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PARTNERSHIPS FOR ENHANCED ENGAGEMENT IN RESEARCH (PEER)
Cycle 5 (2016 Deadline)


Investigation of services delivered for TB by external care system - especially the private sector (INSTEP)


PI: Bachti Alisjahbana (b.alisjahbana@gmail.com), TB-HIV Research Center, Faculty of Medicine, Universitas Padjadjaran
U.S. Partner: Megan Murray, Harvard Medical School
Project Dates: May 2017 - November 2019

Project Overview:

The PEER project will be comprised of three studies that will cover the whole assessment of services delivered for TB patients in the private sector in Bandung Municipality, Indonesia. The overall study objective is to describe the health care pathways of patients seeking treatment for TB, and describe the behavior, and reasons behind the behavior, of Private Practitioners who diagnose and initiate treatment of TB patients. Specifically, the team will investigate health care pathways of newly diagnosed TB patients according to their socio-demographic characteristics and type of healthcare facility (sub-study 1). The PEER project will also assess the quality of TB case management by private health care providers, including their diagnostic, referral, and treatment practices, by using standardized patients (sub-study 2); and to understand which factors and reasons are associated with the choice of diagnostic, referral and treatment practices among private practitioners (sub-study 3). Cross-sectional, observational, and qualitative study designs will be used to reach the stated objectives.

The study will provide the national TB program a better understanding about the current practices of TB care and management, especially in the private sector. This information is vital since a large proportion of TB cases in Indonesia come to private providers as the first point of care when they first experience sickness. The proposed study method in evaluating the performance of private providers will be different from previous studies conducted in Indonesia by employing an approach which allow the team to investigate real practices performed by private providers.

5-497 Standardized Patient Training
Standardized Patient Training (Photo courtesy of Dr. Alisjahbana).

Summary of Recent Updates:
Completed in December 2019, INvestigation of Health Services for TB by External Private (INSTEP) providers was a 2 years mix method study aiming to assess the services delivered for TB patients in the Private sector in Bandung Municipality, Indonesia. It comprised of three substudies; substudy 1) To investigate health care pathways of newly diagnosed TB patients according to their socio-demographic characteristics and type of healthcare facility. 2) To assess the quality of TB case management by private health care providers, including their diagnostic, referral, and treatment practices, by using standardized patients. And 3) to understand which factors and reasons are associated with the choice of diagnostic, referral and treatment practices among private practitioners.

A total of 448 TB patients completed the interview in substudy 1. The study revealed that most patients first visited either private practitioners (36%) or informal providers such as pharmacies (41%). TB diagnosis was mostly made in hospitals (62%), while treatment was mostly provided in primary healthcare centers (PHCs) (40%). One-third of patients (37%) sought care from more than four healthcare providers (HCP) before diagnosis. The median time was 30 days (IQR 14-61) from the onset of symptoms to visiting a formal HCP; 63 days until TB diagnosis, 67 days until the start of TB treatment.

In substudy 2. 12 trained actors were sent to 320 private general practices, 20 private internist and pulmonologist practices, and 30 puskesmas as a comparator. General practitioners correctly managed 32.1% presumptive TB cases, and specialists correctly managed 22.2% presumptive TB cases. In comparison, puskesmas correctly managed 86.7%, respectively. The number of chest x-ray referrals was higher than sputum examination. Incorrect prescription of anti-tuberculosis drugs and/or fluoroquinolones was identified.

In substudy 3, in-depth interview revealed that the higher use of x-ray over smear microscopy, was because it is perceived that sputum examination has a limitation of sensitivity, patient’s preference, and clinical benefit by excluding other lung abnormalities as underlying reasons. With regard to fluoroquinolone use, patient’s expectation, absence of TB-specific symptoms, risk of losing patients, and disease severity were mentioned. Low notification rates among PPs were attributed to lack of resources, simplified mechanisms, standard reporting protocol and knowledge regarding mandatory TB notification.

Most Indonesian TB patients visit multiple public and private health care sites and suffer significant delays before diagnosis and initiation of treatment. This increases transmission, incurs significant costs, and hampers treatment outcomes. The majority of private practitioners incorrectly managed TB cases. These findings confirm that Indonesian PPs do not adhere to National Tuberculosis Program (NTP) guidelines. The use of chest x-ray as a first diagnostic test may be rational and helpful in the diagnosis of TB and other diseases, but wide prescription of fluoroquinolones can increase drug resistance.

There is a strong need for better integration of public and private services to help TB control in Indonesia. Re-educating and further appropriate approaches and strategies are needed to have private practitioners adhere to current tuberculosis management standards and engage in recording and reporting efforts.



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