Abstract
Background:
Central Java, Indonesia, struggles with low drug-resistant tuberculosis (DR-TB) case detection (33%) and treatment rates (25%), far below the 60% target. Despite policies, including Minister of Health Regulation No. 67/2016 and Presidential Regulation No. 67/2021, along with the National TB Strategy for Tuberculosis Control 2020–2024 have been implemented, targets remain unmet due to weak community involvement. This study analyzed TB policy implementation in high-prevalence Banyumas Regency, focusing on cadres and community organizations.
Design and Methods:
This qualitative study employed the Van Meter and Van Horn framework to assess policy implementation. Key stakeholders involved informants from Puskesmas (community health centers), TB cadres, TB program holders at the Regency Health Office, and the Mentari Sehat Indonesia Foundation. Data collection involved in-depth interviews with these informants, as well as policy documents, guidelines, and reports from agencies or institutions. Triangulation methods were used to enhance the validity of the findings.
Results:
Implementers understood policy standards, supported by consistent communication among Health Offices, community health workers, local organizations, and village leaders. Positive attitudes were reflected in joint commitments and Regional Action Plans. Cadres and communities actively supported case-finding, treatment, education, socioeconomic aid, and stigma reduction.
Conclusions:
Policies lack sufficient local budget allocation. Weak motivation of TB cadres, lack of commitment among regional organizations, and persistent stigma in the community are evident. The Global Fund aids DR-TB control through grants and patient support to ensure treatment adherence. However, sustained impact requires government attention to policy, human resources, infrastructure, and complementary resources to achieve synergy.
Keywords
Significance for public health
The implementation of tuberculosis (TB) control policies is a vital step in the global fight against the disease, yet challenges persist. To enhance TB control, addressing issues like a restricted cadre pool and the lack of on-the-job training is crucial. The enduring stigma surrounding TB impedes progress, seen in the reluctance of drug-resistant TB (DR-TB) patients to seek treatment. Communities, as healthcare partners, can introduce innovative strategies to empower survivors and improve efficiency. Exploring sustainable assistance options for DR-TB patients is essential for treatment access. Examining the roles of cadres and communities from the perspective of DR-TB patients ensures interventions align with genuine needs. While commendable, TB control policies require a united effort from government agencies, healthcare providers, and communities to make substantial strides in the ongoing fight, safeguarding global public health.
Introduction
Tuberculosis (TB) is a global health priority, central to the United Nations 2030 Sustainable Development Goals. According to the World Health Organization (WHO), TB has reclaimed its status as the leading cause of death from a single infectious agent, following 3 years of being overshadowed by COVID-19. The estimated global number of TB patients in 2023 was 10.8 million, comprising 6.0 million men (55%), 3.6 million women (33%), and 1.3 million children (12%). The same year, most cases occurred in the South-East Asian region (45% of new cases), followed by Africa (24%), and the Western Pacific region (17%). More than 95% of cases and deaths occur in developing countries. 1
In addition to harming health, TB burdens the economy, globally and nationally. TB is prevalent in the productive age group (19–59 years), accounting for 75% of all TB patients, resulting in an annual loss of household income of approximately 20%–30%. 2 The Global Fund stated that global economic losses due to TB amount to USD 12 billion per year, including work absences due to TB treatment and deteriorating health due to TB. 3 These costs exacerbate the condition of households that are below the poverty line, affect the patient’s status as the backbone of the family, and increase treatment length due to the need for resistant treatment, including prolonged hospital stays and the need for more specialized care.4,5
Drug-resistant TB (DR-TB) may form part of a “triple burden,” along with TB incidence and HIV, representing a global challenge. The resistance of Mycobacterium tuberculosis germs to anti-TB drugs is a current problem. The treatment success rate for multidrug-resistant or rifampicin-resistant TB (MDR/RR-TB) has risen to 68%. However, in 2023, only 44% of the estimated 400,000 individuals who developed MDR/RR-TB were diagnosed and received treatment. 6 Indonesia accounted for approximately 7.4% of the global burden of drug resistant TB, with an estimated 80,000 cases in 2023, including 3.2% of new TB cases and 16% of previously treated cases. In 2022, notification data for drug resistant-TB in Indonesia reported 7876 cases, substantially lower than the national estimate of 28,000 cases. In addition to the low notification rate, only 65% of patients diagnosed with drug-resistant TB initiated second-line treatment. 7
Several risk factors for DR-TB have been suggested in previous studies, such as undiscovered cases (avoidance or confinement) and failure to complete treatment, which potentially increase the risk of resistance. Incomplete treatment is closely related to patient adherence. One TB control strategy is to involve the community, which aims to increase community participation in finding suspected patients and helping to overcome TB problems in their area, because this involvement relates to regular and continual observation. 8 The Ministry of Health also stated that community participation is an important component of the TB control program in Indonesia. 4
The Central Java Provincial Statistics Agency (BPS), the official government institution responsible for collecting and disseminating statistical data in Central Java Province, showed that TB case findings in Banyumas Regency, Indonesia, have continued to increase, from 166 cases per 100,000 population in 2020 to 179 cases per 100,000 population in 2021 and 205.9 per 100,000 population in 2022, the highest TB case-finding rate in Central Java. 9 The number of TB patients in Banyumas Regency has increased from 3404 in 2021 to 3815 in 2022. The success rate of positive TB treatment for all cases in 2021 was 80.2%, lower than 91.8% in 2020.10,11
To accelerate TB elimination, the government issued Minister of Health Regulation No. 67/2016 on Tuberculosis Control, strengthened by Presidential Regulation No. 67/2021 on Tuberculosis Control. TB control policy is implemented following the principle of decentralization within the framework of regional autonomy with districts and cities as the focus of program management. Countermeasures are carried out based on the guidelines of the National TB Control Strategy, which aligns with global commitments in the WHO’s The End TB Strategy. The national strategy includes strengthening the commitment and leadership of central and regional governments, increasing access to quality and patient-centered TB services, and increasing the participation of communities, stakeholders, and other multisectors. 4
Local governments are thus responsible for TB prevention, cure, and mitigation of its psychosocial and economic impacts. The government’s commitment to TB control is not only held by the community health center (Puskesmas) but also the role of cross-sectors in prioritizing TB. Therefore, the role of the community is needed through the assistance of cadres and TB activist community organizations in TB prevention, early detection of TB suspects, treatment assistance, socioeconomic support, and advocacy. Community participation is a key component in efforts to combat TB in Indonesia. One important example is community-based support and monitoring of TB patients’ treatment adherence. However, modern society increasingly favors independent problem-solving, which may reduce awareness of communal values such as mutual assistance and cooperation.
