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Neglected Tropical Diseases An Integrated Plan of Action
Ministry of Health Indonesia 2011-2015 World He latnh
An Integrated Plan of Action to successfully achieve elimination and sustained control of 5 of the mostimportant neglected tropical diseases in Indonesia: Lymphatic Filariasis, Schistosomiasis,Leprosy, World He latnh
Yaws and Soil-Transmitted Helminths.
Neglected Tropical NEGLECTED TROPICAL DISEASES
Diseases in Indone IN INDONESIA
An Integrated Plan of Action An Integrated Plan of Action Ministry of Health Indonesia
Ministry of Health Indonesia 2011-2015
2011 - 2015
World He latnh
An Integrated Plan of Action to successfully achieve elimination and sustained control of 5 of the most important neglected tropical diseases in Indonesia: Lymphatic Filariasis, Schistosomiasis, Leprosy, Yaws and Soil-Transmitted Helminths. Foreword by WHO Representative Foreword by Director General Disease Control & Environmental Health Executive Summary
Neglected diseases in Indonesia Plan of Action for NTD control/elimination General objectives Country Profile
Geography and demographics Political situation and administrative structure Health care system School Health Programme (UKS) School Immunization Month Programme (BIAS) Background of NTDs & disease control initiatives in Indonesia
Lymphatic filariasis Soil-transmitted Helminths Overlapping of NTDs endemicity Health, hygiene & nutrition promotion Integrated vector management Integration between disease control initiatives Drug supply and logistics Development of Plan of Action
Plan of Action for NTD Control
General objectives
Expected results
ER I Updated strategies based on international guidelines and best practices 43 ER II Accurate estimation of the burden of the 5 NTDs ER III Successful management of drug donations ER IV Strengthened capacity of health workers and volunteers ER V Integrated social mobilization ER VI Integrated and improved MDA for LF, schistosomiasis, and STH ER VII Integrated and intensified morbidity case detection ER VIII Integrated and intensified case management ER IX Strengthened monitoring and evaluation (M&E) system for the 5 NTDs 50ER X Establishment of a surveillance system for leprosy, LF, schistosomiasis and yaws after their elimination as public-health problems ER XI Establishment of a national NTD Taskforce ER XII Increased visibility, advocacy and political commitment for NTD control and elimination ER XIII Increased advocacy for comprehensive NTD control linking water, sanitation, hygiene education and chemotherapy ER XIV Integrated health promotion Milestones
A. Accelleration Program of Filariasis Elimination, Drug Availability and B. Program Management, Advocacy, Socialization and Surveil ance (MONEV) 57 A. Detailed activities & Times AusAID - Australian Agency for International Development
DC & EH - Disease Control & Environmental Health
DEC
- Diethylcarbamazine - Directorate General - Department of Education - District (or city) Health Office - GlaxoSmithKline - Information, Education and Communication - Lymphatic Filariasis - Multi-bacillary - Mass Drug Administration - Millennium Development Goals - Monitoring and Evaluation - Ministry of Health - Neglected Tropical Diseases - Primary Health Centre - Provincial Health Office - Serious adverse events - School Health Programme - Soil-transmitted Helminthiasis UNICEF - United Nations Children Education Fund
USAID
- United States Agency for International Development - World Food Program - World Health Organization Health is recognized as an essential component of human development. In collaboration with Ministry of Health, World Health Organization and other development partners created several opportunities for improving the health of people, enhancing quality of life and ensuring a better future. In spite of various constraints, tangible progress has been made by governments, communities and partners towards improved health outcomes; nevertheless, many challenges lie ahead. These includes, weak health system, an increasing burden of communicable and non- communicable diseases, high child and maternal mortality, recurrent epidemics and humanitarian crises aggravated by disaster and limited financial resources. In accordance with WHO's mandate, vision and collaboration and coordination with other partners, we have pledged to continue to focus on partners role in the provision of normative and policy guidance; strengthening of partnerships and harmonization of support to the country, supporting health systems strengthening based on the primary health care approach; putting neglected tropical disease at top of the agenda and intensifying the prevention and control of communicable and non-communicable diseases; and accelerating response to the determinants of health.
Indonesia is endemic for neglected tropical diseases (NTDs) for which chemotherapy is available: lymphatic filariasis, soil-transmitted helminthes and schistosomiasis, leprosy and yaws are among the major. Different studies have indicated that there are a number of provinces and districts, where these diseases are co-endemic. Control programs for these diseases are managed vertically and the potential benefits of integration of the programs have not been explored. The country is uniquely positioned to make major advances to reduce, and in some cases eliminate NTDs as public health problems given the demonstrated commitment and strong programmatic experience of the government, and a number of development partners working in NTD control. The NTDs form group diseases are strongly associated with poverty, and these disease agents thrive best in tropical areas, where they have very favorable conditions for the breeding and further development. These diseases are largely silent, as the people affected or at risk have little recognition in the communities and rarely have any political voice. At present, the neglected tropical diseases have their breeding grounds in the places left furthest behind by socioeconomic progress, where substandard housing, lack of access to safe drinking water and poor sanitation, filthy environments, and abundant insects and other vectors contribute to efficient transmission of infection for these diseases. Close companions of poverty, these diseases also anchor large populations in poverty. In developing countries like Indonesia the leprosy and lymphatic filariasis deform in ways that hinder economic productivity and cancel out chances for a normal social life. The infectivity of soil transmitted helminthic infection disrupts school attendance, contributes to malnutrition and impairs the cognitive development of children. The consequences are costly for societies and for health care such as rehabilitation for leprosy and lymphatic filariasis. Fortunately, in the country these problems are now much better documented and much more widely recognized. Good medicines are available for many of these diseases, and research continues to document their safety and efficacy when administered individually or in combination. Generous drug donations by pharmaceutical companies have helped relieve some of the financial barriers and allowed programmes to scale up coverage. A strategy of preventive chemotherapy, which mimics the advantages of childhood immunization, is being used to protect entire at-risk populations and reduce the reservoir of infection. The fact that many of these diseases overlap geographically has practical advantages preventive chemotherapy regimens are being integrated so that several diseases can be tackled together, thus streamlining operational demands and cutting costs. An integrated approach to vector management likewise maximizes the use of resources and tools for controlling vector-borne diseases are practical and feasible.
While the report highlights a number of remaining challenges, the overall message is overwhelmingly positive. It is entirely possible to control neglected tropical diseases. Aiming at their complete control and even elimination is fully justified, and this integrated action plan sets out the solid evidence needed to achieve control.
Even though each Disease Control Sub-directorate at the MOH DG CDC & EH has its own plan including some level of integrated activities for different diseases, this Plan of Action was needed in light of recent announcement of enhanced drug donations for NTD by pharmaceutical companies globally, renewed donor interest in funding NTD activities for accelerating elimination and control, review and evaluation of schistosomiasis program in Central Sulawesi (October-November 2010), finalization of LF plan for 2010-2014 (May 2010), and need to revitalize MOH integrated disease control strategy developed in 2007 that integrates some activities in the LF, leprosy, yaws and STH program. This single document with key activities about a number of NTD in Indonesia is illuminate synergies between NTD programs that enhance cost-effectiveness. This document can help refine activities for accelerated control of NTD in light of recent international and national developments and could be used as a tool to promote funding at national level in the country and external funding for activities implementation. I would like to express my sincere thanks to the Joint Mission Members from World Health Organization, USAID, and AusAID for the technical support and helping in the process of the development of integrated action plan on neglected tropical diseases to promote NTD Control in the Republic of Indonesia Khanchit Limpakarnjanarat
WHO Representative The neglected tropical diseases (NTDs) are a group of infectious diseases which primarily affect the poorest sectors of society, especially the rural poor and the most disadvantaged urban populations. More than 1 billion people are affected with one or more neglected tropical diseases, yet these diseases remain neglected at all levels. Although some of NTDs affect Indonesia, over the past five years three of them in particular – leprosy, lymphatic filariasis, and yaws – have been targeted for elimination. These diseases not only affecting large number of population also carry high mortality and morbidity; they also affect people's productive and social lives. Moreover, most of them are feared and are the source of strong social stigma and prejudice and as a result, these diseases are often hidden- out of sight, poorly documented and unmentioned.
Strategic steps taken by the international community have contributed to such progress: the World Health Assembly passed resolutions for the global elimination of leprosy and lymphatic filariasis in 1991 and 1997, respectively. In 2006, the WHO South-East Asia Regional Committee passed a resolution calling all Member States to intensify efforts towards achieving the goals of eliminating selected NTDs including yaws.
The Ministry of Health has targeted to decrease the diseases transmission, to prevent diseases related disability, especially for leprosy and lymphatic filariasis and to diminish the social stigma toward the diseases. Early case detection and early treatment with MDT (Multi Drug Therapy) are the important strategy to be carried out to reduce leprosy burden. Yaws elimination programme has been started out in hyper-endemic provinces and has completed active case finding and treatment with benzathin penicillin, while the elimination strategy for lymphatic filariasis relies on the mass administration of diethylcarbamazine and albendazole to all individuals living in endemic areas. Minimizing public stigmatization on leprosy and lymphatic filariasis patients are also an important role to be conducted. We should push for integrating these programmes with other sectors by implementing this developed integrated national action plan. We should act rightly and promptly, working in teams which have high integrity, transparent and accountable. NTD control requires an integrated approach with chemotherapy being backed up by a range of supplementary interventions, along with inter-sectoral cooperation by Ministry of Health, education, agriculture and other development related ministries. I would like to make it clear that to make people healthy, there are four main strategies that should become the guideline of every health worker, as follow: 1. Mobilize and empower people to live clean and healthy2. Improve the accessibility of people to the qualified health services3. Improve the surveillance system, monitoring, and information of health4. To ensure implementation of the activities outlined in this integrated plan of action, additional funding need to be allocated from the government of Indonesia at central, and district levels, as well as external funds from international donors. Prof. dr. Tjandra Yoga Aditama
Director General DC and EH WHO/USAID/AusAID Joint Mission for the Promotion of NTD Control
in the Republic of Indonesia
15-19 November, 2010
Aim of the mission is to promote the development of a National PoA for the integrated control
of NTD.
International Participants
A Montresor, Scientist, Control of Neglected Tropical Diseases, World Health Organization,
Geneva, SwitzerlandM. Brady, Advisor, Control of Neglected Tropical Diseases, World Health Organization, Geneva, SwitzerlandM. Pacque, GHFP Technical Advisor, USAID/Washington DCM. Linehan, Infectious Diseases Team Leader, USAID IndonesiaK. Kopoc, Director or CWW (Children without Worms)M Rebollo, Consultant, World Health Organization, Geneva, Switzerland Ministry of Health Indonesia
Tjandra Yoga Aditama, Director General of DC & EH
Rita Kusriastuti, Director of Vector Borne Disease Control
H. Mohammad Subuh, MPPM, Director Direct Transmitted Diseases
Trihono, Director General National Institute of Health Research & Development
Saktiyono, Programme Manager. LF, Schistosomiasis and STH
Christina Widaningrum, Programme Manager, Leprosy and Yaws
Taniawati Supali - Indonesia University
World Health Organization: Regional Office
A.P. Dash, Regional Advisor for NTD, WHO/SEARO, India
World Health Organization: Country Office
Khanchit Limpakarnjanarat, WHO Representative, Indonesia
Anand B. Joshi, Program Manager for NTD, WHO- Indonesia
USAID Indonesia
Irene Koek, Director, Office of Health
Kendra Chittenden, Senior Infection Disease Advisor
Artha Camelia, Emerging Infections Diseases Specialist
Gerard Cheong, First Secretary Health Australian EmbassyGina Samaan, Consultant AusAID, Jakarta JICA – Indonesia
Yurico Egami
WHO Indonesia - Neglected Tropical Diseas Working Group
• Khanchit Limpakarnjanarat, WHO Representative - Advisor and overall guidance • M.R Kanaga, Administration/Management • Anand B Joshi, Member: NTD focal point • Graham Tallis, Member: Communicable Diseases Expert • Sharad P. Adhikary, Member: Environmental Health Expert • M Sudomo, Member: Schistososomiasis and LF expert • Benyamin Sihombing:, Member: Leprosy, Yaws and other NTD specialist • Nursila Dewi, Member: Information/ Communication • Representative from USAID, Indonesia • Representative from AUSAID - Indonesia • Representative from JICA - Indonesia Executive Summary The Government of Indonesia has demonstrated awareness of the important burden of neglected tropical diseases (NTDs). National plans and policies have been developed to fight leprosy, lymphatic filariasis (LF), schistosomiasis, soil-transmitted helminths (STH) and yaws. Successful experiences have demonstrated the political commitment both at the central and district levels. Community compliance and participation are an important part of the NTD programs, as shown by the example of LF, where mass drug administration (MDA) is carried out with help of community volunteers or school deworming where children receive the drug during immunization days, achieving coverage of almost 90% of school-age children (SAC) in the areas where the program is implemented. However Indonesia faces many challenges to achieve the goal of control of STH and elimination of leprosy, LF, schistosomiasis, and yaws. Lack of coordination between different programs and stakeholders, insufficient and irregular political commitment at the district level, and limited funding to fully implement strategies and achieve sufficient coverage, makes it difficult for Indonesia to succeed in achieving the targets set by WHO for sustainable control and elimination of NTDs.
This Integrated Plan of Action (PoA) confronts many of those obstacles and proposes a roadmap for integrated control of 5 of the main NTDs in Indonesia: leprosy, LF, schistosomiasis, STH and yaws. Under the leadership of a national NTD Taskforce, integration will focus on advocacy and social mobilization, use of a common pathway to distribute drugs and detect disease cases, capacity building of health workers, and health promotion at community level. This integrated NTD Program will facilitate cost savings and optimal use of human resources, as well as speed up implementation to find the shortest route to achieve the goals on time.
To ensure implementation of the activities outlined in this PoA, additional funding will need to be allocated from Indonesian government at central and district levels, as well as external funds from international donors. Drug donations will continue to play a key role in the success of the plan.
Neglected diseases in Indonesia
Neglected tropical diseases (NTDs) blight the lives of a billion people worldwide and threaten the health of millions more. These ancient companions of poverty weaken impoverished populations, frustrate the achievement of health in the Millennium Development Goals and impede global development outcomes1.
