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Background: In Indonesia, Family Medicine as a discipline is being developed through short courses since 12 years ago. A conversion program to become Family Physicians has been introduced recently. Among the 70,000 primary care physicians there are variety of practitioners, from new interns who start general practice to senior general practitioners. This study aims to describe the current Indonesian Primary Care Physicians (PCPs) profile which includes services provided and facilities as well as comparing the profile according to participation in the conversion program and practice hours. Methods: A survey was carried out by using pre-tested, semi-structured and self-administered questionnaire among Indonesian primary care physicians (PCPs) who attended ASEAN Regional Primary Care Conference in Jakarta, November 2011. The survey elicited information regarding their practice environment, services provided, equipment, investigations provided, procedures, facilities and continuing medical education (CME) activities. Results: Out of 240 PCPs participated, 65.4% (157/240) of them were family physicians and 67.1% (161/240) of them were full time practitioners (practice > 30 hours per week). Services like body mass index (BMI) measurement, substance abuse program, respiratory function test, mental health assessment, and cardiovascular assessment were provided by less than 50% of the PCPs as well as some investigations like electrocardiograph (ECG), proctoscopy, ultrasound, visual examination and funduscopy. Family Physicians significantly provided more house call services (77% vs 63%; p = 0.01), than those who are not. No other significant difference was found in the practice of the family physicians compare to non-family physicians. Conclusions: The Indonesian PCPs were lacking in the provision of some particular medical procedures, management and follows up of acute and chronic conditions, and preventive medicine and health education. Improvement of primary health care has been seen globally as necessary effort in health systems reform and this information could provide guidance toward the efforts to improve the quality of primary care physicians in Indonesia. Keywords: Primary health care, General practice, Family practice, Health service survey, Indonesia * Correspondence: firstname.lastname@example.org Department of Community Medicine, Faculty of Medicine Universitas Indonesia, Jl. Pegangsaan Timur 16, Jakarta 10430, Indonesia Full list of author information is available at the end of the article © 2014 Widyahening et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Widyahening et al. Asia Pacific Family Medicine (2014) 13:16 Page 2 of 6 Background Regional Primary Care Conference in Jakarta, November Primary care is one level of health system which pro- 2011. The survey form is modified from the Malaysian vides first point of care to the population and has easy Quality Improvement Program which has detailed sur- access, low cost, continuous, coordinated and compre- veys on structure, clinical processes and clinical out- hensive care as its core attributes . General practi- comes . The modified version has been used to profile tioners/family physicians hold a central role in provision practicing doctors in Malaysia. The survey elicited infor- of healthcare services in most countries even though mation which reflect four areas of service provision pro- there are variations with regard to the levels of training, vided by primary care: 1) as the doctor of first contact in organization and service deliveries . health-related matters, 2) in minor surgical and investi- Different surveys to describe the profile of primary care gative procedure, 3) in the management and follow-up practice has been conducted in several countries [3-6]. of a broad range of acute and chronic diseases, and 4) in However, none of these surveys described the primary care preventive medicine [5,6]. The items in the questionnaire practice in South East Asian countries. Indonesia is the were classified in to practice environment, services pro- biggest country with the largest population within the vided, equipment, investigations provided, procedures, fa- South East Asian countries. The number of general practi- cilities and continuing medical education (CME) activities tioners (GP) in Indonesia is around 70,000 while the spe- in accordance with the Malaysian Private Healthcare Facil- cialist is 16,000. Currently, every medical school graduates ities and Services Act Regulation 2008 which is then ad- in Indonesia is prepared to practice as GP after they justed to the Standard of Practice of the Indonesian complete a one year internship program. Family medicine Family Physicians. is not yet recognized as a specialty. Other neighboring A pilot test was done and modification of the ques- countries such as Malaysia, Singapore and the Philippines, tionnaires was done in accordance with the finding of have general practice vocational training program (3–4 the pilot test. Reliability of over all 46 items