The Quality of Child Health Care Services in Community Health Centers in Urban Indonesia: Health Workers’ Perspectives

The quality of health delivery in primary care is crucial to improve the health status of sick children. The purpose of this study is to explore the experience of health workers in providing health care services to children under five years old in community health centre in Depok, Indoneisa. The viewpoint of these professionals can provide the necessary information for improving the quality of these services at the community health centers. The study utilizes a qualitative study design with a phenomenological approach. Twelve health care professionals from the community health centers in the city of Depok were interviewed. The data were analyzed using the Colaizzi approach. The result of the study covers three major themes, i.e. (1) the significance of health workers in delivering health care services to children under five years old, (2) factors affecting the delivery of health care services to children under five years old, (3) the continuing efforts in providing health care services to children under five years old.

centers cover programs such as integrated services for children under five (posyandu balita), immunization services, and the integrated management for sick children under five years old (6). Primary health care is a reflection of priorities on the essential elements, one of which is providing health care for mothers and their children (7). This is done to achieve the level of equality in access to health care that is in line with the basic human rights (8). If the health care provided at the community health centers matches the maximum prescribed quality, then it may lower the gap in health care that still occurs until today. The availability of health care at the primary level can improve the efficiency of health care budget and make the health care budget more effective (9). This view is in line with the findings from previous studies that show a better health care at the primary level will ultimately lead to a healthier community investment and a sound budget (10)(11)(12). The programs in health care are highly dependent on the role of the health workers in carrying out their duties. Therefore, the number of qualified health workers should be proportional to the population as a whole. The 2017 Indonesian Health Profile Report shows that there are 136,203 health workers consisting of 17,954 doctors and 118,249 nurses spread over the community health centers throughout the nation (13). The figure shows that based on quantity alone, the proportion still leaves a lot to be desired, i.e. the number of health workers in the community health centers is still inadequate. Moreover, as it turns out, the revitalization of community health centers is also at odd with the projected quality of health care resources serving in primary health care centers. The fact is revealed in Volpintesta's study that shows there is only a limited funding to train medical personnel (14). The role of health workers is clearly an important factor in achieving quality health care services to children under five years old. Consequently, the perception or viewpoint of health workers with regard to health care services to children under five years old is crucial as an input for improving the services at the primary or community health centers.

Research Design
This study employs a descriptive phenomenological approach. The implementation of health care services to children under five years old at the community health centers is one of the complex phenomena in Indonesia. At present, the implementation of health care for children under five years old is still a cause for concern because we have not been able to suppress the morbidity rate among these children down to 24 per 1,000 live births (4). Complexity of an issue is a character of the phenomena that can be described in a qualitative study (15).

Population and Study Setting
The current study was carried out in six community health centers in Depok, an urban city in Indonesia where the university is located. The participants consis of 6 doctors, 5 nurses, and 1 midwife. The inclusion criteria cover, among others, (1) the participants must have worked in a primary health center for at least six months, (2) the participants are responsible for providing health care for children under five years old. The participants were selected using a purposive sampling technique, wherein the samples are selected based on the stated research objectives (16).

Data Collection
The data collection process employs in-depth semi-structured interviews with openended questions about the health workers' perceptions with regard to delivering health care for children under five years old (Table 1). The participants were interviewed for 30-45 minutes and the interviews were recorded on a recording media.

Data Analysis
The data were analyzed using the Colaizzi approach with the following stages (1) the researcher reviewed the interviews 3-5 times; (2) after reviewing the transcripts several times, the researcher searched and noted the key and important points from the interviews; (3) next, the researcher grouped these key points into themed categories; (4) afterwards, the researcher prepared a description of the results of analyzed data; (5) then, the researcher prepared a definition based on the structured phenomena; (6) last but not least, the researcher validated the result of the research description with the participants (15,16). The data are valid if the results of the analysis possess the characteristics of data validity, i.e. credible, dependable, confirmable, and transferable.

