Indonesia Work Plan - ENVISION · Indonesia Work Plan FY 2016 Project Year 5 October 2015–September 2016 ENVISION is a global project led by RTI International in partnership with

Indonesia Work Plan FY 2016

Project Year 5

October 2015–September 2016

ENVISION is a global project led by RTI International in partnership with CBM International, The Carter Center, Fred Hollows

Foundation, Helen Keller International, IMA World Health, Light for the World, Sightsavers, and World Vision. ENVISION is funded by

the US Agency for International Development under cooperative agreement No. AID-OAA-A-11-00048. The period of performance

for ENVISION is September 30, 2011, through September 29, 2016.

The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International

Development or the United States Government.

ENVISION FY16 PY5 Indonesia Work Plan

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ENVISION PROJECT OVERVIEW

The US Agency for International Development (USAID)’s ENVISION project (2011–2016) is designed to

support the vision of the World Health Organization (WHO) and its member states by targeting the

control and elimination of seven neglected tropical diseases (NTDs), including lymphatic filariasis (LF),

onchocerciasis (OV), schistosomiasis (SCH), trachoma, and three soil-transmitted helminthiases (STH;

roundworm, whipworm, hookworm). ENVISION’s goal is to strengthen NTD programming at global and

country levels and support Ministries of Health (MOHs) to achieve their NTD control and elimination

goals.

At global level, ENVISION—in close coordination and collaboration with WHO, USAID, and other

stakeholders—contributes to several technical areas in support of global NTD control and elimination

goals, including:

• Drug and diagnostics procurement, where global donation programs are unavailable

• Capacity strengthening

• Management and implementation of ENVISION’s Technical Assistance Facility (TAF)

• Disease mapping

• NTD policy and technical guideline development, and

• NTD monitoring and evaluation (M&E).

At the country level, ENVISION provides support to national NTD programs by providing strategic

technical and financial assistance for a comprehensive package of NTD interventions, including:

• Strategic annual and multi-year planning

• Advocacy

• Social mobilization and health education

• Capacity strengthening

• Baseline disease mapping

• Preventive chemotherapy (PC) or mass drug administration (MDA)

• Drug and commodity supply management and procurement

• Program supervision

• M&E, including disease-specific assessments (DSA) and surveillance.

In Indonesia, ENVISION project activities are implemented by RTI International (RTI).


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TABLE OF CONTENTS Page ENVISION PROJECT OVERVIEW ..................................................................................................................... II

ACRONYMS LIST ............................................................................................................................................ V

INDONESIA COUNTRY OVERVIEW ................................................................................................................. 7

1) General Country Background ............................................................................................................ 7

a) Administrative Structure ........................................................................................................... 7

b) NTD Program Partners .............................................................................................................. 7

2) National NTD Program Overview ...................................................................................................... 8

a) Lymphatic Filariasis ................................................................................................................... 9

b) Schistosomiasis ....................................................................................................................... 12

c) Soil-Transmitted Helminthiases .............................................................................................. 12

3) USAID History of Support ................................................................................................................ 13

a) Snapshot of NTD Status in Indonesia ...................................................................................... 13

PLANNED ACTIVITIES ................................................................................................................................... 14

1) Project Assistance ........................................................................................................................... 14

a) Strategic Planning ................................................................................................................... 14

b) NTD Secretariat ....................................................................................................................... 15

c) Advocacy ................................................................................................................................. 15

d) Social Mobilization .................................................................................................................. 16

e) Capacity Building/Training ...................................................................................................... 17

f) Mapping .................................................................................................................................. 18

g) MDA ........................................................................................................................................ 18

h) Drug and Commodity Supply Management and Procurement .............................................. 19

i) Supervision .............................................................................................................................. 20

j) Short-Term Technical Assistance ............................................................................................ 21

k) M&E ........................................................................................................................................ 22

2) Maps................................................................................................................................................ 26

TABLE OF TABLES

Table 1. Administrative and health structure in Indonesia .......................................................................... 7

Table 2. NTD partners working in country, donor support, and summarized activities ............................... 8

Table 3. Snapshot of the expected status of NTD program in Indonesia as of Sept. 30, 2015 ................... 13


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Table 4. USAID-supported districts and estimated target populations for MDA in FY16 ........................... 19

Table 5. Technical assistance (TA) request from ENVISION ........................................................................ 21

Table 6. Planned disease-specific assessments for FY16, by disease ......................................................... 26

LIST OF FIGURES

Figure 1. Stopping MDA TAS results in Indonesia, 2011 to mid-2015 ........................................................ 11


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ACRONYMS LIST

ALB Albendazole

ALPEN Aliansi Perempuan Sulawesi Tenggara

B-Trust Bandung Advisory Trust

BELKAGA Bulan Eliminasi Kaki Gajah (LF elimination month)

BinFar Subdirektorat Bina Obat Publik (Subdirectorate for Public Drug Awareness)

BR Brugia Rapid tests

BTKLPL Technical Office of Environment Health and Disease Control

CDC Communicable Disease Control

DEC Diethylcarbamazine

DKAP Kelompok Dukungan Sebaya Pekanbaru

DQA Data Quality Assessment

DSA Disease-Specific Assessment

EU Evaluation Unit

FIRD Flores’ Institute for Resources Development

FY Fiscal Year

GoI Government of Indonesia

GSK GlaxoSmithKline

ICT Immunochromatographic Test

IEC Information, Education, Communication

IR Intermediate Result

IU Implementation Unit

LASP Yayasan Lembaga Analisis Social dan Pembangunan

LF Lymphatic Filariasis

M&E Monitoring and Evaluation

MDA Mass Drug Administration

Mf Microfilaremia

MOE Ministry of Education

MOH Ministry of Heath

NGO Nongovernmental Organization

NIHRD National Institute of Health Research and Development

NTF National Task Force

NTD Neglected Tropical Disease

PC Preventive Chemotherapy

PKBI Perkumpulan Keluarga Berencana Indonesia

PHO Provincial Health Office

PreTAS pre Transmission Assessment Survey

PSA Public Service Announcement

PZQ Praziquantel

RPRG WHO Regional Program Review Group

SAC School-Age Children

SAE Serious Adverse Event

SCH Schistosomiasis

STH Soil-Transmitted Helminthiases

STTA Short-Term Technical Assistance

Subdit Subdirectorate for Control of LF, STH and SCH


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TA Technical Assistance

TAF Technical Assistance Facility

TAS Transmission Assessment Survey

TIPAC Tool for Integrated Planning and Costing

TOT Training of Trainers

UI University of Indonesia

UNICEF United Nations Children’s Fund

USAID United States Agency for International Development

USCDC United States Centers for Disease Control and Prevention

WCC Women Crisis Center

WHO World Health Organization


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INDONESIA COUNTRY OVERVIEW

1) General Country Background

a) Administrative Structure

Indonesia is the fourth largest country in the world, with a population of over 255 million people spread

throughout thousands of islands. Indonesia is in the midst of redistricting; in 2012, the country had 33

provinces and 497 districts. By the end of 2015, Indonesia will have 34 provinces and 514 districts. The

Indonesia administrative and health structure is summarized below (Table 1).

Table 1. Administrative and health structure in Indonesia

Level Bahasa Indonesia

term

Head official Related health structure

National Negara Presiden Ministry of Health, Subdirectorate for Control

of LF, STH and SCH (“Subdit”)

Provincial Provinsi Gubernur Provincial Health Office (PHO)

District Kabupaten – rural

Kota – urban

Bupati

Walikota

District Health Office (DHO)

Subdistrict Kecamatan^ Camat Health center (“puskesmas”)

Village Desa – rural

Kelurahan – urban

Kepala Desa

Lurah

Health post (“posyandu”)

Hamlet Rukun Warga --

^ In Papua and Papua Barat, this level is called a “distrik.”

Mass drug administration (MDA) is carried out by health center staff and “cadres,” who are community

members that help government health workers with activities such as weighing children, immunization

campaigns, and Vitamin A distribution.

