Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia.
BMC Health Serv Res. 2020 Jun 3;20(1):502. doi: 10.1186/s12913-020-05350-y.
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.
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.
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).
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.
尽管结核病（TB）患者在获得结核病相关服务时往往需要承担高昂的费用，但在 2014 年印度尼西亚实施全民健康覆盖（UHC）之前，尚不清楚这是否会降低直接费用并改变寻求医疗服务的模式。因此，在引入 UHC 后，我们评估了结核病患者的就医行为和他们在诊断过程中产生的费用，以及这些费用的决定因素。
在这项横断面研究中，我们于 2016 年 7 月至 9 月在印度尼西亚城市、郊区和农村地区采访了成年结核病患者。我们连续选择在基层医疗中心接受结核病治疗至少 1 个月的患者，直到每个地区至少有 90 名患者。在确定他们在诊断前阶段所产生的直接和间接费用后，我们计算了总费用（以美元计）。为了确定这些费用的决定因素，我们应用了一般线性混合模型来调整我们的聚类抽样设计。
在我们分析的 282 名患者中，有 93 名（33%）首先在私人诊所就诊。在农村地区（比值比 1.88，95%置信区间 0.85-4.15，P=0.119）和教育程度较低的患者中，这种诊所的就诊偏好更高（比值比 1.69，95%置信区间 0.92-3.10，P=0.090）。首次就诊选择私人诊所也会导致更多的就诊次数（β 0.90，95%置信区间 0.57-1.24，P<0.001）和更高的费用，无论是直接费用（β 16.87，95%置信区间 10.54-23.20，P<0.001）还是总费用（β 18.41，95%置信区间 10.35-26.47，P<0.001）。
尽管实施了全民健康覆盖，但结核病患者寻求医疗服务的费用仍然很高，直接医疗费用对总费用的贡献最大。首次向私人提供者寻求医疗服务往往会导致更多的诊断前就诊次数和更高的费用。为了减少诊断延误并尽量降低患者的费用，必须加强公私混合服务，并减少国家健康保险计划和国家结核病规划之间的分散系统。
