The study participants described current practices in the provision of TB-DM services, identified complex challenges affecting the integration of both disease care. They explored the opportunities and potential roles of PPC. The main four themes identified from the data analysis were health system-related barriers, HCW's knowledge and perception, un-implemented bi-directional screening, and multisector role needs.
Theme 1: Health System-Related Barriers
In our study, private GPs/ solo providers more frequently found TB-DM cases among their patients than clinic staff who have never had the cases at all until now. Although all TB-DM cases were always referred to a hospital and/ or Puskesmas, some private-sector challenges related to TB-DM services were identified as health system-related barriers. These problems occurred due to the in-adequate collaborative system from national into the local network.
In this first theme, five categories were identified. These categories include BPJS-Kesehatan procedure, health financing, diagnostic procedures, health facilities networking, and human resources issues.
As a national social security agency for health, BPJS-Kesehatan has some mismatched regulations with TB-DM services provision needs. Almost all informants in this study remarked that regulation restrictions for non-specialist referrals made it challenging to do hospital referrals. According to this regulation, TB is a disease that must be managed by primary care facilities. The problem occurs mainly if DM patients had atypical TB symptoms and required a chest X-ray for TB screening. As well-known, almost all primary healthcare facilities in Indonesia have no radio imaging equipment for these purposes.
"The problem will arise if the patient DM needs to screen TB. Not all of them have symptoms because there is an immune response, while the national consensus suggests using X-rays to check effusion or infiltrates. Meanwhile, the primary health facility did not have X-rays facilities, but referral (to the hospital) could not be done due to this BPJS regulation." (FGD Clinics, R7)
The complexity of electronic referral and re-referral forms that must fill out by doctors was also not acceptable. Some senior doctors often face barriers due to non-user-friendly applications or may be due to illiteracy of new technology, i.e., in completing the TACC (Time-Age-Complication-Comorbidity) section for referring patients to a hospital. Complicated procedures of patient referral sometimes lead to fraud in diagnosis writing, as disclosed by informants.
"There was a case yesterday. A patient was diagnosed with DM in my clinic, then he complained of prolonged cough, and so on. Then I referred him to the hospital with the same diagnosis that other doctors had reported earlier (Bronchitis). Since we were not able to refer (to the hospital) with a diagnosis of TB, so we wrote Bronchitis."(FGD Private GPs, R6)
Interesting issues pointed out by private sectors was related to health cost beyond the national health insurance scheme. Since the TB program was established in Indonesia, services are mostly provided at CHCs. Private clinics/ GPs are allowed to refer TB patients to these public health facilities. Due to some patient participation in BPJS are not registered at the CHC, specific procedures and services require additional fees, i.e., registration/ administration, cost-sharing, and/or payment of fees for supporting examination or other health services needed. Health costs barriers arise not only because of the patient's inability to pay but also because of a low willingness to pay. In turn, this barrier will disrupt patients from accessing health services according to their current needs.
"The patient often say, 'How will it cost, Doc? If I am told to pay, I am (still a BPJS membership) here ... .’ So far, BPJS patients only know if BPJS participants should not pay anything. Anyway, they all know (that health services) should be completely free." (FGD Private GPs, R4)
"Patients do not pay (for TB services at the Puskesmas), but every month a patient visits, they must register. Every time a patient registers, they have to pay, so instead of being complicated, it is advisable to move their BPJS membership to Puskesmas."(FGD Private GPs, R3)
On the other hand, there are several types of PPCs located in Yogyakarta City. Variations of the PPCs’ ownership, organization/ managerial, and membership coverage have existed even before the universal health coverage (UHC) era. This situation has left a variety of health programs and potential sources of health funding in addition to the BPJS-Kesehatan scheme that could be used in TB-DM care and control.
"There are funds allocated to National Police officers for annual health checks, but this is not routine, either. It needs to be separated and sorted, and it takes turns for the individuals being examined."(FGD Clinics, R11)
"Because the company also covers our health costs, so even without BPJS, a patient can seek treatment outside. Yes, we discuss it there (with the patient)."(FGD Clinics, R9)
The informants expressed that chest X-ray screening, which is suggested by national guideline, have been procedurally constrained, as explained above. In general, private health workers are not familiar with the other tests, such as gen-Xpert/ rapid molecular test, even though DHO promoted gen-Xpert for increasing TB case finding in Yogyakarta. Instead of being more accessible, the diagnosis by sputum smear test was very challenging in DM patients. Informants conveyed that they always refer the patient to a third party if they require a supporting exam to validate a TB diagnosis. These conditions were challenging for proper and timely diagnosis in suspected patients.