According to Van Meter and Van Horn, policy implementation is influenced by several factors: policy standards and measures; resources; inter-organizational communication and implementing activities; characteristics of implementing agencies; implementing dispositions; and the social, economic, and political environment. 12 Innovative DR-TB approaches, ranging from cash transfers and mHealth tools to public-private partnerships and decentralized care, have been implemented in high-burden areas including Mumbai, South Africa, Brazil, and Vietnam.13-16 These international best practices provide insightful information for bolstering Indonesia’s DR-TB policy, especially in places like Banyumas. Because its DR-TB cases are significant, indicating that the chance of transmission is high, Banyumas Regency has made various efforts to overcome TB, including through community participation, namely cadres and communities. Therefore, this study was conducted to analyze the implementation of TB control policies based on community roles in the context of controlling DR-TB in Banyumas Regency.
Design and methods
Study setting
This qualitative study explored and analyzed the implementation of TB prevention policies by examining the role of the community cadres and organizations in controlling TB in Banyumas Regency. It was conducted at the Banyumas Regency Health Office, Sumbang 1 Health Center, and Purwokerto Barat Health Center in June–July 2023.
Participant selection
The selection of informants was based on the principles of adequacy and appropriateness. Using the purposive sampling method, informants representative of the research characteristics were selected. They included health cadres assisted by the Puskesmas, DR-TB cadres from MSI (patient support), the person in charge of the TB program of the Sumbang 1 Puskesmas, the person in charge of the TB program of the Purwokerto Barat Puskesmas, the coordinator of the infectious disease prevention and control field of the Health Office, and the MSI Foundation.
Theoretical framework
This research focused on Van Meter and Van Horn’s theory of policy implementation, among others, on policy standards and objectives, resources, communication among implementers, characteristics of the implementing agencies, disposition of the implementers, and the social, economic, and political environment (Table 1). The Van Meter and Van Horn model is chosen because it comprehensively addresses the multi-dimensional aspects of policy implementation, particularly relevant to DR-TB control, which involves various actors, resources, and contextual challenges. This framework enables a detailed examination of how DR-TB policy is translated into practice at different levels. Van Meter and Van Horn offer an operational lens suited for assessing the extent to which policy implementation aligns with national strategies and regulations, especially in complex, decentralized health systems. Its practical focus and structured approach make it ideal for evaluating DR-TB control policies in Indonesia’s diverse and resource-constrained settings (Appendix 1).
Description of the research variables.
Data collection
The qualitative data collected was obtained using in-depth interviews with structured interview guidelines. The sources were primary data in the form of interview results from key informants and secondary data comprising supporting research documents obtained from the Health Office, Puskesmas, and Mentari Sehat Indonesia (MSI) Foundation such as regulations, guidelines, and reports. The in-depth interview began by advising the informants about the informed consent form. The tools used included a voice recorder, field notes, and a camera for documentation. The data processing began with transcribing in-depth interviews and field notes. Data organization was then carried out, coding, involving categorizing the data, summarizing the data with a matrix, then interpreting the data and drawing conclusions.
The research was conducted by interviewing 8 informants (Table 2), consisting of TB cadres (2 persons) who had never had DR-TB training, DR-TB cadres (2 persons) who had attended DR-TB training, MSI Foundation, Banyumas Regency (1 person), the TB Program Holders at Sumbang I Health Center and West Purwokerto Health Center (2 persons), and the P2PM Sub Coordinator for Banyumas District Health Service (1 person). This research collected secondary data in the form of Banyumas Regent’s Regulation Number 50 of 2016 concerning the Regional Action Plan for Controlling Tuberculosis in Banyumas Regency for 2018–2023, in addition to guidelines for controlling TB issued by the Ministry of Health such as the Technical Instructions for Management of DR-TB in Indonesia and Technical Instructions for Assistance DR-TB Patients by Community. Data collection continued until thematic saturation was reached—when no new themes or insights emerged in the final interviews. This indicated that the data gathered were sufficient and comprehensive.
Description of in-depth interview informants.
Data validity
While comprehensive quantitative data (e.g., detailed case statistics or budget allocations) were unavailable due to institutional restrictions, qualitative insights were rigorously validated via triangulation. For data validity, this research used triangulation of sources and methods. Source triangulation was done by re-examining information obtained from various sources to ensure valid and accurate data. This involved checking data from in-depth interviews against document reviews of secondary data from the Puskesmas, MSI, Banyumas Regency, and the Health Service, ensuring the findings complemented and supported each other.
Results
Policy standards and objectives
Policy standards and objectives explain the measures or standards for policy achievement, the targets that have been set, and the objectives of the policy as known and understood by policy implementers. The national TB elimination strategy, outlined in Minister of Health Regulation No. 67/2016 and Presidential Regulation No. 67/2021, aims to reduce incidence to 65 cases per 100,000 population by 2030. However, in 2021, the actual incidence rate was 179 cases per 100,000, and the proportion of successful TB treatment for all cases reached 85.2% (target 90%). The coverage of DR-TB detection was 59.8% (target 70%), and the proportion of DR-TB patients who started treatment was 85% (target 95%). The national strategy is being implemented through several efforts, including strengthening the commitment and leadership of central and regional governments; increasing access to quality and patient-oriented TB services; intensifying health efforts; increasing research, development, and innovation in TB control; increasing the participation of communities, stakeholders, and other multisectors; and strengthening program management. Most informants knew and understood the objectives of the TB program and implemented it in their Puskesmas work area.
“Regarding the implementation of TB and TB RO control policies, what are the standards/measures for achieving success in Banyumas Regency?”
“We are still using the technical guidelines from 2022, which are from the Ministry of Health. For new regulations, the health minister is also used. Yesterday’s presidential decree had already arrived at the Puskesmas. But we are still using the TB Technical Guidelines for 2022. Of course, the goal is to have TB-free Banyumas, the number of cases will decrease, and, of course, we hope that many DR-TB patients will recover.”
