Analysis of TB-DM Collaboration Program at the Hospital in Semarang City, Indonesia

Indonesia contributes to 45% of TB cases in the world. Currently, Diabetes mellitus (DM) case is increasing. DM may worsen TB. The risk of developing latent into active TB increases with the presence of DM. Treatment failure in TB patients with DM is more frequent than non-DM. The aim of this study was to analyze of TB DM collaboration program at the one hospital in Semarang City. This was a qualitative study with content analysis. Informants consisted of internists, nurses, patients. This study showed there was a gap between technical guidance from minister of health and implementation of DM screening from TB patient. Besides, human resources factors also contribute to that gap.


Introduction
TB case is currently increasing. Similarly, the number of patients with DM is increasing. Based on WHO report (2018), it was estimated that there were 10 million people developed TB. Indonesia had 8% of TB cases from all around the world. In 2017, TB-caused death was about 1.6 million. In Indonesia, there were 842,000 of TB suspects and 116,000 TB-caused death in 2017 [1]. TB problem gets heavier with DM. DM will weaken the immune system, increasing the risk of developing latent TB into active TB. From 2010 to 2016, TB patients were diabetic with an annual prevalence increased from 12.5% to 18.7% [2].
In Pulmonary Diseases Center, Semarang City, Prevalence of HBA1c > 7 was 29% [3]. Reported TB-DM patients had higher mortality (10.3%) than non DM patient (7.6%) [2]. Diabetes also a risk factor for adverse tuberculosis treatment outcomes, including death [4]. Since 2015 there has been the Technical Guidance of TB-DM case finding at the Secondary Referral Health Facility (FKRTL) [5]. However, in health facilities have not been implemented, until the socialization of TB-DM collaboration by the City Health Office of Semarang in May 2017.
The aim of this research was to analyze TB-DM collaboration program at hospital in Semarang City, center of Java Indonesia.

Method
This research was a qualitative method with the secondary data observation step in one selected hospital, indepth interviews to the informants Informants in this study were internist-DM, internist-TB, nurse in DOTs clinic, nurse in TB-DM program, analyst, TB-DM patients. Additional informants in this study were health assurance (BPJS). Data were collected through 3 techniques, they are: 1. Observation, to analyze initial condition related to TB-DM program in chosen health facilities 2. In-depth interview, to identify the obstacles of integrated TB-DM program and factors contributed to the problems 3. Focus group discussion, to identify an alternative model of integrated TB-DM program development This study also conducts dissemination of the research result in order to make a commitment to developing the integrated TB-DM program. Data were analyzed using content analysis based on the result of in-depth interview and focus group discussion..

Result and Discuss
Secondary data was from medical records in hospital.
showed an increase in the number of TB cases and an increase in the number of DM cases. But the cases of TB-DM did not increase. This showed that there was a "gap" in TB-DM.   The problem that emerges in this hospital was that the huge number of DM patients caused the nurses and doctors do not have enough time to fill the form of TB screening to DM patients. Prevalence of diabetes is increasing globally, but most rapidly in low-income and middle-income countries where tuberculosis is a grave public health problem [4].
There was no internal legal from hospital that strengthens the implementation of TB-DM collaboration program, for example, SOP. So the implementation of collaboration TB-DM program cannot be done well by all health workers in hospital.

Conclusion and sugestion
Conclusion from this research were: There was a gap in the implementation of collaboration TB-DM program in hospital. There were problems of implementation of collaboration TB-DM program in health facility. Factors that contribute to the problems of collaboration TB DM program in health facilities are : human resources and internal regulation Suggestion : Important to make internal regulation management of TB-DM such as Standard Operational Procedures of TB-DM in the hospital. Important to dissemination of TB-DM report for the health workers in hospital. Important to disseminationof the Technical Guidance of TB-DM case finding at the Secondary Referral Health Facility for the organization of internist (lungs and endocrinologist).