"We are also in the same situation as other clinics that do not do supporting examinations by ourselves. But, we cooperate with third parties, including sputum examinations and X-rays." (FGD Clinics, R9)
Health facilities networking
The informants highlighted the weakness of networking between health facilities. Even though private health facilities cooperate in immunization, diarrhea, and other national programs, TB collaboration control, and care are un-established. The majority of private HCWs informants were not familiar with the concept of Public Private-Mix (PPM), nor do they have a cooperation MoU with the local Puskesmas, mainly in TB management. However, discussions to initiate MoU formulation have been done since accreditation for all primary health facilities were implemented.
Data recording and reporting are the other essential components that should be discussed in the development of MoU between PPC and Puskesmas. However, most informants expressed mixed feelings between their desire for MoU to increase authority in health services and potential obstacles that would be faced. The solemn reporting obligations, how to report, and un-established reporting system were complex challenges that need to be resolved.
"I do not know my obligation to report to the Puskesmas. This challenge is about how to establish cooperation with the Puskesmas. We are asked to propose MoU cooperation (to Puskesmas) as required by BPJS and for the TB disease eradication. Private GPs also has to play a role, it must be a written MoU cooperation, and so far, I have tried to propose it, but the Puskesmas has not answered yet. The word formulation of MoU is still being discussed with the Health Office; what kind of cooperation is this. The formulation cooperation is still in the process." (FGD Private GPs, R5)
Another reported problem was communication and coordination between private and public primary care and hospitals. Although some of the GPs informed that they have an excellent relationship with public health workers, in general, but they still experienced minimal feedback or responses from referral healthcare facilities. Some of the referrals never received feedback, and they were lost during the follow-up for the patient.
"There is a TB patient who is a BPJS participant also, and we just handled once. And maybe we don't know the procedure, because we just got it. If I am not mistaken for the treatment, this is served in the Puskesmas around the patient's house; that is the closest Puskesmas. Yesterday, because of the information from the Puskesmas close to our clinic, the last case had to be reported. So, there was a miscommunication. That is our problem when there is no communication between the Puskesmas and our clinic. (FGD Clinics, R2)
The District Health Office (DHO) and CHCs acknowledge that the private sector has not been involved in TB-DM care and control collaboration. From the perspectives of DHO officers, private sectors seemed to lack attention to government programs. On the other side, the DHO is preoccupied with many of the Government's health program burdens, including the Minimum Service Standards' target achievement. Hence, the DHO is still more focused on fostering Puskesmas as a Regional Technical Implementing Unit than private sectors.
"To be honest, because of the progress, yeah… TB-DM has not yet reached them (PPC). Because on the way, even on applying DOTS, their attention is low. So, we prioritize what we can do.(IDI DHO officer, R1)
Human resources issues
Although private HCWs showed positive attitudes by stating the possibility of assisting and being involved in TB-DM management, they still pointed out human resources issues that lack designated staff in TB programs. TB and TB-DM patients need to be adequately managed according to DOTS (Directly Observed Treatment Short-course) strategies. There was still limited PPCs’ staff who were trained for DOTS/ TB management programmatically. Meanwhile, a portion of chronic non-communicable disease patients was managed systematically with PROLANIS (BPJS chronic disease service program), although it still needs improvement.
"Our problem is that there is no person in charge (PIC) for TB cases. For DM and Hypertension, whose patients are members of PROLANIS, there is a designated appointed PIC. There is no PIC for TB at us, but we have a quality and patient service department that will further explore TB cases even though we rarely have cases. DM and Hypertension patient always managed and followed-up, but because TB patients go directly to the hospital, we don't have TB PIC." (FGD Clinics, R2)
Theme 2: HCWs’ Knowledge and Perceptions
Informants expressed wide variations in the baseline of knowledge and perspectives on TB-DM and its management. Three categories were emerged, i.e., variation knowledge in TB-DM, false perceptions, and lack of TB socialization and training.