Ethical Aspects
The study was endorsed by the Ethical Committee of the Faculty of Nursing, Universitas Indonesia whilst taking into account the prevailing research ethics, i.e. the principle of expediency, the principle of risk mitigation, the principle of fairness for all participants, and the willingness of each participant to be involved in the study by signing the informed consent form. Table 2 shows the characteristics of the health workers' demographic variables as participants in the study. Health workers' personal opinions are described in the perception of the factors and efforts that have been taken to improve the quality of health care for children under five years old.

Results
Health workers' perception is part of the section on the significance of health workers in delivering health care services to children under five years old. Six health workers describe the meaning of delivering health care, which they see as part of their responsibilities and their efforts to prevent the death of children under five years old. The health workers realize that delivering health care for children under five is part of their main duty, and they function as health care professionals.
One of the health workers reiterates the perception with regard to delivering health care for children under five years old by acknowledging the patient's right to receive the best care possible. Health workers acknowledge that delivering health care for children under five years old means providing information on how to access health services to the parents.
"Caring for them or satisfying their needs for information", (P7, a midwife).
The viewpoint of these two workers with regard to health care services to children under five years old should be seen as an effort in early detection. Health workers assigned to a community health center are aware that health services to children under five years old at a community health center are part of the preventive measures to minimize the occurrence of severe illness and child mortality in a specific area.
"We are making a judgment call, we can assess whether something is wrong with a child or not", (P1, a nurse).
The perspective of the health workers with regard to the factors affecting the quality of health care for children under five years old is to provide professional care with supporting facilities. Professional services are delivered as follows: (1) the services shall be delivered in accordance with standard operating procedures; (2) the flow of services (from registration all the way down to the queuing process to have their prescription filled) should be clear and easily understood; (3) establishing priority services for patients under five years old; (4) aspects associated with health workers' competence; and (5) health workers' commitment to improve the quality of health care for children under five years old.
According to the health workers, an aspect of the standard operating procedures, which is also a factor in the delivery of health care for children under five years old, is the wait before a patient receives the care he/she needs. Health workers are aware that child health care should be a priority. This is one of the factors that must be considered in improving the health of children under five years old.
"We must stay in course…we must put the interest of the child first", (P9, a nurse).
Good commitment from the health workers is part of the efforts to improve the quality of health care for children under five years old. Patient counseling is not only done on location, but some of the health workers also provide counseling outside the building.
"For the public, we go to posyandu (integrated health services), for weighing and immunization, which may be done outside the building, every month", (P3, a midwife).
Some of the health workers admit that sometimes they are overwhelmed by their duties, so when it comes to providing education, it is mostly limited to handing out leaflets. However, in addition to the traditional printed media, some health workers also use social media to disseminate health information to the public. Another form of cooperation is also formed with the local health workers, in this case the midwives. This type of cooperation is quite effective as a medium for disseminating information on issues related to public health or medical emergency involving a child under five years old in a specific area.
"We have an area of responsibility, so when a medical emergency occurs, we will refer to the appropriate department", (P5, a doctor).
Coordination is also carried out across programs that generally require collaboration from other departments to manage health related issues involving children under five years old.
"When a child is suffering from malnutrition, we will refer that child to a nutritionist consultant", (P12, a nurse).
Good coordination is not limited to inter profession or across programs, but it should also include coordination with leaders or heads of departments in charge of delivering health care for children under five years old. Such coordination is usually in the form of supervision and coaching. "There will be a coaching session with the department's head", (P8, a doctor).
In the effort to improve the quality of the health workers, they should be allowed to attend the relevant training on health care for children under five years old.
"A medical worker should keep his/her knowledge and skills up to date" (P11, a doctor).

