1. Community Involvement
in Indonesia
27 November 2006
Dr Delyuzar,
Medan

2. The STOP TB Strategy
Component 5:
Empower people with
TB and communities

3. 5yr Strategic Plan to Control TB
in Indonesia 2006-2010
EXPANSION of TB CONTROL
1. Pursue quality DOTS expansion and
enhancement
2. Address TB/HIV, MDR-TB and other
challenges
3. Involve all care providers
4. Engage TB patients and affected
communities
Supported by Health System Strengthening:
5. Strengthened policy and ownership
6. Strengthened health system and TB control
management
7. Research

4. What is Community TB Care (CTBC)
Operational partnership between the health services and
civil society (motivated individuals, existing community
volunteers, etc.) aimed at contributing to TB care.
Support to patients (DOT) throughout treatment
Bringing services closer to patients (sputum collection)
Patient, family and community education
Case detection (referral of pts with chronic cough)
Advocacy for political commitment to TB control
Health promotion (creating demand for services in society)

5. Community Challenges in Indonesia
• Access to healthcare (private, remote)
• Cost-barriers (transport, userfees)
• Low local political commitment to health
• Lack of partnerships at local level
• Low level of involvement of (ex) TB
patients
• Health care seeking patters differ across
country

6. Treatment seeking practices in patients with hx of TB
(Prevalence survey 2004)
Initiation of treatment
60%
50%
Initiation of treatment
40% Hospital & BP4
Initiation of treatment
30%
Primary Health Care
20% Initiation of treatment Private
Practicioners
10%
0%
Ending of treatment
SUMATRA KT I JAVA
70%
60%
50% Ending of treatment Hospital
& BP4
40%
Ending of treatment Primary
30% Health Care
Ending of treatment Private
20% Practicioners
10%
0%
SUMATRA KTI JAVA

7. TB Community models
1. Sub healthcentre/ TB posts (mobile) linked to
health centre with TB program
2. Community members linked to health centre TB
program
3. Urban health centre managed by NGOs/ faith-
based networks

8. Family/ Clan leaders (‘Ninik Mamak’)
Indonesia, West-Sumatra
• Clan-leaders identify, support,
accompany and refer suspects to health
centre (referral form), and become
support to daily treatment supporter
(PMO) who is family member
• Standardized referral sheets are used by
Health centre for the suspect
identification. This adds to:
1. Professionalize referral from community
groups
2. Account and validate community contribution
3. Encourage positive contributions

9. Effectiveness of Ninik Mamak involvement
at Kampung Dalam Health Center, Padang Pariaman – West Sumatra
300 266
250 Suspect (refered by Ninik
200 179 Mamak)
144 Suspect Total
150
Sm (+)
100
36 42
50 18 16
0 10
0
2004 2005 2006 (Q1)
Suspect (refered by 0 144 16
Ninik Mamak)
Suspect Total 179 266 42
Sm (+) 18 36 10
Support from Ninik Mamak:
• Increase of TB suspect thanks to Ninik Mamak (54%: 2005 and 38%: Q1 2006)
• Proportion of Sm+ among suspect examined > 10% identify TB patient
• TB knowledge increased people come themselves

10. Indonesia: Active community
participation
180
Family members as DOTS
160
treatment observers
140
120 Central Sulawesi 1996-1998
100
• TB case notification increases in
a community based tuberculosis
80 program (CBTP)
• Results before and after
60
introduction of the program
40 • Comparison with area where the
CNR - CTB
CNR - non CTB
program was and was not
20
SR - CTB
introduced.
0
SR - non CTB • Maintain high treatment success
1996 1997 1998 rates and sputum conversion
rates
M. Becx-Bleumink, H. Wibowo, W. Apriani, H. Vrakking,
INT J TUBERC LUNG DIS 5(10):920–925 © 2001 IUATLD

11. TB PROGRAM
JARINGAN KESEJAHTERAAN/ KESEHATAN
MASYARAKAT
JL. WILLIEM ISKANDAR NO. 107 B
Phone: (061) 77817575 – 4576350, Fax. (061) 4576350
Email: jkm_mdn@yahoo.com

12. Tackling TB in 7 districts in North
Sumatra Province, Indonesia

13. Phase I performance (First Year):
• 2 interventions
– five new microscopy
centers and 21 satellite
clinics,
– training community
volunteers to enhance
suspect identification
and case holding.
• Facilitate inaccessible
populations in remote
areas

14. Socialization & set-up
• 5 districts mobilize the
Provincial Health
Authorities and Municipal
Health Authorities
• Selection and recruit of
staffs and Health Cadres
(HCs)
• Preparation of project
(laboratory and health
service)
• Method of training,
orienting the staffs in
technical work, and
operational standard
procedure

15. Community volunteers
• From permanent resident
in target areas
• Motivated to care for TB
control, and cure patient
and their family.
• An initial 500 community
volunteers were trained to
increase community
awareness, and assist with
case holding.
• Of 500 community
volunteers initially
trained, 360 remained
active during the project.

16. Training Curriculum
• Communication skills
• TB Basic Science-
epidemiology
• Health Promotion
• Collecting sputum &
Case Holding

17. Phase II activities (Second year):
• 3 Interventions:
1. Community
empowerment through
existence of health
cadres/ volunteers;
2. develop two mobile
clinics unit;
3. setting up two new
microscopy centers in
one new district.

18. Health promotion
• Health promotion Materials
• Radio broadcast (52 times in
a year)
• Newspapers advertisement
(everyday during the project
life)
• Leaflets

22. Mobile clinics
• Two mobile clinics unit to
cover more remote areas.
• Mobile clinic visit
suspect’s house and
patient’s house, with
smear preparer and TB
medicine. (collect sputum,
sputum fixation of slide,
case holding activities).
• Achieved 60% increase of
category of limited access
from those specific areas
in phase II

23. Results
• 7 additional diagnostic
centres,
• New staff working:
– 7 doctors
– 14 nurses
– 7 lab technicians
– 29 smear preparers
– 440 volunteers
• Quaterly meetings
• 5322 cases detected
(between July 2004 and June 2005)
• 54% increase of the
previous year

24. Thank you