Internet Quality across Public Health Centre in Indonesia: Access and Barriers

doi:10.21203/rs.3.rs-4694975/v1

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Internet Quality across Public Health Centre in Indonesia: Access and Barriers

https://doi.org/10.21203/rs.3.rs-4694975/v1

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Background

Primary health care (Puskesmas) is an integrated healthcare service that serves to improve individual health, preventing and curing disease, and also providing health promotion in Indonesia. To support these roles, the provision of technology infrastructure in Puskesmas is highly important, including the availability of internet connection. Thus, assessing the availability and quality of internet connection among Puskesmas is essential to understand the capacity of Puskesmas to undergo its role in providing optimum health service for the community.

Objective

This paper provides a thorough examination of the quality of internet connectivity and its relevant information technology infrastructure in Indonesian Puskesmas.

Methods

A cross-sectional survey was taken throughout all Puskesmas (10,382) in 34 provinces in Indonesia, using an online questionnaire. Categorization was done to analyze internet quality level results.

Results

A total of 10,378 public health centres (99.96%) participated in this study, with 745 (7.18%) did not have internet access, 1,487 (14,33%) have limited internet access, 5,567 (53.64%) have sufficient internet access, and 2,579 (24.85%) have sufficient and fast internet access. Moreover, 832 Puskesmas (8.02%) do not have 24-hour electricity, 44,196 (43.7%) have CPU with i3 specifications, 43,044 (42.56%) have 512 GB hard disk capacity, and 67,272 (66,5%) uses antivirus.

Conclusions

Although 79% of Puskesmas in Indonesia already had sufficient internet access, 21% still have limited and insufficient access. To ensure universal internet availability, it is essential to build collaborative support among internet providers and government to foster the availability and utilisation of internet satellites, high-quality computers, and electrical power to support internet connectivity.

Public health centres

Puskesmas

internet

infrastructure

access

Primary health care (Puskesmas) is a core component of health systems (1). Based on the Alma Ata Declaration in 1978, Puskesmas is defined as essential health care that meets the needs of communities, easy to access, acceptable, and affordable (2). The declaration combined three elements considered core to delivering sustainable and equitable health services: multisectoral public policy; empowered communities; and primary public health care (2, 3).

It is important to note that not every country with a strong system of primary health care realises all of its benefits. International comparisons of individual countries’ performance in population health in relation to their health expenditure and aspects of health care processes and structures have helped us to understand the benefits of effective and efficient primary health care. Starfield’s landmark publication in 1994 (4), followed by research from Europe, Canada, the United States and other high-, low- and middle-income countries, has confirmed that health systems with strong primary health care at their core have lower health costs, better population health, higher patient satisfaction, fewer unnecessary hospital admissions and greater socioeconomic equity (5–8).

In 2022, the Ministry of Health (MoH) of the Republic of Indonesia launched its health system transformation strategy. There are six pillars of the transformation strategy, and one of them is primary health care transformation, which in its implementation focuses on strengthening promotive and preventive activities to create more healthy people, improve health screening, and increase primary service capacity. The number of Puskesmas has increased since 2017, from 9,825 units to 10,374 Puskesmas in 2022. The ratio of Puskesmas in Indonesia to sub-districts in 2022 is 1.4. This illustrates that the ideal ratio of Puskesmas to sub-districts, namely a minimum of 1 Puskesmas in 1 sub-district, has been fulfilled nationally. In terms of an average ratio, each Puskesmas serves 27,000–30,000 thousand residents in 2023. What needs to be considered is the distribution of the Puskesmas in all sub-districts, especially in remote, frontier and outermost areas to provide public health services to households with a focus on maternal and child health services, elderly health, communicable disease and non-communicable disease prevention (9).

Puskesmas in Indonesia spread across all types of characteristic regions such as urban, rural, remote, and very remote in Indonesia within all 38 provinces and 514 districts/cities. In Indonesia, there are two main functions of Puskesmas, 1) Provide an integrated individual healthcare that includes the activity and a series of basic individual medical services to improve the individual health, preventing and curing disease, and 2) Provide essential public health services to the community includes health promotion, maternal and child health, nutrition, disease prevention and control, and environmental health. Puskesmas in Indonesia also has a responsibility to carry out technical guidance to clinics and other community health services as the Puskesmass networking partner institutions in the area. Other tasks of Puskesmas are to provide continuous and comprehensive care, to refer to specialists and hospital services, to coordinate health services, to guide the patient within the network of public health services, and to provide the best possible health services (10).

