Indo-Pacific Health Leaders Series: Dr Ari Probandari and Dr Virginia Wiseman

Welcome to Contain This brought to you by the Indo-Pacific Center for Health Security, an initiative of the Australian Government housed at the Department of Foreign Affairs and Trade. Today's episode is hosted by Francette Dusan, Senior Advisor at the Center. 

In today's episode, Francette speaks to Dr. Ari Probandari and Dr. Virginia Wiseman, from the PINTAR study, which is protecting Indonesia from the threat of antimicrobial resistance. PINTAR was launched in 2018 and focuses on combating the oversupply of antibiotics without prescription by private drug sellers in Indonesia, and the impact it has on antimicrobial resistance. This is the first episode in a two-part series on PINTAR. 

Our two guests reflect on leadership, their greatest career moments, and how they've managed the uncertainty of COVID-19. In the second of our two-part series, we'll talk about the great work that PINTAR is doing in Indonesia, so keep an eye out for that. 

You can learn more about the work of our guests via the following links:

https://indopacifichealthsecurity.dfat.gov.au/pintar-research-project-supports-indonesian-response-covid-19

http://www.pintarstudy.org

https://www.pintarstudy.org/team/ 

https://kirby.unsw.edu.au/people/professor-virginia-wiseman

https://indopacifichealthsecurity.dfat.gov.au/health-security-hero-dr-ari-probandari

You can join the conversation via our social media channels, through @CentreHealthSec and @AusAmbRHS.

Enjoy the episode. 

Transcript

 Francette  00:02

Welcome to Contain This brought to you by the Indo-Pacific Center for Health Security, an initiative of the Australian Government housed at the Department of Foreign Affairs and Trade. I'm your host of today's episode, Francette Dusan, Senior Advisor at the Center. 

In today's episode, I chat to Dr. Ari Probandari and Dr. Virginia Wiseman, from the PINTAR study, which is protecting Indonesia from the threat of antimicrobial resistance. PINTAR was launched in 2018 and focuses on combating the oversupply of antibiotics without prescription by private drug sellers in Indonesia, and the impact it has on antimicrobial resistance. This is the first episode in a two-part series on PINTAR. 

In today's episode, our two guests reflect on leadership, their greatest career moments, and how they've managed the uncertainty of COVID-19. In the second of our two-part series, we'll talk about the great work that PINTAR is doing in Indonesia, so keep an eye out for that. You can join the conversation via our social media channels. The links are in the show notes. Enjoy the episode. 

Today I'm joined by Doctors Wiseman and Probandari, who are the Chief Investigators on the PINTAR project. PINTAR seeks to improve the use of antibiotics by private drug sellers in Indonesia. As the largest country in the region with about 258 million people, most of whom obtain their antibiotics without prescription from private drug sellers, Indonesia has a major role to play in addressing the inappropriate use of antibiotics and curtailing the threat of antimicrobial resistance. But today, we're going to find out a little bit more about these Chief Investigators.

It's been a huge and unprecedented two years for everyone working in the health sector. When you started working in public health, did you ever anticipate experiencing something to the magnitude of COVID-19? Dr. Ari, we might start with you on this one.

Ari  02:11

Thank you, Francette. Yeah, I think COVID-19 is something that we never expect. Or maybe we never imagined, actually. Because maybe we think that we do all the, all the effort for disease control and I think that's already in the health system, including in Indonesia. So, I think it's quite something new, something dramatic, but I think it's also a reality that we should face and mitigate and also, we learn from the situation of COVID-19 to better health system, including in Indonesia.

Francette  03:00

And what about yourself, Virginia?

Virginia  03:04

Look, I think I'm on exactly the same page as Ari, completely unexpected, I think I've still got a half-drunk cup of tea and a cardigan sitting on my chair at work waiting for me to return. It felt like a huge change, very sudden change. I think it's has, however, shown me that work is really anywhere now. And that research, sort of research that PINTAR is doing has been quite resilient over the last year or so has continued. And that's because I think we found that we have trusted and long-standing partnerships with groups like ours, that that we've been able to continue. But yeah, it's completely unexpected. And I think that we've all sort of been trying to adapt as best we can.

Francette  04:07

Thank you for those responses. It's really interesting to hear how the sheer scale of the pandemic was a surprise, especially within the health sector, where we know there was already some preparedness in place, but also about the resilience of your partnerships. How did you start working together on Pinta in Indonesia? And how has your partnership evolved over the years you've been working together? Virginia, I might go back to you.