The Indonesian Ministry of Health (MOH) procures some diethylcarbamazine citrate (DEC) for lymphatic

filariasis (LF) MDA, albendazole (ALB) for soil-transmitted helminthiases (STH)-only MDA, procures some

rapid diagnostics for LF mapping and surveys, and supports supervisory visits by the national team to

oversee activities. Provinces are responsible and have small budgets for supervision and monitoring and

evaluation (M&E) activities. District governments are required to provide operational budgets for LF and

STH MDA, including training, drug distribution, and monitoring.

b) NTD Program Partners

Indonesia has a few players involved in neglected tropical disease (NTD) work, with USAID and the

World Health Organization (WHO) being the largest contributors (Table 2). WHO provides support for LF

transmission assessment surveys (TASs), MDA campaign month launching, and schistosomiasis (SCH)

elimination. The United Nations Children’s Fund (UNICEF) provides limited technical support for the

distribution of ALB through the Vitamin A program. Since the beginning of the LF MDA program, the

MOH has accepted donations of ALB from GlaxoSmithKline through WHO. In calendar year 2015,

following budget cuts, the Indonesia MOH accepted a large donation of 151 million DEC tablets to

enable the Ministry to expand programmatic support to more endemic districts, which included all of

the USAID-funded districts. This support from WHO/Eisai will be reduced in calendar year 2016, due to

need to comply with MOH regulations regarding use of locally made pharmaceuticals. However, the


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MOH budget likely will not be enough to support local procurement for all districts implementing LF/STH

MDA in 2016, so some donated DEC will be requested.

Table 2. NTD partners working in country, donor support, and summarized activities

Partner Location

(Regions/States) Activities

Is USAID

providing

direct

financial

support to

this partner?

Other

donors

supporting

these

partners/

activities?

RTI/ENVISION

Indonesia

Jakarta with field

support visits to

implementing

provinces/districts

Provides direct technical assistance to

the MOH in strategic planning, M&E,

advocacy, and capacity building. Yes

No

Supports MDA implementation in 50

districts through local NGOs No

MOH Central, Province,

District

LF/STH MDA support in ~80 districts in

2015; provides direct technical support

for strategic planning, M&E, advocacy,

capacity building

Drug procurement for LF/STH MDA and

STH-only MDA

No Yes

WHO

Jakarta with field

visits to

implementing

provinces/districts

Provides technical and limited financial

support for strategic planning, M&E and

importation of ALB and DEC No

Yes

Provides financial and technical support

for the elimination activities of SCH in

two endemic districts

Yes

Eisai Jakarta

Will donate some DEC for 2016 LF/STH

MDA, capacity building by developing

internship opportunities for medical

students, IEC

No No

Fit for School West Java Provides support to school health,

including deworming in 2 districts No Yes

2) National NTD Program Overview

Lymphatic filariasis (LF), soil-transmitted helminthiases (STH), and SCH are endemic in Indonesia. With

its large population, Indonesia has one of the heaviest burdens of NTDs globally, spread throughout all

514 districts. In calendar year 2014, LF/STH MDA reached 20.5 million people in 75 LF-endemic districts,

with 8 districts implementing partial coverage. LF/STH MDA coverage was estimated to include

approximately 1.5 million preschool (1–4 years) and 3.2 million school-aged children (5–12 years) at risk

of STH. In addition, approximately 1 million children were dewormed through STH-only MDA in

coordination with Vitamin A and school health programs. A detailed plan to eliminate SCH, which affects

a small area of 20,000 people in two districts, Poso and Sigi, in Central Sulawesi province, is being

implemented by the Indonesia MOH.

The Subdirectorate for Control of LF, STH and SCH (Subdit), a unit within the Directorate General of

Disease Control and Environmental Health of the MOH, is the lead for LF, STH, and SCH activities. A


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National Task Force (NTF) exists to oversee NTD policy, plans, and activities. It consists of MOH staff, ex-

MOH staff, and academics, with multilateral agency representatives (WHO, UNICEF) being invited as

observers. The NTF meets at least once a year to discuss specific issues and provide technical

recommendations for improving the LF, STH, and SCH programs.

Control and Elimination Strategies

An integrated five-year plan of action for five NTDs including LF, STH, SCH, yaws, and leprosy was

prepared in 2010, with assistance from WHO, UNICEF, USAID, the Australian Agency for International

Development (now the Australian Department of Foreign Affairs and Trade), Johnson & Johnson, and

RTI International. The integrated NTD Plan of action is currently being updated with support from

ENVISION and WHO to encompass activities planned between 2016 and 2020. It includes an ambitious

goal of elimination of LF as a public health problem by 2020. It also incorporates the 2012 STH strategic

plan’s goal of MDA coverage of at least 75% of preschool and school-age children in all endemic districts

by 2020. Strategies follow the latest WHO guidance for LF (primarily guidance outlined in the 2011 TAS

manual) and STH (outlined in the STH Strategic Plan and Deworming for School Aged Children manual).

As a step towards having the resources to scale up LF/STH MDA to full geographic coverage, the 2016–

2020 plan of action proposes an LF MDA campaign plan, which includes a rapid scale-up of MDA as well

as an attempt to designate October as Bulan Eliminasi Kaki Gajah (BELKAGA) or “LF elimination month,”

instead of having districts implement MDA on their own schedules.

The Government of Indonesia (GoI) continues to provide strong support for NTDs at both the central

and district levels. However, there still remains a large funding gap that prevents Indonesia from

reaching full-scale MDA in time to meet 2020 goals of LF elimination and STH geographic coverage.

a) Lymphatic Filariasis

In 2005, the GoI decreed filariasis elimination to be one of the national priorities to combat

communicable diseases and agreed to the global WHO goal of eliminating LF as a public-health problem

by 2020. All three types of lymphatic parasites—namely Wuchereria bancrofti, Brugia malayi, and Brugia

timori—are prevalent in Indonesia, with B. malayi the most widespread. In 2014, a total of 14,932

chronic cases of either lymphedema or hydrocele were reported.

GoI’s LF program objectives are to reduce and eliminate transmission of LF through MDA, and to reduce

and prevent morbidity in affected persons. The central government is responsible for ensuring the

procurement of drugs, developing strategies, and monitoring and evaluating the program, while the

local government is expected to contribute the operational and maintenance budget. Given that district

governments do not always include MDA activities in their annual budgets, the central MOH has

difficulty strategically scaling up and ensuring their strategic plans are implemented. Without further

support, the GoI will not be able to meet the 2020 elimination goal, given that approximately 80 districts

have not started MDA nor currently have budgets to support MDA.

In order to fill this gap, the Subdit has conducted several advocacy meetings for provincial and district

level in order to increase local support. The Subdit also has developed the President’s Instruction for LF

MDA (IMPRES), which is a national policy that stating that endemic districts must use their local budgets

to conduct LF MDA; however, it allows them to use non-health unrestricted funds to support MDA. This

policy should be finalized by end of 2015.

As another approach to increase district support, the MOH developed the BELKAGA campaign approach

to intensify its elimination efforts. The core principles of this approach to be implemented in 2015

include:


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• making LF elimination a national movement and initiating a campaign month for drug

distribution (October), with approximately 144 districts conducting MDA in 2015

• streamlining the coordination of the implementation of national LF elimination program at all

stages—planning, preparation, execution, and evaluation; and

• enhancing the efficiency and effectiveness of the social mobilization campaigns in order to

achieve high treatment coverage in every village.

In addition, Indonesia is on schedule to complete all mapping activities by the end of September 2015,

including 5 districts WHO recommended be re-mapped. TAS to determine whether MDA can be stopped

were completed in 66 districts from 2011 to mid-2015, with 25 districts currently in the post-MDA

surveillance phase (Figure 1). Of those districts implementing TAS1, 34 of 47 passed. Of those

implementing TAS2, 10 of 18 passed. Of those implementing TAS3, 0 of 1 passed. Those districts that

failed TAS1 were either (1) not eligible (but implemented with district/provincial budgets); (2) reported

adequate MDA coverage and <1% microfilaremia (Mf) in PreTAS sentinel and spot-check sites; however,

the MDA coverage numbers were likely a reflection of drugs distributed and not drugs consumed;

and/or (3) were Brugian districts that, following WHO guidelines, used antibody testing, resulting in a

more conservative threshold for passing TAS than the Bancrofti districts that used antigen testing. Of

those that failed TAS2, 7 had used the COMBO test (tests used to detect antibodies to Wuchereria

bancrofti and Brugia malayi) during TAS1 (before WHO guidelines were available), which could be a less

sensitive test than the Brugia Rapid. Districts that did not pass TAS1, TAS2, or TAS3 will seek WHO advice

on next steps or continue with two further rounds of MDA.


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Figure 1. Stopping MDA TAS results in Indonesia, 2011 to mid-2015

In fiscal year 2015, 18 districts have implemented TAS (TAS1=3, TAS2=14, TAS3=1). In FY16, 33 districts

are planning to implement TAS. Fifteen districts will implement 15 TAS1 surveys, 14 districts (one of

which has 1 EU which is implementing TAS1) are implementing 15 TAS2 surveys, and 5 districts are

implementing 5 TAS3 surveys.