One of the elements that support healthcare services is information technology. In the era of digital, Internet of things (IoT), and artificial intelligence (AI), the digital transformation in healthcare also increases expectations of the quality of care (11). Since the Coronavirus Disease (COVID-19) pandemic, digital information from the internet has gained importance in all areas of life. This trend was already evident before the COVID-19 pandemic. However, it accelerated this development and is also reflected in the healthcare sector (12). With the widespread use of smartphones, downloadable or internet-based applications (apps) will play a major role in the diagnosis of diseases, and monitoring and management of patients. However, the implementation of digital health is not without challenges and concerns. Based on another literature study conducted in developed and developing countries, many barriers can occur during digital information system implementation. These include the limited availability of human resources with Information Technology competency, as well as infrastructure issues such as the availability of the Internet, computer, and electricity (13).

Indonesia, is the world's fourth most populous country with over 270 million people residing across more than 17,000 islands (14, 15). As an archipelagic country, this condition results in disadvantages in terms of information and communication technology (ICT) infrastructure (16). In addition, almost all internet users in Indonesia connect through mobile devices. Although mobile broadband (3G, but now increasingly 4G/LTE) is the most widely used internet service in Indonesia, it is not on par with fixed broadband with respect to capacity, quality of service, high bandwidth performance, and cost-efficiency. Such limited access to high-quality internet prevents the population from unlocking its productive capabilities to fully reap the benefits of a digital economy and points to two key challenges: how to make fixed broadband internet access universal and increase internet quality. Increased optical fiber network coverage is a necessary but insufficient solution to meeting the key challenges. While investment by private service providers, along with government projects such as Palapa Ring have steadily increased connectivity and service availability across Indonesian districts, internet subscriptions have not increased in parallel. Only 26% of homes with access to a fixed broadband provider subscribe to this service (17).

Several research regarding information technology infrastructure in supporting health information systems in healthcare facilities have been conducted in Indonesia and other countries (13, 18, 19), However, there is no detailed information available that can describe the accessibility and quality of the internet at Public Health Centers (Puskesmas) in Indonesia. This paper aims to provide for the first time, a comprehensive overview of accessibility and quality of the internet connection, including supporting information technology infrastructure availability across Public Health Centers in Indonesia.

Data Collection

A cross-sectional approach was conducted, using a survey conducted between 15 November 2022 and 16 March 2023. The population study covered 10,378 puskesmas in 34 provinces in Indonesia. A questionnaire was used to collect data from participants. To ensure the validity and reliability of the questionnaire, a pilot survey was conducted with a total of 20 participants, resulting in a satisfactory Cronbach alpha value (0.76).

A standardised questionnaire survey was created using KoboToolbox, an online application that allows users to create survey forms and collect data in real time. This tool was chosen because it can be accessed online or in offline mode (with automatic synchronisation), even when internet connectivity is poor. The tool also allows users to save drafts as they have completed the surveys, giving them the flexibility to participate in surveys and carry out their daily tasks at Puskesmas. This is well suited to the uneven internet conditions in Indonesia.

The questionnaire consisted of four sections, including (i) Result of bandwidth speed test measured using www.speedtest.net in the morning and afternoon. Speedtest measures the speed between the device and the test server, using the Puskesmas device's internet connection; (ii) Type and quality of internet network such as WIFI, LAN, routing, etc. This section also provides qualitative information such as the condition of frequent internet disconnections and how the internet speed in Puskesmas; (iii) Specification and quantity of computers or laptops in Puskesmas. This section collects information such as the capacity of CPU, Memory, RAM, the total number of computers/ laptops, antivirus installation and the ownership of the computer/ laptop; (iv) Availability of electricity in Puskesmas. This section collects information on 24-hour electricity availability and any backup electricity used in Puskesmas.

