Social Science & Medicine 73 (2011) 1386e1394

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Social Science & Medicine

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Life of a partnership: The process of collaboration between the National

Tuberculosis Program and the hospitals in Yogyakarta, Indonesia
Ari Probandaria, *, Adi Utarinib, Lars Lindholmc, Anna-Karin Hurtigc
a
Department of Public Health, Faculty of Medicine, Universitas Sebelas Maret, Jl. Ir. Sutami 36A, Surakarta 57126, Indonesia
b
Universitas Gadjah Mada, Indonesia
c
Umeå University, Sweden

a r t i c l e i n f o a b s t r a c t

Article history: Publiceprivate partnerships (PPP) for improving the health of populations are currently attracting
Available online 10 September 2011 attention in many countries with limited resources. The PublicePrivate Mix for Tuberculosis Control is an
example of an internationally supported PPP that aims to engage all providers, including hospitals, to
Keywords: implement standardized diagnosis and treatment. This paper explores mainly the local actors’ views and
Indonesia experiences of the process of PPP in delivering TB care in hospitals in Yogyakarta Province, Indonesia. The
Publiceprivate partnership
study used a qualitative research design. By maximum variation sampling, 33 informants were
Tuberculosis
purposefully selected. The informants were involved in the PublicePrivate Mix for Tuberculosis Control
Hospitals
Content analysis
in Yogyakarta Province. Data were collected during 2008e2009 by in-depth interview and analyzed
using content analysis techniques. Triangulation, reference group checking and peer debriefing were
conducted to improve the trustworthiness of the data. This analysis showed that the process of part-
nership was dynamic. In the early phase of partnership, the National Tuberculosis Program and hospital
actors perceived barriers to interaction such as low enthusiasm, lack of confidence, mistrust and
inequality of relationships. The existence of an intermediary actor was important for approaching the
National Tuberculosis Program and hospitals. After intensive interactions, compromises and acceptance
were reached among the actors and even enabled the growth of mutual respect and feelings of
programme ownership. However, the partnership faced declining interactions when faced with scarce
resources and weak governance. The strategies, power and interactions between actors are important
aspects of the process of collaboration. We conclude that good partnership governance is needed for the
partnership to be effective and sustainable.
Ó 2011 Elsevier Ltd. All rights reserved.

Introduction 2009; Nishtar, 2004; Oyediran et al., 2002; Widdus, 2005). By

Initiatives for collaborations between the public and the private
sector have recently received increased interest, particularly in
countries with limited resources (Nishtar, 2004). Such initiatives
are commonly called publiceprivate partnerships (PPPs) and
involve public and private sector organizations in collective
decision-making to improve the health of the population (Buse &
Harmer, 2007; Buse, Mays, & Walt, 2005; Reich, 2000). PPPs work
in broad public health fields at international, national and local
levels (Buse & Harmer, 2007; Croft, 2005; Gardner, Acharya, &
Pabloz-Mendez, 2005; Keane & Weerasinghe, 2008; Ngoasong,
* Corresponding author. Tel.: þ62 81328048659.
E-mail addresses: ariprobandari@yahoo.com (A. Probandari), adiutarini@gmail.
com (A. Utarini), lars.lindholm@epiph.umu.se (L. Lindholm), anna-karin.hurtig@
epiph.umu.se (A.-K. Hurtig).
nature, PPPs work for purposes of service delivery, policy, infra-
structure, capacity building and economic development
(Brinkerhoff & Brinkerhoff, 2011).
The concept of PPPs has also been adopted for engaging all
health care providers in delivering standardized tuberculosis (TB)
care. This has been called the PublicePrivate Mix approach for TB
Control (PPM for TB Control). The PPM for TB Control is an inter-
national concept of partnership but its implementation is
commonly local. Among various models of PPM for TB Control, the
engagement of hospitals is common in many high-burden coun-
tries, including Indonesia (WHO, 2009).
Previous publications mainly focus on the technical aspects of
supporting PPM for TB Control. For example, some articles argue for
the importance of training, standardized referral and information
systems, the provision of anti-TB drugs and financial incentives (Bai
et al., 2008; Lönnroth et al., 2004; Uplekar, 2003). The concept

