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Achieving quality in the directly observed treatment short-course (DOTS) strategy implementation process: a challenge for hospital public–private mix in Indonesia
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
Department of Public Health, Faculty of Medicine, Gadjah Mada University, Yogyakarta, Indonesia.
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.ORCID iD: 0000-0001-7087-1467
2008 (English)In: Global health action, ISSN 1654-9880, Vol. 1Article in journal (Refereed) Published
Abstract [en]

Background: The Directly Observed Treatment Short-course (DOTS) expansion strategy through Public–Private Mix (PPM) is in progress at an international level as well as in Indonesia. The number of hospitals involved in PPM has been rapidly scaling up, requiring the assessment of quality of implementation.

Objective: The paper presents the assessment of quality in implementing DOTS strategy in hospitals in Indonesia and emphasises the challenge of achieving high process quality in managing adult TB cases seen in the outpatient unit.

Design: A multiple-case study, involving eight general hospitals in Yogyakarta and Central Java provinces. The cases are comprised of public and private hospitals as well as teaching and non-teaching hospitals. Using the Donabedian's model, the quality of DOTS strategy implementation in hospitals was assessed in three aspects, i.e. structure, process and outcome. Data were collected through self-administered questionnaires, focus group discussions, interviews, observation and documents.

Results: The study revealed the importance of process, i.e. mainly commitment and case holding process, to the treatment success rate, treatment completion rate and default rate.

Conclusion: A systemic approach and structural support from the hospital is critical in this endeavour. Process improvement in the implementation of DOTS strategy in hospitals should be given more emphasis in hospital PPM-DOTS.

Place, publisher, year, edition, pages
Co-Action Publishing , 2008. Vol. 1
Keyword [en]
tuberculosis, quality of health care, Public-Private Mix, hospital, Indonesia
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
URN: urn:nbn:se:umu:diva-21838DOI: 10.3402/gha.v1i0.1831OAI: diva2:211951
Available from: 2009-04-20 Created: 2009-04-20 Last updated: 2015-04-29Bibliographically approved
In thesis
1. Revisiting the choice: to involve hospitals in the partnership for tuberculosis control in Indonesia
Open this publication in new window or tab >>Revisiting the choice: to involve hospitals in the partnership for tuberculosis control in Indonesia
2010 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Tuberculosis (TB) is a major public health problem in many low- and middle-income countries, including Indonesia. To accelerate TB case detection, and to improve the quality of diagnosis and treatment provided by all providers, the Public-Private Mix for implementing Directly Observed Treatment Short-course (PPM DOTS) was introduced in 2000. However, previous studies on PPM DOTS have focused on private practitioners and there has been a scarcity of research on PPM DOTS in the hospital setting. This dissertation aims to capture the potential of the PPM DOTS strategy, and identify the barriers to its implementation in hospitals in Indonesia.

This dissertation is based on four separate but interrelated studies: 1. A costeffectiveness analysis, comparing incremental cost per additional number of TB cases successfully treated under three strategies of PPM DOTS in four provinces. 2. An evaluation of the access to TB services by a cross-sectional study among 62 hospitals, by estimating the proportion of TB cases receiving standardised diagnosis and treatment according to the DOTS strategy. The data were analysed using poststratification analysis. 3. The quality aspect was explored in a multiple-case study, including eight selected hospitals. The data were analysed using cross-case analysis. 4. The process of partnership was explored through a qualitative study. In-depth interviews were conducted with 33 informants, who were actors involved in PPM DOTS in hospitals in Yogyakarta province. Content analysis was applied to the qualitative data.

PPM DOTS in hospitals was shown to be a cost-effective intervention in this particular context. However, the quality of the implementation was commonly suboptimal. In addition, a substantial number of TB cases did not get standardised diagnosis and treatment as per the DOTS strategy. The process of creating partnership among hospitals and National TB Programme was shown to be complex and dynamic. Process factors, such as commitment to collaboration and interaction and trust among the actors, were shown to be important. The rapid scaling-up of PPM DOTS in hospitals at the national level in Indonesia should be revisited. Indeed, considering the importance of hospitals in TB control, the implementation should be continued and expanded. However, more attention needs to be given to process, context and governance.

Place, publisher, year, edition, pages
Umeå: Umeå universitet, 2010. 56 p.
Umeå University medical dissertations, ISSN 0346-6612 ; 1383
tuberculosis, public-private partnership, formative evaluation, health service research, health system research
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health
urn:nbn:se:umu:diva-37894 (URN)978-91-7459-108-8 (ISBN)
Public defence
2010-12-10, Sal 135, Allmänmedicin, by 9 A, Norrlands universitetssjukhus, Umeå, 13:00 (English)
Available from: 2010-11-19 Created: 2010-11-18 Last updated: 2015-04-29Bibliographically approved

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