Univariate analysis was conducted using open-source tools, employing Python and R languages, to examine the internet quality in Puskesmas across Indonesia. Scoring was performed to determine the categories of internet quality. There were 11 principal component indicators used for scoring the quality of internet, including (1) Result of morning upload speed test, (2) Result of afternoon upload speed test, (3) Result of morning download speed test, (4) Result of afternoon download speed test, (5) Type of internet connection, (6) The quality of internet connection, (7) Computer/laptop RAM specification used, (8) Computer/laptop CPU specification used, (9) 24-hour electricity availability, (10) Presence of backup/alternative electricity power supply, and (11) Number of laptop/computer with installed antivirus. The detailed scoring calculation and weighting can be seen in Appendix 1.

Final scores were divided into 4 categories, namely Level 1, 2, 3, and 4. Level 1 is for Puskesmas that have fast and reliable internet connection with 24-hour electricity and backup, as well as high specification of computer/laptop. Level 2 is for Puskesmas with normal and sufficient internet connection, standard specification of computer/laptop, and 24-hour electricity availability. Level 3 is for Puskesmas that have unreliable or insufficient internet connection, computer/laptop below standard, and lack of 24-hour electricity. The lowest level, Level 4, is for Puskesmas with no internet connection, computer/laptop below standard, minimum quantity, and lack of 24-hour electricity.

The major islands of Indonesia were classified into five categories: (1) Java Island, which includes provinces such as Banten, DKI Jakarta (Special Capital Region of Jakarta), West Java, Central Java, Yogyakarta Special Region, and East Java; (2) Bali and Nusa Tenggara, comprising Bali, East Nusa Tenggara, and West Nusa Tenggara provinces; (3) Sumatra, encompassing Aceh, North Sumatra, West Sumatra, Riau, Riau Kepulauan, Jambi, South Sumatra, Bengkulu, Bangka Belitung, and Lampung provinces; (4) Kalimantan, which includes West Kalimantan, Central Kalimantan, South Kalimantan, East Kalimantan, and North Kalimantan provinces; and (5) Maluku and Papua, consisting of Maluku, North Maluku, Papua, and West Papua provinces. After weighting each performance category of Puskesmas and understanding the demographic landscape of Indonesia, we utilised descriptive analysis, a statistical method employed to summarise and describe the characteristics of a dataset to depict the condition of the internet in Indonesia.

Ethical Consideration

We declare that the data collected for this paper do not require ethical approval as no individual data are presented and informed consents were collected during the survey implementation.

Internet Quality across Puskesmas

A total of 10,378 Puskesmas (99.96% of the total 10,382 Puskesmas in Indonesia), spread across 514 districts/cities from 34 provinces, participated in the survey. Among the 34 provinces, all Puskesmas in 30 provinces (88%) successfully participated in this survey. Based on the location of Puskesmas, 3,034 (29.2% of 10,378) were located in urban areas; 4,700 (45.3% of 10,378) in rural areas; 1,446 (13.9% of 10,378) in remote areas, and 1,198 (11.5% of 10,378) in very remote areas.

Based on the study results, 745 Puskesmas in Indonesia (7.18%) has no internet access (level 4), 1,487 Puskesmas (14,33%) has insufficient internet access (level 3), 5,567 Puskesmas (53.64%) has sufficient internet access (level 2), and 2,579 Puskesmas (24.85%) has sufficient and fast internet connection (level 1). Given this condition, 78% of Puskesmas in Indonesia, categorised under Levels 1 and 2, exhibit sufficient internet access, whereas 22% of Puskesmas in Levels 3 and 4 experience inadequate internet connectivity.

After obtaining data on each Puskesmas, we calculated the level of internet quality at the provincial level by averaging the scores of all Puskesmas in each province (see Fig. 1). Provinces with the highest proportion of Puskesmas had level 1 internet access were DI Yogyakarta (86/121; 71%), followed by DKI Jakarta (206/315; 65.4%), and Bali (51/120; 42.5%). In contrast, 48.9% (222/454) Puskesmas in Papua, 48.9% (81/227) Puskesmas in Maluku, and 25.7% (42/163) Puskesmas in West Papua have the highest number of Puskesmas with no internet access in the province. Out of 745 Puskesmas without internet, the provinces with the highest number of Puskesmas with no internet access were Papua (222), Maluku (81), North Sumatra (45), West Papua (42), and North Maluku (35). Further details are available in Appendix 2.

