Background: Indonesian maternal health policies state that community health workers (CHWs) are responsible for detection and referral of pregnant women and postpartum mothers who might suffer from mental health problems (task-sharing). The documents have been published for a while, however reports on the implementation are hardly found which possibly resulted from feasibility issue within the health system. Aims: To examine the feasibility of task-sharing in integrated mental health care to identify perinatal depression in Surabaya, Indonesia. Methods: Semi-structured interviews were conducted with 62 participants representing four stakeholder groups in primary health care: program managers from the health office and the community, health workers and CHWs, mental health specialists, and service users. Questions on the feasibility were supported by vignettes about perinatal depres- sion. WHO’s health systems framework was applied to analyse the data using framework analysis. Results: Findings indicated the policy initiative is feasible to the district health system. A strong basis within the health system for task-sharing in maternal mental health rests on health leadership and governance that open an opportunity for training and supervision, financing, and intersectoral collaboration. The infrastructure and resources in the city provide potential for a continuity of care. Nevertheless, feasibility is challenged by gaps between policy and practices, inadequate support system in technologies and information system, assigning the workforce and strategies to be applied, and the lack of practical guidelines to guide the implementation. Conclusion: The health system and resources in Surabaya provide opportunities for task-sharing to detect and refer cases of perinatal depression in an integrated mental health care system. Participation of informal workforce might facilitate in closing the gap in the provision of information on perinatal mental health. Keywords: Community health workers, Integrated mental health, Perinatal depression, Health system framework, Indonesia, Primary health care *Correspondence: firstname.lastname@example.org Centre for Mental Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/ publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Surjaningrum et al. Int J Ment Health Syst (2018) 12:27 Page 2 of 16 depression was 22% [4, 5] (based on a cut-off point > 10 Background of Edinburgh Postnatal Depression Scale (EPDS), far Community health workers (CHWs) in Indonesia are higher than the reported global prevalence of 12% [6, encouraged to be able to examine mental health prob- 7]. Both the lack of information regarding implementa- lems experienced by pregnant women and postpartum tion of policies on maternal mental health and the high mothers, which are stated in two policy documents: “the prevalence of depression are reasons to initiate mental Guidance of Integrated Antenatal Care”  and manual health care as part of maternal care in Surabaya, par- for CHWs . Nevertheless, despite policy and guide- ticularly identification of perinatal depression. Under lines available, there is little data to indicate that this con- the guidelines on integrated mental health in PHC cept is being implemented. , integrated mental health care could be developed. The prevalence of maternal mental health problems Within PHC system, there are integrated health service in Indonesia is under-recorded. Neither the national posts (ISPs) where CHWs work for maternal care in the health survey conducted regularly every 5 years nor community (see Fig. 1). A recent mental health policy the annual Indonesia health profiles [3 ] present specific accommodates the role of CHWs in mental health areas information regarding maternal mental health. Only , even though not all administrative governments a small number of epidemiologic studies on mater- have implemented the decree. This policy provides an nal mental health have been conducted, including one opportunity for task-sharing, i.e. CHWs to identify in Surabaya , that found the prevalence of perinatal Fig. 1 PHC system and networks Surjaningrum et al. Int J Ment Health Syst (2018) 12:27 Page 3 of 16 mental health problems in women during pregnancy child health [30, 31], but also in other health areas. The and the postpartum period. relationship and roles of the PHC centre, FWM, and ISP Task-sharing in general mental health care has been working group in relation to the ISP and CHWs are pre- reported in other district in Indonesia  and other sented in Fig. 2. countries [11, 12]. This approach has also been applied In certain circumstances, the role of ISPs extends to for maternal mental health care [13–15]. In Surabaya, other health areas or areas other than health, such as mental health care has been integrated into primary social services and family welfare [30, 32]. When there health care (PHC) centres, for several years [16–18], are no people who have agreed to work voluntarily, a MCH providing a basis for initiation of mental health care by CHW may also be co-opted for this purpose, result- CHWs [15, 19, 20]. ing in multiple roles for one CHW  including popula- While task-sharing in maternal mental health care has tion and civil administration-related services . a legal policy foundation, annual reports indicated that it has neither been implemented in Surabaya nor known Aim of the study whether this is feasible and acceptable within this district The current study aimed to examine the feasibility of health system [21–23]. To fill this knowledge gap, a com - task-sharing of perinatal depression care in the health prehensive qualitative study was conducted to examine system in Surabaya. The aim was achieved through inter - the feasibility and acceptability of task-sharing for peri- views to obtain perspectives of four types of stakeholders natal depression, as well as the skills and competencies in the health system: (1) program managers, (2) health of CHWs to carry out the role. This article reports on a workers, including CHWs, (3) mental health specialists, feasibility study based on perceptions of health system and (4) service users. stakeholders. Methods Setting Role of CHWs within health system The research took place at PHC centres in Surabaya that The health system in Indonesia is administered in line provide a psychological service, several ISPs managed by with decentralization of the government system, such that PHC centre and a district hospital in Surabaya, and that services are decentralized to provincial and dis- the District Health Office. There are 62 PHC centres in trict governments under the Ministry of Home Affairs Surabaya and some of them provide psychological ser- (MoHA) . District governments operate health ser- vices. Three PHC centres were selected as the study sites: vices provided through PHC centres called puskesmas, which typically reside in a sub-district. These centres supervise and support a wide network in the village level, including integrated health service posts (ISPs) known as posyandu, and village midwives (see Fig. 1). An ISP involves intersectoral cooperation between the Ministry of Health and the MoHA at the village level , through a body called ‘ISP working