The shifting landscape of private healthcare providers before and during the COVID-19 pandemic: Lessons to strengthen the private sectors engagement for future pandemic and tuberculosis care

Abstract

Introduction: COVID-19 pandemic changed many aspects of healthcare services and deliveries, including among private healthcare providers (i.e., private healthcare facilities [HCFs] and private practitioners [PPs]). We aimed to compare the spatial distribution of private providers and describe changes in characteristics and services offered during and before the COVID-19 pandemic, and explore the tuberculosis (TB) and COVID-19-related services offered by the private sector in Bandung, Indonesia.

Methods: A cross-sectional study with historical comparison was conducted in 36 randomly selected community health centers areas (locally referred to as Puskesmas) in Bandung, Indonesia, during the COVID-19 pandemic from 5th April 2021 - 27th December 2021. Data pertaining to before the COVID-19 pandemic was abstracted from a similar survey conducted in 2017 (i.e., INSTEP study). We obtained latitude and longitude coordinates of private healthcare providers and then compared the geographical spread with data collected for INSTEP study. We also compared characteristics of, and services provided by private healthcare providers interviewed during the COVID-19 pandemic with those previously interviewed for INSTEP study. Differences were summarized using descriptive and bivariate analyses.

Results: From April-December 2021, we surveyed 367 private HCFs and interviewed 637 PPs. Compared to INSTEP study data, the number of operating HCFs was reduced by 3% during the COVID-19 pandemic (401 vs. 412 before COVID-19), although we observed increases in laboratory service (37.8% increase), x-ray service (66.7% increase), and pharmacy (18.1% increase). Among a subset of private HCFs managing patients with respiratory tract infection symptoms, a quarter (60/235, 25.3%) indicated that they had to close their facilities in response to the emerging situation during the COVID-19 pandemic. For PPs, the number of practicing PPs was reduced by 7% during the COVID-19 pandemic (872 vs. 936 before COVID-19). Interestingly, the number of practicing PPs encountering patients with TB disease increased during the COVID-19 pandemic (42.9% vs. 35.7% before COVID-19, p = 0.008).

Conclusion: This study confirmed that the COVID-19 pandemic adversely impacted health care service deliveries in private sectors, largely marked by closures and shortened business hours. However, the increased service capacities (laboratory and pharmacy), as well as significant increase in the number of patients cared for TB disease by PPs during the COVID-19 pandemic, made a more compelling case to further the implementation of public-private mix model for TB care in Indonesia.

Fig 1. Flowchart depicting the flow and inclusion of private healthcare facilities mapped and interviewed in Bandung during COVET study period (5^th Apr 2021– 24^th Dec 2021).

We identified 394 HCFs from our prior study (INSTEP study) conducted in 2017; of these, 132 were not operating during the COVET study mapping process. There were 247 HCFs that we newly identified during COVET study (and these were not identified during INSTEP study), but 108 were not operating at the time of COVET study mapping process. Of 401 operating HCFs, we successfully interviewed 367, which were included in our primary analyses.

Fig 2. Flowchart depicting the flow and inclusion of private practitioners mapped and interviewed in Bandung during COVET studies period (15^th May 2021 – 27^th Dec).

We identified 807 PPs from our prior study (INSTEP study) conducted in 2017; of these, 396 were not operating during the COVET study mapping process. There were 555 PPs that we newly identified during COVET study (and these were not identified during INSTEP study), but 94 were not operating at the time of COVET study mapping process. Of 872 operating PPs, we successfully interviewed 637, which were included in our primary analyses.

Fig 3

Maps of private healthcare facilities’ density and TB Notifications rates relative to population size in included study areas during INSTEP (A) and COVET (B) study periods, Bandung [26]. The same area as in the INSTEP study, but has experienced an expansion in the number of health centers compared to the INSTEP study. There were 36 study areas included in COVET study. The blue color gradation shows the density of healthcare facilities relative to the population size; darker shades of blue indicate areas with higher HCFs density (i.e., the area has more operating healthcare facilities per 100,000 population). The orange dots with differing sizes indicate the magnitude of TB notification rates in the study areas. Orange dashed-line marks the downtown Bandung area, which is more crowded compared to other study areas. Printed texts are the names of selected Community Health Centers (CHCs) study areas.

Fig 4. Changes in services provided by private healthcare facilities interviewed during INSTEP and COVET studies.

Percent changes (presented in %) were calculated by subtracting the absolute numbers observed during COVET and INSTEP study then divided by the number observed during INSTEP study.

Fig 5

Absolute numbers and median of patients diagnosed with (A) and treated for (B) tuberculosis by private practitioners in the past month during COVET study.