Indonesia has one of the heaviest burdens of NTDs globally, with one of the largest populations at risk. The country is endemic for five of the NTDs for which chemotherapy is available: leprosy, LF, schistosomiasis, STH, and yaws.
1 Working to overcome the global impact of neglected tropical diseases. WHO 2010 In 2000, Indonesia eliminated leprosy at the national level, with a prevalence rate of less than 1 case per 10,000 populations. However, the number of new leprosy cases, approximately 20,000 per year, has remained stable for ten years. In 2009, 14 provinces and 160 districts, mostly in the east and central and west Java, still reported a prevalence rate of >1 per 10,000 population. Epidemic indicators such as the proportion of grade-2 disability (10.5%), the proportion of child cases (12.01%) and the proportion of multi-bacillary (MB) cases (82.43%) indicate that ongoing support is needed to reduce the leprosy burden. The leprosy program aims to reduce disability from 10% to 5% by 2015, through rapid index-case finding in high endemic areas. The National Programme for Leprosy's strategy consists of four main activities i.e., case finding, case detection, case management and mitigation of the impact of leprosy. Comprehensive case finding and detection efforts are important initial activities to identify and detect cases in a leprosy service area unit. Case management emphasizes accurate diagnosis and treatment. Counseling is an integral activity in case management to ensure treatment compliance and to overcome stigma. Mitigation of the impact of leprosy includes improving the quality of life of for people affected by leprosy through disability care and rehabilitation and psychosocial and economic support. The leprosy program estimates a cost of $60,000 per district for active case finding, for a total of $3 million for 50 districts. The Novartis Foundation supplies free drugs through WHO. The Netherlands Leprosy Relief and Sasakawa Foundation provide operational and technical assistance to the MOH program.
Lymphatic Filariasis (LF)
LF is one of the major public health problems in Indonesia. All three types of lymphatic parasites namely Wuchereria bancrofti, Brugia malayi and Brugia timori are prevalent in Indonesia, but B. malayi is the most dominant. Twenty-three species of mosquitoes are vectors for LF in Indonesia as of 2009, an estimated 125 million people are at risk of filariasis infection, in 337 endemic districts, which function as the LF program's implementation units. The highest prevalence rates were in Maluku, Papua, West Irian Jaya, East Nusa Tenggara and North Maluku provinces (all in east Indonesia). A total of 11,914 chronic cases have been reported nationally between 2000 and 2009. The Government of Indonesia has decreed filariasis elimination as one of national priorities to combat communicable diseases in line with Presidential decree number 7, 2005, and agreed to participate in the international goal launched by WHO to eliminate LF as a public health problem by 2020. The LF program's objectives are to reduce and eliminate transmission of LF by MDA, and to reduce and prevent morbidity in affected persons. In 2009, MDA with diethylcarbamazine (DEC) + albendazole covered more than 19 million people in 30% of the endemic districts, with an average program drug coverage rate of 66.5% of the at-risk population in those districts. Albendazole is donated by GlaxoSmithKline (GSK) through WHO and DEC is purchased locally. According to the 2011-2014 National Plan for LF, the central government is responsible to ensure the procurement of drugs and provide routine budget, while the local government is expected to contribute the operational and maintenance budget. External funding is required to achieve the goal of elimination by 2020. The cost of distribution per person calculated in the National Plan is US $0.23. Schistosomiasis, due to Schistosoma japonicum, is endemic in the Lindu, Napu and Bada valleys in Central Sulawasi province, with an at-risk population of 25,000 to 50,000. Although control activities ended in 2005, 2010 surveys showed a resurgence of transmission with an average prevalence of infection of 9.6% among 5 villages in Napu Valley. These areas have restricted access to potable water and sanitation, with few families having latrines. The program has limited resources for control operations and praziquantel for treatment of those infected has not been readily available. A detailed and budgeted plan (2011-2014) for schistosomiasis elimination was developed by the Vector-Borne Disease Control Directorate (VBDCD) within MOH. The total cost of the programme in the draft plan is US $4,838,760 for the period. The unfunded gap is equivalent to 65% of the total amount. Soil-transmitted helminths (STH)
In the last 15 years, hundreds of districts have been surveyed in Indonesia to assess the STH prevalence. Over 40,000 individuals (mostly children) were involved. Results show that STH infection is widespread in the country and, according to WHO guidelines, most of the areas surveyed need at least one treatment/year. Preliminary predictive mapping for areas for which data are not available suggests that STH are intensively transmitted through the entire country. In 2009, more than 19 million individuals were treated with donated albendazole through LF MDA; this treatment resulted in deworming of 1 million preschool children and 3.6 million school-age children. An additional number of children were dewormed through the school system by local authorities and international partners such as the World Food Programme (WFP); however exact treatment figures are not known at national level. Twenty-one and a half million children live in districts where LF is not endemic and therefore do not benefit from the impact of albendazole distribution through LF MDA. As some of these districts are highly endemic for STH, they would benefit from a donation of mebendazole.
Currently 18 of the 33 provinces are believed to be affected with yaws, with five classified as high burden. In 2009, 8,309 cases were reported (mostly from 6 districts in Nusa Tenggara Timur province), and numbers have been increasing steadily since 2001 (when 2,112 cases were reported). From the remaining provinces, no information is available. The MOH strategy is designed to eradicate the disease by 2013. The strategy includes active case-finding of cases and their contacts, mobilization of community support, capacity building of health staff for detection and management of cases, and establishment of partnerships with other disease control programs and external partners. Active case finding, or annual ‘search and treat' missions, is planned to scale up from 10 districts in 2010 to 18 districts in 2011, using an island-by-island approach. Technical assistance, monitoring, supervision and 2 WHO. Preventive chemotherapy in human helminthiasis. Geneva, World Health Organization, 2006.
training are integrated with the leprosy programme. The program estimates a budget of $80,000 per district, not including technical assistance and monitoring, for a total cost of $9 million over 5 years.
Plan of Action for NTD control/elimination
The Government of Indonesia is committed to intensify its efforts to control and eliminate five of the most important NTDs affecting the country and causing suffering and impoverishing millions of people. This Plan of Action (PoA) was developed to improve the management of each disease and make the programs more efficient by integrating some of the activities in a way that will save human resources, time and money. This integrated approach should obtain better health results and help achieve the final goal of sustained control of STH and elimination of leprosy, LF, schistosomiasis, and yaws from Indonesia. to strengthen the Indonesian health system through improved training, advocacy and coordination at all levels of the health system, ii) to strengthen multi-sectoral collaboration within the MOH, Ministry of Education, Ministry of Internal Affairs and Ministry of Religious Affairs among others, and iii) to strengthen the national capacity for successful management of international cooperation funding (USAID, AusAID, WHO and other international agencies) and drugs donations (DEC, albendazole, mebendazole, benzathine penicillin, praziquantel, leprosy multidrug combination). The main expected results of this PoA are: Updated strategies based on international guidelines and best practices
ii) Accurate estimates of the burden of these 5 NTDs to improve macro and
micro planning, monitoring and evaluation. iii) Successful management of drug donations. Lack of timely access to drugs
constitutes a barrier for success of most of the programs. However, there are companies willing to donate their drugs to countries which can demonstrate their capacity to forecast and distribute the drugs to those in need. iv) Strengthened capacity of health workers and volunteers through integrated
training at all levels. Activities which strengthen the knowledge, abilities, skills and behavior of individuals (MoH, health workers, school teachers and communities) and improve institutional structures and processes help the program more efficiently meet its mission and goals in a sustainable way. v) Integrated social mobilization activities, key for the success and sustainability
vi) Integrated and improved MDA for LF, schistosomiasis, and STH including
scaling up and increasing coverage to achieve the individual program goals. vii) Integrated and intensified morbidity case detection for leprosy, LF and
yaws through MDA campaigns and field visits of health care workers (index case contacts study). Intensified case-finding during LF MDA campaigns and IEC activities is a unique opportunity for leprosy and yaws elimination efforts to screen communities. viii) Integrated and intensified case management for leprosy, LF and yaws
through field visits of health workers and support to self-care groups. Improving case management is one of the best ways to fight stigma and discrimination of chronic patients, win the trust of the community, and increase self declaration by suspected patients. ix) Strengthened monitoring and evaluation system for the 5 NTDs.
x) Establishment of a surveillance system for leprosy, LF, schistosomiasis and yaws
after the elimination of these diseases as public health problems. ‘Supporting' expected results are:
xi) Establishment of a national NTD Taskforce. By joining all national and international
stakeholders in a single network, the program will improve coordination among the different programs, integrate of activities, share results, facilitate solutions, and maximize impact. xii) Increased visibility, advocacy and political commitment for NTD control
and elimination. Having one PoA for 5 different NTDs will increase their visibility and will facilitate political and financial commitment by maximizing results with minimum cost. xiii) Increased advocacy for comprehensive NTD control which links water,
sanitation, hygiene education and chemotherapy. A long-term solution to fight and eliminate diseases related to poverty is to fight poverty itself, by improving living conditions and enabling people to change their behavior by having access to water, sanitation and hygiene education. xiv) Integrated health promotion and hygiene education. Every opportunity will
be used to promote health and hygiene in the community. Social mobilization campaigns, MDA, school deworming days, self-care groups as well as every contact with the health system will be use to promote hygiene and health habits.

an integrated actions
Social mobilization Summary budget

Integrated Neglected Tropical Disease Budget Estimation in USD
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government
government
government
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Lymphatic filariasis Soil Transmitted Helminthic Infection (STH) Leprosy and Yaws Grand Total
11,650,000
6,000,000
11,650,000
6,000,000
11,650,000
6,000,000
11,650,000
6,000,000
11,650,000
6,000,000
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Integrated Neglected
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escription
phatic filariasis
inthic Infection
Soil Transm
Geography and Demographics
Indonesia is the largest archipelago country in the world with 17,508 islands of which 6,000 are inhabited3 . It is located in Southeast Asia between the Indian Ocean and the Pacific Ocean, and spans a total area of 1,919,440 sq km (land 1,826,440 sq km & water 93,000 sq km). Indonesia has a number of natural resources including petroleum, tin, natural gas, nickel, timber, bauxite, copper, fertile soils, coal, gold, silver. Various islands periodically face natural disasters such as floods, severe droughts, tsunamis, earthquakes, volcanoes and forest fires4. In 2008, the population was estimated at 228.8 million, of which 168.3 million are ≥15 years old. The gross income per capita was estimated at USD 3,310 (Box 1). The major religion in Indonesia is Islam with 88% of the population, followed by Protestant 5%, Roman Catholic 3%, Hindu 2%, Buddhist 1%, other 1% (1998 data)4. Infant mortality rate (IMR) nationally is 26.8, ranging from 8.2 in DKI Jakarta province to 43.2 in West Nusa Tenggara Box 1: Demographic statistics in Indonesia5
Total population: 228,864,000Gross national income per capita (PPP international $): 3,310Life expectancy at birth m/f (years): 66/69Healthy life expectancy at birth m/f (years, 2003): 57/59Probability of dying under five (per 1 000 live births): 34Probability of dying between 15 and 60 years m/f (per 1 000 population): 231/192Total expenditure on health per capita (Intl $, 2006): 87Total expenditure on health as % of GDP (2006): 2.2 Based on Bureau of Statistics 2008 data,3 mean years of schooling is higher for males than females (8 years vs. 7.1 years) nationally. The National Socio-economic Survey (SUSENAS), a household survey conducted by the Indonesia Bureau of Statistics (BPS), found that 96.1% of children 7-12 years old were enrolled in school, compared to 79.2% for children 13-15 years old, and 49.8% for children 16-18 years old. School enrollment varies from 99.52% in Jogjakarta province to 83.38% in Papua province. The percentage of households using an improved drinking water source, such as a pump/ well/spring water (that are at least 10m away from a septic tank), was 52.72% nationally. This varied widely from 69.21% in Jogjakarta province to 34.86% in West Papua. Importantly, the regional variation did not necessary correlate with urbanization since city provinces such as Jakarta also had low rates (44.33%). 3 Bureau of Statistics: www.dds.bps.go.id/eng/download_file/booklet_leaflet/booklet_okt2009.pdf4 Asian Center for the Progress of Peoples 2007: www.acpp.org/uappeals/cprofile/Indo%20Country%20Profile.pdf 5 World Health Statistics: http://www.who.int/healthinfo/statistics/en/ Political situation and administrative structure
Indonesia is a democratic republic with 33 provinces encompassing 397 districts and 98 cities3. Indonesia's governance was decentralized to the level of district/city on 1 January 2001. The 495 districts and cities have become the key administrative units responsible for providing most government services including health but excluding defense and national security, foreign affairs, fiscal policy and religion. Since 2001 the situation has evolved and currently decentralization in Indonesia has entered a new phase of consolidation; however local institutions in many districts and cities still lack the capacity to fulfill their new mandates effectively. Further, development indices, poverty rates, and proneness to crisis (conflict or natural disasters) vary across different provinces. Coupled with the diversity in culture, terrain and population, these have made implementation of interventions a challenging task6 . The Ministry of Interior Affairs (Dalam Negeri) is the key ministry responsible for decentralization and the funding of regional governments. Health care system
The overall health financing situation in Indonesia is complex and incompletely documented7. In 2003, around 34% of total health expenditure was undertaken by public sector agencies, while 66% was private. By far the largest single source of private expenditure was direct out-of-pocket payments by households, accounting for nearly half of the total expenditure. Insurance coverage has been increasing since the advent of the new social insurance scheme for the poor7.
The general decentralization process implemented in 2001 has had many impacts on the health system, even though it was not designed specifically with the health sector in mind. In particular, health financing, health information system, human resources for health and service provision have been affected. Under decentralization, responsibility for health care provision is largely in the hands of district/city governments. Despite this, the central government continues to set the national agenda, targets for health and along with the provincial governments, provides a supervisory, support and monitoring role for district/city governments.