group’ . This working group coordinates with women’s agency of the MoHA called the family welfare movement (FWM) to run an ISP monthly activity  whose operationaliza- tion is managed by a PHC centre . The FWM recruits CHWs who are volunteers from local community and allocate tasks for them. There are five main services of maternal and child health care at an ISP [28–30], there- fore the FWM should ensure that there are at least five people to run an ISP. CHWs who specialize in this task MCH are called CHWs in this article. CHWs are responsible to assist health workers (e.g. vil- lage midwives) in maternal and child health care, nutri- tion advice and family planning during ISP activity; Fig. 2 The relationship among ISP, CHWs, and PHC centre. assist them in antenatal care such as organizing mater- PHC centre is health service providers at sub-district; an ISP is a community-based health care; CHWs are the community volunteers nal classes; and undertake home visits for perinatal care running an ISP; IWG is a village agency that establishes ISPs; FWM is . Before taking the role, CHWs are trained in health- women agency at the village that support ISPs related areas by the health office, mainly in maternal and Surjaningrum et al. Int J Ment Health Syst (2018) 12:27 Page 4 of 16 Centres A, B, and C, whereas Centre D was selected for a participant according to their stakeholder group. The pilot study. They have different numbers of ISPs and Cen - vignettes were presented before questions on whether tre C was selected as it has the highest number of preg- participants have experienced a similar situation (for nant women, ISPs, and CHWs. ISPs were selected based service users) or have dealt with similar clients (for on the centre’s advice. service providers and community program managers), their perception of the importance of maternal mental health, and their views on the feasibility of task-shar- Participants and inclusion criteria ing. Data collection was pilot tested in Centre D. All Participants in the study were recruited from four groups interviews were carried out in private settings, such as of stakeholders: program managers, health workers, at home (for CHWs, pregnant women and postpartum mental health specialists, and service users. Program mothers), or at their workplace (for health workers and managers consisted of two participants from the health program managers) and transcribed in Indonesian. office (district program managers) and three partici - pants from three villages (community program manag- ers). District program managers were the Head of the Data analysis section of primary care service delivery that is in charge Analysis of the data was carried out deductively with a of maternal care and the head of the section of special framework analysis (FA) approach in the local language health care that is responsible for mental health care. (Indonesian) using MS Word and the NVivo software The three community program managers were mem - program. Framework analysis has five key steps [34, bers of an ISP working group from three villages which MCH 35]: (1) coding (indexing), (2) developing a working are responsible for organizing C HWs in the selected analytical framework, (3) applying the analytical frame- ISPs, viz. an ISP from Centre C with a high population of work, (4) charting data into the framework matrix, and Madurese (ISP CM), one populated by Javanese (ISP CJ), (5) mapping and interpreting the data. WHO’s health and one from a non-slum area (ISP CN). Health workers systems framework was applied to direct the analysis. comprised 12 formal health workers from three centres This framework suggests that a health system consists and 12 CHWs. Health workers were the centre manag- of six building blocks: health service delivery, leader- ers, (mental health) counsellors, midwives, and nurses. ship and governance, health workforce, health informa- CHWs were recruited from six ISPs, each of which typi- tion system, medical products and technologies, and cally has five CHWs and two of them were recruited: one a health financing system . Using MS Word, the leader (CHW-manager) and one member (CHW-mem- researcher (ES) and an independent analyst, who is an ber). Mental health specialists were a psychologist and a Indonesian researcher holding a Masters degree from psychiatrist at the district hospital (Dr. Soewandhi Hos- the University of Melbourne, read a set of transcripts pital). Two other psychologists and one psychiatrist were from pilot interviews to identify emerging themes and recruited from other places. Service users were 15 preg- to initiate the development of a thematic framework. nant women and 13 one-year postpartum mothers (they The framework, which was presented in English, was will be called ‘women’ and/or ‘mothers’ interchange- then validated by the research team until a develop- ably). Pregnant women were in their first pregnancy ing framework was agreed to be applied. The next step (primigravida) or subsequent pregnancy (multigravida) was indexing, which applied the framework to all the at any stage of pregnancy and had visited a health facil- transcripts using NVivo 11. Frequent discussions with ity at least once. Postpartum mothers were mothers of a the whole research team took place throughout the first child (primipara) or mothers of subsequent children data analysis phase, for which some transcripts were (multipara). Two to three women were recruited from translated into English and analysis was evaluated by each ISP based on the percentage of pregnancy among research team (RK), to ensure that interpretations were women aged 15–49 . The research setting and the credible, valid, and shared. participants are summarized in Fig. 3. Data collection Ethics approval Semi-structured interviews were conducted individu- Ethics approval for the study was obtained from the ally by ES. The interviews consisted of questions on: (a) University of Melbourne (No. 1543833). A research demographic information; (b) knowledge and attitude permit was given by the Health Office of Surabaya. to mental health of mothers; (c) two vignettes about Informed consent was obtained from all participants perinatal depression cases; and (d) the feasibility. Four prior to data collection. different vignettes about perinatal depression cases were developed, two of which were presented to each Surjaningrum et al. Int J Ment Health Syst (2018) 12:27 Page 5 of 16 Fig. 3 Research setting and the participants. PHC primary health care, ISP integrated health service post, CHW community health worker, FWM family welfare movement (PKK), CM, CJ, and CN sites for majority groups of population within Centre C coverage: CM for Madurese, CJ for Javanese, CN for non-slum area village agreed to participate in the study to enrich the Results voices of Madurese. Participants The demographic composition of the participants is as Recruitment of participants and interviews were carried follow. Only four participants were male: three were spe- out simultaneously from June to August 2015. In total, 62 cialists and the other one was a health worker. The ethnic participants from four groups of stakeholders were inter- background of the majority of participants was