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New insights into the provision of health services in Indonesia : a health workforce study
Indonesia has made improving the access to health workers, especially in rural areas, and improving the quality of health provider's key priority areas of its next five-year development plan. Significant steps and policy changes were taken to improve the distribution of the health workforce, in particular the contracted doctors program and later the contracted midwives program, but few studies have been undertaken to measure the actual impact of these policies and programs. This book is part of the inputs prepared at the request of the government of Indonesia's national development agency, Bappenas, to inform the development of the next national development plan 2010-14. Other inputs include reports on health financing, fiscal space for health, health public expenditure review, and assessments of maternal health and pharmaceuticals. Study findings highlight the importance not only of improving the supply of health care, but also of improving quality, so as to improve health outcomes. Over the period studied, important gains in the determinants of health outcomes have occurred in Indonesia. At the same time, however, the study shows that Indonesia, despite the significant gains, continues to suffer from serious challenges in the number and distribution, and in particular the quality, of its health workers.
eBook
New Insights into the Supply and Quality of Health Services in Indonesia
Indonesia has made improving the access to health workers, especially in rural areas, and improving the quality of health providers key priority areas of its next five-year development plan. Significant steps and policy changes were taken in the past to improve the distribution of the health force, but few studies have been undertaken to measure the actual impact of these policies and programs. This study begins the process of reviewing the impacts of the past policies and policy changes. It links the changes in supply and quality of health workers to past health work force policies but also to changes in financing and civil service reforms policies. In addition, important aspects of health professional education and changes in demand for services are reviewed.
eBook
Depressive, anxiety, and burnout symptoms on health care personnel at a month after COVID-19 outbreak in Indonesia
Background
Health care personnel (HCP) who demonstrated close contact with Corona virus disease (COVID-19) patients might experience a higher risk of infection and psychological problems. This study aims to explore depressive, anxiety, and burnout symptoms among HCP with a higher risk for psychological trauma.
Methods
This study was a cross-sectional study using secondary data from an online assessment, which was conducted 1 month after the COVID-19 outbreak. A total of 544 respondents from 21 provinces in Indonesia were included. Data on depressive, anxiety, and burnout symptoms were transformed first using the Rasch model and then categorized. Data from HCP in the higher risk group and the lower risk group were analyzed.
Results
A higher percentage of HCP experiencing depressive symptoms (22.8%), anxiety (28.1%), and burnout (26.8%) are found in the higher risk group. The chance for the higher risk group’s HCP to present with moderate and severe depressive symptoms, anxiety, and burnout are: 5.28 (Confidence interval (CI): 2.01–13.89;
p
< 0.05), 1.36 (CI: 0.09–1.96;
p
> 0.05), and 3.92 (CI: 2.08–7.40;
p
< 0.05) times higher, respectively. The probability for patient-induced burnout is 2.13 (CI: 1.51–3.007;
p
< 0.05) times higher and highest among the other burn out dimensions. The depressive symptoms complained were similar between groups: loneliness, sleep disturbances, difficulty concentrating, and inability to initiate activities. Loneliness demonstrates the highest logit value among the symptoms.
Conclusions
HCP with direct contact and responsibility to treat COVID-19 patients exhibit a higher risk to experience depressive symptoms and burnout. Communication with peers and staying in contact with family needs to be encouraged. Psychological well-being should be considered for high-risk HCP. Incentive or insurance guaranteed by the government or institution is essential as a reward and compensation during this period.
Journal Article
Readiness of health posts for primary health care integration in Indonesia: a mixed-methods study
Background
Primary Health Care Integration (PHCI) is part of Indonesia’s health transformation initiated in 2022. After two years, not all districts/cities have implemented the change, especially related to Health Posts (HP). The study aims to assess the HP’s readiness to implement this transformation.
Method
A sequential exploratory mixed-method design was used. The first stage was explorative using a qualitative design and developing a quantitative research instrument. The second stage conducted a survey. Qualitative data collection through in-depth interviews and focus group discussions involving 42 informants: health cadres, health care workers, and City Health Office representatives. The qualitative data was processed with the ScreenQ software, and content analysis was carried out. Afterward, quantitative research instruments were built using predetermined theory, and validity and reliability tests were carried out. The quantitative survey involved 139 health cadres and 128 health care workers. The data obtained is transformed first using Rasch modeling (Winsteps 37). Then it was analyzed using SPSS software (SPSS 20), with readiness levels categorized into “not ready”, “moderately ready”, and “ready”. A comparison of readiness was performed between groups of respondents.