Virginia  04:34

Yeah, thanks for. So, I mean, for me at the Kirby Institute, and also at London School of Hygiene and Tropical Medicine. I've been working in Indonesia for quite a number of years, mainly with colleagues at the University of Indonesia on a large health financing project, and Ari had been working, I understand with other colleagues at the Kirby Institute, so you know, our worlds research well started to collide a bit and we got to know each other and, and in fact, we, we designed the PINTAR study together but then you falling out of that we've now developed two new studies, sort of, on the back of PINAR. One is called DOMINO, which is looking at the impact of COVID on HIV and TB services in Indonesia. And another one is the MENJAGA trial, which is a large trial evaluating point of care testing for HIV and syphilis in pregnancy in Indonesia. So, so, yeah, we've really sort of capitalized on PINTAR and got some new and exciting work going on together now as well.

Francette  05:39

Dr. Ari, what drew you to working with Virginia and the team? 

Ari  05:47

Yeah, I think it's a great experience for me to work with Virginia, as well as the other members from the PINTAR project. One it is a great experiment, because I think it's expand my network of researchers in global. And then the second one, I learned also how to harmonize the way of the way of working between Indonesian culture and Australian culture of works. So, I think that's very interesting. And then, of course, why it's great, because we can expand from one project to several more projects that Virginia already stated. I think that's a good experience. And also, I learned also, the perspective the other perspective, we, we face the problem health problem, particularly in AMR in Indonesia, but because we learn about different perspective to see the problem, I can learn as well how to, some ideas to solve the AMR from, from several perspectives from the researchers.

Francette  07:09

And Virginia, what are you learning from your Indonesian colleagues during the project and others you've done in Indonesia?

Virginia  07:20

Well, I think one of the main things is the incredible networks that that our colleagues like Ari have in Indonesia. So, for PINTAR, for example, which is about protecting, as you said, protecting the use of antibiotics, we've, you know, we've been working really closely with Pharmacy Association, and also the Pharmacy Technician Associations, with district health officers, with many different members of the Ministry of Health. Ari and her team had really, existing, solid, good relationships with these groups. 

And, you know, these are, these are the sort of foundations for the research that that we rely totally not to mention that they’re, you know, as research scientists, they're, they're very well respected as well. But it's, yeah, it's working in this as Ari said, a large multidisciplinary team. I mean, we have people also involved in our projects from University College of London, we have people from, a whole range of other universities, academic institutions, and together, you know, the anthropologists, sociologists, we have clinicians, we have health services research, we have the economists, it's a, it's a real melting pot. And, you know, it's the only way to go when you are tackling complex problems like AMR and Ari’s team have such a diverse set of skills, complementary skills to us, it was it's been a great partnership.

Francette  09:14

That's wonderful. I might go back a little bit in time now to ask you, Ari, what led you to start working in the field of public health? What drew you to this area? And was there an early experience that shaped your passion for doing this type of work, both public health work and this multidisciplinary work that Virginia’s touched on?

Ari  09:37

Yeah. Okay. Thank you, Francette. See, when I was young, younger than now, in 2000, I just graduated as a medical doctor. And then I took an opportunity to work in the remote area of Indonesia, working in a public health center and District Hospital in North Sulawesi province. And by that experience, I realized that actually, health problem in Indonesia was also related to public health aspects. Including, the implementation of program or policy, and also the management of the health services. So, by that experience of three years in the remote area, I realized that that's something that we should improve in Indonesia. And I'm willing to be a part of the persons or individual that give, to contribute to the improvement of health policy, and systems in Indonesia. So that's, I think, a milestone of my life as a public health expert. And after that field experience, I took a master degree in public health at Umeå University Sweden.  That really put additional insight and also skills on public health field. Then I continue as an academician. Thank you, Francette.

Francette  11:21

And how about you, Virginia? What led you to start in this field? And was there a similarly early experience that shapes your passion for looking at population health rather than individual health?

