Missed opportunity for standardized diagnosis and treatment among adult tuberculosis patients in hospitals involved in Public-Private Mix for Directly Observed Treatment Short-Course strategy in Indonesia: a cross-sectional study.

Abstract

The engagement of hospitals in Public-Private Mix (PPM) for Directly Observed Treatment Short-Course (DOTS) strategy has increased rapidly internationally - including in Indonesia. In view of the rapid global scaling-up of hospital engagement, we aimed to estimate the proportion of outpatient adult Tuberculosis patients who received standardized diagnosis and treatment at outpatients units of hospitals involved in the PPM-DOTS strategy.
A cross-sectional study using morbidity reports for outpatients, laboratory registers and Tuberculosis patient registers from 1 January 2005 to 31 December 2005. By quota sampling, 62 hospitals were selected. Post-stratification analysis was conducted to estimate the proportion of Tuberculosis cases receiving standardized management according to the DOTS strategy.
Nineteen to 53% of Tuberculosis cases and 4-18% of sputum smear positive Tuberculosis cases in hospitals that participated in the PPM-DOTS strategy were not treated with standardized diagnosis and treatment as in DOTS.
This study found that a substantial proportion of TB patients cared for at PPM-DOTS hospitals are not managed under the DOTS strategy. This represents a missed opportunity for standardized diagnoses and treatment. A combination of strong individual commitment of health professionals, organizational supports, leadership, and relevant policy in hospital and National Tuberculosis Programme may be required to strengthen DOTS implementation in hospitals.

Full text

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Probandari et al. BMC Health Services Research 2010, 10:113
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Open Access
RESEARCH ARTICLE
Missed opportunity for standardized diagnosis and
treatment among adult Tuberculosis patients in
hospitals involved in Public-Private Mix for Directly
Observed Treatment Short-Course strategy in
Indonesia: a cross-sectional study
BioMed Central
© 2010 Probandari et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Com-
mons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduc-
tion in any medium, provided the original work is properly cited.
Research article
Ari Probandari*1,2,4, Lars Lindholm2,4, Hans Stenlund2, Adi Utarini†3 and Anna-Karin Hurtig†2,4
Abstract
Background: The engagement of hospitals in Public-Private Mix (PPM) for Directly Observed Treatment Short-Course
(DOTS) strategy has increased rapidly internationally - including in Indonesia. In view of the rapid global scaling-up of
hospital engagement, we aimed to estimate the proportion of outpatient adult Tuberculosis patients who received
standardized diagnosis and treatment at outpatients units of hospitals involved in the PPM-DOTS strategy.
Methods: A cross-sectional study using morbidity reports for outpatients, laboratory registers and Tuberculosis patient
registers from 1 January 2005 to 31 December 2005. By quota sampling, 62 hospitals were selected. Post-stratification
analysis was conducted to estimate the proportion of Tuberculosis cases receiving standardized management
according to the DOTS strategy.
Result: Nineteen to 53% of Tuberculosis cases and 4-18% of sputum smear positive Tuberculosis cases in hospitals that
participated in the PPM-DOTS strategy were not treated with standardized diagnosis and treatment as in DOTS.
Conclusion: This study found that a substantial proportion of TB patients cared for at PPM-DOTS hospitals are not
managed under the DOTS strategy. This represents a missed opportunity for standardized diagnoses and treatment. A
combination of strong individual commitment of health professionals, organizational supports, leadership, and
relevant policy in hospital and National Tuberculosis Programme may be required to strengthen DOTS implementation
in hospitals.
Background
The World Health Organization (WHO) has promoted
the Directly Observed Treatment Short-Course (DOTS)
strategy at the international level since the mid-1990s,
and it has proved a cost-effective strategy to combat
Tuberculosis (TB) [1-3]. DOTS strategy consists of five
strategic pillars:
• Political commitment,
• Case detection by quality-assured sputum micros-
copy,
• Standardized short-course chemotherapy under
direct observation of treatment,
• Quality-assured drugs,
• Recording and reporting system [4].
However, the implementation of DOTS strategy by
public health facilities is insufficient to ensure the notifi-
cation of all TB cases in the community as well as to pro-
vide adequate treatment
transmission [5,6].