USAID support started in FY2011, with financing of LF/STH MDA in 13 districts (2 of which now use their

own budgets), scattered throughout the country. After a review of LF endemicity and MDA data,

ENVISION scaled up in FY2012 and FY2013, mostly in Sumatra, to help the MOH reach full geographic

coverage in that region. ENVISION will support calendar year 2015 LF/STH MDA activities through

October 2015, through support to local nongovernmental organizations (NGOs) in 50 districts, including

11 new districts in Sumatra. Eight of these districts are implementing MDA for the first time and need

support for five rounds of MDA, while 3 failed TAS and need support for two additional rounds. For

calendar year 2016 LF/STH MDA, ENVISION will continue its support in 50 districts: 45 districts that have

previously received ENVISION support and 5 new districts that will be supported for the first time in


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FY2016 (Aceh Timur, Kota Banda Aceh, Kota Sabang, Nagan Raya, and Lahat). Five districts that received

past ENVISION support for five rounds of MDA will implement PreTAS in FY16 and TAS in FY17 (October–

December 2016).

Recognizing that USAID has not in the past supported full geographic coverage of LF/STH MDA,

ENVISION support has focused on completing LF mapping so that the MOH can accurately estimate the

burden of disease, plan advocacy measures with districts to support LF/STH MDA, and advocate to other

donors and to the GoI for support. ENVISION has provided capacity building for (1) MDA implementation

at national, district, and village levels in 50 districts; (2) mapping of LF; (3) TAS at national, provincial,

and district levels; (4) data quality assessment (DQA) and an integrated NTD database at the national

level; and (5) overall LF/STH policy and strategies at national, provincial, and district levels. ENVISION

has also provided support to the MOH in implementation of LF sentinel and spot-check site assessments,

TAS, DQA, and data review.

b) Schistosomiasis

SCH, due to Schistosoma japonicum, is endemic in Poso and Sigi districts in Central Sulawasi province,

with an at-risk population of 20,500 people. Indonesia’s goal is elimination of SCH as a public health

problem by 2020. Control activities had ended in 2005; however, 2010 surveys showed a resurgence of

transmission with an average prevalence of infection of 3.81% (range: 0-12.33) in 21 sites in the two

districts. These areas have restricted access to potable water and sanitation, with few families having

latrines. The GoI has designed an elimination strategy along with WHO that includes surveys and

treatment of humans, vectors (snails), and animal reservoirs (rats, cattle, and dogs). The GoI provides

the funding for the distribution and procurement of praziquantel. Selective treatment (test and treat of

positives and family members) occurred twice in 2013, with 91% and 100% coverage of total population

in at-risk communities in Poso and Sigi districts, respectively. Surveys in 2014 showed an increase in

average prevalence from 0.80% to 1.61% in Sigi and from 0.64% to 0.82% in Poso. Currently, the

program has gaps in funding for surveys and treatment of animal reservoirs.

c) Soil-Transmitted Helminthiases

Indonesia has one of the highest numbers of children requiring preventive chemotherapy for STH in the

world. In the last 15 years, 173 districts have been surveyed in Indonesia to assess STH prevalence. Over

40,000 individuals (mostly children) were involved. Results show that STH infection is widespread in the

country, with an average of 28.12% prevalence (range: 0%-85%). In 2012, the MOH released a new STH

policy. It states that all districts should implement one annual round of STH MDA in preschool and

school-age children (SAC), unless districts have evidence showing the need for no treatments or two

annual treatments. This policy results in 19.7 million preschool children (1–4 years) and 39.6 million SAC

(5–12 years) needing at least one round of MDA per year. In districts without LF/STH MDA, STH-only

MDA for preschool children will be delivered through the Vitamin A or National Weighing Programs and

STH-only MDA for SAC will be implemented through the Directorate of Child Health Support’s school

health program in primary schools.

Currently, coverage of preSAC and SAC with STH is at approximately 11%. Given delays with local

procurement of ALB by the MOH, STH-only MDA has been slow to scale up. In calendar year 2014, 12

districts in the mostly non-LF-endemic provinces of Bali and Nusa Tenggara Barat reported STH-only

MDA. After provincial coordination meetings in calendar years 2013 or 2014, Jawa Tengah, Jawa Timur,

Sulawesi Utara, and Sulawesi Selatan also are supposed to implement STH-only MDA between August

and December 2015. In calendar year 2016, non-LF districts in the provinces of Yogyakarta, Lampung,


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Sumatra Barat, and Sumatra Utara should implement STH-only MDA. ENVISION has provided technical

assistance and a small amount of funding for advocacy and information, education, and communication

(IEC) to kick-start STH-only MDA, which will be fully supported by MOH and MOE after the first year of

activities in each province.

3) USAID History of Support

a) Snapshot of NTD Status in Indonesia

Table 3. Snapshot of the expected status of NTD program in Indonesia as of Sept. 30, 2015

Columns C+D+E=B for each

disease Columns F+G+H=C for each disease

MAPPING GAP

DETERMINATION MDA GAP DETERMINATION

MDA

ACHIEVEMENT DSA NEEDS

A B C D E F** G H I

Disease

Total No.

of

Districts

in

COUNTRY

No. of

districts

classified

as

endemic

*

No. of

districts

classified

as non-

endemic

*

No. of

districts

in need

of initial

mapping

No. of districts

receiving MDA

as of 09/30/15

No. of districts

expected to be in

need of MDA at

any level: MDA not

yet started, or has

prematurely

stopped as of

09/30/15

Expected no. of

districts where

criteria for

stopping

district-level

MDA have been

met as of

09/30/15

No. of districts

requiring DSA

as of 09/30/15

USAID-

funded Others

Lymphatic

filariasis

514

243 268 0 50 81 82^ 25^^

Pre-TAS:8

TAS1:15

TAS2:14

TAS3:5

Onchocerciasis N/A N/A N/A N/A N/A N/A N/A N/A

Schistosomiasis 2 512 0 0 2 0 0 0

Soil-

transmitted

helminthiases#

514 0 0 50 212 252 0 0

Trachoma N/A N/A N/A N/A N/A N/A N/A N/A

* 3 districts in Maluku Utara province will have LF mapping results by end of September 2015 and are not included in columns C

and D above. 6 districts in Jawa Timur province that are currently non-endemic will be re-assessed to ensure the non-endemic

status by September 2015; they are currently included in the non-endemic column. 4 currently endemic districts (Kota Banda

Aceh, Karimun, Jakarta Selatan, and Kota Balikpapan) will be re-assessed in 2016 due to district refusal of endemic status; they

are currently included in the endemic column.

** Column F for LF includes districts planning 2015 LF/STH MDA for Sept–Nov 2015.

^ 5 districts will not have LF/STH MDA because of pending TAS1 implementation (Oct–Dec 2015). They are not included in the

gap in column G.

^^ Column H for LF includes 1 district implementing TAS1 between July–Sept 2015 with assumption that it will pass.

* Treatment for SCH has always been at a subdistrict rather than district level. # 129 districts will do deworming through LF/STH 2015 MDA, which starts in Sept–Oct 2015. 131 districts in Bali, Nusa Tenggara

Barat, Sulawesi Utara, DI Yogyakarta, Jawa Tengah, Jawa Timur, and Sulawesi Selatan provinces should be implementing STH-

only MDA in calendar year 2015.

Due to reporting timeframe and budgetary reasons, FY16 workbooks capture calendar year 2015 LF/STH MDA for GoI-funded

districts, FY2016 LF/STH MDA for USAID-funded districts, and calendar year 2016 STH-only MDA for GoI-funded districts.


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PLANNED ACTIVITIES

In FY16, USAID support to Indonesia’s NTD National Program will continue through ENVISION. The

Subdit will continue leading the planning and implementation process, with support from ENVISION at

district, province, and national levels. Activities outlined in this work plan contribute to the following

ENVISION objectives in support of the national program:

• Technical assistance and funding for NTD control and elimination activities

• Capacity development for NTD control and elimination

• Improved M&E for NTD program activities

1) Project Assistance

a) Strategic Planning

NTD Plan of Action Printing and Shipping: Following up on ENVISION’s support for development of the

NTD Plan of Action 2016–2020 in FY15, ENVISION will support the printing and shipping of the Plan of

Action document to all provinces and districts. A first draft of the Plan of Action will be finalized by end

of September, reviewed by the Subdit, and presented at a small stakeholders meeting with the MOH

and WHO to finalize. Then the Subdit will get endorsement from the Ministry of Health. Included in the

Plan of Action is the BELKAGA approach to achieving scale up goals through standardizing time of MDA

and increasing the cohesiveness of a national program. It is being distributed to all endemic districts in

an effort to reinforce global standards and strategies, advocate for scale-up of MDA, and standardize

local Indonesian LF elimination strategies. This plan will be used over the next five years to gauge annual

progress.

