Annual Progress Report

2008
LEPROSY CONTROL PROGRAME

South East Sulawesi Province

12 Februai 2009

1
Table of contents
List of abbreviations................................................................................................................................................................4
1.1 Geographical characteristics..........................................................................................................................................8
1.2 Infrastructure of the health care system.........................................................................................................................8
1.3 The Leprosy Control Program........................................................................................................................................9
1.3.1 Structure of the Leprosy Control Program...............................................................................................................9
1.3.2 Human resource.......................................................................................................................................................9
2 Analysis of activities............................................................................................................................................................11
2.1 Case finding, diagnosis, and classification..................................................................................................................11
2.2 Chemotherapy and Case holding (treatment)..............................................................................................................13
2.1 Prevention of disabilities...............................................................................................................................................14
2.2 Care and Rahabilitation................................................................................................................................................15
2.3 Planning and Organization(incl. integration)................................................................................................................17
2.4 Training.........................................................................................................................................................................18
2.5 Health Education to General Public..............................................................................................................................19
2.6 Supervision...................................................................................................................................................................20
2.7 Recording and Reporting..............................................................................................................................................22
2.8 Laboratory Services.....................................................................................................................................................22
2.9 Monitoring and Evaluation............................................................................................................................................23
2.10 Logistict and Maintenance ........................................................................................................................................24
2.11 Staff Employment......................................................................................................................................................25
2.12 New Inisiative.............................................................................................................................................................25
3 Epidemiological developments............................................................................................................................................27
3.1 Overview last ten years................................................................................................................................................27
3.2 Graphs..........................................................................................................................................................................29
3.2.1 CDR / 100.000 in the last 10 years, line graph.....................................................................................................29
3.2.2 Disability grade 2 proportion and child proportion in the last ten years, line graph...............................................30
3.3 Overview last year per district......................................................................................................................................31
3.3.1 Total number of patients per district.....................................................................................................................37
3.3.2 Mapping..................................................................................................................................................................38

2
4 Conclusions and recommendations ...................................................................................................................................39
5 Successes...........................................................................................................................................................................43
6 Annex..................................................................................................................................................................................45
6.1 Annex 1; counter budget..............................................................................................................................................45
6.1.1 Counter budget province........................................................................................................................................45
6.1.2 Counter budget districts.........................................................................................................................................46
6.2 Annex 2; Clofazimine stock and requirements.............................................................................................................47
6.3 Annex 3; MDT stock and requirement..........................................................................................................................47

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 List of abbreviations
APBD : Anggaran Pembangunan dan Belanja Daerah /Local Funding
CDR : Case Detection Rate
HC : Health Centre
IEC : Information Education and Communication
JPKMM : Jaring Pengaman Masyarakat Miskin/Fund for Poor People
KPD : Kelompok Perawatan Diri
MDT : Multi Drug Therapy
MB : Multi Basiler
Monev : Monitoring and Evaluation
NCLY : National Consultant for Leprosy and Yaws
NLA : Netherlands Leprosy Assistance
NLR : Netherlands Leprosy Relief
OJT : On the Job Training
PB : Pauci Basiler
PHO : Provincial Health Office
PNS : Pegawai Negeri Sipil
POA : Plan of Action
POD : Prevention of Disability
PTT : Pegawai Tidak Tetap
RFT : Released from treatment
RRI : Radio Republik Indonesia
RVS : Rapid village survey
SCG : Self Care Group
VMT : Voluntary Muscle Test
ST : Sensory Test
SWOT : Strength, Weaknes, Oppurtunity
TVRI : Televisi Republik Indonesia

4
Summary

The NLR had been supporting the Leprosy Control Program in Southeast Sulawesi since 1991. Because of some
reasons, the supports had been stopped in 2001 and continue in 2002 but only covered two regencies (Konawe and
Kendari). NLR started supporting for all districts since July 2004. In 2006, the local governments (provincial and districts)
started to allocate some fund for leprosy program. The advocacy efforts have continually conducted so that the local
governmental roles can more increase their efforts to cope with the leprosy problems in Southeast Sulawesi. In 2008,
there are two new districts (North Konawe and North Buton), so total districts in Southeast Sulawesi is 12. Increasing of
districts have implicates for more sub-districts and public health centers and need more funding, particularly for training
and building efforts through supervisions.

1. Case Finding

During January – December 2008, it is found 289 new cases of leprosy (CDR 13.5/100.000 populations), 269
cases (93.1%) was found through passively case findings, 20 cases (6.9%) was found by active case findings
(contact examination of new case, School Survay, RVS). The Proportion of children is 8 % and two-grade
physical deformity is 4.5%. The Child Proportion 8 % and Disability grade 2 proportion 4.5%.
The findings of this year are 20 cases higher (7.4%) than the previous year. This reflects improvement in
system of program implementation , either in public health centers, districts, or provincial level. This
improvement is supported by a number of activities that has been conducted so far. For example, training for
public health centers doctors and nurses, leveled supervision, the advocacy, monitoring, and evaluation both on
districts and provincial level. In public health center level, there are 18 public health center that not report the
finding of new cases in previously year, but report the new case findings this year. Decreased proportion of
disability grade 2 indicates the early findings before the people with leprosy get physical defect. This efforts of
early findings need to be kept to reach the leprosy elimination and eradication in Indonesia, particularly in
Southeast Sulawesi.

2. Prevalence

Prevalence rate on 31 Desember 2008 is 1.4 per 10.000 populations (294 cases), decrease by 0.1 compared
the last year (1.5/10.000 population). Nevertheless, province of Southeast Sulawesi has not reach the leprosy
elimination according to national target, i.e. less than 1/10.000 population.

5
 3. Case Holding

RFT rate for PB cases in cohort 2007 is 100%, and for MB case in cohort 2006 is 86%. This number is lower
than last year (PB 100% and MB 94%). Among 29 non-RFT patients, 19 patients was default, 7 patients was
moved, and 3 patients was dead. The default patients is due to some reasons, including weakened counseling
on early treatment that failed to make sure the patients to take medicine regularly and continuously. Moreover,
patients’ difficulties to get to the public health centers and less proactive leprosy staff (Juru) to trace the missing
patients are the other obstacles. For moved patients, it is necessary to make inter-regional coordination, and to
prevent the default needs good counseling so that the patients are not stopped for medicine.