Tuberculosis (TB) patients can receive care from a wide
array of services, such as community health centres, gen-
eral practitioners, traditional healers, chest clinics, and
hospitals [7-11]. These facilities, however, do not neces-
sarily implement the internationally-recommended
and prevent further
* Correspondence: ariprobandari@yahoo.com
1 Department of Public Health, Faculty of Medicine, Universitas Sebelas Maret,
Jl. Ir. Sutami 36A, Surakarta 57126 Indonesia
† Contributed equally
Full list of author information is available at the end of the article

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DOTS strategy nor link to the National TB Programme.
Evidence shows that without proper linkage to National
TB Programme, these facilities are in fact providing poor
quality diagnoses and treatment [12-15]. The need to
engage different care providers in providing TB services
is therefore urgent and the Public-Private Mix (PPM) for
the DOTS initiative by WHO has been launched in
response to this challenge [10,16].
Hospitals in particular play a major role as a source of
TB treatment in many high-burden countries [11,17,18];
thus hospitals have been identified as priority targets for
PPM-DOTS initiatives. Public-general and medical-col-
lege hospitals are the two types of health care providers
most engaged in PPM-DOTS schemes [19]. Improved
case detection and treatment outcome has been noted in
several countries as the result of involving hospitals in
PPM-DOTS strategy [19-22]. This favourable outcome
has led to rapid scaling-up of hospital involvement. The
number of high-burden countries adopting the hospital
PPM-DOTS approach at the national level increased rap-
idly from 4 to 14 countries during 2005-2007 [19]; Indo-
nesia is no exception, with an increase from 31% in 2005
(two years after the scaling up) to 37% of hospitals
involved in PPM-DOTS by early 2007 (Unpublished data
from Ministry of Health Republic of Indonesia).
Several publications have raised concerns regarding the
quality of DOTS strategy implementation in hospitals
[17,18,23-25]. Poor compliance with diagnostic and treat-
ment guidelines, and the increase of Multi-Drug-Resis-
tant-TB, further raises concerns about quality [18,24]. In
view of the rapid global scaling-up of hospital engage-
ment, we aimed to analyse the access to DOTS based ser-
vices in hospitals already involved in PPM-DOTS strategy
in Indonesia by determining the proportion of outpatient
adult TB patients who actually received standardized
diagnosis and treatment.
Methods
Study design
This was a cross-sectional study that was part of a larger
research entitled: Assessment of the implementation of
DOTS strategy in hospitals in six provinces on Java
Island, Indonesia. The study was conducted from August
2006 to July 2007, with a pilot-study organized in three
hospitals located in two provinces (Central Java and Yog-
yakarta).
Figure 1 describes the flow of patients and information
about TB patients in hospitals. Depending on the main
symptoms, TB suspects may have different entrances
when using the outpatient service. They may visit general
outpatient service or more specialized outpatient units
(such as pulmonary, internal medicine, neurology, and
surgery) prior to visiting a specially designated DOTS
unit. To confirm the diagnosis, ideally a sputum smear
examination should first be carried out and the results
recorded in the laboratory register [26]. A certain propor-
tion of TB suspects may also have to undertake other
diagnostic tests simultaneously, most commonly a chest
X-ray [17,18,27]. After completing the diagnostic tests,
TB suspects return to the outpatient unit they initially
visited. The diagnosis is recorded in the medical record,
and later sent to the medical record department for the
purpose of coding using the International Classification
of Diseases (ICD) system. TB diagnoses are coded as ICD
X A.15-A.19. However, it has been observed that the
majority of hospitals do not record the specific ICD code
but merge into a group of ICD codes for Tuberculosis.
Based on the medical records, the hospital produces
quarterly morbidity reports, including TB.
For treatment of TB patients, there are three possible
scenarios. First, not all TB patients are managed in an
outpatient unit with proper diagnosis and close monitor-
ing of treatment using standardized TB patient register as
in the DOTS strategy. Secondly, TB patients are treated
with DOTS strategy in the unit where the patients were
originally diagnosed or in the hospital DOTS unit (if
available). Finally, confirmed TB patients are referred to
other DOTS facilities closer to the patients' homes (such
as to a community health centre). Due to incomplete
recording of TB referrals from hospitals to other DOTS
facilities, this study used the assumption of the referral
rate from a study in Yogyakarta [22]. The median referral
rate among hospitals during 2003-2005 was 31.5% for all
Figure 1 Flow of patients and information among Tuberculosis
cases in PPM-DOTS hospitals.