Virginia  11:36

Um, well, for me, a lot of what I do, I look back has been motivated by particular people. So, so I've always as a health economist, I mean, my early training I did, I think, what was the very first course that was offered by Jeff Richardson at Monash University, this is a long time ago, before health economics was really on the on the agenda in Australia. And I did that course, I really enjoyed it. And then I had an amazing opportunity to work with the late Professor Gavin Mooney, Professor of Health Economics, who many will know. He had a real passion for equity and addressing inequities in access to health care, especially amongst disadvantaged or vulnerable populations. So and with whom I sort of started to think, a lot more about equity. And it also, I think, there were a couple of things happening at that time. One was the fact that in the in the sort of 90s, we had policies like user fees were being implemented across many low- and middle-income countries. And we were seeing the negative impact of these on, on access to health care by the poor in many, many countries. And then later, I went on to work with the London School in both, both East and West Africa, on the economics of malaria. There, I kind of witnessed firsthand, some of the health system bottlenecks to actually implementing, scaling up control. tools like bed nets, and medicines and rapid tests. I also saw a lot of these items sitting in warehouses where they were, where they were expiring, while at the same time, facilities were low on stocks. And so, all of these thing’s kind of cemented a, I guess, a real interest or confirmed my, my strong interest in in trying to, to undertake research that will improve access to these priority interventions, particularly by those in in greatest need.

Francette  14:03

And are there any success, particular success stories, from throughout your career that really have stood out for you, Virginia?

Virginia  14:11

Again, I keep coming back to people all the time, but I have to say that training and mentoring some very successful economists. You know, I look back and there, there are some that are, for example, lead for the UK African health observatory. I've also got someone else who was the head of an economics department now in in university in Uganda, or the head of the UN Development Programme in Nigeria. I mean, these kind of, their achievements just I think, I'm just privileged to have been able to help support them in their studies. From a sort of policy point of view and research feeding into policy, I think that we have had a five or six year research program on health care financing going on in Indonesia with Professor Hasbullah Thabrany  from the University of Indonesia, that work has been presented to some inquiries in Parliament to see the work really feeding into financing reforms is very rewarding. And also, with Professor Hasbullah Thabrany, I'm now have the opportunity to work with him and his team on preparing  for the T20, which then is going to fade into the G20 Summit. So, so this kind of nexus between the research and financing is financing policy for Indonesia and the region is I think, something that that I will look back on and feel, you know, it's been a very worthwhile thing.

Francette  16:05

Yeah, absolutely. The financial requirements for health care, I think have become, have come to the fore, particularly this year and last year. Especially when we consider that many countries will be going forward with having spent a lot on pandemic response, but still having to finance ongoing health issues. So, as you say, having an impact or input into those discussions will be very powerful. How about you, Ari? Are there particular success stories that you'd like to point out? Or bring fond  memories for you?

Ari  16:56

Yeah, I think one of success stories in my career was when I just graduated from PhD program in 2010. Then I was recognized by one of the prominent researchers in TB field, tuberculosis field in Indonesia, Dr. Bachti Alisjahbana. He was the chair of tuberculosis operational research group. He identified my work through publication and then he invited me as a member of tuberculosis operational research group in national level. And by then, I know, many influential persons in the field of TB control in the Ministry of Health, as well as in other institutions. And right now, I'm a coordinator of Research and Innovation of Tuberculosis Expert Committee in the national level. And also, because my interest of research, particularly in implementation research, then I also got opportunity to have training, and then be one of the facilitators of implementation research course in WHO TBR. And even right now, I'm an advisor for Tuberculosis Research Network, Indonesia. So, I think that's part of the success story that that happened in my career. And when that success story, I think now, I expand my network, not only with other researchers in Indonesia, but also with the policymakers in the Ministry of Health and also in other national institutions. So, I think that's one, one thing that helped me to facilitate the process of translating knowledge from research into policy.

Francette  19:12

Thanks so much. I just wanted to touch a little bit on the research to policy influence that Virginia, you have talked about in terms of providing the financial or health economic information and are you touched on there as well, in terms of that important link between the research work that you do and then the policies that are implemented? Could you talk a little bit more about those aspects of satisfaction you get? 

Ari  19:49

Okay, maybe I can start. I think that process is a dynamic process. So, it's sometime it's maybe it's easy, but sometime is not easy. So that's what I meant by dynamic process. But in I think we need to have networks with policymakers that the capital of doing the process of advocacy of evidence from research to policy, so we have to have a networks with policymakers, but also in, on the other hand, I think we are as researchers, researchers should have an independent value, independent value, and also a valid and solid arguments about the evidence, that's, we would like to transfer to the policy. So that's my insight about the process between. Virginia, please like to add?