The Ministry of Health (MOH) in Indonesia, situated in the capital Jakarta, has 4 Directorate-Generals, 2 Institutes, an Inspectorate-General and a Secretariat-General under which there are 14 Centers and Bureaus (Figure 1). A number of these structures are critical for the control of NTDS under consideration in this PoA. Primarily, the Directorate- General of Disease Control & Environmental Health (DG DC & EH) has five directorates, where the Directorate of Vector-Borne Disease Control oversees LF, schistosomiasis & STH control and the Directorate of Directly-Transmitted Diseases oversees leprosy and yaws control. Under the DG DC & EH, there is a planning unit, finance unit and a regulation unit that are involved in the overall management of the business of the Directorate-General. 6 Government of Indonesia and UNDP Country Programme Action Plan, 2006-10 www.undp.or.id/pubs/docs/CPAP%202006-2010.pdf 7 World Health Organization Indonesia Country Office www.searo.who.int/indonesia Figure 1: Organizational structure of Ministry of Health, Indonesia*
STRUKTUR ORGANISASI DEPARTEMEN KESEHATAN
STAF AHLI MENTERI
KEUANGAN DAN
HUKUM DAN
DAN ANGGARAN
BINA KEFARMASIAN DAN ALAT
PENYAKIT DAN PENYEHATAN
PEMBERDAYAAN SDM KESEHATAN
PUSAT PEMELIHARAAN
PENINGKATAN, DAN
DATA SURVEILANS
PEMBIAYAAN DAN
KOMUNIKASI
SARANA, PRASARANA DAN KERJASAMA LUAR
*Menteri kesehatan = Minister of Health, Direcktorat Jendral Pengendalian Penyakit dan Penyehatan lingkungan = DG DC & EH, Direktorat Jendral Bina Kefarmasian dan Alat Kesehatan = DG Pharmacy and Health Supplies, Pusat Promosi Kesehatan = Centre for Health Promotion, Pusat Kerja Sama Luar Negeri = Centre for International Collaboration, Direktorat Jendral Bina Pelayanan Medik = DG General Medical Services, Direktorat Jendral Bina Kesehatan Masyarakat = DG Community Health.
For NTD control, the DG DC & EH also coordinates with the Centre for Health Promotion, the Bureau of Planning & Budgeting (under the Secretary-General), as well as the Directorate-General for Pharmacy & Medical Services and the National Institute for Health Research & Development. In addition to lateral coordination, the DG DC & EH also coordinates with the provincial and district health authorities. Structures for disease control such as vector-borne diseases and directly-transmitted diseases are replicated on a smaller scale in provincial governments. The general division of mandate between national, provincial and district/city governments can be seen below: • Central MOH: prepare national strategy, guidelines & regulations for disease control and provide a supervision, monitoring and support role to provincial and district/city • Provincial Health Office (PHO): adopt national strategies to develop provincial strategy based on local situation, provide training, funding support, supervision & monitoring for district/city level health offices • District/City Health Office (DHO): develop district/city level plans, directly implement disease control activities, supervise lower health structures such as primary health School Health Programme (UKS)
There are about 175,000 public, religious and private schools in Indonesia, all of which are eligible to participate in the School Health Programme (UKS - Upaya Kesehatan Sekolah). There are about 27 million students in primary school, about one quarter of whom are in religious schools (Madrasah Ibtidaiyah). Education is compulsory and provided free of charge in public schools for children from 7 to 15/16 years of age, corresponding to all 6 classes of primary school and 3 classes of secondary school. The number of teachers working in primary schools is 1.38 million. The three major UKS programmes include health education, health service delivery through schools, and a healthy school environment. In addition to immunization, the health services delivered include health and nutrition screening for new students; height and weight monitoring; health education, dental care; iron and iodine supplementation; and de-worming in some areas. Booklets and materials have been developed for UKS, which provide the objectives of the program, health information, how to conduct health promotion in schools and monitoring/evaluation procedures. Content includes information about good nutrition and how to build latrines and water pipes.
The MOH Child Health Directorate coordinates activities relevant to the UKS. Four ministries (MOH, Ministry of Education, Ministry of Internal Affairs and Ministry of Religion) are involved in UKS. The implementation is mandated by teachers and supported by primary health care staff in all schools, including religious schools. There is also a ministerial decree about minimum standards in schools for ensuring health (KepMenKes 1429/MENKES/SK/ XH/2006).
School Immunization Month Programme (BIAS)
In 1998, the Ministries of Health, Education (MoE), Religious Affairs (MRA), and Internal Affairs launched Bulan Imunisasi Anak Sekolah (BIAS), School Immunization Month Programme. BIAS was designed to be a sustainable routine activity to eliminate tetanus and provide diphtheria boosters. In 2000, measles campaigns for 6-12 year olds were included in provinces that had funding. Since 2003, reported vaccination coverage in schools through BIAS has been about 95% each year. The MOH has the responsibility for policy, service delivery and evaluation, while the MoE and MRA handle social mobilization. The Ministry of Internal Affairs, through its local government and municipality offices, is responsible for covering operational costs. The UKS team leader at each level coordinates and monitors implementation of the overall integrated school health programme, including BIAS. Within the MOH, the staff in charge of health promotion at each level looks after UKS overall; however, the Expanded Programme on Immunization (EPI) is given responsibility at each level to implement BIAS. The UKS guru(s) oversees BIAS within the school.
BIAS is managed, supplied and implemented without the technical or financial involvement of multilateral or bilateral partner agencies. While BIAS was integrated within the existing UKS structure, most respondents at lower levels indicated that the existence of the UKS structure was helpful but not in fact required for the adoption of BIAS, since the health workers felt they were able to forge good relations with local schools on their own.

Background of NTDs & disease control initiatives in Indonesia Leprosy is a disease caused by Mycobacterium leprae, a bacterium which primarily af ects the skin and peripheral f NT main mode
Ds & disea of
se ctransmission
ontrol initia is consider
tives in In ed
sia air-borne,
through droplets discharged from the respiratory tract of untreated infectious cases, who form <10% of the clinical The disease is completely curable with multi-drug therapy (MDT) and is considered yc ectious obacteriu m diseases, leprae, a bwith skin and peripheral nerves. The main mode of transmission is considered to be air-borne, through having adequated i can be victims of the discrimination clinical cases. The and sease is c displacement.
ompletely curable This MDT) disabilities and deformities that occur as a consequence of peripheral ner considered to be one of the least infectious diseases, with ov vere damage in lepr 99% of the populati osy adequate immunity against the disease. The disease causes stigma and those affected can be victims of discrimination and often displacement. This is mainly due to the disabilities and Epidemiologydeformities that occur as a consequence of peripheral nerve damage in leprosy.
chieved leprosy elimination (yearly prevalence rate <1 per 10,000) at the national le 1 rpte ra 1p0,r0e0v0a) len of >1 per 10,00n0 el aisn e2 0d0e0, te 14c toiuot no f rat the e3 3 opf ro>vi1n0 10,000 and a case detection rate of >10 per 100,000 population. 2007 data from the MOH show from 460 districts. Furth cati torn aotf ifi heaviest diseasei n bur stricts . ofFi gthe cates the b . urden of disease by province in Figure 2: Indicates the bur
den of disease by province in Indonesia
Figure 2: Leprosy burden in Indonesia as of 31 December 2009, by province

Leprosy Burden in Indonesia (31 Desember 2009) Total number new cases 17,260 (Rate:7,49/100 000) Population 2009 : 230.473.991
North Maluku
West Papua
High burden
Or new case>
1000
Low burden
DKI Jakarta
WestJava Central Java EastJava WestSulawes S
i outh Sulawesi SE Sulawesi C. Sulawesi
CDR<10/100000 573 (6.33) 1.559(3.69)1574(5.08) 5923 (15.82) 195 (14.62) 1236(16.2) 249(11.62) 313 (12.93)
Or new case
<1000
As per MOH Report
Since 2000, 17,000-18,000 new cases have been reported each year, of which 10% have grade-2 disability and of which 10% are children. More than 70% of the new cases are of the multi- Since 2000, 17,000-18,000 grade-2 disability the multi-bacillar ases wi (MB).
ated cases wi risk grade-2 disabilities thus increasing the burden of socio-economic rehabilitation on the national, developing disabilities for disease transmission. Each year about 1,500 new cases with grade-2 disabilities are added to the pool of about 26,000 accumulated cases with grade-2 disabilities thus increasing the burden of socio-economic rehabilitation on the national, local governments and communities (Figure 3). e 3: igure 3: Leprosy disea
Indicates the bur se trends in Indone
den of disease b sia,
y pr 2o000-2008
vince in Indonesia
Leprosy Trend -Indonesia 2000-2008
In Jul y 2009, the MOH conducted a survey to assess the extent of under-detection. A district ess the (total extent of un trained ct (total village il ion) in health vEast Java pro rapidly screened by trained health workers, village health volunteers (cadres); people affected by people affected by leprosy and community leaders. A total of 338 new leprosy cases were leprosy and community leaders. A total of 338 new leprosy cases were identified (case detection identified (case detection rate was 60 per 100,000 examined population), of which 262 rate was 60 per 100,000 examined population), of which 262 (78%) were of MB type. The MB (78%) were of MB type. The MB case detection rate was 46 per 100,000 population. Forty- case detection rate was 46 per 100,000 population. Forty-three (13%) new cases had grade-1 grade-1a de-2 disab disability. i lity, of which Sixty-one . 49 (1 e lyd rscale up public ecommended awarene eness g in highly e omote early case finding in highly endemic areas. Strategy and Activities Strategy and Activities
The Sub-directorate for Leprosy and Yaws, in which the National Leprosy Control Programme is Sub-dir as 12 staff ectorate aft nati National ne staff of leprosy, more than one staff works on the program. Health center workers, other health care staff member is trained and responsible for the leprosy program. In provinces and districts workers, and health volunteers (cadres) also help implement the program's activities. with heavy burdens of leprosy, more than one staff works on the program. Health center workers, other health care workers, and health volunteers (cadres) also help implement WHO recently published the enhanced Global Strategy for Further Reducing the Disease Burden ogram'o Leprosy: Pl s activities. an 2011-20158. This strategy sets a new global target to reduce the grade -2 disability rate per 100,000 population among new cases by 35% by 2015, compared to a 2011 WHO recently published the enhanced Global Strategy for Further Reducing the baseline level. The strategy promotes the use of voluntary self-reporting for case detection, Disease Burden due to Leprosy: Plan 2011-20158. This strategy sets a new global target rather than large-scale campaigns since these have become less effective. Further, the strategy 100,000 these peopl populatione are at g compared to a 2011 baseline level. The strategy promotes the use of voluntary self- case the global str detection, ategy f than 1-2015, the large-scale Leprosy Prog emphasizes communicatio household n (IEC) acti contact vities to prom examination ote earl finding in the high-burden districts to reduce grade-2 disability and to reduce disease people are at greater risk of disease. transmission, focusing on 10 districts per year. The activities in the broad plan include orientation 2011-2015,u nity ormation, paigns and unication onitori omote early case finding in high-burden districts to reduce grade-2 disability and to disease d Global Strategy transmission, ffor Further (WHO, 2009). http://www.searo.who.int/LinkFiles/GLP_SEA-GLP-2009_3.pdf plan include orientation of health workers, micro-level planning, community mobilization, IEC material production, IEC campaigns, rapid case finding campaigns and supportive 8 Enhanced Global Strategy for Further Reducing the Disease Burden due to Leprosy: Plan 2011-2015 (WHO, 2009). supervision/monitoring. MOH has produced ample IEC material of excellent quality ready for dissemination, which is also available in CD format so that local governments can duplicate/print the standard materials. The Leprosy Programme conducts 21-day annual training of province and district leprosy workers at the National Leprosy Training in Makassar, South Sulawesi. Health center workers take part in 5 day trainings, other health workers are trained for 1 day, and cadres are trained for half a day. However, in sub-districts with intensified case finding with IEC campaigns, the programme conducts an additional 1-day annual training that focuses on the an overview of leprosy and yaws, a description of the local epidemiology, and how to identify suspect cases. The morning session is for health care workers and cadres, as well as other sectors (religious, social welfare, education and local government). The afternoon session is for health center works only and focuses on more technical aspects of disease recognition and treatment.
The Programme receives drug donations via WHO yearly for case management. The drugs are imported into the country by WHO and are then distributed to district level from MOH budget. The budget is reliable but has been delayed in previous years. The total cost is approximately USD 66,000 to enable distribution of drugs four times per year to district level, handling a total of 25 ton (25,000 kg). The cost per kilogram averages Rp24,000 (2.65 USD). Further dissemination is the responsibility of the local government, which is problematic since it relies on the assurance that the budget line is maintained by the local level planning system. Another aspect of the control program is the recent establishment of PerMaTa – groups for people affected by leprosy. PerMaTa is now present in parts of East Java, South Sulawesi, East Nusa Tenggara and Jakarta. The Netherlands Leprosy Relief (NLR), an international non-governmental organization (NGO), is supporting the MOH in leprosy case detection and disability management. NLR has an office in Jakarta but also has staff in some of the high-burden provinces. Among the activities conducted by NLR include monitoring and evaluation meetings in high-prevalence districts which provide an opportunity to re-train field staff, and support to some of the 13 leprosy hospitals around the country including five hospitals for prosthesis. In addition, the Sasakawa Foundation provides support to manage the disabilities arising from leprosy. Further information regarding the Sasakawa support will be available once the workplan is completed. The WHO also provides limited funds to the MOH for leprosy control, which in the past have been used to fund case finding missions and national meetings.
Lymphatic filariasis
Lymphatic Filariasis (LF) is caused by helminthic worms inhabiting the lymphatics. The disease predominantly afflicts poor people in both urban and rural areas as well as marginalized and neglected populations. It is usually acquired in early childhood and is responsible for considerable morbidity, causing social stigma among men, women and children. LF is one the only six infectious diseases considered eradicable by WHO with the available tools9. 9 Lymphatic Filariasis: the disease and its treatment (WHO, 2006). www.searo.who.int/en/Section10/Section2096_10583.htm LF is one of the major public health problems in Indonesia. All three types of lymphatic parasites namely Wuchereria bancrofti, Brugia malayi and Brugia timori are prevalent in Indonesia (Figure 4), but B. malayi is the most dominant. Twenty-three species of mosquitoes are vectors for LF in Indonesia. Figure 4: Distribution of filarial parasite in Indonesia
Since 2005, districts or cities have been used as the implementation unit (IU) to determine endemicity and implement MDA. The MOH finished mapping endemicity throughout the country in 2009, albeit some districts were mapped using epidemiological surveys (proximity of district to endemic districts, presence of chronic cases and MF rates surrounding chronic cases) rather than MF surveys using Lot Quality Assurance Sampling (LQAS), as recommended for confirmation of endemicity in WHO guidelines.10 As of 2009, an estimated 125 million people are at risk of filariasis infection, in 337 endemic districts, i.e. where microfilaremia (MF) >1% (Figure 5). Based on blood surveys for MF in Indonesia, province level prevalence varied from 0-38.57%. The highest rates were in Maluku, Papua, West Irian Jaya, East Nusa Tenggara and North Maluku provinces (all in east Indonesia). A total of 11,914 chronic cases have been reported nationally between 2000 and 2009, although this is most likely an underestimate given that it only includes cases that sought care through the national health system.
