Quality Tuberculosis Care in Indonesia: Using Patient Pathway Analysis to Optimize Public-Private Collaboration

Abstract

Background: Tuberculosis (TB) is the fourth leading cause of death in Indonesia. In 2015, the World Health Organization estimated that nearly two-thirds of the TB patients in Indonesia had not been notified, and the status of their care remained unknown. As such, Indonesia is home to nearly 20% of the world's "missing" TB patients. Understanding where patients go for care may enable strategic planning of services to better reach them.

Methods: A patient pathway analysis (PPA) was conducted to assess the alignment between patient care seeking and the availability of TB diagnostic and treatment services at the national and subnational level in Indonesia.

Results: The PPA results revealed that only 20% of patients encountered diagnostic capacity at the location where they first sought care. Most initial care seeking occurred in the private sector and case notification lagged behind diagnostic confirmation in the public sector.

Conclusions: The PPA results emphasize the role that the private sector plays in TB patient care seeking and suggested a need for differentiated approaches, by province, to respond to variances in care-seeking patterns and the capacities of public and private providers.

Keywords: Indonesia; care seeking; patient pathway analysis; private sector; tuberculosis.

© The Author 2017. Published by Oxford University Press for the Infectious Diseases Society of America.

Figures

Figure 1.

Patient pathway visual, national level. The patient pathway describes the care-seeking patterns of patients and how those patients may intersect with tuberculosis (TB) services. Column 1 starts by showing the sectors and levels of the health system (sectors and levels where no data was available are not included in the pathway, eg, public L0). The percentage next to each sector title is the share of patients who initiate care seeking in this sector [6]. Next is the estimated number of health facilities at each level within each sector [10]. The final part of column 1 shows the location of initial care seeking among participants in the 2014 National TB Prevalence Survey at which patients sought care for TB symptoms (14 days of cough or hemoptysis) at each level of the health system [6]. Column 2 shows the percentage of health facilities that have microscopy across each sector and level of the health system (ie, coverage) [10, 14]. Column 3 shows the estimated percentage of patients likely to access a facility with TB diagnosis available on their initial visit to a healthcare facility. This column was calculated by multiplying the share of care seeking at each sector/level of the health system by the coverage of microscopy at each respective sector/level and summing the total. Column 3 separates public and private sectors based on each sector’s contribution to TB services access at initial care seeking. Column 4 shows the TB diagnosis location of participants in a 2010 national-level health survey [15]. Column 5 shows the location of treatment among those participants who were diagnosed with TB in the 2014 National TB Prevalence Survey [6]. Column 6 shows which sector provided case notification and is calculated as a share of the overall estimated incidence in 2015 [7, 13]. Column 7 shows the treatment outcome of notified cases among the overall estimated incidence for 2015 [7, 13]. Columns may not add to 100%, due to rounding. For more details on the data sources used in the pathway, see the Supplementary Materials. Abbreviations: Dx, diagnosis; Tx, treatment.

Figure 2.

Access to microscopy at initial care seeking by province. The patient pathway analysis was completed for 33 of 34 provinces in Indonesia. This figure shows the access to diagnosis at initial care seeking for each province (column 3 of the patient pathway visual) as well as the population of each province. Dots representing each province are colored based on the share of initial care seeking in public (brown) vs private (blue) health facilities [6]. Abbreviations: DI, Daerah Istimewa; DKI, Daerah Khusus Ibukota.