4. Prevention of Disability

From cohort analysis on PB case in 2007, it is noted that there is no additional deformity, while on cohort MB
case in 2006, among 173 cases, there is one case (0.6 percents) experiencing additional deformity and 7 cases
(4 percents) experiencing declined deformity. The examination of POD is important to prevent the deformity or
additional deformity, so it is expected that all patients can be tested regularly with POD each month.

5. Care and Rehabilitation

Generally, the care on patients with leprosy has been conducted individually on public health centers. Self-
care on group through Self Care Group (SCG) is newly established on Mokoau public health center of Kendari
City, and it is expected that this will be followed by all district . Post-FRT Surveillance especially for former
defected patients has been proposed for rehabilitation activities, but not all district send their data so that
medical rehabilitation problems arise. The efforts of social rehabilitation have not conducted optimally; even the
commitment with related institution has been approved.

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6. Training
Leprosy Staff (Juru) who is trained this year is 24 and 15 doctors. Total leprosy staff (juru) who has been
trained since 2004 is 212, but only 162 who is still active in program. While total doctors who has been trained
is 101, but only 59 doctors is still active. Highly turnover, particularly non-permanent staff, is another challenge
that should be anticipated by local government to make sure the doctor availability with enough competence for
leprosy program. The percentage of public health center with trained officer and trained doctor are 76.4 and
27.7 percents, respectively.

Main Issue

Much substantial improvement has been reached in the Leprosy Control Program. Nevertheless, a number of
problems is still founded, either related with human resources, logistic, or budgeting policies. The number of public
health center with trained doctor is still inadequate (27.7 percents), Juru and wasor performance are not optimal,
highly default cases; i.e. 19 cases, inadequate POD (52 percents), contact examination is only 49 percents index
case, HE materials (poster, leaflet, lembar balik) and national manual book and atlas are inadequate, so that not all
public health center have it. During post-training, the juru’s knowledge and skill decreases, inadequately quality of
supervision, self care and management reaction is not optimal, there are also some district that have not prepare
sharing fund for leprosy program (58 percents).

Recommendation

It is necessary to add sharing fund from district and provincial level (APBD1 dan APBD2). It needs some training
for the doctors, the improvement of supervision quality on all levels, advocacy strengthening, supplying IEC
material (poster, leaflet), national manual book, pocket book for Juru and atlas that made by leprosy department
(subdit) should be distributed to all public health center. The fund allocation for non-permanent doctors (dokter
PTT) orientation and post-training assessment

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Introduction

1.1 Geographical characteristics

Number of inhabitants 2.143.040

Number of districts 10

Number of municipalities 2

% urban area 16,3 % which consist of 3 district with

population 646191

% remote area (difficult to reach) 32,8 % archipelago , consisted of 4

district with population 795331

Other specific characteristics 4 archipelago district which only can be

reached with boat when good weather.

1.2 Infrastructure of the health care system

Number of government hospitals 1 General Province Hospitol, 10 District

Hospitol, 2 Militery Hospitol
Number of private hospitals 9
Leprosy hospital No
Total number of puskesmas/HC 212

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1.3 The Leprosy Control Program

1.3.1 Structure of the Leprosy Control Program

The Leprosy Control Program is combined with the TB Yes, at most all aspects in Health Centre and district level, but
Program only some activities at provincial level

The Leprosy Control Program is combined with the TB 129 Healt Centre dan 2 General Hospital
Program
Number of Puskesmas with NO registered leprosy patients 83

1.3.2 Human resource

number trained
total number
(of presently working staff)
Provincial leprosy doctor 1 1
Provincial Wasors involved in
2 2
Leprosy Control Program
District leprosy doctor 1 1
District Wasors involved in
13 10
Leprosy Control Program

number of capable
total
and available
number
facilitators
Available facilitators
(trained through TOT 5 5
total number total number trained
number trained in reporting (of those still working for the programme)
trained year

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 In Puskesmas with In Puskesmas with NO
registered leprosy registered leprosy
patients patients
Doctors
101 15 44 15
Jurus
212 24 106 56

Trained TOTAL Still in Programme

2004 2005 2006 2007 2008
Doctors 14 19 17 36 15 101 59

Jurus 20 36 92 40 24 212 162

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2 Analysis of activities

2.1 Case finding, diagnosis, and classification

Kegiatan Hasil Sumber dana

Contact Examination:
20 contact per new patient was
examined, with target 70% new
case ( 258 cases) or 3612
contacts.
126 new cases was done contact examination or 49% NLR
from new case index, lower than target ( 70%) 1716 APBD 2
contacts examined or 48 % from target ( 3612)
Average 7 contacts per new case
From contact examination we found ] 20 new cases
( MB 14, PB 6) and among them nothing deformity .

Explanation

The target of contact examination has not reached because of following reasons:
• In some district with hard geographical area (Wakatobi, North Buton, North Kolaka regencies), Juru confront some
difficulties to reach the patients for contact examination, and need expensive cost to make the examination.
• There are only 8 district reporting the activities of contact examination.

• Cross-regional patients is difficult to exam their contact.

• Patients who live either with their nearly family or another family reject to be examined for their contact, because
there are afraid to be known as people with leprosy

Kegiatan Hasil Sumber dana

Rapid Village Survay ( RVS) was APBD 2
done in Kolaka Utara at 5 village Found 9 new patients ( 7 MB and 2 PB)

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Explanation:

These activities are actually not planned in POA, but North Kolaka make budgeting through APBD2. It is expected
that the implementation of RVS can be conducted better in the future by all district and still making good coordination
with provincial team.

Kegiatan Hasil Sumber dana

School Survay to 17 Elementary APBD 2
School Kolaka Utara • Found 2 new case ( PB 1,
and MB 1)

Explanation :

This activity seems not efficiently and this has been discussed in MONEV Meeting 2009 that attended by all division
heads and wasor from the district.
Beside contact examination, an active findings that highly suggested and already have the commitment is RVS.

