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Revisiting the choice: to involve hospitals in the partnership for tuberculosis control in Indonesia
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
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.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1383
Keyword [en]
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
Identifiers
URN: urn:nbn:se:umu:diva-37894ISBN: 978-91-7459-108-8 (print)OAI: oai:DiVA.org:umu-37894DiVA: diva2:371012
Public defence
2010-12-10, Sal 135, Allmänmedicin, by 9 A, Norrlands universitetssjukhus, Umeå, 13:00 (English)
Opponent
Supervisors
Available from: 2010-11-19 Created: 2010-11-18 Last updated: 2015-04-29Bibliographically approved
List of papers
1. An analysis of the costs and treatment success of collaborative arrangements among public and private providers for tuberculosis control in Indonesia
Open this publication in new window or tab >>An analysis of the costs and treatment success of collaborative arrangements among public and private providers for tuberculosis control in Indonesia
2009 (English)In: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, 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.

Keyword
Tuberculosis; Public–private mix; Cost-effectiveness; Indonesia
Identifiers
urn:nbn:se:umu:diva-37598 (URN)10.1016/j.healthpol.2009.08.004 (DOI)19729220 (PubMedID)
Available from: 2010-11-10 Created: 2010-11-10 Last updated: 2017-12-12Bibliographically approved
2. Missed opportunity for standardized diagnosis and treatment among adult tuberculosis patients in hospitals involved in public-private mix for directly observed treatment short-course strategy in Indonesia: a cross-sectional study
Open this publication in new window or tab >>Missed opportunity for standardized diagnosis and treatment among adult tuberculosis patients in hospitals involved in public-private mix for directly observed treatment short-course strategy in Indonesia: a cross-sectional study
Show others...
2010 (English)In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 10, 113- p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: The engagement of hospitals in Public-Private Mix (PPM) for Directly Observed Treatment Short-Course (DOTS) strategy has increased rapidly internationally - including in Indonesia. In view of the rapid global scaling-up of hospital engagement, we aimed to estimate the proportion of outpatient adult Tuberculosis patients who received standardized diagnosis and treatment at outpatients units of hospitals involved in the PPM-DOTS strategy.

METHODS: A cross-sectional study using morbidity reports for outpatients, laboratory registers and Tuberculosis patient registers from 1 January 2005 to 31 December 2005. By quota sampling, 62 hospitals were selected. Post-stratification analysis was conducted to estimate the proportion of Tuberculosis cases receiving standardized management according to the DOTS strategy.

RESULT: Nineteen to 53% of Tuberculosis cases and 4-18% of sputum smear positive Tuberculosis cases in hospitals that participated in the PPM-DOTS strategy were not treated with standardized diagnosis and treatment as in DOTS.

CONCLUSION: This study found that a substantial proportion of TB patients cared for at PPM-DOTS hospitals are not managed under the DOTS strategy. This represents a missed opportunity for standardized diagnoses and treatment. A combination of strong individual commitment of health professionals, organizational supports, leadership, and relevant policy in hospital and National Tuberculosis Programme may be required to strengthen DOTS implementation in hospitals.

National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-37600 (URN)10.1186/1472-6963-10-113 (DOI)000278379800001 ()20459665 (PubMedID)
Available from: 2010-11-10 Created: 2010-11-10 Last updated: 2017-12-12Bibliographically approved
3. Achieving quality in the directly observed treatment short-course (DOTS) strategy implementation process: a challenge for hospital public–private mix in Indonesia
Open this publication in new window or tab >>Achieving quality in the directly observed treatment short-course (DOTS) strategy implementation process: a challenge for hospital public–private mix in Indonesia
2008 (English)In: Global Health Action, ISSN 1654-9716, E-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
Keyword
tuberculosis, quality of health care, Public-Private Mix, hospital, Indonesia
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Epidemiology
Identifiers
urn:nbn:se:umu:diva-21838 (URN)10.3402/gha.v1i0.1831 (DOI)
Available from: 2009-04-20 Created: 2009-04-20 Last updated: 2017-12-13Bibliographically approved
4. Life of a partnership: the process of collaboration between public and private providers for tuberculosis control in Yogyakarta, Indonesia
Open this publication in new window or tab >>Life of a partnership: the process of collaboration between public and private providers for tuberculosis control in Yogyakarta, Indonesia
(English)In: Article in journal (Refereed) Submitted
Identifiers
urn:nbn:se:umu:diva-37601 (URN)
Available from: 2010-11-10 Created: 2010-11-10 Last updated: 2015-04-29Bibliographically approved

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