of the data year), commencing after a basic medical education degree collecting tool (Cronbach’s alpha) was 0.804. Indonesian . To make the Indonesian GP’s qualification equal with PCPs who practiced more than 30 hours per week are other South East Asian countries, a structured post- defined as full time practitioners while those who prac- graduate training program is currently being developed. ticed less than 30 hours per week are classified as part- As part of the preliminary process, a conversion program time practitioners. The PCPs were also classified into is being conducted to accredit GPs who already imple- family physicians who passed the conversion program ment certain level of family medicine approach in their and non- family physicians who have not yet attained clinical practice. The conversion program is intended for the conversion program. GPs who have been in practice for at least 5 years and The questionnaire was put in the delegates pack to- undergo an assessment of competence for the GPs who gether with an information leaflet on consent for survey want to improve their status to family practitioners . participation. Returning of the self-completed question- They have to complete a form which serves as record of naire by responders was taken as their consent. The their past and current medical practice and professional Health Research Ethics Committee of the Faculty of activities. After the conversion, they become the member Medicine Universitas Indonesia reviewed and approved of the Indonesian Association of Family Physicians (PDKI) the study. with status as Family Physicians and need to participate in A cross analysis using chi-square or fisher test (as ap- continuing professional development program on a regu- propriate) was done to find out the association between lar basis. practice hours, conversion program and their practices. This survey is part of a surveys conducted in four coun- All analyses were performed using the SPSS 11.0 (SPSS tries (Indonesia, Malaysia, Myanmar and the Philippines) Inc., Chicago, IL). to assess the current Primary Care Physicians/General Practitioners profile and their CME activities. In this re- port we only describe the Indonesian data and aim to Results compare the profile of those participated in the conversion Total 240 Indonesian PCPs participated in the study; 144 program with those who do not participated as well as of them (60%) were female. Most of them (175/240, 73%) comparing based on the practice hours. practice in Java (the most populated island in Indonesia) or in the provincial capital cities of Indonesia. Out of 240, Methods 65.4% (157/240) of them were Family Physicians and A cross-sectional descriptive and analytic study was car- 67.1% (161/240) of them were full time practitioners. ried out by using pre-tested, semi-structured and self- Majority (150/157, 95%) of the family physicians prac- administered questionnaire among Indonesian primary ticed more than 5 years and 83% (134/161) of full-time care physicians (PCPs) who attended the 2nd ASEAN PCPs were the main practitioners in the clinic. Widyahening et al. Asia Pacific Family Medicine (2014) 13:16 Page 3 of 6 The Family Physicians significantly provided more house that services provided by Indonesian PCP were espe- call services (77% vs 63%; p = 0.01), than non-family physi- cially lacking in the application of medical procedures cians. Certain aspects were found more in family physi- such as minor surgical and investigative procedures, cians such as dispensing medicine in clinic, certifying management and follows up of acute and chronic condi- workers for fitness, women’s health services, family plan- tions, and preventive medicine and health education. ning services, providing substance abuse program, cardio- The low availability of certain investigative procedures vascular assessment, prescribing herbal medicine to some such as respiratory function test, electrocardiography, patients, medical nutrition therapy, satisfactory with med- ultrasonography, visual examination with an ophthalmo- ical equipment they have, doing urine examination, blood scope or proctoscopy might due to the cost of equipment glucose test, visual examination, fundoscopy, soft tissue and cost of services. When this survey was conducted, uni- infiltration, cosmetic surgery, and keeping medical rec- versal coverage had not been implemented in Indonesia ord; but these variations were not statistically signifi- thus higher proportion of Indonesian population was not cant (Tables 1 and 2). covered by health insurance. Yet, it is possible to encourage Fewer family physicians provide acupuncture (16% vs the use of some equipment such as ophthalmoscope or 29%; p = 0.02) and hypnotherapy (7% vs 16%; p = 0.03) simple respiratory function test which is quite affordable. compare to non-family physicians. Provision of those services determine the comprehensive- There was significant differences between full-time prac- ness of primary care services ; one of the role intended titioners and part-time practitioners with reference to