10 WHO. Preparing and implementing a national plan to eliminate lymphatic filariasis (in areas where onchocerciasis is not co-endemic). ure LF endemicity in Indonesia based on sur
5: LF endemicity in Indonesia based on surve
v ys up to September 2009,
eys up to September 2009, b
b y district
y district
Strategy y and
The LF Program sits within the Sub-directorate for Filariasis and Schistosomiasis. At ari , schistosomiasis asis and Schistoso and omiasis an df or LF STH. , schistosomiasis, At provincial and and/or the Head of Health, the Head of Division, the Chief of Section and functional staff are responsible staff are responsible for communicable diseases. At primary health centre level, the Head for communicable diseases. At primary health centre level, the Head of Health Centre and of Health Centre and functional staff also are responsible for control of all communicable functional staff also are responsible for control of all communicable diseases. aigns, scalin gscaling esource c oresour districts ofte ndistricts only partial coverage of the at-risk population within the district. often provide only partial coverage of the at-risk population within the district.

Table 1. MDA coverage 2006-2009
MDA2 (DEC+ALB)
Population Targeted
7,075,000
11,116,000
16,799,000
28,719,000
Population Treated
5,325,000
8,411,000
12,310,000
19,160,000
Geographical Coverage Programme Coverage National coverage
The LF Program conducts 5-days annual training of central and province LF workers central management ining management ent prog conduct vince level tray, training management of district LF of wLF management program, treatment and case management of LF. In district level LF annual training of health center that focuses on management program, treatment and case training conduct 2 days annual training of health center that focuses on management management. Whereas in health center level conduct one day training that focuses on the program, treatment and case management. Whereas in health center level conduct one d w of LF and mass tr ay training that fo cuses on the an overview of LF and mass treatment. DEC for MDA campaigns is purchased locally and albendazole is donated by GSK through WHO. The donated albendazole takes approximately two weeks to get cleared by customs. The central program covers the cost of distribution from central to province level; distribution is arranged by the Directorate General Pharmacy and Health Equipment and takes approximately one month from Jakarta to the district level. Districts contribute to the cost of distribution from the province level to the villages. The district health office repackages the drugs and distributes to health centers; a process taking approximately two The Sub-directorate developed a National Plan for the Acceleration of Filariasis Elimination in Indonesia (2011-2014). The plan is expected to be sustained until 2020, where the first 5 years of acceleration will be to scale up application of MDA campaigns in all endemic districts. However, even though this is the target, the plan only outlines the timetable for implementation of MDA for some endemic districts. The main pillars of the National Plan are: 1. Transmission elimination through MDA in endemic districts once a year for at least 5 years covering at least 65% of the total population in the implementation unit.
2. Increasing coverage of clinical treatment of acute and chronic cases to 90% of Currently, MDA has been scaled up in a geographically scattered way to address high prevalence areas and political needs. The 2010-2014 plan does not include a justification why certain districts were chosen for scaling up in certain years, beyond an emphasis on the eastern part of the country. Ideally, this plan would be realigned so that contiguous districts would scale up MDA at the same time, both for epidemiological and logistical reasons. If the plan cannot be adjusted, it is recommended that donor support be used to fill in the gaps to achieve geographical coherence. Case management has been introduced in some provinces and districts, through hospital care and self-support treatment. However, there is currently limited financial support for training of health care staff or treatment of cases.
Donors, universities and NGOs have played a critical role in assessing disease burden, supporting trainings and MDA campaigns. GTZ supported the University of Indonesia to undertake operational research to implement MDA campaigns, including health promotion aspects and M&E, in Alor Island, East Nusa Tenggara province. The district raised the budget for operational aspects such as distribution of drug and monitoring of severe adverse events (SAE). This study showed that the initial mapping undertaken underestimated the prevalence of MF and that ongoing stakeholder negotiations with local government and health staff training are required to achieve high MDA coverage. Research in Indonesia has been critical to inform the national program but also provide information to the global understanding and recommendations on LF control. A University of Indonesia study concluded that the combination of albendazole and DEC is effective for Brugian species, but takes more than five days to decrease MF for Bancroftian filariasis. Further, the University of Indonesia, with support from the Bill & Melinda Gates Foundation, is comparing the impact of twice-yearly MDA campaigns for three years versus once-yearly MDA campaigns for five years. Schistosomiasis in Indonesia is caused by a parasite, Schitosoma japonicum, which infects a number of mammals, including humans. The intermediate host is Oncomelania hupensis lindoensis, an amphibious snail. The snail lives in abandoned rice fields, along ditches, known as "disturbed habitat", under dense wild canes, along creeks or seepage waters. In humans, the disease has toxic and dysenteric symptoms as well as loss of appetite and weight, emaciation, retarded growth, in young patients. Hepato-splenomegaly and ascities are characteristic, progressing to death. Currently, single dose treatment with praziquantel is the treatment of choice since it is highly effective, easy-to-administer, and with minimum side effects. WHO provides donations of praziquantel to affected countries, however, global supplies of the drug are limited. In Indonesia, schistosomiasis is known to occur in three very isolated areas in two districts in Central Sulawesi province: the Bada, Napu and Lindu Valleys (Figure 6). A comprehensive control program was initiated in Lindu and Napu valleys in 1973. Control strategies included chemotherapy, hygiene & sanitation improvements and agro-engineering. However, due to diminishing funding after the termination of a specific control program in 2005 and the absence of post-elimination campaign activities, infection rates started to rise in 2006. By 2009, prevalence in the Napu valley reached 3.8%. In the same period, the infection rate among snails increased from 0 to 13.4% and 0 to 9.09% in Napu and Lindu Figure 6: Schistosomiasis endemicity in Indonesia
Strategy and Activities
The Schistosomiasis Program sits within the Sub-directorate for Filariasis and Schistosomiasis. At central level, there are 11 staff members working on LF, schistosomiasis and STH. At provincial and district health offices, there are no specific staff members for LF, schistosomiasis, and/or STH. Instead the Head of Health, the Head of Division, the Chief of Section and functional staff are responsible for communicable diseases. At primary health centre level, the Head of Health Centre and functional staff also are responsible for control of all communicable diseases. Based on an Oct-Nov 2010 evaluation mission by WHO, a number of challenges were identified for the disease control program. Since disease levels were brought to low levels in previous years, there have been difficulties in sustaining policymakers' interest and allocation of budgets for disease control activities. Further, there has been a lack of coordination between the MOH and others departments involved in the environmental and agricultural aspects of the overall strategy. Based on the evaluation mission, resumption of the control program would be critical to eliminate the disease where the at-risk population is up to 50,000 people, with mapping done to clearly define if there are other endemic areas in the highlands of Central Sulawesi. At the core of the strategy is yearly MDA to reduce disease incidence in humans. This would slowly reduce environmental contamination and thus snail infection, curbing the disease cycle over time. The core strategy of MDA can be coupled with education to the local community, rat and snail surveillance, and support to the environmental management programs including introduction of latrines and suitable water sources.
Soil-transmitted Helminths
Soil Transmitted Helminthiasis is the infection with one or more intestinal parasitic worms: roundworms (Ascaris lumbricoides), whipworms (Trichuris trichiura), or hookworms (Necator americanus and Ancylostoma duodenale). Infected people excrete helminth eggs in their feces, which then contaminate the soil in areas with inadequate sanitation. Other people can then be infected by ingesting eggs or larvae in contaminated food, or through penetration of the skin by infective larvae in the soil (hookworms). Infestation can cause morbidity and, in rare instances, death, by compromising nutritional status, affecting cognitive processes, inducing tissue reactions, such as granuloma, and provoking intestinal obstruction or rectal prolapse. Control of helminthiasis is based on drug treatment, improved sanitation and health education.
Soil-transmitted helminth (STH) infections are considered to be an enduring public health problem in Indonesia, although national-level data are not complete. Available national data consist of those collected during periodic school surveys (conducted in 8 provinces per year), the historical data collected during surveys conducted in the last 10 years and available in literature and a complete review of the literature conducted by the London School of Hygiene and Tropical Medicine (LSHTM) for UNICEF Dr S. Brooker and Dr. R. Pullan from LSHTM updated the 2002 revision with more recent data12,13 and produced the following map providing a visual localization of the available data and their level of endemicity (Figure 7a).
Figure 7a. Maps of STH prevalence in Indonesia: a. Data-based
Based on this epidemiological data and on climatic and population information the same group in LSHTM extrapolated a map in which the areas that have a strong possibility to have a prevalence of STH over 20% are marked in purple (Figure 7b).
11 Brooker S.(2002) Human helminth infections in Indonesia, East Timor and the Philippines. UNICEF 12 Albright JW, Hidayati NR, Basaric-Keys J. Behavioral and hygienic characteristics of primary schoolchildren which can be modified to reduce the prevalence of geohelminth infections: a study in central Java, Indonesia. Southeast Asian J Trop Med Public Health. 2005 May;36(3):629-40.
13 Albright JW, Basaric-Keys J. Instruction in behavior modification can significantly alter soil-transmitted helminth (STH) re-infection following therapeutic de-worming. Southeast Asian J Trop Med Public Health. 2006 Jan;37(1):48-57.
Figure 7b. Maps of STH prevalence in Indonesia: b. Predicted
Figure 7a. Maps of STH prevalence in Indonesia: b. Predicted
According this extrapolation, the population in need to be treated is presented in Acco (details , the po table: (details based on the province positives for LF and STH and province population according population according the 2010 census data are available in the annex the 2010 census data are available in the annex)
Table 2 Population living in STH endemic areas

Total Population (2010 Census)
Total population living in STH endemic areas Pre-school children living in STH endemic areas School-age children living in STH endemic areas Pre-school children living in STH endemic areas not 4.6 mil ion School-age children living in STH endemic areas not 13.5 mil ion endemic for LF Strategy and Activities The res y and ty of STH sits
Activities under the Diarrhea Sub-directorate in DG DC& EH but will relocate
to Sub-directorate LF & Schistosomiasis in 2011. At central level, there are 11 staff members The responsibility of STH sits under the Diarrhea Sub-directorate in DG DC& EH but working on LF, schistosomiasis and STH. At provincial and district health offices, there are no will relocate to Sub-directorate LF & Schistosomiasis in 2011. At central level, there are specific staff members for LF, schistosomiasis, and/or STH. Instead the Head of Health, the Head 11 staff members working on LF, schistosomiasis and STH. At provincial and district health of Division, the Chief of Section and functional staff are responsible for communicable diseases. At p staff e ad of Health or LF, and functional staff al schistosomiasis, so are Division, the Chief of Section and functional staff are esponsible for communicable diseases. At primary health centre level, the Head of Health Centr date, the activities conducted by e and functional staff also ar the esponsible f -directorate or contr include: ol of all communicable diseases. To date, the activities conducted by the Diarrhea Sub-directorate include: Periodic school surveys (usually in 4 schools each in 8 provinces per year) Provision of MDA or selective treatment of positive cases (depending on availability of • Periodic school surveys (usually in 4 schools each in 8 provinces per year) resources and drugs nationally and at local level) • Provision of MDA or selective treatment of positive cases (depending on availability Health promotion and hygiene education of resources and drugs nationally and at local level) Promoting improvement in sanitation especially latrine coverage pr g of health car omoting toral and sanitation ation especially latrine coverage Monitoring and evaluation of activities • Training of health care workers and community • Intersectoral and inter-program coordination • Monitoring and evaluation of activities On average less than 2 000 school age children were treated every year.
The STH Program conducts 4-days annual training of central and province STH workers central and province STH workers central and province STH workers. The training focuses on epidemiology, management program, laboratory diagnostic and treatment. In district level training conduct 2 days annual training of district STH worker and health center. The training focuses on epidemiology, management program, laboratory diagnostic and treatment of STH. Whereas in health center level conduct one day training of cadres (school teachers) that focuses on the an overview of LF and mass treatment .
In addition to the activities conducted by the DG DC & EH, other stakeholders such as the Child Health Directorate (under the DG Community Health at MOH) have undertaken MDA activities for STH. The Child Health Directorate encourages provincial authorities to adopt MDA twice per year and coordinates with the Ministry of Education. Due to the decentralization process, provinces and districts need to self-purchase drugs for the MDA which has reduced compliance with the national program since the budget is not routinely Other STH partners include the World Food Program (WFP)'s school feeding program with which de-worming activities are paired. WFP highlighted two major challenges in the deworming aspect of their campaigns: parents need to be educated before the deworming campaign otherwise there is reluctance to participate, and, transportation of the WFP drugs from the district to the schools has proved challenging. WFP operates in three provinces NTT (Kupang, TTS and Belu districts), NTB (Central Lombok, West Lombock and East Lombock districts) and East Java (Sampang). WFP conducted systematic deworming in all schools in these districts during the period 2007- 2009. After that deworming was interrupted. Only Sampang and TTS districts continue deworming with local resources.
Yaws (Framboesia tropica) is a chronic, contagious, non-venereal infection caused by the spirochete Treponema pertenue. The disease is most prevalent in children <15 years old and is usually associated with lack of personal and environmental hygiene. Eighteen of the 33 provinces in Indonesia report cases of yaws, with five provinces considered to have a high burden of the disease. The remaining 13 provinces that were endemic in the past are considered to be very low burden. Based on the available data from provinces, 33 districts, mostly in east Indonesia, are considered to be highly endemic and 43 are considered to be low endemic. Figure 8 shows the geographical areas in Indonesia that still report cases of yaws.