0277-9536/$ e see front matter Ó 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2011.08.017
 A. Probandari et al. / Social Science & Medicine 73 (2011) 1386e1394
of PPM for TB Control implies a partnership (Lönnroth & Uplekar,
2005; WHO, 2009). However, few publications discuss the
processes of the partnership, such as the role of intermediary
parties, commonly non-governmental organizations (Hurtig et al.,
2002; Rangan et al., 2004), or commitment from actors
(Probandari, Utarini, & Hurtig, 2008; Rangan et al., 2004). Among
the theories of partnerships (Brinkerhoff, 2002; Hardy, Hudson, &
Waddington, 2003; Hudson, Brian, Henwood, & Wistow, 1999),
we find the aspects of mutual partnership as defined by Brinkerhoff
(2002) to be useful. Meanwhile, Hardy et al. (2003) and Hudson
et al. (1999) focus on components and steps to successful part-
nership. Mutual partnership contains values of (1) maximum
benefit for each party, (2) equality in decision-making, (3) shared
objectives, processes, outcomes and evaluation and (4) agreed
purpose and values, mutual trust and respect.
Brinkerhoff and Brinkerhoff (2011) describe the gap between
rhetoric and reality as well as the diversity of PPPs. A study by
Palmer and Mills (2005) reveals that the contractual relationship
within PPP does not work in the setting of developing countries,
which differs from that of developed countries. Studies on the
process of collaboration in a country like Indonesia will add to the
current knowledge on how to create effective partnerships in
developing countries. This is important at a time when such part-
nerships are advocated as a solution to societal problems in general
and TB control in particular.
This paper explores the local actors’ views and experiences in
the process of collaboration between the National Tuberculosis
Program (NTP) and the hospitals in delivering TB care within the
internationally supported PPP. To situate the PPP the context is
initially described, the theme “life or a partnership” is then elabo-
rated and finally policy implications are discussed.
Methods
Research settings
The study was carried out in the province of Yogyakarta, Java
Island, Indonesia. The province consists of one municipality and
four districts. There are public and private health care facilities that
serve the population of 3.5 million. In the province there are 118
community health centres (called Puskesmas), which are the public
primary care facilities, 6 public hospitals and 39 private hospitals.
The health system is funded by a mix of public and private
financing. About 35.9% of the population receives social insurance
from the government. More than 70% of the population lives in the
radius of 1e5 km from health care facilities such as community
health centres, hospitals and private medical doctors’ practices. In
general, public health programmes are financed by local and
national governments (Yogyakarta Provincial Health Office, 2009).
Some public health programmes such as TB and HIV/AIDS controls
receive support from external donors.
In 1999, the Ministry of Health introduced a pilot PPM for a TB
control project in the Yogyakarta Province hospitals. The pilot
project received funding from the Gorgas TB Initiative/University of
Alabama, the Netherlands Tuberculosis Foundation (Koninklijke
Nederlandse Centrale Vereniging/KNCV) and the Tuberculosis Coa-
lition for Technical Assistance (TBCTA). The Hospital Association in
Yogyakarta Province was appointed to manage the operational
arrangement of the pilot project during 2000e2005. A formal
agreement (Memorandum of Understanding) between the Ministry
of Health and the Hospital Association was made at the start of the
pilot project (Irawati et al., 2007). The donors appointed interna-
tional consultants to provide periodic technical assistance during
the pilot project.
1387
Within the PPM for TB Control, the health care providers are
expected to implement the Directly Observed Treatment Short-
course (DOTS) strategy (WHO, 2005). In accordance with the
DOTS strategy, TB cases are diagnosed by sputum microscopy tests.
In addition, the DOTS strategy uses standardized anti-TB drug
regimens and durations with direct observation by the patient’s
family or a health worker. A recording and reporting system is used
to monitor and evaluate the process and outcome of the diagnosis
and treatment of TB cases.
In all the districts included in this study, the hospitals that
agreed to be involved in the PPM for TB Control received trainings,
anti-TB drugs (called “programme drugs”), laboratory supplies,
recording/reporting forms and financial incentives for every posi-
tive TB sputum smear case detected and successfully treated. The
hospitals were also conducting standardized diagnosis and treat-
ment procedures for TB patients. The patient’s family or a close
relative commonly performs treatment observation for a TB
patient. The TB patient and the observer come to the health facility
weekly during the first two months of treatment (intensive phase)
and then every two weeks during the continuation of treatment.
The provincial laboratory conducts quality assurance for sputum
testing. The district NTP is responsible for the monitoring and
supervision of health facilities and for checking the supply of anti-
TB drugs in the health facilities. The provincial NTP monitors and
provides technical assistance to the district NTP. The procurement
and distribution of anti-TB drugs remains the responsibility of the
Ministry of Health (Ministry of Health Republic of Indonesia, 2007;
Stop TB Partnership Indonesia, 2010).
The Hospital Association established a team consisting of ten
individuals from various backgrounds, including internal medicine,
pulmonologists, provincial NTP staff, academics and Hospital
Association personnel. The team was formalized as the Provincial
DOTS Committee in 2002. The Provincial DOTS Committee’s task
was primarily to give technical assistance for the supervision to
assist with resolving a high default rate (Irawati et al., 2007). The
default rate is the proportion of smear-positive TB cases that
dropped out of treatment among all the smear-positive TB cases
registered for treatment (WHO, 1999).
After the pilot project ended in 2005, the arrangement of
hospital PPM for TB Control was handed over to the Provincial
Health Office in Yogyakarta with funding from the Global Fund. In
2007, the TB control programme in Indonesia (including Yogyakarta
Province) suffered from a 6-month lapse in Global Fund funding
(WHO, 2009).
Research design and sampling method
Qualitative research was conducted in order to gain an in-depth
understanding of the partnership among the Provincial Health
Office, District Health Offices and public and private hospitals
within the PPM for TB Control. This study applied a maximum
variation sampling technique to select actors of the partnership in
