Abstract
Background
Indonesia has endeavoured to strengthen primary health care (PHC), a task requiring comprehensive measurement of PHC performance which remains a challenge. This scoping review aims to describe PHC performance measurement pertaining to service delivery in Indonesia and identify what has not been measured.
Methods
We conducted a scoping review, following the Preferred Reporting Items for Systematic Reviews Extension for Scoping Reviews guideline. We mapped the measurement used in the included studies to the WHO/UNICEF PHC measurement framework at the service delivery level. Our analysis involved process (domains: models of care, systems for improving quality, resilient health facilities and services) and output (domains: access and availability, quality care) indicators, 38 in total. These indicators are broadly categorised in the WHO/UNICEF framework based on their feasibility and relevance for measuring PHC performance as either Tier 1 − measurable in most contexts, or Tier 1 global − important for global monitoring, or Tier 2 − difficult to measure or requiring further assessment.
Results
Of the 4,831 studies initially identified, 33 were included in this review. The domains of PHC performance assessed included access and availability, models of care, and quality care. No studies reported on the domains: systems for improving quality, or resilient health facilities and services. Overall, 18/38 of the WHO/UNICEF framework indicators were not measured: 1 of 3 Tier 1 global indicators (admissions for ambulatory care sensitive conditions (ACSC)), 4 of 11 Tier 1 indicators, and 13 of 24 Tier 2 indicators. Few studies utilised instruments that have been designed for national reporting, and time-trend analysis was limited.
Conclusions
This study identified measurement gaps in PHC service delivery performance in Indonesia. Addressing these gaps, by developing a more comprehensive monitoring framework that incorporates unmeasured domains and indicators, adapting relevant global measurement instruments to the Indonesian context, and conducting time trend analyses, may contribute to improve PHC performance monitoring and support Indonesia PHC transformation agenda. These potentially offer insights for other countries with similar setting.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12913-025-12955-8.
Keywords: Primary health care, Performance, Measurement, Service delivery, Indonesia
Background
The main pathway by which universal health coverage (UHC) can be attained is through primary health care (PHC). A strong PHC system improves health outcomes and patient satisfaction while simultaneously reducing costs and hospital admissions [1]. This point is emphasised in the Astana Declaration [2]. A recent estimate indicates that PHC can deliver 90% of essential interventions to reach UHC [3]. However, PHC performance in most low- and middle-income countries (LMICs) continue to have many challenges [4, 5]. This issue is exacerbated by a lack of reliable and comprehensive data in this regard, which makes it difficult to identify specific weaknesses in PHC performance that can offer the evidence necessary to support targeted policy decisions [6]. The task of measuring PHC performance is complex, but such performance measurement is crucial with regard to efforts to strengthen PHC effectively [7].
As is the case in many LMICs, Indonesia has invested considerable effort and resources in the task of strengthening PHC on the basis of a variety of policy interventions over the last two decades. These interventions include the decentralisation of health care management to the subnational level, the implementation of Jaminan Kesehatan Nasional (JKN), which is Indonesia’s social health insurance programme, an increase in the number of accredited PHC providers, the provision of targeted funding for PHC [8, 9], and the implementation of performance-based capitation, in which context of payment is linked to provider performance [10]. In 2022, Indonesia introduced a health system transformation policy consists of 6 pillars in which one of them is PHC transformation that aimed at improving capacity and capability of PHC, as well as enhancing the public health function of PHC [11].
In the context of ongoing efforts to improve PHC in Indonesia, there is a need for assessments of performance at the service delivery level. The service delivery in this study refers to the level at which health services are directly provided to patients by PHC facilities, including community health centres (Puskesmas in the Indonesian context) and clinics. At this level, policy interventions have direct effects on both healthcare providers and communities they serve and performance measurement can facilitate the assessment of how resources are used (input) to generate the desired PHC services (process and output) [12, 13].
While previous studies have focused on emerging efforts to measure PHC service delivery performance in Indonesia, such as those involving accessibility [14], readiness [15–18], utilisation [19–21], and effectiveness [15, 22], no comprehensive research has attempted to synthesise measurement of PHC performance and identify unexplored measurement in this country. The aim of this study was to produce a scoping review of the literature on measurement of PHC performance in the context of service delivery, specifically with the goals of describing how PHC performance has been measured and analysed and identifying measurement that have not yet been made.
Methods
To synthesise the evidence on PHC performance measurement in Indonesia, we conducted a scoping review. This method is used to address a broad and complex issue by mapping the literature [23], and it is appropriate when diverse sources of literature, including academic papers and the grey literature, are involved. We followed on Peters et al.’s [24] updated scoping review technique as well as the Preferred Reporting Items for Systematic Reviews Extension for Scoping Reviews (PRISMA-Scr) guideline [25] (Supplementary material 1). We conducted this scoping review across a series of six stages.