Variation of HCW's Knowledge about TB-DM
During the discussion process, private HCWs showed diversity in their knowledge of the pathophysiology of TB-DM, treatment, type of screening, and standard treatment. Although most informants realized that DM was a risk factor for TB, none of them mentioned if TB patients also have a risk factor for DM. Informants, who expressed their opinions, generally understood well the impact of DM on worsening TB patient outcomes.
"Based on the theory, handling TB with DM or DM with TB will be more difficult." (FGD Clinics, R10)
"If I was asked about the relationship between DM and TB, in my opinion, it is related. Because it is associated with the immune system, which might at that time if we conduct anamnesis, it is indeed experiencing a decline in these patients."(FGD Clinics, R9)
Some clinics' health workers perceived that TB-DM was rare because they had not or only seldom found the case. In the diagnostic procedures and treatment aspect, almost all private HCWs also still have a preoccupation that procedurally TB-DM is difficult to manage even though various government policies allow this to be done. They believe that the patients cannot get insulin if their HbA1c level was lower than 9%, according to the BPJS-Kesehatan requirement, even though this requirement not applicable for patients with comorbid conditions.
"As long as I practice in the clinic, I have not found DM patients with TB symptoms. We haven't. I've never got a TB-DM case while practicing there. So, I haven't thought much about how the relationship between the two diseases."(FGD Clinics, R2)
"This is another problem. Insulin can only be given if HBA1c above 9. Yeah, that is just a new problem, recently."(FGD Private GPs, R5)
Lack of TB socialization and training
Variation of knowledge and perceptions among HCWs may occur due to a lack of training, socialization, and coordination between them, public sectors, and DHO. Only one private GP reported being invited to TB training in 2015. All private providers stated that they have never seen or read the guideline or national consensus about TB-DM. This situation also causes HCWs to be unaware of the importance of bi-directional screening, regimen standard, and integrative care for TB/ TB-DM patients.
"The Health Office is already undertaking a lot of accreditation-related socialization intensively. But, in my opinion, socialization regarding new guidelines and regulations (about TB-DM) is still limited."(FGD Clinics, R2)
Theme 3: Un-implemented bi-directional screening
In this vital theme, three categories were identified. These categories include screening pathways, screening difficulties, and screen opportunities.
None of the private HCWs stated that the bi-directional screening was being done comprehensively and regularly in their health facilities. TB screening in DM patients was performed sporadically, which was only superficially investigating if patient complaints. This screening was usually performed based on the physician's clinical judgment or if symptoms suggest a suspected TB disease appear.
"… the problem is (only) if there are complaints, we then anticipate it. Complaints of cough are rarely or not become the patient's main reason to come for treatment. There could be inaccuracy or inadequacy during the history taking due to many patients, long queues, and many more. So, we only explored the primary diagnosis (DM) or if the patient did not appear to be coughing in the room. It was considered sufficient to ask cough complaints, especially in DM patients who generally only checked the blood glucose then asked for the referral form and finished. It's not well organized."(FGD Clinics, R6)
Informants noted that some factors could become obstacles in bi-directional screening implementation. It was highlighted that DM patients often have atypical symptoms or could not expectorate or produce sputum for smear examination. The difficulty of accessing X-rays also remains a prominent obstacle in implementing bi-directional screening. On the other hand, patients who refused to be referred for diagnostic procedures might also delay the diagnostic examination.
"It's not easy to diagnose TB, either, because there are many elderly patients who say that, ‘When I'm old, it's common that I have a prolonged cough.’ There are still a lot of opinions like that. 'It's a cough because I'm an old man.' So he came back two months or three months later. The cough does not heal, or the child is sick, the family members are sick, the grandchild is sick. It turned out that his grandparent was ill first." (FGD Clinics, R3)
"The X-ray might facilitate the technique, whereas the sputum screening test is difficult."(FGD Private GPs, R3)
Despite complicated existing obstacles, the informants identified several opportunities to screen for TB in DM patients. Some routine activities that have been done routinely before can be used to start TB screening intensively, i.e., initial assessments by HCWs in health facilities, general routine check-up examination, and Posbindu/ Posyandu (integrated community health services post).
