Acceleration on Maternal Mortality Reduction in Indonesia: Strengthening Integrated Referral Information System in The District Level

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1 Available online at GlobalIlluminators Full Paper Proceeding ITMAR -2014, Vol. 1, FULL PAPER PROCEEDING Multidisciplinary Studies ISBN: ITMAR-14 Acceleration on Maternal Mortality Reduction in Indonesia: Strengthening Integrated Referral Information System in The District Level Popy Yuniar 1* & Wiwiek Widyawati 2 1Dept. of Biostatistics and Population Studies, Faculty of Public Health, University of Indonesia* 2 District Health Office, Serang District Abstract The aim of this study is to establish a model of integrated referral information system for maternal and neonatal emergency cases. This system was developed by the need to over come poor performance of referral system at health facilities. This was happened because there is no adequate integrated information system to support mechanism of referral system as a health facilities network. System Development Life Cycle was conducted as basis on system development. Current referral information system at Basic Emergency Obstetric at primary health center and Neonatal Care (BEONC) and Comprehensive Emergency Obstetric and Neonatal Care (CEONC) at secondary health center was captured. After the gap and need analysis was the design and prototype model was created and tested at the field. The prototype of referral information system provide some function to do real time communication between primary and secondary health services which provide basic obstetric and neonates services. The communication channel considers the nearest location and availability of basic services. From the simulation it showed that the system would effectively support the referral mechanism and prevent the delay on giving the service. An adequate referral system will contribute to reduction of maternal and neonatal mortality; this can be improved toward integrated information system. Strengthening referral information system should do both side, at the primary and secondary health services. For the implementation it will need some regulation as the legal aspect, especially for the data sharing mechanism The Authors. Published by Global Illuminators. This is an open access article under the CC BY-NC-ND license ( Peer-review under responsibility of the Scientific & Review committee of ITMAR Keywords: Referral, Integrated, Information System, Maternal, Neonatal Introduction This research report describes the development of prototyping model of integrated referral system for emergency maternal and neonatal care in the health facilities at district level. The high number of maternal mortality in Indonesia brought with it many challenges, including the need for high performance of emergency care at health services. Geographic constrains in the remote area for accessing the adequate emergency services is becoming another strategic issue to be tackled. In response to this need a referral system must be supported by an information system, which can reduce the delay of the emergency services. This prototype is design to strengthen the referral networking system among primary and secondary health center including the private hospital regarding maternal and neonatal emergency care. *All correspondence related to this article should be directed to Popy Yuniar, Dept. of Biostatistics and Population Studies, Faculty of Public Health, University of Indonesia. popyyuniar@gmail.com 2014 The Authors. Published by Global Illuminators. This is an open access article under the CC BY-NC-ND license ( Peer-review under responsibility of the Scientific & Review committee of ITMAR-2014.

2 Background In Indonesia, maternal mortality is still the highest rank compared to other ASEAN countries. From Indonesia Demographic Health Survey it stated that the MMR decrease to 120 per 100,000 live births, infant mortality rate decreased from 68 to 34 per 1,000 births [5]. The downward figure still have to be reduced to achieve the Millennium Development Goals (MDGs) by 2015, which to reduce maternal mortality to 102 per 100,000 live births, and the infant mortality rate 23 per 1,000 live births and under-five mortality rate 32 per 1,000 live births [8]. Maternal and infant mortality is related to the mother s and fetus health during pregnancy and also delivery process. Therefore the process of delivery and infant care should be done in an integrated system in the form of basic services at the health center level and comprehensive care in the hospital (Dogba et al. 2009; and Ministry of Health Republic of Indonesia 2012). WHO Technical Report Series 2010 reported that one of the failures of health basic services is because the health services (including its referral system) at the district level as a part of integrated health system management do not properly functioned (WHO 1994). In 2011 the number of maternal death in Serang District is 33 cases, increase 3 cases compared to the previous year, while 381 cases of infant deaths was occurred in the same year [10]. Complications of maternal and infant, which lead to mortality has been occurred in the period of delivery, most often bleeding during delivery and pre-eclampsia, while for infant mortality caused by asphyxia, Low Birth Weight (LBW) and congenital defects (Ministry of Health Republic of Indonesia 2012). Various efforts have been taken by the government to improve maternal and neonatal health care, but the referral system especially from primary health care facilities to the referral hospital is still need to be improved. The main obstacle why the referral system is still in poor performance is because there is no integrated information system among the primary and secondary health services (Ministry of Health Republic of Indonesia 2012). Based on the assessment result, to build integrated information system in Serang District is feasible, in fact the communication technology infrastructures are already there. Support of these technologies can be utilized to develop an integrated referral information system from primary health centers, which provide Basic Emergency Obstetric and Neonatal (BEONC) to referral hospital, which provide Neonatal Comprehensive Emergency Obstetric Care (CEONC). Research Method The research is an operational research which using System Development Life Cycle (SDLC) approach. SDLC contains four phases: Planning, Analysis, Design and Implementation (Kendall et al. 2012) 107