Kegiatan Hasil Sumber dana

Diagnosis Confirmation There is no complete information APBD2
about confirmation diagnosis

Explanation :

The confirmation of diagnosis is held by Wasor on the newly-reported patients by public health center. The allocation
of APBD2 budget for this activity is only conducted in Kolaka . It is not obtained information how much patients who
done by diagnosis confirmation. For cost efficiency, this activity should be combined with supervition activities.

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2.2 Chemotherapy and Case holding (treatment)

Kegiatan Hasil Sumber dana

To treat all new cases with MDT.
To treat 206 MB case (kohort
2006) dan 47 PB case (Kohort
2007)
All new cases was treat with MDT on time
• 47 PB case (cohort 2007) have NLR
RFT(RFT Rate PB 100 %).
• 177 MB case (cohort 2006) have RFT
(RFT rate 86 %)

Explanation :
There are 29 patients categorized not RFT for some reasons; 3 patients died, 7 patients moved, and 19 patients
default. Highly mobility among the population make many patients move into other region. Inadequately counseling
on newly patients and their family contributes highly default cases where the patients experiencing drugs reaction or
leprosy reaction during treatment often stop the treatment, and patients felt that such treatment did not give any
progress as they expect, such as repairing lesions or deformity. In some district with hard geographical area, the
patients face some difficulties to reach the medicine in public health center. For these reasons, creativity is needed
from each region to anticipate the causes of default case

Kegiatan Hasil Sumber dana

Levying of 2000 sheets leaflet for
counseling new patient
Quality of leaflet good enough. Leaflet
contains counselling for new patient, NLR
caused of leprosy, leprosy can be healed
if takes medicine regularly, danger if not
regulary taken medicine, etc.

Explanation :

Leaflet have been distributed to each district for distribute to each Healt Centre.

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 Kegiatan Hasil Sumber dana
Detection of Patient that absent There is no adequately information about APBD 2
patient was traced

Explanation :

Three districts that budgeting this activity are Bombana, Kolaka, and Buton. The trace was conducted by public
health centers’ Juru and the doctor (if needed). There is no adequately information from the district about this activity,
particularly of the number of traced-patients and the follow-up action from that activity. In Monev Meeting, it is
suggested that every region may conduct the same activity and send the data of activity results to the provincial level
functioned as analysis materials for provincial team

2.1 Prevention of disabilities

Kegiatan Hasil Sumber dana

Test of Nerve Function each
month for 95 MB patients and 39
PB patients .
By the end of cohort there was no
increasing deformity to patient was done NLR
test of nerve function monthly , but from APBD 2
patient that was not routinely examined
there is 1 patient with increasing deformity.

Explanation
The patients who follow Nerve Function Test routinely are only 52 percents. Following some reason of this: only 8
regencies make the activities report, a number of patients did not come routinely to take the medicine because of
some reasons (far distance and difficulties to reach for the public health center, lowly motivation to get medical
treatment, problems arise when treatment such as drug reactions and leprosy reactions), Juru are not aware of the
importance of the activity so that they did not conduct it routinely.

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 Kegiatan Hasil Sumber dana
Treatmen 31 patient with severe 33 Patients can finalize treatment of NLR
reaction ( 22 reaction of type I reaction without increasing deformity, but 1 APBD 2
and 9 reaction of type 2) that patient increasing deformity.
requires prednisone and 3 Both patients referred to Province General
patient experiencing recuring Hospitol can be handled carefully
ENL reaction requiring clofazimin
and prednisone. Two patient
with chronic ENL was refered to
Provincial General Hospitol.
Penjelasan :

2.2 Care and Rahabilitation

Kegiatan Hasil Sumber dana

Levying of Packet of for limbs / Not Realized
shoes fitting NLR

Explanation

There is no district reporting patient requiring limbs/shoes fitting. Survailans patient post RFT doesn't run at Health
centre level, so patient have RFT not been watched by Juru.
There are no districts that report the patients requiring limbs/shoes fitting. The reason is that the surveillance of post-
RTF patients does not conducted in public health centers’ level so that the patients who categorized as RFT is not
monitored by public health center Jurus.

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 Kegiatan Hasil Sumber dana
Refers 1 patient from Kolaka Patient successfully was handled carefully NLR
Utara with recurrent ENL reaction and back to Kolaka Utara in good APBN (Jamkesmas)
with heavy generality condition. APBD (Bahteramas)

Explanation :

The patients was successfully handled because of some reasons; good cooperation among provincial team, district
team, hospital and specialist doctor at the hospital. Even though, in the beginning, the patients and their family reject
to be referenced, but provincial and district teams convince them. Team working ranged from patients delivery,
acceptance in emergency room (UGD), and accompanying during at hospital and also good coordination with hospital
and specialist doctors make patients felt comfort and save, so that they have willingness to get into the treatment until
their good condition. Furthermore, the patients are then take back to North Kolaka district. The availability of
Jamkesmas (APBN) and Bahteramas (APBD) absolutely help the funding of the treatment, while the NLR give their
supports in form of patients transport.

Kegiatan Hasil Sumber dana

Levying of protective device ; Not realized NLR
eyeglasses and 5 protective
footwear and treatment wound

Explanation :
There is no district reporting patient requiring protective device .

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2.3 Planning and Organization(incl. integration)

Kegiatan Hasil Sumber dana

Meeting district health manager Not Realized NLR
for advocacy and planning APBD

Explanation

This meeting will be funded by Sharing Funds of NLR and APBD, but as there is no APBD, then fund from NLR was
assumed inadequate to invite all district health manager (Kepala Dinas). But because of the importance of this
meeting, especially in context to get the supports of program integration policies, it should be make the combination
via budget sharing with another meeting in the province attended by district health manager .

Kegiatan Hasil Sumber dana

Meeting of Staff Puskesmas in
10 district
NLR
Done at 9 district except Konawe Utara. APBD
Some commitment agreed on:
• Integrates Leprosy Control Program in
other program
• Increases active case finding, POD,
Contact Examination
• Commitment for allocation budget of
HC’s operational and fund JAMKESMAS
for the activity of Leprosy Control
Program .

