Smarter Healthcare for Indonesians
How Jhpiego Indonesia wants to improve health care systems and decision-making
By Christ Ponderosa
Wednesday, February 14, 2018
Jhpiego is an international nonprofit organization dedicated to improving the health of women and families in developing countries. Affiliated with Johns Hopkins University, Jhpiego (pronounced Jay-Pie-Go) began as a technical expert in maternal and child health over 40 years ago. Since then, it has grown to work in 155 countries, covering many health challenges including HIV/AIDS, cancer prevention, tuberculosis, malaria and diabetes.
Jhpiego is also an active partner of leading global public health institutions such as USAID, the World Health Organization (WHO) and the United Nations Population Fund, as well as many national health ministries.
Dr. Claudia Surjadjaja, Jhpiego Country Director for Indonesia, worked in Indonesia’s Ministry of Health before becoming a global public health professional and independent consultant for the past 15 years. She recently joined Jhpiego to develop sustainable solutions for addressing health challenges especially persistent high maternal mortality in Indonesia. According to the latest Intercensal Survey (SUPAS 2015), Indonesia’s maternal mortality ratio remains high at 305 per 100,000 live births and an infant mortality rate of 22.38 per 1000 live births
AmCham Indonesia sat with Dr. Claudia and her team: Dr. Irfan Riswan, FP Team Leader and Dr. Hendrik Rupang, M&E Data Manager, to discuss the issues surrounding technology and innovation.
AmCham Indonesia: Tell us about Jhpiego in Indonesia - what are your core capabilities and programs, especially those related to innovation and technology in health?
Jhpiego has been in Indonesia since 1980. We originally focused on women’s and family health. With the nation’s development, the health challenges that we face have evolved, and we found that it is not enough to focus only on maternal and neonatal health. We expanded our scope to include communicable diseases, such as malaria and TB as well as strengthening the health system. Across all of our disease areas we design innovative, effective and low cost health care solutions.
We serve as technical and service delivery experts to advise our partners on the best methods to deliver care for these challenging diseases. Jhpiego embraces science and innovation at the core of our mission, and we have an in-house innovations team dedicated to providing new evidence-based thinking to apply to our programs and partnerships. This group harnesses the potential of a human-centered design principle to capture the voice of the women and families we are serving, the health care workers delivering lifesaving interventions and the needs of stakeholders to adapt programs that will best meet the needs of the people who use health services.
Jhpiego also works to advance digital health solutions to improve the quality of care, affect health outcomes and empower people. Our digital health team serves as in-house experts for technology strategies, research, trends, and business models to help our programs leverage innovative and evidence-based mHealth [mobile health], eHealth [supported by electronic processes and communication], and eLearning [learning by electronic media] technologies. Our digitalization projects can be divided into two subcategories: ones that involve the digitalization of administrative and data management systems, and others that involve the digitalization of health care services. In digitalizing the provision of health care services, we introduced online counseling, which improved the efficiency of the counseling process.
Through SMS technology, we also enabled the conditions of emergency patients to be reported to health care providers prior to the arrival of the patient at the hospital, to ensure faster service delivery and emergency response. We have online family planning counseling, which makes counseling services more efficient. Through SMS Bunda, we provide information for pregnant mothers. Currently we are working to have more interactive communications through Info Bunda – a mobile platform (SMS and smartphone app) that can also measure knowledge on pregnancy and hypertension, tuberculosis and diabetes.
On Pilihanku Project digitalized data collection and reporting by introducing online forms and portals where health care providers can input their clinical data. The portal is centralized at the local government level, and enables the local government to access all clinical data gathered by participating providers. This not only allows them to input and access data, it also helps health care workers to analyze data and generate charts automatically. We also created tutorial videos for health care providers on how to use the data.
How, in your opinion, can technology and innovation be leveraged in the health industry?
To really address health challenges we need to accelerate not only the best new technologies, but also service delivery innovation. New technology is only as good as the enabling environment, so we work at all levels of to enable the ecosystem to deliver new technologies.
An example is technical advocacy to enable new policies, new training methods that increase health provider capacity and quality of health outcomes, of incubating new solutions through proof-of-concept to then address how best to scale new solutions for optimal adoption.
