Evaluation of Tuberculosis Control Programs in Indonesian Community Health Centers Using Systemic Approach

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1 Artikel Penelitian Evaluation of Tuberculosis Control Programs in Indonesian Community Health Centers Using Systemic Approach Jowy Tani, Herqutanto, Tommy Dharmawan Faculty of Medicine University of Indonesia, Abstract: Community health centers (CHCs) play an important role in Indonesian national tuberculosis (TB) control. Using the systemic approach, an approach for community health program evaluation developed by Department of Community Medicine, Faculty of Medicine, University of Indonesia, we evaluated two CHCs in East Jakarta by systematically identifying the problems, prioritizing problems, formulating alternative solutions, and prioritizing alternative solutions. For Jatinegara Kaum CHC, proportion of sputum examined suspects was 7.8%, proportion of smear-positive patients among suspects was 60.87%, proportion of smear-positive TB patients among all registered TB patients was 60.87%, conversion rate was 92.86%, cure rate was 91.60%, and case detection rate was 46.74%. For East Pisangan CHC, proportion of sputum examined suspects was 10.26%, proportion of smear-positive patients among suspects was 58.62%, proportion of smear-positive TB patients among all registered TB patients was 58.62%, conversion rate was 82.35%, cure rate was %, and case detection rate was 60.16%. Error rates were not available in both CHCs. Low case detection rate was considered prioritized problem for both CHCs. Prioritized solution for Jatinegara Kaum was new case finding training for cadres, while for East Pisangan periodic public health education events. Systemic approach was able to demonstrate its capabilities. Keywords: program evaluation, tuberculosis, Community Health Center 116

2 Evaluasi Program Penanggulangan Tuberkulosis di Puskesmas Indonesia Menggunakan Pendekatan Sistem Jowy Tani, Herqutanto, Tommy Dharmawan Fakultas Kedokteran Universitas Indonesia, Abstrak: Puskesmas berperan penting dalam menentukan keberhasilan program penanggulangan tuberkulosis (TB) nasional Indonesia. Menggunakan pendekatan sistem yang dikembangkan Departemen Ilmu Kedokteran Komunitas, Fakultas Kedokteran Universitas Indonesia, dilakukan evaluasi program penanggulangan TB di dua puskesmas di Jakarta Timur dengan identifikasi masalah secara sistematis, penentuan prioritas masalah, perumusan solusi alternatif, dan penentuan prioritas solusi alternatif. Di Puskesmas Jatinegara Kaum, didapatkan 7,8%, proporsi penderita BTA positif di antara suspek 60,87%, proporsi penderita TB paru BTA positif di antara seluruh penderita TB paru tercatat 60,87%, angka konversi 92,86%, angka kesembuhan 91,60%, dan angka deteksi kasus 46,74%. Di Puskesmas Pisangan Timur, proporsi suspek 10,26%, proporsi penderita BTA positif di antara suspek 58,62%, proporsi penderita TB paru BTA positif di antara seluruh penderita TB paru tercatat 58,62%, angka konversi 82,35%, angka kesembuhan 100,00% dan angka deteksi kasus 60,16%. Data error rate tidak tersedia di kedua puskesmas. Angka deteksi kasus yang rendah adalah masalah prioritas untuk kedua puskesmas. Solusi utama untuk Jatinegara Kaum adalah pelatihan penemuan kasus baru untuk kader, sedangkan untuk Pisangan Timur diperlukan pendidikan kesehatan massal secara berkala. Pendekatan sistem berhasil menunjukkan kemampuannya. Kata kunci: evaluasi program, tuberkulosis, puskesmas Introduction Tuberculosis (TB) is among the most pressing public health concerns in Indonesia. In fact, globally, Indonesia ranked third in term of estimated number of TB incidents. 1 According to Indonesia Health Profile 2005, 259,969 new cases of TB was detected annually, and 158,640 of them were smear-positive. 2 With recent outbreak of HIV/AIDS infections in Indonesia, the prevalence of TB is expected to raise even higher. 3 In order to contain and to reverse the impact of TB in the country, government of Indonesia had started the National TB Control Program, a comprehensive program involving both government and private healthcare services. Since 1995, the National TB Control Program had been carried out based on Directly Observed Treatment Short-course (DOTS) strategy, in accordance to WHO recommendation. Government funded Community Health Centers/CHCs (Pusat Kesehatan Masyarakat/Puskesmas), as the spearhead of Indonesian national health development, is one of the key players in the management of TB. The success of national TB control largely relies on the collective effort of CHCs scattered throughout the Indonesian Archipelago. Understanding TB control program in the CHCs is thus the key to understand the national effort in controlling TB. However, in order to properly evaluate and propose solution for the TB programs, a comprehensive and systematic approach would be necessary. For over a decade, Department of Community Medicine, Faculty of Medicine University of Indonesia has developed an approach for community health program evaluation. The approach, termed systemic approach, integrating several problem solving concepts such as problem solving cycle 4 and decision matrix, 5 was able to systematically identify the problems, prioritize problems, formulate alternative solutions, and prioritize alternative solutions. 6 The approach had been used to evaluate and generate solutions for hundreds of public health programs. We therefore evaluated and compared TB control programs in two CHCs located in East Jakarta using the systemic approach. We expected that it would not only provide insight concerning TB control programs in individual CHCs, but also afford us an illustration of TB control programs carried out in the entire country. The interpretation of results would provide feedback for programs improvement. 117