Figure 8: Geographic distribution of provinces reporting cases on yaws, Indonesia
SITUASI FRAMBUSIA DI INDONESIA
Figure 8: Geographic distribution of provinces reporting cases on yaws, Indonesia

TAHUN 2009
Total Kasus: 8309
S. Sumatera (0)
C Sulawesi (94)
Papua (639)
Jatim (20)
High burden province Low burden province As per MOH Report (03.08.2010)
No information available The Yaws Eradication Program has been reporting a steady increase in number of new prrogram has been rep ogram reported orting 2001. The program reported 7,751 new cases from five provinces at the end of 2009 (Figure 9). 2009 (Figure 9). Of these, 7,400 cases were reported from active surveys carried out in 6 Of these, 7,400 cases were reported from active surveys carried out in 6 highly endemic districts highly endemic districts in East Nusa Tenggara (NTT) province.
in East Nusa Tenggara (NTT) province.
Fi
Figur gure
a Yaws case
ws case r repor
epor ting in Indonesia, 200
ting in Indonesia, 1-2009
2001-2009
Fig.1 Trend in Yaws case reporting Indonesia 2001-2009
Strategy and Activities Strategy and Activities
The Sub-directorate for Leprosy and Yaws, in which the Yaws Eradication Program is based, has 12 s Sub-dir onal level which is 1 staff ogram. In Java and program and yaws eradication program are held by one staff, except in Papua, East Java and Central Sulawesi provinces.
The MOH strategy is designed to eradicate the disease by 2013. WHO guidelines recommend that whe is an 5%, as is t eradicate nesia, al cases, household members and obvious contacts should be treated with a single injection of long-acting benzathine penicillin. The MOH strategy includes active case finding and treatment of cases and their contacts, mobilization of community support, capacity building of health staff for detection an 33 management of cases, and establishment of partnerships. The main operational activity is to The MOH strategy includes active case finding and treatment of cases and their contacts, mobilization of community support, capacity building of health staff for detection and treat" missions at l of par east o tnerships.
the di operational atio n. would then be followed by sero-surveillance for eradication certification, The Yaws Eradication Program conducts 2 days training of district and health center staff. HThe this program i Pr lability. staff.
ocuses on case diagnostic, case management and reporting-recording system. enzathine p penicillin re responsibility sponsibility for dfior stridistributing the district level. However, the Indonesian supplier is not currently making the drug; therefore, it to the district level. However, the Indonesian supplier is not currently making the drug; the Yaws Program will have to procure it elsewhere. therefore, the Yaws Program will have to procure it elsewhere.
erad eradication ication in In in ent with gl with mendations14, low 14 itment and funand ional activities activities ple implementation mentation of the e of icat eradication cognizin Recognizing g this limitatio this n, th limitation, ated acti integrated vities with activities programs including leprosy and LF. The integrated strategy and activities are described further in disease control programs including leprosy and LF. The integrated strategy and activities are latter sections of this document. described further in latter sections of this document. appingpping of NTDs endemicity
of NTDs endemicity complete lis listing schi schistosomiasis stosomiasis was was rector ectorates OH. It i MOH.
that STH is e that A summ varies.
LF and STH can be seen in seen in Table 3.
Table 3: At-risk population for diseases that need mass drug distribution (LF, SCH and STH)

Population
5-12 years
(school-aged children)
Total population
237.3 million
45.1 million
LF endemic/ STH endemic/SCH endemic LF endemic/ STH endemic LF not endemic/ STH endemic ( 70.6 million) Total in need of treatment
124.9 million
37.1 million
LF not endemic/ STH not endemic
Health, hygiene & nutrition promotion
Health, hygiene & nutrition promotion iving a cl "Living a. Indonesia.
The activiti The es for activities each. Fo education for ea activities raphi or each school under their geogra phic purview.
ealth In Indicator are Jogjakarta (58.2%), Bali (51.7%), East Kalimantan (49.8%), Central Java (47%) and North 14 Yaws Goals, Objectives & Strategy (WHO, 2006). www.searo.who.int/en/Section10/Section2134_10840.htm Yaws Goals, Objectives & Strategy (WHO, 2006). than 38.7% are Jogjakarta (58.2%), Bali (51.7%), East Kalimantan (49.8%), Central Java (47%) and North Sulawesi (46.9%). Provinces with low performance scores are Papua (24.4%), East Nusa Tenggara (26.8%), Gorontalo (27.8%), Riau (28.1%) and West Sumatera (28.2%). The Riskesdas 2007 also assessed hygienic behavior, measured by appropriateness of defecation practices (at minimum, use of latrine) and appropriateness of hand-washing practices (wash hands with soap before eating, before handling food, after defecation, after cleaning children's defecation and after handing animals). The survey found that 71.1% of population ≥10 years surveyed practiced appropriate defecation practices, but that only 23.2% had good hand hygiene. The province with best hygiene practices was Jakarta: 98.6% for defecation practices and 44.7% for hand hygiene. Provinces with low performance for defecation practices were West Sulawesi (57.4%), Gorontalo (59.2%) and West Sumatera (59.3%). Provinces found to have low hand-hygiene practices were West Sumatera (8.4%), North Sumatera (14.5%) and Riau (14.6%). Recent activities by the MOH Child Health Directorate and supported by WHO included developing a teaching guide for teachers in primary schools about child health, development, hygiene and nutrition. The book was finalized in 2010 and is awaiting the endorsement of the Ministry of Education before it can be circulated to schools nationwide. This will soon be followed by a similar book for high school students. Integrated vector management
In Indonesia there are 23 species of mosquitoes from 5 genera found as filariasis vectors. These are Mansonia, Anopheles, Culex, Aedes and Armigeres. Figure 10
Species of Anopheles are the main vectors of nocturnal periodic W. bancrofti in rural areas. The main vector of nocturnal periodic W. Bancorfti in urban areas is Culex quinquefasciatus, a highly anthropophilic species which feeds readily both indoors and outdoors and has its peak biting period between midnight and 3 am. The main vector of diurnal subperiodic W. Bancrofti is the day-biting, exophilic Ae. Polynensiensis. It breeds in small water containers and has a peak of feeding just before sunset. Mansonia uniformis is one of the main vectors of nocturnal periodic Bancroftian and Brugian Filariasis.
Malaria is another mosquito-borne disease that plagues much of the population in lymphatic filariasis endemic areas and is spread by Anopheles mosquitoes. In Indonesia, it is concentrated on the outer islands of Papua, Maluku, Nusa Tenggara, Sulawesi, Kalimantan, and Sumatra. A primary control strategy is the use of long-lasting impregnated nets (LLINs) to reduce the number of indoor-resting mosquitoes and shift mosquito feeding from humans to animals. With funding from the Global Fund for AIDS, Tuberculosis, and Malaria, UNICEF and the International Red Cross, the National Program for Malaria Control in Indonesia delivers LLINs through either: • Routine distributions in which every pregnant women receives 1 LLIN in the prenatal services (immunization and maternal and child health program, midwifes, malaria post). From 2007 to 2009, over 2.2 million LLINs were delivered according to the Malaria World Report 2010.
• Campaigns which distribute two LLINs per family in areas at risk. The number of bed nets distributed under this strategy is unknown.
Malaria program educational materials in Indonesia include messages about the benefits of using LLINs for decreasing both malaria and LF transmission. During LLIN distribution and MDA campaigns the use of LLINs should be encouraged, as advocacy for bednet use will benefit malaria and LF control. Malaria and LF programs should strengthen their links and send integrated messages related to vector control and protection during the routine and campaign distribution of LLINs and during MDA campaigns.
Integration between disease control initiatives
Disease control integration has taken place between the various programs within the MOH structure, as well as through integration with various partner agencies such as World Food Program, Ministry of Education and Ministry of Religious Affairs. Within the MOH structure, NTD integrated control received some attention in the last few years. In 2007, the MOH prepared Integration Guideline for the Control of LF, leprosy, yaws and STH. The basic concept is demonstrated diagrammatically, where the various Sub- directorates under DG DC & EH work with other units of the MOH and jointly enable the integration of activities at the provincial and district level (including monitoring, supervision, case detection, case management etc) (Figure 10). Schistosomiasis is not included in the list of the diseases in this guideline since the public health problem is limited to a small geographical area and population.
The integrated guideline outlines the principles of integration, the objectives, the strategy, the structural organization, and the roles and responsibilities of different levels of the health system. Importantly, the guideline recognizes that there are some activities that have the potential for integration but that there are those that have to stand alone. The guideline describes the mechanisms for integrating rapid mapping, endemicity surveys, health care worker training, health volunteer training, MDA campaigns, self-care groups for case management, health promotion activities, documentation and reporting, and monitoring and evaluation. The guideline includes the forms that can be used by health care workers at each level (PHO, DHO, PHC and cadres), but it does not provide scripts (step-by-step instructions) for how each activity such as the integration of LF MDA registration with osy suspect case finding will be conducted. Such operational guidelines are needed to simplify the concepts, enable rapid training of health care workers and assist in standardizing processes and activities.
operational guidelines a re needed to simplify the concepts, enable rapid training of health care workers and assist in standardizing processes and activities. Figure 11: Coordination between different units in MOH to enable integration of NTD
contr e 10: Coordination betw
ol activities at local le e
el different units in MOH to enable integration of NTD control
activities at local level
health & Nutrition health & Nutrition Integrated
Since 2007, there has been limited uptake by provinces and districts of the integrated n limited uptake of the integrated and nce of limite especiall in the allocated process for integration, especially due to the vertical budget lines allocated to each disease to each disease control program. Nevertheless, the MOH undertook a pilot project in control program. Nevertheless, the MOH undertook a pilot project in 2007 in two locations: 2007 in two locations: Subang in West Java to integrate leprosy and LF, and Buton in East Subang in West Java to integrate leprosy and LF, and Buton in East Sulawesi to integrate leprosy, the pilot wer these areas, availability of staff availability on makers. staff als showed tdecision ents of all di for care gr commitment to the activities of the self-care In addition to integration within the MOH, activities have been integrated with other programs at example is within on of dactivities aigns integrated activi combination ty is conducte of mary heal campaigns district classes level. In 1-3.
ion, in activity Indonesia where WFP provides supplemental feeding, deworming activities including MDA twice per year, latrine provision and water provision have been integrated. The WFP no longer suppo 37 the STH control campaign but has seen sustainable local government continuation of the program in two of the seven districts. primary health care workers who are also in charge of the UKS at sub-district level. In addition, in the seven districts in east Indonesia where WFP provides supplemental feeding, deworming activities including MDA twice per year, latrine provision and water provision have been integrated. The WFP no longer supports the STH control campaign but has seen sustainable local government continuation of the program in two of the seven districts. Drug supply and logistics
Adequate
and timely supplies of drugs constitute a barrier to success for most of the NTD programs. However, drug donation programs now exist for all 5 of the NTDs in the PoA, • In 2010, Johnson & Johnson announced the donation of 200 million tablets of Drmebendazole ug supply and l for ogisti countries heavily burdened by STH. This donation program is Adequate an y the NGO Childr d timely supplies of en rugs constiWorms (CWW).
tute a barrier to success for most of the NTD programs. However, drug donation programs now exist for all 5 of the NTDs in the PoA, as • In 2010, Eisai Co., Ltd. announced a donation of DEC for LF endemic countries. This is still in the negotiation phases, but WHO will facilitate the donation starting in 2012. In 2010, Johnson & Johnson announced the donation of 200 million tablets of • GlaxoSmithKline coun talbendazole ries heavily b fr program is managed thr thout Wo .rms (CWW). 2010, Ei praziquantel sai Co., Ltd. an nfor ou nschistosomiasis ced a donation of contr in the negotiation phases, but WHO will facilitate the donation starting in 2012. countries. This program is managed by WHO.
GlaxoSmithKline provides albendazole free of charge for LF elimination programs. This by Novartis. This program is managed by Merck donates praziquantel for schistosomiasis control in Africa and other selected penicillin for some endemic tidrug therapy for leprosy is donated by Novartis. This program is managed by WHO. WHO supports the procurement of benzathine penicil in for some endemic countries. Albendazole and multidrug therapy for leprosy have previously been donated to Indonesia. prosy h ya. v eDEC drugs are fully registered in the country. DEC is produced and procured locally. Mebendazole is Mebendazole is registered as Vermox produced by Janssen – Cilag, which is a division of registered as Vermox produced by Janssen – Cilag, which is a division of Johnson & Johnson in Johnson & Johnson in Indonesia. Benzathine penicillin was produced locally but production Indonesia. Benzathine penicillin was produced locally but production has been discontinued in has been discontin ued in 2010.
Within Indonesia, the MOH's DG for Pharmacy & Health Supplies procures a range of & He quantities 201 04., the drug quantities procured through the MOH system can be seen in Table 4.
Table 4: Number of tablets procured by MOH for distribution to district level, 2010
NTD
Tablet/box
procured
Blister pack combinations Benzathine penicillin The process of procurement commences each year in January, where the DG Pharmacy & Health 38Supplies compiles and agrees with pharmaceutical companies on the list of generic drugs & prices for purchase. A ministerial decree is then signed listing the drugs and the agreed MOH purchase price. The price of the drug is adjusted for four regions in Indonesia based on the geographic distance from Jakarta. Regions and the price adjustment can be seen in Table 5. The process of procurement commences each year in January, where the DG Pharmacy & Health Supplies compiles and agrees with pharmaceutical companies on the list of generic drugs & prices for purchase. A ministerial decree is then signed listing the drugs and the agreed MOH purchase price. The price of the drug is adjusted for four regions in Indonesia based on the geographic distance from Jakarta. Regions and the price adjustment can be seen in Table 5.

Table 5: Drug price adjustment based on regions
Region
Provinces
Price Adjustment
Jakarta, West Java, Central Java, Jogjakarta, East nil Java, Bali, Lampung, Banten North Sumatera, West Sumatera, Riau, Jambi, 5% South Sumatera, Bengkulu, Riau Islands, Bangka Belitung, NTB NAD, West Kalimantan, Central Kalimantan, 10% South Kalimantan, East Kalimantan, North Sulawesi, Central Sulawesi, South-East Sulawesi, South Sulawesi, West Sulawesi, Gorontalo NTT, Maluku, North Maluku, Papua, West Papua The ministerial decree is then circulated to each disease control program so that they can make The ministerial decree is then circulated to each disease control program so that they can requests for drug purchase based on their available budget and needs. These requests are make requests for drug purchase based on their available budget and needs. These requests submitted by April of each year. Following this, the MOH DG Pharmacy & Health Supplies submitted by tender Supplies ible to deliver The elivery of dr er the drugs to district level. Delivery of drugs commences after April and may take until the end of the year.