practice. We primarily selected nurses, medical doctors and labo-
ratory staff from the public and private hospitals, as they are the
core personnel in the DOTS strategy implementation in hospitals
(Utarini, Probandari, & Lestari, 2007). Thirty-three informants were
interviewed. They consisted of:
 Three nurses, five laboratory staff and two medical records staff
from five public hospitals
 Three nurses and three laboratory staff from three private
hospitals
 Two medical doctors who worked at both public and private
hospitals, a medical specialist from a private hospital and
a general practitioner employed by a public hospital
1388 A. Probandari et al. / Social Science & Medicine 73 (2011) 1386e1394
 NTP staff (three provincial NTP staff members, six district NTP
staff members and one central NTP staff member)
 A representative of the Hospital Association
 Two international consultants for the PPM pilot project.
Two medical doctors in the sample and the representative from
the Hospital Association took roles in the Provincial DOTS
Committee. Two medical doctors (not included in the list above)
declined to participate due to time constraints.
Data collection
In-depth interviews were conducted from January 2008 to June
2009. A semi-structured interview technique was used. The inter-
view guidelines were tested in the pilot study by a researcher (AP)
and a research assistant. The results of the pilot interviews were
discussed with the other authors so that improvements might be
made. The interview topics concerned:
 What was the process of the initiation of collaboration between
the NTP and the hospitals?
 How do you perceive common problems in the partnership?
 In practice, how do you experience the partnership between
your organization/yourself and other institutions in PPM for TB
Control?
The three general topics were elaborated to address the prin-
ciples of mutual partnership (Brinkerhoff, 2002), such as benefits
for each partner, equal decision-making, trust, shared objectives
and evaluation. During the interviews we considered some
important milestones, i.e. the establishment of the Provincial DOTS
Committee (2002), the change in the financing scheme for the
partnership (2005) and the temporary cessation of Global Fund
funding (2007).
The average interview length was 1 h (a range of 0.5e3 h). The
interviews were conducted in places where the informants thought
they could feel free to talk. The first author and a research assistant
conducted the interviews, except those with the two international
consultants in which the first author was assisted by the second
author. All the interviews except those with the international
consultants were carried out in Bahasa Indonesia.
Data analysis
The records of the interviews were transcribed into verbatim
transcripts (in Bahasa Indonesia). The transcripts were translated
into English to facilitate discussions between the Indonesian and
the Swedish researchers. The first researchers performed content
analysis on the transcripts to explore both the manifest and the
underlying meanings of the texts (Graneheim & Lundman, 2004). In
particular we conducted directed content analysis (Hsieh &
Table 1
An example of the coding process, from meaning units to sub-categories.
Topics Meaning units
How do you perceive common “Basically, the hospital supports the
problems in the partnership? DOTS strategy, but I doubt the quality
of antieTB drugs and the procedure of TB
treatment [in the national guideline].”
In practice, how do you experience “[During the supervision] the Hospital
the partnership between your Association and district NTP staff collected
organization/yourself and other all data and listen to our complaints and
institutions in PPM for TB problems, then we discussed the problem
Control? solutions.”
Shannon, 2005) to explore the actual implementation of the PPM
for TB Control in light of the mutual partnership model
(Brinkerhoff, 2002). During the coding process we used key
concepts of the partnership model while we constantly sought new
insights from the data. In the initial stage of analysis, transcript
phrases with meanings (meaning units) were identified. From the
text of meaning units, manifest meanings were generated. Inter-
pretations from the manifest meaning units were labeled as codes.
Codes that shared common meanings were grouped into sub-
categories or categories (see Table 1). Open Code 3.4 (Department
of Public Health and Clinical Medicine, Umeå University Sweden,
2010) was used to organize the codes and categories.
A theme was developed that linked the meanings of categories,
and therefore the theme allowed for overlapping of categories. This
is seen in Fig. 1. All the sub-categories, categories and the theme
were discussed and reflected upon by all the involved researchers.
In analyzing and presenting the data, a time scale was used to frame
the results within the study context.
Trustworthiness
Triangulation of information was used to compare and confirm
the interview issues between informants. In addition, discussions
between the first author and the research assistant or the other
authors were held during the data collection and analysis to
identify preliminary interpretations. The first author wrote
analytical comments during the data collection and analysis to
scrutinize the author’s own interpretation and informant percep-
tions. Peer debriefing was conducted between the first and the
second author and with other colleagues at the Universitas Gadjah
Mada who were knowledgeable about the research issue. The
researchers also used reference group checking by presenting the
research results to people who were knowledgeable about the PPM
for TB Control at hospitals in Yogyakarta Province but who were not
informants.
Ethics
Before the interview, the researcher gave brief information
about the objectives and topics to be discussed, confidentiality of
information and the informants’ right to withdraw at any time. The
informants were aware of the fact that the interviews would be
tape-recorded as well as their right to decline to have the interview
recorded. Ethical approval was received from the Universitas Gad-
jah Mada, Yogyakarta. The informants were anonymous during the
analysis and presentation of results.
Findings
The theme, “life of a partnership”, represents the dynamic
process of partnership from birth, to growth, to decline of
Condensed meaning unit Codes Sub-categories
Hospital supports DOTS but - Hospital supports DOTS Mistrust
quality of drugs and TB - Doubt quality of drugs
treatment doubted by provider - Incoherence
- Rejection
Hospital Association and NTP - Listen to partner Sharing of evaluation
listen during supervision, - Discuss
problems are discussed and - Shared problem solutions
solved together - Openess
 A. Probandari et al. / Social Science & Medicine 73 (2011) 1386e1394 1389