Outpatient Unit
TB suspects
Outpatient Unit
Hospital
Laboratory
Treated in
outpatient
unit or in
DOTS unit
under DOTS
strategy
TB suspects do not
perform sputum test
TB suspects perform
sputum test
TB cases Not TB cases
Treated in
outpatient
unit, not
under
DOTS
strategy
Referred
to other
health
service
facilities
Morbidity
Report
TB Patient
Register
Lab
Register
: Flow of patients
: Flow of information

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TB cases and 32.6% for sputum smear positive TB cases
[22].
For those treated with DOTS strategy, the TB patient
registers are then sent to the TB supervisor at the District
Health Office and the information is further aggregated
at the province and national levels.
Data collection
Trained surveyors collected the morbidity reports, labo-
ratory registers and TB patient registers from the hospi-
tals. Data from registers were double-entered. In order to
improve the validity of data, the trained surveyors con-
tacted the medical record staff to guarantee the com-
pleteness of the data and to clarify any issues arising.
Study population, sampling strategy and sample
The study population included hospitals participating in
PPM-DOTS strategy based on 2006 data from the
National TB Programme in Indonesia. It consisted of 72
public general hospitals, 70 private general hospitals, and
8 pulmonary hospitals in Java Island, Indonesia. Provid-
ers from all these hospitals had taken part in standardized
DOTS training activities conducted by the National TB
Programme.
The sampling for the larger study was carried out using
quota sampling. The quota was determined by consider-
ation of the proportion, type, and ownership of PPM-
DOTS hospitals among Java Island provinces. Based on
type and ownership, the hospitals were differentiated into
public general hospitals, private general hospitals, and
public pulmonary hospitals. For this paper, we included
hospitals in the study population which had been
involved in PPM-DOTS for at least two years prior to
2006, and which had both a TB recording and reporting
system and an outpatient-morbidity report system in
place. Sixty-two hospitals met the inclusion criteria.
Analyses
The analyses included, firstly, demographic characteris-
tics of TB cases for each hospital group and evaluation of
the differences by Kruskall Wallis tests and, secondly,
post-stratification analysis to estimate the proportion of
TB cases not treated under a DOTS unit. Post-stratifica-
tion analysis estimated the weighted cumulative number
of TB cases in the morbidity report and patient register as
well as cases who were sputum smear-positive in the lab-
oratory and TB registers. To calculate the post-stratifica-
tion weight, the number of hospitals in the study
population was divided by the number of sampled hospi-
tals. The weighted cumulative number of TB cases was
then estimated by multiplying the post-stratification
weight by the cumulative number of estimated TB cases
in the sample.
Ethics
Approval for the study's ethics was received from Univer-
sitas Gadjah Mada, Indonesia. Permission for accessing
the hospital registers was obtained from the local govern-
ments and hospitals. Patient confidentiality was assured
during data analyses and presentation of study findings.
The findings were shared with the hospitals, District-Pro-
vincial Health Offices and the National TB Programme.
Results
The numbers of hospitals sampled were: 31 public gen-
eral hospitals, 29 private general hospitals, and 2 pulmo-
nary hospitals. All included hospitals have access to the
National TB Programme guidelines and manual. Never-
theless, this does not mean that the hospitals have already
integrated the National TB Programme guidelines into
their standard operating procedure for TB patients seek-
ing care at the hospital (Table 1). Not all hospitals have a
formal Memorandum of Understanding for the imple-
mentation of the DOTS strategy.
The number of TB cases from the morbidity reports,
laboratory registers and TB patient registers had a
skewed distribution. In general, public pulmonary hospi-
tals registered a higher number of TB cases per hospital
compared to general hospitals. The medians were 712 in
pulmonary hospitals, 247 in public general hospitals and
102 in private general hospitals (p = 0.03) (Table 2). Fur-
thermore, the total number of TB cases (n = 349) regis-
tered in pulmonary hospital DOTS units was higher than
in public (n = 52) or private (n = 19) general hospitals (p =
0.01). Similarly, the number of sputum smear positive TB
cases identified by the pulmonary hospital laboratories (n
= 198) was greater than in public (n = 43) or private (n =
17) general hospitals (p = 0.001). A similar pattern was
found for the number of sputum smear positive TB cases
undergoing treatment at DOTS units (p = 0.004).