Javanese, viewed. The distribution of participants was as planned, with slightly more than ten percent being Madurese, but some adjustment was needed for the service users and other ethnic groups comprising less than two per- group. There was one pregnant woman from village CM cent. The age of participants was varied, but was above who agreed to be interviewed but at the end refused to 25 years of age for all groups other than service users. do so, whereas another pregnant woman from the same Surjaningrum et al. Int J Ment Health Syst (2018) 12:27 Page 6 of 16 All CHWs and community program managers were in of strategic and technical policies at national and district their 40 s or above, had finished high school (junior and level, the intersectional collaboration between the gen- senior) but had no formal employment. Half of the ser- eral health service delivery sector and the special health vice users were in their 20 s and only ten percent were care sector, and the autonomy of PHC centres to design under 20 years. More than three-quarters of these users context-specific programs. had finished high school. Around 20% were primigravida, almost 70% had one or two children, and about ten per- The provision of national mental health policies cent had three or more children. One factor that enables the feasibility of task-sharing in perinatal depression is the availability of two national Feasibility of extending CHWs’ role within the health policies on mental health. The first one is a national system policy that shifted mental health care from hospital to There were many shared views among stakeholders community-based, called Community Mental Health on factors that enable or hinder feasibility, as shown in Action Team (also known as Tim Pelaksana Keseha- Fig. 4. tan Jiwa Masyarakat or TPKJM), adopted in 2002. The second policy is the current national strategic policy Leadership and governance “Indonesia bebas Pasung (Indonesia Free from Shack- Perceptions of feasibility based on leadership and govern- les) by 2015”. A program manager stated that the latter ance factors were reported by program managers, a cen- program has become the pivotal point and timeframe tre manager and a specialist. These participants described for mental health actions, such as training on mental feasibility in these areas as being related to the availability health detection to general practitioners and nurses in Fig. 4 Factors contributing to feasibility of CHWs taking role in integrated mental health care in Surabaya Surjaningrum et al. Int J Ment Health Syst (2018) 12:27 Page 7 of 16 Coordination between sections in the district the centres, and out-reach activity to find mental health Beside intersectoral collaboration conducted by the cases in the community. These policies do not refer to community mental health team, coordination between maternal mental health directly; however, they have sections in the health office has worked well. The head brought about the establishment of mental health ser- of the section of general service delivery that organises vice units in several centres. The program manager for maternal care felt sure that mental health care could be specialist care described how the policies have guided facilitated within maternal care. She said that integrated the formation of an out-reach team involving CHWs to antenatal care is an obligation and the integrated care for find out people with mental health problems who live mental health has been implemented by referring preg- shackled. The significant number of cases found by the nant/postpartum mothers to the psychologist in the cen- team generated attention to the importance of mental tre. She described: health issues and led to the establishment of mental health service units in several centres. She said: “It actually can be done, if the metal health [sec- “Mental health is not a primary program, but an tion] wants. Even though I am from maternal and extended program. It has not got attention until child health I facilitate this…Those are compulsory, during the outreach program–visiting patients whether a mother is sick or not. An example of this at their original places-we found a lot of cases. is HIV assessment, it is compulsory…like that. When Finally, the head office said ‘let’s develop your there is a complaint…yeah… it can be referred to the mental health unit’…. Because it should be free expert. You may have known that there are psychol- from pasung [shackle] by 2015, isn’t it?” (DPM 2) ogists in several centres, so when there is a complaint or as a result of assessment by a GP or midwife, the The manager added that two centres have established patient would be referred to the psychologist… if a mental health unit and another one is under prepa- there is no one in the centre, she may be referred to a ration. Moreover, the community mental health action psychologist at the closest centre.” (DPM 1) team policy led to the formation of a collaborative team across sectors to find and tackle mental health cases in the community based on their needs. Subsequently, the program manager explained that the team works regu- Policy on training of CHWs larly and is monitored directly by the Mayor. Strategic policy at the district level on mental health training for CHWs is another factor to enabling feasibil- “…Tim Pelaksana Kesehatan Jiwa Masyarakat ity. The training program for CHWs has been placed into [Community Mental Health Action Team], the strategic planning for the following year, focusing on TPKJM. Yes, we haven’t formed the structure, but early detection and referral. The training was designed as I think… The team has not been structured, yet an extension of the one provided for doctors and nurses. coordination among sectors has worked. Struc- The program manager explained: turally it has not formed yet but the coordination has worked…. Usually each sector sends a letter “We have run training on early detection of mental to the Mayor and then the Office of Human Wel - health cases for health workers, and we plan to do fare would organize a meeting. These are from the so for CHWs this year….and in 2016 they will be Office of Social Affairs, of Health, of Housing…” trained in the basic knowledge of early detection and (DPM 2) referral. That’s what we want to do.” (DPM2) The training at district level is more likely to be fol - lowed by centres because they have the autonomy to set Health leader role up MCH-related training for CHWs in their area, allow- The involvement of the Mayor in coordinating the com - ing the inclusion of mental health in the program. Again, munity mental health team was perceived as giving sup- the manager emphasized: port and attention to mental health care in the city. A “It is the autonomy of the PHC to set up training specialist reported how he was impressed by the Mayor: materials for CHWs, not only about the health of “The Mayor, indeed, believes in two principles, first children under five but anything that supports the there is no child in Surabaya who does not go to health of those children.” (DPM 1) school, and second no sick people in Surabaya are neglected, including people with mental health problems….” (Sp 1) Surjaningrum et al. Int J Ment Health Syst (2018) 12:27 Page 8 of 16 Challenges in implementation mental health problems. For example, CHWs reported In contrast to policy and planning that supports feasi- typical behaviours suggestive of a mental health problem, bility, several factors were viewed as challenges to fea- including isolation at home and missing check-ups dur- sibility. First, practical guidelines are required before ing pregnancy. task-sharing can be implemented in the community. A Some CHWs viewed home visits as convenient, as program manager made the point that even though a they live close to users and the cost of transportation is guideline has been regulated in the policy document, minimal. Home visits also allow CHWs to gather more it may take several years until the guideline results in information from mothers, and enable them to approach direct action. Second, there are practical problems with women in more acceptable ways. A CHW explained: the shared responsibility between centres and the family “I usually spend time to visit occasionally, during a welfare movement (FWM) in the village. Recruitment of spare time. So, it is not in a particular time, because CHWs is supposed to be a FWM task; however, a com- it would be seen as a serious matter. Just pop in, munity program manager complained that in fact the have a chat, sharing as a neighbour friend.” (CHW PHC centre took over the task. Third, a centre manager J4) was concerned about financial issues with the autonomy of a centre to arrange particular training for CHWs. Run- ning a local program, which is centre specific is allowed, Referral even though it is not part of a national or district prior- There are two types of referrals, internal and external, ity, however the centre is responsible for the financial and CHWs could be involved in the former. Internal arrangement and the justification. The centre should find referrals are those that occur among professionals within the money either from within its own or other funding a PHC centre. These procedures were illustrated by all sources and be able to justify the spending. program managers, some health workers, and by the CHWs. They explained that CHWs could refer depres - sion cases in three formats: a verbal report directly or Service delivery via telephone, a written report within a monthly report, Identification at an ISP is not feasible and a written note in a communication book that delivers This study was to assess the feasibility of task-sharing MCH messages between CHWs and midwives at a PHC. The to be carried out by C HWs in their place of work, basic pathway for either format is from CHWs to village which is in an ISP. Nevertheless, stakeholders perceived midwife to PHC centre midwife to counsellor at the cen- that carrying out the task in an ISP is not feasible. Health tre (CHW → village midwife → centre midwife → coun- workers stated that there are a lot of tasks to be accom- sellor). Sometimes a CHW and a village midwife go plished by CHWs and that they are unable to also carry together to report a case, as one CHW described: out task-sharing within the time available. In addition, the ISP was seen by mothers as a place for the health of “Two of us. Together. When we cannot handle it, we children under five. Therefore, a lot of adults and children have a midwife coordinator and the coordinator will are around, resulting in a lack of sufficient space for pri - report to bu Nl [the centre manager]. If we cannot vacy. A mother said: handle it, for example [because of ] a psychological thing or need for a mental health consultation, we “Prefer during home visit. It is impossible to talk will go to Lk [the counsellor] ….” (Mw 3) about my personal situation because the ISP is for children’s health…it’s better to visit home for that CHWs might accompany mothers to the PHC centre issue.” (Ppt A3) when required. For other cases, the village or centre mid- wife and the counsellor come and visit the mother, either with or without a CHW. However, a centre manager was Service through home visit concerned about the lack of a referral book or note that In contrast to the ISP, carrying out task-sharing through provide details of the problem. Other health workers per- a home visit was viewed as feasible. Home visits were ceived that referral guidelines which describe the path- expected, both culturally and officially. A CPM said that it ways and tasks of each professional are also needed. is culturally accepted in the community to visit a mother External referrals send patients from the PHC to who has just delivered a baby. She also stated that CHWs higher-level facilities. These referrals can occur when must carry out home visits when required, as part of a professionals at the centre cannot handle a health issue government program. A nurse emphasized that home MCH anymore, such as when a counsellor cannot handle a visits have been conducted by CHWs to regularly mental health case. A specialist and program manager at monitor all aspects of the health of mothers and during the health office explained that an external referral can these visits CHWs sometimes encountered women with Surjaningrum et al. Int J Ment Health Syst (2018) 12:27 Page 9 of 16 only be made by a doctor in the centre and is directed keeping new and younger CHWs. She illustrated this to the district hospital. A specialist explained that even with the example of a potential woman who agreed to be though a patient was being handled by a counsellor, the recruited only if a particular CHW was not active in the referral letter must be sent by a doctor. taskforce anymore; and by another case in which a newly- recruited CHW stopped the role because she was treated Workforce badly by a current CHW. Additionally, cultural and The study participants raised numerous issues related to demographic issues, such as ethnicity and literacy, came human resources. Concern was expressed about recruit- up when a CHW described a difficulty in engaging with ing a CHW workforce of the quality required for work women from a particular ethnic background because of on perinatal depression. However, participants also per- their cultural beliefs and/or of low level of education. pregnancy ceived that the health system has training and supervi- Recently, a new group of CHWs, called CHWs , sion programs which could enhance skills and minimize was established to work for a PHC centre and the Fam- such issues. ily Welfare Movement (FWM) at the district level, which could also be seen as supportive of the feasibility of task- Availability and recruitment sharing and as an enrichment of the workforce. These The primary concern about workforce was the shortage particular CHWs have several tasks, including find - of existing CHWs who qualify as suitable for task-shar- ing pregnant and postpartum women in the village and ing. Even for the general/current role, CHWs’ perfor- monitoring their health status through home visits, tak- mance was often seen as being inadequate, due to their ing their pictures regularly to be documented, and mak- often being sick, being too old or their workload simply ing health record on monthly basis. The existence of pregnancy being too high. Program managers and health workers CHWs and their tasks