TIPAC Update: With technical assistance from the Indonesia ENVISION team, the Subdit will update the

TIPAC with calendar year 2016 activity plans and budget information in January–February 2016. The

results will be used for advocacy purposes, including being presented at the national NTD stakeholders

meeting in April 2016. No budget is needed for this activity.

BELKAGA 2015 LF/STH MDA Coordination Meeting with Provinces: A two-day strategy meeting for

representatives from all 34 provinces will be conducted in Jakarta in February 2016. The purpose of the

meeting is to advocate for the BELKAGA strategy throughout Indonesia and discuss any issues that arose

during calendar year 2015 LF/STH MDA. While one round of BELKAGA will have taken place in 2015, the

Subdit requested support to continue to advocate to provinces on the importance of LF/STH MDA and

the strategy to meet the 2020 goals. ENVISION team members will provide support for the development

of the meeting agenda, planning, and logistical assistance in advance of this meeting, as well as provide

technical assistance during the meeting.

BELKAGA National Coordination Meetings: Two one-day planning meetings will be conducted in Jakarta

in March and July 2016 to prepare for calendar year 2016 LF/STH MDA scale up. The participants of the

meetings will be the representatives from the Ministry of Religious Affairs, the MOE, and the MOH,

including the Subdit, as well as the School Age and Adolescent Health, Under Five, and Nutrition

subdirectorates, and participants from NTF, the University of Indonesia (UI), USAID, ENVISION, Eisai, and

other stakeholders.

ENVISION LF/STH MDA Project Review and Planning Meeting: The ENVISION LF/STH MDA project

review and planning three-day meeting is planned for March 2016. The participants of the meeting


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include the Subdit staff, 2 DHO staff from each of the 50 districts, the LF focal points from the PHOs in

17 provinces, and NGO representatives, as well as representatives from WHO and USAID/Indonesia. The

purpose of this meeting will be to evaluate calendar year 2015 LF/STH MDA activities, including

documenting lessons learned. Data gathered from NGOs on social mobilization and MDA supervision will

be presented with the MDA coverage data (at district and health center levels) during the review

meeting in an effort to discuss and find ways of improving these activities through refined plans of

action.

LF/STH MDA District Coordination Meetings: During May and June 2016, district coordination meetings

will be organized by the district health officer with relevant stakeholders to secure annual district-level

commitment for social mobilization and cadre training activities. ENVISION will finance district

coordination meetings in districts where this is a financial gap. ENVISION will support the travel

expenses for NGOs to attend these meetings at the district level and will provide a standardized MDA

data template for presentation at the district coordination meeting.

LF/STH MDA Health Center Coordination Meetings: After the district coordination meeting, a health

center coordination meeting will be organized in each health center in June and July 2016 with heads of

villages and representatives from health posts and other sectors to review timelines of activities.

ENVISION will help finance these meetings in districts where this is an identified financial gap.

b) NTD Secretariat

ENVISION will continue to provide limited funds for the MOH operational costs, including monthly

internet and national mobile phone service within Indonesia for the Subdit. This is to allow for a network

among team members to access the M&E database and program files and to improve data sharing.

ENVISION will also provide small amounts for stationery and supplies.

c) Advocacy

STH-only MDA Provincial Advocacy/Coordination Meetings: The MOH has developed a strategy for

scaling up the STH-only MDA by conducting advocacy meetings one year prior to the districts

implementing STH-only MDA activities. ENVISION will fund advocacy or coordination meetings in

January and February 2016 at the provincial level in three provinces (Banten, Gorontalo, and Jawa Barat)

in which many districts are preparing to transition from LF/STH MDA to STH-only MDA. The advocacy

meetings are critical to ensure commitment from provincial and district levels and to secure the

availability of STH MDA operational budget allocation, as well as provide half-day training of trainers

(TOT) for district staff on STH background, MDA logistics, serious adverse events (SAEs), and reporting.

The implementation of STH-only MDA will begin in the following year. The participants in these

advocacy meetings will be PHO (child health, nutrition, and communicable disease control [CDC]

sections) staff, the provincial education officer, provincial government staff, DHO (CDC and maternal

and child health sections) staff, and the district education officer. ENVISION will measure the success of

these meetings by collecting plans of action from each province that include district-level commitments.

National NTD Stakeholders Meeting: Indonesia is planning to conduct a one-day national NTD

stakeholders meeting to be held in Jakarta in March 2016 including the relevant subdirectorates in MOH

and MOE, WHO, UNICEF, USAID, Eisai, German Society for International Cooperation, Save the Children,

and other potential partners and donors including the private sector. The meeting will present updates

to the overall LF BELKAGA strategy and updated TIPAC results for calendar year 2016. The MOE, Ministry

of Environment, Nutrition subdirectorate, Vector Control subdirectorate, Subdit, WHO, Eisai,


16

ENVISION/USAID, and other identified partners will present current activities and identify areas for

integration and further planning. ENVISION completely funds this meeting as costs are minimal and

provides technical assistance in the planning and preparation for this meeting. A BELKAGA secretariat

funded by WHO has been established with a role to follow up with stakeholder commitments, including

pledges made during the annual stakeholders meeting. ENVISION will measure the success of this

meeting by collecting a plan of action that will include proposed funding or activities supported by

stakeholders. ENVISION will work with the Subdit and the BELKAGA Secretariat to ensure that these

donations are captured in the TIPAC for historical records.

Supply Chain Management Meeting: There is a need to strengthen the supply chain management for

the LF/STH Program at the national level, including coordination amongst the Subdit, Subdirektorate

Bina Obat Publik (Binfar), Eisai, and WHO. ENVISION has not supported SCM activities in the past in

Indonesia. With the Government of Indonesia decreasing the procurement budget, and therefore

needing Eisai donations, it has become a more complex issue and the Subdit has asked for ENVISION’s

support. (Please see Procurement of DEC section for more information.) This meeting will include

developing a plan for calendar year 2016 activities including a review of 2015 activities, coordination

mechanisms and developing a timeline for 2016. ENVISION will support a one-day meeting at the

national level, which WHO will facilitate.

MDA Advocacy Package Development: ENVISION recognizes the challenges that the GoI faces with

helping districts commit operational budgets to support LF/STH or STH-only MDA. ENVISION has

supported district-level advocacy meetings in the past, at which districts commit to fund 5 years of

LF/STH MDA. Unfortunately, even with this commitment, their budgets often are slashed or priorities

change, and they still have gaps in implementing all the activities needed for effective MDA. Instead of

supporting district-level advocacy meetings, ENVISION will produce an advocacy package (in conjunction

with the advocacy activity discussed in the global ENVISION work plan) that will be tailored to Indonesia

and will provide it to the Subdit; the Subdit can present the package to districts that have not started

MDA. It can also be used by national experts or provincial staff to discuss with districts that have failed

TAS and need additional MDA. ENVISION will identify a local consultant to tailor the global advocacy

package to the Indonesia context. The cost for a consultant to develop the MDA advocacy package is

captured under STTA.

d) Social Mobilization

BELKAGA Launch: In Year 5, ENVISION will provide minimal support for supplies and advocacy materials

to the BELKAGA launching in early October for 2015 LF/STH MDA. In preparation of the launch,

ENVISION will fund the development and distribution of a national-level press release.

LF/STH MDA IEC Materials and Shipping: In Year 4 ENVISION supported the development of an LF/STH

IEC package using standardized language for messaging throughout Indonesia, which includes more

specific messages about SAEs, eligibility, and the need for increased community involvement to reach

coverage targets. The IEC electronic package, which will be sent to all districts prior to 2015 MDA,

includes redesigned pamphlets, posters, and MDA post banners, as well as newly created cadre

handbooks, flip charts, fact sheets, t-shirt designs, promotional pins, press releases, patient testimonials,

radio spots, and photo booth backdrops. ENVISION will also produce a fake lymphedema leg to use

during advocacy meetings to help convince decision-makers of the severity of lymphedema and the

need to eliminate transmission to protect future generations from disease.


17

ENVISION will continue to support printing and shipping of limited IEC materials (posters, pamphlets,

banners, and flip charts) for calendar year 2016 LF/STH MDA activities. Other items provided in the

electronic IEC package such as radio messages, press releases, t-shirt designs, etc., are for districts to

utilize with their own funding. ENVISION did an extensive cost comparison to determine whether

printing in provinces or districts was cheaper than printing in Jakarta and shipping. The cost comparison

showed that printing in Jakarta and shipping to districts was less expensive.