“TB is a regulation from the center as a TB prevention and control program. The TB program is included in the Minimum Service Standard because it is the Regent’s report card. Apart from the central regulations, we also have a RAD regarding Regional Action Plans regarding TB, which the Regent sign(ed). Yes, the indicators for TB control are there, starting from case detection, treatment, DR-TB patients, and so on.”
This shows that implementers are familiar with the strategic documents and goals of the TB program and apply them in their operational context. The TB control program is also included in the Minimum Service Standards in the health sector as a performance report for regional heads (regents), as stated in Banyumas Regent Decree Number 440/756/2022. Therefore, TB control is prioritized not only at the health facility level but is also embedded in regional performance metrics and planning instruments.
Resources
Adequate resources are needed to support successful policy implementation. Resources consist of budget (funding), facilities and infrastructure, and incentives. Currently, TB and DR-TB patients have the right to receive free treatment services under a government program. The financing system for TB control comes from the State Budget (APBN), the Regional Budget (APBD), grant funds, and the private sector, including the Global Fund.
“How is the budget availability for accelerating TB and DR-TB elimination in Banyumas Regency? How is the budget allocation for TB control at the health center (Puskesmas) level?”
“Seeing the RAD, the budget for TBC comes from the APBN, APBD, and Global Fund. For activities in the field, namely Puskesmas, they are funded through BOK funds, and it is the policy of each region (Puskesmas) to allocate TB operational funds.”
While strategic documents exist to outline funding sources (central, regional, and international), operational allocations are still determined at the discretion of each Puskesmas, potentially leading to variability in program delivery across regions. The fulfillment of supporting facilities and infrastructure to control TB continues to be improved. Banyumas Regency has health service facilities as DR-TB referrals: 4 hospitals and 6 TB Culture Media (TCM)-supporting health centers and satellite health centers around the DR-TB referral health centers. Likewise with antitubercular medications stocks, health worker informants stated that they had not experienced problems with the availability of antitubercular, which has been supplied from the center and hospitals, especially for DR-TB patients.
“How is the availability of facilities (means and infrastructure) in implementing TB control, especially controlling TB-RO?”
“That’s enough, especially large hospitals support us, then health facilities with TCM that are spread out. There are 6 TCMs in health centers, and we have the most in Central Java.”
“Thank God, so far, the stock of medicines is safe. As far as I know, the medicines are dropped if we run out of stock. We usually apply to the department. So far, medicines for DR-TB patients have been obtained from the hospital.”
This indicates that Banyumas Regency has adequate TCM facilities and a reliable supply of anti-TB drugs, supported by effective coordination with hospitals and the health department. Implementing TB control in the field is a shared responsibility. Programs issued by regional governments are managed from the Health Service to the Puskesmas level. As appreciation for the energy and input provided by the cadres, incentives are provided. Cadres are assisted by the Puskesmas with local transportation, and cadres from the community receive incentives for tracking, assisting until the completion of treatment, and reporting.
“Is there a special budget allocation for providing incentives for cadres as motivation/increased support in efforts to combat TB-RO?”
“In West Purwokerto (West Purwokerto Health Center) so far, there has been funding for cadres and visits from BOK cadres. If the cadre comes from the village, the transportation will be from the Puskesmas. Because cadres are not paid, the cadres are volunteers and go out into the field. At least if there is a little, it can make them enthusiastic.”
“We (MSI Foundation) go to the cadres. If we suspect we have a reward for both positive and negative results, our contact investigation has a reward, including mentoring them for 6 months. We have our own reward.”
Although cadres are primarily volunteers, there are modest financial incentives provided either through BOK or organizational support such as from the MSI Foundation.
Communication among implementers
Communication is the main requirement for the success of implementing a policy. Good communication, without interruption, and containing correct and appropriate information, can prevent mistakes, whereas poor communication can cause them. TB control policies from the central government are accepted by regional implementers, hoping that they can be implemented and become a reference. The informants stated that the current policy has been implemented, conveyed by the Health Service to the Puskesmas. The Puskesmas also communicates to cross-sectors to produce one commitment. From the community’s perspective, the MSI Foundation emphasized that their participation in Banyumas Regency was part of a joint commitment involving the central, provincial, and regency governments, as well as the Social Support and Rehabilitation (SSR) program. This collaboration served as a framework for implementing TB control policies.
“How is the implementation of TB-RO control policies communicated and monitored to ensure clear understanding among health centers, regional leaders, and cross-sector stakeholders?”
“There is a health regulation, such as the presidential decree that was recently submitted to Puskesmas. Like MICA activities from the Health Department, sometimes providing updated information from the center of the Ministry of Health, we carry it out in the field. Then, the department also updates TB patient data periodically through meetings. From the Puskesmas side, we then coordinate with cross-sectors such as with the military, sub-district military, sub-district head, police, and their staff. At these meetings, we usually report the results or evaluations regarding TB findings every 3 months.”
“First, we have information from our superior SR, who accesses it from PR, and PR accesses it from the Ministry of Health. Second, we coordinate with the health center and the Health Office, regarding policies or regulations. These rules also reach the cadre level.”
TB control policies from the central government can be implemented at the regional level, through meetings and socialization activities, as well as monitoring and evaluation to ensure that implementers receive the same information and guidelines to synergize in TB control efforts.
“How consistent is the delivery of information related to TB and TB RO management?”
“I emphasize to my friends (officers at the Puskesmas) to increase education and information media so that people understand TB disease. One of our shortcomings is that there are so many programs to concentrate on TB programs, especially monitoring and evaluation, which is quite difficult. But we make it a habit to evaluate through frequent meetings.”
Characteristics of the implementing agencies
The Health Service is the implementing element of government affairs in the health sector. It has the task of assisting the Regent in carrying out policy formulation, implementation, evaluation, and reporting on the implementation of government affairs in the health sector, which is the authority of the region, and assistance tasks given to the Regency. Puskesmas carry out operational technical tasks. Their duties and functions refer to the regional government’s health development policies. The Puskesmas has one person with a nursing background in charge of the TB program.
“What are the competencies and number of staff/program implementers in implementing TB-RO control in Banyumas Regency?”
“In my work area, apart from me being a PJ, the doctor is, of course, a counselor and diagnostician and drug prescriber and health worker, there are also pharmacist friends. I am a nurse (nurse professional education). So far, I have accompanied the cadres during visits.”
