The contribution of service density and proximity to geographical inequalities in health care utilisation in Indonesia: A nation-wide multilevel analysis

Obstacles in Basic Health Service When Dealing with COVID-19: A Reflection for Improvement

Background & Aims

COVID-19 has been in control since mass vaccination and other coordinated efforts have been conducted. The WHO has even made an announcement to stop the public health emergency of international concern (PHEIC) toward COVID-19. Because of the very massive impacts of COVID-19, it is necessary to have a reflection toward what we have gone through to obtain information from inside the health service by interviewing the health officers who were the frontliners in fighting the disease during the pandemic. This research attempts to reveal the practical experiences of the officers when the COVID-19 pandemic took place.

Methods

This research conducted in-depth interviews with the Heads of Puskesmas (a Public Health Center) and the staff of Puskesmas in Medan. The total sample number of informants is 30 people. The data were managed by preparing the suitable themes with the inductive approach.

Results

There are three main themes obtained from the analysis results. Those three themes are 1) the condition of Puskesmas, 2) the impacts of the health service, and 3) the COVID-19 control. Those three themes show the fundamental problems affecting the efforts to overcome COVID-19. It is revealed that funding, personnel quantity, and bureaucracy cause the effort to overcome COVID-19 to have been impeded. Meanwhile, based on external factors, the officers had to deal with negative issues on COVID-19. Therefore, whether we like it or not to admit the fact, the health service has not been conducted maximally.

Conclusion

It is necessary to have comprehensive revision and change to evaluate the condition of health service, particularly in Puskesmas. A wider and deeper reflection is required so that the pandemic preparation in the future can be improved further.

The impact of multimorbidity among adults with cardiovascular diseases on healthcare costs in Indonesia: a multilevel analysis

BACKGROUND

Cardiovascular diseases (CVDs) are the leading cause of death in Indonesia, accounting for 38% of the total mortality in 2019. Moreover, healthcare spending on CVDs has been at the top of the spending under the National Health Insurance (NHI) implementation. This study analyzed the association between the presence of CVDs with or without other chronic disease comorbidities and healthcare costs among adults (> 30 years old) and if the association differed between NHI members in the subsidized group (poorer) and non-subsidized households group (better-off) in Indonesia.

METHODS

This retrospective cohort study analyzed the NHI database from 2016-2018 for individuals with chronic diseases (n = 271,065) ascertained based on ICD-10 codes. The outcome was measured as healthcare costs in USD value for 2018. We employed a three-level multilevel linear regression, with individuals at the first level, households at the second level, and districts at the third level. The outcome of healthcare costs was transformed with an inverse hyperbolic sine to account for observations with zero costs and skewed data. We conducted a cross-level interaction analysis to analyze if the association between individuals with different diagnosis groups and healthcare costs differed between those who lived in subsidized and non-subsidized households.

RESULTS

The mean healthcare out- and inpatient costs were higher among patients diagnosed with CVDs and multimorbidity than patients with other diagnosis groups. The predicted mean outpatient costs for patients with CVDs and multimorbidity were more than double compared to those with CVDs but no comorbidity (USD 119.5 vs USD 49.1, respectively for non-subsidized households and USD 79.9 vs USD 36.7, respectively for subsidized households). The NHI household subsidy status modified relationship between group of diagnosis and healthcare costs which indicated a weaker effect in the subsidized household group (β = -0.24, 95% CI -0.29, -0.19 for outpatient costs in patients with CVDs and multimorbidity). At the household level, higher out- and inpatient costs were associated with the number of household members with multimorbidity. At the district level, higher healthcare costs was associated with the availability of primary healthcare centres.

CONCLUSIONS

CVDs and multimorbidity are associated with higher healthcare costs, and the association is stronger in non-subsidized NHI households. Households' subsidy status can be construed as indirect socioeconomic inequality that hampers access to healthcare facilities. Efforts to combat cardiovascular diseases (CVDs) and multimorbidity should consider their distinct impacts on subsidized households. The effort includes affirmative action on non-communicable disease (NCD) management programs that target subsidized households from the early stage of the disease.

Effects of the COVID-19 pandemic on healthcare utilization among older adults with cardiovascular diseases and multimorbidity in Indonesia: an interrupted time-series analysis

BACKGROUND

The COVID-19 pandemic has disrupted healthcare utilization globally, but little is known about the effects among patients with cardiovascular diseases (CVDs) and other multimorbidities. This study analyzed the impacts of COVID-19 on healthcare utilization for patients aged 30 years and older with cardiovascular diseases (CVDs) with or without other chronic disease comorbidities in Indonesia.

METHODS

We designed a retrospective cohort study based on the Indonesian National Health Insurance (NHI) sample data from 2016-2020. We defined healthcare utilization as monthly outpatient and inpatient visits related to chronic diseases at the hospital and primary healthcare levels per 10,000 NHI members. We used interrupted time series analysis to evaluate how the healthcare utilization patterns had changed due to the COVID-19 pandemic.