Results of the post-stratification analysis showed the
discrepancy between the number of TB cases recorded in
the TB patient register and those in the hospital morbid-
ity report. After adjusting for the referral rate, the pro-
portion of TB cases not recorded in TB patient register
was 53% (in public general hospitals) and 52% (in private
general hospitals). This proportion was larger in general
hospitals than that in public pulmonary hospitals (i.e.
19.5%) (Table 3).
After considering the referral rate, the gap between the
number of sputum smear positive TB cases recorded in
the laboratory register and those recorded in the TB
patient register ranged from 4% to 18%. The highest pro-
portion was in public general hospitals, followed by pub-
lic pulmonary hospital and private general hospitals
(18.2%, 8.1%, and 4.2% respectively) (Table 3).

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Discussion
The findings show sub-optimal access to the DOTS strat-
egy among TB patients in hospitals involved in the PPM-
DOTS initiative. This inconsistent access to DOTS strat-
egy is more prominent in public general hospital whereas
the general and medical college hospitals are the most
common type of hospitals involved in PPM-DOTS [19]. A
similar phenomenon was also reported in a study by
Loveday et al. (2008), which found that 58% of smear pos-
itive TB cases did not access standardized National TB
Programme treatment in the hospitals [18]; this could be
due to a lack of cooperation in the application of diagno-
sis and treatment based on DOTS strategy for all TB
patients [15,28], perceived complexity of DOTS based
diagnosis and treatment [29], and perceived low quality
of services due to provision of free TB drugs [29].
Taking into account the reliance on secondary data in
this study, the findings still raise the issue of missed
opportunity for PPM-DOTS hospitals to deliver quality
diagnosis and treatment for all TB suspects. This could
lead to misdiagnosis of TB patients and, consequently,
improper treatment of TB patients. With the present, and
alarming, problem of multiple-drug-resistant TB [18,24],
low quality of TB case management in hospitals imple-
menting PPM-DOTS strategy certainly requires urgent
attention. Therefore, we argue that a better balance is
required between the expansion of PPM-DOTS strategy
to new hospitals, and improvement of quality DOTS
strategy implementation in existing hospitals.
Since services for TB patients can be delivered at sev-
eral outpatient units in collaboration with other units
(DOTS units, laboratories, medical records units, etc),
the findings also reflected the complexity of internal link-
ages between those different micro systems involved in
delivering TB care in hospitals. Several factors may con-
tribute to the weakening of internal linkages, i.e. from
micro system to organization level, up to the policy at the
national level. At the micro system level, individual com-
mitment of health professionals [25], as well as team-
work, information, performance and improvement, and
clinical leadership [30] are key factors. Subsequently, hos-
pital and National Tuberculosis Programme policies that
help to support and strengthen those factors (in order to
improve quality) are critical.
Different mechanisms exist to enhance the quality of
DOTS strategy implementation in hospitals. At the micro
system level, launching of the International Standard for
TB Care can be an initial bridge for improving the com-
mitment of health professionals involved in delivering TB
care [31,32]. Endorsement from professional organiza-
tions and operational support to ensure implementation
of the International Standard for TB Care among special-
ists are required [33]. Staff incentives are important to
focus the staff on providing high quality services to
patients [30]. However, there is limited evidence of the
types of incentives that are effective in the context of
PPM-TB control [34,35]. At the hospital level, Siddiqi et
al. (2008) implemented TB clinical audit as a process
measurement for improving clinical TB care [36]. Experi-
ence in the Philippines suggests that national level regula-
tions such as accreditation and certification of PPM-
DOTS hospitals can also be effective in improving the
quality of TB services [34]. Finally, existing mechanisms
in TB control management, i.e. internal and external
Table 1: Characteristics of hospitals in the sample.
CharacteristicPublic general hospitals
(n = 31)
Private general hospitals
(n = 29)
Public pulmonary hospitals
(n = 2)
n%n%n%
Outpatient visits
per year
<12,000516.2 1241.400
12,000-120,000 2271.01551.72100
>120,000412.92 6.900
Had NTP* guidelines
and manual
31 10029 1002 100
Had Standard of
Operating Procedure for
adult TB patients
2374.216 55.2150
Had MoU** 1238.71344.800
*NTP = the National Tuberculosis Program; ** MoU = document of Memorandum of Understanding with the National Tuberculosis
Programme.

