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POLICY
INTEGRATION OF PRIMARY HEALTH SERVICES
by
dr. Then Suyanti, MM
Director of Public Health Governance

Delivered to:
Socialization and Advocacy for Primary Health Care Integration
November 26, 2023

1
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1. Background 2.
Integration of Primary Health Services 3.
ILP Trial Results
TOPIC 4. Scale – Up
ILP 5. Conclusion

2
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Achievement of Minimum Service Standards (SPM) year

2022 still low—target 100%
Data until March 13, 2023 Increase Decrease

Achievements (%)

SPM Indicator No 2020 2021 20221

1 Health services for pregnant women 84.51 82.54 75.83

2 Maternal health services 84.29 83.65 76.29

There are no SPM
3 Newborn health services 87.54 86.33 78.03
indicators that reach the
4 Toddler health services 87.54 79.07 71.98 100% target
5 Health services for primary education age 62.26 60.47 72.3

6 Health services for productive age 49.56 52.07 61.38

The SPM target will be achieved
7 Elderly health services 60.20 62.85 68.4 if health services
8 Health services for hypertension sufferers 48.22 49.53 59.69 strong primer with
ease of access
9 Health services for diabetes mellitus sufferers 72.12 71.86 73.56
society will
10 Health services for ODGJ are difficult 77.20 76.55 72.94 quality service
11 Percentage of people suspected of Tuberculosis 61.52 58.33 68.56

12 Health services for people at risk 62.80 63.19 69.26

infected with a virus that weakens the immune system
human body (HIV)

Source: SPM Secretary General, Directorate General of Regional Development, Ministry of Home Affairs 3
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Most of the deaths that occur in Indonesia are

preventable cases
Leading causes of death by age group
Preventable Some can be prevented Accidents and others

Baby Ratings Children Teenager Productive age Elderly

1 Neonatal disorders Neonatal disorders Transport accident Cancer Strokes

2 Congenital birth defects Congenital birth defects Cancer Heart disease Heart disease

Sexually transmitted Diarrhea Tuberculosis Strokes Cancer

3 infections exc. HIV

Accidental injury Diabetes mellitus

4 Lower respiratory infections Lower respiratory infections Lower respiratory infections

Diarrhea Accidental injury Diabetes mellitus Chronic obstructive pulmonary

5 Typhus and paratyphoid disease

Accidental injury Cirrhosis and other Tuberculosis Cirrhosis and other

6 Dengue fever
chronic liver diseases chronic liver diseases

Sexually transmitted Self-harm and inter-

7 Tetanus Transport accident Tuberculosis
infections exc. HIV personal violence

% of total 96.8% 76.4% 63.9% 72.6% 73.5%

deaths

Source: Health Metrics Evaluation Institute, Ministry of Health 2019 data 4

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Chronic diseases that are largely preventable are a leading

cause of death and fiscal burden

Indonesia is experiencing changes in the pattern of These 4 diseases cause the largest financing
diseases that cause the highest number of deaths burden
% change, Cardiovascular
2009 2019 2009-2019 diseases
10,300

Strokes 1 1 Strokes 25.9%

Cancer 3,500
Ischemic heart disease 2 2 Ischemic heart disease 28.3%

Tuberculosis 3 3 Diabetes 49.9% Strokes 2,500

Cirrhosis 4 4 Cirrhosis 8.2%

Kidney failure 2,300

Diarrheal diseases 5 5 Tuberculosis -26.8%

Thalassemia 0.509
Diabetes 6 6 COPD 10.7%

Neonatal disorders 7 7 Diarrheal diseases -21.2% 0.405

Haemophilia

COPD 8 8 Hypertensive heart disease 23.8%

Leukaemia 0.361
Lower respiratory infection 9 9 Lung cancer 42.4%

Hypertensive heart disease 10 10 Lower respiratory infection -14.4% Hepatic Cirrhosis 0.310

Lung cancer 13 12 Neonatal disorders -43.6% 0 2 4 6 8 10 12

Source: Institute for Health Metrics and Evaluation (IHME), BPJS Health (2020) 5
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1. Background 2.
Integration of Primary Health Services 3.
ILP Trial Results
TOPIC 4. Scale – Up
ILP 5. Conclusion

6
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The Ministry of Health is committed to transforming the health system

Indonesia—one of which focuses on primary services
Focus on Primary Health Care Integration

Vision

In line with the President's vision to create a healthy, productive, independent and just society

Improving maternal, child Strengthening the health

Accelerate improvements in Improve disease Community Movement system & drug
Outcomes health, family planning
and health community nutrition control Healthy Living (GERMAS)
RPJMN and food control
reproduction
sector
health

1 Primary Care Transformation 2 Transformation 3 Resilience System Transformation

Referral Service Health
a b c d a b
Education Prevention Prevention Increase primary Improve access Increasing the Strengthening
Resident primary secondary service capacity and quality resilience of the emergency
Role strengthening Addition and capability secondary services pharmaceutical response resilience
Screening for
cadres, campaigns and & tertiary & medical devices sector
6 Pillars routine immunization 14 causative diseases Reserve power
movement building, through
Transformation to 14 antigens highest mortality at each Network revitalization Development Deep production emergency response,
digital platforms and
and expansion target age, stunting and standardization service network country 14 routine table-top crisis
community figures
screening , & increased health center services, priority diseases, immunization vaccine preparedness exercise
coverage throughout ANC for maternal Integrated Healthcare Center, improved management antigens, top 10 raw materials
Indonesia health Health lab & government hospital medicine, top 10 medical
& baby home visits devices by volume & by value

