Indonesians prefer costly private clinics for TB care

A preference by Indonesians to seek initial care for tuberculosis (TB) at private clinics rather than public facilities is resulting in diagnostic delays and escalated costs, says a new study.

According to the WHO, Indonesia ranks next to India and China with the highest TB burden in the world. Other high-burden countries include the Philippines, Pakistan, Nigeria, Bangladesh and South Africa. These eight countries account for two-thirds of the total burden. Nearly half (44 percent) of the new TB cases in 2018 occurred in South-East Asia.

In 2014, Indonesia implemented universal health coverage through Social Security Agency for Health or Badan Penyelenggara Jaminan Sosial Kesehatan (BPJSK) to provide insurance coverage for essential health care services, including diagnostic tests for TB, conducted by primary health centers (PHC) and designated private clinics.

However, according to the study, published this month in BMC Health Services Research, patients prefer private clinics owing mainly to a perception that they offer better service and accessibilitythan government-run primary health centers, Muchtaruddin Mansyur, an author of the study from the Universitas Indonesia, Jakarta, tells SciDev.Net.

Patients approaching private clinics that are not covered by BPJSK's insurance facilities end up paying from their pockets, Mansyur says. In the pre-diagnostic phase, the average direct medical cost incurred by each patient seeking care in a private clinic was US$21 against US$5 in a primary health centers.

Preference for private clinics was substantially higher in the rural districts and among those with low educational levels. "Visiting a private clinic as the first contact also led to more visits…and higher costs than first visiting a PHC, both in terms of direct costs…and total costs," according to the study led by Ahmad Fuady of the University Medical Center Rotterdam, Netherlands.

Rural patients' preference for starting care at a private clinic may have been influenced by the greater distance they may have to travel to reach a primary health center. The number of PHCs in these areas is limited, the cost of transport to them is higher, and the waiting time can be long, prompting patients to seeking a private health care provider or facility that is closer home.

Fihiruddin, a researcher affiliated with the department of medical laboratory technology in Politeknik Kesehatan Mataram, Indonesia, explains to SciDev.Net that TB patients infected with HIV also usually visit a private clinic rather than a primary health center.

"High-income people are usually not only infected by TB but [also] are infected by HIV… [and] the stigma of HIV in Indonesia is still so bad that they keep it a secret from everyone, including their families," says Fihiruddin who is not involved in the study.

Mansyur says patients with TB and the larger community "should have sufficient knowledge of national health insurance, including their rights and responsibilities". They also need to know that those living below the poverty line have a right to get a full subsidy of the membership premium from the government, he says.

The researchers suggest that in order to reduce diagnostic delays and minimize costs to the patient, it is essential to strengthen the public-private mix and reduce the fragmented system between the national health insurance scheme and the National TB Program.