Virginia  20:59

Yes, I'm not sure. If I've got much to add, that's a very good answer. I think I would just like to pick up on your point about the sort of relationship between the policymakers and the researchers. So a lot of what we do, for example, the work particularly with Ari, and her team is about evaluating quite complex interventions to support access or improved delivery of, of healthcare into public health interventions. And, and in that role, we do have to, we clearly have to, work in partnership with government ministries of health and sometimes ministries of finance. But at the same time, when you're evaluating interventions, part of the reason as academic institutions you're being asked to do that is to do it as an independent, unbiased third party. And so, you do have to be a little bit careful about the way you kind of navigate that space. But, you know, on the whole, we are always very well-guided, by our by our teams in country who, who, who are much, you know, very well placed to sort of steer that side of things. Yeah.

Ari  22:31

Okay with that, Virginia. So, I think we have to have solid evidence as well. Yeah, a good evidence to be translated to policy.

Francette  22:43

Very much so. And the economic evidence is, I think, particularly speaks to certain people as well, how we can sustain and support any decisions and ongoing policies that are made.

Virginia  23:03

I think the issue about financing is, as you say, it's really critical. And I would say that as a, as a health economist, but we are facing a really challenging time, obviously, with the pandemic, but also that even pre pandemic, we had a lot of countries who were having to try and find more and more funding for health, through, you know, national sources. So, so overseas development assistance, has been shifting and countries are having to really put more resources into health themselves or, you know, as a term is to create fiscal space. And, and, you know, you can do that by allocating more funds, or you can do that by making processes within the health system are more efficient with less wastage, but whatever way you do it, countries were already facing quite a challenge pre COVID. And, you know, we, I think when we talk about introducing lots of new medicines or new technologies for health, really providing solid evidence about what are the long-term kind of returns going to be, is really important, because the reality is that lots of countries only spend, you know, are only spending, perhaps, I don't know, between 500,000 per annum of per capita, on health and so we really need to think carefully about what going forward. And COVID is a really good example of this with with new rapid tests and so on, what countries can actually afford to provide?

Francette  24:56

I do think that's a really important point, Virginia and as you said, the conversations need to happen to say what is sustainable going forward. Ari, did you have a comment to add to that?

Ari  25:13

In my experience, when communicating the evidence from research to policymaker, I think we need, we need evidence. We call it hard data and soft data. But the data from economic point of view, I think, part of the hard data, and I think that's very important for them, for particularly for decision making process. In addition to that, I think soft data like a qualitative, qualitative data, I think, also are important aspects to give illustration about what problems that happen in the field. And then also, how is the implementation of the policy that the already design in the field. So I think, good evidence from our research from quality research project, I think that's also a very important thing for communicating, communicating research into practice or policy.

Francette  26:22

That's very insightful Ari. I'd like to ask now, what impacts you see your work in Indonesia having on a global scale? And what perhaps we can expect to see in the next 12 months?

Ari  26:36

Maybe I can start Francette about AMR project, related to PINTAR project I think what we did, particularly in in the way we give contribution to AMR policy in Indonesia is, I and one of the chief investigator of the PINTAR project, Professor Tri Wibawa from Universitas Gadjah Mada, we were invited into the process of developing the national action plan for AMR  control in Indonesia. And I think, right now, the document, even now in the process of, of regulation, to be a regulation by a presidential decree. So, I think that's one of the contribution of PINTAR project to the development of AMR- related policy in Indonesia. And right now, we are still in the process of doing, doing intervention in the field so, we hope in the next 12 months, we will have more evidence that the intervention that we apply in the in the PINTAR project is effective to improve the, the dispensing of, to improve the antibiotic dispensing in Indonesia, particularly by private, private drug stores and pharmacies.