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 Explanation :

To strengthen better commitment to increase the quality of implementing Leprosy Control Program in public health
center level, the meeting should be attended by Jurus, doctors and the head of public health center, as the material
of meeting does not only include case management, but also program management, including funding policies in
public health center level. However, as the sharing fund from APDB is not realized, then, in some districts, the
meeting is only attended by Jurus , or meeting only attended by some Public Health Centrein district..

2.4 Training

Kegiatan Hasil Sumber dana

1 batch training for HC’s jurus 1 batch training for HC jurus have been
(24 jurus) done 5 days . The training was joint by 20 NLR
partisipant from 8 district

Explanation

All participants trained have never been trained before all, but it has been a long time works in program p2kusta.

Kegiatan Hasil Sumber dana

1 batch training for HC’s doctors 1 batch training for Public Health Centre’s NLR
(15 doctor) doctors have been done . The training was
attended by 15 participant from 7 district

Explanation :

Medical doctor following this training was PNS, and majored from puskesmas having leprosy case.

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 Kegiatan Hasil Sumber dana
Training of Village Midwife This training followed 6 village midwife NLR
from 6 health centre APBD 2

Explanation :

This meeting will attended by 19 villages midwifes, but because of sharing fund of APBD2 is not realized, it, in fact,
only attended by six villages midwifes. The training was aimed to support PHC’s Jurus, especially for case finding,
medicine controlling, managemen reaction, self-care and leprosy-counselling in their working area.
Training Subjects: the epidemiology of leprosy disease, the diagnosis and classification, Treatment, leprosy reaction
and deformity.

2.5 Health Education to General Public

Kegiatan Hasil Sumber dana

Radio Spot in RRI, Swara Alam Radio, NLR
Radio Spot in RRI and Raodah FM Radion. Broadcasting of APBD
3 times one day with duration 5 minute.

Explanation

Radio spot contains short messages on leprosy disease, early signs of leprosy disease, leprosy can be healed, the
medicine is obtained freely on public health center and suggested with local pattern. For Indonesian Broadcast
(RRI), it has covered all district of southeast Sulawesi, while Swara Alam Radio covers all areas of Kendari City,
Konawe and South Konawe districts, and Raodah FM reach out all areas of Kendari City with youth segment. To

19
 increase the information explanation via radios, it is expected that all local radios (FM and AM) can broadcast the
same radio spot.

Kegiatan Hasil Sumber dana

Commemoration of World NLR
Leprosy Day Done with making 16 banner and leaflet of APBD
leprosy 1500 sheets.

Explanation :

All Banners and Brosur has been distributed to kabupaten/kota.

2.6 Supervision

Kegiatan Hasil Sumber dana

Supervisi oleh Tim Provinsi di
daerah endemis tinggi(12
kabupaten ).
Supervision by provincial team in
high endemic area (12 district ).
Supervision was done 2 times per year per NLR
district for 12 district. Supervition done by;
Provincial Wasor , Leprosy Medical Doctor,
Kasubdin, and Kepala Seksi according to
requirement of the supervision and problems is
field with highest proportion on wasor.

Explanation

Ideal supervision should be conducted at least 4 times a year. This can be held by sharing fund APBD, but because
ABPD fund is not budgeted for that, the supervision is only held 2 times a year. In some districts, particularlynew
districts, the supervision frequency should be increased as it not only needs more intensively technical assistance
from provincial wasor, it needs also technical building from the heads of Sub-department and sectional about the

20
program policies. Likewise, in districts with newly wasor or even with wasor who have not follow the wasor training
(four regencies), the technical assistance from province should be conducted intensively.

Kegiatan Hasil Sumber dana

Extra Transport for 5 district or Realized for 5 district ( Wakatobi, Buton, NLR
health centre at remote area Buton Utara, Bombana, Kolaka Utara)

Explanation :

Some district has areas that hard to be reached and need larger transportation cost to hire automobiles. They are
North Kolaka, Wakatobi, North Buton, Buton, Bombana. In these districts , the implementation of supervision some
times must wait for specific seasons.

Kegiatan Hasil Sumber dana

District supervision 4 times to District Supervision 2 times to health NLR
health centre which easy centre which easy reached and health APBD
reached and health centre which centre which difficult to be reached
difficult to be reached

Explanation

Supervision plan 4 times, but done only 2 times because fund sharing APBD is not exist. The supervision of
provincial wasor was aimed to estimate the regency wasor’s performance in making supervision to the public health
center dan give technical assistance if needed.

Kegiatan Hasil Sumber dana

PL /PC supervision at 5 district (20 5 district have supervised by PL dan PC NLR
days)

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 Explanation
Supervision PL and PC was doing if any problem; especially technical problem, policy, and monetary

2.7 Recording and Reporting

Kegiatan Hasil Sumber dana

Supplying of Register Book There is no complete information about APBD 2
,Form POD,and Form amounts form and register book
Prednisone .

Explanation
The supplying was conducted by Bombana and North Kolaka ditricts, but there is no information from both regencies
about the number of supplying. It is expected in the future that all districts can establish themselves formats needed
for Leprosy Control program

2.8 Laboratory Services

Kegiatan Hasil Sumber dana

Slit Skin Smear 39 Terealisasi 20 skin smear, 10 yang
Cros Check 10 dilakukan wasor, dan 10 di Laboratorium NLR
Kesehatan (dari rujukan dokter praktek)
20 skin smear was done, 10 done by
wasor, and 10 in Laboratorium Kesehatan
( from medical doctor reference)

Explanation
The activity of Skin Smear Obtaining was conducted by wasor for diagnosis confirmation, particularly for doubtful
cases. Some cases was also conducted at health laboratory that is reference from skin specialist doctors, or private
doctors and public health centers’ doctors.

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2.9 Monitoring and Evaluation

Kegiatan Hasil Sumber dana

NLR Project Leader Meeting The meeting was attended by project
leader during 4 days (20-23 August 2008) NLR
in Surabaya
.
Explanation

The meeting results some agreement; it is necessary to have counter budget of APBD 1 and II for leprosy program,
financial management should prepare the plans of quarterly activities and funding estimation as well as innovative
activities to increase the findings of patients.

