Problems in Poor Paediatric Pneumonia Case Findings in Sumenep

Andi Susilo, Nyoman Anita Damayanti, Ernawaty Ernawaty, Nuzulul Kusuma Putri

Faculty of Public Health UniversitasAirlangga, Mulyorejo, Surabaya, Indonesia

nuzululkusuma@fkm.unair.ac.id

Keywords: Paediatric pneumonia, Case finding, Remote islands.

Abstract:

Sumenep is one of the districts in Indonesia with various geographical features. This district not only has a

mainland, but also remote archipelago. The number of paediatric pneumonia cases is high in Sumenep,

while new case findingsare still low. The remote conditions between regions mean that the healthcare

workers are limited when it comes to actively finding new cases of pneumonia which will lead to delayed

treatment. This study has analysed the factors that inhibit health workers in remote areas when it comes to

performing pneumonia case finding. This is an observational analytic research study with a cross-sectional

design. The samples in this study are 21 Puskesmas (public health centres) across Sumenep located in 18

mainland sub-districts and 9 island sub-districts. This study shows that a lack of knowledge is the only

responsible factor that affects the health workers’ performance in finding new cases of pneumonia (p=0,029;

ß=0,148). Surprisingly, limited upgrading skills for health workers and the high workload is that often

complained about does not significantly influence performance.

1 INTRODUCTION

The World Health Organization denoted that there

are at least 151.8 million incidents of pneumonia in

individuals under five in developing countries as

well as 4 million cases in developed countries every

year. Almost 10% are severe pneumonia that needs

hospitalisation. This forgotten killer of children has

increased in Indonesia. Even though prompt

treatment is a success when it comes to combating

the disease, it cannot always be done due to the low

number of new case findings. In order to improve

prompt treatment, the Indonesian Ministry of Health

has forced primary healthcare workers to actively

find new cases of paediatric pneumonia. Through

this active method of case finding, health workers

will sweep every corner of their coverage area to

identified suspected children. Geographical

problems then existed that obstruct the active case

finding.

East Java, as the province with largest

population in Indonesia, is also haunted by high

paediatric pneumonia. There is only one district in

East Java that has successfully reached the target of

paediatric pneumonia case finding. Moreover, with

the various geographical features, Sumenep faces

challenges in finding new cases across its remote

archipelago region. The coverage of the new case

finding method of paediatric pneumonia was only

7.59% in 2015.

Sumenep and other remote areas in Indonesia

have an experienced health worker shortage. There

is enough evidence that geographic location is

related to the high retention of health workers in

remote areas (Russell et al., 2013). Other studies by

Gross et al. (2012) have also explained that health

workers in remote areas tend to experience weak

health infrastructure and health system failures. This

condition refers to the high work load. Moreover, a

study by Mkoka et al. (2015) showed that health

workers in remote areas potentially have low

motivation to work because they feel abandoned and

lost within the unsupportive system that they serve,

and the difficult working and living environments.

The difficult access to the coverage area and the

high risk of poor employee retention makes it

possible to decrease the Puskesmas’ performance

not only in relation to paediatric pneumonia case

finding but also other Puskesmas tasks. This study

analyses how knowledge, upgrading skill

experience, motivation and workload will impact the

Puskesmas performance in the context of paediatric

pneumonia case finding.

350

Susilo, A., Damayanti, N., Ernawaty, . and Putri, N.

Problems in Poor Paediatric Pneumonia Case Findings in Sumenep.

In Proceedings of the 4th Annual Meeting of the Indonesian Health Economics Association (INAHEA 2017), pages 350-354

ISBN: 978-989-758-335-3

2 METHOD

This is an observational analytic study with a cross

sectional design. The data collection was conducted

from July to August 2016. The population in this

research study were Puskesmas (Primary healthcare

facility in sub district level) in Sumenep, which

amounted to 30 Puskesmas. The sample population

of this study was selected based on a stratified

random sampling technique resulting in 24

Puskesmas. The sample was proportionally based on

the criteria of the geographical condition of

thePuskesmas. It selected 17 Puskesmas located in

the mainland, 3 Puskesmas in remote islands, and 4

Puskesmas in the highly remote islands.

Unfortunately, 1 Puskesmas in remote areas and 2

Puskesmas in very remote areas were excluded from

the research sample due to high storms causing the

researcher to not be able to safely reach the location

of the Puskesmas.

The respondents consist of 5 peoplel each

Puskesmas have a job as a pneumonia program

manager. The technical officers consist of doctor,

midwife, nurse, and health promotion officer at the

Puskesmas. The knowledge, upgrading of skills and

experience, work motivation, and workload were

calculated on average to represent the condition of

the Puskesmas.A multiple linear regression test was

used to find the influence between the independent

variables with the achievement of the Puskesmas’

performance in relation to new case finding.