was described by a com- identified that most CHW-managers have multiple tasks munity manager: related to their role in health assistance, i.e. in MCH, pregnancy “Now we have what we call CHWs . Here we aged care, TB, dengue prevention, etc. A centre manager have Wi, while Wa is from the next neighbourhood. stated: One CHW would work for 2-3 neighbourhoods. palliative “I have a lot of CHWs: CHWs , I have a They record pregnant women: how is their health LKB CHW who handles HIV and IMS [sexually trans- status, the risks, including depression, and others. TB mitted disease], I have CHWs , leprosy and basi- The CHWs monitor them until they give birth. To cally those for communicable diseases, and then do so, the CHWs come to FWM representation at for nutrition CHWs called CFC [Community Feeding ‘dasawisma’ [smallest aggregate of neighbourhood] Centre] which are based at ISPs that handle mal- to collect the data on pregnant women in the area nourished-children. Sometimes only one person and then they visit the women at home. The com - handles all of these because it is hard to recruit. But munity health centre also guides them. There are we think the person is able to handle all those roles.” some in every village, for example this village has 6 pregnancy (GP 3) CHWs .” (CPM 1) Despite the recognition of high workload from multiple tasks, some health workers perceived CHWs as having Training and supervision the capability to handle those tasks. A program manager Training and supervision were perceived as other solu- in the community suggested that CHWs could carry on tions for quality improvement that were available in the several tasks in one go, referring to a strategy to man- system. Counsellors from three centres reinforced the age tasks. This view underlined the feasibility in terms of previous statement from a program manager that men- human resources. tal health training for CHWs and health workers has Having new recruits might be seen as an ideal solution been carried out in the previous year. Unfortunately, to ease the overburdened CHWs and overcome the qual- follow-up of the training was challenged by staff rotation ity issue. However, there were some issues involved in when the trained staff moved to a different centre, result - getting new people. Firstly, because CHWs are lay com- ing in the program ceasing. While concerns were raised munity members volunteering their time to contribute to regarding the adequacy of training, the current strategic their community, other commitments such as work and plan for training seems to be trying to address this issue. domestic responsibilities were among the difficulties in A counsellor said: The health office has provided train - mental health recruiting new CHWs, as was described by some CHWs. ing for CHW . But I think mere training is not A CPM listed social relationships as a second issue, when enough; it needs to be continued with follow-up programs” existing CHWs were seen as an obstacle to attracting and (Cs 3). A district program manager expected that an Surjaningrum et al. Int J Ment Health Syst (2018) 12:27 Page 10 of 16 already- established strategic plan for future training for service delivery to a mother, most CHWs and nurses did mental health CHWs from all centres would allow continuous not know how the FWM uses this data. training and sustainability of implementation. “There are CHWs for high risk of pregnancy; there “That will be for next year. We will train them. For are two of them: one is assigned by FWM at district all centres. The previous one took only one day… level, and the other is assigned by the centre. In fact, therefore we will run the socialization so [the imple- they are similar in their role and responsibility… The mentation] will not ‘come and go’ anymore.” (DPM 2) one assigned by the centre will provide a report to us [village midwife] from which the report will be com- In addition, there is an opportunity for all centres to piled into the MCH unit. The one assigned by FWM support the program and to provide supervision sessions will send the report to the FWM at district level.” (Nr for CHWs in the form of a monthly refresher program 1) between health workers and CHWs. As well as supervi- sion, the session is in fact also used for professional devel- opment when new and high-priority material needs to be Financing introduced to the CHWs. Such a session could be used if The financial feasibility of task-sharing is indicated by mental health needed to become a topic area. Even bet- the availability of incentives for CHWs as compensation ter for feasibility is the fact that these regular sessions are for taking the voluntary tasks, the budgeting policy to financially supported by the health office. assign funding to support mental health screening dur- ing the pregnancy and 1-year postpartum period, and Information the open possibility for other funding sources. Currently, Information systems that generate data about perinatal CHWs receive transport compensation for their role in depression hardly exist, at either national, provincial or each area they undertake (e.g. MCH, elderly, dengue) district level. Midwives and a district manager clarified and, according to a district manager, they will also receive that data on pregnancy and childbirth and mental health funding from the mental health program when it is set pregnancy together is available, but there is no option to include up. CHWs also receive incentives from the FWM information about mental health during pregnancy or or health office, depending on whom they work with. across age. A CHW explained that a special case would She emphasized that while the amount may be minimal, be reported in a descriptive note within the regular it shows the recognition of their roles. The other man - maternal and child health recording sheet. Health work- ager described the financial system assigned for PHCs ers suggested several potential ways of producing data through universal health coverage (the capitation fund) on perinatal depression, basically through home visits or which could potentially be allocated to support depres- approaching pregnant and postpartum mothers directly sion identification in maternal care: and recording the information in a specific form. A nurse “There is a solution to do so, using the capitation strongly suggested that the psychology unit could develop fund from universal health coverage. Here in Sura- pregnancy a form that could be completed by CHWs : baya, which may be different from other districts, pregnancy “…[CHWs ] are still working right now and there is 60% from the operational budget to be they have to send a report, so it would be better if addressed to services’ fee and 40% for others. The psychology can provide the sheet. But we may not 40% will be divided into 30% for medicine and 10% nd fi , I mean cases are not always found. So, when for operational. One third of the 10% operational there are no cases they cannot just leave it blank, budget is targeted for health promotion programs rather they still have to write a report, just write ‘nil’ which can be arranged for any required actions for example.” (Nr 1) such as a goodie bag, leaflet, and so on. So, if men - tal health…, would