Introduction
Methods
Study setting
Participants
Study design and data collection
Data analysis
Results
Participant’s code | Gender | Age (years) | Profession | Position | Length of employment (years) |
---|---|---|---|---|---|
FGD of Clinic Representatives | |||||
R1 | Female | 30 | GP | Health services manager | 5 |
R2 | Male | 42 | GP | Functional GP | 2 |
R3 | Female | 30 | GP | Functional GP | 2 |
R4 | Female | 26 | Midwife | Health service manager | 4 |
R5 | Female | 45 | GP | Functional GP | 3 |
R6 | Female | 50 | Midwife | Health services manager | 20 |
R7 | Female | 55 | GP | Head of clinic | 4 |
R8 | Female | 32 | GP | Functional GP | 3 |
R9 | Male | 32 | GP | Functional GP | 2 |
R10 | Female | 37 | Nurse | Health services manager | 11 |
R11 | Female | 33 | GP | Head of clinic | 5 |
R12 | Female | 40 | Nurse | Health services manager | 21 |
R13 | Female | 54 | GP | Head of clinic | 25 |
FGD of Solo General Practitioners | |||||
R1 | Female | 45 | GP | Owner and functional GP | 20 |
R2 | Female | 43 | GP | Owner and functional GP | 16 |
R3 | Male | 41 | GP | Owner and functional GP | 15 |
R4 | Male | 52 | GP | Owner and functional GP | 5 |
R5 | Female | 69 | GP | Owner and functional GP | 9 |
R6 | Female | 46 | GP | Owner and functional GP | 12 |
R7 | Female | 62 | GP | Owner and functional GP | 1 |
R8 | Female | 54 | GP | Owner and functional GP | 5 |
Theme 1: health system-related barriers
The BPJS-Kesehatan procedures
The complexity of electronic referral and re-referral forms that must be completed by doctors was also not acceptable. Some senior doctors often face barriers due to non-user-friendly applications or their lack of familiarity with new technology, i.e., in completing the TACC (Time-Age-Complication-Comorbidity) section for referring patients to hospital. Complicated procedures of patient referral sometimes led to the recording of incorrect diagnoses in referral forms, as disclosed by informants.The problem will arise if the patient DM needs to be screened for 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 of Clinics, R7)
In triangulation with the BPJS-Kesehatan representative, opportunities for discussion and piloting pathways for enhancing TB-DM case detection are still open. By applying national guidelines in TB-DM care and collaboration to mandatory chest X-rays for TB screening in DM patients, BPJS-Kesehatan representative identified potential barriers. These concerns regarding the increasing number of hospital patients and the risk of resources mobilized ineffectiveness compared to the screening results obtained. Hence, pilot testing of specific referral pathways for TB screening may be required to assess how these procedures affect health financing and case finding. On the other hand, BPJS-Kesehatan also recognizes the necessity of early detection of TB patients in primary care. Moreover, there are chances and needs to assess potential and risk for providing chest X-rays in primary care to resolve the gap.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). As we were not able to refer (to the hospital) with a diagnosis of TB, so we wrote Bronchitis." (FGD of Solo GPs, R6)
Health financing
The patient often say, “How much will it cost, Doc? If I am told to pay, I am still a (BPJS) member here ... .” So far, BPJS patients only know that BPJS participants should not pay anything. Anyway, they all know (that health services) should be completely free." (FGD of Solo GPs, R4)
On the other hand, there are several types of PPCs located in Yogyakarta City. Differences in PPCs ownership, organisation/management, and membership coverage existed even before the universal health coverage (UHC) era. This situation has left a variety of health programmes and potential sources of health funding, in addition to the BPJS-Kesehatan scheme that could be used in TB-DM care and control.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 of Solo GPs, R3)
There are funds allocated to National Police officers for annual health checks, but this programme is not routine, either. It needs to be separated and sorted, and it takes turns for the individuals being examined. (FGD of 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 of Clinics, R9)
Diagnostic procedures
We are also in the same situation as other clinics that do not do supporting examinations by themselves. But, we cooperate with third parties, including for sputum examinations and X-rays. (FGD of Clinics, R9)
Health facility networking
Another reported problem was communication and coordination between private and public primary care and hospitals. Although some of the GPs stated that they have an excellent relationship with public HCWs in general, they still experienced minimal feedback or responses from referral healthcare facilities. They never received feedback for some referrals, and they were lost during the follow-up of the patient.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 (to the Puskesmas) MoU cooperation as required by BPJS and for TB eradication. Solo 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 term formulation of MoU is still being discussed with the Health Office; what kind of cooperation is this? The formulation of cooperation is still in the process. (FGD of Solo GPs, R5)
The DHO and CHCs acknowledge that the private sector has not been involved in collaborative TB-DM care and control before the COVID-19 pandemic. From the perspectives of District Health Officers, the private sector did not seem to pay attention to government programmes. On the other hand, the DHO is preoccupied with many of the government’s health programme burdens, including achievement of target specified in the Minimum Service Standards. Hence, the DHO is still focused more on fostering Puskesmas/CHCs as Regional Technical Implementing Unit rather than the private sector.There is a TB patient who is also a BPJS participant 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 provided in the Puskesmas near the patient's house; that is, the closest Puskesmas. Yesterday, because of the information from the Puskesmas near 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 of Clinics, R2)
To be honest, because of the progress, yeah… TB-DM has not yet reached them (PPCs). Because on the way, even on applying DOTS, their attention is low. So, we prioritize what we can do. (IDI of District Health Officer)
Human resources issues
Our problem is that there is no person in charge (PIC) for TB cases. For DM and hypertension patients that are members of PROLANIS, there is a designated appointed PIC. We do not have PIC for TB, 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 a TB PIC. (FGD of Clinics, R2)
Theme 2: HCW’s knowledge and perceptions
Variation of HCW’s knowledge about TB-DM
Based on the theory, handling TB with DM or DM with TB will be more difficult. (FGD of Clinics, R10)
If I was asked about the relationship between DM and TB, in my opinion, they are 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)
False perceptions about TB-DM
As long as have I practised 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 the relationship between the two diseases. (FGD of Clinics, R2)