Results
Qualitative analysis identified Facilitators including health cadres enthusiasm, collaboration, and commitment. Barriers included human resource, facilities, data synchronization, and digital reporting. Quantitative results showed that 83.5% of Health Posts were classified as “moderately ready”, meaning they had some essential elements in place but still faced gaps requiring further strengthening before full implementation could succeed. No statistically significant differences were found in readiness perceptions between health cadres and health care workers (3.19 logit, CI: -12.91–19.27,
p
= 0.697).
Conclusion
This study provides baseline data for future research and policy development, offering insights into how to strengthen PHCI readiness in similar contexts, particularly by addressing the serious barriers that may hinder successful implementation.
Journal Article
Determinants of immunization status among 12- to 23-month-old children in Indonesia (2008–2013): a multilevel analysis
Background
Immunization is one of the most cost-effective public health interventions to prevent children from contracting vaccine-preventable diseases. Indonesia launched the Expanded Program for Immunization (EPI) in 1977. However, immunization coverage remains far below the United Nations International Children’s Emergency Fund (UNICEF) and World Health Organization (WHO) target of 80%. This study aims to investigate the determinants of complete immunization status among children aged 12–23 months in Indonesia.
Methods
We used three waves of the Indonesian National Socioeconomic Survey (2008, 2011, and 2013) and national village censuses from the same years. Multilevel logistic regression was used to conduct the analysis.
Results
The number of immunized children increased from 47.48% in 2008 to 61.83% in 2013. The presence of health professionals, having an older mother, and having more educated mothers were associated with a higher probability of a child’s receiving full immunization. Increasing the numbers of hospitals, village health posts, and health workers was positively associated with children receiving full immunization. The MOR (median odds ratio) showed that children’s likelihood of receiving complete immunization varied significantly among districts.
Conclusions
Both household- and district-level determinants were found to be associated with childhood immunization status. Policy makers may take these determinants into account to increase immunization coverage in Indonesia.
Journal Article
Individual and area-level factors associated with depression in Indonesia: a multilevel analysis using the 2018 national basic health research
Background
Depression has become the leading cause of disease burden in low- and middle-income countries. However, evidence on the determinants of depression in those countries has been limited. This study aims to identify the factors in individual and area levels associated with depression using existing nationally representative data in Indonesia.
Methods
Multilevel mixed-effects logistic regression models were performed on various national-scale Indonesian cross-sectional surveys and Indonesian Population Census to estimate those associations. We included adults aged 18 + who participated in the National Basic Health Research 2018 in this study. Depression was measured using the Mini International Neuropsychiatric Interview (MINI). Individual level variables include demographic characteristics, socioeconomic status, history of diseases, health behaviours, healthcare accessibility, and familial history of psychosis. District-level variables include the availability of health providers and professionals, regional gross domestic product, and the happiness index.
Results
We found that individual-level factors, i.e., education, occupation, marital status, economic status, comorbidities, health behaviours, and difficulty with healthcare access were associated with the risk of depression. Happiness index as district-level factor, is related to the odds of depression. District-level factors, including the availability of general practitioners and mental health professionals and the density of healthcare providers, had no significant association with depression. The measured variables provided modest explanatory value overall.
Conclusion
Individual-level factors are associated with depression among adults in Indonesia. Among the district level factors, only happiness index is related to depression. These results strengthen previous studies which stated determinants at the individual level are an important factor in depression. Therefore, effective prevention programs in mental health need to target both individuals and families.
Journal Article
Adolescent weight management counseling: The effectiveness of an online training program for primary healthcare professionals in Indonesia
Overweight and obesity are growing public health concerns globally for which innovative prevention and care delivery efforts are required. We recently developed a web-based training program to improve the quality of health professionals' weight management counseling of adolescents in Indonesia. Having previously confirmed its acceptability, this study aimed to measure the effectiveness of the program through a randomized controlled trial.
