The problem.
Case detection rate (CDR) of the district has increase from 35% (2018) to 104.42% in the year of 2019. Private hospitals contribute 3 times as much as public hospitals. So, both hospital could achieve more than a half of district target. The contribution of private hospitals is relatively high and has changed positively from the previous year. This is a major advance in the public-private mix.
Achievements in 2020, during the pandemic, appear to be decreasing, but records are not complete until the end of the year, meanwhile it cannot be concluded. The achievement of CDR in the sub-district (under Puskesmas responsibility) was almost half of district target on average as can be seen in Figure 1. However, there is almost no contribution from primary PHC facilities.
Hospital outreach to TB cases is very limited as a result of its function, namely a referral facility. On the other hand, PHCs (public or private) are actually closer to the community. The performance of PHC in TB case outreach can be further encouraged in increasing access for TB sufferers to health facilities.
As stated above, Public PHCs (Puskesmas) contributed almost half of the district's CDR achievement. Notably, in this pandemic situation, 30% of the sub-districts have increased the CDR, whereas others' CDR of this Public PHCs has drastically dropped. The assumptions that arise from program holders are population factors and turnover of subdistrict case managers. This phenomenon supports the suspicion that many TB suspects do not have access to healthcare services. By contrast, the Covid-19 pandemic situation has affected the TB control program. Case detection and reporting activities from private hospitals are increasing every year, but almost none from primary private healthcare facilities.
In this district, the role of the private sector is illustrated by the CDR donated by private hospitals. However, the role of private PHC is almost non-existent (Table 2). This situation occurs because the private PHC does not manage TB patients. They tend to refer TB patients to hospitals and health centers. In addition, there are cases where private PHC does not report the cases found. This means that many missing cases still occur.
Hospitals tend to be passive in accepting and managing TB patients, because of their given role as referral facilities. Considering that the problem of TB is access to health services, the role of PHC can actually increase access to services better than hospitals, because of the role in the health system.
Indeed, the Puskesmas have detected cases with variations, there are Puskesmas whose performance exceeds the target, some are still far from the target. The phenomenon of Puskesmas having exceeded the target performance proves that cases in the community are far higher than the target set by the government. This means that more intensive case detection and tracing efforts are needed. This includes the role of a private PHC, the private clinics and phycisians as well.
Reflect on the results of the analysis above, engaging private PHC facilities in increasing CDR is absolutely essential. Several reasons why doctors in private facilities are reluctant or hesitant to treat or manage tuberculosis patients are 1) increase the risk of transmission at the practice site, 2) high drug costs, 3) treatment complexity, 4) human resource limitations and 5) feeling excluded. Then, we explored stakeholders’ perception regarding the possibility of engagement from private PHCs into the DPPM strategy.
Readiness to engage concept mapping.
Based on the results of the qualitative study analysis, substantive theory has been successfully developed as illustrated in the Figure 2. DPPM as strengthening of the PPM strategy really requires the engagement of private and public health facilities to be involved in it. Before this engagement occurs formally, it is necessary to know factors of the involved individuals' readiness to engage.
Readiness to engage depends on individual and ecosystem factors. Individual factors consist of an attitude of awareness and concern for the tuberculosis problem; comprehension of drug management, the tuberculosis control program and PPM management; and involvement in the tuberculosis control program. Institutional support is an environmental factor for individual doctors and health workers to engage in tuberculosis control programs and DPPM.
So far, private physicians (PPs) have mostly referred TB patients or suspected TB patients, because it is risky for their place of practice/clinic. However, they are willing to treat if the medicine is provided by the government freely. PPs are willing to record and report if requested. They are also willing to be trained when requested. However, they objected to tracking cases. One respondent suggested coercive action through regulation:
"……maybe it needs to be made a regulation that forces the private sector..." (PPs, male).
