Impact of the COVID-19 pandemic on quality of tuberculosis care in private facilities in Bandung, Indonesia

Background: Indonesia has the second highest incidence of tuberculosis (TB) in the world. 74% of people with TB in Indonesia first accessed the private health sector when seeking care for their TB symptoms, although the private sector provided only 18% of TB notifications. Indonesia was also one of the global hotspots for the COVID-19 pandemic and COVID-19 led to further disruptions in the health system. However, little is known about private sector care for TB in Indonesia after the emergence of COVID-19. There is therefore an urgent need to understand existing and widening gaps in the quality of TB care. Using unannounced standardized patients (SPs) visits to private providers, we aimed to measure quality of TB care during the COVID-19 pandemic.Methods: A cross-sectional study was conducted using SPs in Bandung City, West Java, Indonesia with 292 private sector providers. Ten SPs completed 292 visits between 9 July 2021 and 21 January 2022. All SPs were trained to present a presumptive TB case (cough for 2–3 weeks). Results were compared to SP surveys conducted in the same geographical area during 2018–19, before the onset of COVID-19. Results: Overall, 35% (95% confidence interval (CI): 29.2–40.4%) of visits were managed correctly according to the 2016 Indonesian national TB guidelines. More than two-thirds of SPs were prescribed unnecessary antibiotics (68%, 95% CI: 62.1–73.1%) and 27% were prescribed steroids (95% CI: 21.8–32.2%). Correct TB management was associated with more history questions asked (aOR: 1.07, 95% CI: 1.02–1.13, p=0.004) and more cardinal TB symptoms inquired (aOR: 2.78, 95% CI: 1.82–4.23, p<0.001). Comparing SP visits conducted before and during the COVID-19 pandemic uncovered no major differences in the clinical management of presumptive TB patients apart from an increase in likelihood of providers conducting temperature checks (aOR: 8.05, 95% CI: 2.96–21.9, p<0.001) and a decrease in likelihood of providers conducting throat examinations (aOR 0.16, 95% CI: 0.06–0.41, p = 0.002) during the pandemic.Conclusion: Findings show sub-optimal management of SPs with presumptive TB by private providers in Bandung, but no significant changes in quality of care during COVID-19, compared to pre-pandemic SP surveys. As TB notifications declined in Indonesia during COVID-19, there remains an urgent need to increase private provider engagement in Indonesia to find people who have been missed and improve quality of care