1. Lessons learned from Hospital DOTS Linkage (HDL) in Yogyakarta Indonesia
Jan Voskens MPH, KNCV
GTI/UAB

2. Efforts to achieve quality DOTS expansion in Government and Private Hospital sector in Indonesia

3. Trend New Smear Positives & All Cases, NTP Indonesia
Data NTP Indonesia

4. Need for Acceleration
% CDR %

5. ? ? PIOT MODEL notified cure notified cases
Reported
notified cure
Cured
PIOT MODEL
Treated
notified cases
Diagnosed ? ?
Sputum examined
hospitals /
Lung clinics
Private
sector
Health Centers (Puskesmas)
Patients with access to health services
Patients aware of their disease
Total of new smear positive cases:
Real Incidence

6. Indonesia Country situation Population 213 Million Islands 17,000
Provinces 30
Districts
60 % of population lives in 7 % of
total land area (Java)
Health Centers ,200
Hospitals ,100
Indonesia
Country situation
Yogyakarta

7. “Uncontrolled” DOTS expansion, 1996-200?
(Inter-) national ‘’push’’ for rapid DOTS expansion in Indonesia. Were targets rational ? , feasible ?
Separate systems : Health Centers – Hospitals – Private Sector
Hospitals were flooded with TB drugs without proper preparation (human resource development, laboratory etc)
Hospitals were poorly equipped for DOT.

8. Case detection in a sample of 18 hospitals in 4 provinces , 2002
Detected (all cases)
New SS+
Relaps
New
SS –
Extra Pulm.
East Java (8)
5.993
32 %
< 1 %
67 %
1 %
Central Java (3)
6.228
9 %
< 0.1 %
91 %
0.5 %
Jakarta (6)
761
31 %
5 %
60 %
3 %
W Kal (1)
477
53 %
45 %
NTP
49 %
2 %
47 %

9. Treatment Results of NEW SS + in a sample of 18 hospitals in 3 provinces Jan-June 2002.
East Java
Central Java
West Kalimantan
NTP (2001)
Case Finding
3.476
399
328
56.705
DOTS Eval.
1.075 37
154
Conversion
46 %
3 %
1 %
71 %
Cure
40 %
0 %
2 %
74 %
Completion
31 %
24 %
17 %
Default
27 %
73 %
94 %
6 %

10. Treatment Performance of 18 Hospitals in 3 provinces, Indonesia (1st half 2002)

11. Case detection EAST JAVA Hospitals 2002
DOTS Ev
New SS (+)
Relaps
New SS (-)
E.P
Sutomo Hosp
1.310
29 %
<1 %
68 %
3 %
Nganjuk Hos
130
39 %
60 %
Batu L.Hosp
1.373
69 %
31 %
Dungus L.H
273
22%
77 %
1 %
Jember L.H
1.004
> 99 %
Madiun LC
154
13 %
87 %
Pemakaran
801
32 %
Surabaya LC
948
22 %
2 %
75 %
Total
5.993
< 1 %
67 %
<1 %

12. Treatment results New SS+ 8 hospitals East Java (Q1-2, 2002)

13. The Hospital DOTS and Linkage (HDL) project in Yogyakarta,
Effort to “controlled” DOTS expansion
Aim : to expand DOTS coverage in Yogyakarta through linkage of government and private hospitals within the National Tuberculosis Control Program.
HDL is supported by KNCV , in collaboration with GTI, USAID, WHO
Started in 1999

14. Objectives of the HDL project:
TB control network through integration of government -and private hospitals into NTP
Referral link between these hospitals and government health centres

15. Objectives of the HDL project:
Improved diagnosis of TB (laboratory network and Quality Assurance established)
Improved reporting: uniform TB surveillance system established.

16. Strategies of the Hospital DOTS Linkage:
Stepwise approach : expansion only when targets (Conversion and Cure) were met ( hospitals)
Human resource development as priority (training and supervision)
Uniform Surveillance.
Networking and coordination (?)
Referral system (?)

17. Results of HDL Progress was slower then expected, due to:
decentralisation and its implications
high turn over of trained staff in HC’s
constraints in management capacity
‘’culture’’ differences ‘’private’’ ‘’public’’

18. Findings (1)
Involvement of hospitals has greatly increased Case Notification (CNR) of Smear positive patients in Yogya:
More then 400 % increase over a period of 3 years.
Linkage has drastically improved (referral, surveillance) after difficult start. (see later)

20. Findings (2)
The HDL experience in Yogyakarta has provided ample evidence base and directions for further DOTS expansion in hospital and private sector involvement.
In general great enthusiasm and willingness to introduce DOTS in hospitals.