3 As TB is a disease tightly linked to the socioeconomic status and demographic condition of the population, an urban population with low socioeconomic status and lived in crowded condition is at great risk of being affected by TB. 7,8 We deliberately evaluate CHCs that served urban populations with such condition so results and conclusions of this article could serve greater public interests. The evaluation was also intended to serve as examples of program evaluation using the systemic approach. It is hoped that this approach would be available to the public as one of the approaches that could be employed to evaluate and generate solution for community health programs. Methods The two CHCs evaluated were Jatinegara Kaum CHC and East Pisangan CHC, both located in East Jakarta. The TB Control Programs were evaluated from January to December The evaluation was done using the systemic approach as proposed by the Department of Community Medicine, Faculty of Medicine University of Indonesia. 6 Demographic data presented in this article were obtained from Jakarta Areal Government Welfare Activity Report December 2006 and the area demographic data, while data concerning TB control programs were obtained from Pulmonary TB Data Registry January-December 2006 and Pulmonary TB Patient Medical Records from the CHCs. Indicators Indicators used in the evaluation were inferred from both national and international guidelines for TB control evaluation. 9,10 The following indicators were used in the evaluation: 1. Proportion of sputum examined suspects (percentage of suspects among estimated total suspects) 2. Proportion of smear-positive patients among suspects (percentage of smear-positive patients among all sputum examined suspects) 3. Proportion of smear-positive TB patients among all registered TB patients (percentage of smear-positive pulmonary TB patients among all registered pulmonary TB patients) 4. Conversion rate (percentage of smear-positive TB patients undergone conversion into smear-negatives after intensive phase medication) 5. Cure rate (percentage of smear-positive TB patients cured after complete treatment among all registered smear-positive TB patients) 6. Error rate (percentage of error of the initial referred laboratory of slide interpretation after cross-checked by other laboratory) 7. Case Detection Rate/CDR (ratio of new smear-positive patients reported to estimated new smear-positive patients) Identification of Problems and Problems Prioritizing Problems were identified by comparing the program output with expected result using aforementioned indicators. The problems were then prioritized by utilizing decision matrix. 5 The criteria used in the decision matrix including importance (I), technical feasibility (T), and resources availability (R). All criteria were equally weighted since they were considered as equally important. The Importance score was determined by the sum of prevalence (Pv), severity (S), rate of increase (RI), degree of unmet need (DU), social benefit (SB), public concern (PB), and political climate (PC) scores of a particular problem. All problems would be entered into the decision matrix and a score of 1 (not important) to 5 (very important) will be given for each criterion. Priority score was the sum score of the three criteria. Problem with highest priority score would be given highest priority. Identification of Causes of Problems Causes of problems were identified by taking into consideration input, process, environment, and feedback components of the problems. The causes of problems was presented in a conceptual framework using modified Ishikawa diagram. 11 Identified causes would be confirmed by assessing actual conditions. Identification of Problem Solving Alternatives and Prioritizing Problem Solving Alternatives A number of problem solving alternatives was proposed for each causes of problems identified, by utilizing the law of causality. The Priority score for prioritizing of problem solving alternatives was determined based on the following formula: Priority (P) = Effectiveness (E)/Cost (C) Effectiveness score for an alternative was determined by timing the magnitude (M) score with importance (I) score and vulnerability (V) score of the alternative. All proposed alternatives would be entered into the problem solving alternatives prioritizing matrix. A score of 1 (not important) to 5 (very important) will be given for each criterion. Alternative with highest priority score would be given highest priority. Results Demographic Data As of December 2006, total population of Jatinegara Kaum area was 23,035 and total population of East Pisangan Area was 21,736. Table 1 presents the educational level of the populations served by both CHCs. 118

