Strengthening Private Provider Engagement to Improve TB Outcomes in Indonesia: An Institutional Review

The Global TB Report 2018 estimated a total of 842,000 new and relapse TB cases per year in Indonesia, while only 53% of estimated cases in 2017 were reported to the National Tuberculosis Program (NTP). Indonesia's National Tuberculosis Prevalence Survey (NPS) in 2014 indicated that 74% of initial care-seeking for TB and nearly half of all TB treatment occurs in the private sector among general practitioners, clinics, and hospitals operating outside the public healthcare system. The private sector plays a significant role in TB treatment in Indonesia, with 74% of initial care-seeking and nearly half of all TB treatment occurring in private facilities. However, only 13% of TB cases reported to the NTP in 2017 originated from private providers. The rapid expansion of Indonesia's JKN (Jaminan Kesehatan Nasional) insurance coverage is impacting diagnostic pathways and client and provider behaviors. The NTP's district-based public-private mix (DPPM) is prioritizing TB connections at two levels: between GPs and Puskesmas; and between hospitals and Dinas Kesehatan (the District Health Office, or DHO). The US Agency for International Development (USAID) commissioned this review to deepen understanding of the institutional relationships and incentives of private sector health facilities and organizations in TB care in Indonesia. The objective of this review was to more fully understand the behaviors and underlying motivations of private sector institutions in order to identify potential ways to improve the quality of TB services in the private sector. The review aimed to provide information to support the implementation of future initiatives to increase uptake and improve the quality of TB services, particularly opportunities to use JKN as a lever to change the behaviors of private sector providers. The review addressed five study objectives, including understanding the business case for providing TB services and drugs in the private sector, understanding attitudes among private sector providers toward participation in JKN, developing district-level estimates of unreported TB cases treated in the private sector, developing a landscape of key district-level actors, and socializing findings with Dinas Kesehatan and others. The review built on a previous review commissioned by USAID, which focused on understanding the key behaviors of individual private providers and patients in private sector TB care in Indonesia. The review found that the private sector plays a significant role in TB treatment in Indonesia, with 74% of initial care-seeking and nearly half of all TB treatment occurring in private facilities. However, only 13% of TB cases reported to the NTP in 2017 originated from private providers. The review also found that the rapid expansion of JKN is impacting diagnostic pathways and client and provider behaviors. The NTP's DPPM is prioritizing TB connections at two levels: between GPs and Puskesmas; and between hospitals and Dinas Kesehatan. The review identified several key findings, including the need to improve the quality of TB services in the private sector, the importance of using JKN as a lever to change the behaviors of private sector providers, and the need to develop district-level estimates of unreported TB cases treated in the private sector. The review also identified several key actors in the district-level landscape, including Dinas Kesehatan, private sector providers, and civil society organizations. The review provided several recommendations for improving TB services in the private sector, including increasing uptake and improving the quality of TB services, particularly opportunities to use JKN as a lever to change the behaviors of private sector providers. The review also recommended developing district-level estimates of unreported TB cases treated in the private sector and developing a landscape of key district-level actors. The review's findings and recommendations will inform USAID's upcoming Tuberculosis Private Sector (TBPS) activity, which will serve as USAID's main investment in supporting Indonesia in improving TB services in the private sector.