RESULTS

Overall, hospital outpatient visits decreased by 39% when the pandemic occurred (95% Confidence Interval (CI): 0.48,0.76), inpatient visits by 28% (95% CI: 0.62,0.83), and primary healthcare visits by 34% (95% CI:0.55, 0.81). For patients with CVDs and multimorbidity, hospital outpatient and inpatient visit rates were reduced by 36% and 38%, respectively and primary healthcare visits by 32%. Some insignificant differences in the reduction of out-and inpatient visits were observed across diagnosis groups and regions.

CONCLUSION

Healthcare utilization among patients with chronic diseases decreased significantly during COVID-19 and consistently across different chronic diseases and regions. To cope with the unmet needs of healthcare utilization in the context of the pandemic, the healthcare system needs to be strengthened to cater to the needs of the population-at-risk, especially for patients with CVDs and multimorbidity.

Exploring Inequalities in the Use, Quality, and Outcome of the Diabetes Management Program of Indonesian National Health Insurance

Introduction

Access to diabetes management programs is crucial to control the increasing contribution of diabetes to the global burden of disease. However, evidence regarding whether such services are equally accessible for all population groups is still lacking, particularly in the context of low-middle-income countries and under the National Health Insurance (NHI). This study aimed to assess the extent of socioeconomic and geographical inequalities in the use, quality, and outcome of a diabetes management program for beneficiaries of Indonesian NHI.

Methods

A total of 628 participants in the NHI diabetes management program in Banyumas District, Indonesia, were included in 2021 in this cross-sectional study. The main variables measured were regular visits to primary care facilities, standard medication, and glycemic control. The rate difference and rate ratio of age-sex standardized prevalence rates, as well as multiple logistic regressions, were used to measure the extent of inequalities.

Results

Around 70% of participants regularly visited primary care facilities and received standard medication, but only 35% had good glycemic control. Highly educated participants were more likely to have regular visits compared to low-educated participants (odds ratio [OR] 1.92; 95% confidence interval [95% CI]: 1.04-3.56). Based on employment and type of NHI beneficiaries, a small extent and even reverse inequalities were found although these findings were insignificant statistically. Urban residents were also more likely to have regular visits (OR 6.61; 95% CI: 2.90-15.08), receive standard medication (OR 9.73; 95% CI: 3.66-25.90), and have good glycemic control (OR 3.85; 95% CI: 1.68-8.83) compared to rural residents.

Conclusions

Evidence on the extent of socioeconomic inequalities is inconclusive but substantial geographical inequalities in the use, quality, and outcome of diabetes management programs exist among Indonesian NHI beneficiaries. Future implementation policies of the program should consider particularly the geographical characteristics of participants to avoid and reduce inequalities and, hence, the disease burden of diabetes.

Knowledge, attitude, and practice of medication therapy management: a national survey among pharmacists in Indonesia

Introduction

The use of medication therapy management (MTM) is a proven method for reducing medication errors. MTM services rely heavily on pharmacists as service providers, particularly in community health centers (CHCs). Thus, understanding the knowledge, attitudes, and practices (KAP) of MTM among pharmacists in CHCs is crucial to the strategy for the implementation of MTM program in Indonesia. This study aimed to assess the level of KAP regarding MTM among pharmacists working at CHCs and its associated factors and investigate pharmacists' perceptions of the barriers and facilitators of MTM provision in the future.

Methods

A cross-sectional online survey was conducted. The respondents were pharmacists working at CHCs in 28 provinces in Indonesia. Descriptive statistics were used to summarize the responses. Demographic differences were determined using Chi-square and Kruskal-Wallis tests, and associations were identified using multivariable ordinal regression for knowledge and multivariable logistic regression for attitude and practice. Barriers and facilitators were determined from codes and categories of frequency derived from pharmacists' responses to the open-ended questions.

Results

Of the 1,132 pharmacists, 74.9% had a high level of knowledge, 53.6% had a positive attitude, and 57.9% had a positive practice toward MTM. Gender, practice settings, province of CHCs, years of practice, and experience in MTM services were factors associated with the KAP level. Respondents perceived that the chronic disease conditions in Indonesia, MTM service features, and current practices were facilitators of MTM provision. The lack of interprofessional collaboration, staff, pharmacist knowledge, patient cooperation, facilities/drug supply/documentation systems, stakeholder support, and patient compliance were the most common barriers to MTM implementation in the future.

Conclusion

Most of the pharmacists had high knowledge of MTM; however, only half had positive attitudes and practices toward MTM. Information about factors associated with the KAP level suggests that direct involvement is essential to improve pharmacists' understanding and view of MTM. Pharmacists also perceived barriers to the MTM provision in the future, such as interprofessional and pharmacist-patient relationships. A training program is needed to improve the KAP of MTM and develop skills for collaborating with other healthcare professionals and communicating with patients.