The disparities in the distribution of Puskesmas with different levels of internet quality across the islands of Indonesia were identified. Java Island led with large number of Puskesmas having Level 1 internet access (41.95%; 1,525/3,635), marking a stark contrast to other islands, such as Sumatra Island, Sulawesi, Kalimantan, Bali and Nusa Tenggara where the proportion of Puskesmas with fast internet access do not exceed more than 20%. Nationally, the Level 2 internet category is most common, with 5,567 (10,378; 53.64%) Puskesmas have sufficient internet access, and Sumatra Island has the highest proportion within this category (57.54%; 1556/2704). In sharp contrast, the Maluku and Papua Islands have the highest distribution of Level 4 internet quality with 380 (992; 38.31%) puskesmas having no internet access, significantly higher than other islands (see Fig. 2A).

The distribution of Puskesmas with varying levels of internet quality is also significant across different locations in Indonesia. Puskesmas located in urban areas were more likely to have better internet quality, with 39.42% (1,177/2,986) Puskesmas having sufficient and fast internet access. Puskesmas located in rural areas were more likely to have sufficient quality internet with 59.34% (3,004/5,062) Puskesmas were in level 2. Puskesmas in very remote areas were disproportionately affected by lower internet quality, with the highest occurrences of Level 4 and Level 3 internet quality (34.93%; 335/959 and 30.55%; 293/959 respectively) (see Fig. 2B).

Based on computer connection, majority type connection in Indonesian Puskesmas were Wifi (49.9%; 5,179/10,378), followed by Wifi and LAN (22.05%; 2,288/10,378), and tethering from mobile data (7.44%; 772/10,378). Referring to participants’ perspective, 38.83% (4,030/10,378) Puskesmas have robust internet access, 31.83% (3,303/10,378) have slow internet connection, 22.16% (2,300/10,378) have very slow internet connection, and lastly 7.18% (745/10,378) have no access to internet at all (see Fig. 3). Type of Internet Connection and Internet Connection Quality in Public Health Centers have a weight of 8% each of the total assessment.

Factors Influencing Internet Quality across Public Health Centres

Computer Specification

A separate analysis was conducted to determine other factors that affect internet quality, including RAM specifications, CPU, hard disc capacity, and antivirus updates on the hardware used. Based on the study, the most common RAM specification used in Puskesmas was 4 GB RAM (60.7%; 61,390/101,140), followed by 2 GB RAM (17.34%; 17,536/101,140), and 8 GB RAM (16.85%; 17,038/101,140).

Based on regional distribution, the provinces with the largest proportion of 4GB RAM were Bali (71.53%; 1,472/2058), followed by North Maluku (70.61%; 932/1,320) and West Java (66.97%; 9,942/14,072). In addition, East Nusa Tenggara had the highest proportion of Puskesmas with 23GB RAM computer specification (7.66%; 174/2,272), followed by Papua (7.41%; 90/1214), Riau Islands (7.16%; 84/1174) and Bengkulu (6.93%; 70/1010). On the other hand, West Papua Province was the province with a highest proportion of hardware with a low specification less than 2GB RAM (6.49%; 44/678), followed by Bengkulu (2.77%; 28/1010), Papua (2.47%; 30/1214), and North Sulawesi (2.05%; 26/1268) (see Fig. 4).

Based on CPU specifications, nationally, hardware with i3 specifications dominated at 43.7% (44,196/101,140), followed by i5 at 22.63% (22,892/101,140), and Celeron at 13.01% (13,158/101,140) (see Fig. 5B). By region, the provinces with the highest proportion of hardware with CPU type i3 were Central Java (53.34%; 6,860/12,860), followed by Jambi (48.53%; 560/1,154), and East Java 47.29% (6,128/12,958). In addition, provinces with highest CPU specification of i7 type were DKI Jakarta (18.45%; 5,242/ 2,840), Riau Islands (15.5%; 182/1,174) and Banten (14.21%; 390/2,744). In contrast, the provinces that have below average CPU type distribution with Celeron type, were Maluku (39.84%; 816/2,048), followed by North Maluku (28.64%; 378/1,320) and Bangka Belitung (25.43%; 176/692) (see Fig. 5A).