The Health Service, as the leading sector in the health sector, has been building relationships with other regional apparatus organizations (non-health). This is because TB is a multifactorial health problem requiring cross-sector support and participation. Therefore, the Health Service is trying to network with BAPPEDA in terms of budget, as well as with correctional institutions, educational institutions, and the private sector in tracking new cases, even though this is not optimal in reality.
“Are there any communication forums or meetings involving cross-sectors in controlling TB RO?”
“For the case of workers, we have coordinated with prisons, workers (Manpower and Transmigration Department) are making concepts, standard operational procedures (SOPs), making flows, making decrees regarding DR-TB workers. So, what do these workers want to do if there is a positive case so that it doesn’t harm the workers or the company? Because TB sufferers have to have an off period, for Drug Sensitive, it can be 2 weeks at the earliest. But if you have drug resistance for at least 3 months, you have to turn it off first so you don’t infect it.”
To clarify the implementation of services in controlling TB, the Health Service and Puskesmas created SOPs, including for treatment services, patients absent from follow-up, and home visits, as well as mapping collaboration with several agencies and companies in handling DR-TB patient cases in the workplace.
Disposition of the implementers
This disposition refers to how the implementer responds to and understands TB control policies in DR-TB control, accepting, rejecting, or being neutral toward the policies that have been established. So far, the TB control policy has been running with a positive response from regional leaders (Regents), so the Health Service has followed up with a Regional Action Plan on TB in Banyumas Regency.
“What is the disposition regarding TB and TB RO control policies in Banyumas Regency?”
“We in the regions support this because the Minimum Service Standard is the Regent’s report card, so we get quite good support from regional leaders, especially the Regent. Apart from that, we also involve people outside the Health Department. In making regulations, regional leaders also support. Until then, we had RAD. We will report the implementation later to the Regent, what percentage has been carried out in the field.”
Overall, the attitude of policy implementers at the Puskesmas level, in the community, and across sectors supports the success of TB control. This is also supported by commitment at the Puskesmas (sub-district) level through the signing of a joint commitment and the formation of the Banyumas Regency Tuberculosis Control Regional Action Plan.
Social, economic, and political environment
TB is an infectious disease that still carries a stigma. TB patients feel ostracized if the local community knows their condition so many refuse treatment when surveyed by cadres. This often becomes an obstacle in finding active cases in the community. This is also due to a lack of dissemination of information and education to the public about TB.
“How are the aspects of the community’s economic environment in the implementation of TB and TB RO control policies?”
“The stigma still exists, let alone village people; for example, city people in the West Purwokerto area have easy access, but they still think TB should be hidden, kept to themselves, and other people shouldn’t know.”
From an economic perspective, most TB patients have middle to lower income levels. The price of medicine does not burden them, but access to health facilities is felt to be a burden because no transportation or nutrition costs exist as a barrier to improving their quality of life. Considering the political environment, the regional government of Banyumas Regency has issued a Regional Action Plan for TB Control as a form of government commitment to eradicating TB in Banyumas Regency. Additionally, the coverage of the discovery and treatment of people with TB acid-fast bacilli is used as a performance indicator, as well as support from several professional organizations such as KOPI TB, IAKMI, and an association of lung specialist doctors, thereby strengthening the regional government’s commitment to tackling TB.
Implementation of community-based TB control policies
Banyumas Regency initiated DR-TB control efforts in 2011, peaking at 25 cases in 2017. In response, the Regency issued Regulation No. 50/2018 to establish a Regional Action Plan (2018–2023).
“How are TB control policies, especially for TB RO, implemented in Banyumas Regency?”
“We at the Puskesmas (are) very supportive; other health workers are also supportive; the Health Service is also extraordinary; even the village head and sub-district head are also involved in controlling TB.”
Through the Health Service, the regional government is synergizing with all parties because all sectors support TB control. Therefore, in Banyumas Regency, the TB control program is a program of not only the health service but also related agencies, government and private, professional organizations, TB activist organizations (communities), and the community up to the village government level.
Community role (cadres and community)
Community participation in TB control efforts can encourage program achievement. Communities specifically involved include cadres and communities through 4 areas of TB control: case-finding, making referrals, TB prevention, and support for regular treatment, as well as socioeconomic support and reducing stigma. In case-finding, cadres play an active role in contact tracing and investigations, providing education and motivation for patients and close contacts. Through case managers at hospitals and patient support, the community recruits DR-TB patients through DR-TB referral hospitals. The case managers coordinate the diagnosis results with the Health Service, Puskesmas, and patient support, with the aim of DR-TB patients being immediately accompanied and followed up with contact investigations. The MSI Foundation (as a community organization) is consistently involved in TB control activities, whether initiated by the District Health Office or aligned with programs from SR.
“What is your view on the role of TB cadres and community organizations in case detection, assisting DR-TB patients, supporting treatment and prevention, and addressing social barriers?”
“At the Puskesmas, we get information about DR-TB cases; for example, from the hospital or BKPM. Then, they contact the department, then the department asks the Puskesmas to move. Because the patient is a resident of the work area of the Puskesmas, we collaborate with cadres for the approach because they understand the character of the people better.”
Discussion
Policy standards and objectives are the fundamental aspirations of a program or policy. They are pivotal in determining the success of policy implementation. Ambiguity in the definition of measurements and objectives can cause diverse interpretations, rendering policies challenging to apply. 17 According to the Banyumas District Health Profile of 2022, the treatment coverage for all TB cases treated reached 68.1%, slightly below the target of 70%. Similarly, the treatment success rate for all TB cases in 2022 was 85.2%, falling short of the intended 90%. Additionally, the DR-TB case discovery scope in 2022 was 59.8%, below the target of 70%. These figures underscore the necessity for a more proactive and extensive approach in the upcoming program implementations to achieve the TB elimination target, thereby enhancing public health.
The figures indicating a shortfall in reaching targets signify a collective task, suggesting that the current program is not operating optimally. This responsibility extends beyond the health service sector because TB affects various facets of society. Furthermore, garnering support from the community is imperative for the program’s success. The understanding of policy standards and objectives by implementers is evident in the decline of cases, heightened treatment success, reduced instances of TB patients lost to follow-up, and diminished mortality rate. These outcomes signify the effective functioning of the program, aligning with its objectives. Realizing program objectives is contingent on the support of the Pentahelix, involving collaboration with local governments, the private sector, business entities, academia, community organizations, and the public, who are both targets and users of the program. This collaborative effort is indispensable for the holistic accomplishment of the policy’s aims.