Virginia  28:30

One, one thing I would probably say that I would, I think is important is that, you know, many, many countries, like Indonesia, in the region have a, you know, a very thriving private sector. And I think, you know, even looking beyond AMR; COVID, for example, is shown us that, you know, to really tackle big public health threats, you need a whole of system, or what's often called a whole of system response. And for COVID, you know, we've needed to mobilize actors in the private sector. So for PINTAR, we had an offshoot of the study or a sub-study looking at the activities and experiences of the pharmacies and drugstores during the pandemic and what their role has been and, and really what, what that has shown us is that they've been doing an awful lot but not necessarily in the most sort of coordinated way and that these providers, whether it's a public health threat or if it's the day to day delivery of core programs like HIV or TB or whatever it might be or,  or access to, to medicines like antibiotics, they really need, we need to begin working in a, you know, more integrated way. Having as part of the, particularly the primary, health care delivery system. Because at the moment, many of the sort of regulatory frameworks, they, they don't really account for these, this huge pool of providers. And I think that, during COVID, we've seen that they've had many changing roles. You know, the pharmacies have been doing, doing a whole range of activities to protect themselves and their staff, but of course, the community as well. And I think this is this is kind of where we hope that PINTAR not only looks at the role of these providers, these private providers, in the healthcare system in the context of antibiotics and AMR. But also, there will be broader lessons about other sorts of public health problems and crisis that may also lie ahead.

Francette  31:15

That's a really important point that you've touched on there, Virginia, the importance of integrating private providers into healthcare responses, and facilitating, if you like, public-private partnerships, so that it is a more comprehensive, whole of society approach to providing health care, and the important work that the PINTAR project teams have been doing in terms of creating these linkages between the private drug sellers and the public health response system. 

You've both mentioned, a number of important role models that you've had in your lives and your careers. I wonder now, do you see yourselves as role models for the next generation of public health leaders? And if so, what do you hope to inspire them to do?

Virginia  32:16

I'll start on this one. Look, I'm not sure - I think you'd have to ask some of the people I work with and mentor about whether I'm, I'm good at it. But I feel like, over my career, I really have been taken under the wing, as I've, you know, flagged before, by some very generous and skillful people. And what I've tried to do is to also show that kind of support to others. So, one quick plug for the UNSW University New South Wales Scientia scheme, PhD scheme. That scheme has enabled us over the last couple of years to train and support health economists, particularly, from Indonesia, China, Papua New Guinea, all of them are due to graduate in the next year. And I really, I guess, my hope is that it won't be too long before they also, by the way these are all women, that they will actually be working in the same, the cycle will go on basically, and they will soon be supervising people, as well. And I guess the one other thing I would say is that what I would also like to inspire these early and mid-career researchers to do is to break perhaps some of the molds, around the way global health research is conducted. I think there's a lot of debate and discussion going on about that now, and I don't want to delve too deeply, but I just I just think the way we run international projects, right, from setting up agreements and finances through to the way we actually conduct research and write up that work. You know, we need to continually be conducting reality checks and making sure that those partnerships are with, in global health, are as equal as possible. And I know that that's one of the things I love about working with our in the team is that they expect nothing, nothing else and that that you know, they are they are a you know a team that that have the same goals as us and working in an equal partnership and trying to break some of the, I think some of the past practices that that we, we have seen.

Ari  35:09

I also can add about that. Yeah, I think I pass 20 years of my career since I graduated, I was graduated from medical doctor, and experience for 20 years of period as a medical doctor, and public health expert by training. And now I'm also a senior researcher and academician I think that's placed me in the in the position of I have to do mentoring for others. So I, perceive that as a mentor, that's my duty right now. So, by sharing all the skills of public health, and then also about the experience, share all the experience and  thinking about, particularly about, the problem of health system, strengthening.  I think I hope that all the works will inspire the new generation of young people that have the same vision to build the better public health in Indonesia. And I hope also in other country, because I also supervise some international students right now. So that's Francette, some additional thinking about that.

Francette  36:49

Well, it's been wonderful to talk with you both today. I've certainly been inspired by your partnership and the activities that you're doing in the PINTAR project. Did you have any final comments that you wanted to add or final messages for the listeners?

Virginia  37:07

Just to say, thank you for listening and thank you Francette and DFAT giving us the opportunity to have these reflections. And yeah, we hope that people enjoy listening to it.

Francette

And you Dr. Ari?

Ari  37:24

Yeah. also thank you, for me for DFAT for this opportunity to share, the thinking, the reflection, the insight, from this podcast. So, I hope that it will inspire others; to contribute to the better public health. Thank you.

Francette  37:47

Thank you so much, Dr. Ari and Virginia. 

That was Dr. Ari Probandari and Dr. Virginia Wiseman, speaking on Contain This. My name is Francette Dusan and I'm thrilled you could join us for this inspiring conversation. Make sure you subscribe in order to be notified when our next episode airs. Catch you next time.