Life of a partnership: birth, growth and decline

THEME

Perceiving unseen Reaching compromises and Growing in respect, equality in Having fewer interactions and
barriers to the start of acceptance through the relationships, feeling of less motivation and trust among
CATEGORIES
the partnership intermediary actors’ power ownership and trust among the the partners in the setting of
(2000–2002) and strategies (2002–2004) partners (2004–2005) scarce resources and weak
governance (2006–2008)

Less Intermediary Power and Respect Feelings of

enthusiasm strategies to ownership Fewer
actors
increase Weak interactions
SUB- interface of governance
CATEGORIES Mistrust Optimum Equality of Inequality of
partners
benefit relationships relationships Less motivation
Compromises Scarce
Inequality of
and resources
Lack of relationships Tension
acceptance Trust among
confidence to
Mistrust partners
interact with Sharing of Mistrust
partners objective and Sharing of
evaluation objectives and
evaluations

Fig. 1. The sub-categories, categories and theme generated from the interviews.

interactions between the actors involved in the PPM for TB
control in hospitals in Yogyakarta from 2000 to 2008. The theme
was a link between four categories: (1) perceiving unseen
barriers to the start of the partnership; (2) reaching compro-
mises and acceptance through the intermediary actor’s power
and strategies; (3) growing in respect, equality in the relation-
ship, feeling of ownership and trust among the partners; and (4)
having fewer interactions and less motivation and trust among
the actors of the partnership in the setting of scarce resources
and weak governance. The first category reflects the phase of
birth (initiation) of the partnership. The second and third cate-
gories are the phases of growth of interactions and mutual values
in the partnership. The last category mirrors the phase of decline
(Fig. 2).

Mutuality in partnership (Brinkerhoff’s criteria: trust and respect, equality of decision-

making, maximum benefit and shared objectives, processes, outcome and evaluation)

Level of
Existence of
mutuality
intermediary actors

Time
2000–2002: 2002–2004: 2004–2005: 2006–2008:

Formal Perceiving Reaching Growing in Having fewer

agreement to unseen compromises and respect, interactions and less
start of the barriers to the acceptance because equality in motivation and trust
partnership start of the of intermediary relationships, among partners in the
partnership actors’ power and feeling of setting of scarce
strategies ownership resources and weak
and trust governance
among the
partners
Fig. 2. A life course metaphor of the partnership.
1390 A. Probandari et al. / Social Science & Medicine 73 (2011) 1386e1394
Perceiving unseen barriers to the start of the partnership
(2000e2002)
During the two years after the formal agreement for the part-
nership, the informants perceived both technical and non-technical
constraints in arranging the PPM for TB Control in the hospital
setting. Hospital directors’ responses to the Memorandum of
Understanding varied. Some were passive and others were enthu-
siastic. The majority of informants mentioned reluctance on the
part of the hospital staff even though the hospital director
responded positively to partnership participation. The informants
perceived that public and private hospital medical specialists were
commonly reluctant to perform diagnostic and treatment proce-
dures such as the DOTS strategy, because they believed in their own
clinical experience. “There is a different vision between the clini-
cian and the programme staff. If you have experience [in diagnosis
and treatment of TB patients], you will have a feeling [about the
right diagnostic and treatment]. It [diagnosis and treatment] is not
so mathematical” (a medical specialist who worked at a private
hospital with unsatisfactory TB programme performance).
Some district NTP staff thought they lacked power and were less
capable of solving the constraints from medical specialists. “Every
time I visited hospitals, I felt so embarrassed. I was feeling down . I
lacked confidence” (a district NTP staff member).
Meanwhile, the medical doctors tended to view the NTP staff as
being at the same level as hospital nurses. “Every time the district
NTP officer comes, I ask the nurse to meet her. They are at the same
level as an administrative person.” (a medical doctor who worked
at a private hospital with unsatisfactory TB control programme
performance). The NTP staff also felt it was difficult to reach and
approach the medical specialists. “When the hospital recognized
that I came to the hospital alone, there would only be a nurse to
meet me” (a district NTP staff member).
Reaching compromises and acceptance through the intermediary
actor’s power and strategies (2002e2004)
The majority of the informants perceived that the Provincial
DOTS Committee was analogous to a door opener and intermediary
actor. The Provincial DOTS Committee enabled the NTP and hospital
staff to interact. “I think the intermediary actor is needed. I feel the
barrier of entry to hospitals, it is an unseen barrier. We need the
door opener” (a district NTP staff member).
Most informants thought that the Provincial DOTS Committee
was a strong intermediary actor. Meanwhile, the Hospital Associ-
ation was perceived as having sufficient power and authority to
command hospitals: “. hospitals are the subordinates of the
Hospital Association. Thus, the hospitals automatically fall under
their umbrella. Agreement at the upper level, indeed, has conse-
quences for the lower level” (a district NTP staff member).
Almost all the informants related the influence of the Provincial
DOTS Committee to the existence of medical specialist personnel
from the Hospital Association on the committee. The actor from the
Hospital Association mentioned the important roles of other
medical specialists who had no affiliation with the Hospital Asso-
ciation. A professional background as a medical specialist was
perceived as enabling a specialist to become close to the influential
personnel in the hospitals. A background as a medical specialist
was thought to balance the power of the reluctant hospital medical
specialists.
When we found a problem, for instance a reluctant specialist,
we reported to the Provincial DOTS Committee coordinator who
will then find “a rival” for the specialist .. (A district NTP staff
member)
The informants who were members of the Provincial DOTS
Committee perceived the process of finding compromises to be
time-consuming. They mostly used an informal approach, which
was perceived as a more effective strategy than asking the physi-
cians for formal meetings.
The process of approaching [medical] specialists was quite long.
I needed about one year. They are my seniors. It is difficult to
change them. I mostly use a personal approach with them. They
are so busy that it is difficult to invite them to meetings. I came
to their departments and explained about DOTS. (A medical
specialist who worked at a public hospital with good TB control
programme performance and who also was a member of the
Provincial DOTS Committee)
The informants who are members of the Provincial DOTS
Committee mentioned that the medical specialists tended to think
that the diagnosis and treatment of TB in hospitals should be
different from the diagnosis and treatment in community health
centres. The specialists viewed the hospital as providing speciality-
based medical services. Physical examinations and X-rays were the
main tools for TB diagnosis in hospitals. Sputum tests were less
frequently used for diagnosis. Sputum testing was perceived as the
way the community health centres diagnose TB. The use of only an
X-ray for diagnosis obviously contradicted the guidelines, which
state that sputum examination is the main diagnostic test. Through
intensive dialog, the NTP welcomed hospitals’ use of X-rays as
a concurrent diagnostic test along with sputum examination.
DOTS-based treatment was perceived as treatment that used
the “programme drugs” from the NTP and some medical specialists
doubted the quality of the programme drugs. Some hospital staff
received programme drugs that were close to their expiration
dates. Most of the informants thought that the use of drugs might
reduce hospital and specialist incomes. The Provincial DOTS
Committee compromised and allowed physicians not to use the
programme drugs but requested the use of the regimen recom-
mended by the guidelines.
The loss of income due to DOTS strategy implementation was
tolerable. The medical specialists said that hospitals could still gain
income from consultation fees, X-rays and sputum tests, and that
the number of TB cases was relatively small. In addition, some of
the TB patients at hospitals had insurance or their workplaces paid
for them. In those instances, they might prefer to pay for the anti-TB
drugs rather than to use the drugs provided by the NTP.
We think the loss due to this partnership is not much, because
patients have to pay for the laboratory tests and X-ray exami-
nations. Of course, there is a decrease of income due to the use of
programme drugs. We prioritized the free treatment for patients
who really need it. Those who have insurance or are paid for by
their worksite usually preferred not to use the programme
drugs. I can still raise income from other patients. (A medical
specialist who worked at a private hospital with satisfactory TB
control programme performance)
Some of the NTP staff could understand the conflict of interest of
hospitals with the implementation of the DOTS strategy. “. They
[public and private hospitals] have their own market and roles. I do
understand” (a district NTP staff member). Meanwhile, some
informants said that the implementation of the DOTS strategy in
hospitals could improve the image of the hospitals by providing
“free services” for the poor.
The treatment is free but the patients may still have to pay for
doctor consultation, laboratory and radiology services. It is
a person-to-person marketing, [it is] because [that by our
service] the patient [may] say e hey look, the hospital X gave
 A. Probandari et al. / Social Science & Medicine 73 (2011) 1386e1394 1391

