Author: Dr. Muhammad Karyana (Associate Health Administrator, BKPK, Ministry of Health)
In a village far from the city center, a young mother had to stop working because of a persistent cough. She lost weight, tired easily, and began to withdraw from her surroundings due to her discomfort. For months, she postponed getting tested, dismissing her symptoms as a common illness. When she finally went to a health facility, the diagnosis was clear: tuberculosis (TB). But what was not visible in that diagnosis was the chain of transmission that may have occurred to her children, her neighbors, and the people she interacted with every day.
This story is no exception. It is a portrait that is repeated in many places. And behind every story like this, there is one fundamental question: why do these preventable and curable diseases continue to cause suffering on a large scale?
TB Burden: Big Numbers, Bigger Impact
Tuberculosis remains a major health problem in Indonesia. Every year, more than one million people fall ill with TB. Around 125.000 to 130.000 die. Translated into time, this translates to more than 10 to 14 people losing their lives every hour. Hundreds of families grieve in a single day. In a single year, we lose the population equivalent of a small town. However, these numbers are only part of the story.
The burden of TB is measured not only by the number of cases and deaths, but also by its impact on social and economic life. Most TB sufferers are of productive age. When they become ill, they lose income, their families lose their livelihoods, and national productivity is impacted.
On the other hand, TB also deepens inequality. This disease disproportionately affects vulnerable groups, those living in limited socioeconomic conditions, with inadequate access to healthcare. TB is not only an infectious disease but also an indicator of inequality.
The TB Paradox: An Old Disease, an Unsolved Problem
Scientifically, TB is not a new disease. The causative agent, Mycobacterium tuberculosis, has long been recognized. Effective treatments are available. Diagnostic technology continues to advance. However, amid all these advances, TB remains a significant cause of death.
Herein lies the paradox. We have the knowledge, but we haven't yet fully translated it into equitable impact. We have the technology, but not everyone has quick access to it. We have programs, but not all systems are working in an integrated manner.
The TB issue is not simply a medical issue but a health systems issue. It concerns how services are designed, how access is ensured, and how interventions are linked.
A Known, But Not Fully Solved Problem
Upon closer examination, the challenges facing TB in Indonesia are quite clear. There remains a gap between the number of estimated and detected cases. This means many TB patients remain undiagnosed and remain in the community as a source of infection. Diagnosis is not yet fully rapid and equitable.
In some regions, access to molecular-based testing remains limited. As a result, the diagnosis process takes longer and treatment is delayed. Treatment is not always complete. TB requires long-term therapy, and not all patients can complete it without adequate support. When patients stop taking their medication, the risk of therapy failure and drug resistance increases.
Prevention efforts are also suboptimal. Contact investigations and preventive therapy have not yet reached all high-risk groups. Yet, these interventions are crucial for reducing long-term incidence.
Behind all this lies one fundamental problem: systems that aren't fully integrated. Data is still scattered across multiple platforms, services aren't always connected, and funding doesn't fully drive results.
When Systems Are Fragmented, Impact Becomes Limited
TB control is not a series of stand-alone interventions. It is an interconnected system. Effective screening must be followed by rapid diagnosis. Diagnosis must be followed by comprehensive treatment. Treatment must be supported by a robust monitoring system. And this entire process must be supported by accurate and integrated data.
When one component fails to function optimally, the entire system is impacted. For example, if screening fails to reach at-risk groups, cases will not be included in the system. If diagnosis is delayed, transmission will continue. If treatment is not completed, resistance will increase. If data is not integrated, policies will not be well-targeted. Thus, the success of TB control is determined not only by the strength of each intervention, but also by the interconnectedness of these interventions.
The Necessary Transformation: From Reactive to Proactive
To face these challenges, current approaches need to be transformed. The health system can no longer wait for patients to arrive. It must be more proactive, reaching out to communities before the disease progresses further.
Risk-based active detection is crucial because it allows for earlier case detection. Rapid diagnosis is crucial because it accelerates treatment and breaks the chain of transmission.
Treatment approaches also need to change. TB is not just a medical problem, but also a social one. Patients need support from their families, communities, and systems to complete therapy. Prevention must be a core part of services. Contact investigation and preventive therapy are not just additional interventions, but key strategies for reducing the future burden of TB. All of this requires an integrated system, supported by digitalization and real-time data, so that every patient can be optimally tracked, monitored, and supported.
The Role of Financing: From Activity to Impact
One aspect that often receives less attention is how health financing is designed. Traditionally, financing has focused on activities. However, in the context of TB, this approach is insufficient.
What's needed is results-oriented financing. This means that success is measured not by the number of activities, but by the impact they generate. This approach can encourage the system to focus on case detection, successful treatment, and transmission prevention. It can also improve accountability and efficiency in resource use. With proper financing, the system not only works harder but also more effectively.
Collaboration: The Key in Complex Systems
TB is a complex problem, and it cannot be solved by one party alone. Governments play a primary role in setting policies and providing services. However, the private sector, civil society, and communities also have important roles to play.
Private health facilities, for example, are often the first point of contact for patients. Without proper integration, many cases go unreported in the national system. Communities have a role to play in education, patient support, and stigma reduction. The business sector can contribute by creating a supportive work environment for TB detection and treatment. Strong, structured collaboration is key to ensuring the entire system works in concert.
Key Challenges: Speed and Consistency
In many ways, Indonesia does not lack capacity. We have competent healthcare workers, increasingly advanced technology, and a clear policy framework. However, the main challenge often lies in the speed and consistency of implementation.
TB is a disease that doesn't wait. Every day of delay means new infections. Every delay in diagnosis means an increased risk of death. Therefore, speed is key, not only in formulating policies, but also in ensuring that those policies are actually implemented on the ground.
Decisions to be Made Now
Ending TB requires more than just commitment. It requires concrete decisions.
The decision to strengthen primary services.
The decision to expand access to rapid diagnosis.
The decision to integrate data systems.
The decision to direct financing towards results.
The decision to strengthen cross-sector collaboration.
These decisions may not always be easy, but without them, change will not happen.
Finally: Returning Focus to Humans
Ultimately, TB isn't just about numbers. It's about people. Every case is an individual with a story, a family, and hopes. Every death is a preventable loss.
Ending TB is part of the nation's commitment to protecting its people. This is not just about health, but about justice—that everyone has an equal right to a healthy life.
And ultimately, our success will not be measured by how many policies we enact, but by one most fundamental thing: how many lives we save.
