engaged public sector. The experiences of CTB in mobilizing the GF-funded data officers in obtaining data from hospitals has been successful and the methods for doing this are now used to update notifications throughout the country. This is complemented by the successful introduction of WIFI-TB as a mandatory notification smartphone app alongside the DPPM approach. Although full impact is yet to be

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demonstrated by its application at scale, it is clear that this is a useful tool not only for notification by GPs, but also to facilitate their active engagement. SO2: Comprehensive, high quality diagnosis The expansion and increasing utilization of GeneXpert is progressing in CTB areas and Indonesia as a whole, be it slow. Especially in areas without CTB support underreporting of utilization plays a role. A continuous effort is needed to further promote the standing policy to use GeneXpert as the first diagnostic test, and this can be enhanced by a well-functioning specimen transport system, preferably for other than sputum samples as well. Whereas GLI standards are almost all met and about to be incorporated in the national accreditation schemes, and lab tests related to DRTB increasingly becoming available, the EQA for microscopy still meets many implementation problems and data are not readily available. With microscopy still being the mainstay of diagnosis of TB in Indonesia, in Year 5 we will propose a more feasible EQA approach combining LQAS and panel testing. SO3: Patient-centered care and treatment Childhood TB is addressed well, except for LTBI treatment of child-contacts, partly because this is not well recorded/reported. However, concerted efforts of CTB, NTP and GF-SRs, with the latter having absorbed CTB experiences, have given contact investigation an important boost, and this is expected to continue. TB-HIV collaborative activities are improving. The project shows that if special efforts are done for joint service delivery, quick gains can be made. The increase in HIV/TB testing and ARV treatment coverage in CTB supported areas other than the JSD implementation areas, shows that where such joint service delivery is not done, a sustainable alternative is to include TB-HIV activities into the DPPM approach, so that the integration of services is done at the level where the patients are being treated: the puskesmas level. The PMDT program is in full swing, and the quality improvement tools developed with the assistance of CTB have been adopted nationally. The actual uptake of these tools at field level is still incomplete. Indonesia plans for a rapid scale-up of initiation centers from a current 159 to 514 in 2020 and consequently the continuation phase of treatment at many more puskesmas. This will be a big test for the uptake of quality improvement tools that have been developed in the past 2-3 years, the use of which will have to be accompanied by a strong push for training and human resources development in the health facilities involved. For this reason, CTB will continue to expand the PMDT program in Year 5 as long as this is possible, in close collaboration with the national and provincial teams of master-trainers, while having delivered the quality improvement tools for use by others for the further PMDT expansion. SO5: Infection control: - SO6: management of latent TB infection CTB has worked successfully to improve contact investigation, showing that investigation of close (household) contacts is the most effective. However, reported IPT has lagged behind, although the very state of affairs is not well known due to erroneous recording and reporting. Efforts are underway to introduce 3HP for DS-TB contacts and Lfx-E for DR-TB contacts. SO7: Political commitment and leadership

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Indonesia has made big steps in increasing domestic funding in general (see the 2-3-fold increase shown in the Global TB Report 2018). Good progress has been made with establishing district and provincial action plans, which are expected to gain strength and popularity in the upcoming 2019 and 2020 budget rounds at provincial and district levels. Having set the example in a limited number of districts and provinces has created a precedent for others to follow, a process that has received the backing and guidance by the Ministry of Health and the Ministry of Home Affairs. It shows the importance of both having the relevant authorities involved from the beginning in an innovative health budgeting exercise such as the district action planning, leading to a health financing intervention. SO8: Partnerships and community involvement: The NTP has for years now approached TB from a multi-sectoral perspective, which is expressed in the collaboration of various ministries, including that of Education and Culture. CTB has collaborated actively in this partnership and liaised with the various ministries and CSOs, as far as the MOU with the MOH permitted, but this has never been a problem. In our experience it is important to recognize government agencies as the owners of the process and program, and that with CTB acting as innovator and front-line implementor at the same time, it is possible to give reality based technical assistance to all the aspects of TB control in Indonesia. SO10: Data, surveillance and M&E: CTB has contributed greatly to the improvement of recording & recording of TB in Indonesia, through developing the online notification system (SITT), WIFI-TB, and general support to M&E in the provinces and districts that are supported by CTB. This process will be finalized in Year 5 with the design and establishment of a vastly improved TB Information system (SITB) that is able to integrate various TB-related databases. This shows that some of the challenges in the TB control program have a mere technical solution. The operational studies carried out by CTB were done with existing university groups that work together with TB specialists from KNCV, the combination giving a good level of guarantee that the studies are carried out in a satisfactory manner. This is also advisable in the future.

Annex I: Year 4 Results on Key Performance Indicators including Mandatory Indicators (see PDF file attached)

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Annex II: Status of EMMP activities

Year 4 Mitigation Measures Status of Mitigation Measures Outstanding issues to address in Year 5

Additional Remarks

Related to the used Xpert cartridges, CTB will ensure this infectious waste is managed/disposed properly in line with the national guidelines for Xpert implementation.

All Xpert sites have been trained that used cartridge should be treated as infectious waste and will be demolished according to the national regulation.

N/A N/A

CTB will ensure clinical waste management is integrated into training programs and NTP guidelines. Training material will align with the national regulations and procedures for medical waste (The Indonesian Environmental Impact Management Agency (BAPEDAL)).

- Training materials contains clinical waste management align with the regulation of BAPEDAL

- 14 Lab technicians from 14 TB Lab trained on clinical waste management incorporated in safe working practice training

- 16 Lab technicians from 16 TB Labs were trained on clinical waste management incorporated in culture training

N/A N/A

During supportive supervision visits, management and disposal of medical waste will be discussed and checked; when necessary corrections will be made.

Check list was done during supervisory visits consisted of verification of SOPs availability and usage, to ensure proper management and disposal of medical waste, and necessary revision was made accordingly.

N/A Regular TA was provided to Xpert sites within CTB supported provinces

The Healthcare Waste Management Minimum Program Checklist and Action Plan will be completed by all health facilities being supported by Challenge TB. Responsible staff will be trained on how to use this tool to assess the status of and improve waste management practices.

Check list was done during supervisory visits consisted of verification of SOPs availability and usage, to ensure proper management and disposal of medical waste.

N/A N/A