for primary care . emergency care services (85%. vs 70% -p = 0.01), in provid- Non-communicable diseases including cardio-vascular ing substance abuse program (42% vs 28%; p = 0.04), doing diseases, diabetes mellitus, chronic respiratory problem, urine examination (75% vs 62%; p = 0.04), blood glucose mental health problem and substance abuse are emer- test (90% vs 77%; p < 0.01) and ECG (39% vs 23%; p = 0.01) ging as the major threat in Indonesia  and the PCPs at clinic, providing minor surgery (89% vs 77%; p = 0.03) were expected to be actively involved in managing those and soft-tissue infiltration (47% vs 32%; p = 0.02); and problems. Yet in this survey we found that low propor- keeping registers for chronic disease (68% vs 53%; 0.04) tion of PCPs provide services that were highly relevant and electronic medical records (54% vs 41%; P = 0.04). to those problems such as body mass index (BMI) meas- Regarding continuing medical education for general urement, cardiovascular assessment substance abuse practitioners, no statistically significant different was found program and mental health assessment. between the family physicians vs non-family physicians It was found that Family Physicians tend to provide and the full-time vs part-time practitioners (Table 2). more house call services and less acupuncture and hypno- therapy compare to those who are not Family Physicians. Discussion Those who practice more than 30 hours per week tend to This study demonstrates the variety of skills and services have facilities to cope with emergency care, providing sub- provided by some practitioners in order to examine stance abuse program, treadmill assessment, urine exam- whether any or all of the services which are essential in ination, blood glucose test, ECG, minor surgery and soft an Indonesian environment were provided. Fifty percent tissue infiltration, have separate register for chronic dis- or less of the PCPs provides body mass index (BMI) ease and electronic medical record when compared to measurement and cardiovascular assessment as well as those who practiced less than 30 hours a week. providing substance abuse program and mental health This pilot study was limited in that it was conducted assessment. Investigative procedures such as respiratory among a selected group of delegates who attended a function test, electrocardiography, ultrasonography, vis- conference. It is evident that this cross-sectional survey ual examination with an ophthalmoscope and even proc- studied the primary care physicians who worked in the bigger cities of Indonesia and has shown that encour- toscopy are also low among the PCPs. The range of services provided by primary care varies aging primary care physicians to submit to a conversion considerably from country to country. Boerma, et al. program has elevated the practitioners to a higher level of care in terms of skills and services in a developing found that primary care physicians in western Europe generally have stronger role compare to those in the country like Indonesia. Further this study has shown eastern Europe . The practice among countries in that longer hours of practice also improves provision of care by primary care practitioners possibly due to the eastern Europe itself shows considerable differences . Our study shown that many of the Indonesian primary higher number and variability of patients/cases managed care physicians do not provide services usually carried- by the physicians. As Roger Jones  argues, strength- ening general practice especially with strong educational out by primary care physicians in other countries. With regard to the four areas of service provision provided by support is the basis of primary healthcare system and primary care as defined by Grielen et al.,  we found not secondary or tertiary care. Profiling general practice Widyahening et al. Asia Pacific Family Medicine (2014) 13:16 Page 4 of 6 Table 1 Practice environment, services, investigation and procedures provided by primary care physicians (PCPs) in Indonesia (N = 240); comparison based on the participation in Family Medicine conversion program and practice hours Overall PCPs classification Practice hours per week Family physicians* Non-Family p*** >30 hours <30 hours p*** (N = 157) Physicians (N = 83) (N = 161) (N = 79) n% n % n % n % n % Practice environment Full time practice** 161 67 102 65 59 71 0.34 - - - - Practice > 5 years 221 92 150 96 71 86 <0.01 148 92 73 92 0.9 Main practitioners in the clinic 185 77 123 78 62 75 0.42 134 83 51 66 <0.01 Services Facilities for emergency care 191 80 129 82 62 75 0.07 136 85 55 70 0.01 House call 173 72 121 77 52 63 0.01 116 72 57 72 0.46 Dispensing Medicine in clinic 191 80 128 82 63 76 0.35 130 81 61 77 0.81 Immunization 170 71 110 70 60 72 0.88 121 75 49 62 0.1 Measuring BMI 110 46 72 46 38 46 0.92 82 51 28 35 0.06 Certifying workers for fitness 151 63 103 66 48 58 0.12 105 65 46 58 0.15 Women/reproductive health 169 70 114 73 55 66 0.93 117 73 52 66 0.37 Family planning services 198 83 135 86 63 76 0.05 133 83 65 82 0.88 Substance abuse program 