4 System Transformation 5 HR Transformation 6 Technological Transformation

Health Financing Health Health
Health financing regulations with 3 objectives: Increased student quota, domestic & Development and utilization of technology, digitalization
available, sufficient and sustainable; fair allocation; international scholarships, ease of and biotechnology in the health sector
and effective and efficient utilization equalization of health workers from
overseas graduates
a Information technology b Biotechnology

7
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3 Main Programs to Strengthen Preventive Efforts in Primary Services

Routine immunization: 14 Screening Improved maternal health

from 11 to 14 types of vaccines
BCG, DPT-Hib, Hep B, MMR/MR,
Polio (OPV-IPV), TT/DT/td, JE, HPV,
PCV, Rotavirus
Cervical Cancer is cancer
which can be prevented by
Human Papillomavirus immunization
(HPV)
Pneumonia and diarrhea are
Priority Diseases and child
Screening for the highest cause of Monitoring children's growth and
death in each target age: development at Posyandu with tools
standardized anthropometry
1. Congenital hypothyroidism Pregnancy checks (ANC) from 4 times to
2. Thalassemia
3. Anemia
6 times, including 2 times
Ultrasound with a doctor in the 1st and 3rd
4. Strokes
trimester
5. Heart attack
6. Hypertension
7. Chronic obstructive pulmonary disease Breast cancer screening with
8. Tuberculosis Ultrasound

9. Lung cancer
2 of the 5 highest causes of under- 10. Hepatitis
five deaths in Indonesia* which can be 11. Diabetes Congenital Heart Disease Screening in
prevented by immunization 12. Breast cancer Community Health Center with Pulse Oxymetry
(PCV and Rotavirus) 13. Cervical cancer Neonates
14. Bowel cancer
8 8
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The Ministry of Health has set 3 focuses +270 million population

Integration of Primary Health Services Indonesia gets
Quality Primary Health Care

1. Life cycle as the focus of service integration

health as well as a focus for strengthening
promotion and prevention
+300 thousand units providing
2. Bringing health services closer through networks
rimer health services with
down to the village and hamlet level, including for standardized facilities and
strengthening promotion and prevention as well human resources
resilience to pandemics

3. Strengthen Local Area Monitoring

(PWS) through digitalization and monitoring with
health situation dashboard per village, as well as 100% of areas and
family visit
population health conditions
are monitored regularly
1. PWS: Local Area Monitoring

9
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One of the Important Strengthening in the Transformation of Health Services

Primary is Strengthening Structures that Reach the Community
Existing Conditions The expected conditions
Still fragmented
SUBDISTRICT
7,281 PUBLIC HEALTH CENTER PUBLIC HEALTH CENTER

VILLAGE/
WARD
83,794 Health Service Unit in Village/
POSCHESRI POLINDS PUSTU POSKESDES
PUSTU HEALTH CENTER Subdistrict
SERVANT (PUSTU)

DUSUN/
RT/RW Various types of UKBM (not yet integrated)

~300,000
Integrated Healthcare Center
Integrated Healthcare Center
Posbindu PTM UKK post
Elderly

INTEGRATED HEALTHCARE CENTER

Integrated Healthcare Center Malaria Post TB Post

Teenager

~273.5 million FAMILY / COMMUNITY HOME VISIT

resident

10
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Efforts to standardize services at Puskesmas, Pustu, Posyandu—across the life cycle

Strengthening Structure accompanied by Standardization of Health Service Packages
Service Providing Unit
Problem Target
Public health center
Health Pustu (Village/Subdistrict) Posyandu (Hamlet/RT/RW)
(Subdistrict)
1. Integrated ANC (6x + ultrasound by doctor) 1. Integrated ANC (K2,K3, K4, K6) 1. Class for pregnant
2. Class for pregnant 2. Class for pregnant women 2. Providing additional
women 3. Providing additional nutritional intake for pregnant women lacking energy women 3. Providing additional nutritional intake to pregnant women nutritional intake for pregnant
Chronicle (KEK) Chronic Energy Deficiency (CED) women with chronic energy
Pregnant women, giving
birth, 4. Normal postpartum deficiency (CED)
4. Postpartum Services (postpartum)
delivery 5. Postpartum services (postpartum) 5. Screening of violence against women and children
6. Screening for Violence against Women and Children (KtPA) (KtPA)
7. Dental and oral health services 8. Treatment 1. 6. Simple treatment
Essential Neonatal
Services 2. Classes for Mothers of 1. Essential Neonatal Services 2. Mother 1. Mother of Toddler
Toddlers 3. Services for of Toddler Classes 3. Class 2. Monitoring
Low Birth Weight (LBW) Babies Monitoring of Low Birth Weight Babies Growth and Development
4. Collection and delivery of SHK samples 5. Monitoring (LBW) 3. Complete Routine
Growth and Development 6. Complete Routine Immunization 7. 4. Monitoring Growth and Development 5. Complete Routine Immunization 4. Providing Vitamin
Providing Vitamin A and worm Immunization 6. Providing Vitamin A and worm medicine 5. Early

