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An analysis of the costs and treatment success of collaborative arrangements among public and private providers for tuberculosis control in Indonesia
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
Centre for Health Service Management, Faculty of Medicine, Gadjah Mada University, Sekip Utara, Yogyakarta 55281, Indonesia.
Department of Public Health, Faculty of Medicine, Gadjah Mada University, Sekip Utara, Yogyakarta 55281, Indonesia.
2009 (English)In: Health Policy, ISSN 0168-8510, Vol. 93, no 2-3, 214-224 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES: To identify the cost-effectiveness of collaborative arrangements among public and private providers to employ the Directly Observed Treatment short-course (DOTS) strategy for tuberculosis (TB) control in Indonesia.

METHODS: Three strategies were assessed: hospital out-patient diagnosis with referral to public health centres (PHCs) for treatment, hospital out-patient diagnosis and treatment, and private practitioner referral of suspects to PHCs. The outcome was the number of sputum smear positive TB cases successfully treated. Costs include direct costs to providers and patients. Uncertainty analysis was done for both costs and effectiveness data.

RESULTS: The average cost per case successfully treated ranged from US$169 to $567 for different strategies. The cost per additional case successfully treated incremental to existing TB programmes ranged from US$152 to $982. In three of four provinces assessed, there was a clearly preferred strategy or strategies, although the preferred strategy differed by province; in one province a preferred strategy could not be identified.

CONCLUSIONS: All strategies increased TB case finding, although attribution is tentative because of the study design. Neither collaboration among private practitioners nor among hospitals is clearly preferred based on cost-effectiveness. For hospitals, this study suggests that having hospitals refer patients to health centres is preferable over hospitals administering treatment.

Place, publisher, year, edition, pages
2009. Vol. 93, no 2-3, 214-224 p.
Keyword [en]
Tuberculosis; Public–private mix; Cost-effectiveness; Indonesia
URN: urn:nbn:se:umu:diva-37598DOI: 10.1016/j.healthpol.2009.08.004PubMedID: 19729220OAI: diva2:369334
Available from: 2010-11-10 Created: 2010-11-10 Last updated: 2010-11-19Bibliographically 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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