Recent data from the World Health Organization (WHO) shows that indicators of overall health status in Indonesia have improved significantly over the last two and half decades. Life expectancy, for example, has increased from 63 years in 1990, to 71 years in 2012. Despite the progress made, Indonesia still struggles with a high incidence of tuberculosis (TB). According to the Global Burden of Disease study, TB remained the third most lethal disease in Indonesia from 2005 to 2016, due to a high prevalence rate and the large population in Indonesia. Sadly, Indonesia is the world’s second largest contributor of TB patients.
As the world commemorates World Tuberculosis Day on March 24, it remains unacceptable that 300 people here die every day because of TB, which is preventable.
TB is caused by Mycobacterium tuberculosis, an airborne bacteria that commonly causes damage to the lungs. This deadly bacteria can easily enter some parts of the body with no symptoms, causing a latent infection. According to 2014 research from the London School of Hygiene and Tropical Medicine, 47% of Indonesians have latent TB. It can become active when the immune system drops dramatically, with common causal factors being HIV, diabetes, malnutrition, or active smoking.
Tuberculosis is an indiscriminate disease, able to be contracted by anyone regardless of gender and socio-economic status. It does however, predominantly impact people in the prime of their lives, from 15–59 years old. This decreases their ability to contribute to the economy and support their families because they often become unable to work. Research published in The International Journal of Tuberculosis and Lung Disease shows that the loss of productivity due to illness in Indonesia was approximately 9.6 trillion rupiah in 2015. This number will continue to increase if more people are detected with TB, and if it remains poorly controlled.
While the percentage of successful treatments reached 87% last year, Ministry of Health data indicates that the case detection rate of TB still remains under 50 percent. Progress in the campaign to eliminate TB in Indonesia remains slow, with new cases emerge every year, and many of the infected remain untreated. In fact, treatment is the best prevention for TB. The more people with active TB receiving treatment, the smaller the risk of spreading the disease.
The eradication of TB is a challenge, but it can be achieved through the momentum of the current era of the global Sustainable Development Goals, which involves actors from different sectors competing to achieve development targets, including in the health sector. The government has also committed to speeding up the eradication of TB through Health Ministerial Regulation No. 67/2016, the first specific regulation on TB that details measures to overcome TB – but given the country’s vast challenges, it states that the targeted year of zero TB in Indonesia is still a few decades away in 2050.
Fever and the coughing up bodily fluids are the main symptoms of TB. A serious issue in case detection, however, is that in Indonesia, a chronic cough is rarely considered as a symptom of a disease. The 2013 Prevalence Survey of Tuberculosis shows that of 8,377 participants, only 12.3% with a cough of 14 days or more reported their symptoms. Of these patients, 43.1% did not get treatment, 30.8% self-treated, and only 26.1% actually went to a health facility. This results in delayed treatment or maltreatment of this serious disease, and is increasing the prevalence of the multi-drug resistant strain (MDR) of TB.
While the government ensures that all treatment can be accessed through the National Health Insurance System (BPJS), global data suggests that only half of all MDR TB patients will be successfully cured. With Indonesia experiencing 7,000 new MDR TB cases annually, this will cause greater strain on the system’s budget, with only small returns in improved health.
The data from the prevalence survey shows that of the participants who had been diagnosed, 36.5% went to the private hospitals. This number highlighted the need for strong private hospital administration optimization in TB treatment. The private hospitals however, contribute to a large number of un-notified TB cases in the Integrated Tuberculosis Information System, a National Tuberculosis Program of Indonesia.
In 2015, WHO estimated that nearly two-thirds of the TB patients in Indonesia had not been notified, and the status of their care remained unknown. As such, Indonesia is home to nearly 20% of the world’s missing TB cases. Understanding where patients go for care will be vital to enabling the strategic planning of services to reach them more effectively, and allow systematic monitoring to evaluate the outcomes of every patient who has commenced treatment.
TB incidence could be forced down quicker, by as much as 30 percent per year, if new cases are found quickly enough to eliminate transmission. TB spreads in households and communities, ranging from rural villages to urban house blocks, schools to workplaces, and crowded places like industrial environments. Community-oriented efforts can both help prevent the spread of TB and support diagnosis and treatment. This can happen through educating the public and health workers, finding people with TB symptoms and getting them to use diagnostic and other treatment services, offering daily support for those taking the medicines and advocating for improved services.
Awareness raising and availability of knowledge services can facilitate early diagnosis and appropriate treatment. Advocacy, communication and social mobilization activities can help build public knowledge and foster positive attitudes and practices that contribute to efforts to stop TB. Such efforts are most powerfully organized from the inside, by people who really know and belong to the community.
Community participation can be strengthened to improve the performance of a TB control program with a comprehensive approach. However, it should be followed by the efforts to increase the health system capacity because, by any standard, the fact that 300 people die of TB every day, when steps can be taken to prevent this, is unacceptable in the homeland of Indonesia.
The article has been published in The Jakarta Post, March 24th 2018 to commemorate World Tuberculosis Day.
Aghnia Jolanda Putri is a medical doctor graduated from Universitas Andalas and Ika Kartika Febriana is a political science graduate from Universitas Indonesia. Both work for Center for Indonesia’s Strategic Development Initiatives (CISDI).