Babies and pre- school medicine 8. Prevention, early detection A and worm medicine Management and referral of detection, assistance
, toddlers 7. Prevention, early detection, management and referral of weight faltering, underweight, malnutrition, and referral for
children
malnutrition and stunting of toddlers weight faltering, underweight , malnutrition, malnutrition and stunting 8. Integrated Management of Sick Toddlers (IMCI) weight faltering, underweight,
9. Integrated Management of Sick Toddlers (MTBS) malnourished, malnourished
10. Screening for TB cases and stunted toddlers 6.
11. Screening for 9. Screening for TB cases Screening for TB cases
Thalassemia 12. Screening for Violence against Women and Children (KtPA) 10. Screening for
13. Dental and oral health services 14. Treatment Thalassemia 11. Screening for Violence against Women and Children
(KtPA)
12. Simple treatment 1. Health
1. Health screening (PTM & PM) screening 2. Vaccination / 1. IEC Adolescent Health 2.
2. Vaccination / Immunization Immunization 3. Adolescent Prevention of anemia
School age and 3. Adolescent Caring Health Services 4. UKS Care Health Services 4. Prevention of anemia 5.
Facilitation 5. Simple treatment
teenagers
Screening for Violence against Women and Children (KtPA)
6. Dental and oral health services 7. Treatment
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Efforts to standardize services at Puskesmas, Pustu, Posyandu—across the life cycle

Service Providing Unit
Target
Public health center Pustu
Health problems Posyandu (Hamlet/RT/RW)
(Subdistrict) (Village/Subdistrict)
1. Obesity screening 2. 1. Obesity Screening 1. Obesity Screening
Hypertension screening 2. Hypertension Screening 2. Hypertension Screening
3. DM screening 3. DM Screening 3. DM Screening
4. Stroke risk factor screening 5. 4. Cancer Screening (Breast Cancer, Cervical 4. Tuberculosis
Heart disease risk factor screening 6. Cancer Cancer, Lung Cancer) Screening 5. COPD
screening (cervical cancer, breast cancer, 5. Thalassemia Screening Screening 6. Malaria
Colorectal Cancer, Lung Cancer) 6. COPD Screening Screening 7. Visual Sense Screening
7. COPD screening 7. Tuberculosis 8. Mental Health Problem Screening 9.
8. Tuberculosis Screening 8. Malaria Pregnancy Screening for PUS 10.
screening 9. Vision screening 10. Screening 9. Vision Screening 10. Family Planning
Adult Age and Malaria screening 10. Mental Health Problem Screening 11. Services 11. Geriatric Screening
Elderly Fitness screening 11. Pregnancy Screening for PUS 12.
Thalassemia screening Screening for cases of violence against
12. Screening for cases of violence against women 13. women 13.
Screening for mental health problems 14. Family Planning
Reproductive health services for prospective brides and grooms 15. Services 14. Geriatric
Appropriate screening pregnancy for Screening 15 .Simple treatment
PUS 16. Family
planning services 17. Occupational disease
services 18. Geriatric
screening 19. Dental and oral health services
20. Treatment services 1.
Prevention, Early Awareness, Response 2.
Control
Environmental Quality Monitoring
Infectious diseases
1. Laboratory 2. 1. Laboratory with RDT 1. Laboratory with RDT
Pharmacy 3.
Other services Emergency 4. Inpatient
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Illustration of Primary Health Care System Working Patterns

To increase the scope and reach of interventions

Examples of local area monitoring patterns to increase coverage

X
services for the Pregnant Women-Teenager Cluster

Public health center

(Subdistrict) Area Monitoring

Local (PWS)
Dashboard to level
Management Cluster village

Mother Cluster - Age Cluster Mitigation Cluster

Child Adults-Seniors Infectious diseases

Laboratory
Community Health Centers and Units in
7
The village did
low ANC; Pregnant women with high SEZ; monthly evaluation
1 Act
Immunization coverage is low
The Community Health Center carries out an evaluation carry on
Units in Villages and Hamlets
5 Scheduled visits for cadres
coverage by area 6 carry out evaluations
check home based records (KIA book) during the visit
weekly
Pustu Follow-up home and identify missing services

Health Unit
Village/Subdistrict
The Community Health Center forwards the Hamlet/RT/RW
2
achievement evaluation data to the unit at
Village

4 Cadre followed up
evaluation problems
achievements and problems found
3 Posyandu forwards achievement Integrated Healthcare Center
with
evaluation data to cadres in the
Hamlet/RT/RW make home visits
Hamlet/RT/RW
Posyandu serves
all life cycles
13
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Organizational arrangement and resources of Community Health Centers based on clusters

• Cluster 1 coordinates
management and
Head of Community Health Center
administration
• Clusters 2 and 3 provide

Cluster 2 Cluster 3 Cluster 4 comprehensive service

Cluster 1
(Adult age and (Countermeasures Cross Cluster (prom, prev, curative,
(Management) (Mother and child)
Elderly) Infectious diseases)
rehabilitation and/or palliative) and P
Pregnant mother, Health Emergency • Cluster 4 stops
Administration Adult Age
Maternity, Postpartum Environment tan disease transmission with
surveillance and surveillance
Management Toddlers and Children environmental quality
Elderly Surveillance Hospitalization1
Resource Pre-school • In the event of limited human
resources, services can
Age Children
Management School and Laboratory be provided by officers from
Public health center
Teenager other clusters who have
appropriate
Management competence and authority.
Quality and Pharmacy
Safety One of the competencies
possessed by PJ and members
Management
Networking and Cluster 2 and Cluster 3 are
Network Community Health Services
Public health center

Information Systems
• The distribution of
Community Health Center and service rooms follows the cluster
PWS Dashboard system and service
1. At the Inpatient Health Center targets, 14 rooms are given
priority
close together in 1 cluster.
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The Health Service Unit in the Village/Subdistrict provides services

health and coordinating community empowerment in the health
sector
HR / implementing staff
Minimum:
• 2 Health Workers (1
nurse and 1
midwife), Activity
Health services and • 2 cadres empowerment
every day community in
the health sector