LF/STH MDA Public Service Announcement (PSA): In 2014 and 2015, ENVISION aired a PSA on national

TV and on local TV in ENVISION districts to raise awareness of LF/STH as well as improve coverage in

poor performing districts. To evaluate the reach of the PSA after 2014 MDA, ENVISION added questions

onto a survey on LF/STH MDA best practices and compliance implemented in December 2014 by the UI

in three districts (1 ENVISION-supported district—Kota Batam, and 2 non-ENVISION-supported

districts—Agam and Kota Depok). The survey included 1,218 respondents and found that the PSA had a

positive impact on awareness and behavior, with a significant association between seeing the PSA and

complying with MDA, awareness of MDA, and influencing drug taking behavior in others. Depending on

the district, between 22% and 49% of people reported they had seen the PSA.

Additionally, the analysis showed that people did not participate in the MDA because they were fearful

or indifferent to taking the drugs, attributes that were associated with higher incomes and, in the case

of indifference, higher education levels. However, many of these respondents had not seen the PSA,

perhaps because it was shown mostly on local TV. Because TV viewership usually is higher amongst the

more educated in Indonesia, PSAs may be a good way to reach these non-participators, providing that

the timing and channel are modified to be more appropriate to their viewing habits.

In Year 5, following the positive feedback from the survey, ENVISION will air the PSA in the weeks before

the calendar year 2016 LF/STH MDA, concentrating on coverage on national stations at prime time. Due

to low viewing of local stations, the MOH decided that airing the PSA on a national station in Indonesia

Bahasa would be more effective than translating to local languages and airing on local stations. Costs for

revising and airing the PSA are captured on the social mobilization tab in the budget. The PSA will

accompany a social media strategy by the MOH involving Facebook and Twitter announcements.

e) Capacity Building/Training

NTD Partner Team Building: ENVISION will support a team building exercise for the Subdit, WHO and

ENVISION to strengthen relationships and improve communication. A local management consultant will

be used to facilitate this exercise.

NGO Training: In Year 5, NGO training is planned as a one-day training, conducted back to back with the

ENVISION 2015 LF/STH MDA review and planning meeting. Over the past three years, ENVISION has

been building local NGO capacity through training, site assessments, and on-the-job supervision,

starting with training on USAID rules and regulations and a basic knowledge of LF and continuing with

training on data collection and analysis. In FY16, ENVISION will conduct a survey with the NGOs to

identify areas of focus for the training, potentially including organizational strategic planning, financial

capacity building, or proposal writing. The aim is to ensure the local NGOs have the capacity to influence

local health programs and find continuing funding after ENVISION ends.

Training for LF/STH MDA

Training for the LF/STH MDA is a cascade process that starts with refreshing of knowledge and skills of

PHO and DHO staff at the ENVISION project review and planning meeting. The DHO staff then train the

health center staff, who then train the cadres.


18

LF/STH MDA Health Center Staff Training: In Years 3 and 4, based on the results of the DQA, the project

added one additional day to the district coordination meeting to facilitate training of health center staff

in use of updated reporting forms. Because of the success of this training in bridging this communication

gap in the field, ENVISION will continue this activity in Year 5 with a strengthened focus on improved

SAE management and reporting at the health center level. ENVISION will work with the Subdit to

provide SAE training for DHOs and NGOs, as well as provide the materials for the DHOs to train health

center staff, in the ENVISION project review and planning meeting.

LF/STH MDA Cadre Training: Through local NGOs in the 50 districts where LF/STH MDA is being

supported with USAID funding, ENVISION will ensure that all the cadres receive timely and adequate

training on all aspects of the LF elimination program (Table 4). The training, which uses a standardized

powerpoint and pre/post-tests, will emphasize the need to participate in the program, how to register

the population and record treatments, supervised distribution of the drugs, identification and treatment

of side effects, and referral and documentation of SAEs. Three health center staff overseeing the MDA

campaign will conduct the training. The aim will be to train four cadres per health post. Over 95% of

cadres are women and this training aims to give them skills to become respected advocates for

preventive health care in their communities.

While this will be refresher training for many of the cadres who were trained in previous years, the high

turnover of cadres and the fact that LF/STH MDA only happens once a year necessitates refresher

training annually in order to ensure cadres can adequately respond to the communities’ questions and

report population registration and treatment coverage data correctly.

Local NGOs will attend approximately 20% of cadre trainings in each district in order to monitor

appropriate implementation using a training supervision checklist. NGOs will choose the 20% to attend

based on conversations with DHOs, with an aim to include health centers that could need extra support

because of past performance or difficulty in logistics. ENVISION will work with NGOS to prioritize health

centers for supervision, sharing reviews of health center-level coverage data from past MDA years.

f) Mapping

There are no mapping activities included in this work plan or budget. Reassessment with a mini-TAS

protocol is included under M&E activities.

g) MDA

Mass Drug Administration: ENVISION will fill the funding gaps in district budgets for LF/STH MDA in 50

districts. The cadres will conduct the LF/STH MDA with the target population in the community under

the supervision of the health center. Five previously supported ENVISION districts will be preparing for

PreTAS and TAS in FY2016 so will not be included in calendar year 2016 MDA activities. In place of these

5 districts, ENVISION will support 5 new districts in Sumatra that have partial local government funding,

but still have some gaps. Seven districts that have received ENVISION support for five MDA rounds do

not have adequate coverage in all years, and therefore did not meet the criteria qualifying them for TAS.

These districts will receive one additional round of MDA in calendar year 2016. With effective coverage

in calendar year 2016, these districts will qualify for pre-TAS and TAS activities in calendar year 2017.

Population Registration

In July and August 2016, ENVISION will support population registration activities in all 50 ENVISION-

supported LF/STH MDA districts through local NGOs (Table 4). One week after the cadre training, cadres


19

will collect information on their allocated households, including village name, age and sex of household

members (stratified by <2 years, 2–5 years, 6–14 years, and >14 years). This registration will help ensure

that if adequate numbers of drugs are not available in the health centers, PHOs or DHOs can deliver

more drugs before the start of LF/STH MDA. In addition, cadres use these household visits to deliver

flyers and verbal messages about the logistics of and benefits of participating in the MDA.

Table 4. USAID-supported districts and estimated target populations for MDA in FY16

NTD

Age groups

targeted (per disease

workbook

instructions)

Number of rounds

of distribution

annually

Distribution

platform(s)

Number of

districts to

be treated

in FY16

Total # of

eligible

people

targeted

in FY16

Lymphatic

filariasis

Entire population

from the ages of 2

to 70

1

Community and

door-to-door

MDA

50 15,862,249

Soil-transmitted

helminths

Entire population

from the ages of 2

to 70

1

Community and

door-to-door

MDA

50 15,862,249

h) Drug and Commodity Supply Management and Procurement

Procurement of DEC (no associated budget): The Subdit procures DEC for the LF/STH MDA through

WHO donations and its own government (GoI) budget. The procurement process is initiated through a

request for a budgetary allocation by the LF/STH Subdit through the director of the Vector Borne

Disease Control Program. The Subdit calculates the number of tablets required (and their cost) to treat

the population targeted for the next round of MDA across the entire country. The Subdit then submits

annual needs to BinFar, which initiates the purchase process. Drugs are purchased through an open

tender system and there is no pre-qualification of bidders except that they should be good

manufacturing practices certified. At least three companies must submit a bid for the initiation of the

next steps. The tendering process takes approximately 45 days from the time the tender is announced

to the time a contract is signed with the successful bidder. The supplier usually seeks 2–3 months for the

supply of the drug. Suppliers are required to deliver the drug to the districts.

Starting in Year 2, the tendering for drugs switched to online processing, aiming for time efficiency, but

the shifting from manual to the online system caused delays in Year 2. In Year 3, the delay was caused

by the cut-off of the central government budget just before BinFar initiated the purchase process. The

budget cut-off not only affected the time of purchasing the drugs, but also forced a decrease in the

number of drugs purchased for program implementation. To prevent the DEC stock-out for Year 4, the

Subdit used Eisai’s donation for the remaining DEC. In 2016 the Subdit will apply for Eisai’s donation in

early 2016, after the remaining stock from 2015 MDA is known and the 2016 MDA need can be

estimated. This donation will include supplies for all ENVISION-supported districts.

Procurement of Albendazole (no associated budget): The Subdit procures ALB for LF/STH MDA and STH-

only MDA through WHO donations and its own government (GoI) budget. The Subdit submits the Joint

Application Form and the Joint Reporting Form to WHO for LF/STH MDA. WHO makes a

recommendation to GlaxoSmithKline (GSK) on the number of ALB tablets to be shipped for the LF/STH

MDA in Indonesia. GSK delivers the donated ALB to Jakarta. The Subdit then approaches BinFar for the

release of the drug. The donated ALB takes approximately two weeks to be cleared by customs. For STH-


20

only MDA, the Subdit usually procures through BinFar, which initiates the process described under DEC

procurement above.