One main challenge is the rapid development of technology that exceeds the abilities of busy health workers and a resource-constrained health system to absorb. The policymaking process is lengthy and often not able to keep up. The key is to choose wisely the technologies and innovations that we adopt into our health approaches, looking for those that are likely to have a lasting impact and will be affordable and sustainable.
We see that Indonesia has plenty of health data to collect, but even if all necessary data is collected, the quality of data tends to be poor without sufficient monitoring. Awareness and understanding of the importance of having high quality data is still lacking.
But with technology and system improvement, we can achieve tremendous improvements in data quality.
Now, how do we accelerate the adoption and utilization of technology and innovation in the health sector? The most important thing is that we need to see innovation not only as something new –sometimes innovation can be as simple as adopting an existing technology and then implementing it to other contexts.
How do you assess the current utilization of technology and innovation in the health sector in Indonesia? What can we do to achieve better use of technology and innovation?
The Ministry of Health in Indonesia has been a critical partner in the implementation of new health care innovations, and we work through it to deliver on a number of large scale programs. In one of our programs, Si Jari Emas, we used technology and innovation in collaboration with the ministry and district health office to drive improved decision making and timely referral to hospitals.
A big challenge is uneven development and distribution of the health workforce. If we only focus on Java, it will be comparatively fast to implement any project. However, a system has to impact the whole country and it takes time for successful implementation. Jhpiego follows the trends set by the government, but works on how to accelerate them.
To achieve greater impact, we follow evidence-based decision-making, and complement the expertise of our partners. In collaboration with those leading in life science discovery, in machine learning and data analytics – some of whom are members of AmCham, such as GE and Pfizer – and with the industry, academic, and government groups we can leverage our collective impact to make progress on our health goals.
How can the government enhance the regulatory climate to speed up the adoption of technology and innovation?
We are committed to supporting the Ministry of Health to achieve its goals, and we are dedicated to collaborating with it toward delivering on Indonesia’s health objectives.
Given Indonesia’s geography, government support for more reliable, accessible, and affordable connectivity is critical to speed up the adoption of digital health solutions. The government can encourage the use of standards that will enable health information to be exchanged at different health facilities. Health workers would then be empowered to make more informed decisions because they have access to a patient’s full health history, and the patient would receive higher quality care, thus leading to better outcomes.
People often think that Jhpiego is focused mainly on capacity building for the health workforce. This is not entirely correct. We also involve in the after-training processes, by ensuring desired quality of service delivered is achieved through the aforementioned standardization programs, and also by ensuring sustainability of the systems implemented.
We seek to reconfigure the existing system in ways that enable us to achieve the desired health care quality. We want people to see us as focusing not only on capacity building, but also on health system transformation. To achieve this, we have been partnering with the government in many levels to use technology and innovation to translate evidence into policy.
Indonesia is an archipelago, which makes it logistically challenging, especially for those living in remote areas. We also have a scarcity in our health workforce. How can we leverage technology and innovation in health to overcome such challenges?
Technology is critical but technology alone cannot ensure quality health outcomes. Here at Jhpiego, we have devised innovative training approaches, such as the LDHF [low dose high frequency] principle that improves healthcare worker knowledge and skill retention, and eventually leads to improved outcomes for women and families.
In the past, the way it worked was to have one training session for a high volume health workforce, which was not effective, e.g. gather everyone in province-level facilities. But now, with the LDHF principle, we conduct frequent training sessions that each caters to a small volume health workforce. We also have JLearn [short for Jhpiego Learn], which contains learning materials for health workers, including information on how to manage programs, data and clinical information.
These training interventions and resources can be delivered and amplified through technology, of course, but the research evidence base and collaboration with stakeholders across the health system must be in place to be successful. There must be an incentive and a clear benefit to using technology.
The goal is to make our health system more effective and systematic. To increase capacity in an archipelagic system, it requires huge cost and effort. Sometimes all that we need is a simple idea implemented in a new context. In terms of training, we do not need complex online training. A simple approach such as through video tutorials would suffice. We have developed some tutorial videos which can be freely accessed. We use the same approach for improving the quality of data reporting. For clinical skills training, we combine technology with the mentoring system or training for trainer system. Our counseling application for post-partum family planning using tablets enables midwives to conduct counselling in less than 10 minutes compared to the old method which took more than 20 minutes and was not-standardized.