Room for weekly evaluation

cadre home visits and activities
Facilities, infrastructure and medical equipment comply with standards society participation
Health Service Unit in
Standardized service packages according to life cycle: Villages/Subdistricts are Empowerment activities in the health sector:
1. Screening, health education available in all villages/subdistricts 1. Village planning & empowerment
villagers
2. Limited treatment
Open time: 2. Posyandu cadre management
3. Laboratory with PoCT1
• Pk. 08.00 – 11.00: Service 3. Home visits
4. Village planning and assistance
• Pk. 11.00 – 15.00: Empowerment 4. PWS
Integrated Healthcare Center
community or visits
5. Home visits home—or in accordance with
6. Local Area Monitoring (PWS) local conditions

15
1. Point-of-Care Testing
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Pustu is responsible for the results of the community health status

in the village/sub-district
Pregnant women, giving birth, postpartum
Nutritional status of pregnant women.
Pregnancy, childbirth and postpartum are at risk.
Health problems in each life cycle that you want to overcome
Productive age Elderly
Babies and toddlers Teenager
PTM (hypertension, DM, Stroke, COPD), PTM (hypertension, DM, stroke,
Nutritional status, growth and development, Nutritional status, Juvenile anemia,
cancer, infectious diseases/infections COPD), cancer, nutritional
infections Dental caries, Vision hearing,
(TB, etc.), nutritional problems problems, vision, dementia.
Risky behavior , obesity, fitness problems
(anemia, obesity), mental emotional
the level of independence of
disorders and depression, fitness
the elderly, emotional mental disorders
problems, problems getting pregnant

• All Pregnant Women get checked

Pustu and Posyandu
content (ANC) Babies and • All targets are met • All targets receive • All targets receive
• All pregnant women attend prenatal Toddlers get: screening
health screening. screening
classes • Exclusive breastfeeding
• Ensure targets have health Hypertension, Diabetes Hypertension, Diabetes
• All pregnant women receive balanced • Basic immunizations and
problems Mellitus, heart and stroke,
nutrition education Mellitus, cancer, COPD,
advanced cancer, COPD, obesity,
• All pregnant women receive and get health services integrated geriatrics, symptoms
• Growth monitoring TB symptoms, mental
consume TTD
flower health problems, fitness, TB, cataracts, fitness
• Pregnant women with KEK get and • All young women consume
consuming additional food • Ensures sick targets get TTD suitability for pregnancy • Monitoring treatment
• All teenagers • Ensure fertile age compliance in
• All postpartum mothers health services receive reproductive health become a family planning acceptor targets with chronic diseases
get postpartum services education
• All mothers breastfeed

Home visits by cadres: ensuring the family has received health services, early discovery of health problems and danger
signs, monitoring compliance with treatment
2134
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The Ministry of Health continues to encourage integrated posyandu

services to support the transformation of primary services
Before Transformation Step2
Hope in the Era of Transformation
Still fragmented Integrated

1 Programmatic posyandu
DUSUN/ mapping
RT/ There are various types of UKBM

RW ~300,000 OPEN EVERY MONTH

2 Determination of posyandu
Integrated Healthcare Center Posbindu Integrated Healthcare Center

Integrated Healthcare Center Elderly PTM Teenager per work area (KK)
- Programmatic posyandu
THE ENTIRE CYCLE
amalgamation, or
LIFE
- Increase in the number of
posyandu, or
- Increase in the number of cadres, etc

3 Integrated posyandu
~273.5
VISIT development
Families/community who come to UKBM and Health Facilities
million inhabitants
HOUSE - Cadre training in 25
basic skills
- Provision of life cycle services

- Carrying out home visits

17
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Posyandu in the Era of Primary Service Transformation

Posyandu Opening Day Outside Posyandu Open Days

1 Every month 1 Home visit

Simultaneous or scheduled implementation to reach • Routine visits: all families • Special
all targets: visits: as needed for targets without access, incomplete

Executor: • Pregnant mother

• Toddlers
Productive age
Elderly services, etc
• Teenager
• Cadre 1
at least 5
2 Goals throughout the life cycle 2 Community empowerment
people
Integrated health services: Assisting health cadres/facilitators
•2Accompanied by • Pregnant mother Productive age
empowerment of the community within
• Toddlers Elderly
Health do:
• Teenager
• Introspective survey
workers • Village community deliberation

3 Preventive promotional services

3 Coordination of Subsidiary Health Centers
• Counseling Immunization,

• Early detection
• Cadre management
Supplementation
• Monitoring of local areas
• Rapid tests

18
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Increased cadre skills with 25 basic health skills

The Community Health Center carries out supervision and assigns a 'proficiency mark' if the cadre meets the health service skills at the Posyandu.
Embedding can be scheduled with the Head of Village/Outer Affairs/TP PKK/etc

Management Skills Pregnant Mother Skills, School Age Skills & Productive Age Skills &
Baby and Toddler Skills
Integrated Healthcare Center Breast-feed Teenager Elderly

Explain Conduct counseling

Conduct counseling Conduct counseling Conduct counseling
1 Posyandu management using the toddler section of the Germas
Fill My Plate Pregnant Women and fill my plate and activities
MCH Book
Breastfeeding mothers physique