Effective policy implementation requires sufficient resources. Inadequate quality or quantity of resources can hinder success. The correlation between well-defined objectives and the provision of robust resource support underscores the heightened probability of successful policy implementation. 18 Presidential Regulation Number 67 of 2021 mandates that both the central and regional governments are obligated to ensure the availability of a budget specifically for TB control. This directive underscores the imperative for regional governments to optimize their support for the TB program, notwithstanding the distinct disease priorities with which each may contend. Such support may materialize through the acquisition of funds via grants or collaborative initiatives with various stakeholders. 19
The sustainability of the TB program in Banyumas Regency has hitherto relied on funding derived from the Regional Budget (APBD) and financial contributions from the Global Fund. Concurrently, Special Allocation Fund (DAK) resources are designated to enhance facilities and infrastructure, encompassing medical equipment, laboratory materials, and cartridge test-monitor cartridges. In 2021, Banyumas Regency anticipated the provision of 10 TCM tools to support 4 hospitals and 6 Puskesmas, distributed across 27 sub-districts. The use of TCM adheres to the regulatory framework stipulated in Minister of Health Regulation 67 of 2016 and the National Strategy for Controlling TB, emphasizing laboratory strengthening. The availability of TCM has satisfactorily met the exigencies of Banyumas Regency, extending assistance even to patients from neighboring districts. Limited APBD funds, the potential that can be exploited is the use of village funds and support from the private sector through corporate social responsibility (CSR).
Notably, the Banyumas District Health Service has not allocated budgetary provisions for incentive funds in the implementation of the TB control program. Incentive funds are sought through Health Operational Assistance (BOK) allocations from Puskesmas, serving as remuneration for cadre activities during contact investigations or home visits. Concurrently, the community allocates funds to underwrite the responsibilities and functions of patient support and case managers engaged in assisting DR-TB, including financial provisions for aiding DR-TB patients, facilitating treatment, and monitoring defaulting cases.
The communication strategies orchestrated by the MSI community and the Health Service, in conjunction with Puskesmas, are fundamentally oriented toward engaging cadres and patient support. The primary objective is to effectively reach the targeted demographic of TB and DR-TB patients. During home visits, cadres and patient support diligently cultivate persuasive and empathetic communication approaches. This deliberate effort is aimed at fostering a mutually beneficial relationship between cadres, patient support personnel, and the families of TB patients. Pragmatically, the effectiveness of such communication is heightened when it is articulate and easily comprehensible and encompasses health education, transparency, and motivational elements.
The seamless flow of communication is methodically and consistently administered, manifesting through various channels such as home visits, as well as during treatment sessions at health centers and hospitals. The health service and the community collaborate synergistically, each reinforcing communication strategies through coordinated efforts with pertinent agencies. An exemplary initiative includes soliciting assistance for DR-TB patients. Communication channels established by the Health Service and the community are perpetuated through routine meetings. These serve multiple purposes, including the scrutiny of DR-TB data, dissemination of pertinent regulations, and collaboration on activities related to case identification through contact investigations. This structured and collaborative approach underscores the commitment to maintaining effective communication channels for the optimal management and support of TB and DR-TB patients.
At the Puskesmas level, the Health Service’s Directly Observed Treatment Short-course team is composed of a designated individual overseeing the TB program, medical practitioners serving as diagnostic providers, laboratory personnel (analysts), and pharmaceutical personnel, aligning with the provisions outlined in Minister of Health Regulation Number 67 of 2016. The MSI community in Banyumas Regency is administratively overseen by a Head of SSR, supported by financial and administrative staff, as well as SSR program personnel. Operational responsibilities at the implementation level are managed by District-based Public Private Mix case managers; DR-TB case managers; and SSR cadre coordinators, inputors, and supervising cadres, totaling approximately 70 individuals distributed across each sub-district in Banyumas Regency.
In response to the shortage of TB cadres in Banyumas Regency, the Health Service endeavors to establish the “Jides Jider – Siji Desa Siji Kader” Program. Despite setting a target of 331 cadres (one for each sub-district), only 50 have been identified. The health service collaborates with the community to address this shortfall: the work areas of Puskesmas lacking cadres are supplemented by those from the MSI community. However, this approach is deemed suboptimal. The mobilization of cadres faces challenges, including the prevailing stigma associated with TB and the inadequacy of existing incentives that do not proportionally compensate for the risks incurred while assisting TB patients. Moreover, Banyumas Regency is religious area enough, it is important to involve the public figure/relogious figure in changing the stigma, and changing communities behavior that can support TB program. By integrating cadres, cross-sector collaboration (e.g., prisons, Islamic schools), and stigma reduction through religious leaders, Banyumas tackles low DR-TB detection and cultural barriers, challenges often overlooked in centralized programs.
Interorganizational relationships are a critical determinant of policy implementation success. The Health Service actively collaborates with the community to target correctional institutions and Islamic boarding schools to track high-risk groups. Additionally, collaborative efforts extend to philanthropic institutions, academic entities, educational institutions, business enterprises, and cross-sectoral engagement with military command posts, sector police, sub-district offices, and village governments. These collaborative initiatives underscore the multifaceted approach adopted to enhance the effectiveness of TB control and support policies.
Embracing policy standards and objectives that garner widespread acceptance among policy implementers is a catalyst for the success of policy implementation. 20 Empirical findings underscore positive receptivity among implementers, buttressed by the endorsement of regional leadership, as evident in Regent Regulation Number 50 of 2018 delineating the Banyumas Regency TB Control Regional Action Plan. Since this endorsement, Puskesmas have demonstrated commitment by formulating SOPs pertinent to TB services. These SOPs encompass the delineation of TB treatment service protocols, procedural guidelines for home visits, and SOPs addressing TB patients who do not adhere to prescribed regimens. The disposition or inclination of implementers is reflective of their attitudes to the policy’s direction and the execution of its associated programs. A positive inclination is conducive to the smooth progression of policy implementation, whereas a negative one can pose impediments. The alignment of implementer attitudes with policy goals and program implementation is pivotal in determining the efficacy and success of initiatives. 21
The policy environment is intricately linked to acceptance or responsiveness—both positive and negative—each of which significantly influences the implementation process outcome. Nearly all respondents affirmed that the community’s response to TB remained largely unfavorable. 22 A prevailing perception exists associating the disease with lower economic strata, compounded by the stigma surrounding its contagious nature, prompting TB patients to conceal their health status. This reluctance extends to avoiding visits from community cadres and health professionals because TB patients often feel compelled to sequester themselves during such encounters. The apprehension of potential discovery and subsequent social ostracization intensifies these concerns.