Figure 6B shows that nationally, the most hard disk capacity used in Puskesmas was 512 GB (42.56%; 43,044/101,140), followed by 1 TB (24.64%; 24,924/101,140), 256 GB (20.7%; 20.932/101,140), and 128 GB (12.1%; 12,240/101,140). At the province level, the provinces with highest distribution of 512GB hard disk capacity were West Nusa Tenggara (51.04%; 986/1,932), followed by East Java (48.65%; 6,304/12,958), Central Kalimantan (47.95%; 632/1,318) and Jambi (46.45%; 536/1154). In addition, provinces with highest proportion of highest hard disk capacity of 1 TB was North Kalimantan (45.41%; 890/1,960), followed by DKI Jakarta (43.8%; 1,244/2,840), Banten (32.43%; 890/2,744), and North Maluku (31.67%; 418/1320). In contrasts, province with highest distribution of lowest hard disk specification of 128 GB was Bengkulu (27.13%; 274/1,010), followed by Papua (23.56%; 286/1,214), North Sumatra (22.27%; 866/3,888), and North Maluku (21.36%; 282/1,320). The details can be seen in Fig. 6A.

Based on the study, 33.5% (33.868/101,140) of computers in Puskesmas did not install antivirus. Among the computers with installed Antivirus, the most antivirus used was Smadav (78.44%; 52,768/67,272), followed by Avast (8.03%; 5,402/67,272), and others (10.83%; 7,284/67,272). Furthermore, province with highest proportion computers with installed antivirus was North Kalimantan (92.24%; 1,808/1,960), followed by Gorontalo (83.8%; 538/642), Central Sulawesi (83.18%; 1,286/1,546), and East Nusa Tenggara (82.92%; 1,884/2,272). In contrast, DKI Jakarta with 49.58% (1,408/2,840) of their computers did not installed antivirus, followed by Banten 48.1% (1,320/2,744), West Java 47.85% (6,734/14,072), and North Maluku 47.42% (626/1,320) (Fig. 7A).

Electricity Access

At national level, 91.98% (9,546/10,378) Puskesmas in Indonesia have electricity access for 24 hours, whereas 8.02% (832/10,378) Puskesmas do not have access to 24-hour electricity (See Fig. 8A). In terms of provinces distribution, 100% (120/ 120) Puskesmas in Bali have access to 24-hour electricity, followed by Central Java (99.66%; 877/880), DKI Jakarta (99.37%; 313/315), and Gorontalo (98.92%; 92/93). In contrast, provinces with highest number of Puskesmas that do not have access to 24-hour electricity was West Papua (53.37%; 87/143), followed by Papua (52.86%; 240/454), Maluku (33.92%; 77/227), and North Maluku (19.59%; 29/148).

The provision of electricity backup is also an important point in the operational process of public health centres. Based on the study, 29.09% (3,019/10,378) of Puskesmas did not have electricity backup. Among the Puskesmas who had electricity back up, the most common type of electricity backup owned by Puskesmas was a generator (63.36%; 6,575/10,378), followed by other backups (4.83%; 501/10,378), and UPS (2.73%; 283/10,378) (see Fig. 9B). At provincial levels, the provinces with the highest number of Puskesmas having electricity backup were Central Java (91.02%; 801/880), followed by DI Yogyakarta (90.91%; 110/121), East Java (88.79%; 863/972), and West Nusa Tenggara (84.66%; 149/176). In contrast, 53.08% (241/454) Puskesmas in Papua did not have any electricity backup, followed by South East Sulawesi (50.99%; 154/302), West Papua (48.47%; 79/163), and North Maluku (46.62%; 69/168) (see Fig. 9A).

The Internet's significant role in aiding public health services is undeniable. This paper marks the first comprehensive depiction of the accessibility and quality of internet connections and computer systems across Indonesia's Puskesmas, providing crucial insights into the information technology infrastructure. The internet availability in the health facility is highly crucial to foster the delivery of healthcare among communities (20–22). By presenting the internet quality, this study serves as a cornerstone for improving both the accessibility and standard of healthcare services, addressing deficiencies in health information systems, and stimulating technological progress as the foundations for building more efficient and promoting healthcare equity across the country.