"We also carry out routine activities for the National Police, which are periodic for Polri (Police of Republic Indonesia) members themselves as well as X-rays and so on. So that it is found that members of the police who should be healthy, who so far have no complaints, we direct them to the clinic or the hospital." (FGD Clinics, R11)
Some informants also reported that 'fee for service' or non-BPJS patients were more flexible for screening procedure uptake. Some patients usually would pay for diagnostic procedures suggested by the doctor.
"Our advice to patients, for example, 'If you haven't had an X-ray for the last three months, I recommend X-rays.' If he is not a BPJS patient, it will be more comfortable, but for this BPJS patient, it's still a bit difficult to do."(FGD Clinics, R7)
Theme 4: The needs of multisector roles
TB-DM patients need to be managed collaboratively. Hence, the functions of stakeholders, health facilities, and also health organizations/associations have a crucial part to play. Many DM patients sought health care in private health facilities. Meanwhile, to involve and engage private sectors, the needs for multisector supports were identified.
Five categories organized this theme. The categories were roles of DHO, roles of health facilities/ health profession associations, patients' roles, potential roles of PPCs, and encouragement by BPJS-Kesehatan.
Roles of District Health Office (DHO)
DHO has keys roles in initiating the private sector to involve in TB-DM collaboration. Socialization for private primary care has not started yet; hence DHO should ensure that all health facilities which serve TB/DM are well informed about this new program. Such a strategy could use the DHO, i.e., by engaging healthcare/profession associations.
"If I may suggest how if the Health Office cooperates with professional organizations in socialization regarding new guidelines, new regulation, or the program of the DHO itself in the city. Because Asklin (private clinics associations) already accommodates almost all private clinics in their respective cities. So, in my opinion, if the DHO reaches them, it will be much easier than the DHO approaches private primary care one by one. (FGD Clinics, R2)
In addition to socialization and beginning to connect or coordinate with relevant organizations, systematic monitoring in health facilities should be considered to ensure the program implementation. The private sector needs guidance, monitoring, and evaluation for program implementation. They also need advocacy about an appropriate payment mechanism.
"We have come to attend DHO socialization on other topics, but usually just socialization. We do not get any guidance or monitoring and so on to ensure its implementation." (FGD Private GPs, R9)
"We have not done that screening. Because clinics are also not burdened for screening, right? Well, who pays the fee? So, if there are clinical symptoms and support the suspicion of the disease, we refer (to hospital/ Puskesmas)." (FGD Clinics, R2)
Roles of health facilities or health professional associations
Asosiasi Klinik (Asklin), or private clinic association, which accommodates all private clinics in Yogyakarta City, has not been involved in initiating the collaborative TB-DM program in private health facilities. This organization also focuses more on its function in advocacy or assistance for members on accreditation and issues related to BPJS-Kesehatan rather than support from other government programs.
"Asklin, until now, the focus is still on accreditation related to the BPJS requirements that in 2021 all health facilities must be accredited. …. As far as I know, Asklin, the focus is still more on accreditation. As for seminars or programs, there is not yet a particular program for it (TB-DM)." (FGD Clinics, R6)
Asklin could play some roles in increasing private sector engagement with government programs. Until now, only limited programs have had a reasonably good collaboration between the public and private sectors, such as immunization and DHF (Dengue Hemorrhagic Fever). Although TB has been initiated in various public-private mix activities, its implementation has not yet been going well. Hence, Asklin can play a role in designing the MoU of cooperation between PPC and government health facilities and conducting various educational sessions or socializing national programs to its members.
"Asklin's role was included due to the BPJS credentialing this year requiring an MOU with the Puskesmas so that Asklin then intervened in the clinic's relationship with the Puskesmas (CHC) because before that it was only independent between the clinic and the Puskesmas concerned."(FGD Clinics, R2)
Roles of health profession associations similar to Asklin could be an extension of the health office to disseminate information about priority programs. IDI/ Ikatan Dokter Indonesia (GPs Indonesia Association), specialist doctor associations, and other organizations of HCWs have not been much involved until now. Although in the discussions of the several national-level consensuses, health professional organizations have often been invited to discuss.