4 Table 1. Educational Level of Population in Jatinegara Kaum and East Pisangan Area Educational Level Jatinegara Kaum East Pisangan Area Area Male Female Male Female Elementary school ,782 1,375 Junior high school 1,995 1,980 1,904 1,662 Senior high school 2,601 2,397 3,648 1,829 Higher education / ,614 1,816 Academy Total number 5,076 4,818 11,948 6,682 Achieved Values for Indicators and Problem Identification Achieved values for each TB control program indicator for both CHCs are presented in Table 2. Any achieved value that did not meet the expected value for the particular indicator is considered a problem and were marked in the table. Please note that error rate were not available for either CHCs. Upon inquiry, officials in both CHCs reported that such data was not kept in the centers database, because sputum specimens were examined at external microscopic examination facilities. Prioritizing Problems Each of the problems identified was entered into the problems prioritizing matrix. Problems prioritizing matrixes for Jatinegara Kaum CHC and East Pisangan CHC are shown Table 2. Achieved Values for Indicators in Jatinegara Kaum CHC and East Pisangan CHC Variabel Expected Value Achieved Value Jatinegara Pisangan Kaum East Proportion of Minimum 70% 7.68% 10.26% sputum examined suspects Proportion of Around 10% 60.87% 58.62% smear-positive patients among suspects Proportion of Minimum 65% 60.87% 58.62% smear-positive TB patients among all registered TB patients Conversion Rate Maximum 80% 92.86% 82.35% Cure Rate Minimum 85% % % Error Rate Maximum 5% N/A N/A Case Detection RateMinimum 70% 46.74% 60.16% Considered as problem in Table 3 and Table 4. CDR below 70% was considered as prioritized problem in both CHCs. Identification of Causes of Problems After considering input, process, environment, and feedback aspects of the prioritized problem in the CHCs, causes of the problems were identified. The causes, confirmed by Table 3. Problems Prioritizing Matrix for Jatinegara Kaum CHC Problems Importance (I) T R Priority Pv S RI DU SB PB PC (P) Proportion of sputum examined suspects below 70% Proportion of smear-positive patients among suspects above 10% Proportion of smear-positive TB patients among all registered TB patients below 65% Non-availability of Error Rate CDR below 70% Problem with highest priority Table 4. Problems prioritizing matrix for East Pisangan CHC Problems Importance (I) T R Priority Pv S RI DU SB PB PC (P) Proportion of sputum examined suspects below 70% Proportion of smear-positive patients among suspects above 10% Proportion of smear-positive TB patients among all registered TB patients below 65% Non-availability of Error Rate CDR below 70% Problem with highest priority 119

5 assessing the actual conditions, were presented in Table 5. Table 5. Causes of Problems for Jatinegara Kaum CHC and East Pisangan CHC Jatinegara Kaum East Pisangan Input Components Human resources Insufficient number of health Insufficient number of professionals involved in the health professionals in volprogram ved in the program Funding Program officials stated - government funding was inadequate Hardware Lack of public health educa- Lack of public health education media tion media Lack of FAS-slide micros- Lack of FAS-slide microscopic examination capabi- copic examination capability lity Method Components - - Process Components Program execution Improper registration of TB Improper registration of TB suspects and patients suspects and patients Public health education Public health education event held less than 4 /year event held less than 4 /year No active case finding activities No active case finding activities Feedback and Environmental Components Environment Low educational level of the Low knowledge-attitudepopulation practice of the population Low knowledge-attitude-practice of the population Identification of Problem Solving Alternatives After taking into consideration causes of the problems, several problem solving alternatives were identified utilizing law of causality. The alternatives proposed for the prioritized problem in Jatinegara Kaum CHC were: (1) Seeking new funding sources from the local government and non-government organizations for case detection, (2) Providing TB public education media, (3) Held TB public health education events, (4) New case finding training for CHC cadres, and (5) Sputum examination of household contacts. Alternatives proposed for prioritized problem in East Pisangan CHC were similar to that of Jatinegara Kaum CHC except for seeking new funding sources. Prioritizing Problem Solving Alternatives All alternatives were entered into the problems prioritizing matrix. Table 6 is the alternatives prioritizing matrix