Banyumas’ community-driven approach aligns with the WHO’s End TB Strategy pillars, that is, integrated patient-centered care, bold policies, and multisectoral collaboration, yet distinguishes itself through hyper-local innovation. While the WHO emphasizes universal health coverage and community engagement, Banyumas operationalizes this by embedding cadres and cross-sector actors (e.g., religious leaders, private sector CSR programs) into its governance framework, as evidenced by the Regent’s Action Plan (No. 50/2018). Aligned with existing research, 23 a prevailing sentiment in Tegal City is that pulmonary TB is a curse, an affliction attributed to sorcery, and a source of shame. The pervasive stigma in society toward DR-TB patients remains deeply entrenched, compelling numerous TB patients to maintain secrecy or provide misleading information when interacting with health care professionals. This prevailing social dynamic underscores the formidable challenges posed by societal perceptions and attitudes concerning TB, further underscoring the complexities that impact the transparency and cooperation of patients in divulging critical health-related information. 24
To contextualize Banyumas Regency’s findings, global comparison with other high-burden countries reveals actionable key insights for Indonesia. Mumbai’s public-private partnerships (PPPs) boost case detection, 13 suggesting Banyumas could strengthen private-sector collaboration, especially in peri-urban areas. Similarly, South Africa’s nurse-led decentralized DR-TB clinics achieve treatment adherence and reduced delays, 14 a model Banyumas might adopt to reduce reliance on hospital referrals by piloting task-shifting models at Puskesmas. Brazil’s DOT Plus program, combining DOT with the provision of conditional cash transfers, 15 offering a template for Banyumas to enhance cadre support. Although the Global Fund provides support for Banyumas, DR-TB completion rates could be raised by expanding this through a structured conditional assistance scheme. Vietnam’s mHealth technologies to Strengthen the Management of Multi-Drug-Resistant Tuberculosis, 16 highlighting a gap in Banyumas’ manual tracking and monitoring. While Banyumas excels in community engagement, integrating decentralized services, incentives, and digital innovations could address its challenges in DR-TB detection and adherence, aligning with global best practices for resource optimization.
In this study, nearly all interviewees expressed the perception of an inadequate community response to TB. The prevailing viewpoint attributes the ailment to individuals from lower economic strata, thereby contributing to the stigma surrounding TB as a contagious disease necessitating avoidance. Consequently, TB patients manifest reluctance to disclose their health status, resisting visits from community cadres and health professionals and often concealing themselves during such interactions, fueled by concerns about potential discovery and subsequent ostracization by neighbors.
Concurring with previous research, 23 a prevailing belief in Tegal City associates pulmonary TB with a curse, attributing its origin to witchcraft and deeming it a source of disgrace. The persistent societal stigma against DR-TB compels many TB patients to maintain secrecy and withhold truthful information from health care professionals. 24 These socio-cultural dynamics exert a palpable influence on policy implementation, given the inherent interconnection between health policies and societal attitudes, with society being the primary target of health policies. 25
Information gleaned from the MSI Health and Community Service indicates that a substantial proportion of TB patients hail from communities with lower-middle income levels. This accentuates the economic strain on families, particularly when the DR-TB patient has the role of family head or primary breadwinner. Research underscores the catastrophic financial burden imposed by TB, resulting in a significant decline in patient income, with patients of lower income dedicating 14% of household earnings to TB treatment. This economic burden poses a tangible risk: DR-TB patients may opt to forgo treatment to avert economic hardships, leading to diminished income and even loss of productivity, including potential job displacement due to the exigencies of DR-TB treatment. 26
Concerning the political landscape, Banyumas Regency exhibits a notably robust commitment, evident through the adoption of the Strategic and Performance Management framework within the health sector. This commitment is further underscored by the enactment of Banyumas Regency Regent Regulation Number 50 of 2018, delineating the Regional Action Plans for Tuberculosis Management in Banyumas Regency for 2018–2023. Additionally, the commitment of Puskesmas and their personnel spans various sectors, exemplified by the formal endorsement of a collective commitment to TB control within the respective work areas. This commitment is articulated through joint agreements involving the Puskesmas, sub-district administrators and staff, and sub-district military units and police stations. These concerted efforts underscore the influential role of commitment in providing TB support and treatment, thereby influencing the optimal implementation of TB control policies. 27
Community engagement in TB control strategies aligns with the overarching vision of the Ministry of Health as part of its endeavors to foster self-reliant and healthy communities. This commitment is further enshrined in Minister of Health Regulation 67 of 2016. The multifaceted nature of TB control, particularly the management of DR-TB, necessitates the collaborative involvement of various stakeholders. These include TB program managers at the Provincial, Regency, and City Health Services; personnel from Puskesmas; community case managers; patient support teams; and cadres. 28 The imperative lies in continually elevating the awareness, willingness, and motivation of DR-TB patients, given their proclivity to seclude themselves from social environments. Cadres and communities are pivotal in achieving heightened case discovery through meticulous contact investigations and outreach initiatives. Their responsibilities extend to providing education and fostering empathetic communication with DR-TB patients and their families, delivering social support to mitigate stigma, and offering economic assistance through community-provided enablers funded by the Global Fund to Fight AIDS, TB, and Malaria (GF-ATM). The overarching objective is to empower DR-TB patients to persist in seeking treatment through outreach to health facilities.
An additional dimension of community engagement involves reinforcing the coordination between case managers in hospitals and patient support teams, hospitals, Health Offices, and Puskesmas. This collaboration aims to streamline service flows, rendering the process more accessible for DR-TB patients. Simultaneously, efforts are directed at expanding the support network for sustained assistance to DR-TB patients, particularly those facing socioeconomic constraints. This concerted approach underscores the commitment to comprehensive and sustainable support mechanisms for individuals with DR-TB, especially those confronting limited socioeconomic conditions. This study’s limitation is its use of a purposive sampling technique, precluding the generalizability of the results to the entire population. The qualitative approach, while robust in capturing stakeholder experiences, underscores the need for future research with expanded data access to corroborate findings through quantitative indicators (e.g., treatment success rates by cadre type). Such efforts would strengthen policy evaluations and provide a more holistic understanding of the program’s impact.