Stage 1: defining key terms, conceptual framework, and research questions
We defined PHC in accordance with the definition provided by the WHO, which describes PHC as the first contact with health care and includes both medical services provided by primary care and public health functions [26, 27]. This definition is consistent with the Indonesian context, in which PHC is related to both functions. The term primary care (“pelayanan primer” or “pelayanan dasar” in Indonesian language) is often used synonymously with PHC (“pelayanan kesehatan primer” or “pelayanan kesehatan dasar” in Indonesian language) across Indonesian studies. Although we used both terms in the process of searching, screening, and selecting relevant literature, the term “PHC” is used throughout this scoping review.
To evaluate PHC performance, various frameworks have been developed. One such framework is the PHC Performance Initiative (PHCPI), which was designed to allow LMICs to measure PHC performance at the system, input, service delivery, output, and outcome levels [28]. A more recently developed framework for PHC measurement, which was produced by the WHO/UNICEF [12, 13] in 2022, has broader application since it is based on multiple global models, including the PHCPI framework. On the basis of this WHO/UNICEF PHC measurement framework (hereafter referred to as the WHO/UNICEF framework), this review assessed PHC performance measurement at the service delivery level. This notion includes five domains (Fig. 1): three domains at the process level (models of care, systems for improving quality care, and resilient PHC facilities and services), and two domains at the output level (access and availability as well as quality care), which account for a total of twelve subdomains across the two levels [12, 13].
Fig. 1.
Primary health care service delivery performance adapted from the WHO/UNICEF primary health care measurement framework [12, 13]
The WHO/UNICEF framework includes indicators for each domain and subdomain. These indicators are classified based on their feasibility and relevance in measuring PHC performance as Tier 1, which includes indicators that can be measured in most contexts; or Tier 1 global, which refers to certain prioritised Tier 1 indicators that are identified as key indicators for monitoring at the global level; or Tier 2, which highlights indicators that are challenging to measure in most contexts or that require methodological development [12, 13].
Across these tiers, the WHO/UNICEF framework also classifies indicators into two types: 1) “PHC-oriented indicators”, which focus primarily on measurement within PHC settings, or hospital measures, which are influenced by or related to PHC performance (namely, admissions for ambulatory care sensitive conditions), and 2) “hospital-oriented indicators”, which rely only on hospital-based measurement to evaluate the broader context of PHC [12, 13]. Our review is limited to PHC-oriented indicators, as they provide more direct evidence regarding ways of improving PHC performance. The only “hospital-oriented indicator” on which we relied in this study was “bed occupancy”, which was applied in the context of PHC facilities. In the Indonesian health system, PHC facilities also commonly manage brief overnight admissions for minor conditions that require such treatment [9], such as uncomplicated childbirth, rather than referring patients to secondary- or tertiary-level facilities. This review refers to the short-name versions of the PHC-oriented indicators defined by the WHO/UNICEF framework; however, both the short- and long-name versions are provided in Supplementary material 2.
The research questions addressed in this review are as follows: 1) What domains and indicators have been used to measure PHC performance in the Indonesian context? 2) What domains and indicators have not yet been assessed in existing Indonesian studies?
Stage 2: identifying the literature search strategy
We developed keywords (regards as search terms) on the basis of the population, concept, context (PCC) approach as recommended in the updated methodological guidance for scoping reviews [24]. The concept included in this review was “performance measurement at service delivery level” and the context was “primary health care (PHC)” and “Indonesia”. We did not restrict this review to a specific population group. We used broad search terms consisting of combinations of PCC in which the concept referred to PHC service delivery performance outlined in WHO/UNICEF framework. For Indonesian publications, we used equivalent search terms in Indonesian language. As these search terms are quite extensive we list them in detail in Supplementary material 3.
We searched for English-language articles in PubMed, Scopus, and Web of Science; we also searched for Indonesian-language publications through Garuda. Furthermore, we identified grey literature in ProQuest for dissertations and theses, as well as the websites of relevant Indonesian government agencies, research institutes, and international organisations. Electronic searches were completed by the end of March 2024. All coauthors and a librarian contributed to the process of refining the search terms, which was developed by the lead author. We identified 4,831 records from our initial search (Supplementary material 3), which included peer-reviewed articles (1,110 from PubMed, 3,416 from Scopus, 201 from Web of Science, 55 from Garuda), and grey literature (35 from ProQuest and 14 from relevant websites). Of these 4,831 records, 33 met the eligibility criteria and were included in this review (Fig. 2).
Fig. 2.
PRISMA flow diagram
Stage 3: defining the inclusion and exclusion criteria
The inclusion criteria used in this review were as follows: (1) reported PHC performance measurement using PHC-oriented indicators that were considered to be relevant to the WHO/UNICEF framework; (2) published in a peer-reviewed journal/commentary/editorial/review, in the grey literature, including theses/dissertations, or in reports from research institutions/international agencies/governments in Indonesia; (3) conducted in Indonesia; (4) featuring any type of study design, including quantitative, qualitative, mixed-methods, and review; and (5) written in English or the Indonesian language. The searches conducted for this review did not involve any limitations in terms of publication date.
The exclusion criteria used in this research were as follows: (1) relied on hospital-oriented indicators, as defined by the WHO/UNICEF framework; (2) were published only as an abstract; (3) were conducted outside Indonesia or did not include separate analyses for Indonesia; and (4) did not distinguish between PHC and other health care facilities clearly in the analysis.