Kegiatan Hasil Sumber dana

The Monitoring and Evaluation
Meeting and Refreshing Course
that followed by district wasor
(two times).
Two times Monev Meeting has been held NLR
that followed by provincial teams and all
district wasors.
It is agreed to increase further the quality
of supervision and Jurus building, financial
transparency between regency and
province, uniform recording and reporting,
on-time reporting, refreshing course.

Explanation

A number agreement has been resulted in this meeting. However, wasor is not the policy maker in district level. For
agreement related with budgeting policies and cross-program, it is far better if this Monev meeting will be attended
by the heads of sub-department (Kasubdin) in each district.

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2.10 Logistict and Maintenance

Kegiatan Hasil Sumber dana

Maintanance and Fuel for Have been purchased according to the
provincial car need, for example for : Diesel fuel, Oli, NLR
vehicle repair, replacement of Access,
Vehicle Tax

Explanation :

With obsolete automobiles age (11 years) and difficult geographical condition in some district, the existing
automobiles should be replaced with newly automobiles. Nowadays, the maintenance cost becomes high as
frequently damages occurred after field visiting on the region with bad road conditions.

Kegiatan Hasil Sumber dana

Maintanance and Fuel for district Have been purchased according to the NLR
motor cycle. need

Penjelasan
It suggested to add operational automobiles for three wasor as there are three broaden districts, and one regency
(Kolaka) has hard-damage operational automobiles.

Kegiatan Hasil Sumber dana

Office stationary and cost in Have been purchased according to the need NLR
province

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 Penjelasan

2.11 Staff Employment

Kegiatan Hasil Sumber dana

Allowance for project leader, Has been paid according to planning NLR
project coordinator and book
keeper

Explanation

There are still no insentives for wasor, if remembering that the working burden and responsibility on wasor is really
hard and should be considered to give intensives each month. .

2.12 New Inisiative

Kegiatan Hasil Sumber dana

Regional Meeting Executed in Manado 16 to 19 june 2008 NLR
and followed by PL and Provincial Wasor.

Explanation
In this meeting, province of Southeast Sulawesi show the success in developing reference system. This success is
resulted from good cooperation among district/public health center teams, provincial team and hospital/specialist
doctors. There are efforts to catch the patients who needs reference, convince the patients to reference them, to pay
attention and help them during the treatment, routinely coordinating with referred-specialist doctor, give
understanding to the nurses who treat the patients.
Beside, another issues becoming learning subjects for Southeast Sulawesi team are:

25
Establishing of self care group, the implementing of RVS, Local Alliances for Eliminating Leprosy in local area,
exploring fund from APBD, remote area activities. From such activities, some activities that has been implemented
in province of Southeast Sulawesi are establishing Self Care Group and Fund Exploring from APBD. This meeting
give much benefit for all district to get innovative inspiration from another region.

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 3 Epidemiological developments
3.1 Overview last ten years
Indicators 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Total population x 1000 1,689 1,690 1,815 1,815 1,825 1,874 1,915 1,965 2,093 2.143

New detected cases PB 63 55 42 29 22 18 34 52 47 42

New detected cases MB 191 201 174 151 151 147 233 206 222 247
Total 254 256 216 180 190 165 267 258 269 289

MB % 75,2 78,5 80,6 83,9 79,5 89,1 87,3 79,8 82,5 85.5
CDR per 100.000 15 15 12 10 10 9 14 13 13 13

% disability grade 2 in new

5.5 4.3 12.5 7.2 4.2 7.3 8.2 10 10 4.5
cases
% children < 15yr in
11.0 0.8 4.2 7.2 8.9 9.7 9.4 10 7 7.9
new cases

% females in new cases 35% 41% 38% 37% 32% 40% 38% 34% 39% 46.1%

Registered cases PB 44 29 27 13 20 13 11 31 30 21
Registered cases MB 221 225 191 179 208 181 265 233 277 273
Total 265 254 218 192 228 194 276 264 307 294
Prevalence per 10.000 1.57 1.50 1.20 1.06 1.25 1.04 1.44 1,3 1,5 1.4

RFT rate MB (Kohort MB 2

94.0 90 86.5 89.6 90 87 93 91 94 866
tahun ke belakang)
RFT rate PB (Kohort PB 1
92.3 90 98.5 100 100 100 100 100 98 100
tahun ke belakang)
Indikator 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Total number of cases with 39 18 19 29 22 56 39 45 15 31
severe reaction (including

27
ENL)
From the above number, the
number of cases with chronic 1 0 2 1 3 2 0 2 1 3
ENL
Number of relapse cases 2 0 2 3 2 3 2 1 0 1

Number of Dapsone allergy

1 2 0 3 0 1 0 1 3 1
cases
Number of deaths due to
0 0 0 0 0 0 0 0 0 0
Dapsone allergy

Case finding method

Passive Case Finding
187 125 167 134 140 121 189 177 217 269

Contact Examination
7 7 13 9 14 11 25 11 19 20

School Survey
0 0 0 0 0 0 0 0 0 0

Other Surveys
60 59 0 0 4 1 1 0 33 0

Yes input through Kendari District Health Office and

Data of hospitals are
sent to Provincial Health Office . since: 1996
included

28
3.2 Graphs
3.2.1 CDR / 100.000 in the last 10 years, line graph

LEPROSY PR AND CDR OF SOUTH EAST SULAWESI PROV.

1999 - 2008

16 1.57 1.6
15 15
1.5 1.5 1.5
14 1.44
14 1.4 1.4
13
1.3 13 13 1.3
1.25
12 12
1.2 1.2
1.06 1.1
10 10 10 1.04 1
9 0.9
CDR

PR
8 0.8
0.7
6 0.6
0.5
4 0.4
0.3
2 0.2
0.1
0 0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Years

From the tabel above, it seems that during 1999 to 2004, CDR and PR showed declining trend, but then showed
inclined trend until 2008. In last three years, CDR shows constantly rate, while PR decreases in a last year. The
declined trend until 2004 can be related with the stopping NLR-supported funds and, in the same time, there is no
APBD fund to implement the P2 leprosy program. The inclined trend in the next year is related with available NLR-
supported funds and cover all regency/cities. Moreover, a number of regencies is started to conduct the funding
via APBD2.