possibly be printing a screening Another way was suggested by a CPM and CHWs- tool….” (DPM 1) manager from three ISPs. They recommended that pregnancy CHWs compile mental health information A similar approach has been adopted to support super- qualitatively, together with other health data for which vision during the monthly refresher session. The manager they are responsible. Either way, the existence of added that funds from other sources are also accepted, pregnancy CHWs was considered an opportunity for data such as from NGOs or the community. For example, collection on perinatal depression. there is an ISP in an exclusive residential area whose pregnancy At present, a CHW reports data to the cen- activities are fully funded independently by community tre through village midwives and to the FWM at Dis- members. trict level. While PHC centres use the data to determine Surjaningrum et al. Int J Ment Health Syst (2018) 12:27 Page 11 of 16 Medical products and technologies the perspectives of leadership and governance, home- Medical products and technologies needed for depres- based service delivery and internal referrals, training and sion identification by CHWs are basically related to the supervision, financing, and technologies. Information production of screening tools, and technologies for com- systems and other areas need to be improved somewhat, munication and transportation. CHWs currently detect including the ISP-based service, operational regulation, mothers’ mental health in a common way using obser- and workload of the volunteers. vation and then record the case as a note in the regular Leadership and governance is a strong support for the maternal and child health recording sheet. involvement of CHWs in the identification of depres - sion. The vision of both district government and the “They [CHWs] detected them in a common way: province as seen in mental health policy clearly indicates when a person isolates herself and never out from the potential for development of practice in this area. home and do not go for pregnant examination.” (Nr Indeed, mental health policy at the national level has had 2) a significant development in the last two decades, and There was a disagreement between two specialists on the lessons learnt can be useful in thinking about men- how the identification should be acted upon. One sug - tal health policy for women and children. Perinatal men- gested two steps, starting with an interview and then fol- tal health is an important component of mental health lowing up with a scale. The other completely disagreed overall (with implications for both the mother and the with CHWs identifying depression through an interview, child) and must be in one of the priorities within men- as he believed that this requires a high level of knowledge tal health. The recent development of mental health poli - and skill and therefore requires long-term training. He cies such as the mental health law and the law of persons thought that a simple scale was preferable and he high- with disability is progressive, which gives hope for the lighted that tools for assessment of depression already development of policies on women and children. This exist and a simple one is quite easy to find. was seen when a new mental health law was approved by the house of representatives in 2014 (law number 18 year “For identification, it must use a tool that is inter - 2014), replacing the previous one that had been used for nationally recognized, so using a depression rating about five decades (the first mental health law was sanc - scale is very simple…that is easy and the depression tioned in 1966). Not long after its release, another related tools are not only one [type], from the simplest to law, the law of persons with disability, was authorized in the complex. It is so easy; indeed the tool to detect 2016 (law number 8 year 2016) as a result of the ratifi - depression is easy so that we can teach CHWs. Iden- cation of the United Nation convention on the rights of tification using interview is more difficult, it needs a persons with disabilities (UNCRPD). For a specific pop - long time to educate CHWs.” (Sp 2) ulation, those affected by a disaster, the disaster mental Means of communication and transportation are not health policy was developed in 2003 , while for those necessary, as CHWs live close by the mothers and the who have severe psychosocial disabilities living in physi- village midwife is not far away. However, health workers cal restraint, an initiative from Aceh has been applied as and CHWs expressed concerns about the cost involved in a national program [38, 39]. These other laws/policies/ taking mothers to the centre or if mothers live far away. initiatives can be used to advocate for high quality health and mental health care during the perinatal period. “Because it is around the area, therefore transpor- Regarding the role CHWs in mental health care, the tation is not a problem. I would think twice if it is establishment of the TPKJM or community mental far away because I cannot ride a motorcycle and health action team in the district, whose performance automatically I need to ask others to take me there.” is monitored by the Mayor, is another promising step (CHW J4) for implementation of policy documents in task-shar- ing for perinatal depression. The fact that East Java is among the provinces that have established initiatives to implement TPKJM  is a good support for districts Discussion within the province such as Surabaya. The regulation is This study aimed to examine the feasibility of task-shar - also reinforced by the policy on “Indonesia Free from ing in the identification of perinatal depression within Pasung (shackle)” launched in 2010, that was aimed to the health system of the City of Surabaya, from the per- be achieved by 2014 (it has since been extended to 2019) spective of the health system’s stakeholders. Policy doc- . These two national programs and the commitment uments stated that CHWs can carry out this role [1, 2]. of the leaders to them are evidence of a good founda- Results indicate that the proposed task is feasible to be tion of health leadership and governance, and are most implemented within the health system of Surabaya, from Surjaningrum et al. Int J Ment Health Syst (2018) 12:27 Page 12 of 16 likely to support task-sharing in the mental health area. continuous care so that the care does not end with the In particular, policies with a timeline, such as the free CHWs or village midwives. Continuity of care could from shackle policy, seem to be having a greater impact, also be understood in terms of protecting the rights of because the government is putting in greater effort to users to get treatment. The complete resources avail - meet the goal within the schedule. This phenomenon able for mental health care are: (1) the provision of men- accentuates WHO’s suggestion that a policy maker tal health care by a counsellor in a PHC centre, (2) the should have a timeline in mind when developing a mental availability of two district hospitals that provide mental health policy . health services by both psychiatrists and psychologists, The policy emphases that facilitate task-sharing were and (3) the provincial mental hospital that is located in also strengthened by organisational management in the the city. With these resources, community-based mental health office. The existence of mental health within the health care fits within the national health system. Lack special care section provides open opportunities for the of continuous care was a concern for women who were mobilization of more resources in the health system. This reluctant to disclose their feelings during a mental health can be seen from its roles in: facilitating the establish- assessment . Findings from another study have sug- ment of centres with mental health units; in putting in gested that mental health screening as part of integrated place a strategic plan for mental health training, includ- routine maternity care would be a possible intervention ing the training of CHWs; assigning a source of funding pathway  which would involve less stigma. Partici- for depression identification; and organizing multisec - pants in that study emphasized the unease and feeling of toral collaboration that could support resource manage- shame from talking about their experience of depression ment, including the application of integrated antenatal with multiple professionals in a fragmented care system, care. Not all these efforts are right now directed specifi - something that is not required in integrated care. In addi- cally to the mental health of mothers; however, there is tion, continuity of care is supported by the financing sys - potential within the section for commencing subsequent tem of universal health coverage. The economic cost of steps to realise the vision. perinatal depression is high for both individuals (mothers According to stakeholders, home visits are the pos- and the family) and the public sector , therefore the sible answer for the service delivery model for CHWs health coverage scheme needs to make service delivery in carrying out the task of depression identification. As and referral procedures easy and accessible. The connec - a model of care, this approach is not a novel one within tion with other health systems, such as the PHC and the MCH the national health system, particularly for CHWs . social welfare system, is also needed for well-functioning Several documents openly regulate this responsibil- mental health care. ity and provide structured guidance on what and how The financial source and policy in financing both sup - to conduct home visits [2, 30], even though not specifi - port task-sharing, congruent with the arguments related cally for mental health care. For example, home visits to service delivery and continuity of care. How the capi- are directed for mothers whose children under five did tation budget could be allocated so that a specific amount not attend an ISP activity, and those of malnourished could be used to establish a depression screening tool children, among others. The home visit approach is also was clearly explained by a district manager. This finan - pregnancy MCH used by CHWs , many of whom are also CHW cial policy would open several possibilities for further (mostly the managers). At a practical level, there is agree- steps, for example to identify and validate a simple and ment among stakeholders that a home-based approach locally-acceptable screening tool. Studies from a vari- is the best option to overcome the space limitation issue, ety of settings suggest several possible perinatal depres- the difficulties of accessing primigravida, and time con - sion screening tools that can be accessed worldwide and straints which resulted from many services being pro- have good psychometric properties [46–48], however vided during an ISP activity and the unsuitability of this adaptation in the new context is required. Several stud- schedule for working mothers. This approach allows for ies in Indonesia have reported the use of some of these flexible scheduling, as has been stated by CHWs and tools (e.g. the Edinburgh Postnatal Depression Scale) [4, users, and is consistent with findings from another study 5, 49]), nevertheless there is a need to examine whether . similar tools can be administered by CHWs. Specialists Service delivery should also be connected to infrastruc- in this study also emphasized the use of simple tools and ture and resources in the health system to make it fea- believed that CHWs are able to administer them. Health sible for task-sharing. Resources could provide a wider workers suggested using a symptom list which is sim- opportunity to assure that users get continuity of care ple to administer and quite similar to a pregnancy risk after being identified by CHWs, e.g. infrastructure for scale with which CHWs are familiar. Another method is referrals. It means task-sharing is supported by relevant using a structured interview, but this was debated among Surjaningrum et al. Int J Ment Health Syst (2018) 12:27 Page 13 of 16 specialists, since it requires a high level of competence. task-sharing in maternal mental health care has not yet Furthermore, a specialist strongly suggested not using started, the specific skills and competencies, as well as the word ‘depression’ to avoid stigma, with the term training, that fit the local context need to be examined. ‘mood changes’ being preferable instead. This suggestion is in line with previous findings in which the experience Challenges and recommendations of depression was expressed in many forms and terms by The findings indicated three main challenges to feasi - Javanese . This means that an understanding of the bility. These are: (1) inconsistency between policy and personal and cultural terms should also be considered in practices, (2) an inadequate support system for data man- choosing or adapting an identification tool. Possible bias agement and technologies, and (3) unsupported means in interpreting a woman’s mental health state resulting for implementation. Gaps between policy and action are from unfamiliar terms requires attention, considering revealed from the shortcut practices in recruiting CHWs the level of education, language and ethnicity of both the by the centre instead of by the FWM. Several approaches CHWs and users. may alleviate these challenges, such us inviting all par- In regard to human resources, the findings on work - ties (FWM and PHC centres) to sit together and review load, scarcity, and personal barriers are consistent with the policies, or hearing about the best possible strategies feasibility issues reported by previous studies [51, 52]. for a collaboration process before a proposed program is These issues may result from the role of CHWs as the released. However, this study did not explore this possi- frontline workforce for many governmental sectors, not bility further. The fact that there were gaps between writ - only health and home affairs, but also others such as edu - ten regulations and the reality generates a concern: even cation and social services . At least 12 roles for CHWs if stakeholders’ perceptions lead to the conclusion that have been listed in health-related areas , not includ- the health system can feasibly accommodate task-sharing ing others in civil services . Management of CHWs by in integrated mental