Drug Shipment from Jakarta to 50 Districts: At the central level, drugs are stored in the MOH drug

storage facility located at the BinFar offices in Jakarta, Indonesia. For calendar year 2016 MDA,

distribution for non-ENVISION districts will be covered by GoI and distribution for ENVISION-supported

districts will be covered under the FY16 budget. Once received at the provincial level, provinces

distribute the drugs to the DHO, using district funds. The DHO repackages the drugs and distributes to

health centers; a process taking approximately two weeks. Storage facilities located at the provincial and

district health offices are generally in good condition and are usually a storage room connected to the

health office and managed by a designated staff member. Drugs are stored at the health centers until

distributed in the MDA; the conditions of these facilities vary by district. LF/STH drugs are generally

picked up by the health center staff from the DHO once per year before MDA and stored at the Health

Center level until distributed in the MDA.

After the completion of MDA, an inventory of the remaining drugs is made at the district level and

consolidated at the national level. The number of tablets available, including those stored at the

provincial level, after the completion of the MDA is taken into account in making purchases of DEC and

preparing the reapplication for ALB.

Serious Adverse Events (no associated budget): Importantly, as part of the LF/STH MDA campaigns, the

cadre and health center staff will monitor for SAE and report and refer any patients with serious

concerns to health professionals. The triage will initially be to local doctors/nurses, followed by the

district or the provincial hospital if indicated. Cases of SAE that are referred to the district hospital will

be reported to the central MOH to monitor and to manage any negative impact. Training of central and

provincial staff, district staff, and health center staff and cadres will include the updated

modules/messages from the new global SAE guidance. ENVISION will continue to persuade districts to

report any SAEs that might occur to the Subdit and work with the Subdit to report any SAEs to RTI,

WHO, GSK, and Eisai.

i) Supervision

LF/STH MDA Supervision: During the LF/STH MDA campaign, staff from the DHO, PHO, and MOH will

support the cadres and monitor coverage. ENVISION pays for supervisory visits by MOH staff to 20% of

USAID-supported districts for MDA, including travel expenses and per diems. MOH staff fill out

supervisory checklists and submit trip reports to ENVISION, which are reviewed by ENVISION Indonesia

staff. Due to the large number of implementing districts, support from the central level government

unfortunately cannot be conducted in all implementing districts around Indonesia. RTI ENVISION will

provide additional level supervision covering many areas that may not be reached by the DHO, PHO and

MOH. RTI EVISION operations and finance team will also provide financial support supervision to

districts during field visits. All RTI ENVISION staff use standardized supervision checklists or NGO

assessment forms to collate information and include these in their trip reports.

LF/STH MDA Supervision by NGOs: To provide supervision assistance, local NGOs selected to assist with

MDA activities will attend activities in at least 20% of subdistricts in each of their respective districts in

order to monitor progress. ENVISION works with local NGOs and DHOs to help prioritize

subdistricts/health centers that have had problems in the past. 20% is a feasible goal in terms of staff

time, travel necessary (particularly as a NGO is responsible for more than one district and MDA is

happening simultaneously), and budget. The NGO will fill out monitoring forms and checklists with DHO

staff to assess the implementation of the MDA; these are submitted and reviewed by ENVISION staff.


21

Results from these checklists are presented at the ENVISION program review and planning meeting to

highlight common issues, such as inconsistent use of directly-observed treatment, misclassification of

eligible people, and reasons for non-compliance. ENVISION staff will review these supervisory checklists

upon submission and discuss any critical issues immediately with central MOH staff in order to quickly

give feedback to the NGO and DHO on how to resolve the issues.

Coverage Supervisory Tool Implementation: In Year 4, during the provincial NTD focal point training,

provincial staff were trained in how to use routine DQA, a coverage supervisory tool, and supervisory

checklists in order to improve the quality of their supervision. During the calendar year 2015 MDA

ENVISION will implement a coverage supervisory tool in two districts (Siak and Tasikmalaya) that will

help identify weaknesses in early MDA implementation so that quick remedies can be identified and

instituted prior to annual MDA activities ending. This tool—which interviews one person in each of 20

villages in a subdistrict within 2 weeks of MDA in order to get an estimate of whether the subdistrict has

reached the effective coverage threshold—has been developed by the Task Force for Global Health. The

results of ENVISION’s piloting this tool in Indonesia will be shared with the Task Force in order to

improve the tool. ENVISION staff will be conduct this supervision in conjunction with the previously

trained PHO staff, as well as NGO and DHO staff, in the first quarter of Year 5.

j) Short-Term Technical Assistance

Table 5. Technical assistance (TA) request from ENVISION

Task-TA needed

(Relevant Activity

category)

Why needed

Technical skill

required; (source

of TA (CDC,

RTI/HQ, etc.)

Number of days required

and anticipated quarter

Provision of on-

the-job training

for integrated

TAS/STH

assessments

(M&E)

Although Indonesia

piloted the integrated

TAS/STH assessment

methodology, there is

a need for a

consultant to provide

on-the-job training

for this integrated

survey in the two

districts

implementing it in

FY16

Expertise in TAS

and STH

assessment

methodology,

facilitating on-the-

job training (local

consultant)

10 days in Q1

TAS and Post-MDA

Surveillance

Expert Meeting

(M&E)

Review TAS results

and support the

development of

protocol specific to

Indonesia for post-

MDA surveillance

Expertise in NTDs,

TAS, M&E

(international LF

experts, likely CDC

and/or Vector

Control Research

Centre)

14 days in Q2

Technical

supervisor for

MDA, TAS and

M&E activities

Supervision of MDA

and M&E Activities

Expertise in NTDs,

TAS, M&E (local

consultant)

6 months in Q1 and Q4

(20 days per month per 6

months )


22

(M&E)

Data quality

assessment (DQA)

(M&E)

Supervision and

implementation of

DQA

Supervision and

implementation

of DQA (local

consultant)

21 days in Q1

MDA advocacy

package

development

(Advocacy)

Adaptation of global

advocacy package to

Indonesian context

Expertise in

advocacy; MDA

strategy; program

development;

local experience

(local consultant)

20 days, Q1 and Q2

ENVISION will hire consultants to help provide on-the-job training during the roll out of the TAS/STH

assessment integrated surveys; help Indonesia review TAS results and develop a post-MDA surveillance

protocol; assist with the supervision of MDA and M&E activities; implement a DQA in two districts; and

develop an MDA advocacy package. Further information about these activities is included in the M&E

and advocacy sections of the work plan.

k) M&E

Integrated NTD Database: In Year 3, ENVISION supported the rollout of the integrated NTD database,

including training of the Subdit staff and hiring consultants to enter historical LF data. The Subdit is using

the database to generate WHO forms, such as the Joint Reporting Form. In Year 4, the ENVISION M&E

Specialist and M&E Assistant will work closely with the newly appointed M&E focal person at the Subdit

to build her capacity to sustain the database. This will be accomplished through established monthly

(and more often during periods of heavy activity) meetings to provide on-the-job training on the

integrated NTD database, including ensuring a review of data received from the field and timely entry

into the database.

Data Quality Assessment: In Year 3, ENVISION conducted a DQA in two project districts to assess the

strengths and weaknesses of data management related to LF/STH MDA at health posts, health centers,

DHOs, PHOs, and the national level. The DQA helped MOH staff at all levels (1) understand the strengths

and weaknesses of data management and reporting system, and (2) make action plans to improve the

system. Since the DQA, ENVISION has taken steps to help the MOH correct errors in the reporting and

archiving procedures as well as providing more training to DHOs. To help the MOH continue to monitor

and improve its data quality, ENVISION will support the implementation of the DQA, using the same

WHO/RTI DQA protocol piloted in Year 3, in two non-ENVISION-supported LF/STH MDA districts,

Karawang (Jawa Barat) and Barito Kuala (Kalimantan Selatan) in Year 5.

LF Transmission Assessment Surveys (TAS) and STH Assessments: In FY16, TAS will be conducted in

districts/municipalities which have conducted five rounds of MDA with greater than 65% coverage of

total population and have sentinel and spot-check site assessments showing <1% Mf prevalence. The

TAS is required to determine whether or not to stop MDA, with MDA to be stopped if the number of

positive results is less than or equal to the critical cut-off point determined by WHO guidelines. The

evaluation will apply antigen testing with immunochromatographic tests (ICTs), or filariasis test strips (if

available) in Bancrofti areas, or antibody testing with Brugia Rapid tests in Brugian areas among SAC

who are sampled according to WHO guidelines.


23

TAS will be conducted among first- and second-year primary school pupils (if >75% of children in the

area attend school) or among children aged 6-7 years within the community (if <75% of children in the

area attend school). The survey will use a cluster methodology.