This is another problem. Insulin can only be given if HBA1c is above 9. Yeah, that is just a new problem. (FGD of Solo GPs, R5)
Lack of TB information dissemination and training
The Health Office is already undertaking a lot of accreditation-related information dissemination intensively. But, in my opinion, information regarding new guidelines and regulations (about TB-DM) is still limited. (FGD of Clinics, R2)
Theme 3: the lack of bi-directional screening implementation
Screening pathway
… 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 inaccuracies or inadequacies during history taking due to many patients, long queues, and many other reasons. So, we only explore the primary diagnosis (DM) or if the patient does not appear to be coughing in the room. It is considered sufficient only to ask about cough complaints, especially in DM patients who are generally only checked for blood glucose then asked for the referral form and finished. It's not well organised. (FGD of Clinics, R6)
Screening difficulties
It's not easy to diagnose TB, either because there are many elderly patients who say that, “When I'm old, it's usual to 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 is not cured, or the child is sick, the family members are sick, the grandchild is sick. It turned out that his grandparent was ill first." (FGD of Clinics, R3)
The X-ray might facilitate the technique, whereas the sputum screening test is difficult. (FGD Private GPs, R3)
Screening opportunities
Some participants also reported that ‘fee for service’ or non-BPJS patients were more flexible about taking up the screening procedure. Some patients would usually pay for diagnostic procedures suggested by the doctor.We also carry out routine activities for the National Police, which are periodic for POLRI (The State Police of Republic of Indonesia) members themselves, as well as X-rays and so on. (FGD of Clinics, R11)
Our advice to patients is, 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 of Clinics, R7)
Theme 4: the needs of multisector roles
Roles of the district health office (DHO)
In addition to information dissemination and connecting or coordinating with relevant organisations, systematic monitoring of health facilities should be undertaken to ensure the programme implementation. Greater effort at direction, monitoring, and evaluation of the private sector is required to implement the programme. PPCs also need to advocate about an appropriate payment mechanism.If I may suggest how if the Health Office cooperates with professional organisations in information dissemination regarding new guidelines, new regulation, or the programme 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 approaching private primary care one by one. (FGD of Clinics, R2)
We have come to attend DHO information dissemination on other topics, but usually just delivering information. We do not get any guidance or monitoring and so on to ensure its implementation. (FGD of Solo 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 that support the suspicion of the disease, we refer (to hospital/ Puskesmas). (FGD of Clinics, R2)
Roles of health facilities or health professional associations
ASKLIN or other similar organisations could play a role in increasing private sector engagement with government programmes. Until now, there has been reasonably good collaboration between the public and private sectors in a limited number of programmes, such as immunisation and DHF (dengue hemorrhagic fever). Although the TB programme has been initiated in various Public-Private Mix (PPM) activities, its implementation is not progressing well. Hence, ASKLIN can play a role in designing the MoU of cooperation between PPCs and government health facilities and conducting various educational sessions or publicising national programmes to its members.Until now, the focus of ASKLIN 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 of Clinics, R6)
The role of health professional organisations similar to ASKLIN could be an extension of the role of the DHO to disseminate information about priority programmes. IDI/ Ikatan Dokter Indonesia (Indonesian Medical Association), specialist doctors’ associations, and other HCW organisations have not been much involved until now. However, health professional organisations have often been invited to several national-level discussions to reach a consensus.ASKLIN's role was included due to the BPJS credentialing this year which requires 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 of Clinics, R2)
… In my opinion, it is much easier than the DHO calling or coming to each private primary health facility. Because it does not represent all primary care, maybe if the health office calls the health facilities, the DHO will invite large health facilities or from a certain area only. But if DHO can hold talks with ASKLIN or professional organisations, all of them would be accommodated. It is more coordinated. (FGD of Clinics, R2)
Patients’ roles
Yes, we first check the X-Ray. In our clinic, when there are X-ray and sputum data that show TB, we will discuss it with the patient. … 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. (FGD of Clinics, R9)
Potential roles of the private sectors
According to the participants, referral to DOTS facilities is the only action that can currently be taken by PPCs after identifying suspected TB-DM patients. This situation has beenc caused by several issues related to PPCs’ authority, including untrained staff, unavailability of TB drug regimens according to the current ISTC standards, and the inability to prescribe insulin. When patients are finally referred to other health facilities, PPCs often have difficulty in following up the patients’ treatment because of minimal feedback and coordination, as stated above. Thus, challenges on continuity of care have also emerged as obstacles.We are closer to the patient so that they are better able to warn against routine treatment because usually… those with chronic comorbid diseases routinely come every month. We can request from 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 touchthem because there are so many patients. And by that way, we can monitor them. (FGD of Solo GPs, R4)
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 being customer-satisfaction-oriented, they intend always to pay attention to every clinical complaint with appropriate follow-up. However, they also indicated their reluctance to conduct home visits, which are usually required in TB management, due to the high workloads.We were unable to order TB drugs. We detected the TB patients who came to us with cough through anamnesis. Then, even for sputum smear examination, we also referred 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, we are not very involved in monitoring TB patients. (FGD of Clinics, R2)
… if I am asked whether or not this programme can run actively in private health facilities, 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 of 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 at home. 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 of Clinics, R2)
Encouragement by BPJS-Kesehatan
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 six-month programme, for example. (FGD of Clinics, R7)