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Table 2: Number of Tuberculosis cases: comparison of morbidity reports, laboratory registers and TB patient registers at
general hospitals and pulmonary hospitals, 2005.
Public general
hospital
Private general
hospital
Public
pulmonary
hospital
All hospitals
Number of hospitals
31292 62
TB* cases in morbidity report (n)**
Median (min-max)247 (5-1,601) 102 (5-1,584)712 (631-793)211 (5-1,601)
Cumulative 11,2236,8431,424 19,490
TB cases in TB patient register (n)
Median (min-max) 52 (1-169) 19 (2-170)349 (264-434)37.5 (1-434)
Cumulative1,7101,140 6983,522
SS (+)***TB cases in laboratory
register (n)
Median (min-max) 43 (0-296)17 (0-115)198 (157-239) 35 (0-296)
Cumulative2,053 9293963,378
SS (+) TB cases in TB patient register (n)
Median (min-max)25 (2-126) 9 (2-80) 117.5 (113-122)17 (0-126)
Cumulative1,011 587 2351,833
* TB = tuberculosis; **n = number; ***SS (+) = sputum smear positive.
Table 3: Result of post-stratification analysis.
Public general
hospital
Private
general
hospital
Public
pulmonary
hospital
All hospitals
Hospitals in the study population (n)*72708 150
Hospitals in the sample (n)31292 62
Post-stratification weight2.322.414.002.42
Weighted cumulative number of TB** cases in
morbidity report (A)
26,066 16,5185,696 47,153
Weighted cumulative number of TB cases in TB patient
register (B)
3,9722,7522,7928,521
Weighted cumulative number of SS (+)*** TB cases in
laboratory register (C)
4,7682,2421,584 8,173
Weighted cumulative number of SS (+) TB cases in TB
patient register (D)
2,3481,417 9404,435
Adjusted gap of cumulative number TB cases between
TB patient register and morbidity report, applying
referral rate of 31.5%
[(100-(B/A))-31.5%]
53.3%51.8%19.5%50.4%
Adjusted gap of cumulative no. SS (+) TB cases
between TB patient register and Lab register, applying
32.6% of referral rate
[(100-(D/C))-32.6%]
18.2%4.2%8.1%13.1%
*n = number; **TB = tuberculosis; ***SS (+) = sputum smear positive.

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supervision, should also be strengthened to improve
practices in the context of PPM-DOTS hospitals.
This study is limited to measure, not explain, the phe-
nomenon of missed opportunities on TB diagnosis and
treatment in PPM-DOTS hospitals. The assumed referral
rate for sputum smear positive TB cases may be consid-
ered too high for Java Island and other areas in Indonesia
because the rates were calculated under a closely moni-
tored pilot project. If this is the case, our results in fact
underestimate the proportion of cases not administered
under DOTS strategy.
Conclusions
This study found that a substantial proportion of TB
patients cared for at PPM-DOTS hospitals are not man-
aged under the DOTS strategy. This represents a missed
opportunity for standardized diagnoses and treatment. A
combination of strong individual commitment of health
professionals, organizational supports, leadership, and
relevant policy in hospital and National Tuberculosis Pro-
gramme may be required to strengthen DOTS implemen-
tation in hospitals.
Authors' contributions
AP was responsible for developing the research idea, designing the study, exe-
cuting the data collection, analysis and interpretation of the results, as well as
for the writing of the manuscript. LL and HS contributed to the interpretation
of the data, and revision of the manuscript. AU participated in the study
design, execution of the data collection, analysis and interpretation of the data,
as well as in substantially revising the manuscript. AK gave intellectual inputs
to the study design, analysis and interpretation of data and performed the crit-
ical revision of the manuscript. AU and AK made equal contribution to the
study. All authors read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Acknowledgements
The researchers gratefully acknowledge the assistance of the participating hos-
pitals. We also acknowledge Hari Agus Sanjoto and Mohammad Arifin for their
contribution to data collection and data entry. This research was supported by
the Sub-Directorate of Tuberculosis, Ministry of Health, Republic of Indonesia
and funded by DFID-UK through the World Health Organization (Project: INO
TUB 002 XW 06 EC0. P01. A01) and the Centre for Global Health at Umeå Uni-
versity (supported by FAS, the Swedish Council for Working Life and Social
Research, grant no 2006-1512).
