Dr. Mardiati Nadjib (Indonesia): The economic burden of dengue in Indonesia

Dr. Mardiati Nadjib is a researcher in the Health Policy and Administration Department at Universitas Indonesia, in Depok, Indonesia. Indonesia has some of the highest rates of dengue cases worldwide and in recent work, Dr. Nadjib and colleagues have sought to improve the evaluation of the economic burden of dengue on the Indonesian health system, making the case for reinforcing investment in dengue prevention and in strengthening local and international partnerships to tackle this disease.

Indonesia has one of the world’s highest dengue burdens and it is estimated that the Asia Pacific region accounts for more than 50% of the global economic cost of dengue cases. Which specific knowledge gaps in the evaluation of the economic burden of dengue did your research seek to address?

There is a lack of evidence for economic burden estimation in Indonesia. Previously, most published studies related to the economic burden of dengue only captured direct medical costs and were only conducted in particular levels of health facilities (i.e: one hospital/community health center).

Therefore, we needed to estimate the economic burden of dengue with a more comprehensive scope. We collected data both from public and private hospitals, and all perspectives were included: primary data for non-direct and indirect costs to capture patients’ perspectives. We used expansion factor based on Delphi panel, intended to estimate the actual cases for ambulatory and hospitalization services, since data for cases treated in IP and OP was not available.

Which methods did you use to build a national picture of the burden of dengue?

We extrapolated the dengue cases to capture the national disease burden. Indonesia is a big country in terms of population as well as geographical variation (there are over 17,000 islands). We also needed to take into account the variation of sub-national level fiscal capacity, services availability etc under a decentralized system which might influence the cost of care. To represent a national picture, we needed to be careful about including factors and credible data in order to correctly extrapolate from them.

What were some of the main challenges of your approach?

Dengue is a seasonal disease, which adds specific difficulties on data collection, particularly to get the most eligible patients. Also, given the geography of Indonesia, some adjustments were needed for effective calculations. From the facility perspective, we have large numbers of health centers and hospitals in 34 provinces, which can be either publicly and privately owned, and even the public hospitals themselves could vary in terms of type of hospital as well as owner (ie. central or local government). Compliance to clinical practice standard may also affect the resources used and therefore costs. However, we have carefully assigned samples based on criteria for both cases and socio-economy status.

Dengue has been recently listed by the WHO as one of the main global health threats for 2019 - what will be the impact of your estimates on local, national and international policy making and agendas in terms of public health?

Our study revealed that there is a considerable economic burden both for health facilities and patients. The study can provide essential information, and could be used as the basis for advocacy specifically for decision makers in terms of dengue prevention and control. This study is potentially beneficial, for example as a prevention strategy such as for boosting vaccination and/ or other interventions.

What are some of the other main public health threats in Indonesia and what coordination exists or should be improved between those public health priorities and investment in dengue prevention and control?

Indonesia is currently facing a triple burden of disease: non-communicable, communicable and re-emerging diseases. Dengue has a substantial economic burden for the country and therefore dengue should be a major part of the discussion when policy makers discuss priorities. Yet, investment in dengue prevention and control are challenging. There is a need to improve integration of program interventions. Also, more emphasis should be placed on setting public health priorities by using on the one hand burden of disease calculations and matching this with resources available, both at national and subnational levels.

How does the economic burden of dengue in Indonesia compare to the cost of other strategies to control dengue such as vector control or vaccination programs?