From the registries of the City Health Office and the Indonesian Medical Association, we identified 2,593 physicians who were practicing primary or secondary HCFs, including those practicing single and multiple provider-HCFs, in the 30 selected CHC areas. Of these, 979 were duplicates, leaving 1,614 on the list. Upon field exploration, we identified 561 PPs (34.8%; 561/1,614) on the list, 470 of which (29.1%; 470/1,614) were actively practising in HCFs. Those recorded as inactive (n = 91) were due to either HCF-related reasons (permanently closed) or physician-related reasons (moved to another HCF, retired, or deceased). Enumerators identified an additional 466 PPs who were not on the list, for a total of 936 PPs providing health services in the 30 selected areas. With this figure, we calculated that the median number of PPs was 27 (IQR: 12–40) per CHC area. Moreover, the median number of PPs available for every 100,000 inhabitants was 53.9 (IQR: 37.5–91.7) per CHC area. Seventy-two percent (n = 674) of PPs were able to be interviewed. Of the interviewed PPs, 88.1% (594/674) provided services to patients with RTI symptoms. Among the PPs who managed RTI patients, 241 (40.6%; 241/594) had TB (Fig. 1).
Table 1 shows the characteristics of the PPs. The majority of the PPs interviewed were general practitioners (GPs: 73.3%), practising in clinics with multiple physicians (78.6%), and half were female (54.7%). The median age was 40 years (IQR: 30–53 years). In addition to GPs, we successfully interviewed specialists, including those practicing obstetrics and gynecology, pediatrics, internal medicine, radiology, and other specialty areas. Two pulmonologists working in the study area were unavailable for interviews.
Table 1
Characteristics of the interviewed private practitioners and those managing patients with respiratory tract infection symptoms
Characteristics | Total interviewed (N = 674), n (col %) | Managed patients with RTI symptoms (N = 594), n (col %) |
Female | 369 (54.7) | 329 (55.4) |
Age, years, median (IQR) a | 40 (30–53) | 39 (29–52) |
Qualification | | |
General practitioner | 494 (73.3) | 474 (79.8) |
Pediatrician | 26 (3.9) | 25 (4.2) |
Internist | 22 (3.3) | 21 (3.5) |
OBGYN | 39 (5.8) | 28 (4.7) |
Radiologist | 5 (0.7) | 4 (0.7) |
Other specialists | 88 (13.1) | 42 (7.1) |
Type of healthcare facility | | |
Single provider | 144 (21.4) | 130 (21.9) |
Multiple providers | 530 (78.6) | 464 (78.1) |
Primary level | 307 (57.9) | 291 (62.7) |
Secondary level | 223 (42.1) | 173 (37.3) |
Practicing in healthcare facility b | | |
with in-house X-ray | 68 (10.1) | 60 (10.1) |
with in-house laboratory | 180 (26.7) | 161 (27.1) |
with in-house pharmacy | 472 (70.0) | 412 (69.4) |
accepting national health insurance | 149 (22.1) | 138 (23.2) |
Time of practice, schedule | | |
Both weekdays and weekends | 191 (28.3) | 174 (29.3) |
Weekdays only | 436 (64.7) | 377 (63.5) |
Weekends only | 24 (3.6) | 23 (3.9) |
By appointment only | 19 (2.8) | 18 (3.0) |
Unknown | 4 (0.6) | 2 (0.3) |
Number of days of practice per week, median (IQR) | 4 (3–5) | 4 (2–5) |
Time of practice, during weekdays c | | |
Office hours (7 am to 5 pm) | 418 (66.7) | 371 (67.3) |
After office hours (5 pm and above) | 209 (33.3) | 180 (32.7) |
Encountered TB patients d | | |
Diagnosed TB in the past 3 months | n/a | 241 (40.6) |
Were treating TB patients | n/a | 101 (17.0) |
Abbreviations: IQR = interquartile range; OBGYN = obstetrician and gynecologist; RTI = respiratory tract infection. |
a A total of 137 PPs refused to provide their age (113 of those who managed patients with RTI symptoms) |
b Not mutually exclusive (the percentages may add up more than 100%) |
c Obtained from those who practiced during both weekdays and weekends and those who practiced only on weekday |
d Not mutually exclusive |
Most of the interviewed PPs routinely provided services only during weekdays (64.7%), followed by both weekdays and weekends (28.3%) or weekends only (3.6%). Approximately one-third of them provided service after office hours. Of the 594 PPs who managed patients with RTI symptoms, most (69.4%) practiced in an HCF that provided pharmacy services. In addition, some of the HCFs provided in-house X-ray (10.1%) and laboratory (27.1%) services. During the study, approximately one-quarter (23.2%) of the PPs were working in an HCF linked with the national health insurance system. (Table 1).
Among the PPs who managed RTI patients, 241 had TB, and 17.0% (101/594) had TB according to their treatment program (Table 1). When stratified according to PPs’ qualifications, pediatricians were the most likely (60%) to encounter TB cases, followed by internists (48%) and GPs (42%). Despite the lower proportion of GPs encountering TB patients, they were present in the largest number (n = 199) compared to pediatricians and internists (n = 15 and n = 10, respectively) (Fig. 2). In contrast, less than one-fifth of obstetricians and gynecologists (OBGYN) and other specialists encountered TB patients (18% and 19%, respectively). All radiologists managing patients with RTI symptoms also encounter TB patients, primarily by detecting presumptive TB via chest X-ray examinations.
Figure 3 shows the number of PPs practising in HCFs with in-house pharmacies, followed by laboratories and chest X-rays (n = 412, n = 161, and n = 60, respectively). We did not observe differences in the proportions of PPs who encountered TB patients according to whether they had laboratory or X-ray data linked with their services. Moreover, less than half of the PPs in the HCF with pharmacies and accepting national health insurance were TB patients (41% and 45%, respectively). Additional information about the characteristics of the PPs who managed patients with RTI symptoms according to whether they encountered TB patients is provided in supplementary Table S1.
Figure 4 shows the total reported number of TB patients diagnosed in the past three months and under treatment by PPs. Overall, 937 patients were diagnosed with PPs in the past three months (median of 3 per PP), and 354 TB patients were diagnosed (median of 2 patients per PP) (additional files: Table S2). The physician group with the highest cumulative number of TB diagnoses (n = 687) and treated patients (n = 218) were GPs. Other physicians treating numerous TB patients were pediatricians (78 patients) and internists (38 patients). However, internists have twice as many TB patients per person as pediatricians.
If the stratification is based on Health Care Facilities, we identified 412 operating private HCFs (Figure S1), consisting of 195 single-provider HCFs, 141 primary-level HCFs, and 76 secondary-level HCFs. Of these private HCFs, 45 (11.0%) had laboratories and 12 (3.0%) had X-ray facilities. The specific characteristics of the private HCFs, including their service types and support facilities, are described in supplementary Table S3.
Figure 5 (and supplementary Table S4) shows the distribution of PPs per population in the study area and the corresponding TB notification rates for each CHC area. Compared with the HCs, the CHCs southwest of Bandung had the highest annual TB notification rates in the northern and eastern parts of the city. The density of PPs per population varied, with 21 CHC areas (70%; 21/30) having adequate PPs per population (ratio > 1:2500) and three CHC areas in the southeast having the lowest ratios (< 1:5000 PPs per population). Areas with the highest TB incidence tended to have significantly lower concentrations of PPs (Supplementary Figure S2).