21. Findings (3)
In general hospitals are strong in diagnosis of cases (strong potential for direct smear miscroscopy)
However hospitals are weaker in case holding and treatment supervision (compared to health centers).

25. “resistance to change’’
Findings (4)
The change from NON-DOTS DOTS
in hospitals requires considerable energy and time due to:
“resistance to change’’

26. “resistance to change’
Findings (5)
“resistance to change’
Reluctance to accept DOTS (specialists have their own interpretation)
“Clinical’’ versus ‘’Public Health’’ approach:
In many hospitals D.O.T is NOT consistent with the national guidelines:
Lack of regular treatment supervision endangers treatment compliance.

27. Findings (6)
There is a considerable risk that UNCONTROLLED DOTS EXPANSION in hospitals (poor treatment observation and high default rate ) is currently generating MDR on a large scale
It is crucial to ensure quality DOT (proper diagnosis & supervised treatment) in hospitals.

28. Conclusion
The NTP needs to define sound national policies and guidelines (based om evidence) to regulate the involvement (role and functions) of hospitals and private sector in the NTP
Expansion to hospital and private sector should be stepwise

29. First steps: Start first with hospital sector (before P.S.)
Sensitize hospital management to get their commitment to accept DOTS
Make MoU to clarify roles and responsibilities of the private / government hospitals

30. MoU
NTP to provide free TB drugs & other resources (lab supplies/ equipment, TB funds) only to hospitals that :
are committed to follow the national DOTS guidelines (smear microscopy and proper treatment supervision)
provide free diagnostic and treatment services (exempted from user fees)

31. Second step: Preparing hospitals
Train medical staff, nurses, lab, rec staff. etc
Build coordination team within hospital
Establish a DOTS unit in each Hospital
Introduce standard NTP Recording and Reporting formats.

32. Third step: build the link
A strong interface between Hospitals and Public Health Services (Provincial DOTS Committee) is essential for an effective linkage .
This “coordinating mechanism’’ is indispensable
for successful referral

33. Professional Organisa-tions
G E R D U N A S DI Yogyakarta
HOSPITAL ASSOCIATION
PERSI
P R O V I N C I A L
H E A L T H
S E R V I C E S
Hospital
Districts
Health Centers
Professional Organisa-tions
NTP
GORGAS
UAB
KNCV
PROVINCIAL
D O T S
C O M M I T T E

34. Elements of the link
Provincial DOTS Committee (including representatives from hospitals and public health services),
Full-time referral coordinator within the Provincial DOTS Committee,
Referral register
Monthly meetings for coordination between hospitals and district health services, and
Direct communication by telephone/SMS for referral and tracing.

35. Referral system (1)
In principle all routine (uncomplicated ) TB cases detected in hospitals should be referred and treated in the health facility (preferably health center ) which is nearest to the home of the patient.
this to enable
regular monitoring of treatment
and timely tracing of defaulters

36. Options for TB patients diagnosed in hospitals

37. Referral system (2):
The referral coordinator at provincial level - registers the referral and - notifies the receiving district supervisor directly by telephone / SMS.
Confirmation of referral: The receiving unit gives feedback to the referral coordinator.
Monthly coordination meeting to follow-up and confirm the outcome of each referral between health units or districts

38. In Provincial DOTS Committee ‘’Receiving’’ district Supervisor
Referral Coordinator
In Provincial DOTS Committee
Notification of referral
feedback
‘’Receiving’’ district Supervisor
Receiving Unit
e.g. Puskesmas B
Referring Unit
(e.g. Hospital A)

39. Implications for NTP : Potential contribution of hospitals to CDR in Indonesia
Variation between 20 – 900 SS+ cases / hospital / year
Assume: average is 100 SS+ cases / hospital / year (50-150)
Potential yield in SS+ Cases between :
1.100 x 50 = , and
1.100 x 150 = cases / year
Which is 20 – 60% of total estimated SS+ incidence in Indonesia !

40. Involve hospitals
and
private sector
but
BE PRUDENT and CAREFUL !!!

41. Treatment results EAST JAVA Hospitals new SS + (1st half 2002)
Lung clinic
All Cases
SS+ Eva-
luated
Conver
ted
Cured
Treatm. compl
Lost
Sutomo Hosp
764
231
36%
8 %
47 %
44 %
Nganjuk Hos 95 25
94 %
96 %
4 %
Batu L.Hosp
685
489
46 %
58%
38 %
3 %
Dungus L.H
142 44
97 %
80 %
0 %
18 %
Jember L.H
783 2
100 %
Madiun LC 66 7
57 %
43 %
Pamekasan
440
190
24 %
10 %
45 %
Surab. L.C
501 87
36 %
29 %
Total
3.476
1.075
40 %
27 %