Most drugs are purchased from the three state-owned companies producing generic products: Most drugs are purchased from the three state-owned companies producing generic PT Phapros (ceased but may in future years recommence production of benzathine oducts: enicillin) • PT Phapros (ceased but may in future years recommence production of benzathine PT Indo Farma (produces mebendazole) Farma ailable for drug donations to MOH. The first option is to establish a Special Indo e (SAS).
oduces an agreement b mebendazole) etween MOH and the donating agency that is valid for one year to enable drug importation. This is especially useful for drugs that are not registered in the country. Another option is to register the drug in Indonesia; a process that takes A separate system is available for drug donations to MOH. The first option is to establish 6-12 months. The registration is valid for five years. a Special Access Scheme (SAS). The SAS is an agreement between MOH and the donating agency that is valid for one year to enable drug importation. This is especially useful for drugs that are not registered in the country. Another option is to register the drug in Indonesia; a process that takes 6-12 months. The registration is valid for five years. Development of Plan Rationale
Even though each Disease Control Sub-directorate at the MOH DG CDC & EH has
its own plan including some level of integrated activities for different diseases, this Plan of Action was needed in light of: • Recent announcement of enhanced drug donations for NTD by pharmaceutical companies globally. • Renewed donor interest in funding NTD activities for accelerating elimination and • Review and evaluation of schistosomiasis program in Central Sulawesi (October- • Finalization of LF plan for 2010-2014 (May 2010)• Need to revitalize MOH 2007 integrated disease control strategy that integrates some activities in the LF, leprosy, yaws and STH program. • Need to leverage resources already made available to certain NTD for the purpose of supporting and enriching other NTD programs receiving little attention.
• Achievement of MDG goals• Decentralization of health services • Single document with key activities about a number of NTDs in Indonesia• Illuminate synergies between NTD programs that enhance cost-effectiveness• Refine activities for accelerated control of NTDs in light of recent international and national developments • Promote external funding for activities • Wider consultation in developing Plan of Action: limited to current partners but little involvement from other sectors of government (Dalam Negeri, Bappenas).
• The large size of the country and the considerable population at risk will require a progressive scaling up of the control activities, but the entiere area endemic fore LF should be covered by 2015 in order to get the target of LF elimination by 2020 • The east part of the country include very remote areas with major logistic difficulties for covering the population at risk Plan of Action for Plan of Action for NTD Control
i) to strengthen the Indonesian health system through improved training, advocacy and General coor dination at all le vels of the health system, then the Indonesian h collaboration ealth system thro within trainin gMinistr coo y of Internal rdination at all l Affairs and Ministr evels of the health systey of Religious Affairs among others, and to strengthen multi-sectorial collaboration within the MOH, Ministry of Education nistry of In the , and international i i) cooperation to strength funding capacity fo , r WHO anageminternational ent of internatiagencies) cooperation funding (USAID, AusAID, WHO and other international agencies) and drugs donations (DEC, albendazole, mebendazole, benzathine penicillin, praziquantel, drugs donations (DEC, albendazole, mebendazole, benzathine penicillin, praziquantel, leprosy ultidrug combination).
multidrug combination).
Table 6: Main goals and targets by disease
Frequency of
Goal Dise
b sj ectives D
rugs Drug In
Population
population
combination finding and ar eas below comb finding and applicable (excluding <2 - To interrupt DEC + ALB Once a year Entire hea-l t hT o cover at 2020 risk population - To c as public health - To eliminate PZQ To eliminate yaws Once or twice School-aged is 20% or higher. coverage for 5 years Frequency of
Goal Disease
Objectives
Intervention Intervention Population Implementation
combination finding and hyperendemic areas below 1 per 1000 population disability due to leprosy below 35% (excluding <2 least 65% of at-risk population with MDA by 2016 as public health of the total at-risk population with MDA 2013a te BenzathiPneen icillActi year All cases Vi Frequency of
Goal Disea y
se aws by 2013
Objec tive P
s enicillin Drufign
Population
- To achieve a ALB or MEB MDA combination finding and year-s To interrupt MDA=mass drug admintis and achieve SAC=school-age children (excluding <2 MEB=mebendazole elimination of egy towards control of STH and elimination of leprosy, LF, somiasis and yaws 2020 in Indonesia, the PoA will achieve the following expected results (ER): establish an Updated st integrated rategies elimination of leprosy, LF, Accurate estimation of the burden of these 5 NTDs schistosomiasis and DA by Indonesia, the PoA will achieve the following expected results 2016 ccessful management of drug donations Strengthened capacity of health workers and volunteers Integrated social mobilization Updated strategies based on international guidelines and best practices Integrated and improved MDA for LF, schistosomiasis, and STH including Accurate estimation of the bur as public health den of these 5 NTDs 4 yrs scaling up and increasing coverage Successful management of drug donations Integrated and intensified morbidity case detection for leprosy, LF, and 75% ugh MDA campaign pacity of health w s an ers and v ts of health olunteers care workers Integrated social mobilization ER VIII risk In
ation and intensified case management for leprosy, LF, and yaws Integrated and improved MDA for LF, schistosomiasis, and STH including scaling up h field visits of the health workers and self-care groups and increasing coverage Strengthened monitoring and evaluation system for the 5 NTDs To eliminate yaws Integrated ablish and ment of a sur intensified veillance sy case o r leprosy, L detectionF , f schi osy, s, LF, and yaws car e workers (contact case STH ' Suppor- t i n a results Once or twice School-aged ER VIII Integrated rage o fintensified case management f ildren yaws through field Creation of a National NTD Taskforce joining all stakeholders including visits of the health w erna ork tional actors ers and self-care groups Increased visibility, advoca engthened monitoring and e cy and political comm valuation system f itment for NTD co or the 5 NTDs ntrol e surveillance system for leprosy, LF, schistosomiasis, and yaws ER XIII is In
d advocacy for comprehensive NTD control linking water, after their elimination as public health problems her. itation, hygiene education and chemotherapy main grated heal ‘Supporting' expected results s a National NTD Taskforce joining all stakeholders including national and international actors Increased visibility, advocacy and political commitment for NTD control and ER XIII Increased advocacy for comprehensive NTD control linking water, sanitation, hygiene education and chemotherapy ER XIV Integrated health promotion To achieve these 14 expected results the PoA will implement the following operational ER I Updated strategies based on international guidelines and best practices
In 2011 WHO will be publishing updated guidelines for implementation of STH control
programs and monitoring and evaluation of LF programs. In light of this, as well as the
revised integrated NTD strategy spelled out in this PoA, the following priority activities are
recommended:
1. Creation of new national STH strategy. The MOH will develop an updated strategy for the control of STH, based on predicted prevalence mapping and international guidelines. This strategy will include MDA through schools in areas without LF MDA, instead of the current practice of testing and treating. It will aim to harmonize STH MDA activities currently being implemented by various partners, including the Ministry of Education and World Food Programme.
2. Creation of a new LF monitoring and evaluation strategy. The MOH will develop an updated strategy for monitoring and evaluating LF programs, based on the new WHO guidelines to be published in 2011. This strategy will include revisions to sentinel site monitoring, assessing transmission after five effective rounds of MDA, and post-MDA surveillance.
ER II Accurate estimation of the burden of the 5 NTDs
There is a significant amount of information on the burden and geographical distribution of
the 5 NTDs; however, there are still some gaps that need to be filled. Geographical mapping is necessary to assess existing situation more accurately and develop macro and micro planning.
1. LF mapping gaps. 135 districts (total population: 102.8 million) have been classified as non- • A 2009 WHO expert visit confirmed that 66 districts were non-endemic, given that a large number of people were tested without finding any positive results. • However additional districts were classified as non-endemic because they were surrounded by non-endemic districts or because no cases of hydrocele of elephantiasis were declared. For these districts, additional efforts should be made to ensure there is appropriate evidence to classify the district as non-endemic prior to the development of the verification dossier. The MOH will collect information on the methodology used to map each district for review by the Regional Programme Review Group in March 2011 to seek advice on whether these districts should be remapped according to WHO guidelines.
2. STH mapping gaps. STH are known to be widespread in Indonesia, but little information is available at central level on district-level prevalence and intensity. To rectify this problem, the following activities will be implemented: • The epidemiological information presented in the prediction map at page 22 is sufficient to start control activities.
• The periodical collection of epidemiological data in sentinel sites will allow to refine the data and to progressively adjust the control activities 3. Schistosomiasis mapping. Given that a new focus of transmission was recently detected in the Bada valley, there is concern that schistosomiasis is more widespread than currently thought. The MOH will implement surveys in the highlands of Central Sulawesi, which have similar ecological features as the infected areas and have migration from the infected areas, to clearly define the endemic areas.
4. NTD overlap mapping. The information available for leprosy, LF, schistosomiasis, STH, and yaws will be compiled into maps. Those maps will help to advocate for the integrated PoA for NTDs and the planning of the diff erent activities. ER III Successful mana
which have similgement of drug donations
ar ecological features as the infected areas and have migration from the Without successful ed areas, to clearly d of e the en donations, the cost of the NTD Program would ping. T individual he information disease leprosy, LF, could H, asuccess.
following activities compiled in national cate for the drug PoA for NTDs and the planning of the different activities. well as distribute drugs throughout the country. ER III Successful management of drug donations
m w Schistosomiasis, and anpplication one of the in fdor disease prog mebendazole rams could achiev do and man(CWW).
age drug d o nThis ations, donation as well as could be distribute drugs throughout the country. deliv ered to the School Immunization program (BIAS) and distribution could be integrated force, specif distribution ically the Sub-di with rectorat minimal and Schisto transpor somiasis, wil tation prepare an application for a potential mebendazole donation from Johnson and Johnson ren accomplished delivered drugs provided to the National disease contr School Immunization program (BIAS) aol pr nd disogram.
tribution could be integrated with the vaccines distribution with minimal additional transportation cost. A list of what needs to apply for CWWf or gram. r eporting to donors. Table 7 shows the current estimate of drugs needed f 2. The NTD or the next 5 y Taskforce will be respo ears.
nsible for the annual forecasting of the drugs, calculation of coverage and reporting to donors. Table 7 shows the current estimate le 7.h e nex
Ann t 5 years.
ual drug forecasting
Total number of people to be treated
Table 7. Annua
Number of
g rug forecasting
tablets per
Total numb2e
20p1l2e to b2e
13 r eated
Number of A
tablets per
* Total amounts of drugs needed were calculated by multiplying the population at risk by number of rounds nts of drugs needed were calculated by multiplying the population at risk by number of rounds TaTable 8. Calculation of requirements
ble 8. Calculation of requirements
Calculation of requirement
Albendazole (400mg) Multiply total population targeted by 1.1 (adding 10% reserve) Multiply total population targeted by 5.5 (adding 10% reserve) Multiply total population targeted by 2.75 (adding 10% reserve) It is likely that the Government of Indonesia will need to continue procuring some supplies of DEC locally, as the potential global donation might not be sufficient.
3. Develop guidelines for managing and referring severe adverse events (SAEs). The MOH should update their guidelines for managing and referring SAEs, following the WHO guidelines15, developing integrated guidelines and training materials where appropriate. Training on these guidelines should be done at provincial and district levels as part of preparation for MDA and/or active case finding and treatment.
4. The NTD Taskforce, in collaboration with BINA, will develop a plan for strengthening drug procurement (including drug donation applications) and supply logistics. This plan should include the following for all 5 disease programs: • Who will be responsible for costs of customs clearance, demurrage, storage, and transport within Indonesia.
• Opportunities for integration, particularly for transporting drugs for disease- specific MDA and/or treatment to districts at the same time.
• Timeline of needed to ensure drugs reach district level at appropriate time.
ER IV Strengthened capacity of health workers and volunteers
In order to improve the capacity of the health system to implement MDA, case finding and management, and disability prevention, priority activities include integrated training of health workers at all levels of the health system. 1. The national NTD Program will develop integrated training materials that will be based on the revised strategies for LF and STH. Training materials will be based on a module system so that they can be tailored to the diseases that are endemic at the provincial or district level.
2. The national NTD Program will train different workers at the province level, following the methodology of Training of Trainers. These provincial-level workers then will train the health workers and volunteers at district and community levels to improve their skills and knowledge.
a) Central level. National sub-directorate for Filariasis and Schistosomiasis staff will receive specific training for implementation of program-specific updated strategies and guidelines, as well as the integrated approach.
b) Provincial level. c) District level. Health care center (Puskesmas). Depending on what diseases are endemic at the provincial or district level, at least one health worker at every health care center will be trained in a two-day course to undertake the following: • MDA at population or school level • Case finding and management for leprosy • Case detection and management for yaws • Case detection and management for elephantiasis and hydrocele • Training of trainers to create self care groups at community level • Contacts study to identify new leprosy and yaws cases at community level • Monitoring and evaluation (form filling and collating) 15 WHO 2005. Preventive Chemotherapy for Human Helminthiasis.
d) Village level. In districts where LF MDA has already started volunteers have been trained for the conduction of MDA. In leprosy and yaws endemic areas, every village has at least one volunteer who has been trained for leprosy and yaws detection. The program will integrate these volunteers and will conduct annual one-day training for them with the following objectives: • Case detection of leprosy patients• Case detection of yaws patients• Case detection of LF morbidity (elephantiasis and hydrocele)• Declare the detection of new cases for leprosy, yaws and LF (elephantiasis or hydrocele). The volunteers will be trained on the use of forms to inform the health center.
• MDA: Schoolteachers and community volunteers can be recruited to deliver these medicines to many people who are beyond the reach of the peripheral health-care system. • Register important data for every person receiving the drugs. This data will serve for important statistical analysis such as coverage, demographic distribution of the population attending the MDA, etc. Volunteers will be trained on how to fill the different forms • Community mobilization prior to MDA campaigns• Health education during MDA campaigns.
• Severe adverse reaction detection and declaration to the health center using adequate forms.
• Community care of chronic patients: Providing instruction to people on how to care for relatives or others in their community suffering from disabling morbidity from leprosy and lymphatic filariasis strengthens health systems, thereby achieving delivery and equitable access.
ER V Integrated social mobilization
Social mobilization is imperative to ensure community compliance in accepting MDAs and should increase the motivation of the at-risk individual to accept treatment as well as on the health-care provider or community volunteer adequately informing and motivating the community. Social mobilization is a complex process – the programme, health-care delivery services, health-care providers and strategies for mobilization and communication, interact to influence and provide the acceptance of the programme(s) to local communities. 1. The Sub-directorates will work closely with the Health Promotion Department in the MOH to produce integrated IEC materials and tools used for social mobilization.
