Driving out drug-resistant TB in Indonesia

By Access and Delivery Partnership

A patient at a hospital in Jakarta, Indonesia examines an x-ray of their lungs. Photo: Fauzan Ijazah/UNDP

Despite significant progress, tuberculosis (TB) continues to claim an estimated 1.5 million lives each year, making it the second most deadly infectious disease behind only COVID-19.[1] In Indonesia, TB is one of the top causes of death, with nearly 100,000 people dying in 2020.[2]

TB is caused by a bacterium, Mycobacterium tuberculosis, which infects the lungs. In recent years, new strains have emerged that are resistant to existing treatments (known as drug-resistant TB or DR-TB). DR-TB is a debilitating and life-threatening condition that requires longer and more intensive treatment.

TB can leave patients and their families in catastrophic financial hardship. Even though the government provides free TB tests and medicines at public facilities across Indonesia, it has been shown that loss of income and out-of-pocket expenses (such as travel, follow-up visits, hospitalization and food supplements) can amount to around US$169 for each TB patient. Such costs can be up to 14 times greater for DR-TB patients, at US$2,342 each, due to the greater severity of the disease, length of treatment and the resulting loss of income.[3]

The barriers to effective diagnosis and treatment of DR-TB are multidimensional and influenced by social factors. They include TB-related stigma, which often impedes people from accessing testing or treatment services, as well as issues related to mental health, poverty, housing and unemployment.

Driving out drug-resistant TB in Indonesia

Indonesia’s national TB programme is making significant progress responding to the threat of DR-TB. In 2017, Indonesia achieved 100 percent national coverage by establishing 360 DR-TB treatment facilities and 2,300 DR-TB satellite sites across all 34 provinces.

In 2020, the World Health Organization recommended an all-oral treatment for DR-TB, which lasts for around 9–11 months. This new regimen is shorter, easier to administer and more effective than the conventional DR-TB treatment, which can take up to 24 months and also requires daily injections.

But the new treatment regimen remains a challenge for many patients. On top of financial hardship, the treatment can have a range of side effects, including nausea, drowsiness, depression, psychosis, kidney impairment and hearing loss.

Much remains to be done. From January to September 2022, there were 8,042 patients with confirmed cases of DR-TB, and approximately only 54 percent of them received treatment,[4] likely because of the barriers posed by the range of economic and social challenges associated with DR-TB.

The Access and Delivery Partnership (ADP) has contributed to the TB response efforts in Indonesia, especially through its support to set up surveillance systems that ensure the safe scale-up of new TB medicines.

Between 2014 and 2016, ADP supported the national TB programme, the National Drug and Food Control Agency and public hospitals to enhance their ability to detect and properly manage unwanted side effects of bedaquiline, a new medicine that is part of the shorter treatment regimen for DR-TB. This included the training of nearly 200 health care providers and pharmacists for ‘active safety monitoring’, which is the active and systematic clinical and laboratory assessment of patients while on treatment, to detect, manage and report suspected or confirmed adverse drug reactions.

In 2021, ADP supported a comprehensive situation analysis of DR-TB drug safety monitoring, from which the national TB programme developed an action plan aimed at bolstering weak points in the monitoring system. Lessons learned will be useful for other national TB programmes adopting the shorter, all-oral treatment regimen.

ADP has also worked with the Ministry of Health on strengthening other related systems, including those supporting the selection and purchase of quality, affordable medicines, and health systems research that addresses gaps in TB programme implementation. Technical support from the United Nations Development Programme to strengthen the Ministry of Health’s financial management information system, human resources and reporting contributed to the success in securing grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria from 2018 to 2023 for the country’s HIV, TB and malaria response.

Further information:

National Institute of Health Research and Development, Ministry of Health, TDR and ADP, ‘National strategy for implementation and operational research to support prevention and control of tuberculosis, malaria and neglected tropical diseases 2016–2019’, 2 March 2017

ADP, ‘The ADP Public Forum, Jakarta, Indonesia’, 11 January 2017

This is part of a collection of impact stories highlighting the work of the Access and Delivery Partnership in ensuring access to health technologies for those in need. For more information and to read additional impact stories, please visit the ADP website.

Footnotes

[1] World Health Organization, ‘Tuberculosis’, 14 October 2021, https://www.who.int/news-room/fact-sheets/detail/tuberculosis. [2] World Health Organization, ‘Tuberculosis profile: Indonesia’, 3 October 2022, https://worldhealthorg.shinyapps.io/tb_profiles/?_inputs_&entity_type=%22country%22&lan=%22EN%22&iso2=%22ID%22. [3] Susan van den Hof, David Collins, Firdaus Hafidz, Demissew Beyene, Aigul Tursynbayeva and Edine Tiemersma, ‘The socioeconomic impact of multidrug resistant tuberculosis on patients: results from Ethiopia, Indonesia and Kazakhstan’, BMC Infectious Diseases 2016; 16(1): 470, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5011357/. [4] Based on data presented at the Ministry of Health’s quarterly review meeting in September 2022.