Discussion
Health workers' perception with regard to health care services to children under five years old is seen as a form of responsibility to their duties as caregivers. A health worker's responsibility is realized by ensuring that the patients' rights are fulfilled.
As stated by a mother of a child under five years old, to have a caring health worker is a solution for everything (18). Furthermore, a health worker's responsibility does not end at delivering curative care inside a health center building; if necessary, it will be followed through with consultation outside the premises. A number of programs on health care for children under five years old are actually carried out at primary health centers, which help reduce the mortality rate among children under five years old (3). Disease prevention is carried out using a community-based approach or posyandu. Posyandu is a program whose objective is to reduce the mortality rate among children under five years old through immunization and early detection of diseases (19). It has been proven as an effective way to monitor children' nutritional status and provide access to vaccination to protect children under five years old (20). Participants in the current study believe that providing health care for children under five years old is by focusing on early detection of diseases as an elucidation of their responsibilities as health care professionals. In addition to the community based preventive measures, the health workers also believe that health care for children under five should be supported by the integrated management for sick children under five years old (Manajemen Terpadu Balita Sakit/MTBS) at the primary level. It is part of the early detection process before a medical emergency occurs. An effective implementation of the program at the primary level may actually help lower the state budget for medical care.
A successful early detection program can be a cost-saver because prevention is less expensive than treatment (21). Implementation of the program at primary level should not be limited to early detection; it could also cover special programs to improve the quality of health care for children under five years old. Some of the services available for children under five years old at the community health centers include weighing the children's weight, which is done monthly, vaccination, and integrated management for sick children. These programs are implemented as preventive measures at the primary and secondary level. This will literally restore the community health centers' function as health service providers at the basic level. Findings from previous studies show that a better health care at the primary level will ultimately lead to a healthier community investment and a sound budget (11,22).
Health workers describe that their professional services are carried out based on prescribed standards, such as clear service pathway, duration of waiting for examinations, competent health workers, and prioritizing health care for children under five years old. Improving the quality of health care for children under five years old is closely linked to the facilities that support the delivery of health care for these children, including among others, the availability of children's playroom and nursing room. The health workers skills when delivering the care to the children and their parents are the crucial factors that determine a successful management of sick children at the community health centers (23). Health care for children under five years old should also allow ample time for the parents to have a consultation with the health workers. Allowing ample time for the parents for consultation will ultimately lead to satisfied parents and will give them with the necessary knowledge to provide certain care that should be done by parents (24).
The immune system of a child under five years old is different from that of an adult; therefore, it is only appropriate that the children are given a priority at the primary health center. The high number of patients' visits at the community health centers increases the risk of disease transmission due to the shared waiting room for adult and child patients. This should be taken as an input by the policy makers to prioritize health care for children under five years old at the primary health centers.
Moreover, the policy makers should also take the necessary steps to separate the waiting room for adults and child patients. Providing an adequate playroom for children in health facilities will also help to achieve quality health care centers for children under five years old (18). The availability of a nursing room in primary health care facilities will also help to promote the Exclusive ASI program. Nursing room in a health facility will support the creation of child-friendly environment in public facilities. This will ultimately boost the level of satisfaction among mothers of children under five years old with regard to the care they receive at the health centers (25). The health workers in the current study are fully aware that the availability of good facilities will lead to a quality health care for children under five years old.
Health workers' efforts to deliver health care for children under five years old are implemented though health education, establishing close coordination and acrossprograms, and improving the capacity of health workers through training. Health education by health workers is delivered through health counseling intervention and disseminating health related leaflets. Most of the participants employ an outreach or counseling session outside the building targeting the parents who have brought their children to the community-based health services or posyandu. The counseling is delivered to the healthy people in the community-based health services (26). In addition to the outdoor education session in the community-based health services, health workers also provide counseling to parents who are accompanying their children in the health centers' waiting room. Besides that, health related information is also disseminated through promotional media to educate the public.
These promotional media are useful to educate the public and promote healthy way of life (27).
Health workers are working together with the policy makers to improve the delivery of health care for children under five years old. Establishing partnership with relevant organizations and the community is crucial in the efforts to improve the quality of health care (28). Coordination with local cadres is one way to improve the quality of health care for children under five years old. Involving local cadres in the services is a preventive step in minimizing the death of children under-five. The socio-ecological model also highlights the behaviors related to disease prevention, which is influenced by organizational, community, and population factors (29).

Ethics approval and consent to participate
We obtained ethics approval from the ethical committee faculty of Nursing Unitversitas Indonesia. Informed concent was sought from the participants prior to data collection.

Consent for Publication
All authors agreed to publish this manuscript.