3 RESULT AND DISCUSSION

The Sumenep region consists of not only land, but

also islands. The land area is approximately as large

as 1.146.93 square kilometres (54.79%) consisting

of 17 districts. Although called ‘the land’ overall,

there is still a small island in this region. The

archipelago of Sumenep covers 946.53 square

kilometres (45.21%) which includes 126 inhabited

and uninhabited islands in 9 districts. Many islands

in Sumenep are still anonymous.

The access to health services in Sumenep is

highly correlated with the provision of health

facilities. Sumenep already has hospitals, Puskesmas

and private clinics as well as several other health

facilities. Puskesmas are the primary healthcare

facility managed by the District Health Office to

ensure that every person even in the more remote

areas of Sumenep will be able to access qualified

primary healthcare. The development of Puskesmas

in each sub-district is expected to improve the health

status of people not only through curative but also

through preventative actions.

Unfortunately, the availability of health workers

at the Puskesmas in Sumenep is still very limited.

With a large and difficult to reach area, there are

only 43 general practitioners (GPs) available with

ratio of 4.29 GPs per 100,000 populations. This ratio

is still far below the ideal ratio of 40 GPs per

100,000 populations. The ratio of nurses also only

reaches 38.43 per 100.000 populations, below the

ideal ratio of 117.5 nurses per 100,000 populations.

The midwife ratio also reaches only 51.04 per

100,000 populations, which means that it is still

under the ideal 100 per 100,000 population.

3.1 Factors of new case finding

performance

The Puskesmas performance in relation to the new

finding of cases of paediatric pneumonia is still low.

The majority of Puskesmas only can reach new case

findings no more than 30% per month. The low

achievement of new case discovery finding means

that prompt treatment for patients cannot be done

earlier. Many cases that should be able to be treated

precisely in the earlier phases are instead found in

the later stages. The Puskesmas performance in

paediatric pneumonia case finding is the result of

teamwork specially formed to tackle the paediatric

pneumonia in Sumenep. The team consists of 5

health workers who have their respective duties

according to their scientific fields. The team consists

of a program manager, doctor, midwife, nurse, and

health promotion officer.

This study shows that the majority of the team’s

knowledge about pneumonia and its prevention is

still low. Only 8 teams in Puskesmas have good

knowledge about pneumonia case finding activities.

The low knowledge of the Puskesmas officer in

performing the task potentially ruins the

performance of the case finding task. Knowledge is

fundamental and important, and must be owned by

someone before doing a certain job. Moreover, the

lack of knowledge is on what is meant by infant

pneumonia (47.6%). Most health workers are also

unable to answer correctly about how to calculate

the estimated cases of paediatric pneumonia

(81.0%). Table 1 shows the tendency of this low

knowledge in the Puskesmas performance.

Problems in Poor Paediatric Pneumonia Case Findings in Sumenep

351

Table 1: Puskesmas factors of new case finding

performance

Case Finding

Performance

Total

Poo

Goo

Knowledge n % n % n %

Poo

1 100 0 0 1 100

Moderate 12 100 0 0 12 100

Goo

6 75 2 25 8 100

Skills

upgrading

Never 10 90.9 1 9.1 11 100

Less 7 100 0 0 7 100

Enou

h 2 66.7 1 33.3 3 100

Work

motivation

Low 10 83.3 2 16.7 12 100

Moderate 7 100 0 0 7 100

h 2 100 0 0 2 100

Workload

High 12 92.3 1 7.7 13 100

Mediu

4 80 1 20 5 100

Low 3 100 0 0 3 100

Upgrading the skills in the case finding of

paediatric pneumonia is assumed to improve the

Puskesmas performance. The majority of officers on

all of the existing teams in the Puskesmas revealed

that there are only limited upgrading skills related to

paediatric pneumonia case finding that are available.

Supposedly if an officer has attended the training,

then the officer is more skilled at executing their

tasks in relation to case finding. The intensity of the

upgrading of the skills given to officers is still low.

Almost all of the team members at each Puskesmas

in Sumenep have not participated in training related

to the activities associated with paediatric

pneumonia case finding. This situation may prevent

the Puskesmas from achieving the established

performance targets.

In addition to the knowledge and skills of the

team of Puskesmas in performing their duties, team

performance can also be influenced by the

motivation of the officers to find new cases of

paediatric pneumonia. Most of the teams (12 teams)

have low motivation to do with finding new cases of

paediatric pneumonia. More than half of the

Puskesmas are not performing well due to the low

motivation of the team members in making new case

discoveries.