According to this study, it was found that 78.4% of Puskesmas have good and sufficient internet quality, 14.4% Puskesmas have insufficient internet connection, and 7.2% of the Puskesmas don’t have internet access at all. The study depicts that the Eastern Part of Indonesia had the least internet connection in Puskesmas compared to other parts of Indonesia, which includes Maluku and Papua regions. This is aligned with previous findings related to the limited internet access in eastern part of Indonesia and low ICT development index in 2020–2021 throughout the areas (23–26). The ICT Development Index (IDI), published by the United Nations International Telecommunication Union, serves as a crucial benchmarking tool for measuring the information society by utilising internationally agreed ICT indicators, assisting governments, operators, development agencies, researchers, and others in assessing the digital divide and comparing ICT performance globally (27).

The underlying causes of limited internet access in the Eastern part of Indonesia may be due to several aspects, including challenging geography, archipelagic region, size of territory to cover, limited infrastructure, which should be taken into account as barriers that limit the accesses (29–31). High service costs to provide IT infrastructure (including tower, fibre optic, etc) have become the challenge to evenly provide internet access across the country, especially in remote areas (28). While at the same time, the user also finds it a burden to subscribe to the certain internet monthly fee (28, 32–34). Some studies also showed that socio-behavioural values & perceptions toward digitalization also influence in enhancing or limiting the internet availability, including unwillingness of the local people to allow the internet infrastructure development, lower education attainment, and low adult literacy (28, 32, 35).

For completing administrative tasks in Puskesmas, such as browsing, data input, upload and download files, or to support any other health service tasks, studies have shown that it requires a minimum specification of 4 GB RAM and CPU i3 or above for computer or laptop (36, 37). These findings show that the majority (81.66%) of the Puskesmas in Indonesia already had 4 GB RAM or above in their computers, while 18.34% of them were lower (2 GB and 1 GB). As for the CPU specification, 83% of the Puskesmas had the sufficient CPU specification (i3 type or above), while 17% of them had insufficient which were Celeron and Core2. It is understood higher RAM capacity and newest CPU specification are linked with better computer’s performance, which is highly important to be provided in Puskesmas to ensure smooth operation of critical healthcare software, efficient management of electronic health records, and reliable services, ultimately supporting effective patient care delivery in the healthcare facilities (38, 39).

Similar with RAM capacity and processors, hard disk was also found to affect the computer’s capacity to process (39). This study reveals that the majority of Puskesmas have sufficient hard disk of 256 GB or above (88%), and 12% of them have the insufficient one (128 GB). Literature findings show that 128 GB internal storage is able to undergo basic operations, however it will demand higher capacity for extensive computer use (40). The hard disk is crucial for computer performance as it stores and retrieves data, including the operating system and applications, facilitating efficient multitasking and overall system responsiveness (38, 39). As for the antivirus, this finding shows that the coverage of antivirus installation in Puskesmas’ computer is still incomplete, especially in DKI Jakarta, Banten and West Java Provinces which leave almost half of its Puskesmas unprotected with the antivirus. In healthcare facilities, malware protection is critical for computer performance as it safeguards sensitive patient data, prevents potential cyberattacks, and ensures the uninterrupted operation of vital medical software, maintaining the integrity and security of patient care services (41, 42).

This study found that 8.2% of Puskesmas in Indonesia have no access to electricity for 24 hours. Most provinces that do not have access to 24-hour electricity were located in the eastern part of Indonesia such as Maluku and Papua island. Modern energy enables health service delivery. Access to electricity is, however, unreliable in many health facilities in developing countries (45). Reliable basic infrastructure, particularly electricity, is a critical enabling factor in improving health systems (46). Previous literature showed that the availability of electricity is an important determinant of receiving health information and utilisation of health services (47). Based on a literature study conducted in developing countries (48, 49), there are many barriers that can occur during the electricity provision across the nation, this includes the lack of information technology infrastructure, especially electricity supply. Indonesia started the rural electrification program in the late 1950s, but how to provide electricity in a sustainable way both organizationally and institutionally still becomes a big challenge (50).

