Lessons learned from Hospital DOTS Linkage (HDL) in Yogyakarta Indonesia

1. Lessons learned fromHospital DOTS Linkage(HDL) in YogyakartaIndonesia Jan Voskens MPH, KNCV GTI/UAB

2. Efforts to achievequality 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. 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. Population 213 Million • Islands 17,000 • Provinces 30 • Districts 357 • 60 % of population lives in 7 % of total land area (Java) • Health Centers 7,200 • Hospitals 1,100 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

9. Treatment Results of NEW SS + in a sample of 18 hospitals in 3 provinces Jan-June 2002.

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

11. Case detection EAST JAVA Hospitals 2002

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 networkthrough 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 (9 20 30 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. Findings (4) The change from NON-DOTS DOTS in hospitals requires considerable energy and time due to: “resistance to change’’

26. 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 andproper 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. NTP GORGAS UAB KNCV G E R D U N A S DI Yogyakarta Professional Organisa-tions 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 PROVINCIAL D O T S C O M M I T T E Districts Hospital Hospital Hospital Health Centers

34. Elements of the link • Provincial DOTS Committee(including representatives from hospitals and public health services), • Full-time referral coordinatorwithin the Provincial DOTS Committee, • Referral register • Monthly meetingsfor 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 forTB 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. 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 = 55 .000 , and 1.100 x 150 = 165.000 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)