We recruited 64 primary healthcare professionals from 17 provinces across Indonesia who were randomized to participate in a 4-week online training program (intervention group [IG, n = 32] or a waitlist control group [CG, n = 32]). Using active learning approaches, the training program focused on adolescent development, psychosocial assessment, motivational interviewing (MI), and parent engagement. Participants in each arm were asked to record two counseling sessions with adolescents. These were objectively rated by trained psychologists using a validated tool, and also by qualitative assessment of counseling quality. In both groups, the first recorded counseling session occurred before the training. The second recording took place after the training for IG participants, but not for CG participants.
IG participants demonstrated significant improvements in their knowledge and counseling skills (p<0.001, t-test). This included improvements in introductory remarks, quality of psychosocial assessment, and MI skills. There was no change in the extent of parental involvement. The MI training successfully oriented the counseling sessions towards a more collaborative and participatory conversation for supporting behavioral change.
This novel online training program improved the knowledge and counseling skills of Indonesian primary healthcare professionals. Greater emphasis on engaging parents and more guidance on conducting telehealth counseling may improve parental involvement in future iterations.
Journal Article
Barriers and strategies to successful tuberculosis treatment in a high-burden tuberculosis setting: a qualitative study from the patient’s perspective
Background
Previously treated tuberculosis (TB) patients are a widely reported risk factor for multidrug-resistant tuberculosis. Identifying patients’ problems during treatment is necessary to control TB, especially in a high-burden setting. We therefore explored barriers to successful TB treatment from the patients’ perspective, aiming to identify potential patient-centred care strategies to improve TB treatment outcome in Indonesia.
Methods
A qualitative study was conducted in a province of Indonesia with high TB prevalence. Participants from various backgrounds (i.e., TB patients, physicians, nurses, pharmacists, TB activist, TB programmers at the district and primary care levels) were subject to in-depth interviews and focus group discussions (FGDs). All interviews and FGDs were transcribed verbatim from audio and visual recordings and the respective transcriptions were used for data analysis. Barriers were constructed by interpreting the codes’ pattern and co-occurrence. The information’s trustworthiness and credibility were established using information saturation, participant validation and triangulation approaches. Data were inductively analysed using the Atlas.ti 8.4 software and reported following the COREQ 32-items.
Results
We interviewed 63 of the 66 pre-defined participants and identified 15 barriers. The barriers were classified into three themes, i.e., socio-demography and economy; knowledge and perception and TB treatment. Since the barriers can be interrelated, we determined five main barriers across all barrier themes, i.e., lack of TB knowledge, stigmatisation, long distance to the health facility, adverse drug reaction and loss of household income.
Conclusion
The main treatment barriers can be considered to strengthen patient-centred care for TB patients in Indonesia. A multi-component approach including TB patients, healthcare providers, broad community and policy makers is required to improve TB treatment success.
Journal Article
Determinants of breast self-examination practice among women in Surabaya, Indonesia: an application of the health belief model
Background
Breast cancer has become one of the most common causes of mortality among Indonesian women. Many women in Indonesia present with late-stage breast cancer, negatively affecting prognosis and treatment outcomes. Better prognosis of breast cancer will be achieved if it is diagnosed in an earlier stage, thus efforts to detect breast cancer earlier are important. Breast Self-Examination (BSE) is considered as an important first step to encourage women to actively be responsible for their own health, especially for women in low-and middle-income countries with limited resources and access to other forms of preventive healthcare (e.g., screening programs). The present study aimed to predict BSE practice among women in Surabaya, Indonesia using the Health Belief Model (HBM).
Methods
This investigation was a cross-sectional survey which was distributed among 1967 women aged 20–60 years. The Indonesian version of Champion’s Health Belief Model Scale (I-CHBMS) was used to explain self-reported BSE practice. Logistic regression analysis was used to examine the association of HBM variables with BSE practice.
Results
44.4% of the respondents indicated they had performed BSE. Further, the results indicated that the HBM variables were significantly associated with BSE practice. Specifically, higher perceived benefits and self-efficacy, lower perceived barriers and less cues to action were unique correlates of BSE practice. The result also showed that perceived severity and susceptibility were not associated with BSE practice.
Conclusion
This study indicated that several HBM constructs significantly associated with BSE practice among Indonesian women, suggesting that BSE health education programs should emphasize the perceived benefits of BSE, focus on increasing women’s self-efficacy to address and overcome perceived barriers in performing BSE, and help them in identifying personally relevant cues to action.
Journal Article