Awareness of the Problem
Respondents observed that there are still many TB suspects who do not have access to health services. The respondent awareness of tuberculosis cases, thinking about these problems and having views that should be carried out by the related parties shows awareness of the problem.
“…My worker has relatives, and all of them are positive for TB. So it means that there are many possibilities in that area, it's just that maybe the work area of the puskesmas has not yet reached there... "(PP, male)
Being aware of the tuberculosis problem in their area will encourage health workers to try to handle them according to their competence and authority.
Program involvement
PPs have not collaborated with the government (DHO) and feel they have never been invited to collaborate by the Puskesmas. They have not yet been exposed to information systems for tuberculosis management:
"... education to the community is mostly from the puskesmas program holders; in the private sector, I don't think I have heard either...." (PP, female).
PPs are almost never involved in the program, as stated by a respondent.
“………. I, as a personal doctor, am rarely around (exposed to the program). Most of the meetings with the Health Office are not convened by the doctors; most are by the TB administrators…. "
Private hospitals have started to be involved in the TB program. However, it needs to be realized by the government that private doctors and clinics should be taken into account, given that patients usually come to primary care first.
"…………The TB DOTS program is targeting now that it has entered private hospitals; maybe it would be nice now because there are more clinics than private hospitals, so this clinic is involved ……"
Program Understanding/Comprehension
The understanding of tuberculosis treatment management is not evenly distributed in every doctor, both public and private. Private doctors who have the opportunity to access the program can better understand and manage patients in line with government guidelines. The understanding of PPM is very low, not only in private doctors but also in public healthcare providers. Without good understanding, it is difficult for motivated individuals to become involved in government programs and strategies.
Concern
Concern about TB problems in his area was illustrated by one of the private respondents:
"... during the 7 years I was here, I saw that this TB doesn't go down...."
Concerns about TB problems that have not been resolved are not only in the form of attitudes. This concern is the potential for action when the right situation and moment arrives. In this case, individuals who are concerned will get involved if invited by the public.
Institutional support
Carrying out PPM requires enhancing patient management and program management skills (including recording and reporting). This requires additional human resource support and financing. If the institution that owns the health service is not supportive, then individuals who wish to be involved in the program cannot access public strategies and programs.
Factors influencing readiness to engage
Figure 3 illustrates the measurement results in a representative sample of private and public health facilities where the percentage of four levels out of six dimensions is seen in relation to the readiness of health facilities to be part of the DPPM strategy. Four dimensions, namely awareness, program comprehension, concern, and program involvement, are those aspects that come from internal respondents. Meanwhile, institutional support is a factor that comes from outside the respondent.
The dimension of program involvement has the highest level below the mean (very low and low) (68%) followed by readiness to engage (65%). Circumstances factors describing a negative or less supportive trend. By contrast, it is interesting to follow the phenomenon where the most positive trends (high and high levels) are in the concern (55%) and awareness (42%) dimensions.
All dimensions have a tendency toward the right or a negative trend; this means that a portrait is less supportive of the occurrence of DPPM. The dimension of readiness to engage as the dependent variable also indicates a tendency of lack of support for the implementation of DPPM. This description is a challenge in building a DPPM implementation strategy.
Bivariate analysis indicated a correlation between readiness to action and awareness (r: 0.49; p = 0.02); comprehension (r: 518; p = 0.01), concern (r: 0.620; p = 0.00); involvement (r: 0.405; p = 0.012); and institutional support (r: 0.373; p = 0.019). However, in the regression analysis, there are only two dimensions that are significantly related to readiness to engage, namely concern and institutional support, so that we get Y = 0.205 + 0.239 X1 + 0.758 X2, where Y = readiness to engage, X1 = concern and X2 = institutional support (r2 adj.=50.7%; p<0.05).
The DHO as a dirigent of DPPM should encourage personnel in health facilities to be more concerned with TB problems. Equally important, local government encourages health facilities' owners to support and facilitate professionals in their institution for tuberculosis services.