89 37 59 38 30 36 0.61 67 42 22 28 0.04 Respiratory function test 78 33 47 30 31 37 0.32 56 35 22 28 0.51 Mental Health assessment 129 54 83 53 46 56 0.73 92 57 37 47 0.13 Cardiovascular assessment 127 53 85 54 42 51 0.36 91 57 36 46 0.16 Treadmill assessment 52 22 31 20 21 25 0.29 34 21 18 23 0.9 Prescribe herbal medicine 101 42 69 44 32 39 0.42 70 44 31 39 0.53 Medical nutrition therapy 158 66 108 69 50 60 0.08 108 67 50 63 0.76 Equipment Satisfactory with medical equipment they have 144 60 99 63 45 54 0.1 103 64 41 52 0.2 Investigation Urine examination 170 71 114 73 56 68 0.41 121 75 49 62 0.04 Blood glucose test 206 86 136 87 70 84 0.63 145 90 61 77 <0.01 ECGs 81 34 53 34 28 34 1 63 39 18 23 0.01 Proctoscopy 39 16 25 16 14 17 0.58 29 18 10 13 0.51 Ultrasound 68 28 44 28 24 29 0.91 46 29 22 28 0.88 Visual (visus) examination 138 58 95 61 43 52 0.2 97 60 41 52 0.22 Funduscopy 89 37 59 38 30 36 0.61 59 37 30 38 0.22 Procedures Minor surgery 204 85 132 84 72 87 0.7 143 89 61 77 0.03 Soft tissue infiltration 101 42 67 43 34 41 0.79 76 47 25 32 0.02 Acupuncture 49 20 25 16 24 29 0.02 33 21 16 20 0.97 Hypnotherapy 24 10 11 7 13 16 0.03 14 9 10 13 0.34 Cosmetic Surgery 35 15 24 15 11 13 0.7 20 12 15 19 0.3 Legend: *Family physicians are those passed the conversion program by the Indonesian Association of Family Physicians. ** Full-time practice is practice more than 30 hours per week ***p is calculated with chi-square or fisher test as appropriate. Widyahening et al. Asia Pacific Family Medicine (2014) 13:16 Page 5 of 6 Table 2 Clinic facilities and continuing medical education activities of primary care physicians in Indonesia (N = 240); comparison based on the participation in Family Medicine conversion program and practice hours Overall PCPs classification Practice hours per week Family physicians* Non-family p** >30 hours <30 hours p** (n = 157) Physicians (n = 83) (n = 161) (n = 79) n% n % n % n % n % Facilities Medical record 222 93 147 94 75 90 0.42 147 91 75 95 0.54 Patients’ Register 224 93 150 96 74 89 0.06 152 94 72 91 0.34 Separated register for chronic disease 152 63 94 60 58 70 0.26 110 68 42 53 0.04 Locking cupboard for dangerous drugs 158 66 101 64 57 69 0.51 107 67 51 65 0.85 Having a computer/laptop 222 93 144 92 78 94 0.53 150 93 72 91 0.58 Electronic Medical Record 119 50 71 45 48 58 0.06 87 54 32 41 0.04 Internet access 207 86 131 83 76 92 0.2 140 87 67 85 0.35 Continuing medical education for GPs Post Graduate Qualification 38 16 30 19 8 10 0.06 86 53 29 37 0.05 Short courses in Family Medicine 171 71 129 82 42- 51 <0.01 114 71 57 72 0.82 Conversion program 157 65 - - - - - 102 63 55 70 0.34 Reading > one journal per year 214 89 143 91 71 86 0.31 142 88 72 91 0.76 Attending > one ward round per year 149 62 101 64 48 58 0.61 103 64 46 58 0.54 Attending > five talk or lectures per year 144 60 90 57 54 65 0.35 102 63 42 53 0.27 Attending one workshop/symposium & conference per 219 91 143 91 76 92 0.93 148 92 71 90 0.54 year Attending a full course in the last five years 205 85 138 88 67 81 0.24 136 85 69 87 0.46 Literature search to answer patients’ problem 207 86 136 87 71 86 0.97 142 88 65 82 0.12 (>1x /month) Participated in Quality Improvement Program 195 81 133 85 62 75 0.17 134 83 61 77 0.11 Legend: *Family physicians are those passed the conversion program by the Indonesian Association of Family Physicians. **p is calculated with chi-square or fisher test as appropriate. lends to assessing the current status in order to spring- ever increasing health care costs, the gate keeper role (i.e. board methods of improving the system. provision of first contact services) of primary care should Differences between family physicians and non-family be strengthened. Strengthening the gatekeeping function physicians were small with respect to range of services, of the PCPs and implementation of referral system will facilities and continuing medical education. This was un- improve the provision of comprehensive services [5,14]. expected since conversion program was envisioned to This is also in line with the current a movement of the recognize those already implement family medicine ap- ASEAN countries through establishment of the ASEAN proach prior to structured Family Medicine training is Region Primary Care Physicians Association which one made available. It appears that the checklist utilized in of the aim is “to work towards common standards for the conversion program failed to distinguish those who quality healthcare, education, training, accreditation and provide better range of services. Remedial action may be certification to set competencies for general practitioners/ proposed including developing better instrument which family physicians” in the region. This study provide im- better reflecting the area of services provided by PCPs portant information to support the movement. followed by provision of structured trainings focusing on the essential services which are currently less provided. Conclusion With regard to the availability of formal postgraduate The Indonesian PCPs in our survey were lacking