"… In my opinion, it is much easier than the DHO call or comes to each private primary health facilities. Because it does not represent all primary care, maybe if the health office calls the health facilities, DHO will invite large health facilities or from a certain area only. But if DHO can hold Asklin or professional organizations, all of them have been accommodated. It is more coordinated." (FGD Clinics, R2)
Patients also have essential roles in the successful TB-DM collaboration of care and control. Patients' key roles involve compliance with treatment and following doctor advice, involvement in decision-making, and willingness to pay some health costs and other financial burdens related to diagnostic and treatment beyond the insurance scheme.
"Yes, we first check with X-Ray. In our clinic, when there are X-ray and sputum data that leads to TB, we will discuss it with the patient. I have previously conveyed and because of the absence of drugs and so on. We will discuss whether he is willing to be referred (to other health facilities) because the BPJS is not used here. Generally, that is the case." (FGD Clinics, R9)
Potential roles of private sectors
Informants mentioned some activities that are routinely conducted by PPCs. Some activities listed as potential roles that they can apply if involved in TB-DM control and care collaboration. Private health facilities commonly have a large number of DM patients. Hence, health promotion and patient education become a significant factor for prevention, increasing patient compliance to treatment, and patient referral. The BPJS membership versatility and partnership characteristics between patients and providers in PPCs are also opportunities for program success. In general, patients have a close relationship with health workers, and PPC is highly accessible also. National insurance membership is also quite flexible, which means that participants can temporarily move their health facility membership during TB treatment to Puskesmas or other DOTS facilities if they are worried about additional health service costs.
"We are closer to the patient so that they are more able to warn against routine treatment because usually… those with chronic comorbid diseases routinely come every month. We can order them that even if they take medicine at the hospital with a control letter, ‘If anything happened, please come to our practice!’ If they want a consultation, please come, and they are happy. They sometimes meet a specialist doctor in the hospital, but he doesn't even hold them because there are so many patients. And by that way, we can monitor them." (FGD private GPs, R4)
Referring patients to DOTS facilities is the only effort that can now be done by PPCs when identifying suspected TB-DM patients. This situation was caused by several issues related to PPCs’ authority, including untrained staff, unavailability of TB drug regimens according to the current ISTC’s standards, and the inability to prescribe insulin. When patients are finally referred to other health facilities, PPC often has difficulty in following up the patient's treatment because of minimal feedback and coordination, as stated above. Thus, challenges on continuity of care have also emerged as obstacles.
"We were unable to order TB drugs. The TB patients who came to us were detected coughing through anamnesis. Then, even for sputum smear examination, we are also referring to a third party. After he is positive for TB, we will return him or educate him to take medication at the Puskesmas in the local area where the patient lives. However, in monitoring TB patients, we are not very involved there." (FGD Clinics, R2)
Although some barriers are mentioned above, private providers expressed their mixed feelings about their ability to be involved in successful TB-DM collaboration. Due to customer satisfaction oriented, they intend always to pay attention to every clinical complaint with appropriate follow-up. However, they also exhibited their reluctance to conduct home visits due to the high workload, even though they are usually required in TB management.
"… if I am asked whether this program can run actively in private health facilities or not, I can say that it can indeed run actively. Because we, from the private sector, always try not to ignore patient complaints. It will be followed up unless there are no complaints." (FGD Clinics, R6)
"Even if we are asked for assistance to make a report as long as we can do it, I think the private sector can be quite helpful, as long as we are not asked to visit the patient's house. It will be a hassle. No problem… because I think the private sector will not mind if the Puskesmas can more actively involve us." (FGD Clinics, R2)
Encouragement by BPJS-Kesehatan
Since BPJS-Kesehatan's role as a significant payor in the national health system, it has encouraged several national programs to run well. Comprehensive care through PROLANIS (chronic care program for DM and hypertension) is one of the commitment-based PPCs’ performance assessment items. Informants pointed out their expectations regarding BPJS-Kesehatan's potential role in encouraging screening TB regularly in DM patients.
"BPJS should have regulations to ensure that there must be TB screening in DM cases, for example, in the PROLANIS program. Every six months, there is always an HbA1C examination, complete lipid profile, and urea creatinine. Thus, TB screening could be included in this 6-month program, for example." (FGD Clinics, R7)