In Year 5, ENVISION will support a total of 17 TAS in 15 districts. TAS1 will be conducted in 7 districts

(Kote Tidore, Mappi, Agam, Kuantan Singingi, Kota Bukit Tinggi, Lebak,1 Bogor); TAS2 will be conducted

in 6 districts (Merauke, Pelalawan, Poliwali Mandar, Parigi Mountong, Labuhan Batu, and Rote Ndao

(carried over from FY15)); and TAS3 will be conducted in 2 districts (Kolaka Utara and Bombana). STH

assessments will be integrated with TAS1 in two districts (Kote Tidore and Kuantan Singingi), following

the new WHO protocol. All other diagnostics tests will be procured by GoI. TAS will be implemented by a

team consisting of one PHO staff, DHO staff, two health center staff and two cadres per cluster, as well

as a national level supervisor from Subdit, National Institution of Health Research and Development

(NIHRD), Technical Office of Environment Health and Disease Control (BTKL), or ENVISION. In each

district, there will be four teams implementing TAS simultaneously. The surveys will be implemented

between October 2015 and April 2016. Results and next steps will be shared with the districts through a

formal letter from the Subdit. If any districts fail these TAS2 or TAS3, ENVISION will work with the Subdit

to submit a request to the WHO RPRG for advice on next steps, per the guidance in the 2011 WHO LF

TAS manual.

LF PreTAS Sentinel and Spot-Check Sites: Based on the latest data review with the MOH, provinces and

districts, ENVISION will support eight districts (Aceh Jaya, Pidie, Subang, Melawi, Kote Tidore Kepuluan,

Kuantan Singingi, Donggala, Pasaman Barat) to collect data in one PreTAS sentinel site and one PreTAS

spot-check site per district.

Assessments will be done following the approach below:

• Approximately 300 samples from people aged 5–50 using blood films to detect Mf should be

collected from at least two sites (villages). In Kote Tidore, ICT/FTS will be used instead of Mf.

• Blood collection should be done between the hours of 10pm and 2am.

• Districts with population <1 million will have 1 sentinel site and 1 spot-check site. Districts with

population >1 million will have 2 sentinel sites and 2 spot-check sites.

• Sentinel sites will be areas of known high transmission; spot-check sites will be areas at high risk

of continued transmission, e.g., due to low MDA coverage.

• PreTAS sentinel and spot-check site data will be collected after the 5th effective MDA round to

determine whether the district can move to implementing a TAS. PreTAS sentinel sites are the

same villages as the baseline sentinel sites.

• All other issues with finger blood preparation collection, coloration, and examination follow the

standard protocol that was developed based on WHO M&E guidelines.

The sentinel and spot-check site assessments will be managed by the central level team, engaging

technicians at the provincial and district levels. Results will be entered into the integrated NTD database

and shared with the districts through a formal letter from the Subdit.

LF/STH MDA Coverage Surveys: ENVISION will support a coverage survey in eight 2015 MDA districts

that implemented MDA activities for the first time. In particular the surveys will help confirm if reports

of numbers of drugs distributed are similar to survey responses of numbers of drugs ingested. The

1 Support is needed for 1 evaluation unit (EU); the other 4 EUs in this district will be supported by the Task Force for operational

research purposes, per WHO recommendations.


24

questionnaires will include simple questions, using clear photos, about whether people in the household

have lymphedema or hydrocele. The district estimates generated by these surveys can then be

compared to the health facility listing of known patients to determine whether health facilities are truly

capturing all patients.

ENVISION will engage the UI to implement the surveys in eight districts and will conduct the surveys

using mobile devices. The UI team will consist of eight interviewers who have previously conducted

interviews using mobile technology and will not require much training for this activity. The interviewers

will work with both province- and district-level MOH personnel to implement the questionnaires. With

technical support from the Task Force for Global Health, ENVISION will pilot different methodologies for

conducting enumeration of households in three districts in order to inform WHO global guidance on

NTD coverage survey methodology. Once the data collection is completed, the UI researchers will

analyze the data and submit a final analysis and report. UI will also present the results to the Subdit and

provinces, which will then disseminate the results to the districts.

Mini-TAS Reassessment Surveys: A mini-TAS, using the protocol developed by the Task Force for Global

Health and approved by WHO, will be implemented in February 2016 in four districts: Kota Banda Aceh

(Aceh), Karimun (Kepulauan Riau), Jakarta Selatan (DKI Jakarta), and Kota Balikpapan (Kalimantan

Timur), which refuse advocacy or implementation of MDA. Results of the mini-TAS survey will be used

either to declare them non-endemic (if lower than the critical threshold) or as advocacy to show the

DHOs and mayors’ offices that transmission is still occurring and MDA must be implemented. Kota

Banda Aceh is included on the list of districts that ENVISION will support for LF/STH MDA in 2016 as it is

expected that it will be classified as endemic. If it is not endemic, ENVISION will work with the Subdit to

choose another district in need of support for 2016 MDA.

TAS and Post-MDA Surveillance Expert Meeting: Since 2012, when the first TAS failures occurred,

ENVISION has been working with WHO, CDC and the Task Force for Global Health to better understand

the causes of the failures. First, ENVISION has worked with the Subdit to critically review eligibility data,

which has reduced the number of districts implementing TAS which were not eligible. Second, ENVISION

has collaborated with the Task Force to implement operational research to better understand antibody

results in three study areas (non-endemic, post-MDA, failing TAS, passing TAS). These results showed

that antibody prevalence was higher in all ages in the district which failed TAS versus the districts that

either passed TAS or were non-endemic. The results also showed that results in 6- and 7-year olds

accurately reflected community results. Unfortunately, only one microfilaremia positive was found in

this research, so antibody and microfilaremia prevalence could not be compared. Third, all TAS results

are being analyzed now for presentation at ASTMH and further discussion at the meeting in January.

Finally, the recent TAS2 failure in Tanjung Jabung Barat, a district with low baseline prevalence which

based TAS1 with only 3 positives, will be explored in collaboration with the Task Force, through

collection of Brugia Rapid tests and dried blood spots from communities with the most positive antibody

results in TAS2. Unlike ICTs, positive Brugia Rapid tests cannot be collected for PCR analysis; however, it

is hoped that the dried blood spot analysis will provide some clarity into the accuracy of the Brugia

Rapid tests.

Due to the TAS failures, the Subdit and the NTF were convinced of the need to message correctly about

the importance of full geographic coverage, DOTs, and 65% epidemiological coverage. However, in non-

ENVISION-supported districts that implemented most rounds of MDA before hearing these messages,

they could still be at risk for failing TAS. The key issue in Indonesia now is being able to better predict

which districts will fail TAS, so that the Subdit can convince the other districts to continue and better

implement MDA. ENVISION is continuing to negotiate with the Subdit, with support from WHO, to


25

collect Brugia Rapid data during Pre-TAS sentinel and spot-check sites in order to understand how

community level antibody levels can predict TAS outcome.

In January 2016, Indonesia will hold a technical working group meeting to review Indonesia’s TAS results

and post-MDA surveillance strategy and set new guidelines for surveillance activities moving forward.

The meeting will include WHO Geneva, WHO SEARO, WHO Indonesia, RTI DC/Indonesia, Subdit, NTF, UI,

the Association for Parasitology, the Association of Entomology, and international experts in post-MDA

surveillance and vector control/monitoring. The first day will be a small group review of TAS results, with

a meeting planned with local stakeholders for the second and third days to present the results and

discuss post-MDA surveillance, and the fourth day dedicated to making a draft surveillance action plan

with a small group. ENVISION will support the four-day meeting in Jakarta.

TAS Training for PHOs and DHOs: In 2017, approximately 42 districts are planning to conduct TAS1 to

determine whether they are eligible to stop LF MDA. Districts to be trained come from the following

provinces: Bangka Belitung (5), Bengkulu (3), Jambi (3), Jawa Barat (1), Jawa Tengah (1), Kalimantan

Barat (1), Kalimantan Selatan (1), Kalimantan Tengah (2), Kalimantan Timur (3), Kalimantan Utara (1),

Lampung (1), Aceh (1), NTT (1), Papua (1), Papua Barat (1), Riau (7), Sulawesi Selatan (1), Sulawesi

Tengah (1), Sumatra Barat (2), Sumatra Selatan (1), and Sumatra Utara (4). The Subdit and PHOs are the

levels in the Indonesian health system responsible for conducting TAS. While most of the focal points at

the provincial level have been trained to conduct TAS in earlier fiscal years, there is often turnover of

provincial focal points and a need for refresher training (particularly for Bancrofti areas, which will need

to be trained on the filariasis test strip). In addition, districts that will be implementing TAS1 in 2017

must be trained on eligibility, planning, methodology, and interpretation of results in 2016. To help

PHOs and DHOs understand the purpose of the surveys and the process, a two-day training on TAS

methodology and how to use rapid tests will be conducted in one of the Brugia districts, modeled on the

WHO TAS training modules. A pre- and post-test will be used to evaluate the participants’ change in

knowledge after training. ENVISION will fund, organize, and co-facilitate with the MOH the training, to

be held in August 2016.