health, personal views on partici- the FWM is supposed to enable organization and moni- pation may be different. Buist, O’Mahen  reported a toring of the availability, distribution, and performance mixed attitude to the acceptability of perinatal depression of CHWs. However, it seems that the FWM, even at the detection among women and health providers. Therefore, national level, does not have a strong bargaining posi- it is necessary to understand the personal views of stake- tion in the governance of a village when a new task for holders about the acceptability of their involvement in CHWs is released. In fact, the findings about social rela - task-sharing. tionships as one recruitment issue suggest that the FWM Other issues are logistical support and an information is the agency that best understands the social boundaries system on perinatal depression. While transportation is and cultural life of the community and so is best placed not a significant barrier, because the task is within walk - to map human resources in the area. Several concerns ing distance, the findings imply a need to use telecom - should be addressed to improve workforce management munication devices in doing the job. Lack of financial and quality, such as regulation of skills and characteris- support for communication and transportation is an issue tics required, the need for a working contract that reg- for task-sharing in another area  and a similar prob- ulates the length of employment and a procedure for lem is anticipated by CHWs in this study. In addition, the terminating the role, the training required, and a means lack of an adequate data reporting system on perinatal of distributing tasks. Well-distributed tasks may prevent depression could be solved through the use of qualitative pregnancy duplication, so that new and existing CHWs , for reports from CHWs to village midwives to the centre. In instance, could monitor not only physical but also men- an annual report, the health office presents data on men - tal health efficiently. Even though CHWs are volunteers, tal health cases other than maternal ones , suggesting having professional management of their tasks would an opportunity to do the same for maternal mental health maintain their participation sustainably. data. This possibility is suggested by the existence a men - There is promise for developing and improving CHWs’ tal health qualitative report shown by a district program skills and competencies in task-sharing. This could manager during an interview when describing how the be achieved through the availability of mental health data were collected. Moreover, a study on maternal mor- counsellors at centres and the health office, and men - tality calculation suggested the important role of village tal health specialists at district hospital. Skills enhance- midwives and local registers (volunteers) in gathering ment programs are an opportunity for quality assurance and reporting valid data . The study highlights the in service delivery. Components of mental health train- opportunity to integrate mental health as a component of pregnancy ing for CHWs are found in several studies [10, 40] that health data collected by CHWs . could be a source to learn from, including those address- Finally, the lack of practical regulation for task-sharing ing perinatal mental health [54, 55]. Nevertheless, since and the need for practical guidelines and pathways for Surjaningrum et al. Int J Ment Health Syst (2018) 12:27 Page 14 of 16 identification and referral were anticipated as potential unrealistically sound findings that do not fully identify issues for implementing task-sharing. The health office challenges in the financial area, which is a typical obsta - should prepare staff in order to manage practices and cle in many reports. Second, the study was conducted in roles of each actor. Another challenge for implemen- one district under decentralized governance, therefore tation is financial barriers faced by a centre if it has the extrapolation of the results to other contexts is limited. will to initiate a program. The centre needs to allocate a Third, the participants are only from health system tiers budget or to find funding from other sources and justify and do not extend more comprehensively to home affairs it in a way that is acceptable within the health financing sectors. This strategy leaves several unanswered ques - system. The procedure is perceived as a significant diffi - tions, such as the management of data by the FWM. culty by centre managers. Figure 5 presents a summary of Moreover, the number of areas sampled to represent challenges and recommendations. the PHC centres was quite small compared to the total number of centres in Surabaya, even though it is quite Limitations large in the context of a qualitative study using individual The current study has several limitations. First, the study interviews. This limitation has, however, been alleviated was purely dependant on the perceptions of participants, through the recruitment strategy for the research sites which may not represent the mechanism and procedure which took account of the socio-economic and cultural in the health system. Using this strategy can produce diversity of the city. Fig. 5 Challenges and recommendations of CHWs playing a role in task-sharing in mental heath care in Surabaya Surjaningrum et al. Int J Ment Health Syst (2018) 12:27 Page 15 of 16 Ethics approval and consent to participate Conclusion Ethical approval for the study was obtained from the University of Melbourne It can be concluded from this study that the health sys- in the Document No. 1543833. A research permit was released by Health tem and resources in Surabaya are sufficient for the Office of Surabaya. Informed consent was obtained from all participants prior to data collection. feasibility of task-sharing in integrated maternal men- tal health to detect perinatal depression. Most health Funding system areas support or provide an opportunity for This study is part of the doctoral degree project conducted by the first author under supervision of the co-authors. There is no external funding to support this concept, with there being a strong basis in govern- the research. ance and resources. The decentralized governance of the health system allows contextualization of a national Publisher’s Note policy. The role of CHWs also demonstrates their Springer Nature remains neutral with regard to jurisdictional claims in pub- potential for filling the gap that exists in the data infor - lished maps and institutional affiliations. mation system. Further studies are necessary before the Received: 9 November 2017 Accepted: 25 May 2018 idea can be prepared for implementation, including, but not limited to, exploring the acceptability of task- sharing and the characteristics of CHWs required for this purpose. References 1. Ministry of Health Republic Indonesia. Guidance for integrated antenatal care. Jakarta: Ministry of Health of Republic of Indonesia; 2010. Abbreviations 2. Ministry of Health Republic Indonesia. Manual book for cadres of Posy- MCH CHWs: community health workers; CHWs : community health workers andu. 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