for Jatinegara Kaum CHC, and Table 7 is the alternatives prioritizing matrix for East Pisangan CHC. New case finding training for CHC cadres was prioritized in Jatinegara Kaum CHC, while periodic TB public health education events were prioritized in East Pisangan CHC. Table 6. Problems Solving Alternatives Prioritizing Matrix for Jatinegara Kaum CHC Alternatives Effectiveness (E) Cost Priority M I V (C) (P) Seeking new funding sources from the local government and Non-Government Organizations for case detection Providing TB public education devices Periodic TB public health education events New case finding training for CHC cadres Sputum examination for household contacts Alternative with highest priority Table 7. Problems Solving Alternatives Prioritizing Matrix for East Pisangan CHC Alternatives Effectiveness (E) Cost Priority M I V (C) (P) Providing TB public education devices Periodic TB public health education events New case finding training for CHC cadres Sputum examination for household contacts Alternative with highest priority Discussion The demographic data clearly indicated that population in East Pisangan area has a higher education level comparing to the population in Jatinegara Kaum area. Not only population in East Pisangan Area had higher percentage of population that had formal education (85.71% vs %), but they also had higher percentage of the population that had higher education (15.78% vs. 1.14%). Indicator values in both CHCs had revealed similar problems and priority. In both CHCs, CDR below 70% is considered a prioritized problem as it had high Prevalence, Severity, Rate of Increase and Degree of Unmet needs scores contributing to its high Importance score. Proportion of sputum examined suspects below 70% had scores close to that of CDR below 70%, but CDR below 70% was considered to have higher Degree of Unmet need compared to proportion of sputum examined suspects below 70%. In fact, we consider that low proportion of sputum examined suspects, high proportion of smear-positive patients among suspects above 10%, and low CDR all rooted from inadequate case detection ability. Therefore, CDR have the highest Degree of Unmet 120

6 need score; solving low CDR would probably solve other two problems as well. The CDR of both CHCs (46.14% for Jatinegara Kaum and 60.16% for East Pisangan) was not only lower than Indonesian national CDR, which was 68% in 2005, but also lower than average CDR of South-East Asia region, which was 64%. This confirmed that low CDR was indeed a pressing problem. 2 Causes of problems for both CHCs primarily differ in that official in Jatinegara Kaum stated that government funding was inadequate for the program, while officials in East Pisangan make no such statement. Jatinegara Kaum also had a population with lower educational level. We consider the statement made by official in Jatinegara Kaum, although relatively subjective, should not be ignored as it is a statement made by one of the important stakeholders in the program. Improper registration of TB suspects and patients may also contribute to the apparent low proportion of sputum examined suspect and CDR. In both CHC, almost all patients presented with TB symptoms would undergo microscopic and radiographic examination, and almost all of them would ultimately being diagnosed as TB patient, either based on microscopic examination, radiographic examination, or based on the presenting symptoms alone. However, the CHC officials admitted that a small number of patients with indefinite TB symptom and negative microscopic examination may not be properly entered into the TB registry as TB suspects. Confirming suspect data with microscopic examination facilities was not possible because microscopic examinations were referred to numerous different microscopic examination facilities. As the medical records at both CHCs were poorly classified and not stored in a computerized database, it is very difficult to confirm the exact number of TB suspects. New case finding training for CHC cadres was considered prioritized solution for Jatinegara Kaum CHC. Active case finding had been recognized as one of the most efficient methods to raise CDR in many part of the world. 12,13 We expect that augmenting passive case finding currently practiced by official in Jatinegara Kaum CHC with active case finding would improve the low CDR in the CHC. Considering the limited availability of health professional involved in the TB control program, it would be ineffective for the few health professionals that already burdened with many other tasks to carry out the active case finding activities. Instead, CHC cadres could be utilized for active case finding in this situation. The CHC cadres are one of the unique elements of Indonesian grassroots public health efforts that have become an integral aspect of Indonesian society. These cadres are local residents (primarily housewives) that voluntarily assist CHCs in carrying out its public health programs. Generally, their main duty is to participate in monthly comprehensive service post (Posyandu) that provides basic