TY - JOUR
T1 - Cost of seeking care for tuberculosis since the implementation of universal health coverage in Indonesia
AU - Fuady, Ahmad
AU - Houweling, Tanja A.J.
AU - Mansyur, Muchtaruddin
AU - Burhan, Erlina
AU - Richardus, Jan Hendrik
N1 - Funding Information:
We would like to thank the Heads of Jakarta Provincial Health Office, Tasikmalaya District Health Office, and Depok District Health Office for issuing permits for data collection in their districts. We also thank Dedi Suhendar, all TB Programme Officers in Primary Health Centres, and all enumerators, for their support with data collection. Finally, we thank LPDP for funding this project and USAID, SHERA, and CCR SMART CITY Universitas Indonesia for their support through the Smart City Project. TAJH was supported by a Research Excellence Initiative Grant from Erasmus University Rotterdam, The Netherlands.
Funding Information:
This study was funded by the Indonesian Endowment Fund for Education (Lembaga Pengelola Dana Pendidikan, LPDP), Indonesia. The LPDP granted a funding for the study, but did not involve and interfere in designing the study protocol, conducting data collection and data analysis, as well as finalizing the manuscript.
Publisher Copyright:
© 2020 The Author(s).
PY - 2020/6/3
Y1 - 2020/6/3
N2 - Background: Although tuberculosis (TB) patients often incur high costs to access TB-related services, it was unclear beforehand whether the implementation of universal health coverage (UHC) in Indonesia in 2014 would reduce direct costs and change the pattern of care-seeking behaviour. After its introduction, we therefore assessed TB patients' care-seeking behaviour and the costs they incurred for diagnosis, and the determinants of both. Methods: In this cross sectional study, we interviewed adult TB patients in urban, suburban, and rural districts of Indonesia in July-September 2016. We selected consecutively patients who had been treated for TB in primary health centers for at least 1 month until we reached at least 90 patients in each district. After establishing which direct and indirect costs they had incurred during the pre-diagnostic phase, we calculated the total costs (in US Dollars). To identify the determinants of these costs, we applied a general linear mixed model to adjust for our cluster-sampling design. Results: Ninety-three patients of the 282 included in our analysis (33%) first sought care at a private clinic. The preference for such clinics was higher among those living in the rural district (aOR 1.88, 95% CI 0.85-4.15, P = 0.119) and among those with a low educational level (aOR 1.69, 95% CI 0.92-3.10, P = 0.090). Visiting a private clinic as the first contact also led to more visits (β 0.90, 95% CI 0.57-1.24, P < 0.001) and higher costs than first visiting a Primary Health Centre, both in terms of direct costs (β = 16.87, 95%CI 10.54-23.20, P < 0.001) and total costs (β = 18.41, 95%CI 10.35-26.47, P < 0.001). Conclusion: Despite UHC, high costs of TB seeking care remain, with direct medical costs contributing most to the total costs. First seeking care from private providers tends to lead to more pre-diagnostic visits and higher costs. To reduce diagnostic delays and minimize patients' costs, it is essential to strengthen the public-private mix and reduce the fragmented system between the national health insurance scheme and the National TB Programme.
AB - Background: Although tuberculosis (TB) patients often incur high costs to access TB-related services, it was unclear beforehand whether the implementation of universal health coverage (UHC) in Indonesia in 2014 would reduce direct costs and change the pattern of care-seeking behaviour. After its introduction, we therefore assessed TB patients' care-seeking behaviour and the costs they incurred for diagnosis, and the determinants of both. Methods: In this cross sectional study, we interviewed adult TB patients in urban, suburban, and rural districts of Indonesia in July-September 2016. We selected consecutively patients who had been treated for TB in primary health centers for at least 1 month until we reached at least 90 patients in each district. After establishing which direct and indirect costs they had incurred during the pre-diagnostic phase, we calculated the total costs (in US Dollars). To identify the determinants of these costs, we applied a general linear mixed model to adjust for our cluster-sampling design. Results: Ninety-three patients of the 282 included in our analysis (33%) first sought care at a private clinic. The preference for such clinics was higher among those living in the rural district (aOR 1.88, 95% CI 0.85-4.15, P = 0.119) and among those with a low educational level (aOR 1.69, 95% CI 0.92-3.10, P = 0.090). Visiting a private clinic as the first contact also led to more visits (β 0.90, 95% CI 0.57-1.24, P < 0.001) and higher costs than first visiting a Primary Health Centre, both in terms of direct costs (β = 16.87, 95%CI 10.54-23.20, P < 0.001) and total costs (β = 18.41, 95%CI 10.35-26.47, P < 0.001). Conclusion: Despite UHC, high costs of TB seeking care remain, with direct medical costs contributing most to the total costs. First seeking care from private providers tends to lead to more pre-diagnostic visits and higher costs. To reduce diagnostic delays and minimize patients' costs, it is essential to strengthen the public-private mix and reduce the fragmented system between the national health insurance scheme and the National TB Programme.
KW - Care-seeking behaviour
KW - Costs
KW - Indonesia
KW - Tuberculosis
KW - Universal health coverage
UR - http://www.scopus.com/inward/record.url?scp=85086008029&partnerID=8YFLogxK
U2 - 10.1186/s12913-020-05350-y
DO - 10.1186/s12913-020-05350-y
M3 - Article
C2 - 32493313
AN - SCOPUS:85086008029
SN - 1472-6963
VL - 20
JO - BMC Health Services Research
JF - BMC Health Services Research
IS - 1
M1 - 502
ER -