The findings of this study have several policy implications. First, despite the emphasis on community engagement in current national policies, implementation remains uneven across districts due to cadre shortages and inconsistencies in incentive structures. This discrepancy could be addressed by reevaluating the allocation of village funds for health or by mandating minimum TB engagement targets in regional budgets. Second, a national policy initiative involving the Ministry of Health and Ministry of Communication is needed to support the integration of digital tools for contact tracing and treatment monitoring. Third, to address the persistent stigma surrounding TB, particularly a major barrier to early detection, policies should be revised to formally and systematically engage religious leaders and informal health workers. Lastly, the continued reliance on donor funding (e.g., the Global Fund) raises concerns regarding sustainability. Therefore, national TB policy should begin transitioning toward co-financing schemes that combine government contributions with support from the private sector.
Conclusion
The implementation of TB control policies has been a significant step forward in the fight against this disease. However, the journey is far from over since the challenges that persist are multifaceted and complex. Optimization necessitates enhanced communication, support, and coordination with pertinent stakeholders. Notably, challenges persist, including a restricted cadre pool and the absence of on-the-job training, particularly regarding motivational incentives and transportation assistance for TB cadres. The community’s current stage of implementation lacks discernible innovations to fortify TB control initiatives. The enduring stigma surrounding TB remains, as evidenced by the reluctance of numerous DR-TB patients to seek treatment, contributing to a climate where avoidance is prevalent. As integral partners of the Health Office and Puskesmas, communities can introduce innovative strategies, empowering survivors to regain efficiency and productivity. Furthermore, an imperative exists to explore sustainable assistance options grounded in evidence-based practices, facilitating the DR-TB patient accessibility of health facilities for treatment completion. A critical aspect is a thorough examination of the roles played by cadres and communities from the perspective of DR-TB patients or survivors. This perspective is indispensable for obtaining an authentic portrayal of program targets, ensuring that interventions are aligned with the needs and experiences of those affected by DR-TB. Therefore, while the implementation of TB control policies is a commendable achievement, more work needs to be done. Addressing these challenges requires a concerted effort from all stakeholders, including government agencies, healthcare providers, and the community at large. The GF-ATM appears futile, serving as a warning signal to global health policymakers. To develop innovative and community-responsive interventions, it is imperative that government agencies, healthcare providers, private sector actors, civil society organizations, and local communities engage in coordinated multisectoral collaboration.
Footnotes
Appendix
In-depth interview matrix of eight informants
| No. | Variables | Informant 1 | Informant 2 | Informant 3 | Informant 4 |
| 1. | Policy standards and objectives | - The number of TB patients decreased, and many were cured | - Banyumas aims to be TB-free | - DR-TB cases are declining | - TB cases in Banyumas are decreasing |
| 2. | Resources a. Funding |
— | — | — | — |
| b. Facilities | Medicine is always sufficient | — | TB treatment facilities are good | — | |
| c. Incentives | — | - Ever received money (transport money) from the community health center (puskesmas) | - There is funding (reward) from MSI foundation for every contact investigation (suspect tracking) and every report made by patient support | - There is a reward every month because the cadre (patient support) makes a report on the condition of TB patients from the beginning of treatment to the completion of treatment | |
| 3. | Communication among implementers | - Socialization by health workers from the community health center (puskesmas) | - Routine community health center activities | - Information comes from the chairman of the MSI foundation of Banyumas district then socialized to cadres and patient support | - Get information from MSI |
| 4. | Characteristics of the implementing agencies | — | — | — | — |
| 5. | Disposition of the implementers | — | — | — | — |
| 6. | Social, economic, and political environment | — | — | — | — |
| 7. | a. Policy implementation | - The implementation of TB eradication involves cadres, TB officer health center (petugas puskesmas), and patient families |
- All stakeholders participated including the health office, puskesmas, community leaders, lurah, RT/RW, cadres. |
- DR-TB cases are decreasing and more are coming from outside Banyumas district |
- The implementation of TB control in Banyumas district is good, there are many cadres both from the village (assisted by puskesmas) and cadres from the MSI foundation |
| b. Community role in case finding | - Some are supportive and some are less supportive |
- There are screening activities, counseling and socialization, visits to find suspects. Suspect data is obtained from health centers and hospitals | - Case tracking starts with data from health centres and hospitals, then a contact investigation is carried out to find out who the people around the patient are and screening is carried out |
- RO TB cadres obtain data/information about the patient from the hospital, then visit the patient’s home to ask for approval for assistance, facilitate if there are complaints during treatment which will be conveyed by patient support to health workers at the community health center or health workers at the hospital |
|
| No. | Variables | Informant 1 | Informant 2 | Informant 3 | Informant 4 |
| c. Community role in assisting DR-TB patients | - Patients must be forced to go to the puskesmas with the aim of starting treatment immediately and recovering. Sometimes they must be accompanied by cadres so that they want to go to the puskesmas |
- If the patient has symptoms, they will be brought to the health center, then laboratory tests are carried out, if the results are positive, the cadres are informed by the health center staff so that regular visits and monitoring of taking medicine are carried out |
- Some suspects have the awareness to come to the health center on their own, but there are also those who deny it, so they have to be persuaded slowly and gently |
- Patients are finally willing to seek treatment when their bodies show symptoms of TB such as continuous coughing, weight loss, and positive laboratory test results |
|
| d. Community role in treatment assistance | - Patients are supervised by their families and cadres, but cadres cannot supervise every day, but are visited as schedule |
- Medication Supervision (PMO) is carried out by the patients family, cadres do not supervise every day, supervision once a week in a month. Cadre reminds patients via phone or whatsapp chat to be educated |
- Cadres remind patients to have regular check-ups at the hospital, help prepare the necessary requirements |
- The cadres remind TB patients about their treatment schedule, information on transportation costs from the MSI Foundation, and checking their control cards |
|
