Achieving quality in the Directly Observed Treatment Short-course (DOTS) strategy implementation process: a challenge for hospital Public-Private Mix in Indonesia

Background: The Directly Observed Treatment Short-course (DOTS) expansion strategy through Public-Private Mix (PPM) is in progress at an international level as well as in Indonesia. The number of hospitals involved in PPM has been rapidly scaling up, requiring the assessment of quality of implementation. Objective: The paper presents the assessment of quality in implementing DOTS strategy in hospitals in Indonesia and emphasises the challenge of achieving high process quality in managing adult TB cases seen in the outpatient unit. Design: A multiple-case study, involving eight general hospitals in Yogyakarta and Central Java provinces.. The cases are comprised of public and private hospitals as well as teaching and non-teaching hospitals. Using the Donabedian's model, the quality of DOTS strategy implementation in hospitals was assessed in three aspects, i.e. structure, process and outcome. Data were collected through self-administered questionnaires, focus group discussions, interviews, observation and documents. Results: The study revealed the importance of process, i.e. mainly commitment and case holding process, to the treatment success rate, treatment completion rate and default rate. Conclusion: A systemic approach and structural support from the hospital is critical in this endeavour. Process improvement in the implementation of DOTS strategy in hospitals should be given more emphasis in hospital PPM-DOTS.