Introduction and implementation of an immunization information system in the Indonesian province of Daerah Istimewa Yogyakarta: lessons for scaling-up

BACKGROUND

Immunization is critical to saving children from infections. To increase vaccination coverage, valid and real-time data are needed. Accordingly, it is essential to have a good report system that serves as defaulter tracking to prevent children's immunization failure. The Daerah Istimewa Yogyakarta (DIY) Health Office introduced an electronic immunization registry and successfully implemented it for more than five years. It is the only individual-based record system in Indonesia that has been sustainably operated for a long time. Yet, no systematic assessment of this system has been conducted to date. This study examines the Sistem Informasi Imunisasi Terpadu (SIMUNDU) introduction and implementation process with a view to extracting lessons that could inform scalability and sustainability across the country.

METHODS

This study used an explanatory sequential mixed-method design, which collected quantitative data from 142 participants and qualitative data from nine participants. The data entry clerk at a health facility was systematically selected to participate in the survey, while in the key informant interview, the informant was selected based on the survey result. A descriptive and thematic approach was adopted to analyze the quantitative and qualitative data. Results from across the two approaches were integrated for comparison and contrast.

RESULTS

Findings are presented according to three core themes that emerged from the data: system strengths, potential threats, weakness and opportunities for scaling-up. Strengths, i.e., factors contributing to the success of SIMUNDU, include management, system performance, people's behavior, and resources. Potential threats to sustaining the system include individual capacity, technical or system issues, and high workload. Opportunities - i.e., a promising factor that influences the SIMUNDU ability to operate sustainably - such as continuity, expectation, and the possibility of scaling up.

CONCLUSIONS

SIMUNDU is a promising innovation for Indonesia, beyond DIY. There is agreement about the potential for scaling up this IIS to other provinces. The experience of implementing this system in DIY over the past five years has shown that the benefits outweigh the challenges, and SIMUNDU has grown into a robust yet user-friendly system.

Moderating effects of regional disparities on the relationship between individual determinants and public health service utilization among internal migrants: evidence from the China migrant dynamic survey in 2017

BACKGROUND

Regional disparities and individual determinants have a significant impact on the accessibility of national essential public health services (NEPHS) for internal migrants (IMs) Nevertheless, few studies have explored the interaction between these two factors.

METHOD

A cross-sectional sample of 102,632 IMs from the 2017 China Migrant Dynamic Survey was selected. The 28 provinces were divided into high-income provinces (HIPs) and low and middle-income provinces (LMIPs) according to their per capita disposable income (PCDI). Logistic regression was conducted using sex, residence duration, education, community type, migration range, social participation and relative personal income as independent variables, NEPHS awareness and health records registration (HRR) as dependent variables, and regional economic development level (REDL) as a moderating variable.

RESULTS

The rate of NEPHS awareness and HRR in HIPs (60.7, 30.6%) were lower (x² = 42.486, p < 0.001; x² = 25.573, p < 0.001) than those in LMIPs (62.9, 32.2%). After controlling for other variables, NEPHS awareness (OR = 1.379, p < 0.001) and HRR (OR = 1.661, p < 0.001) of IMs in HIPs were higher. Sub-group proportion of education Ms. in HIPs were higher. Sub-group = 1.379, p < 0.001) and HRR dependent mong internal migrants:, 61.0, 42.2%) were higher than those in LMIPs (60.4, 19.7, 35.8, 25.5%). Among urban communities, intra-provincial migration, social participation, education > 9 years, and middle-income, the protective effect of the first three factors on NEPHS awareness was greater in HIPs (OR = 1.386, p < 0.001; OR = 1.383, p < 0.001; OR = 2.008, p < 0.001) than in LMIPs (OR = 1.053, p < 0.001; OR = 1.109, p < 0.001; OR = 1.861, p < 0.001), while the effect of all five factors on HRR was greater in HIPs (OR = 1.440, p < 0.001; OR = 1.380, p < 0.001; OR = 1.895, p < 0.001; OR = 1.148, p < 0.001; OR = 1.146, p < 0.001) than in LMIPs (OR = 1.045, p < 0.05; OR = 1.169, p < 0.001; OR = 1.677, p < 0.001; OR = 1.027, p > 0.05; OR = 1.028, p > 0.05).

CONCLUSIONS

REDL directly affected the NEPHS utilization of IMs, and the negative effects of vulnerable characteristics on the NEPHS utilization of IMs were amplified in HIPs. The government is urged to regard IMs with vulnerable characteristics in HIPs as the key population in future NEPHS equalization and take targeted measures to stimulate their enthusiasm to participate in NEPHS.