The bottom line is that digitalization and system improvements smooth out the operation of a clinic and the job of health care workers. With greater data quality and accuracy, health workers can make more reliable projections of required health products based on the demand of the patients. This, in turn, will allow them to serve the community more effectively and efficiently.
How can we best mitigate the risks associated with the learning curve in the adoption of technology? If standardization is the goal, how do you deal with the variances between different health care providers?
Implementing one small change at a time is the key. For instance, in digitalizing reporting processes, we ensure that the online form looks very similar to the offline one. We also try to keep the steps taken and the workflow the same, or as similar as possible as before digitalization. Essentially, we are only updating the system, and thus there is no need for the extensive retraining of health workers.
Using a tool that health workers are already comfortable with can ease the adoption of more complex digital health solutions. For instance, our programs incorporated a web-based system into data collection processes. This resulted in much higher rates of timely and complete reporting. To ensure skill-retention, we also do monthly drills. Ultimately, human-centered approaches to designing and implementing technological and innovative solutions are also key to accelerating adoption of technology and innovation.
Another example is Jhpiego’s own Universal Health Coverage project. We worked with local government to ensure BPJS compliance. Health care providers were hesitant to register with BPJS due to inadequate understanding of the claims process. As a solution, we created a forum that connects the district health office, BPJS, accreditors and health care providers.
In dealing with variations from one health care provider to another, we need to understand that the variables of the data that they are collecting tend to be similar. Variations often occur in the way the data is recorded and interpreted, which in the end affects service quality. For example, when data on the remaining stock of commodities, e.g. drugs, laboratory supplies, etc. is recorded without conducting actual stock counting, the result is either not enough stock or overstock and waste.
Could you identify the areas where contributions by private investors are most pressing within the health sector?
Here at Jhpiego, co-creation is very important. Jhpiego is currently in a conversation with GE about co-creation, and we want to get the government and other sectors involved too. We have started to adopt the principle of human-centered design, applied to the problem of high maternal and child mortality rates. Many of the health problems we see today cannot be solved only by health professionals.
To address this issue, we have to figure out the causes of death, which can range widely. We cannot only rely on those in the health sector. All relevant sectors have to take an active role, be it transportation, environment, etc. Jhpiego initiated a consortium that involves multi-sectoral stakeholders that aims to be actively involved in the maternal and child health movement. If you ask which sectors, the answer is all sectors.
Let me give an illustration. Many people think that a high mortality rate is a problem of the health sector. No. It becomes a problem of the health sector if the deaths occur in a medical setting. But if the death occurs because of, say, a bridge collapse, or a road accident, that becomes a problem for the infrastructure or transportation sector.
If you ask how we can leverage digital health to solve the problem, I would say that we focus on developing and disseminating knowledge that could raise public awareness of health issues. And it goes back to the human-centered design principle. We have to return the question to the stakeholders affected – what, in their opinion, are the most pressing issues, and how do they think we can help them improve things for them. The problem could be caused by clinical factors, and non-clinical ones, such as the low rate of utilization of health care services by the public. We have to figure out which it is.
What is most relevant, given our current condition in Indonesia, is the trend toward system and service quality improvement, as well as standardization. All sorts of companies can play a part in this.
All companies are mandated to have CSR [corporate social responsibility] projects. However, most CSR projects are targeted for the immediate community in which these companies operate. As a result, many projects are benefiting the host companies. If they were serious about contributing to Indonesia’s development, they would want to expand the project scope to include other areas, because what we really need is a system upgrade across the archipelago.
Digital health is definitely something that companies can contribute to by collaborating with players in other sectors. More importantly, companies need to ensure that the collaboration is sustainable. Local governments have the money to invest in health, and they are willing to do so. Jhpiego has been helping with the technical aspects.
We multi-sectoral collaboration where all stakeholders leverage each other’s potential and contribution in addressing health issues.