PHC in Indonesia, is responsible for delivering primary care services to the community in certain allocated areas. PHC is the primary point of contact for individuals seeking healthcare services in their communities. They offer various services, including preventive care, health promotion, disease management, and basic medical treatment. They have coordination lines to their sub-level of community health services in the working area, such as sub-district PHC and posyandu (integrated service centres in rural areas). Their services address the population's healthcare needs and improve overall health outcomes [22].
A previous study presented that Jakarta PHCs have better information management compared to rural areas [23]. Still, our study found that selected PHCs have low control over health data handling, especially data integration and communication. Those conditions made significant challenges for PHCs to expand their roles in managing paediatric health, particularly in further health risk assessment. We found limited records on vaccination history and children's growth for our samples because PHCs expect those data to be stored on each posyandu. Therefore, this study could not analyse the correlation of vaccination history and nutrition status to the risk of COVID-19 infection and further health problems. Even though it was found only 20% of patients who received BCG vaccines had further AURI after COVID-19 infection during the first semester. Based on findings from a systematic review, there was a significant correlation between pneumococcal and influenza vaccine history and the severity of COVID-19 and respiratory problems [24]. Unfortunately, this study had no records on non-mandatory vaccines such as influenza and pneumococcal.
During COVID-19 pandemic, PHCs became the backbone of Indonesian strategic tools for community health handling. PHCs must report the detection and management of COVID-19 patients in their working area to collect them as regional and national reports [17, 18]. Their roles could be optimised in health data governance to prepare future health risk assessments, particularly for special populations like paediatrics. For instance, the patient reports might include comorbidity and nutrition status as enabler factors of severe COVID-19 [12, 25], but there was no provided data regarding those parameters in PHC's reports.
This study also tried to assess the potential risks of COVID-19 in further respiratory problems of children aged less than 5 years. We identified the frequency of revisits to PHC six months after being infected by COVID-19 and its health reasons based on the ICD-10 diagnosis code. The increasing number of patients' visits in the years 2021 and 2022 compared to 2020 might be affected by patients' decision to avoid healthcare during the beginning period of the pandemic. There was no difference in risk of respiratory problems and non-respiratory, six months after COVID-19 infection. The most frequent cause of patient encounters in PHC after COVID-19 infection was AURI. It is well-known that young children are more prone to AURI, like common cold. Most of the cases are related to sociodemographic factors. Previous study in Indonesia revealed that children aged 1 year and 2 years have more risk than others in under five age group [26]. It has similar results in this study, in which AURI is more frequent in 1–3 years age group as a reason for physician visits.
Based on published reports of COVID-19 waves in Indonesia, it could be interpreted that data in 2020, 2021, and 2022 represent cases predominantly caused by Alfa-Beta, Delta, and Omicron variants, respectively. A study in the USA found that the Omicron variant poses less risk of severe symptoms in children under five years compared to Delta. They also received fewer medications than infected patients during Delta emergence [6]. In contrast, the highest frequency of COVID-19 medication prescribing in PHC in this study was found in 2022 during the wave of Omicron cases. It was predicted that the shifting paradigm on parents' perception of healthcare visits, COVID-19 treatment approach, and better health records had affected the findings. At the beginning of pandemic, most people tended to avoid healthcare due to fear of COVID-19 transmission, and most physicians were unsure about COVID-19 treatment [8, 10, 17].
Our study shows that most COVID-19 cases in children under five years in ambulatory primary care had less pharmacological treatment. Most of the prescribed medications were vitamins, supplements, and cough-related medications. Previous studies also reported that multiple treatment approaches for paediatrics patients have been documented with various efficacy and adverse effects. Despite antiviral, supportive therapy was the most prominent option for pediatric patients especially for outpatient treatment [27]. Interestingly, there were no weight records on the day of patients' visits, which should be a practical guideline for considering pediatric dosing.
It is pivotal to have accessible data between healthcare settings to ensure that the government and health officers comprehensively review potential health problems. Application interoperability and data communication should be opted for on PHCs services. It could potentiate their roles in community health management and preparedness for further health risks in the population.