TAS Supervisor Training: The number of districts implementing post-MDA surveillance is growing each

year. With limited personnel at the central and PHO levels to supervise pre-TAS and TAS activities (as

has been done in the past), there is an increasing demand for new supervisors to be trained who can

assist the Subdit in conducting the large number of surveys each year. In FY16 ENVISION will support a

training in February 2016 with personnel from BTKL (regional laboratories in Kep Riau, Sumatra Selatan,

Sumatra Utara, Jakarta, Java Timur, DIY, Kalimantan Selatan, Sulawesi Selatan, Sulawesi Utara, and

Maluku) and NIHRD. These personnel will be trained as supervisors and will help conduct TAS activities

in 2016.

Table 6 shows planned assessments, by disease, for FY16.


26

Table 6. Planned disease-specific assessments for FY16, by disease

Disease No. of endemic

districts

No. of districts

planned for

DSA

Type of

assessment

Diagnostic method

(Indicator: Mf, ICT,

hematuria, etc.)

LF 243 15 TAS ICTs, Brugia Rapids

STH 514 2

STH impact

assessment (in

conjunction

with TAS)

Kato Katz

LF 243 8 Pre-TAS Mf

LF 243 4 Mini-TAS

reassessment ICTs

LF/STH 243/514 8 Coverage survey N/A

2) Maps


27


28


29


30

Appendix 1. FY16 Indonesia Work Plan Activities

National Program Implementation

Management Support

NTD Secretariat Support

Strategic Planning

NTD Plan of Action Printing and Shipping

TIPAC Update

BELKAGA 2015 LF/STH MDA Coordination Meeting with Provinces (National

and Provinces)

ENVISION 2015 LF/STH MDA Project Review and Planning Meeting

BELKAGA National Coordination Meetings

2016 LF/STH MDA District Coordination Meetings in 50 districts

2016 LF/STH MDA Health Center Coordination Meetings in 50 districts

Advocacy

STH-only MDA Provincial Advocacy/Coordination Meetings in 3 Provinces

National NTD Stakeholders Meeting

Supply Chain Management Meeting

MDA Advocacy Package Development

Social Mobilization

BELKAGA Launch

Airing PSAs for 2015 LF/STH MDA

Revising PSA for 2016 MDA

Airing PSAs for 2016 LF/STH MDA

Printing and Shipping of 2016 LF/STH IEC Materials to 50 districts

Capacity Development for Integrated NTD Control (training and systems

strengthening)

NTD Partner Team Building

NGO Training


31

2016 LF/STH MDA Health Center Staff Training

2016 LF/STH MDA Cadre Training

Mapping

N/A

Drug Logistics and Supply Chain management

Shipping of Drugs for LF/STH MDA to 50 districts

Registration

Population Registration for 2016 LF/STH MDA in 50 districts

Drug distribution

2015 LF/STH MDA in 50 districts

2016 LF/STH MDA in 50 districts

MDA Supervision

Supervisory Visits by MOH and NGO Staff for 2015 LF/STH MDA

Supervisory Visits by MOH and NGO Staff for 2016 LF/STH MDA

Coverage Supervisory Tool Implementation (2 districts)

Short-Term Technical Assistance

Consultant to Provide On-the-Job Training for the 2 TAS/STH Integrated

Assessments

Experts to Attend TAS and Post-MDA Surveillance Meeting

Consultant to Help Supervise MDA and M&E Activities

Consultant to Supervise DQA

Consultant to Develop MDA Advocacy Package

Improved M&E for NTD Program Activities

Integrated NTD Database Support

DQA in 2 Districts

TAS in 15 Districts

STH Assessments in 2 Districts (Integrated with TAS)

LF PreTAS Sentinel and Spot-Check Site Surveys in 8 Districts


32

2015 LF/STH MDA Coverage Surveys in 8 districts

Mini-TAS Reassessment Surveys in 4 districts

TAS and Post-MDA Surveillance Expert Meeting

TAS Training for PHOs and DHOs

TAS Supervisor Training


33

Appendix 2. Table of USAID-supported Provinces and Districts

LF/STH MDA

(round 6)

LF/STH MDA

(round 5)

LF/STH MDA

(round 4)

LF/STH MDA (round 2)

LF/STH MDA

(round 1)

Disease Specific Assessments Disease Specific

Assessments

(continued)

Bengkulu

1. Bengkulu

Utara

Kalimantan

Utara

2. Nunukan

Kalimantan

Timur

3. Kutai Barat

Sulawesi

Tenggara

4. Kolaka

5. Kolaka

Timur

NTT

6. Ende

Papua

7. Supiori

Sumatra Utara

1. Gunung Sitoli

Riau

2. Indragiri Hulu

3. Indragiri Hilir

4. Rokan Hilir

5. Bengkalis

6. Siak

7. Kep Meranti

Kep Riau

8. Kota Batam

Jambi

9. Tanjung Jabung

Timur

10. Batang Hari

11. Merangin

Sumatra Selatan

12. Banyuasin

Bengkulu

13. Bengkulu Selatan

14. Muko-muko

Lampung

15. Lampung Timur

Kalimantan Timur

16. Mahakam Hulu

Riau

1. Kampar

Kep Riau

2. Lingga

Sumatra Selatan

3. Muara Enim

4. PALI

5. OKI

6. Musi Banyuasin

Bengkulu

7. Kaur

8. Seluma

Jawa Barat

9. Tasikmalaya

Sumatra Barat

10. Kota Sawahlunto

11. Sijunjung

Aceh

1. Aceh Barat

2. Aceh Besar

3. Aceh Utara

4. Bireuen

Sumatra Barat

5. Pasaman Barat

Sumatra Selatan

6. Musi Rawas

7. Ogan Komering

Ulu

8. Ogan Komering

Ulu Timur

Sumatra Utara

9. Batubara

10. Serdang

Bedagai

11. Tapanuli

Selatan

Aceh

1. Aceh Timur

2. Kota Banda

Aceh*

3. Kota Sabang

4. Nagan Raya

Sumatra Selatan

5. Lahat

* If remapping

results show

endemicity.

Pre-TAS SS/SC Assessments

Aceh

1. Aceh Jaya

2. Pidie

Jawa Barat

3. Subang

Kalimantan Barat

4. Melawi

Maluku Utara

5. Kote Tidore Kepulauan

Riau

6. Kuantan Singingi

Sulawesi Tengah

7. Donggala

Sumatra Barat

8. Pasaman Barat

TAS and STH Assessments

Maluku Utara

1. Kota Tidore (TAS1 + STH

Assessment)

Papua

2. Mappi (TAS1)

3. Merauke (TAS2)

Riau

4. Kuantan Singingi( TAS1 + STH

Assessment)

5. Pelalawan (TAS2)

Sulawesi Barat

6. Poliwali Mandar (TAS2)

Sulawesi Tengah

7. Parigi Moutong (TAS2)

Sulawesi Tenggara

8. Kolaka Utara (TAS3)

9. Bombana (TAS3)

Sumatra Barat

10. Agam (TAS1)

11. Bukit Tinggi (TAS1)

Sumatra Utara

12. Labuhan Batu (TAS2)

Mini TAS

Aceh

1. Kota Banda Aceh

Kepulauan Riau

2. Karimun

Kalimantan Timur

3. Kota Balikpapan

DKI Jakarta

4. Jakarta Selatan

DQA

Jawa Barat

1. Karawang

Kalimantan Selatan

2. Barito Kuala

Coverage Surveys

Aceh

1. Aceh Barat

2. Aceh Utara

3. Bireuen

Sumatra Selatan

4. Musi Rawas

5. Ogan Komering

Ulu

(OKU)

6. Ogan Komering

Ulu Timur

(OKUT)

Sumatra Utara

7. Batubara

8. Serdang Bedagai


34

LF/STH MDA

(round 6)

LF/STH MDA

(round 5)

LF/STH MDA

(round 4)

LF/STH MDA (round 2)

LF/STH MDA

(round 1)

Disease Specific Assessments Disease Specific

Assessments

(continued)

Banten

13. Lebak (TAS1)

Jawa Barat

14. Bogor (TAS 1)

NTT

15. Rote Ndao

Indonesia Work Plan - ENVISION · Indonesia Work Plan FY 2016 Project Year 5 October 2015–September 2016 ENVISION is a global project led by RTI International in partnership with

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