Conduct breastfeeding education Conduct counseling Explain the anemia Conduct counseling
Make home visits
2 Exclusive, MP ASI and Giving using the KIA Book for pregnant prevention program non-communicable disease
Eat foods rich in animal protein women, postpartum (TTD for adolescent girls and infectious diseases
according to your toddler's age
and Hb screening)

Carrying out weighing, measuring Conduct counseling Explain age screening

3 Carry out recording and Conduct counseling
length/height Examination of Pregnant Women productive (hypertension, DM,
reporting dangers of smoking and cholesterol, uric acid, mental
body and head circumference as well and Mrs. Postpartum
drugs
plotting in the KIA Book health)

Implement communication Explain the measurement results
4 effective normal weight and height, deficient,
stunting and follow-up
Explain that pregnant women Explain age screening
advanced (hypertension,
need to monitor their nutritional status
and blood pressure DM, cholesterol, gout,
with the KIA Book curve mental health, geriatrics)

Carry out stimulation counseling Explain recommendations

5 development, vitamin A and medication drink TTD every day
Conduct family planning
worms according to the child's age during pregnancy education

Conducting outreach on routine Conduct counseling

6 immunization services sign monitoring
complete and PD3i dangers for pregnant women, postpartum
mothers

Conduct counseling
7 monitoring danger signs
babies and toddlers
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1. Background 2.
Integration of Primary Health Services 3.
ILP Trial Results
TOPIC 4. Scale – Up
ILP 5. Conclusion

20
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The structure has been tested at 9 locations in

Indonesia with High Success
Kick Off Integration Testing
Collaboration with the Ministry of Home Affairs and the Ministry of Villages PDTT Primary Health Care,
June 10, 2022

What? Period
ÿ Shifting focus to cycle-based primary care
life and conscious efforts to strengthen promotive and preventive. July 18 – October 15, 2022

ÿ Bringing health services closer through networks

maintenance in villages and hamlets, including strengthening
promotive, preventive and pandemic resilience

ÿ Strengthen Local Area Monitoring through monitoring

with a village level health situation dashboard

Locus
From each community
health center, trials were
carried out in 2 villages
and throughout
Posyandu in the village

21
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In general, changes in the number of visits to …apart from that,

health facilities between before and after ILP have cadres also
a positive trend... Increase Do not change carry out home visits
Decreased % % increase

Changes in visits before and after the pilot based on health facilities1
Have home visits been carried out by
District/Ko Province Public health center Prima Posyandu Integrated Healthcare Center cadres to >90% of targets?

Ogan Ilir South Sumatra +*

+42% +128%

Surabaya East Java

+10% +66% +84%

Tual Maluku +*
-40% +67%

Maros South Sulawesi +*

+34% +239%

Sumbawa Nusa Tenggara -5% +197% +19%

West West
Keerom Papua
-12% +* +16%

Garut West Java +457% +* +214%

Banjar Kalimantan +*
+13% +26%
South
Crossword
Nusa Tenggara +91% +187% +74%
East
1. % increase is the difference between the number of visits before the pilot (Jun – Jul) and the median number of visits after the pilot (Jul – Oct); the number of 1 service visits per life cycle is used as a
proxy for the number of visits: pregnant women – ANC, babies & children – Pantuan Tumbang, teenagers – PKPR, USPRO & elderly – hypertension/DM screening; comparison can only be done
temporally (before v after ILP) within 1 locus; comparison between loci is not possible due to variations in DO implementation * Increase of
>500% or cannot be quantified due to primary posyandu not operating well before pilot and only receiving <5 visits
22
Method: time series of number of health facility visits in 2 pilot villages
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Number of visits to health facilities: primary posyandu has changed

the highest number of visits of all health facilities

Changes in visits before and after pilot1 by life cycle group

Pregnant mother Babies and children Remj. Uspro and the elderly
District/Ko Province PKM Posprim PKM Posprim Posy. PKM PKM Posprim Posy.
Ogan Ilir Sumatra +* +* +*
Increase Do not change
N/A N/A 0 N/A -6% -30%
South Decrease % % enhancement

Surabaya, East Java +14% N/A +22% +150% -64% N/A +6% +58% +* There are no patients

Tual Maluku +* +* +*
+12% -8% N/A +29% +84% -52%

Maros Sulawesi +* +*
+158% 0 -5% +250% +117% +64% +16%
South
Sumbawa Nusa Tenggara -4% +250% +39% +200% +3% -15% +5% +196% +257%
West West
Keerom Papua
-39% +100% -9% N/A +40% -17% +133% +* -28%

Garut West Java +* +* +* +* +*

+138% +* 0 +73%

Banjar Kalimantan +* +* +* +*
-57% +22% 0 +33% +19%
South
Crossword
Nusa Tenggara -60% -11% N/A +36% +61% +167% +* +245% +125%
East

1. % increase is the difference between the number of visits before the pilot (Jun – Jul) and the median number of visits after the pilot (Jul – Oct); the number of 1 service visits per life cycle is used as a proxy for the number of
visits: pregnant women – ANC, babies & children – Pantuan Tumbang, teenagers – PKPR, USPRO & elderly – hypertension/DM screening; comparison can only be done temporally (before v after ILP) within 1 locus; comparison
between loci is not possible due to variations in DO implementation
* Increase of >500% or cannot be quantified due to prime posyandu not operating well before pilot and only receiving <5 visits
23
Method: time series of number of health facility visits in 2 pilot villages
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Home visits by cadres: cadres in 7 of 9 loci have carried out

home visits to >90% of targets (1/2)