2. The NTD Program will seek the participation of all possible inter-sectoral partners and allies in strategically selected communication interventions to develop organized ER VI Integrated and improved MDA for LF, schistosomiasis, and STH
This section includes activities to scale up and increase coverage in MDA campaigns to
achieve the goals for control of STH and elimination of LF and schistosomiasis. MDA campaigns will be used as an opportunity to deliver drugs, detect new cases (leprosy, LF, and yaws), and promote hygiene (which will benefit all 5 NTDs programs). 1. MDA in LF-endemic areas will be planned using the following recommendations: • Implementation unit (IU) will be the district.
• When contiguous districts have less than 1 million people each, they can form groups with other contiguous districts, if the total population of each group is no more than 1 million people. These groups can serve as Evaluation Units (EU) for assessing the impact of MDA.
• In districts where the population is higher than 1 million, they should be divided by sub-districts into separate IUs of less than 1 million each.
• All communities within the same IU or EU will start MDA the same year.
• To count as an ‘effective' MDA, each IU or EU should achieve coverage of at least 65% of the total at-risk population in any annual round. • MDA campaigns will follow the principle of directly observed treatment, i.e. each eligible person has to ingest the drug in front of the drug distributor.
Figure 11. Algorithm for integrated MDA

Figure 12. Algorithm for integrated MDA
Districts wher e LF is endemic:
• Schistosomiasis Districts non-endemic
where LF is ende ar
c: : One annual LF MDA round will distribute
DEC+ALB to the entir endemic areas: childr stribute DEC+ALB to the entire population (excluding children under 2 years old, pregnant women, and women, and severely ill). • Schistosomiasis c areas: Si (Lindu gi Distri subdistrict), ct (Lindu subd iPoso strict), district Utara, Lore Timur re P Subdistricts) iore Subdistri (see ee annex for full li list endemic vil ages) will villages) will receiv same logi logistic echanism. The fir The MDA will distribute DEC+Albendazole to the entire population (excluding children under first round of LF ld, p rdistribute en and severely ill). round will distribute (excluding children years. It will be nducted six Praziquantel(without months after the first roun albendazole??) older than 4 years. It will be conducted six months after the first round.
Districts where LF is not endemic:
Districts where LF is not endemic:
STH <20%: (DKI Jakarta, Jawa Tengah) No MDA will be conducted in those areas. MEB or • STH <20%: (DKI Jakar th care conducted center for indin or ALB should be a STHvailable in e ces) One ann e center f ual round or individual tr of MEB (or ALB) eatment.
will be co nducted. Target population will be school age children (5-14 years), both enrolled and non-enrolled. • STH >20%: (7 pro coul conducted.
population will be erage and olled.
There are two possible pr progra ograms with which STH MD m it is the preferred mechanism tA could be integrated: o reach school-age children. The program implements an annual round for TT and DT immunization in November. Teachers are School immunization or distri (BIAS): this program it is . STH drugs c to be de school-age livered to the childr program implements courag .e d to visit Teachers are trained ols odistribution n the days of of vision of health workers fr om the immunization team. STH drugs could be delivered to the BIAS and distributed with the vaccines to the schools. Non-enrolled children would be encouraged to visit schools on the da ys of the campaign to receive MDA.
School Health Program (UKS). Linking deworming with activities conducted by health workers in schools.
ER VII Integrated and intensified morbidity case detection
Case detection for leprosy, LF, and yaws will be integrated and intensified through MDA campaigns and field visits of health care workers (contact case detection). As leprosy or yaws case-detection rates decrease, the average cost of detecting a case increases. Many leprosy control programmes now rely on voluntary case-finding supported by IEC activities to raise and maintain awareness of the early signs and symptoms of leprosy. However integrating case detection with MDA campaigns will have the benefit of increasing case finding without having to support the entire cost of the campaign.
1. In areas where LF is endemic, MDA annual campaigns will be used to detect new cases of leprosy and yaws.
• IEC and communication materials will inform the population of the main signs and symptoms for all 5 NTDs, with an emphasis on leprosy, LF, and yaws. • Suspected cases will be encouraged to present to trained volunteers during the • Trained volunteers will consult suspected cases during the MDA and notify them to the health center.
• Suspected case will be encouraged to visit the health center to confirm diagnosis and receive adequate treatment and advice.
2. After the MDA, forms declaring suspicious cases will be sent to the health care • Trained health workers will receive the forms and will plan field visits to consult every suspicious case and confirm diagnosis.
• Contacts leaving in same community as index cases will be tested to detect new cases of yaws and leprosy in early stages of the diseases. ER VIII Integrated and intensified case management
Case management will be integrated and intensified for leprosy, LF, and yaws through field
visits of the health workers and establishment of self-care groups. 1. Health workers will conduct field visits to every area where new cases of leprosy and yaws are suspected.
2. Patients will receive adequate treatment for leprosy and yaws.
3. Where a number of people suffering from leprosy and LF morbidity live in the same district and at an adequate distance (for instance, 5 kilometers) a self-care group will be established.
• People living with leprosy and LF chronic disabilities will be invited to participate in their nearby self-care group. The patients will be informed about the benefits of joining the self-care group, including: learning improved management of their disabilities, preventing and reducing disabilities, improving treatment and care compliance, and fighting stigma and discrimination in the community.
ER IX Strengthened monitoring and evaluation (M&E) system for the 5 NTDs
To monitor and evaluate the achievements of the NTD Program, three main categories of indicators can be used (Figure 12).
Figure 13. Categories of indicators for monitoring preventive chemotherapy
A: Process indicators B: Performance indicators C: Impact indicators Prevelance/intensity of infection Process and performance monitoring will be carried out to assess the efficiency of program implementers, treatment coverage by drug distributers, and to identify issues that are hindering or enhancing the program. Results will help ensure that appropriate health education messages are being delivered and understood, and that treatment coverage is Impact evaluation starts prior to an intervention in order to determine the burden and geographical distribution of a disease. These results then can be compared with later years after treatment has been implemented. In areas with overlap of LF and STH, it would be possible for the prevalence of STH to be monitored through collection of stool samples in the STH-targeted population in the LF sentinel and spot-check sites. Cross-cutting impact indicators such as anemia and disability also could be added to sentinel site data collection where appropriate.
Academic and research institutes, such as the National Institute for Health Research and Development, and the University of Indonesia, will be key partners in the design and implementation of M&E for the integrated NTD Program.
The following are priority activities for strengthening the M&E system: 1. The integrated NTD Program will conduct M&E in accordance with WHO guidelines, including the following:• Monitoring drug coverage for preventive chemotherapy (2010) http://whqlibdoc.
• Monitoring and evaluation of mass drug administration in the programme to eliminate lymphatic filariasis (draft, to be published in 2011) • Helminth control in school age children, 2nd edition (draft, to be published in • Leprosy Elimination Monitoring (2000) http://www.who.int/lep/monitor/LEM_ • Handbook of Endemic Treponematoses: Yaws, Endemic Syphilis, and Pinta (1984) 2. Integration of disease-specific programme M&E systems: Efforts will be made to reduce the burden of data collection and reporting by combining reporting formats and surveys, where feasible in areas with overlap of diseases.
3. Planning for resources for M&E: As a follow-up step to the planning done as part of this PoA, the NTD Program will forecast annual needs for M&E, including number of districts in which surveys will take place, number and type of diagnostic tests needed, and technical assistance needed. Included in this document will be annual forecasting of the following: o number of districts implementing sentinel and spot-check site data collection for o number of districts implementing transmission assessment surveys for LF,o number of districts implementing prevalence surveys for schistosomiasis,o Number of districts implementing leprosy elimination monitoring (LEM) for ER X Establishment of a surveillance system for leprosy, LF, schistosomiasis
and yaws after their elimination as public-health problems
Indonesia will prepare a surveillance mechanism that will be established once leprosy, LF, schistosomiasis, and yaws are eliminated from the country as public health problems.
Surveillance will include notification of cases from the local to the central level, keeping the health workers on alert and in the community for early detection of any remaining cases. For LF and schistosomiasis, surveillance will include active surveillance like community surveys, snail surveys and use of antibody tests. WHO can technically support the MoH in the development of the surveillance ER XI Establishment of a national NTD Taskforce
The national NTD Taskforce will join all NTD stakeholders including national and international actors. Inter-sectoral networking of stakeholders such as media, social welfare, water and sanitation supply, environment, education, will be promoted to maximize their participation, as NTDs are diseases related to poverty and poor living conditions.
1. A NTD Taskforce will be created including representatives of the following stakeholders:• Ministry of Health Sub-directorates: LF and SCH, Diarrheal, Malaria, Vector Control, Child Health , Health Promotion • Ministry of Education • Ministry of Religious Affairs • Ministry of Internal Affairs• WHO: Malaria and Vector-borne Diseases, Nutrition, Health Promotion • Other International agencies: UNICEF, WFP• International cooperation agencies: USAID, AusAID 2. The NTD Taskforce will have biannual meetings. The main objectives of these meetings will be to coordinate activities, share information, discuss potential conflicts and proposed solutions, and evaluate the NTD program. ER XII Increased visibility, advocacy and political commitment for NTD
control and elimination
Advocacy will be essentially targeted to political leaders and decision makers of affected districts and provinces to build up political commitment and mobilize resources to support 1. The NTD Taskforce will advocate to ensure commitment and participation at the different levels, including government support and funding allocations at central and district levels. 2. The NTD Taskforce will liaise with mass media entities, such as TV, press and radio, to encourage their involvement in the NTD Program. Attempts will be made to obtain TV, press, and radio coverage of IEC messages and MDA campaigns at reduced or no cost.
3. Government staff at all levels will be encouraged to include religious and other community leaders in their program implementation, specifically to aid in community awareness raising, behavior change activities, and outreach to isolated or vulnerable ER XIII Increased advocacy for comprehensive NTD control linking water,
sanitation, hygiene education and chemotherapy
Despite the obvious health benefits that accrue from improved sanitation, the targets set under Millennium Development Goal 7 are far from being met, especially in the African and South-East Asia regions. Until this situation improves, many NTDs and other communicable diseases will not be eliminated, and certainly not eradicated. The development and transmission of the NTDs reviewed in this report are related to water, sanitation and hygiene. The situation is emphasized in the flow chart in Figure 13. Figure 14. Interconnectedness of water and sanitation and the transmission of infectious agents16.
a Source: Adapted from Pruss Aet al (9) The WASHED framework (Figure 14) highlights how water, sanitation, hygiene education and preventive chemotherapy are the best tools to achieve sustainable control and elimination of NTDs included under this NTD Program.
16 Working to overcome the global impact of neglected tropical diseases. WHO 2010 Figure 15. WASHED Framework
WASHED Framework
The following table summarizes the components of the WASHED Framework to promote
comprehensive STH control.
• Access to portable water• Drainage and disposal/re-use/recycling of household waste water (also referred to as "grey water") • Access to safe and sanitary sanitation facilities• Safe collection, storage, treatment and disposal/re-use/recycling of human excreta (feces and urine)• Management/re-use/recycling of solid waste (rubbish) Hygiene Education • Appropriate information regarding prevention and treatment 0f STH and schistosomiasis• Dissemination of key hygiene messages to promote the following practices - Safe water storage - Safe hand-washing and bathing practices - Safe treatment of foodstuffs • Regular mass drug administration Source: Evans, B. (2005) Securing Sanitation: The Compelling Case to Address the Crisis. Stockholm International Water Institute in collaboration with WHO. (Table has been adapted to included education and dewormingcomponents.) 1. The Program will advocate at the central, province and district levels for comprehensive control of NTDs promoting sanitation improvement, water access and hygiene promotion together with the chemotherapy distribution.
ER XIV Integrated health promotion
The 5 NTDs included in the PoA are related to lack of adequate hygiene practices. Patients
suffering from chronic lymphoedema and leprosy ulcers would benefit from improved hygienic behavior. Given this, the PoA will put in place a number of activities related with health promotion and hygiene education.
1. Communication for behavioral change (COMBI) is a holistic planning framework that helps to make a more effective and strategic use of the IEC materials and activities to achieve behavioral impact. COMBI engages people to adopt suggested healthy behaviors through a strategic blend of communication actions in a variety of settings, which are appropriate to the circumstances of the district and the community. Four actions will be taken: • Public relations, including mass media, and meetings and discussions with local administrative and religious leaders. • Community mobilization, including participatory research, traditional media, songs, shows, leaflets, posters, and home visits by volunteers. • Sustained appropriate advertising to engage people by making them review the merits of the recommended behavior in comparison with the cost of carrying the behavior out. The advertising has to be massive, repetitive, intense and persistent. Diffusion via will be radio, television (cost of production of a TV spot around 100.000USD), news papers among others. • Interpersonal communication.
2. Identify the major challenges and the best methodology to change behavior for the different targeted audiences during the planning of the health promotion interventions.
• Hygiene Education during the MDA campaigns: MDA campaigns offer a unique opportunity to educate communities and promote hygiene. Banner, posters, leaflets and other IEC materials will be used to promote hygiene and to educate people about the 5 NTDs. When possible MDA campaigns will be organized near to clean water sources and hand washing will be promoted in the community during the MDA before ingesting the pills as an example of good hygiene practice.
• Hygiene education during the social mobilization activities. Media will be involved in the social mobilization activities. Information about the 5 NTDs together with hygiene promotion will be integrated in the messages sent to the community. Key messages will include hands and body washing, foot wearing, and care seeking when suspicious lesions appear in your body.
• Hygiene Education at the schools. Hygiene Education is already included in school curriculum in Indonesia. Immunization and deworming integrated days will be used to consolidate hygiene messages and hand washing promotion. Every child will be invited to wash his/her hands before taking the deworming pills. Posters with hygiene promotion messages and pictures will be used to decorate primary school classes.
• Hygiene education at the self-care groups. Volunteers and health workers leading self-care groups will train patients on how to improve their quality of life and reduce the appearance of disabilities with good hygienic practices. Patients will help other members of the group to be systematic in their hygiene and insert those practices several times a day in their daily routine.
