Identifying Gaps in the Multidrug-Resistant Tuberculosis (MDR-TB) Cascade of Care: Barriers and Improvement Opportunities in North Maluku, Indonesia

Background: The Multidrug-Resistant-Tuberculosis (MDR-TB) Cascade of Care includes MDR-TB treatments from suspicion to completion. Implementation gaps can lower treatment success. This study aimed to identify gap causes and opportunities to improve MDR-TB treatment in North Maluku, Indonesia Methods: To identify gaps, we conducted in-depth interviews and focus group discussions with health workers at Puskesmas (Indonesian government's primary healthcare centers) and hospitals, MDR-TB patients, and patients’ families. Thematic analysis was conducted using the Consolidated Framework for Implementation Research (CFIR) for health workersand the health belief model (HBM) approach for patients and their families. Results: Significant gaps were found in all MDR-TB services in North Maluku, especially in health facility services. The gaps occurred due to the absence of Standard Operating Procedures (SOPs) and technical guidelines, discrepancy between these guidelines with MDR-TB services at Puskesmas, limited operational funds, and management teams. Other barriers included a lack of TB knowledge among health workers, errors in filling out the TB information system, stigma towards MDR-TB patients, limited health workers for home services, and assignment of officers without training. Patients and their families faced barriers, including lack of knowledge about MDR-TB, use of traditional medicine, belief in magic, delay in seeking health services, and complaints about hospital service times. Conclusions: Improvements should focus on increasing MDR-TB knowledge among health workers and community members, improving management of MDR-TB services, and stregnthening communication and coordination between Puskesmas and hospitals to manage MDR-TB effectively. Keywords: Cascade of Care, MDR-TB, Health barrier, Healthcare gaps, Patients perception