29
3.2.2 Disability grade 2 proportion and child proportion in the last ten years, line graph

CHILD AND DISABILITY GR 2 PROPORTION IN SOUTH EAST SULAWESI

1999 - 2008

14
12.5
12
11
10 9.7 10 10
9.4
8.9
8 8.2 7.9
7.2 7.3 7
6
5.5
4 4.3 4.2 4.2 4.5

0 0.8

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

DISABILITY PROP CHILD PROP

Since 2000, the Child proportion increases until 2006 and then decreases until 2008. for Disability grade 2
proportion, there is increment from 2003 to 2006, but decreases until 2008.

30
 3.3 Overview last year per district

Disability Total nr. Child Total nr. PR/

CDR / New prevalen
No. DISTRICTS Population
100.000 cases
MB % grade 2 disability Proportio child
proportion grade 2 cases si
n 10.000

1 KONAWE 245.098 7 17 100 0 0 0 0 16 1

2 BUTON 281.671 18 50 82 8 4 6 3 57 2
3 MUNA 264.450 10 27 74.4 7.4 2 11.1 3 20 1
4 KOLAKA 284.714 13 38 92.1 3.1 1 - - 34 1
5 KENDARI 272.808 8 23 82.6 0 0 4.3 1 22 1
BAU -
6 32 35 77.1 6.3 2 9.4 3
BAU 108.933 42 4
7 KONSEL 224.749 8 18 94.4 11.1 2 0 0 20 1
8 BOMBANA 122.507 23 28 89.3 0 0 10.7 3 25 2
WAKATOB
9 7 5 80 0 0 0 0
I 73.880 5 1
KOLAKA
10 27 34 91.2 0 0 26.4 9
UTARA 124.551 38 3
KONAWE
11 6 5 100 0 0 0 0 7 1
UTARA 86.866
BUTON
12 15 9 44.4 22.2 12 11.1 1 8 2
UTARA 52.823
Jumlah 2,143,040 13 289 85.9 4.5 13 7.9 23 294 1.4

Tabel above indicate the data in 2008 in province of Southeast Sulawesi, new cases is mostly founded in Buton district
(50 cases) and lowest case in North Konawe district. The district with highest CDR is Bau-Bau (32/100.000) and lowest
is Wakatobi and Konawe district (7/100000), while the highest prevalence is Bau-Bau (4/10.000).

31
3.3.1.a Leprosy Prevalence Rate South East Sulawesi Per District 31 December 2008

ANGKA PREVALENSI PER KABUPATEN/KOTA PROP. SULTRA PER

31 DESEMBER 2008

1
1
Wakatobi
1
1
Kendari
1
1
Muna
1 Prev.

2
Bombana
2
2
Buton
3
4
Bau - Bau
0 1 2 3 4 5

From graphic above, it seems that the highest prevalence rate is Bau-Bau City (4/10.000 populations), followed by North
Kolaka district (3/10.000 populations).

32
3.3.1.b. Case Detection Rate (CDR) in South East Sulawesi per District 31 December 2008

ANGKA CDR PER KABUPATEN/KOTA PROP. SULTRA

TAHUN 2008

Konut 6
Wakatobi 7
Konawe 7
Konsel 8
Kendari 8
Muna 10
CDR
Kolaka 13
Butur 17
Buton 18
Bombana 23
Kolut 27
Bau - Bau 32

0 5 10 15 20 25 30 35

33
From graphic above, it seems that the highest CDR is Bau-Bau City (32/100.000 populations), followed by North Kolaka
district (27/100.000 populations), and Bombana district (23/100.000 populations), whereas the lowest is North Konawe
district (6/100.000 populations).

3.3.1.c Disability Grade 2 Proportion of Each District in South East Sulawesi province 2008

PROPORSI CACAT TINGKAT 2 DIANTARA KASUS BARU

TAHUN 2008

25
22

20

15
11
%

10 8
7
6
5 3
0 0 0 0 0 0
0

na
au

e
ri
on

ut

i
l

a
ur

ut
a

ob
se

aw
da
un

ak

on

ol
ut

-B

ba
ut
on

at
en
ol
M

K
on
B

K
au

om

ak
K

K
B

W
B

From graphic above, it seems that North Buton district is the highest in disability grase 2 proportion (22), followed by
South Konawe district (11), while in six regencies, i.e. Kendari, Konawe, North Konawe, North Kolaka, and Wakatobi,
there is no new case with disability grade 2 among newly people with leprosy founded in 2008.

34
3.3.1.d Child Proportion of Each District in South East Sulawesi Province 2008

CHILD PROPORTION OF EACH DISTRICT

IN SOUTH-EAST SULAWESI PROVINCE 2008

30
26
25

20
%

15
11 11 11 9
10
6
5 4

0 0 0 0 0
0

i
ob
el
t

t
n

Kolu
a
r

nu
tu

ns
to

at
un

ri

ka
au

a
Bu

na

Bu

Ko

ak
Ko

e
M

nd

la
w
-B
ba

W
Ko
Ke

na
m

Ko
Bo

Ba

35
From graphic above, it seems that the highest proportion of children is North Kolaka district (26), followed by North Buton,
Bombana, and Muna district (11 respectively), while in five districts i.e., South Konawe, Konawe, North Konawe, Kolaka,
and Wakatobi, there is no children case among newly people with leprosy founded in 2008.

Nr. of severe
Nr. of chronic Nr. of Dapsone Nr. of deaths due to
No. DISTRICTS % females reaction
ENL cases
Nr. of relapse
allergy cases Dapsone allergy
(including ENL)
1 KONAWE 47.1 - - - - -
2 BUTON 50 - - - - -
3 MUNA 48.1 9 1 - - -
4 KOLAKA 37.5 3 - - - -
5 KENDARI 34.8 - - - - -
6 BAU - BAU 57.1 6 - - - -
7 KONSEL 22.2 2 - - - -
8 BOMBANA 38.5 - - - - -
9 WAKATOBI 100 - - - - -
10 KOLAKA UTARA 45.5 3 2 - - -
11 BUTON UTARA 25 - - - - -
12 KONAWE UTARA - - - - - -
23 3 1 1 -

36
3.3.1 Total number of patients per district

SOUTH EAST SULAWESI PROVINCE 2008

60
50
50

40 38
35 34
28 27 Jumlah pend
30
23 Baru/Kab.Kota

20 18 17

9
10 5 5

0
na
au

ri

e
au k a

i
K sel
K n

ur

ak t
a
om t

ob
B ol u

W onu
da

aw
o

un
ba

ut
-B
a
ut

on

at
en
ol

on

B
B

K
K
K
B

37
Generally, the way to found the new case in all districts is same; that is, passive case finding and active case finding via
contact examination .