| e. Community role in TB Prevention Therapy (TPT) | - The target is toddlers who live in the same house with TB patients. the patient’s family is advised to bring the toddler to the health center to be examined, if negative directly given TPT by the health center | - The target of giving TPT is for TB patients who have toddlers when examined on the Mantoux test the results are negative. however, if a patient is treated positively |
- There are also families who do not want if their children are given TPT | - Cadres also suggested for patients with children under five to be given TPT by the health center. But not all patients have toddlers. |
|
| f. Social Support and Stigma Reduction | - The patient is afraid that his status will be discovered by neighbors when cadres visit. There are still people who stay away |
- Giving socialization that TB is not a hereditary disease, not a curse, because infectious diseases must be vigilant |
- Provide socialization of the causes and Prevention of TB, and ask the surrounding community. not to isolate and stay away from TB patients |
- Strictly maintain patient privacy, remind patients to wear masks |
|
| No. | Variables | Informant 5 | Informant 6 | Informant 7 | Informant 8 |
| 1. | Policy standards and objectives | - Regulation of the Minister of Health of the Republic of Indonesia Number 67 of 2016 |
- Presidential Regulation No. 67 of 2021 has been announced |
- Policies such as the Minister of Health Regulation and Presidential Regulation have been quite effective, with quick responses from all stakeholders | - Banyumas Regent Regulation No. 50 of 2018 concerning the Banyumas Regency Tuberculosis Action Plan for 2018–2023 |
| 2. | Resources |
- TB medication is funded by the central government, but no specific TB budget exists | - TB funds come from state revenue and health operational assistance (BOK) | - The MSI Foundation receives Global Fund support and provides rewards to cadres | - TB budgets come from state, regional, and Global Fund sources |
| b. Facilities | - TB testing facilities are adequate, supported by Purwokerto Barat Health Center |
- Facilities are good, but internet access is occasionally disrupted | - Hospitals and TCM machines are available | - Banyumas has TCM kits distributed across 5 hospitals and 6 health centers |
|
| c. Incentives | - Health centres provide transportation funds for cadres | - Cadres receive transport assistance | - MSI cadres receive monetary rewards and certificates | - Cadres receive petrol reimbursements | |
| 3. | Communication among implementers |
- Monthly MICA meetings are held between the Health Office and health centers. Cross-sector meetings discuss performance | - Presidential Regulation No. 67/2021 and Minister of Health Regulation No. 67/2016 were disseminated |
- The applicable regulations have been effective in Banyumas Regency |
- Regional Action Plans are formulated, monitored, and involve community leaders |
| b. Consistency | - The Health Office updates health centers via meetings; cadres receive training | - Regular meetings ensure policy alignment | - Information is coordinated with the Health Office | - Evaluations confirm implementers receive updates | |
| 4. | Characteristics of the implementing agencies | - One nurse manages TB programmes and opens TB clinics. Jides Jider (one village, one cadre) is active but not optimal | - A nurse oversees TB services and accompanies cadres. Jides Jider is established but underutilized | - MSI coordinates with the Health Office for case finding | - The TB programme has one lead, supported by Global Fund staff. Jides Jider targets 331 cadres (currently 50) |
| 5. | Disposition of the implementers | - Health centers and cross-sector actors (police, military) support TB programmes | - All sectors are supportive. TB is prioritized in Minimum Service Standards (SPM) | - MSI supports government efforts to eradicate DR-TB | - Leadership directives are included in SPM and RAD |
| 6. | Social, economic, and political environment | - TB is stigmatized; healthcare workers need accurate information | - Patients face economic challenges (e.g., transport costs) | - Patients avoid health workers due to shame | Stigma persists, and community knowledge gaps require education |
| 7. | a. Policy Implementation | Success is suboptimal due to lost-to-follow-up cases, but all parties are supportive | Community health centers contribute to TB programmes with cross-sector help | MSI assigns case managers to hospitals for early detection | The Regent supports TB programmes via SPM and RAD, involving activist groups |
| b. Community role in case finding | Health centers receive DR-TB case data from hospitals/BKPM and direct cadres to visit | - Cadres facilitate patient visits; mass screenings are conducted | - MSI case managers coordinate with the Health Office for tracking | — | |
| c. Community role in assisting DR-TB patients | - TB RO patients arrive at health facilities in severe condition, coughing up blood, skin and bones. It is rare for TB RO patients to arrive in good health, as most deny their condition and lack awareness of the need for immediate treatment | - TB RO patients are generally in severe condition, with worsening symptoms. There are one or two healthy patients, but on average they are in poor condition and are admitted to the hospital after being diagnosed with RO | - Patients come to health facilities when they are already seriously ill |
— | |
| d. Community role in treatment assistance | - Medication supervisors (PMOs) are family members. Long treatment (1+ years) requires PMO support | - Initial PMOs were lacking; household members now assist | - Once the patient has been confirmed, an initial visit is made to begin treatment. The patient then undergoes baseline examinations with several specialists to determine the appropriate type of treatment, after which treatment is provided until completion |
— | |
| e. Community role in TB Prevention Therapy (TPT) | Toddlers in contact with TB patients undergo Mantoux tests; TPT is given if negative | TPT targets asymptomatic toddlers after negative Mantoux/X-ray results | - Not all health centers provide TPT | - TPT was initially rejected but now uses shorter regimens (3HR/3HP) | |
| f. Social Support and Stigma Reduction | - Stigma persists; health workers educate communities. Cross-sector support exists | - Village heads and religious leaders combat stigma | - Patients hide their status due to fear. Economic support is sought via Baznas/Lazismuh | - Lack of budget for psychosocial support; cooperation with PERKIM for housing/nutrition aid |
Acknowledgements
The authors would like to acknowledge the Banyumas Regency Health Office, community health centers, and Mentari Sehat Indonesia Foundation for their valuable contributions in this study. This study was supported by the research grant from the Directorate of Research and Community Engagement of Universitas Indonesia. The funders had no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.
Ethical considerations
The Institutional Review Board (IRB) of Universitas Indonesia provided ethical review approval (206/UN2.F10.D11/PPM.00.02/2023).
Consent to participate
Informed consent was obtained from all subjects involved in the study.
Author contributions
MM and HA, conceptualization; MM, data acquisition and curation; MM and HA, methodology; MM, FMH, and HA, interpretation; FMH, AB, and HA, manuscript drafting; MM, FMH, AB, NM, and HA, manuscript review and editing. All authors read and approved the final manuscript.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the Directorate of Research and Community Engagement of Universitas Indonesia, grant number NKB-715/UN2.RST/HKP.05.00/2023. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data availability statement
Data are available upon request.