Family not visited Visiting family XX Total targets in the area

1,575 2,982 1,577 388 669 539 931

1,281 1,120

0% 0% 0% 1% 3% 5% 10%
25% 27%

100% 100% 100% 99% 97% 95% 90%

75% 73%

NTB West Java Sulawesi East Java NTT Maluku Kalimantan Papua Sumatra
South South South

In aggregate, home visits have been carried out in 92% of

families across all loci
Method: the number of home visits made by cadres is compared with the total number of families in the area 24
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Home visits by cadres are able to identify High (>50%) Medium (5-50%)
missing service, non-compliance, and danger sign1 Low (<5%) XX % with missing service /
non-compliance
XX % with danger signs

Findings from home visits conducted at 9 loci

Danger sign
Missing service (health services that don't exist yet Non-compliance (non- (sign
Target danger)
accepted by target) compliance)
Don't have a Not ANC 1/2/3 Don't drink TTD Don't take part in prenatal class KEK's mother no
Pregnant mother
Pregnant mother KIA book
15%
22%
23%
87% get PMT
55% 14%
Don't have a Can't KF Don't give birth in a health facility Don't take vitamins. A
Mother giving birth KIA book
15% 52% 21% 44%
8%
Don't have Do not do Do not do Can't get KN1-KN3
Baby
Baby, child
0-6 months
KIA book
18%
immunization 21% monitoring fell 27% 60%
N/ A 7%
preschool
Don't have a Do not do Do not do
Toddler
6-72 months
KIA book
60%
immunization 21% monitoring falls 32%
4%
No Do not do Don't drink TTD Do not do Not doing PT
Teenager Teenager do check Lila 88% check for anemia screening 95%
BB/TB 52% 44% 60%

Age Don't have a book Not having HT screening 84% Check HT Not taking HT Medication
Age PTM
94%
98% 63%

productive Hypertension
productive
Check DMs
and elderly DM Don't have a book
PTM
Not screening
DM 95%
Do not take DM medication
78%
94% 93%

N/ A
Check HT Do not take HT medication
Elderly Don't have a book
elderly
Not doing HT screening
79% 21%
78% 99%
Hypertension
Check DMs Not taking DM medication
DM Don't have a book
elderly
No DM screening
31%
80% 91% 94%

Do not do Do not take TB3 medication

P2P2 All ages TB screening
Diagnosed with TB3
5%
15% 96%

1. Missing service: patients who have not received primary health services; Non-compliance: patients suffering from diseases (e.g. HT, DM) who do not follow the rules of health care (e.g. eating
drug); Danger sign: patients who show dangerous symptoms (eg swollen feet, fever) | 2. PPP – Controlling Disease Transmission | 3. Based on only ~30 TB patients 25
Method: the number of people receiving health services is compared with the total number of people visited
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1. Background 2.
Integration of Primary Health Services 3.
ILP Trial Results
TOPIC 4. Scale – Up
ILP 5. Conclusion

26
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National Launching of Service Integration

Primary Health
August 31 2023 at JIEXPO Kemayoran

1 2

1 Handover of KMK Juknis ILP

to the Governor of West Sumatra
as a regional representative

Signing of MoU
2
Synergy of Transformation
Health between the Ministry of Health,
Ministry of Home Affairs and Ministry of Village

3 4 3 Partner awards

4 ILP 9 Locus Award

27
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ILP Supporting Instruments (available/ on progress)

NSPK
Regulations
a. Health Law no. 17 of 2023 a. PUSTU Draft Guidelines
b. PP Health (on progress) b. Posyandu and Home Visit
c. Revised PMK 43/2019 – (on progress) Guidelines (along with Home Visit
d. KMK No. Form)
HK.01.07/MENKES/2015/2023 concerning c. ILP e-module (on progress) –
KMK ILP Technical Technical Guidelines online training via
Learning Management System
d. Health Screening Brochure
e. Care Pathway ILP
f. ILP Monitoring and Evaluation Guide
(on-progress)

11/27/2023 28
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Pillars of Transformation
Primary Services to
strengthen promotive
and preventive one of
them is by
screening

29
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Health screening
schedule for pregnant
women during antenatal
visits

30
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Health screening
schedule for babies,
toddlers and pre-school
children

31
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Health screening
schedule for school-
aged children and
adolescents

32
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Health screening
schedule for adult
children and the elderly

33
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Understanding, Functions and Benefits of Primary Care Integration Care Pathway (ILP)
In strengthening primary health care at Community Health Centers, Assistant Community Health Centers (Pustu) and Posyandu

FUNCTION
Care pathways cover a wider service area,
Practical tools for Puskesmas staff and their networks
including various service facilities
(health workers and cadres) in giving
health at various levels
services in accordance with the primary service integration cluster

BENEFITS FOR POSYANDU

Includes the flow of referral services both to higher Reference for posyandu cadres in carrying out ILP
levels and vice versa. home visits, education, detection and
monitoring

BENEFITS FOR PRISONERS

References in health services are appropriate
CARE

Aims to:
with Pustu's service capabilities

1) improve the quality of continuous care,

BENEFITS FOR HEALTH CENTER

2) improve the ability to estimate
risks of treatment outcomes thereby increasing
patient safety,
3) increase patient comfort
4) optimization of resource use.
The reference in preparing further SOPs is based
on the cases encountered in each cycle
ILP, including preparation of SPO for Pustu
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Service Flow: Adults