Author Details
1Department of Public Health, Faculty of Medicine, Universitas Sebelas Maret,
Jl. Ir. Sutami 36A, Surakarta 57126 Indonesia, 2Epidemiology and Global Health,
Public Health and Clinical Medicine, Umeå University, Umeå, Sweden,
3Department of Public Health, Faculty of Medicine, Universitas Gadjah Mada,
Yogyakarta, Indonesia and 4Swedish Research School for Global Health, Umeå,
Sweden
References
1.Vassal A, Bagdadi S, Bashour H, Zaher H, Maaren PV: Cost-effectiveness of
different treatment strategies for tuberculosis in Egypt and Syria. Int J
Tuberc Lung Dis 2002, 6:1083-1090.
2. Xu Q, Jin SG, Zhang LX: Cost effectiveness of DOTS and non DOTS
strategies for smear-positive pulmonary tuberculosis in Beijing.
Biomed Environ Sci 2000, 13:307-313.
Baltussen R, Floyd K, Dye C: Cost effectiveness analysis of strategies for
tuberculosis control in developing countries. BMJ 10 November 2005.
Pursue high-quality DOTS expansion and enhancement: five
components of DOTS [http://www.who.int/tb/dots/en/]. accessed on
March 9, 2010
Uplekar M, Pathania V, Raviglione M: Private practitioners and public
health: weak links in tuberculosis control. The Lancet 2001, 358:912-916.
Uplekar M: Public-private mix for DOTS: demanding, but delay will only
hamper TB control. Int J Tuberc Lung Dis 2003, 7:1113-1114.
Uplekar M, Juvekar S, Morankar S, Rangan S, Nunn P: Tuberculosis
patients and practitioners in private clinics in India. Int J Tuberc Lung Dis
1998, 2:324-329.
Singh AA, Frieden TR, Khatri GR, Garg R: A survey of tuberculosis
hospitals in India. Int J Tuberc Lung Dis 2004, 8:1255-1259.
Ambe G, Lonnroth K, Dholakia Y, Copreaux J, Zignol M, Borremans N,
Uplekar M: Every provider counts!: Effect of a comprehensive public-
private mix approach for TB control in a large metropolitan area in
India. Int J Tuberc Lung Dis 2005, 9:562-68.
10. WHO: Engaging All Health Care Providers in TB Control: Guidance on
Implementing Public-Private Mix Approaches. Geneva 2006.
11. Ministry of Health Republic of Indonesia: TB Prevalence Survey 2004. Jakarta
2005.
12. Arif K, Ali SA, Amanullah S, Siddiqui I, Khan JA, Nayani P: Physician
compliance with national tuberculosis treatment guideline: a
university hospital study. Int J Tuberc Lung Dis 1997, 2:225-230.
13. Portero JL, Rubio M: Private practitioners and tuberculosis control in the
Philippines: strangers when they meet? Trop Med Int Health 2003,
8:329-335.
14. Lonnroth K, Thuong LM, Lambergts K, Quy HT, Diwan VK: Private
tuberculosis care provision associated with poor treatment outcome -
a comparative cohort analysis of a semi-private chest clinic and the
national tuberculosis control programme in Ho Chi Minh City, Vietnam.
Int J Tuberc Lung Dis 2003, 7:165-171.
15. Quy HT, Lonnroth K, Lan NTN, Buu TN, Dieu TTN: Treatment result among
patients treated by private lung specialists involved in a public-private
mix project in Ho Chi Minh City, Vietnam. Int J Tuberc Lung Dis 2003,
7:1139-1146.
16. WHO and the Stop TB Partnership: The Stop TB Strategy: Building on and
enhancing DOTS to meet the TB related-Millennium Development Goals.
Geneva 2006.
17. Chiang CY, Trebucq A, Billo N, Khortwong P, Elmogazy E, Begum V,
Aditama TY, Ansari A, Baral SC, Vianzon RG: A survey of TB services in
hospitals in seven large cities in Asia and North Africa. Int J Tuberc Lung
Dis 2007, 11:739-746.
18. Loveday M, Thomson L, Chopra M, Ndlela Z: A health system assessment
of the Kwazulu-Natal tuberculosis programme in the context of
increasing drug resistance. Int J Tuberc Lung Dis 2008, 12:1042-2047.
19. WHO: WHO TB report 2008: Global TB Control Surveillance, Planning and
Financing. Geneva 2008.