free TB treatment. (A member of laboratory staff who worked at The informants from hospitals perceived that the Provincial
a private hospital with satisfactory TB control programme DOTS Committee provided practical, evidence-based recommen-
performance) dations to improve performance. Further, the hospital personnel
and the district NTP staff perceived the Provincial DOTS Committee
The informants who are Provincial DOTS Committee personnel
supervision as attention to their work.
and the informants from hospitals mentioned that certain hospi-
The hospital staff and district NTP personnel thought the
tals had flexibility so that the patients made less frequent hospital
Provincial DOTS Committee showed high-level commitment and
visits to decrease their costs. These were less frequent than visits
professionalism in carrying out their tasks. Most of the hospital
to the community health centres. After the intensive phase, the
informants mentioned that they could reach Provincial DOTS
hospital patients could attend the DOTS unit monthly instead of
Committee personnel easily by telephone. The committed response
twice a week as in the NTP procedure used in community health
from the Provincial DOTS Committee was not perceived to be
centres.
related to incentives, because the amount of the incentives was
For some hospital nurses and laboratory staff, the imple-
perceived as small.
mentation of the DOTS strategy meant higher workloads. They
One of the international consultants said, “commitment is
perceived the recordingereporting tasks to be too complicated and
developed from face to face interaction”. The collegial environment
time-consuming. After some time, they felt they could tolerate the
within the Provincial DOTS Committee made the personnel happy
additional work burden as part of their routine responsibilities.
while doing their work. “They [personnel of the Provincial DOTS
Some of the nurses and laboratory staff thought their knowledge
Committee] even have lunch together and picnic together” (an
and skills had been upgraded through the training and intensive
international consultant for the pilot project of PPM for TB Control
supervision from the Provincial Committee. The district NTP staff
in hospitals).
thought that acceptance from the hospital staff was influenced by
There was a hospital initiative to provide resources indepen-
the available financial incentives.
dently. For instance, when the recording and reporting form was
out-of-stock, the hospitals produced them with hospital financing.
Growing in respect, equality in relationships, feeling of ownership
However, a lack of trust could still be found among some
and trust among the partners (2004e2005)
hospital staff. The Provincial DOTS Committee personnel and the
district and provincial NTP staff stated that some hospitals
All the informants provided information about the intensive
hindered the work and hid information on the number of TB
interactions among the partnership actors during the period of
patients who dropped out of treatment. The majority of the infor-
2004e2005. Formal interactions happened through quarterly
mants mentioned that reluctance among specialists to treat the TB
monitoring and evaluation meetings among the provincial and
patients according to the guidelines still occurred, but this was
district NTP, the Provincial DOTS Committee and the hospitals.
hidden. They would not frankly say that they refused the DOTS
Hospital supervision by the Provincial DOTS Committee personnel
strategy, but they would not manage patients as agreed. The feeling
together with the NTP staff and laboratory expert was, on average,
of being blamed during supervision led to a reluctant attitude.
conducted monthly or more frequently. The international consul-
tant confirmed this situation: “. someone [the PDC coordinator] We only reported to the district NTP staff when she asked us.
became the interface, monthly meeting, quarterly meeting. [It was] When she did not do that, we would not report the default cases
very interactive.” Beside interactions within the formal forums, . Yes, there are discussions, but sometimes we are blamed. So,
informal communications also occurred between district NTP staff, it seems that implementing the DOTS strategy is difficult. It is
Provincial DOTS Committee members and hospital personnel. In easier not to use DOTS.. (An internal medicine specialist who
particular, they had contact through telephone calls. However, worked at a private hospital with unsatisfactory TB control
there were fewer informal interactions between hospital staff and programme performance)
provincial NTP personnel.
Not all the partnership actors acknowledged equality in their
During the interactions, the hospital personnel perceived
relationships. For instance, the provincial NTP staff stated that
respect from the Provincial DOTS Committee. This was because the
DOTS strategy implementation was a must for the hospitals and no
Provincial DOTS Committee district followed the hospital admin-
room for negotiations existed. Because of that, there could not be
istrative procedures and made appointments with the hospital
equality in the relationship between the hospitals and the NTP. “It
before coming for supervision. Some hospital informants said that
[the partnership between NTP and hospitals] is not an equal rela-
some NTP staff changed communication modes from instructional
tionship. It is an instructional relationship” (a provincial NTP staff
to collegial. “At least they tried to understand our reasons [clinical
member).
reasons of exceptional treatment procedure], they were open to
Some informants mentioned hidden conflicts among the NTP
discussions” (a medical specialist who worked at a private hospital
staff and the Provincial DOTS Committee personnel. The Hospital
with poor TB control programme performance).
Association personnel confirmed this. The conflict was mainly
Conversely, district NTP informants perceived gradual accep-
a disagreement of the provincial NTP staff over the managerial
tance from the hospital staff that changed from apathy to respect.
process during the pilot project of PPM for TB Control in hospitals in
Previously, I thought that I was not respected. I felt that they Yogyakarta.
ignored me. At that time, what I did was ask them for the
book [the TB patient register], and I sat outside the outpatient Having fewer interactions, less motivation and trust among the
