Joining the DOTS in Bali: private practitioners perceptions of tuberculosis control

Transcription

1 INT J TUBERC LUNG DIS 10(9): The Union Joining the DOTS in Bali: private practitioners perceptions of tuberculosis control R. E. Watkins,* K. T. Feeney,* O. Abu Bakar, A. J. Plant* * Australian Biosecurity Cooperative Research Centre, Division of Health Sciences, Curtin University of Technology, Perth, Australia; Jl. Seroja Gang Nyuh Gading Denpasar, Bali, Indonesia SUMMARY SETTING: The Indonesian island of Bali has both a national public tuberculosis (TB) programme and a significant private sector that provides treatment for patients with TB. OBJECTIVE: To explore private practitioners perceptions of barriers to the treatment of patients with TB in Bali to inform strategies for future programme development. DESIGN: Semi-structured interviews were conducted with private practitioners who treated TB patients in their private practice. RESULTS: The main barriers to improved TB control in Bali identified by private practitioners reflect difficulties encountered within the following four areas: patient nonadherence to treatment, limitations of public services, public-private integration and limitations of private services. Private practitioners identified the need for improvements in the level of community education regarding TB, the degree of public-private interaction, the quality of diagnostic services and practitioner access to training. CONCLUSION: This study identified both strengths and weaknesses for TB control in the private sector, as well as considerable variations in perceptions and practice among private practitioners. The development of strategies to address these difficulties and utilise the inherent strengths of both public and private practitioners will be essential for improved service provision and TB control in Bali. KEY WORDS: tuberculosis; Bali; qualitative; private practitioners TUBERCULOSIS (TB) remains a significant contributor to global morbidity and mortality, and Indonesia has one of the highest burdens of TB in the world. 1 The World Health Organization (WHO) has highlighted the importance of collaboration between public and private sector TB service providers in high-burden countries. 1,2 Indonesia has a significant private health sector that accounts for approximately 63% of total national health expenditure 3 and is believed to manage approximately one third of all TB patients. 4 Private practitioners can have a positive impact on TB control if properly engaged. Private practitioners are often the first point of contact for many TB patients; however, research suggests that TB is often treated inadequately in the private sector, leading to multidrug-resistant tuberculosis (MDR-TB) and chronic transmitters of TB that can lead to an increase in TB incidence. 5 Initial work in Indonesia suggests that the practices of private practitioners in the management of TB are far from ideal. 4 Current WHO recommendations include the need for private practitioners to be engaged in national TB strategies, 1 and other work supports the involvement of the private sector as an essential component of successful implementation of TB control programmes in Indonesia. 4,6 Locally specific strategies are required to effectively involve private practitioners in TB control. 5,7 The present study aimed to investigate private practitioners perceptions of barriers to TB control efforts in Bali, Indonesia. METHODS A qualitative descriptive approach was used as the methodological framework for this research. 8 Study context The WHO-recommended DOTS strategy is reported to cover 98% of the population in Indonesia. 1 The National Tuberculosis Programme (NTP) is run from local clinics, called puskesmas, which provide free medication for patients with smear-positive TB. Patients can also receive free medication if diagnosis is based on evidence of TB on chest radiograph (CXR). Correspondence to: Dr Rochelle Watkins, Australian Biosecurity Cooperative Research Centre, Division of Health Sciences, Curtin University of Technology, GPO Box U1987, Perth, Western Australia Tel: ( 61) Fax: ( 61) Rochelle.Watkins@curtin.edu.au Article submitted 28 April Final version accepted 15 May 2006.