3.3.2 Mapping
PETA KABUPATEN/KOTA PROP. SULTRA

Kab.Konut
Kab.Kolut

Kab.Konawe

Kab.Kolaka
Kota Kendari

Kab.Konsel

Kab.Butur
Kab.Bombana

Keterangan : Kab. Muna

- < 5 / 100.000 penduduk
- 5 – 10 /100.000 penduduk Kab.Buton
- >10/ 100.000 penduduk
Kab. Wakatobi

38

4 Conclusions and recommendations
STRENGTHS
• Supports from the head of health department.
• Operational fund aid from NLR, APBD2 (some
districts)
• Consultants from NLYC
• Trained wasors for leprosy program in district
and provincial level (2 wasors)
• Training facilitators (5 facilitators)
• MDT for Leprosy program every district.
• Proper recording dan reporting system based
on national manual.
• Prednisone can be obtained in each public
health center/district.
• Trained Juru and doctors for leprosy
• Good cooperation with hospitals.
Kota Bau-Bau
WEAKNESSES
• Leprosy Program has not entirely integrated.
• The performance and motivation for some Jurus is not
optimal.
• The Leprosy Control Program in all districts is not the
priority .
• Proportion of public health center with trained Jurus is
only 76.4 percents, trained doctors 27.4 percents
• Many Jurus have other tasks in public health center.
• The support and commitment on some local
governments have not optimal .
• Some district wasors and public health center’s Juru did
not conduct the examination of nerve function (POD)
routinely and properly based on the manual.
• The supervision from district team is not effective and
efficient.
• Inadequate KIE material, posters and leaflets in district
and public health centre level.
• Social and medical rehabilitation activities have not
conducted.
39
CONCLUSIONS
• Technical and fund supports from NLR have
been very helped in assisting the
implementing of Leprosy Control program in
province of Southeast Sulawesi. But however
it have not covers all activities.
• The efforts of case finding through contact
examination are not conducted optimally; just
49 percents of 70 percents target.
• The Examination of nerve function (POD) in
routine is still low, just 52 percents.
RECOMMENDATIONS
• NLR only supports a few among many activities in
Leprosy Control program, so that it is expected for local
governments (province and district) to fund activities that is
not registered into NLR funding. For that reason, it is
necessary to make advocacy efforts to the policy maker in
each region.
• The broadening of district, sub-district and public health
center areas have consequences on additional cost burden,
particularly in increasing the human resources (training for
Juru and doctors), supervision, monitoring and evaluation,
HE material supplying, so that it is suggested that there will
be additional fund, either from NLR, APBN, APBD1, and
APBD2.
• Limited facilities, transportation cost especially for
regions that hard to reach make public health centers’
leprosy officer (Juru) have no initiatives to make contact
examination. For that reason, the local government should
allocate the fund through APBD2 or Jamkesmas for contact
examination
• Some patients do not take medicine regularly and
continuously and get medical check/ examined of POD for
40