3 Result Current System Health facilities services are available from sub district level, district and provincial level. From sub distric there are some Primary Health Center, some of it are designed for basic emergency obstatric neonatal care known as BEONC. As the referral path from BEONC is distric hospital with comprehensive emergency for obstetric neonatal care (CEONC), which only one government hospital in each district. An integrated referral information system is necessary, considering the need of referring patiens from BEONC to CEONC. Not only reffering to the CEONC which government hospital, but also to private hospital. The data shows that in 2011, 36% of the total deliveries at hospital CEONC are with complications which has been referred from BEONC (Provincial Health Profiles 2012). Problem Identification The refferal mechanism still done manually, this kind of process will make the patient too late to get the service required, the process to refer the pation will be time consuming. Sometime when the patiens has decided to go to certain hospital, they still have to wait for more hours because the services or the equiptment was unready. That situation will make the patien condition even worse. The primary health centre having difficulties to know which hospitals are ready to accept patient referrals; it is unknown whether patients can receive services or not. In terms of the hospitals, the manual process makes difficulties to do coordination with the health center and any other important facilities such as blood bank. Design System The integrated information system is designed to provide some functions to make effective and efficient communication process from health center BEONC to CEONC and other private hospital. Interface from Primary Health Center (PHC) The need at BEONC level is to monitor the availability of services at hospital level before their send the patients to get the required treatment. First interface is using by the PHC officer to identify nearest location of hospital and additional information such as availability (figure 1). After the hospital was confirmed then health center staff will input the patient s data which directly sent and received at the hospital level (figure 2). Figure 1: Interface to identify the availability of refferal services 108

4 Figure 2: Data Entry Interface Once the data is received by the hospital, the officer will verify to the health center. Verified data is presented in referral recommendation paper; as an administrative document from PHC to hospital, which can be directly printed (Figure 3). This function makes the procedure shorter; the patient doesn't have to go through some administrative procedure. Figure 3: Referral Recommendation letter Interface 109

5 After the hospital approved their will sends back the notification automatically to the health center. This mechanism it is usually an obstacle. Often the hospital does not send back the notification to the health center, so that the health center does not know which patients should be followed up (lost to follow-up) (Figure 4). Figure 4: Interface Feedback From Hospital to PHC To evaluate the quality, PHC services require information on the number of patients referred by this system, they will automatically get information how many patients has already referred and for what cases (figure 5) Figure 5: List of Patients Referred 110

6 Information related performance of referral system is also available for District Health Office (DHO). They will be able to monitor the information in the dashboard which display some key indicators such as number of visit, number of referral patient, list of referral patient by location PHC and medical indication. They also will be able to see the network of referral facilities (BEONC and CEONC). Figure 6: Dashboard Interface at DHO Discussion Integrated referral information system will make some benefit to improve referral system of Maternal and Neonatal Emergencies. Administrative procedure as the bottleneck will be reduced, this will imply to other process. To achieve the objective PHC BEONC need to be equipped by minimum technology and human resources. For wide implementation of this model it will require legal aspect and support from local government. Commitment from secondary facilities especially private hospitals is also important point. They have to be ready to accept the patients and give the appropriate services without requiring complicated term and condition to the patients Information from the system can be used to the evaluation and make improvement of PHC capacity to be able to serve emergency maternal and neonatal case at the first level. 111

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