Family Integrated Healthcare Center Pustu Public health center FKTL
Adult Age

Visit Obesity Screening Thalassemia Screening

Home by
Check your health
Cadre independently
Hypertension Screening Malaria Screening (Endemic Areas)
Integrated Healthcare Center

Diabetes Mellitus Screening Visual Sense Screening

Results Can it be No
There is No Stroke Risk Factor Screening Fitness Screening Inspection
handled Refer to
Complaint
at FKTP? FKTL
Health
Heart Disease Risk Factor Screening Mental Health Problem Screening

Yes

Yes COPD Screening Pregnancy Eligibility Screening

Management in
Tuberculosis Screening Tetanus Immunization Status Screening FKTL

• Education •
Monitoring Breast Cancer Screening Reproductive Health Services
Obedience
Condition
Treatment
Cervical Cancer Screening Family planning services Stable

Lung Cancer Screening Dental and Oral Health Services

Colorectal Cancer Screening Refer Back

Management is in accordance with PPK

Monitoring Treatment Results

35
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Diabetes Mellitus Screening Family Integrated Healthcare Center Pustu Public health center FKTL

Goals that meet the criteria*

Home visit
by cadres
Yes Found
1. Style education Yes
Diagnosed complications/ Refer to
healthy living DM risk factors FKTL
Follow up results
2. Sweeping
home visit Inspection
targets that are
1. Note taking Carry out screening activities: Do complications/
not yet available
the results of the visit 1. Screening for DM risk factors inspection risk factors
screened
House 2. Measurement of height, weight comprehensive disturbance
3. Sweeping
2. Reporting results and abdominal circumference No blood vessel:
patients who
visit • Fundoscopy** Management in
are not in control No
home to Pustu • ECG FKTL
4. Sweeping
18-<40 18-<40 • Lipid profile
patients who
years old years old All ages • Urinalysis
are not compliant
without with ÿ 40 years
take medicine
risk factors risk factors Governance
Monitoring by cadres
according to Clinical Flow Refer back
if conditions
stable
Check sugar levels with a glucometer Refer to
Public health center

Normal Prediabetes Diabetes

(accompanied

symptom Normal Prediabetes

Education and intervention classic)

Education and intervention

Rescreening Control recommendations

Notes:
*Diabetes Mellitus Screening Targets:
1. Age 18-<40 years with risk factors for DM
2. All ages ÿ 40 years
3. All Tuberculosis Sufferers
**Fundoscopy or ophthalmoscopy, a part of the eye examination which aims to examine the back and inside of the eye including the retina, blood vessels, optic nerve and optic disc.
***Source: PPK e-book page 936
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Primary Health Care Integration Timeline

May - July – October January –

Nov – Dec 2022
June 2022 June 10, 2022 2022 August 2023 August 31, 2023 > September 2023

Kick Off Evaluation Preparation Launching

Preparation Trials Scale Up ILP
Trials Post Scale Up Scale Up
ILP trial ILP
ILP
Trials ILP ILP gradually

ÿ Maturation Trial Kick Off ÿ ILP orientation ÿ Preparation of results • Revision of Regulations • Signatory
Permenkes 43 years nan MoU • Complete
ILP concept Service Integration ÿ Mentoring ILP trial
Primary Health Implementation ÿ ILP recommendations
2019 concerning Synergy regulations
ÿ Coordination between K/L
Public health center Transformation
ÿ Preparation of materials-
(ILP) by the Coordinating Minister Trials ÿ Dissemination of results
• Synchronization of regulations
Health • Fulfillment
PMK, Minister of
test material Health, ÿ Evaluation ILP trial between K/L for • KMK Instructions Infrastructure, medical equipment,
Minister of Home Affairs and
strengthening Pustu ILP Technical
Secretary General of the Ministry of Villages
ÿ Revision of Regulations
Prime
HR
PDTT
• Preparation of Instructions • Accompaniment
post ILP technical
trials implementation of ILP
• Level ILP orientation
• Monitoring and
province
ILP Evaluation

37
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Regional Readiness in Implementing ILP

There are regulations issued by the Province/Regency/City for ILP commitment ÿ in the form of a Decree
1 on the implementation of ILP in the region

Kick Off, outreach, cross-sector advocacy ÿ to mobilize cross-sector commitment

2
Increasing HR capacity in implementing ILP (health workers, cadres)
3
Mapping of Community Health Centers, to determine the development of ILP in stages, can be based on
Adequate infrastructure, medical equipment, and human resources as well as the availability of pustu in the village/sub-
4 district, good commitment from stakeholders such as the sub-district head, head of the health center, village head/sub-district
head, and other elements

38
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38 Provinces and 463 Regencies/Cities have received offline ILP orientation (1/2)
Amount
Amount Number of Districts Amount Number of PKM Number of PKM
Amount PKM Number of PKM
No Province District/City in carry out PKM is socialized carry out
District/city Orientation BLUD
orientation ILP Province i ILP ILP
ILP
1 Aceh 23 0 0 365 0 46 0 4
2 North Sumatra 33 33 0 616 0 60 0 34
3 West Sumatra 19 19 0 280 0 95 0 217
25 Community Health Centers already
4 Riau 12 0 1 238 0 145 1* 224
Implement ILP
5 Jambi 11 11 0 208 0 0 0 93
6 South Sumatra 17 17 1 348 1 67 1 228 • 9 Locus Community Health Centers
7 Bengkulu 10 10 1 179 0 20 3 30 Trials
8 Lampung 15 15 0 319 0 42 0 232 • 15 top health centers
9 Kep Bangka Belitung 7 7 1 64 0 0 12 13 initiative and drive
10 Riau Islands 7 7 0 94 0 0 0 18 after the ILP trial
• 1 Community Health Center
11 DKI Jakarta 6 6 0 44 0 0 0 44
in Bali supported by Astra
12 West Java 27 27 1 1100 1 578 1 926
• 1 Community Health Center
13 Central Java 35 35 1 880 0 303 1 853
in Riau supported by Tanoto.
14 DI Yogyakarta 5 5 0 121 0 84 0 121
15 East Java 38 38 1 972 1 61 1 640
16 Banten 8 8 0 251 0 62 0 206
17 Bali 9 0 1 120 0 67 1** 91
18 NTB 10 10 1 176 1 109 9 103
19 NTT 22 22 1 433 1 228 1 10