• Hygiene and health promotion at the health care center. The NTD Taskforce will advocate the inclusion of key messages on any contact with the health system. Bednet distribution for malaria will include messages on LF prevention as well as malaria. Health workers will be trained to inform patients about intestinal parasites when they promote hand washing for flu or diarrhea prevention. Posters promoting hygiene and giving information about NTDs will be placed on health center walls.
FILARIASIS
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onducting m anagem CCase schistosm reacttreatmination to central level icals periodicaly C ely either from min the clinical cases that C clinical cases that are are found found nducti Planning and providing field tran vehicle w and Lindu Laboratory as neede Planning and providing data eq Lindu neede Planning and providing personal eq neede eports on the plem R im elim schsitosom received com tim PH Co systim periodic m and evaluation in overal adm level Spraying chem accordi evaluation result A co (agriculture and PU enco people to do the intensification and extensification of ag icals ent onth nths aticaly and periodic C schistosm reactination plete and tim age C in the clinical cases that are found Planning and providing field tran vehicle w and Lindu Laboratory as neede Planning and providing data ng eq Lindu neede Planning and providing personal eq neede eports on the plem R im elim schsitosom com either from central level Co systim moni in overal adm level Spraying w periodicaly every m duri A coordina and PU and guide people to do the intensification and extensification of agricultural land Supply of field transportation Supply of data processing equipm Supply of personal protection equipm Supply of field transportation Supply of data processing equipm Supplyof personal protection equipm ecording and reporting Snail focused control (spraying) Intensification and extensification of ag ination program act Involving role im irrigation system K successful for the imp schistosom elim and folow coss sector in th ent of entatm iasis ination program plan acti coss sector (PU) apu and Lindu aleys now Involving role im irrigation system K successful for the entatlem im schistosom elim ion act Involving role im irrigation system K successful for the imp schistosom ination programelim actand folow Involving role im irrigation system K successful for the imp schistosom elim and folow entation of iasis coss sector in th ination program on entation plem iasis coss sector in th Involving coss sector (PU) role (PU im irrigation system K successful for the entation emi schistosom ination programelim on actiand action plan as folow- apu and Lindu aleys ing the now Involving role im irrigation system K successful for the emim schistosom ination programelim actiand folow apu and Lindu aleys now Involving role im irrigation system K successful for the im schistosom elim entation of iasis ination program Involving coss sector role (PU provemim irrigation system ng K successful for the entation of plemim schistosom elm and action plan as up Involving coss sector role (PU im irrigation system K successful for the im schistosom ination programelim and action plan as folw- Involving coss sector ent role (PU im irrigation system K successful for the im schistosom elimup and action plan as folow- 2012 2011
entation of iasis ing the successful ination program ination program tion plan as folow- Involving coss sector co (PUrole (PU of irrigation systemim irrigation system K successful for the for the im imschistosom elimschistosom ination programelimac and action plan as folow- Involving coss sector role (PU im irrigation system K successful for the im schistosom elim and action plan as folow- coordinat entat iasis ination program iasis ing the successful plem ing the successful now tion plan as folow- Involving co ) in the im(PU of irrigation system Schsitosomiasis
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ent 4-years prevalence of iasis ent 4-years prevalence of proving irrigation system Evaluation of inter-sectoral for schistosom proving irrigation system Evaluation of inter-sectoral for schitosom C for ST at cetral level routinely 2 tim Conduct coordination m for ST at provincial level 2 tim Conduct coordination m for ST at district level 3 tim year A socialization to stakeholders at central, provincial and district levels that are stated as ST order to support the cross sector im reduction C for ST group at cetral level routinely 2 tim year Conduct coordination m for ST group at provincial level 2 tim Conduct coordination m for ST group at district level 3 tim A socialization to stakeholders at central, provincial and district levels that are stated as ST ende to support the cross sector im of ST Finishing the guideliness of ST reduction eetings for ST orking group at eetings for ST orking group at Coordi m w cetral level routinely 2 tim Conduct coordi m w provincial level 2 tim Conduct coordi m w district level 3 tim a year A socialization to stakeholders at central, provincial and district level that are stated as ST order to support the cross sector im ST ing coordination ing coordination eetings for ST orking group at district dvocacy and socialization C ST cetral level routinely 2 tim Conduct m group at provincial level 2 tim Conduct m w level 3 tim A to stakeholders at central, provincial and district levels that are stated as ST order to support the cross sector im reduction reduction
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Socialization to com ith the ith the strict istrict edia otion otion about ST about ST oordination w oordination w aking the school aking the school onitoring the use of onitoring the use of onitoring the adequacy onitoring the adequacy bservation the bservation the Pl trained field officer as needed Increase ST hea com Increase reduction of ST the com through hea prom Increase reduction of ST through hea prom electronic m heaC health division in the m division in the m copyngand distribution copying and distribution of reductionST of reduction ST m mater C C Provincial and D Provincial and D EducationO Education O m making the school curriculum curriculum Conduct Conduct stool survey on stool survey on elem elem students 6 D students 6 D C C finished finished M Monitoring the use of latrine latrine M Monitoring the adequacy f clea w of clean w O Observation the disposal ofousehold disposal of household w waste hea division in the m copying and distribution of reduction ST m C Provincial and D Education O m curriculum Conduct stool survey on elem students 6 D C finished O disposal of household w ith aking, aking, ith the strict istrict 2014 2014
and providing and providing otion in the unity 2014 prom prom
aterials as aterials as ater ater oordination w oordination w aking the school aking the school istrict / C istrict / C D D has finishedA onitoring the use of onitoring the use of onitoring the onitoring the bservation the bservation the Planning and providing trained resources accordance w needs at the central, provincial and district Pl trained field officer as needed Increase ST through hea prom com com Increase reduction of ST the com through hea prom Increase reduction of ST through hea prom and electronic m heaC health division in the m division in the m copying copying distribution of distribution of reduction reduction m mater C C Provincial and D Provincial and D EducationO Education O m making the school curriculum curriculum Planning Planning laboratory equipm laboratory equipm nd m and m needed needed Conduct Conduct stool survey on stool survey on elem elem students in 30 D students in 30 D / C / City w is non endem is non endem D District / C M MD M Monitoring the use of latrine latrine M Monitoring the adequacy adequacy wat wat O Observation the disposal ofousehold disposal of household w w hea division in the m copying distribution of reduction m C Provincial and D Education O m curriculum Planning laboratory equipm and m needed Conduct stool survey on elem students in 30 D / C is non endem D M O disposal of household w ith aking, aking, ith the strict istrict with the istrict ffice in ffice in 2013 2013
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aterials as needed here filariasis is oordination oordination aking the school aking the school istrict / C istrict / C D D has finished.A onitoring the use of onitoring the use of onitoring the adequacy onitoring the adequacy bservation the disposal bservation the disposal hous hous Pl trained field officer as needed Increase socialization ST hea com Increase reduction of ST com through hea prom Increase reduction of ST through hea prom electronic m heaC health division in the m division in the m copyngand distribution copying and distribution of reductionST of reduction ST m mater C C Provincial and D Provincial and D EducationO Education O m making the school curriculum curriculum Planning and providing Planning and providing laboratory equipm laboratory equipm nd m and m Conduct Conduct stool survey on stool survey on elem elem students in 30 D students in 30 D C C non endem non endem D District / C M MD M Monitoring the use of latrine latrine M Monitoring the adequacy f clea w of clean w O Observation the disposal of of hea division in the m copying and distribution of reduction ST m C Provincial and D Education O m curriculum Planning and providing laboratory equipm and m Conduct stool survey on elem students in 30 D C non endem D M ith aking, aking, ith the strict istrict istricts istricts edia otion otion ffice in ffice in about ST about ST laboratory staff otion in the unity com aterials as needed aterials as needed Management
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has finished as A any as 11.497.076 any as 7.657.457 istrict / C D any as 1.926.432 Ensuring the availability of albendazole drugs as needed M residents in filariasis endem conducting M 109.495.966 peo adm Sel treatm elem students in filariasis endem conducting M m students Sel treatm elem students in filariasis non endem 30 districts/C m students and in 20 D M m students any as 11.300.674 Ensuring the availability of albendazole drugs as needed M residents in filariasis endem conducting M 107.625.467 peo adm Sel treatm elem students in filariasis endem conducting M m students Sel treatm elem students in filariasis non endem districts/C as 5.596.045 students and in 30 D C finished as m 1.709.399 students any as 10.093.122 Ensuring the availability of albendazole drugs as needed M residents in filariasis endem conducting M 97.049.253 people adm Sel treatm elem students in filariasis endem conducting M m students. Sel treatm elem students in filariasis non endem districts/C as 3.169.157 students and in 22 D C finished as m 523.440 students any as 8.493.813 Ensuring the availability of albendazole drugs as needed M residents in filariasis endem conducting M 80,893,457 people adm Sel treatm elem students in filariasis endem conducting M m students. Sel treatm elem students in filariasis non endem districts/C as 1.634.803 students and in 17 D C finished as m 295.982 students Ensuring the availability of albendazole drugs as needed M residents in filariasis endem conducting M 64.171.092 people adm Sel treatm elem students in filariasis endem conducting M m students. ACTIVITIES
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aticaly and aticaly and ination STH ination STH plete and tim plete and tim inistration level inistration level eports on the plem eports on the plem R R im im elim elim com com either from either from central level central level Conduct Conduct systim systim per per evaluation in overal evaluation in overal adm adm plete and plete and 2014 2014
aticaly and aticaly and ination STH ination STH to central level to central level ely either from C C eports on the plem eports on theRR im im elim elim received com received com tim tim PH PH Conduct Conduct systim systim per per and evaluation in and evaluation in overal adm overal adm level level H H plete and plete and aticaly and aticaly and ination ST ination ST to central level to central level ely either from C C eports on the plem R R im im elim elim received com received com tim tim PH PH Conduct Conduct systim systim per per and evaluation in and evaluation in overal adm overal adm level level K K successful for the successful for the im im ST ST program program plan as folow plan as folow H H plete and plete and aticaly and aticaly and ination ST ination ST ely either from ely either from inistration level inistration level eports on the plem eports on the plem R R im im elim elim received com received com tim tim to central level to central level Conduct Conduct systim systim per per evaluation in overal evaluation in overal adm adm H plete and plete and 2011 2011
aticaly and aticaly and ination ST ination ST eports on the plem eports on the plem R R im im elim elim received com received com tim tim to central level to central level Conduct Conduct systim systim per per and evaluation in and evaluation in overal adm overal adm level level Program Program
anagement
imination
anagement
imination
prevalence prevalence STH STH STH
of of of of
ACTIVITIES
ACTIVITIES
ng ng tori torini ni ecording and reporting ecording and reporting Evaluation
Evaluation
(External
required)
26,152,800
13,604,700
(External
required)
26,152,800
13,604,700
et Estimation in USD
ation in U
perational
(External
required)
26,152,800
isease Budget E
13,604,700
ropical D
Tropical Disease Budg
perational
(External
required)
26,152,800
eglected T
Integrated N
13,604,700
perational
(External
required)
26,152,800
Integrated Neglected
13,604,700
escription
rand Total
e (2011-20
m ogramme (2011-2015)
hic Control Program
Transmitted Helminthic Contr
for Soil Transm
ctivities
Financing f
central Province and D proving hum
Strengthening the activities
Socialization to com 0,000 5,000 0,000 ,000 ,500
e (2011-20
hic Control Program
for Soil Transm
tion unity tion pr unity at risk
ctivities
er train ning m
central Province and D proving hum
rand total
Strengthening the activities Prevalenc
Supply of labInterse equi cri A Im Treatm Pro Supply of drug Labo Trea
Im Recordi
M Socialization to com Evalua Socia Evaluation of intersectoral coordination H Eval
Total Estim
required)
perational gaps
O
perational gaps
11-2015) ymphatic Filariasis Pr
rogramme
Financing f
Activities
icroscopis, program Total Est
required)
perational gaps
O
perational gaps
rogramme
Activities
overage survey (assessm - Mee - Baseline Soc - Prevalence survey - Social m - Evaluation Impl - technical assistance Total Est
required)
perational gaps
O
6,000 ,000
l fun60 red)
perational gaps
244,000 663
rogramme
Activities
puter and printer overage survey (assessm - Prevalence survey - H - technical assistance Soc - C - Social m - C - fo - Stationery D - LC - D - Telephone - M - Printing - D G
Financ 7.
or Schistosomiasis Elimination Pr
aterial and equipm ctivities
Financing f
, standard, procedure criteria ental survey
ental sanitation al survey (cattle, buffalo, pig and dog) orking group coordination m proving health prom
Strengthening the activities
Laboratory staff train Prevalence survey
Supply of laboratory and m Stool survey and clin nnual Cos
nnual Cos
aterial and equipm aterial and equipm ctivities
ctivities
, standard, procedure criteria , standard, procedure criteria anagem in
tersectoral coordin anager train anageme ental survey
ental sanitation g the norm ental survey
ental sanitation ent of four year prevalence al survey (cattle, buffalo, pig and dog) al survey (cattle, buffalo, pig and dog) orking group coordination m proving health prom
ss/selective treatm orking group coordination m proving health prom
onitoring an ealth prom rand total
Strengthening the activities
Laboratory staff train Prevalence survey
Supply of laboratory and m Stool survey and clin Rat survey Strengthening the activities Environ Polit Availa W Availa Advocacy an Environm Treatm Com
Supply of drug Im Ma Program Clin Laboratory staff train Strengthening m Fie
Supply Cadres train Supply of data processing equipm Im Penyediaan Socia Recording and reporting Socia M H Snail control Supply Control of snail foci Prevalence survey Supply of bay Supply of laboratory and m Intensification and extensific
land Stool survey and clin 2011-2015
(2011-2015)
Yaws Elimination Pr
eprosy an
ctivities
Financing f
Preparatory Phase: 100,000 50,000 100,000 600,000 200,000 50,000 50,000 3,500,000
2011-2015
300,000 350,000 1,500,000 1,000,000 5,000,000
(2011-2015)
30,000 20,000 10,000 20,000 40,000 50,000 20,000 20,000 90,000 300,000 50,000 1,000,000
eprosy an
ctivities
Preparatory Phase: - Su - Sup - Trai Village Sero surveill - Operati Procurem - Stakehold

Source: http://www.un.or.id/counter/download.php?file=Neglected%20Tropical%20Diseases%20in%20Indonesia%20-%20Ministry%20of%20Health%20Indonesia%202011-2015.pdf