Improving the quality of adolescent and child health care in Indonesia
The young residents of Bogor, a city located 60 km south of the Indonesian capital, Jakarta, have been benefiting from Adolescent-Friendly Health Services (AFHS) and the Integrated Management of Childhood Illness (IMCI) for the past several years. Today, staff from every one of Bogor's 24 health centres have been trained in IMCI and AFHS. The aim of both IMCI and AFHS is to improve the quality of the health services for children aged 0-5 years and adolescents aged 10-19 years, respectively.
In 2003, the Indonesian Ministry of Health in collaboration with WHO, trained staff at five pilot health centres (or Puskesmas, as they are called in Indonesian) to provide AFHS. Bogor Timur health centre was one of the five pilot centres, and has since continued to provide comprehensive AFHS, consisting of:
- Tobacco control;
- A sexually transmitted infections clinic;
- One-stop services for HIV and AIDS prevention, including voluntary counselling and testing; and
- Harm reduction measures, including needle exchange and methadone substitution therapy.
Bogor Timur was the "best performing" health centre in West Java Province in 2007, and is now used as a benchmark of AFHS nationally.
There is a designated counselling room for adolescents at the centre, to provide a more private and confidential environment. Here, they see around 10 adolescent patients per day, who are often accompanied by peer counsellors. For the adolescents who are not comfortable coming into the health centre, Bogor Timur's staff provide counselling by SMS, or arrange to meet them at an alternative location. The number of young people they see has been rising steadily since the introduction of AFHS.
Patients are asked to anonymously fill in feedback forms to measure how happy they were with the services received. The data from the forms is reviewed every three months, and graphs showing levels of patient satisfaction are displayed prominently in the clinic.
Another key function of Bogor's health centres is to train peer counsellors, of which there are currently 1,200. They learn about the main problems that affect adolescents -- sexual and reproductive health issues, drugs and how they affect the body, and healthy lifestyles (smoking, nutrition, and sanitation) -- as well as communication skills. Peer counsellors then disseminate the messages through one-on-one counselling, as well as other media such as seminars and talk shows on local radio.
Seventeen year old Muhammad Fahmi Himawan is the head peer counsellor in Bogor. He has been a peer counsellor for two years: "I was interested in the problems faced by adolescents, including my friends, and I wanted to help. I've also increased my own knowledge through being a peer counsellor."
Tanah Sareal, another health centre in Bogor, has been implementing IMCI since 2006 and was selected as the "best performing" health centre in West Java in 2008. They see approximately 100 patients under-five per month. Before IMCI, the doctors were overloaded. Now nurses help relieve them by classifying illnesses using the IMCI algorithm. They have observed lower prescriptions for antibiotics for children under five since implementing IMCI, and find that there is now more time to spend counselling parents on nutrition, sanitation, and early child development.
Sister Maya, a nurse at Tanah Sareal Puskesmas, said "Using the IMCI algorithms is simple. I go through it step-by-step, using a handful of simple tools like a timer to measure the child's heart rate, and a thermometer to take their temperature. I complete a checklist for every patient, and if a problem is complicated, I refer the patient to the doctor."
The main cases among children under five that they come across at the health centre are covered by IMCI: cough (which can indicate pneumonia), ear problems, diarrhoea, under or over nutrition, and fever (as a symptom of malaria, measles, or dengue).
Tanah Sareal has implemented an innovative system for measuring patient satisfaction. Patients are invited to rate various aspects of the services they received by placing either a green straw in a designated box if they're very happy, a yellow straw if they are satisfied, or a red straw if they are dissatisfied. The straws are tallied on a monthly basis and services are reviewed regularly to ensure high standards of quality are maintained.