clinic, together with patients, doing my job [checking the TB partners in the setting of scarce resources and weak governance
patient register]. . As I said, they did not welcome me. They (2006e2008)
might have felt that my visit disturbed them because there
were a lot of patients at that time. They didn’t offer me use of Most of the informants said that the quarterly monitoring and
any table. It might be because all the rooms were occupied. It evaluation meetings and trainings were not being conducted. Visits
is different now. If I visit the hospital, the nurse will prepare by the district NTP staff still occurred with the purpose of collecting
a room and the TB patient register for me .. (A district NTP routine data. Hospital personnel perceived a lack of problem
staff member) analysis and feedback sessions during supervision by the district
1392 A. Probandari et al. / Social Science & Medicine 73 (2011) 1386e1394
NTP staff. Under the new Provincial DOTS Committee leader during
2005e2008, no informants reported any Provincial DOTS
Committee meetings.
The provincial NTP staff mentioned that they found it difficult to
keep the monthly hospital supervision or arrange Provincial DOTS
Committee meetings under the new Global Fund financing scheme.
However, the central NTP staff viewed the problem as less planning
and budgeting capacity among the provincial NTP staff, and not
because of the rigid Global Fund system. The central NTP staff also
mentioned a lack of capacity to design a sustainable partnership
within limited resources.
It is a mistake to create a lot and various activities during the
Hospital DOTS Linkage model development without thinking
about the sustainability of the program. (The central NTP staff)
Different perspectives of the national NTP staff and the inter-
national consultants existed particularly in regard to the need to
include the monthly supervision in the NTP budget. An interna-
tional consultant stated “they (the NTP) want quality but do not
want to pay for supervisions.”
The nurses and laboratory staff perceived that less interaction
during the supervisions decreased their motivation and perfor-
mance even though they still received similar financial incentives
from the NTP to those during the previous period.
There is no evaluation during these days. We do not know what
our weaknesses and progress are. We feel that they [the
provincial and district NTP staff] do not care about us. We just
carry out the partnership programme, without knowing the
progress. We need challenge for our work. (A nurse who worked
in a public hospital with unsatisfactory TB control programme
performance)
Now we feel that we are working alone .. (A laboratory staff
member who worked in a public hospital with satisfactory TB
control programme performance)
A member of the district NTP staff and some Provincial DOTS
Committee members mentioned a lower quality of recording and
reporting than before. In the previous period (2004e2005), extra
indicators in addition to those in the NTP system were calculated
for the district and provincial levels. The indicators were the
number of hospital referral cases that continued treatment in other
health facilities and the number of referral cases that successfully
completed treatment. During 2006 to 2007, only one district among
five calculated those indicators as part of the NTP reporting system.
Even though the frequency of formal interactions declined,
informal communication, among hospital staff, individuals of the
Provincial DOTS Committee and the district NTP staff, was still in
place. The hospital staff still contacted medical specialists in the
Provincial DOTS Committee when they needed clinical advice.
Informal interactions were also used to solve the problem of out-of-
stock anti-TB drugs. In agreement with the district NTP staff,
a hospital could lend its stock of programme drugs to another
hospital. Similar informal problem solving also took place between
the district NTP staff and their colleagues in other districts. “We
suffered from out-of-stock drugs for almost a month. By informing
the district NTP staff, we can borrow programme drugs from
another hospital” (a nurse who worked at a private hospital with
satisfactory TB control programme performance).
There was mistrust of the NTP staff among the hospital personnel.
The hospital personnel thought the NTP staff did not have the
capacity to replace the Hospital Association’s role in organizing the
partnership because of a lack of time and an extremely high work
burden. All the NTP staff members were commonly responsible for
more than two disease control programmes.
The former leader of the Provincial DOTS Committee asked
hospitals to set a plan of action for the period after 2005. However,
there was no communication or transfer of knowledge and skills
between the former leader and the new leader of the Provincial
DOTS Committee. Some informants mentioned conflicts between
the former Provincial DOTS Committee coordinator and the new
leader over the division of roles in the PPM pilot project. There was
uncertainty about which parties should handle the partnership
during this period of crisis.
Discussion
Dynamic partnership
This paper gives an account of local actors’ experiences of an
internationally supported partnership, the case of the Pub-
licePrivate Mix for TB Control in Indonesia. The result is a picture of
PPP implementation in a country with a high-burden of TB, which
has received substantial technical and financial assistance for its
disease control programme. Our study revealed that the process of
collaboration between an NTP organizer and the hospitals is
dynamic (Fig. 2). As seen in our study, the process of collaboration
comprises a phase of birth (initiation), growth of the relationship
and it can reach a declining phase.
In the partnership birth phase, the informants perceived
“unseen barriers” to interactions even though a formal agreement
had been signed. Our study revealed feelings of inequality, a lack of
confidence, less enthusiasm and mistrust as the main constraints to
initiating the partnership. Other studies (De Costa, Johansson, &
Diwan, 2008; Hurtig et al., 2002) showed similar phenomena,
particularly prejudice between the NTP staff and the private prac-
titioners. Other researchers (Loveday, Thomson, Chopra, & Ndlela,
2008; Siddiqi et al., 2008) also found and discussed physician
mistrust of the diagnostic and treatment procedures in the DOTS
strategy.
Reflecting on Brinkerhoff’s theory of mutuality in partnership