• RFT rate for PB is 100 percents,but MB is still
low (86 percents)
• Some districts (7 districts) has been allocate
the fund for Leprosy Control program, but
there is not adequate coordination with
province about the kinds of activities,
technical implementation, and output from
such funding.
• Self Care group is not conducted optimally
(just established 1 SCG in Kendari City.
Instead, it is difficult to keep its existence),
whereas social and medical rehabilitation
have not conducted.
• The meeting of Head of Health Department
(Kepala Dinas Kesehatan) for Advocacy and
Planning is not conducted, whereas the
meeting of public health center staffs in district
level is only conducted in 9 of 10 districts
planned.
• The efforts of Public Health Education via
some reason (transportation, inadequately understanding
about importance of routine examining). Moreover, Jurus
have not understand entirely the importance of that
examination so that have no motivation to do that. Thus, the
leprosy officer (Juru) should make good counseling about
the importance of get to the public health center in routine,
without accompanied with their family. Moreover,
assistance via on the job training for Juru conducted by
wasor should be better intensified.
• Coordination between districts and province is not
conducted well particularly in planning activities. Thus, it is
necessary to get some agreement in a meeting involving
provincial team with all heads of health department of
districts for transparent funding program.
• There are obstacles to inventory the patients post-RTF
that experiencing deformity. Thus it needs commitment in
district level to activate survailance pasca RTF patients that
causing enable forming SCG at every district.
• Local Funding (APBD) Sharing Fund to present all
district heads of health department is never realized, so
that it is not possible to make meeting attended by the
heads of department. Thus it needs good coordination with
planning division and cross-program to make a head of
department meeting via fund sharing with another
programs.
41
 Radio Spot has been cover about 60-70 %
population in Southeast Sulawesi .
• Provincial and districts Supervision held two
times a year is still low. Moreover, the quality
of supervisor is also important to increase.
• Monev Meeting that only attended by district
wasors does not guarantee successful
agreement, particularly related with the
policies of program funding.
• IEC materials (poster, leaflet) related with
leprosy ,
• National manual book, and Atlas in public
health center is inadequate.
• It is no doubtful that radio media is not so interesting for
public compared with television. So that it is necessary to
establish radio spot as interesting as possible for their
audiences
• As supervision budgeting is only two times from NLR,
while ideally it should be conducted four times, it needs
some efforts to increase the frequency of supervision to be
four times by three alternative ways; adding supervision
funding from NLR funds , budgeting from APBD1, or if all
that not possible, it should used a “selective area” for
supervision, that is, the supervision is only conducted on
specific areas but more intensively and the frequency is
increased. Beside from quantity aspect, the quality of
supervision in all level should be increased.
• The consequences of adding the participants of monev
meeting is cost increment, so that it needs coordination with
the planning division of provincial health department for the
possibility to apply the sharing budget with other meeting for
the heads of sub-departemen of P2M in district to
participate
• Available stigma adhered on public should be replaced
by increasing the activities of health education and health
promotion. Thus, it is necessary to supply IEC material
(poster, leaflet) to the leprosy sub-dit, distributing the
information via mass media, Radio Spot, Interactive
Dialogue in television .
• National Manual Book, pocket book for Juru and atlas
made in Subdit should be distributed to all district and
province immediately.
42
 • Proportion of public health center having
trained Juru is only 76.4 percents, trained
doctors 27.4 percents.
• Self Care by using protective device
( eyeglasses, footgear) and rehabilitation by
hand spurious and peg leg not run optimal
• Post training , knowledge and skill HC’s Jurus
quickly experiences degradation.
• Leprosy Program has not entirely integrated,
either on Public Health center and district
level
5 Successes
• Doctor turnover is extremely high and making doctor
training is not so effective as many doctor still served as
non-permanent doctors (PTT) with short period 6-12
months. To anticipate it, it needs short training or one day
orientation for non-permanent doctors either conducted in
provincial level with APBD fund or in district level with
APBD2 fund.
• There is no surveillance data on post-RTF patients
particularly patients who experiencing physical defect from
districts. Thus it is expected that they does not only take
care of patients who is on treatment (not yet RFT), but they
also send in routine data of patients who need care and
rehabilitation.
• To maintain the competence (knowledge, skill and
attitude) among post-training jurus, it needs Post-Training
Assessment in post-training first 1 or 2 months . Continous
guidance and assistance from the district wasor is needed
especially at the firs of semester of after the training "
• Program ego should be decreased and building the
commitment on districts and public health center levels to
integrate Leprosy program to another program .
43
 One of success was reached in province of Southeast Sulawesi in 2008 is that success in developing the reference
system that in previously years is not conducted well. The success was achieved from good cooperation among
districts teams, provincial teams, hospital/specialist doctors. Following the activities conducted by team:
• The district team is in cooperation with public health center to identify patients who need reference.
• The district regency and public health center’s teams convince patients and their family to be referenced, but in
one case, the provincial team was involved to convince the patients to try to eliminate their afraid and guarantee
them during medical treatment at hospital.
• The public health center accompanies patients and provincial team accepts them at hospital.
• Provincial team previously coordinated with hospital and specialist doctor about patients with leprosy who will
be referred.
• During medical treatment in hospital, every day provincial team monitors and accompanies the patients to give
supports, make them save and comfort, particularly related with various daily needs for patients and their family.
• Every day, provincial team coordinates with specialist doctors who treat the patients to find out the last condition
of patients.
• After patients is getting good and considered possible to back home, the provincial team accompanies the
patients to their own

During the year 2008 patients made reference to by RSUD counted 4 people ( Kolaka Utara, Kolaka, Wakatobi, and Kendari) all is because
reaction of chronic ENL with komplikasi ( 3 people) and ulcus + osteomyelitis ( 1 people). All the patient can return kedaerah in good condition.
During 2008, the patients who referred to Local General Hospital (RSUD) is four patients (North Kolaka, Kolaka, Wakatobi
and Kendari) where all of them is referred because of chronic ENL reaction with complication (3 patients) and ulcus +
osteomyelitis (1 patients). All patients are finally backed home with good condition.

44
6 Annex

6.1 Annex 1; counter budget

6.1.1 Counter budget province

YEAR ABPN ABPD1 NLR Other

% of Total
Amount % of total Amount % of total contribution funding
total (Rp)
(Rp.) (Rp.) (Rp) (Rp)
1999

2000

2001

2002

2003

2004 240.000.000 500.000 240.500.000

2005 - - - - 279,269,136 - 1.765.000 281.034.136

2006 - - - - 287,200,292 - 40.530.500 327.730.792
2007 74,980,000 13,5 45,000,000 8,1 436,155,100 78,4 75.709.000 631.844.100

2008 - - 446.099.625 89.490.000 535.589.625

45
 6.1.2 Counter budget districts

Local funding (ABPD2 and other funding)

2003 2004 2005 2006 2007 2008
No Kabupaten/kota
(Rp) (Rp (Rp) (Rp) Rp) (Rp)
1 Wakatobi 0 0 0 0 18,000,000 0
2 Buton 0 2.500.000 620.000 2.880.000 2.200.000 2.000.000
3 Bau-Bau 0 500,000 765,000 5.215.000 0 0
4 Muna 0 0 0 0 0 0
5 Bombana 0 0 0 0 1,200,000 26.900.000
6 Konawe Selatan 0 0 0 0 0 0
7 Konawe 0 0 0 0 0 0
8 Kendari 0 0 1.000.000 1.500.000 2.500.000 2.500.000
9 Kolaka 0 0 3.250.000 12,000,000 17,241,000 22.200.000
10 Kolaka Utara 0 0 0 23,267,500 30,777,000 35.890.000
11 Buton Utara 0 0 0 0 0 0
12 Konawe Utara 0 0 0 0 0 0
total - 500.000. 1.765.000 40.530.50 75.709.00 89.490.000

46
6.2 Annex 2; Clofazimine stock and requirements

nr. of capsules in stock at the 0 kapsul

start of the reporting year
nr. of capsules received in 2000 kapsul
reporting year
nr. of patients treated with 3 Pasien
clofazimine in reporting year
nr. of capsules in stock at the 200 kapsul
end of reporting year
additional nr. of capsules 1500 kapsul
needed for the next year

6.3 Annex 3; MDT stock and requirement

MB Adult MB Child PB Adult PB Child

nr. of MDT stock 0 21 0 0
at the start of the
reporting year
Jumlah
permintaan MDT 2209 371 316 126
selama tahun
pelaporan
nr. of MDT 1273 228 96 36
received in
reporting year
nr. of MDT stock 852 249 54 24
at the end of
reporting year

47
 Name and signature of the Project Leader

La Djabo Buton, SKM.M.Kes

Name and signature of the Kepala Dinas Kesehatan

Propinsi.

Drs. Amin Yohannis, Apt, M.Kes

48