2 TB treatment by private practitioners in Bali 989 Since 2001, the NTP in Bali has been progressing towards the expansion of the DOTS system to include hospitals, and the programme is currently being expanded to include private practitioners. The expansion to include private practitioners had not directly involved the private practitioners interviewed at the time of data collection. Data collection Private practitioners are defined within this study as medically trained doctors who perform some private fee-for-service practice outside the public health service. Purposive sampling methods were used to recruit private practitioners for this study to obtain a broad range of information-rich respondents. This included the recruitment of doctors who worked both in mixed private-public practice and exclusive private practice, as well as those from both generalist and specialist backgrounds. Interviews were performed in September A semi-structured interview format was used to encourage participants to discuss issues in relation to TB control in Bali, including perceived barriers to more effective TB control. The use of open-ended questions enabled participants to direct the course of the interview. Taped interviews were conducted, with the participants consent, in English and/or Bahasa Indonesian. Sixteen of the 22 (73%) interviews were conducted exclusively in English. A native Bahasa Indonesian/ Bali-speaking translator initially translated the Bahasa Indonesian interviews. This initial translation was transcribed after the interview for initial analysis. The audio-tapes were later translated and transcribed by a native English-speaking translator to check the accuracy of the initial translation. The information collected was de-identified to ensure anonymity. Data analysis Interview transcripts were coded to identify major themes representing the perceptions of private practitioners about barriers to TB control in Bali. Coding involved line by line analysis to identify themes and their inter-relationships. Data collection and content analysis were performed simultaneously in an iterative fashion. This provided guidance during the study for the selection of participants and questions for subsequent interviews, and allowed identification of theoretical saturation. The analysis was first performed by the second author and then independently analysed by the first author to ensure descriptive validity and consistency. No significant differences were noted between the themes derived from these analyses. De-identified, representative statements are included in the results to illustrate the main themes identified. Participation in the study was voluntary, and written informed consent was obtained prior to participation. Ethics approval was obtained from the Human Research Ethics Committee of Curtin University of Technology, Perth, Australia. RESULTS Twenty-two private practitioners participated in the study, 10 of whom were female. The mean age of the participants was 47 years and all were born in Bali. All interviewees completed their undergraduate medical training in Bali, and all participated in some form of for-profit, fee-for-service private practice. The range of private practitioners interviewed included general practitioners (n 7) and other specialists who treated TB patients within their private practice (n 15). The majority of interviewees worked within a mixed private-public setting (n 11), seven participants worked only in private practice, and the remaining four worked in both private practice and for a not-for-profit non-governmental organisation. All study participants had a mainly urban practice. The main barriers to improved TB control in Bali that were identified by private practitioners reflected difficulties encountered within the following four areas: patient non-adherence to treatment, limitations of public services, public-private integration and limitations of private services. These areas are described in more detail in the following sections. Non-adherence to treatment Low levels of patient adherence to treatment were described by all participants as a major difficulty and as the main problem with treating TB in private practice. The failure of patients to adhere to treatment was most commonly attributed to poor levels of awareness about TB within the general population, including both awareness of presenting symptoms and understanding how to prevent the disease. Poor awareness of TB was considered to explain why patients often presented late with advanced TB that was difficult to treat, and to contribute to the stigmatisation of TB in the community: There is a myth about TB in the population... that TB is something like a hereditary disease, it is not infectious, and many people still feel ashamed if they get TB because it is a poor person s disease. The stigma associated with TB was reported to be worst among people of lower socio-economic status, who were considered to have the greatest difficulty adhering to treatment. Poor adherence to treatment was also attributed to the side effects of the medications, an improvement in symptoms and the long duration of treatment required. However, several participants could not understand why some patients did not adhere to therapy when free medication was provided by the public system:

3 990 The International Journal of Tuberculosis and Lung Disease When I find the case the biggest problem is the compliance... Usually the patients don t feel comfortable with medications, such as nausea and headaches, so they stop their treatment because of side effects, or they might start feeling better after only two months so they will stop taking medication. Private practitioners generally believed that responsibility for completion of therapy lay with patients and their families, stating that they don t obey the rules, never come back and they don t particularly want to follow the TB programme. The high rate of TB in Bali was attributed to the effects of nonadherence to treatment. Limitations of public services Private practitioners believed that there were a number of specific barriers to successful TB control associated with the existing public health services. The lack of systematic health promotion efforts aimed at increasing community awareness of TB was widely identified as a major problem: First, education, first let people know about TB properly, how to control TB by themselves and understand how it influences others, signs and symptoms, and let them feel free to tell what the problem [is] in themselves or their family to the doctor... many people lack information about TB... they do not know they have the symptoms of TB. The quality of TB treatment and control services from public clinics and hospitals was given a mixed assessment by the interviewees. Several private practitioners expressed confidence in the quality of services provided by puskesmas and public hospitals and would refer patients with suspected or proven TB to these services; however, they also admitted that they tended to refer wealthier patients or complicated presentations to private respiratory specialists. Other participants, particularly older doctors with experience working in the public sector or receiving patients from public clinics in their private practice, reported the quality of care from puskesmas to be a major impediment to TB control. Participants believed that as a result of a poor level of training of puskesmas staff, DOTS was not well done as staff don t follow the steps that should be followed and don t understand about compliance, resulting in low cure rates: It [the DOTS system] is not working in practice, just in theory, but in the field they do not use it properly all the time. Private practitioners reported that a significant proportion of their patients had first been diagnosed and treated at a puskesmas, but were dissatisfied with the care they had received. Having treatment provided by a single doctor was reported to increase patient confidence in their care and lead to improved adherence to treatment, and puskesmas were considered to provide poor continuity of treatment: They are not really satisfied with the doctors in the puskesmas, because the doctors, they didn t explain what is TB, how to treat, they didn t explain it, they [patients] stopped... the medicine and what happens. Interviewees generally perceived private diagnostic services as superior to public laboratory services, and the standard of public laboratory and radiological services was reported to be poor: Usually the result is much better than the public hospital and we can see clearly whether this is TB or not. Interviewees understood that the current requirement for free TB medication was a positive sputum diagnosis, except when TB was diagnosed by a specialist. As specialist consultations were not considered to be widely accessible, the poor quality of the available microbiological diagnostic services was seen as a major barrier to accurate diagnosis and accessing free treatment. Many interviewees believed that if a positive sputum diagnosis is required for access to free treatment, improved diagnostic capabilities are needed: The problem is the government project needs the positive sputum for TB, but we mostly cannot get that. Many [factors] can influence the positive sputum diagnosis... if we can have the culture, for example, maybe we can increase the positive rate... And also to train the people to examine the specimen... it comes back again with the difficulties to get access to free treatment... I talked to the doctors at the Department of Health, I say we know what is a TB patient but I don t have sputum positive and I ask if I can refer for the free medicine, but they say they have to report the medication with the sputum test, that is the difficulty, not because they don t want to or they don t agree with our diagnosis. Concerns were also expressed over the quality of the generic medications provided by the public clinics as they are very cheap and... the concentration is not the same. These were perceived as being of a lower quality than branded medicines that are not available free of charge: I don t use generic, it costs money, but the results are very good. The branded medications were believed to be associated with better treatment outcomes and reduced side effects. Interviewees also reported that patients did not trust the effectiveness of generic medications dispensed from puskesmas, but most did not have a choice in taking them due to the costs involved:... all people doesn t want to take the generic, because the tablet looks cheap, only small tablet, very limited, not so many kinds of medicine at the puskesmas, just the standard. So some patients will say whatever their illness, the treatment is the same... That is one reason why they don t believe... their health will be improved or cured from the puskesmas.

4 TB treatment by private practitioners in Bali 991 Interviewees believed that the inability to access free treatment from puskesmas for people who are not registered local residents was another important limitation of the current public system. Public-private integration The level of integration of the private and public sectors was found to be mixed. Interviewees who had some experience within the public health service were better informed about current government initiatives and the resources available, and were able to successfully integrate their private patients with public programmes and make use of resources such as free medication when necessary. Some private practitioners who worked within a mixed private-public practice recognised the advantages offered by the public services with respect to promoting adherence to treatment, and would diagnose patients within their private practice and then refer them to public services to receive free supervised treatment: They can get free medication from the puskesmas, the treatment is good there. There is a field worker who uses the DOTS system, so the field worker will go to the house and see whether they take the medication