(2002), our findings suggest that it takes time and strategies to
reach mutuality in partnership (Fig. 2). In addition, not all of Brin-
kerhoff’s values of mutuality were achieved. Some values were
achievable, but imperfectly. While there were signs of increased
trust, levels of mistrust remained among the actors during
2004e2005. In the declining phase (2006e2008), there were fewer
interactions among the actors and this resulted in less motivation
to participate in the partnership. There was also mistrust of the
capacity and commitment of the NTP in leading the partnership.
Governance of the partnership
Our results suggest that it is essential to have a “door opener”
and intermediary actor with sufficient power between the NTP and
the hospitals. Others have discussed the importance of non-
governmental organizations and medical associations to linking
NTP and private TB care providers (Hurtig et al., 2002; Lönnroth
et al., 2004; Rangan et al., 2004). Our study shows that the power
of the intermediary party and intensive dialogs enabled the part-
ners to break “the unseen barriers” that hindered the actors of the
partnership from interactions and reaching compromises.
Hudson et al. (1999) argue the importance of wide organiza-
tional ownership in order to achieve successful collaborative
arrangements. Wide organizational ownership implies that
commitment from the organizational level should be translated
into commitment at the operational level. Brinkerhoff and
Brinkerhoff (2011) also state that a partnership needs commit-
ment and trust to function. This argument supports our findings of
 A. Probandari et al. / Social Science & Medicine 73 (2011) 1386e1394
the importance of commitment from hospital physicians and staff
in addition to a formal agreement at the hospital organization level.
Lönnroth et al. (2004) and Newell, Pande, Baral, Bam, and Malla
(2005) highlight dialog and flexibility as important strategies in the
PPM for TB Control. Dialog and flexibility are useful for articulating
each partner’s expectations and for defining shared partnership
objectives. Hudson et al. (1999) add the importance of personal
relationships as a strategy for investing trust. Further, theoretical
reviews and empirical evidence show that trust is essential for an
effective and sustainable partnership (Buse & Harmer, 2007;
Dhillon, 2009; Shortell et al., 2002; Hardy et al., 2003; ). The
increased level of mutuality during 2002e2005 was likely to be
consistent with the improved performance of hospital TB pro-
grammes in Yogyakarta Province (Irawati et al., 2007). We reviewed
unpublished 2006e2009 data from the Yogyakarta Provincial
Health Office that showed a tendency for lower treatment success
rates and higher default rates. (The treatment success rates
decreased from 78% in 2006 to 71% in 2008. The default rates
increased from 12.6% in 2006 to 15% in 2008.) In addition to dialog
and trust, recognition and anticipation of threats to collaborative
work are other ingredients in successful partnership (Hudson et al.,
1999). Our finding about the phase of decline reflects evidence of
weak governance, particularly a lack of actors’ capacity to plan for
contingencies within the partnership.
Conclusions
Our study argues for the importance of governance of PPPs in
general and in the setting of PPM for TB Control in hospitals in
particular. We agree with others (Brinkerhoff & Brinkerhoff, 2011;
Buse & Harmer, 2007) who argue that governance is essential,
but commonly weak and complex, in PPPs.
We recommend that international initiatives on global TB
control pay more attention to how to strengthen the governance
aspects of TB control programmes, particularly for PPM during
technical assistance. Good governance within the partnership
requires strong leadership and organizational skills, motivation and
commitment (Shortell et al., 2002). Our study suggests that it is
important for the NTP staff to be trained in leadership skills
including negotiation, interpersonal communication, contextual
problem-solving and skills in contingency planning (Mumford,
Zaccaro, Connelly, & Marks, 2000). Our study shows that the
decline phase happened within the context of unexpected
temporary funding cessation from the main international donor for
the TB programme in the country. Moreover, differences of vision
between the international actor and the national/local actors in
regard to the partnership may constrain the actors in bringing the
partnership out of the crisis.
The process of partnership in the setting of PPM for hospital TB
control is dynamic. Strategies, power and interactions between
actors are important aspects of the process of collaboration. The
existence of an intermediary actor is important to minimize the
barriers to interactions between partners, reach compromises and
develop values in the partnership. However, scarce resources and
weak governance can challenge and influence the partnership life.
Good partnership governance is needed for the partnership to be
effective and sustainable.
This study is limited to the exploration of the partnership with
actors at the operational level, such as hospital staff and physicians,
NTP staff and Provincial DOTS Committee personnel. In our study,
hospital directors were not included as study informants. This
limited the descriptions of the collaboration process to the policy
level, which might be relevant to the early phase of partnerships.
The generalizability of the findings to other publiceprivate
1393
partnership situations should be made with caution, and will
depend on consideration and judgment of the context.
Acknowledgments
The researchers thank the study informants who generously
shared their time and experiences. Appreciation also goes to all of
the research staff (Hari Agus Sanjoto and Erma Wijayanti) and
Centre for Health Service Management Faculty of Medicine, Uni-
versitas Gadjah Mada, for assistance during the study. Many thanks
to Yodi Mahendradhata, Hanevi Djasri, Trisasi Lestari and Suharna
for inputs to the manuscript. Ari Probandari gratefully acknowl-
edges stipends for doctoral study from the Swedish Centre Party
Donation for Global Research Collaboration and the Swedish
Research School for Global Health. The study was partially sup-
ported by the Centre for Global Health at the Umeå University, with
support from FAS, the Swedish Council for Working Life and Social
Research (grant number 2006-1512).
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