Two decades ago, Indonesia started an ambitious public health journey — one that would improve the health of millions of poor and vulnerable people. The country began working to eliminate lymphatic filariasis (LF), a neglected tropical disease (NTD) that can cause disability, pain, and severe disfigurement from swollen limbs.

Fast forward to the present, and more than 58 million Indonesians are no longer at risk for LF. The disease no longer takes a physical, economic, and social toll on entire communities.

The story of how Indonesia made this giant leap is one of national ambition, catalytic funding, increasing government ownership, and incremental but important steps towards sustainability.

Leveraging U.S. investment

Indonesia faces immense challenges in fighting LF. Not only is it a country of 270 million people spread across thousands of large and small islands, but Indonesia also has one of the highest burdens of LF in the world. In 2012, about 39 percent of its people were at risk for the disease. To reduce transmission, Indonesia’s government has to reach all of these people — multiple times over multiple years — with preventive medicines.

“Indonesia… is intensively focused on carrying out a wide range of development activities in a variety of sectors across the entire country. All of these activities are aimed at improving the standard of living and the general welfare of the entire population, but each comes at a cost. This large number of development efforts has resulted in limitations on available financing for individual programs such as LF elimination efforts,” says Lita R. Sianipar, SKM, M.Epid, Head of Sub-directorate for Filariasis and Helminths, Ministry of Health.

In support of Indonesia’s journey to eliminate LF, the U.S Agency for International Development (USAID) helped map out how a small but strategic amount of U.S. support could catalyze big progress against the illness. Together with Indonesia’s Ministry of Health (MOH) they developed a plan to scale up mass treatment, with USAID providing a modest amount of funding and technical support to these mass treatment campaigns for several years, while the government, through each district, contributed funding for implementation, supplies, and coordination activities. Pharmaceutical companies Eisai and GlaxoSmithKline donated the more than 75 million doses of LF medicines that reached at-risk people between 2012 and 2018. This combination of focused USAID support, collective action, and strong government ownership at all levels are enabling Indonesia to reach ambitious LF elimination milestones.

Today, support for Indonesia’s NTD activities continues through USAID’s Act to End NTDs | East program, a global effort supporting governments to plan, implement, and finance solutions to fight NTDs using proven, cost-effective public health interventions.

Building local sustainability

Local organizations who know their communities and are already trusted by community members are critical partners in this work.

Mrs. Yeni Roslaini is the Director of WCC Palembang, an organization in South Sumatra that helped carry out mass treatment for LF in the region. She says these campaigns differ from other programs because they are so wide reaching. “This program targets everyone in the community…it is for all people. And the activities involve all sectors, not just the health sector.”

Photo Credit: RTI International/Muhammad Fadli

Yeni Ruslaini from Women Crisis Center (WCC), accompanied by RTI Staff Luciana Berliantari, led a discussion about Lymphatic Filariasis in Nursery Academy (Akademi Keperawatan) Lahat, South Sumatra.

Photo Credit: RTI International/Muhammad Fadli

Portrait of Yeni Ruslaini from Women Crisis Center (WCC). The organization is RTI ENVISION local partner in South Sumatra for eradicating Lymphatic Filariasis among the local population.

By helping to coordinate these mass treatment campaigns in several selected districts throughout South Sumatra, WCC Palembang has learned many lessons that they can apply to their other areas of work. “We learned that if you give the right information to the community regarding the benefits, effects, and goals of certain activities, they get enthusiastic because it has a direct effect on their life and their health…You can see it from the increasing number of people who take the medicine each year,” says Roslaini.

Escalating national ownership

In 2015, USAID helped Indonesia’s government draft a five-year strategic plan for NTDs — an exercise that helped advocate at all levels of government for policy and financing changes that would increase domestic funding for LF. As a result of this advocacy, in 2017, Indonesia’s president designated LF elimination as a priority health intervention, an important step which helped protect its budget. The MOH also secured a new national budget line to fill gaps in district funding, received approval to use village-level development funds to support mass treatment campaigns, and obtained commitments from LF-endemic districts to increase their own budgets for treatment.

“USAID provided support at a time when most districts had limited budgets available for implementing the program. With their assistance, the scope of the program was able to expand, and the entire set of crucial program activities were implemented across all endemic areas, including advocacy, outreach, and coordination; training for health workers and village cadres; data collection; implementation of mass treatments campaigns; follow-up treatment; and evaluation surveys. Mentoring also strengthened program implementation, and this success triggered the steady increase of government budgets at all levels,” says Sianipar.

Gradually, the number of districts where mass treatment campaigns were funded domestically increased and Indonesia now independently funds every single LF mass treatment campaign.

Photo Credit: RTI International/Muhammad Fadli

Photo Credit: RTI International/Muhammad Fadli

Investing in the future

The government’s efforts to fund LF elimination do not stop with treatment campaigns. Multiple rounds of surveys are needed after treatment is finished to ensure the disease is really gone for good.

Building capacity to monitor for LF at the local level is therefore essential. USAID has supported Indonesia to train more than 300 health officials on the quality management of these surveys — forming a remarkable team that is now the backbone of ongoing efforts to monitor LF progress. Surveys are directly carried out by Indonesia’s network of national environmental health laboratories, with USAID providing additional small but crucial support — namely, supporting surveys in around 20% of districts and facilitating an annual training for labs on the most updated survey guidance.

These investments in the health system are now paying off, lessening the disruption of COVID-19 to LF activities supported by USAID’s Act to End NTDs | East program. Years of refining materials and planning at national and local levels through on-the job-training meant that large in-person survey trainings were not required, allowing activities to continue and reducing the need for in-person gatherings in the context of the pandemic. And the annual LF survey planning and coordination meeting was hosted virtually by the government, which now has many years of experience coordinating these activities. By integrating NTD activities into the DNA of Indonesia’s health system, knowledge, platforms, and infrastructures can be sustained at the local level and are available to fight other diseases, including COVID-19.

Indeed, the regional health laboratories that Act | East supports with technical trainings to read and process slides for LF are the same labs responsible for the country’s COVID-19 testing.

Armed with small but crucial support, Indonesia’s relentless efforts against LF will not only free future generations from a disabling disease but will also sustain a stronger health system for years to come. Currently, Indonesia is aiming to eliminate LF as a public health problem in the next ten years.

“Apart from assisting in the implementation of treatment campaigns, USAID has also helped to strengthen the monitoring and evaluation of these activities and to increase the knowledge and skills of program implementers at the central and local levels. The financial requirements of the LF Elimination Program are quite large; and though the government is striving to meet all of these needs, the additional support from USAID is warmly welcomed,” says Sianipar. “USAID’s support has been instrumental in helping Indonesia determine a sustainable path to achieving the elimination of LF throughout the country.”

Guest Author: USAID’s Act to End NTDs | East program, led by RTI International.

The U.S Agency for International Development (USAID) Act to End Neglected Tropical Diseases | East program supports countries to reach their NTD control and elimination goals through proven and cost-effective public health interventions. Building on experience, platforms, and progress gained through more than a decade of USAID investment in NTDs, Act to End NTDs | East provides critical support to countries in their journey to self-reliance, helping them to create sustainable NTD programming within robust and resilient health systems.

Photo Credit: RTI International/ Muhammad Fadli