This study also analysed how the workloads of

the team members was related to carrying out the

task of finding cases of paediatric pneumonia. The

limited number of health personnel in Sumenep has

caused many health workers to have multiple tasks

associated with their other jobs in the Puskesmas.

Team members not only do their job of finding the

cases of pneumonia, but also keep doing their other

duties in Puskesmas. The low motivation of the

health officers makes sense according to this high

workload. They could be thinking that by identifying

new cases, it will multiply their workload.

The results showed that the workload owned by

the team tends to be high (13 Puskesmas). The

majority of the team members (85.7%) have

duplicate tasks within the organisation. This can

disrupt the officers' concentration on the new case

finding. The health workers (76.2%) stated that the

additional tasks prevented them from finding new

cases of paediatric pneumonia. Unclear task

distribution is also a problem for 61.9% of

Puskesmas. This is also exacerbated by the large

number of Puskemas whose team members have

tasks to do that do not fit their role.

3.2 The main problem

The result of multiple linear regression between

knowledge, upgrading skills, motivation and the

workload of Puskesmas with the performance of

pediatric pneumonia case finding in Sumenep

showed that only knowledge significantly influences

the data (p = 0,029; ß = 0,148). The better the health

officers’ knowledge is, the more it will improve the

officers’ performance on peadiatric pneumonia case

finding. Upgrading skills, motivation and workload

does not significantly influence the performance.

Table 2: Multiple linier regression result

Knowled

e 0,029 0,148

Skills upgrading 0,569 0,071

Motivation 0,393 0,890

Workloa

0,880 0,041

Teams in Puskesmas consist of various health

workers with different professional backgrounds.

Sun et al. (2017) explained that a team with diverse

members will trigger different skills and knowledge

needed for optimal individual and team learning. It

will improve the innovations at both individual and

team levels. ThereforePuskesmas should have a

better chance to perform innovative case finding.

Our results show that while both knowledge and the

opportunity for upgrading skill are poor in Sumenep,

it creates no leverage to enhance team diversity to

generate more innovative performance.

This study show that knowledge is the entry

point of upgrading skills to influence the Puskesmas

performance. Due to the poor knowledge of the

INAHEA 2017 - 4th Annual Meeting of the Indonesian Health Economics Association

352

health workers, even intensive upgrading skill

cannot improve performance. It means that the

health workers should be provided good knowledge

first, thus influencing their performance. Health

workers could feel that the limited opportunities for

them to participate in upgrading their skills will

worsen their motivation to do case finding actively.

Careful consideration should be given to risk

reduction strategies, enhanced vaccination coverage,

improved management of hypoxaemia and antibiotic

stewardship (Nguyen et al. 2017).

The low motivation of health workers in

performing case finding does not significantly affect

the Puskesmas performance. Working in difficult

mountainous and rural environments with limited

resources coupled with little opportunity to practice

in order to maintain and develop professional

competencies with poor supervision will demotivate

health workers when it comes to doing and showing

their best performance (Thi Hoai Thu et al., 2015).

This has happened in Sumenep. The various

geographical features of Sumenep hinders the health

workers when it comes to case finding. Limited

resources related to performing case finding worsen

the situation as well. The possibility of why

motivation not significantly influencedby

performance is due to the fact that health workers

could be already adapting to the bad work

environment.

On the other hand, Jaskiewicz & Tulenko (2012)

revealed that the productivity of health workers is

determined by where they work. The work

environment should be managed well to enable the

health workers to perform their tasks. Their study

also explained that a manageable workload, clear

organised tasks, reasonable geographic distance to

cover, supplies and equipment, supportive

supervisor, and community acceptance can allow

them to function better, leading to better

performance. Workload in this study also does not

significantly influence the case finding performance.

In the other hand, government collaboration with

the community agencies should be evaluated. Ortiz

(2011) mentioned that rates of well-child services

and preventive care improve with collaborative

efforts among government and community agencies

and physician offices. These findings imply that

intervention should include how to manage this

collaboration effectively.

4 CONCLUSION

The performance of the Puskesmas when it comes to

finding new cases of paediatric pneumonia in

Sumenep is influenced by the knowledge of its

health care workers. Poor knowledge of health

workers in Sumenep worsen by the limited

upgrading skills that is available. Health workers,

through the limited opportunity for experiencing

training to upgrade their skills, seems to experience

an erosion of their professional competencies and

development. It is also coupled with the difficult

geography of their respective coverage area.

ACKNOWLEDGEMENTS

We would like to express our appreciation to the

Master’s Program of Health Policy and the

Administration Faculty of Public Health at the

Universitas Airlangga for the support they have

given.

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