Strengthening collaborative linkages for better NCD Interventions in Indonesia

Experiences with Posbindu

The increasing trends of Non-Communicable Diseases (NCDs) in the world, including Indonesia, require targeted and specific primary and secondary prevention [1,2].  Almost 1 in 3 adults in Indonesia has hypertension, but only less than 30% is aware of the hypertension status, and only 47% of people with Diabetes is aware of the diabetes status [3]. Therefore, hypertension screening is an important strategy to address increasing NCD burden in Indonesia.  

The Ministry of Health (MOH) in Indonesia launched the Integrated Health Post (Posbindu), as a community-based screening and prevention program for NCDs. However, previous studies have reported suboptimal implementation of Posbindu. Younger persons and males participated less than required; more than 80% of participants were female, and more than 50% were older than 50 years of age. Less than 25% of the visitors reported to be interviewed for NCDs risk factors during their first visit, less than 80% had anthropometric measurements, and less than 15% had blood cholesterol examinations [4].

Other studies also state that although effective pharmacological treatment is available, adherence to antihypertensive medications in patients with type 2 diabetes is known to be suboptimal. Notably, nonadherence to antihypertensive medication is associated with poor health outcomes [5,6,7]. While there is a national guideline on NCD screening, previous evaluation revealed the need for improved operational tools for the community health volunteers, called cadres. 

Posbindu tools

The Scaling up non-communicable diseases interventions in Southeast Asia (SUNI-SEA) project aimed at increasing services for NCD prevention and control in the community in Indonesia. Based on a key stakeholder meeting, with health officers, village midwives and nurses, cadres and Posbindu participants, it was concluded that the key to success lies in the collaborative efforts of stakeholders, particularly in establishing effective coordination between Posbindu cadres, Puskesmas officers, the Department of Health, and relevant resources including the village office. Resolving this issue would lead to improved resource allocation. Additionally, the importance of synergy between cadres, health centres, and the health office was discussed, as it plays a vital role in enhancing the overall quality of healthcare services and successful interventions.

Within the SUNISEA project a simplified algorithm for community-based screening was developed and implemented. This initiative is coherent with the ongoing primary healthcare integration as a part of health systems transformation in Indonesia.  The simple screening algorithm is used to identify people with NCD risk factors, especially hypertension and diabetes and to identify those who need referral. 

Training of cadres

The SUNI-SEA project developed a training programme for cadres. The training includes interactive sessions to improve knowledge and attitude regarding NCDs and the algorithm. Followed by practice sessions and simulation to improve skills and practice. In total 92 cadres were trained in three training sessions in Batang (1 session) and Kediri (2 sessions). Immediately after the training knowledge level increased, but decreased again after four months of training.  Skills levels showed some improvement immediately after the training and one year after the training. This shows that for maintaining levels of knowledge and skills regular supervision, on-the-job training and refresher courses are needed. Cadres indicated that they felt that the practical activities in the training can add more skills in implementing algorithms and doing the health checks in Posbindu activities.   

“The cadres have been able to check blood, have received sticks for glucose check, many cadres have come to check blood glucose for free, and have attended SUNI-SEA training and also training from PHC to take measurements.”(Health worker from PHC in Batang).

“After the training, we become more knowledgeable about Posbindu activities and know about non-communicable disease and also how to prevent it. We were also trained to carry out health checks at Posbindu. We become able to do the health checks at in Posbindu activities” (Cadre from Kediri).

Observations of the Cadres skills and practice showed improvements, and this was also reflected in Posbindu participants’ satisfaction

“Posbindu activities really helped me, I could know my health conditions regularly through blood pressure and blood glucose checks in the Posbindu activities.” (Posbindu Participant from Kediri).

“After joining Posbindu, I understand NCDs especially from the education given and the papers given to me (SUNI-SEA’s leaflet). It is also really helpful for me because we are able to check our health at Posbindu, such as controlling blood pressure and blood glucose.” (Posbindu Participant from Kediri).

Impact

Data regarding referral to Primary Health Care was obtained for a subsample of participants. The data showed that from almost 80 percent of high-risk participants (both from NCDs risk factors and examination), only less than eight percent of them were referred. Among others, reasons for non-referral included that the participants were given medicine during Posbindu activities (22.9%), that the participants were given education to maintain a healthy lifestyle (10.2%). Meanwhile, there were 55.6% of participants who were advised to go to the next Posbindu activities (55.6%). The majority of these participants were mostly those identified by NCDs risk factors screening, i.e., BMI, in which management at PHCs were not the standard of care. For these patients, lifestyle changes and regular visits to Posbindu were recommended. Other reasons were barriers in accessing healthcare such as the distance to next healthcare centre. 

“The primary healthcare facility is far away from my home, so even though it’s free, there are still costs for a motorcycle taxi or transportation to get there and the costs can be more expensive than the medicine. So, it’s better to go to the midwife or just buy medicine in the pharmacy, even though I have to pay, it’s closer to my home.” (Posbindu participant from Batang).

Conclusion

The algorithm improved the implementation fidelity among cadres. Hence, the simplified screening algorithm could be used for tools to strengthen NCD screening as a package of community-based health services by the cadres. However, repetitive training for cadres with methods of simulation, video review and on the job refresher training are needed. Hence, to improve the sustainability, we call for action from village/community authorities, primary health care and province/district health offices to allocate financing support for the implementation of the NCDs algorithm. 

Literature

[1] Zhou B, Perel P, Mensah GA, Ezzati M. Global epidemiology, health burden and effective interventions for elevated blood pressure and hypertension. Nat Rev Cardiol [Internet]. 2021;18(11):785–802. Available from: http://dx.doi.org/10.1038/s41569-021-00559-8 2. 

[2] Saeedi P, Petersohn I, Salpea P, Malanda B, Karuranga S, Unwin N, et al. Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: Results from the International Diabetes Federation Diabetes Atlas, 9th edition. Diabetes Res Clin Pract. 2019 Nov 1;157. 

[3] Riskesdas. 2018. Hasil Utama Riset Kesehatan Dasar. Ministry of Health Indonesia. 2018 

[4] Widyaningsih, V., Febrinasari, R.P., Pamungkasari, E.P., Mashuri, Y.A., Sumardiyono, S., Balgis, B., Koot, J., Landsman-Dijkstra, J. and Probandari, A., 2022. Missed opportunities in hypertension risk factors screening in Indonesia: A mixed-methods evaluation of integrated health post (POSBINDU) implementation. BMJ open, 12(2), p.e051315. 

[5] American Diabetes Association 10. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes-2019. Diabetes Care 2019;42:S103–23. 10.2337/dc19-S010  

[6] Ledur PS, Leiria LF, Severo MD, et al. Perception of uncontrolled blood pressure and nonadherence to anti-hypertensive agents in diabetic hypertensive patients. J Am Soc Hypertens 2013;7:477–83. 10.1016/j.jash.2013.07.006  

[7] Khan R, Socha-Dietrich K. Investing in medication adherence improves health outcomes and health system efficiency: adherence to medicines for diabetes, hypertension, and hyperlipidaemia. OECD Heal Work Pap 2018.