Recommendations

Overall recommendation:

In order to address the needs of MDR TB patients based on their perception of quality of care we recommend including and implementing patient centred approaches in Indonesia and integrating these approaches in the operational plan for PMDT expansion.

From the study and its conclusions, the following specific recommendations can be made as next steps:

Recommendations for next steps in Health Facilities At Hospital level:

1. The responsible clinician (CET) should ensure at least one consultation per month to every patient as regulated in the national PMDT guidelines and provide information about treatment progress to patients.

2. Ensure easy access for patients to information about MDR TB and the treatment such as through printing media.

3. Improve current infrastructure such as provision of drinking water, usable toilets, convenient waiting room

At Health Centre level:

1. Ensure that the delegation of task (task shifting) for supervision of MDR TB treatment supervision is done according to clear SOP, where staff receiving the delegated task are trained properly to enable them to perform according to standards set

2. Improve the services with less waiting times, provide consultation and address patient’s problem

3. Improve current infrastructure such as convenient waiting room, injecting room, usable toilets, drinking water

4. Ensure that patients that are unable to cover the direct and opportunity costs for their treatment are receiving adequate support to enable compliance to their treatment e.g. through existing social funding mechanism such as Provincial/District Community Health Insurance (Jamkesda) and other social security mechanisms.

Recommendations for the National Tuberculosis Control Program

1. Decentralize PMDT treatment services to health centres and assuring quality of the provider at HC level

2. Include patient centred approaches in the operational work plan for expansion of PMDT, and work it out with engaging all stakeholders, recognizing patient rights, enabling partnerships between patient and provider, and empower patients and communities.

3. Develop standardised training on interaction / communication skills for providers.

Suggestions for further research

Based on the findings, I believe that further research is needed to better understand patient’s experience of MDR TB and its treatment in order to improve treatment adherence among MDR TB patients.

Besides that it is also important to look at the challenges related to treatment of co-infected MDR TB patients with HIV/AIDS and taking treatment for MDR TB. Though this number is still relatively small in

Indonesia treatment for both HIV and MDR TB will have its particular challenges to the patients, providers and health care system.

Suggestion for development of tools

This QUOTE TB Light tool was developed for the TB setting. For use in MDR TB settings, the tool needs some adaptation and validation. The modified tool can be a simple tool like an interview checklist that can be used in health facility setting to assess the patient’s perception on the quality of services and patient satisfaction. This is in particular needed to better inform and instruct the providers to provide better and more regular feed back to the patients.

References

Campbell, S.M., Roland, M.O. and Buetow, S.A., (2000). Defining quality of care. Social Science & Medicine 51 (2000), pp. 1611-25.

CBS-ROI (2010A). Population Census 2010. Jakarta: Central Bureau Statistic Republic of Indonesia. [Online]. Available from:

http://www.bps.go.id/aboutus.php?sp=0 [Accessed 12 April 2012]. CBS-ROI (2010B). Illiteracy rate 2010. Jakarta: Central Bureau Statistic Republic of Indonesia. [Online]. Available from:

http://bps.go.id/tab_sub/view.php?tabel=1&daftar=1&id_subyek=28&not ab=5 [Accessed 12 April 2012]

Dagger, T.S., Sweeney, J.C. and Johnson, L.W., (2007). A Hierarchical Model of Health Service Quality: Scale Development and Investigation of an Integrated Model. Journal of Service Research, 10(2), pp.123-142. Donabedian, A.(1988) The quality of care: How can it be assessed? JAMA September 23/30, 260(12): p.1743-1748

Heywood, P. & Harahap, N.P., (2009). Public funding of health at the district level in Indonesia after decentralization-sources, flows and

contradictions. Health research policy and systems / BioMed Central, 7(5). [Online]Available from:

http://www.biomedcentral.com/content/pdf/1478-4505-7-5.pdf [Accessed 1 July 2012]

Massaut, S., Broek, J. van den and Kwaak, A. van der, (2009). QUOTE TB Light. Tuberculosis Coalition for Technical Assistance.

Massaut, S., Kwaak, A. van der, (2010) Patient Centered Approach Strategy. Tuberculosis Coalition for Technical Assistance.

Mesfin, M.M., Newell, J.N., Walley, J.D., Gessessew, A., Tesfaye, T., Lemma, F. and Madeley, R. (2009). Quality of tuberculosis care and its association with patient adherence to treatment in eight Ethiopian districts. Health Policy and Planning 2009, 24: p.457-466.

Mitnick, C., Bayona, J., Palacios, E., Shin, S., Furin, J., Alcantara, F., Sanchez, E., Sarria, M., Becerra, M, Fawzi, M.C.S., Kapiga, S., Neuberg, D., Maguire, J.H., Kim, J.Y., and Farmer, P., (2003). Community-Based Therapy for Multidrug-Resistant Tuberculosis in Lima, Peru. The New

England Journal of Medicine, 348(2): pp.119-128

MOH-ROI (2010A). Rencana Strategis Kementerian Kesehatan tahun

2010-2014 (Strategic Plan of MOH 2010-2014). Jakarta: Ministry of

MOH-ROI (2010B). Breakthrough toward Universal Access, TB control National strategy in Indonesia: 2010-2014. Jakarta: Ministry of Health Republic of Indonesia.