or not... I explain to the patient they need to go to the puskesmas and they need to complete the medication. Private practitioners with more limited exposure to the public system generally described less integration with the public system and had poorer knowledge about what the public system offered and how it might be utilised within their practice. Private practitioners who had little interaction with the public sector would not routinely offer their patients free medications or other services from the public programmes, and often had a lower level of trust in the level of service provided by the public programme. These private practitioners also reported difficulties with accessing continuing medical education: In Bali, we don t have guidelines how to diagnose TB... [if I am unsure of the diagnosis] I usually refer to the specialists... I am not really happy with the government hospitals as they do not have strict guidelines on how to diagnose TB... it is not good enough for me. Limitations of private services Interviewees identified several deficiencies in the management of TB patients within the private sector. The lack of capacity for private practitioners to successfully monitor patient treatment was considered a major limitation of the services offered. This lack of capacity for patient follow-up was associated with a general lack of resources, poor monitoring systems and a lack of time to dedicate to education and follow-up: If the patient doesn t show up it means I have lost the patient. It is not easy to follow them up... because in private [practice] we don t have a field worker. You don t have time to call the patient or find the patient. This is the big big problem... if they don t come we just leave it. We have so many things to do. A number of private practitioners did not adhere to established diagnostic requirements when treating patients for suspected TB. These participants tended to be specialists who were prescribing private medication. Non-adherence to accepted clinical guidelines for diagnosis was attributed to difficulties with finding positive sputum specimens and their confidence in their ability to clinically diagnose TB without the need for positive test results: Usually we [need] the chest X-ray, and acid-fast bacilli, [but] it is hard to find acid-fast bacilli... so we treat the disease and if they get better we think it is tuberculosis. I assume clinical is enough, very simple really. A small number of interviewees identified two additional influences in the private setting that may adversely affect TB treatment outcomes. These were that patients would only continue to be treated within private practice if they had the capacity to pay for treatment, and that pharmacy incentives encouraged private practitioners to use privately prescribed medicines: Some of the doctors may make a prescription for patients who don t really need it, like vitamins or something, because they want to get commission from the pharmacy and you know that it will make the cost of the patients fees go up. But this is the reality of the situation in our country because the income is very low and they live off the money from their private practice and the pharmacy. We know that some of the private doctors are really money orientated and they don t want to use the generic medication from the government... I hear that doctors will get commissions for doing special prescriptions... but in the end it depends upon the honesty and personality of the doctor. DISCUSSION This study describes private practitioners perceptions of the main barriers to improved TB control in Bali, and identifies four main areas of reported difficulty: patient non-adherence to treatment, limitations of public health services, public-private integration and limitations of private services. Patient non-adherence to treatment was considered to be one of the most important contributors to poor TB control in Bali. The lack of health promotion efforts by the government to raise the level of community awareness about TB and the treatment available was thought to underlie difficulties with the stigmatisation of TB, late presentation for treatment and treatment non-adherence. These factors have also been found to be important difficulties facing practitioners in the public sector in Bali, 6 highlighting the common nature of the main challenges faced by TB treatment

5 992 The International Journal of Tuberculosis and Lung Disease providers. This finding suggests that the further development of more effective health promotion efforts to raise awareness about TB in the community and promote adherence to treatment may be widely supported in both the public and private sectors. Previous research in Bali found that TB patients rarely request information from treatment providers and at the same time rarely report receiving explanations about their condition or treatment. 9 This breakdown in communication highlights the need to improve the effectiveness of patient education and ensure that follow-up occurs in the event of non-adherence. The provision of further training for private practitioners has been identified as a key strategy to improve the effectiveness of the private sector in TB control efforts. 10 Private practitioners also attributed patient nonadherence to treatment to lacking the time and resources to dedicate to patient education and followup. Increased collaboration between public and private providers in the areas of treatment monitoring and follow-up appears essential, given the limited capacity for monitoring and follow-up in the private sector and the recognition of this capacity within the public sector services as an area of relative strength. Poor communication is common between public and private providers in many developing countries, 2 and poor communication and differences in perception between public and private providers can significantly hinder efforts for TB control. 