CASE STUDY 2 The challenge of drug-resistant tuberculosis in Indonesia Although Indonesia has the second-largest number of tuberculosis (TB) cases globally, WHO has estimated that 41% of cases go unreported.106 People with TB can often delay seeking medical help and advice due to low awareness and knowledge. While TB medications are covered under Indonesia’s national health insurance and do not require significant out-of-pocket payments by patients, not all citizens are aware of this coverage. Many people with TB continue to buy drugs (to treat symptoms, or antibiotics) over the counter and through online platforms, with uptake of formal, clinically-prescribed TB treatment remaining low. The lack of timely and appropriate treatment enables TB to turn into drug-resistant TB, which increases the difficulty of diagnosis and treatment in due course. Engaging patients, healthcare practitioners and community health workers to tackle drug-resistant TB in Indonesia will be key. Although 75% of initial healthcare visits are to private practitioners, a study conducted in 2024 found that most private practitioners do not adhere to national TB guidelines. Challenges cited include incoherence between national and international TB management guidelines, complex financing systems and lack of access to appropriate diagnostic tools and drugs. The majority of private practitioners do not report TB cases to the National Tuberculosis Programme (NTP), leading to an information gap for monitoring and surveillance of both TB and drug-resistant TB. Another key actor within primary healthcare systems is the community health worker (CHW). CHWs engage directly with citizens on the ground and can be strong advocates for greater TB education and awareness in the community. They also conduct active case-finding and provide psychosocial support to people with TB. However, many CHWs in Indonesia work voluntarily without any formal contract, which undermines their commitment to the role due to lack of job security. CHWs also lack training and supervision, with only 13% of them reporting they had received pre-service training. To ensure that CHWs are equipped and empowered to educate, monitor and treat TB in the community, it is important to provide them with resources and support their livelihoods and capabilities. Sources: See endnote.107 Educate and regulate farmers on proper use of antibiotics in agriculture Globally, farm animals account for an estimated two-thirds of all antibiotic use.108 This practice is routine in farming to prevent livestock from falling sick, especially when they are kept in poor husbandry conditions where disease easily spreads. Antibiotics can also be used to boost animals’ growth to meet food demand. According to a report published by WOAH in 2024, nearly one-quarter of their member countries (36 out of 152) reported using antimicrobial agents in animals to promote growth. Colistin, one of the highest-priority critically important antimicrobial drugs for use in humans, is still reported as being used for animals by four member countries.109 In Asia and Oceania, sales of antibiotics to farmers are nearly four times higher, per head of livestock, than they are in Europe.110 Farmers often resort to antibiotics as they are relatively cheap – in China, for example, antibiotics are just 1-3% of production costs.111 Antibiotics are also considered more convenient than vaccines, which have to be administered well before infection to allow the animal time to develop an immune response. Bacteriophages, or viruses that infect and eliminate bacterial cells, must be administered around the time of infection and can only work effectively when bacteria are present in abundance within the animal.112 Alternatives to antibiotics are available, but farmers need to be educated in the proper use of such alternatives to shift their mindsets away from over- reliance on antibiotics. In any case, dependence on antibiotics is not sustainable in the long run, as the animals may build up their own resistance and in turn require treatment with even more antibiotics, creating a vicious cycle. Ultimately, rather than focusing on a single drug or approach, a more effective solution is to invest in better farm management and biosecurity, combined with a range of alternative drugs.113 To demonstrate this, FAO’s Emergency Centre for Transboundary Animal Diseases (ECTAD) has partnered with Viet Nam’s Department of Livestock Production (DLP) to develop eight small-scale biosecurity model pig farms in the northern provinces of Bac Giang and Nam Dinh that have high pig populations to demonstrate better farm management measures and alternatives to antibiotic utilization. Additionally, to improve AMR monitoring and surveillance in Viet Nam, the farmers at the model farms have been trained to record production data and provide better monitoring of antibiotic usage. In Asia and Oceania, sales of antibiotics to farmers are nearly four times higher, per head of livestock, than they are in Europe. Targeted Action and Financing the Fight Against Antimicrobial Resistance in Asia 25

Targeted Action and Financing the Fight Against Antimicrobial Resistance in Asia 2025