According to the Electricity Power Supply Business Plan 2019–2028, Indonesia’s average electricity growth is at 6.42%. Indonesia successfully surpassed its electrification ratio target at the end of the year 2018 (4). However, there are still 2,510 villages across Indonesia that are not yet electrified (51). Increasing the electrification ratio always becomes a challenging task because Indonesia has many islands and many communities are isolated from one another (50). This geographical situation also worsens with poor infrastructure access, making the area hard to reach (52). There are several fundamental requirements that need to be implemented in order to cope with the rural electrification challenges (53–55). The lessons learned from other countries that have successfully achieved universal electricity access were summarised in several studies (56). Committed governance and supportive regulations and policies are one of the most often stated in the literature (57). Moreover, a collaboration of appropriate policies and government will increase the private sector’s participation in the rural electrification program (58).

Strength and Limitations

This research exhibits several strengths that contribute to its significance in the field. The study at hand is a groundbreaking research effort that has comprehensively assessed a wide range of internet components in primary health care facilities, including device availability, access, and internet quality in nearly all public health centres across Indonesia. The findings of this study provide valuable insights into various supporting factors that can facilitate the implementation of information technology transformation. The study highlights the significance of the availability, quality, and barriers of computer systems, hardware, and software devices, which can serve as instrumental inputs for the government in their decision-making processes regarding the implementation of such transformations.

However, certain limitations must be acknowledged: (i) Bandwidth checks to assess the quality of internet access were only carried out in the morning and evening which depends on local conditions and the respondent's honesty, (ii) The completeness of filling out the questionnaire was influenced by the capacity of the assigned respondents, (3) Validation of CPU, RAM, Antivirus could not be done directly. Nevertheless, this study provides a deeper overview of the access and barriers of internet access and other supporting information technology infrastructure in 10,378 public health centres throughout Indonesia.

The internet plays a vital role in healthcare services, facilitating communication, information exchange, and access to medical resources. Despite the fact that 78% of healthcare centres in Indonesia have sufficient internet connectivity, challenges persist, with some areas experiencing limited access or complete absence of internet connectivity. To ensure universal availability of the internet across primary care services in Indonesia, additional measures are imperative. This includes the provision of high-quality computer systems with adequate specifications to handle healthcare-related tasks efficiently, as well as ensuring uninterrupted 24-hour access to electrical power to support continuous internet connectivity and operational efficiency in healthcare facilities.

Ethics approval and consent to participate

We declare this study did not require ethics approval because it did not involve any invasive procedures. Additionally, all participants took part voluntarily, ensuring that their consent was informed and freely given. This approach aligns with ethical guidelines, ensuring that participants' rights and well-being were respected throughout the research process.

Funding

All authors did not receive funding for the creation of this manuscript. This work was supported in part by the IARC/WHO, through training by the Biobanking and Population Cohort Network (BCNet; CRDF Global, Award No. 66415).

Author Contribution

DNA led the study design, built the paper concept, main structure and methodology. AHS, CAM, AFL carried out the study. MTAE, VW, SD, IL and MA accessed and analysed the data. DNA, AHS, CAM, AFL, MTAE, VW, SD, IL wrote the first draft of the paper. ZK and LM validated the study and critically revised the manuscript content. DNA and AHS had primary responsibility for the final content. All authors read and contributed to reviewing the study data, the manuscript design, and the approval of the final manuscript.

Acknowledgements

The authors would like to thank the Digital Transformation Office Ministry of Health Republic of Indonesia for supporting the study implementation; the Public Health Centres, Districts and Provincial Health Offices across Indonesia who have participated in the study; and MoH Data and Information Centre (Pusdatin), Directorate General of Public Health, Directorate General of Health Care Services who have supported the study implementation.

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Internet Quality across Public Health Centre in Indonesia: Access and Barriers

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Abstract

Background

Objective

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Conclusions

Figures

Introduction

Methodology

Data Collection

Ethical Consideration

Results

Internet Quality across Puskesmas

Factors Influencing Internet Quality across Public Health Centres

Computer Specification

Electricity Access

Discussion

Strength and Limitations

Conclusions

Declarations

Funding

Author Contribution

Acknowledgements

References

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