11 While the role of the public NTP was generally understood, the role of the private sector in TB control was unclear, except as a provider of health care for TB patients who had the ability to pay for private treatment. Clearly defined roles for each sector and effective communication and referral systems are important elements for successful collaboration. 12,13 Communication with the public system, especially for private practitioners without significant public practice experience, was reported to be poor. Private practitioners with significant exposure to the public system were better able to integrate patients into DOTS programmes and could also highlight specific deficiencies in the public system. We anticipate that the planned DOTS expansion in Bali, which will include private practitioners and incorporate the provision of a strengthened regulatory framework and training for selected private practitioners, 14 has the potential to address the communication and knowledge deficit that currently exists for some private practitioners. This programme may also have indirectly influenced the practice of some private practitioners interviewed, although none of the interviewees reported any specific involvement in the programme. In regions with a high burden of TB and a significant private sector, national public programmes alone are not able to effectively control TB. 5 Facilitating the effective participation of private practitioners with no formal interaction with the public sector will be particularly important, as our study has highlighted that this part of the private sector does not necessarily understand or trust the public sector. Improved communication can help dispel misconceptions between private and public practitioners, build trust and facilitate collaborative action. Resource limitations can be a significant barrier for public providers trying to interact successfully with private practitioners. 15 Thus, addressing resource allocation for efforts to improve private-public interaction within the overall NTP is an important consideration for policy makers. Improved involvement of private practitioners will not only bring benefits associated with integration of the large private sector in Bali, it will also minimise the potential deleterious effects that private practitioners can have on TB control stemming from poor patient management. 4 Previous research in Bali found that public practitioners perceived the activities of some private practitioners as a major impediment to TB control efforts. 6 The main issues identified included perceptions that private practitioners had poor diagnostic procedures and provided inadequate treatment supervision and follow-up. 6 A number of private practitioners acknowledged these issues as inherent problems in private practice. However, some interviewees had developed mechanisms to overcome these weaknesses, such as utilising nongovernmental funds for field workers or using public sector field workers to supervise patient treatment. More comprehensive and systematic implementation of solutions such as these for patient management problems in Bali is required. While private practitioners identified deficiencies within the private setting for the treatment of TB, they also identified some strengths. These included the high level of patient confidence in private practitioners and the continuity of care that they can provide. Previous research in Bali highlighted the preference of TB patients to be treated by a local provider whom they know and trust, as well as a reluctance to attend puskesmas early in the course of their illness. 9 As approximately half of all TB cases in Indonesia are first diagnosed by a private practitioner, successful utilisation of the strengths of the private sector is an important element in improving TB control. 4 Utilising strengths inherent in the private system in collaboration with the public NTP has been demonstrated to be successful in other settings The findings of this study are limited, as the sample studied may not be representative of the population of private practitioners within Bali. The purpose of this study was primarily descriptive, and further research is required to systematically study the perceptions and needs of a larger number of private practitioners to inform local policy. Furthermore, these findings may only reflect the perceptions of private practitioners in urban settings. However, it has been recognised that

6 TB treatment by private practitioners in Bali 993 rural and urban practitioners are often similar, and there is a lower level of involvement of private practitioners treating TB in Indonesia in rural areas. 2 CONCLUSION Private providers are a heterogeneous group that provides a unique service which often complements the services provided by the public system. Building on the strengths of private practitioners and addressing the recognised deficiencies of the current system, including the development of more effective health promotion campaigns, improving diagnostic services, promoting interaction between the private and public sectors, and providing training for private practitioners, should assist current TB control efforts in Bali. The limitations of private practice also need to be considered in the development of collaborative disease control programmes. These limitations include the lack of mechanisms to follow up patients and supervise treatment and non-adherence to accepted diagnostic criteria. Private and public providers of TB services in Bali each have mixed perceptions of the other sector, and programme development to improve systematic collaboration and communication among all treatment providers will be of benefit to local TB control efforts. Acknowledgements This study was performed in collaboration with the Foundation for Humanitarian Projects in Indonesia and was funded by Westcare Incorporated. We thank J Fawcett, P Lane and W Sukajaya for their assistance with the logistical arrangements during the study and W Suparta and C Rouse for their interpretation of interviews. We also wish to thank all the private providers who took part in this