20. Mantala MJ: Public private mix DOTS in the Philippines. Tuberculosis
2003, 83:173-176.
21. WHO: Public Private Mix for DOTS: Towards Scaling Up. Report of the Third
Meeting of the PPM Subgroup for DOTS Expansion. Geneva 2005.
22. Irawati SR, Basri C, Arias MS, Prihatini S, Rintiswati N, Voskens J, Kimerling
ME: Hospital DOTS linkage in Indonesia: a model for DOTS expansion
into government and private hospitals. Int J Tuberc Lung Dis 2007,
11:33-39.
23. Uplekar M: Stopping tuberculosis: time to turn urgent attention to
hospitals. Int J Tuberc Lung Dis 2008, 12:986.
24. Ministry of Health Republic of Indonesia and the Stop TB Partnership:
Report of the Joint External TB Monitoring Mission Indonesia 16-27 April 2007.
Jakarta 2008.
25. Probandari A, Utarini A, Hurtig A-K: Achieving quality in the Directly
Observed Treatment Short-course (DOTS) strategy implementation
process: a challenge for hospital Public-Private Mix in Indonesia.
Global Health Action 2008.
26. Ministry of Health Republic of Indonesia: Pedoman Nasional
Penanggulangan Tuberkulosis. Jakarta 2007.
3.
4.
5.
6.
7.
8.
9.
Received: 27 October 2009 Accepted: 7 May 2010
Published: 7 May 2010
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BMC Health Services Research 2010, 10:113

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Probandari et al. BMC Health Services Research 2010, 10:113
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27. Murthy KJR, Frieden TR, Yazdani A, Hreshikesh P: Public-private
partnership in tuberculosis control: experience in Hyderabad, India. Int
J Tuberc Lung Dis 2001, 5:354-359.
28. Caminero JA, Billo NE: Involving private practitioners and chest
physicians in the control of tuberculosis. Tuberculosis 2003, 83:148-155.
29. Lonnroth K, Tran TU, Thuong LM, Quy HT, Diwan V: Can I afford free
treatment?: Perceived consequences of health care provider choices
among people with tuberculosis in Ho Chi Minh City, Vietnam. Soc Sci
Med 2001, 52:935-948.
30. Nelson EC, Baltaden PB, Huber TB, Mohr JJ, Godfrey MM, Headrick LA,
Wasson JH: Micro system in health care: Part 1. Learning from high-
performing front-line clinical units. Journal on Quality Improvement
2002, 28:472-493.
31. Tuberculosis Coalition for Technical Assistance: International Standards for
Tuberculosis Care 2006 [http://www.who.int/entity/tb/publications/2006/
istc_report.pdf]. accessed on May 20 2009
32. Hopewell PC, Pai M, Maher D, Uplekar M, Ravligione MC: International
Standards for Tuberculosis Care. Lancet Infectious Diseases 2006,
6:710-725.
33. Miglioni GB, Hopewell PC, Blasi F, Spanevello A, Ravligione MC: Improving
the TB case management: The International Standards for TB Care. Eur
Respir J 2006, 28:687-690.
34. Lonnroth K, Uplekar M, Blanc L: Hard gains through soft contracts:
productive engagement of private providers in tuberculosis control.
Bull World Health Organ 2006, 84:876-883.
35. Tuberculosis: Incentives and Enablers [http://www.msh.org/projects/
rpmplus/WhatWeDo/Tuberculosis/Incentives-and-Enablers.cfm].
Accessed on May 20, 2009
36. Siddiqi K, Volz A, Armas L, Otero L, Ugaz R, Ochoa E, Gotuzzo E, Torrico F,
Newell JN, Walley J, Robinson M, Dieltiens G, Stuyft P Van der: Could
clinical audit improve the diagnosis of pulmonary tuberculosis in
Cuba, Peru and Bolivia? Trop Med Int Health 2008, 13:566-578.
Pre-publication history
The pre-publication history for this paper can be accessed here:
http://www.biomedcentral.com/1472-6963/10/113/prepub
doi: 10.1186/1472-6963-10-113
Cite this article as: Probandari et al., Missed opportunity for standardized
diagnosis and treatment among adult Tuberculosis patients in hospitals
involved in Public-Private Mix for Directly Observed Treatment Short-Course
strategy in Indonesia: a cross-sectional study BMC Health Services Research
2010, 10:113