MOH-ROI (2011A). Indonesia Health Profile 2010. Jakarta: Ministry of Health Republic of Indonesia

MOH-ROI (2011B). National PMDT guideline. (unpublished)

Munro, S.A., Lewin, S.A., Smith, H.J., Engel, M.E., Fretheim, A. and Volmink, J., (2007). Patient adherence to tuberculosis treatment: a systematic review of qualitative research. PLoS Medicine 4(7): e238

NTP (2012). Monthly PMDT data – National TB control Program (NTP) Indonesia (unpublished)

Shin, S., Furin, J., Bayona, J., Mate, K., Kim, J.Y. and Farmer, P. (2004). Community-based treatment of multidrug-resistant tuberculosis in Lima, Peru: 7 years of experience. Social Science & Medicine 59(2004): p. 1529-1539

Silva, A. (2000). A framework for measuring responsiveness. GPE discussion paper series 32, World Health Organization [Online] Available from: http://www.who.int/healthinfo/paper32.pdf [accessed on 10 February 2012]

Stop TB Partnership (2011). The Global Plan to Stop TB 2011-2015: transforming the fight towards elimination of tuberculosis. World Health Organization.

TBCTA (2007). QUOTE –TB: Guide for improving TB care as seen through the eyes of the patient. Amsterdam: Tuberculosis Coalition for Technical Assistance.

TBCTA (2009). International Standards for Tuberculosis Care (ISTC), second edition. The Hague: Tuberculosis Coalition for Technical Assistance. UNDP (2011). Human Development Report 2011: Indonesia. United

Nations Development Program. [Online]. Available from:

http://hdrstats.undp.org/images/explanations/IDN.pdf [Accessed 1 July 2012]

Vermeire, E., Hearnshaw, H., Royen, P.V., and Denekens, J., (2001). Patient adherence to treatment: three decades of research. A comprehensive review. Journal of Clinical Pharmacy and Therapeutics (2001) 26: p.331-342.

WCC (2006). The Patients’ Charter for Tuberculosis Care: Patients’ rights and responsibilities. World Care Council.

Weyer, K. and Holtz, T., (2005). Factors associated with default from Multidrug resistant Tuberculosis treatment, South Africa, 1999-2001. Medical Research Council Pretoria and Centers for Disease Control and Prevention Atlanta.

WHO (2006). Quality of care: a process for making strategic choices in health systems. France: World Health Organization.

WHO (2007). Indonesia: National Health System Profile. World Health Organization. [Online]. Available from:

http://www.searo.who.int/LinkFiles/Indonesia_CHP-Indonesia.pdf [Accessed 1 July 2012]

WHO (2009A). Death estimates for 2008 and DALY estimates for 2004 by cause for WHO member States. World Health Organization. [Online]. Available from:

http://www.who.int/healthinfo/global_burden_disease/estimates_country /en/index.html [Accessed 12 April 2012]

WHO (2009B). Divisive drug-resistance. Bulletin World Health

Organization July 2009, 87(7): p.493-494.

WHO (2010A). Multidrug and extensively drug-resistant TB (M/XDR-TB): 2010 global report on surveillance and response. France: World Health Organization.

WHO (2010B). National Expenditure on Health. World Health Organization [Online]. Available from:

http://www.apps.who.int/nha/database/StandardReport.aspx?ID=REP_W EB_MINI_TEMPLATE_WEB_VERSION&COUNTRYKEY=84604 [Accessed 14 April 2012]

WHO (2011A). Indonesia health profile. World Health Organization [Online]. Available from: http://www.who.int/gho/countries/idn.pdf [Accessed 12 April 2012]

WHO (2011B). TB/HIV in the South-East Asia Region: Status Report. New Delhi: World Health Organization.

WHO (2011C). Tuberculosis in the South East Asia Region: the Regional Report 2011. India: World Health Organization.

WHO (2011D). Global tuberculosis control: WHO report 2011. France: World Health Organization.

WHO (2011E). Guidelines for the programmatic management of drug- resistant tuberculosis. Geneva: World Health Organization.

WHO (2011F). Towards universal access to diagnosis and treatment of multidrug-resistant and extensively drug-resistant tuberculosis by 2015: WHO progress report 2011. France. World Health Organization.

Widjanarko B., Gompelman M., Dijkers M. and Werf M.J. van der (2009). Factors that influence treatment adherence of tuberculosis patients living in Java, Indonesia. Patient Preference and Adherence 2009 (3): p.231- 238.

World Bank (2007). Spending for Development: Making the most of Indonesia’s new opportunities. Washington DC: World Bank.