in the training program for primary care practice, Indonesia is provision of some particular medical procedures, man- still lagging compare to other member countries of the agement and follows up of acute and chronic conditions, Association of South East Asian Nation (ASEAN) and and preventive medicine and health education. However, the role of primary care is still weakly recognized [2,7]. longer hours of practice improves provision of services With the national governments struggling to contain by primary care physicians more than participation in Widyahening et al. Asia Pacific Family Medicine (2014) 13:16 Page 6 of 6 family medicine conversion program. Improvement of 7. Hays RB, Morgan S: Australian and overseas models of general practice training. Med J Aust 2011, 194(11):S63–S66. primary health care has been seen globally as necessary 8. Wonodirekso S, Pattiradjawane D: The Role of the Ministry of Health in effort in health systems reform . The results of our Empowerment and Career Development of Primary Physician to Achieve study show in which area the role of the Indonesian “MDGs” Targets. J Indones Med Assoc 2010, 60(3):101–106. 9. Academy of Family Physicians of Malaysia: Quality Improvement Program. PCPs is relatively weak and on which skills the emphasis Kuala Lumpur: Academy of Family Physicians of Malaysia; 2013. [updated needs to be placed. This can provide guidance for the 2013; cited 2013]; Available from: http://elms.afpm.org.my/portal/web/ development of training programs for GPs to meet the guest/qip. 10. Kringos DS: The strength of primary care in Europe. Utrecht, the Netherlands: common standards of the ASEAN countries. NIVEL; 2012. 11. Starfield B: Primary Care: balancing health needs, services, and technology. Competing interests New York: Oxford University Press, Inc; 1998. The authors declare that they have no competing interests. 12. World Health Organization Regional Office for South-East Asia: Country profile: Indonesia. 11 Health questions about the 11 SEAR countries. New Delhi: Authors’ contributions World Health Organization Regional Office for South-East Asia; 2007. DMT design the study and the questionnaire. ISW and DV did the data 13. Jones R: Strong medicine: research, education, and patient care in collection. ISW and TMH analyze the data and draft the initial manuscript. All general practice. Br J Gen Pract 2010, 60(571):75–76. authors critically reviewed the manuscript and involve in all revision. All authors 14. Boerma W, Verhaak P: The general practitioner as the first contacted read and approved the final manuscript. health professional by patients with psychosocial problems: a European study. Psychol Med 1999, 29(3):689–696. 15. World Health Organization: Primary health care now more than ever. Authors’ information Geneva: World Health Organization; 2008. Dr. Indah S. Widyahening, MSc, MSc-CMFM is a lecturer in the Department of Community Medicine, Faculty of Medicine Universitas Indonesia, Jakarta. She is also a national board member of the Association of the Indonesian Family Physicians (PDKI). Prof. Dr. Daniel M Thuraiappah, PJM, DPMS, AMN, SSA, BSc, MBBChBAO, MAFP, FAFP,FRACGP, FCGP(SL), FRCPE, FAMM is currently the President of Academy of Family Physicians of Malaysia. He is also a Professor in the Family Medicine Department, MAHSA University College, Malaysia. Tin Myo Han M.B.B.S, M.Med.Sc (PH), MPH, CCFM, D.F.M is the Secretary of International Relations of the Myanmar Medical Association- General Practitioners’ Society. She is also an Assistant Professor in the Medical Statistics Unit, Faculty of Dentistry, International Islamic University, Malaysia. DR. Dr. Dhanasari Vidiawati, MSc-CMFM is a lecturer in the Department of Community Medicine, Faculty of Medicine Universitas Indonesia, Jakarta. She is also a member of Association of the Indonesian Family Physicians (PDKI) and the National Board for the advancement of the primary care physicians education. Acknowledgement The authors would like to acknowledge the Association of the Indonesian Family Physicians (PDKI) who provide access for the data collection. Author details Department of Community Medicine, Faculty of Medicine Universitas Indonesia, Jl. Pegangsaan Timur 16, Jakarta 10430, Indonesia. Academy of Family Physicians of Malaysia and Family Medicine Department, MAHSA University College, Kuala Lumpur, Malaysia. Myanmar Medical Association- General Practitioners’ Society. Medical Statistics Unit, Faculty of Dentistry, International Islamic University, Kuala Lumpur, Malaysia. Received: 14 October 2013 Accepted: 8 December 2014 References 1. Starfield B: Is primary care essential? Lancet 1994, 344(8930):1129–1133. Submit your next manuscript to BioMed Central 2. Hays R, Pong LT, Leopando Z: Primary care in the Asia-Pacific region: challenges and solutions. Asia Pac Fam Med 2012, 11(1):8. Epub 5 October and take full advantage of: 3. 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Asia Pacific Family Medicine – Springer Journals
Published: Dec 20, 2014
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