maternal and child health services. By providing new TB case finding training to these cadres, they would be able to recognize signs and symptoms in TB suspects and notify CHC of their presence. They could also providing simple medical advices to these TB suspects and referred them to CHC for diagnosis and treatment. The cost of such training is comparable to other alternatives such as periodic TB public health education events, however, in Jatinegara Kaum where population had low level of education, such training was considered more effective, as public health education efforts may require a long time to raise the CDR by improve the knowledge of the population with such low educational level. For East Pisangan CHC, periodic TB public health education events were considered prioritized solution. As East Pisangan has a population with relative higher education level, such events were expected to increase the knowledge of population in reasonable amount of time. The knowledge would lead to better health attitude and practice, and increasing the awareness of the population to actively seek medical attention once TB symptoms emerge. Such effort was in accordance to the Enhanced Case Finding paradigm. 12 Indonesian CHCs has enjoyed a legacy of high cure rate since the introduction of DOTS strategy for the national TB control programs. 1 The two CHCs evaluated also enjoyed the similar success, with both of their conversion rate above 80% and cure rate above 85%. However, such high cure rate was not accompanied by an adequate CDR. The fact that that low CDR was determined as prioritized problem in both CHCs suggested that low CDR is the primary problems affecting the success of TB control programs in CHCs. The fact that Indonesia narrowly missed the target of 70% CDR by 2005 suggested this may be a problem experienced not only by the two CHCs evaluated in this study, but also by a significant numbers of other Indonesian CHCs. 1 If CDR would rise as the result of implementing the proposed solutions (especially the prioritized solution), the burden placed by TB on the society is expected to be greatly reduced. A high CDR, coupled with an already high cure rate, will be able to effectively detect and cure the TB patients in the society and contain the spread of TB in a relatively short time. 14, 15 The systemic approach utilized in this study has demonstrated its ability to systematically evaluate and generation solution for a community health program. As the approach is designed to be compatible with virtually all community health programs, it could certainly be applied in evaluation of community health programs other than TB control programs. Community health decision makers could always considered the systemic approach as one of the alternative approaches for community health program evaluation. Acknowledgements The authors were grateful to Department of Community Medicine, Faculty of Medicine University of Indonesia for 121

7 facilitating the study. We also wish to thank officials at Jatinegara Kaum CHC and East Pisangan CHC for their assistance. References 1. World Health Organization. Global TB control: Surveillance, planning, financing. WHO Report Geneva, Switzerland: WHO, Center for Data and Information, Ministry of Health Republic of Indonesia. Indonesia health profile Jakarta: Ministry of Health Republic of Indonesia; World Health Organization. A guide to monitoring and evaluation for collaborative TB/HIV activities. Geneva, Switzerland: WHO; Pretz JE, Naples AI, Sternberg RJ. Recognizing, defining, and representing problems. In: Davidson JE, Sternberg RJ, editors. The psychology of problem solving. Cambridge: Cambridge University Press; 2003.p Pugh S. Creating innovative products using total design. 1st ed. England: Addison Wesley Longman; Azwar A. Pengantar administrasi kesehatan. Edisi ketiga. Jakarta: Binarupa Aksara; Coker R, McKee M, Atun R, Dimitrova B, Dodonova E, Kuznetsov S, et al. Risk factors for TB control in Russia: case-control study. Brit Med J 2006;332: Mitchell D. The return of the white plague: global poverty and the new TB. N Engl J Med. 2004;328: Departemen Kesehatan Republik Indonesia. Pedoman Kerja Puskesmas Jilid II. Jakarta: Departemen Kesehatan Republik Indonesia; World Health Organization. An expanded DOTS framework for effective TB control. Geneva, Switzerland: WHO, Ishikawa K. Guide to quality control. White Plains, NY: Quality Resources; Golub JE, Mohan CI, Comstock GW, Chaisson RE. Active case finding of TB: historical perspective and future prospects. Int J Tuberc Lung Dis. 2005;9(11): Pronyk PM, Joshi B, Hargreaves JR, Madonsela T, Collinson MA, Mokoena O, et al. Active case finding: understanding the burden of TB in rural South Africa. Int J Tuberc Lung Dis. 2001;5(7): Murray CJ, Salomon JA. Expanding the WHO TB control strategy: rethinking the role of active case-finding. Int J Tuberc Lung Dis 1998; 2 (Suppl 1): S9-S Borgdorff MW, Floyd K, Broekmans JF. Interventions to reduce TB mortality and transmission in low- and middle income countries. Bull World Health Organ 2002; 80: SS 122