: Districts/cities have been oriented but have not implemented ILP

39
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38 Provinces and 463 Regencies/Cities have received offline ILP orientation (2/2)
Amount Number of Amount Number of Number of PKM
Amount Number of PKM Number of PKM
No Province District/City PKM
districts implementing it in PKM socialized implemented
District/city ILP orientation BLUD
in orientation n ILP Province ILP an ILP

20 West Kalimantan 14 14 0 249 0 32 0 128

21 Central Kalimantan 14 14 0 204 0 56 0 60
25 Community Health Centers already
22 South Kalimantan 13 13 1 241 1 0 1 90
23 East Kalimantan 10 10 0 188 0 0 0 89 Implement ILP
24 North Kalimantan 5 5 0 58 0 0 0 10
15 15 0 199 0 127 0 0 • 9 Locus Community Health Centers
25 North Sulawesi
13 13 0 218 0 95 0 0 Trials
26 Central Sulawesi
27 South Sulawesi 24 24 1 474 24 173 1 135 • 15 top health centers

22 initiative and drive

28 Southeast Sulawesi 17 17 1 306 0 106 1
after the ILP trial
29 Gorontalo 6 6 0 95 0 77 0 21
• 1 Community Health Center
30 West Sulawesi 6 6 0 98 0 4 0 13
in Bali supported by Astra
31 Maluku 11 11 1 228 1 8 1 0
• 1 Community Health Center
32 North Maluku 10 10 0 149 0 45 0 2
in Riau supported by Tanoto.
33 West Papua 7 0 0 76 0 0 0 0
34 Papua 8 8 1 119 1 0 1 1

35 South Papua 5 5 0 79 0 0 0 0
36 Central Papua 8 8 0 117 0 0 0 0
37 Papua Mountains 8 8 0 148 0 0 0 0
38 Southwest Papua 6 6 0 91 0 0 0 0
2690
TOTAL 514 463 (90%) 15 (2.9%) 10,415 24 (0.23 %) ( 25.93%) 26 (0.25%) 4658 (46%)

: Districts/cities have been oriented but have not implemented ILP

40
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2024 Budget Support Plan

Central Activity Plan and Support for Regional Activities

Central APBN Deconcentrated APBN Physical and Non-Physical DAK (BOK)

Dit. Takelmas:
1. Preparation of the NSPK primary
service integration program
2. Coordination meeting
initiative program activities
primary care integration
3. Socialization of ILP dissemination
Province:
1. Primary Service Integration Management
Orientation for Health Workers and
Cadres
2. Monitoring and Monev
Implementation of Primary
Service Integration
Regency:
1. Renovation of heavily damaged Pustu (with complete
human resources)
2. Preparation for implementing ILP a. coordination and
advocacy b. socialization
3. Assistance in implementing ILP
4. ILP orientation for Community Health Centers
5. ILP orientation for Pustu

4. Orientation of Central Level Primary Public health center:

Service Integration Facilitators 1. PKM assistance to Pustu and Posyandu
2. Transport cadres for home visits
5. Monitoring and Evaluation Assistance
3. Simpus Subscription
implementation of ILP 4. Internet Support
6. ILP Evaluation Meeting 5. Support for the fulfillment of medical equipment for PKM,
Pustu, Posyandu

41
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ILP in Community Health Center Accreditation*

a. Have a Cluster SK according to the life

cycle b. Have an ILP Service SOP
c. Have a Decree on Determining Human Resources at the Pustu (at least one midwife and one nurse as well
two cadres) in at least 1 village/kelurahan
d. Have an integrated Posyandu Cadre Decree in all posyandu in the Pustu work area (as in point
c)
e. Have a Decree on Using the Community Health Center Information System

Operational Definition of ILP Health Center

The Community Health Center has implemented cluster-based services with a life cycle; have a minimum of 1
Pustu with 2 health workers and 2 cadres; All integrated Posyandu must have a minimum of 5 cadres and cadres carry
out home visits under Pustu coordination

*process proposed in accreditation requirements 42

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1. Background 2.
Integration of Primary Health Services 3.
ILP Trial Results
TOPIC 4. Scale – Up
ILP 5. Conclusion

43
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1 2 3 4
Service Integration Reach expansion Through integration Central government,
Primary Health focuses health services health services Regions, Villages as well
primer for primary, role all potential partners
service based closer access Community Health Center as in the health sector
approach service is performed person responsible has a decisive role to
life cycle, no with inner region
program-based utilize health in the work area sustainability
with implementation Pustu as a health will improve service integration
integration of utility services unit in villages/ reinforced with primary health
creating services kelurahan and active PWS level
more health Institution village/sub-district by
Comprehensive, Village Community health workers
responsive and affordable Posyandu at level with cadres
hamlet/RT/RW

44
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