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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?

Our economic burden studies only estimate the cases themselves, and we were not comparing with costs related vector control as well as vaccination programmes. However we understand that little is in fact known about the cost of systematic intervention lead by the Ministry of Health to prevent Dengue and no vaccination program is available.

Although dengue can escalate to severe and debilitation or even fatal cases, the vast majority of dengue infections are milder or even asymptotic, or even misdiagnosed as other febrile illnesses - how important would the accurate evaluation of the dengue burden be to refining measures of its impact on economies? How would this improve advocacy for dengue surveillance and control?

Indonesia is endemic for dengue viral infection, and dengue incidence is reported annually with larger outbreaks within every 5 to 10 years. With dengue, the length of an outbreak will of course increase the economic burden of the country. The accurate evaluation of this burden is very important, because we need the confirmed diagnoses rather that suspected cases. To estimate the economic burden, the costs calculation will be inextricably related to the number of cases. Hence, the more accurate the evaluation of dengue cases, the better the evaluation of the economic burden.

However, dengue diagnosis is currently mostly dependent on clinical manifestations, but for cases requiring hospitalisation, there should also be confirmation by laboratory tests such as dengue antigen detection and anti dengue serological tests. These lab tests are costly though. So, this study will give direct supporting tools for the drafting of healthcare budget plans and also give indirect tools for the active surveillance either in common situations or more importantly in outbreak situations. Intersectoral efforts may improve the surveillance system, because dengue is influenced by vectors, human behaviour and environmental conditions.

What would a World Dengue Day mean in terms of addressing the heavy cost on health systems worldwide and developing economies more specifically?

A World Dengue Day would mean a lot to raise awareness of stakeholders, i.e governments, the people, healthcare providers. Prevention and education need to translate into actions, and move dengue control beyond just reacting if an outbreak is occuring.

Are there partnerships which you would like to see developed to reduce the burden of dengue in Indonesia and worldwide?

Partnership to improve surveillance systems for dengue are a priority. In addition, we should seek to improve partnerships in prevention programmes including health promotion, effective advocacy, vector control, cost-effectiveness of vaccination strategies, careful use of insecticides and larvicides, capacity building for diagnostic test and data analysis for disease itself.

In our study, we did try to involve many stakeholders including the Ministry of Health, colleagues from various backgrounds (clinicians, epidemiologists, public health specialists, health economists) and our study has clearly shown that we need to pay more attention to dengue.

Disease prevention is always necessary, and worthwhile, including for Dengue.


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