study. References 1 World Health Organization. Global tuberculosis control: surveillance, planning, financing. WHO Report WHO/HTM/ TB/ Geneva, Switzerland: WHO, World Health Organization. Involving private practitioners in tuberculosis control. Issues, interventions, and emerging policy framework. WHO/CDS/TB/ Geneva, Switzerland: WHO, Uplekar M, Pathania V, Raviglione M. Private practitioners and public health: weak links in tuberculosis control. Lancet 2001; 358: Uplekar M, Zignol M, Mehta F, et al. Public-private mix DOTS in Indonesia: a strategy for action. WHO/CDS/TB/ Geneva, Switzerland: WHO, Newell J. The implications for TB control of the growth in numbers of private practitioners in developing countries. Bull World Health Organ 2002; 80: Watkins R, Rouse C, Plant A. Tuberculosis Treatment Delivery in Bali: a qualitative study of clinic staff perceptions. Int J Tuberc Lung Dis 2004; 8: Grange J, Zumla A. Making DOTS succeed. Directly observed treatment, short course. Lancet 1997; 350: Sandelowski M. Whatever happened to qualitative description? Res Nurs Health 2000; 23: Watkins R E, Plant A J. Pathways to treatment for tuberculosis in Bali: patient perspectives. Qual Health Res 2004; 14: Caminero J A. Is the DOTS strategy sufficient to achieve tuberculosis control in low- and middle-income countries? 2. Need for interventions among private physicians, medical specialists and scientific societies. Int J Tuberc Lung Dis 2003; 7: Vyas R, Small P, DeRiemer K. The private-public divide: impact of conflicting perceptions between the private and public health care sectors in India. Int J Tuberc Lung Dis 2003; 7: Lonnroth K, Uplekar M, Arora V K, et al. Public-private mix for DOTS implementation: what makes it work? Bull World Health Organ 2004; 82: Murthy K J R, Frieden T R, Yazdani A, Hreshikesh P. Publicprivate partnership in tuberculosis control: experience in Hyderabad, India. Int J Tuberc Lung Dis 2004; 5: Mahendradhata Y, Utarini A. Public-private partnership for tuberculosis control: the bill please? Bull World Health Organ 2005; 83: Newell J N, Pande S B, Baral S C, Bam S D, Malla P. Control of tuberculosis in an urban setting in Nepal: public-private partnership. Bull World Health Organ 2004; 82: Quy H T, Lan N T N, Lonnroth K, et al. Public-private mix for improved TB control in Ho Chi Minh City, Vietnam: an assessment of its impact on case detection. Int J Tuberc Lung Dis 2003; 7: Arora V K, Sarin R, Lonnroth K. Feasibility and effectiveness of a public-private mix project for improved TB control in Delhi, India. Int J Tuberc Lung Dis 2003; 7: RÉSUMÉ CONTEXTE : Sur l île indonésienne de Bali il existe un système de santé mixte public-privé avec un programme national public de tuberculose (TB) et un secteur privé significatif qui assure le traitement à des patients atteints de TB. OBJECTIF : Explorer les perceptions des barrières au traitement de la TB chez les praticiens privés à Bali pour servir de base aux stratégies des développements futurs du programme. SCHÉMA : Des interviews semi-structurées ont été menées auprès de praticiens privés traitant des patients TB dans leur pratique privée. RÉSULTATS : Les barrières principales à l amélioration de la lutte antituberculeuse à Bali qui ont été identifiées par les praticiens privés sont le reflet des difficultés rencontrées dans les quatre zones suivantes : non-adhésion du patient au traitement, limitation des services publics, intégration publique-privée et limitation des services privés. Les praticiens privés ont identifié la nécessité d améliorer le niveau de l éducation de la collectivité au sujet de la TB, le degré d interaction publique-privée, la qualité des services de diagnostic et l accès à la formation. CONCLUSION : Cette étude a identifié à la fois des forces et des faiblesses de la lutte antituberculeuse dans le secteur privé ainsi qu une variation considérable des perceptions et de la pratique parmi les médecins privés. Le

7 994 The International Journal of Tuberculosis and Lung Disease développement de stratégies pour répondre aux difficultés rencontrées par les praticiens privés ainsi que l utilisation des forces inhérentes des praticiens publics et privés seront essentiels pour la mise à disposition d un service amélioré et pour une amélioration de la lutte antituberculeuse à Bali. RESUMEN MARCO DE REFERENCIA : En la isla indonesia Balí, consta de un sistema de salud mixto, público y privado, con un Programa Nacional de Tuberculosis (TB) público que cuenta con una participación considerable del sector privado en la provisión del tratamiento antituberculoso. OBJETIVO : Explorar la percepción de los médicos privados sobre los obstáculos que existen al tratamiento de pacientes con TB en Balí, a fin de documentar las estrategias de desarrollo futuro del programa. MÉTODOS : Se llevaron a cabo entrevistas semiestructuradas a los médicos que tratan pacientes con TB en su práctica privada. RESULTADOS : Los principales obstáculos referidos por los médicos al mejoramiento de la lucha contra la TB en Balí reflejan dificultades encontradas en los siguientes aspectos : incumplimiento terapéutico por parte de los pacientes, restricciones de los servicios públicos, integración de los sectores público y privado y limitaciones de los servicios privados. Los médicos del sector privado reconocieron la necesidad de perfeccionar la educación comunitaria sobre la TB, el grado de interacción entre el sector público y el sector privado, la calidad de los servicios de diagnóstico y el acceso al adiestramiento. CONCLUSIÓN : En el presente estudio se reconocieron los puntos fuertes y débiles de la lucha contra la TB en el sector privado y una gran diversidad en las percepciones y las prácticas de los médicos de este sector. El mejoramiento de la prestación de servicios y del control de la TB en Balí precisa la elaboración de estrategias que den respuesta a las dificultades encontradas por los médicos del sector privado y que aprovechen los puntos fuertes inherentes a la práctica pública y a la práctica privada.