Stage 4: screening and selecting studies
Two authors (D.A.S. and E.S.) independently screened the literature in light of the inclusion and exclusion criteria using Covidence. Phase I involved an initial screening of titles and abstracts for relevance. Phase II involved a full-text review of the articles and documents identified during phase I. These two reviewers engaged in discussions to resolve disputes, and in cases in which no agreement was reached, input was sought from third reviewers (D.C.B. and M.K.). The reasons for the exclusion of articles were recorded.
Stage 5: extracting relevant studies
We extracted literature on the basis of study characteristics (year of publication, study location, type of study, and type of PHC) and PHC performance measurement used (domains, subdomains, and indicators/proxy indicators in line with the WHO/UNICEF framework as well as how indicators/proxy indicators were measured, the measurement instruments used, and data sources). The complete results of the data extraction process are provided in Supplementary material 2.
Stage 6: presenting and analysing the results
We mapped each paper by domain, subdomain, and indicator in line with the WHO/UNICEF framework [12]. In cases in which the indicators used to measure PHC performance measurement in the extracted papers were worded differently but were conceptually similar, we included them as approximations of the WHO/UNICEF indicators. All the authors discussed these proxies with the aim of identifying the domains, subdomains, and indicators that they best represented in light of the definitions and technical specifications included in the WHO/UNICEF framework [13]. Henceforth, the term “indicators” used throughout this review includes such proxy indicators.
Moreover, we described how these indicators were measured in the studies under investigation. We also classified the instruments used to measure these indicators as follows: 1) national instruments that were designed to assess PHC performance for Indonesia as a whole; 2) study-specific instruments that were developed solely to address the needs of a single specific study in one context and not used elsewhere; 3) unmodified international instruments that were derived from sources outside Indonesia, such as from researchers in other countries or institutions such as the WHO, which were applied in Indonesia without any modifications; and 4) modified international instruments that were similar to the third type of instrument but had been adapted to fit the Indonesian context.
The data sources used for the indicators under study were classified as follows: 1) PHC providers’ perspectives (views of GPs, health workers, or government officers); 2) patients’ perspectives (views of patients or the community as beneficiaries of PHC services); or 3) both PHC providers’ and patients’ perspectives in which context the data were collected through community-based surveys, self-administered surveys, in-depth-interviews, or focus group discussions; and otherwise classified as 4) routine or administrative data; 5) direct investigations on the basis of facility visits; and 6) reviews of existing studies or documents.
The types of analysis, in which these indicators were used, were categorised as either 1) determinant analysis, which involves examining various factors (e.g. age, sex, income) associated with outcomes in which the indicators identified in this study were the outcomes of interest; 2) geographic variations or spatial analysis, which involves identifying and examining differences in outcomes across geographic locations or analysing spatial distributions using specific tools, such as geographic information systems (GIS); 3) time-trend analysis, which involves examining changes over time with the aim of identifying patterns and trends; and 4) policy analysis, which involves evaluating the effectiveness or impact of policy implementation.
Results
Of the 4,831 studies initially identified as part of this review, 33 met the eligibility criteria and were included in this review (Fig. 2). This consisted of 28 peer-reviewed articles and 5 documents from grey literature (Supplementary material 2). One study [15] reported multiple WHO/UNICEF framework aligned indicators and was therefore treated as two studies for the purposes of representation and calculation in Tables 2, 3 and 4; therefore, 34 studies are included in these tables. We also included two studies [29, 30] that assessed bed occupancy at PHC facilities, as inpatient care is commonly provided in Indonesian PHC facilities [9].
Table 2.
Domains and indicators used to measure PHC service delivery performance in the Indonesian context (WHO/UNICEF framework alignment)
| WHO/UNICEF Framework [12, 13] (Domains, subdomains, indicators) |
Tiers of indicators | Included studies: How were indicators/proxy indicators measured? | ||||
|---|---|---|---|---|---|---|
| Indicators/proxy indicators in line with the WHO/UNICEF framework | Measurement instruments | Data sources | No. of studies | |||
| Domain: Models of care | n = 11 (33%) | |||||
| Subdomain: Selection and planning of services (n = 1) | ||||||
| Service package meeting criteria | Tier 1 + Global | Local governments’ views on the implementation of the health minimum service standard (HMSS)2) [31] | National instrument [31] |
PHC providers'perspectives (self-administered survey and in-depth interviews) [31] |
1 | |
| Roles and functions of service delivery platforms and settings defined | Tier 1 | N/A | N/A | N/A | 0 | |
| Subdomain: Service design (n = 2) | ||||||
| Existence of an empanelment system | Tier 2 | N/A | N/A | N/A | 0 | |
| System to promote first contact accessibility | Tier 1 | Performance-based capitation payment scheme involving public PHC providers as a financial incentive for the first point of contact on the basis of specified criteria3) [10], GPs’ self-reports on knowledge, attitude, and performance in terms of the gatekeeper role of PHC [32] | National instrument [10], study-specific instrument [32] | Routine or administrative data [10], PHC providers'perspectives (self-administered survey) [32] | 2 | |
| Protocols for patient referral, counter-referral, and emergency transfer | Tier 2 | N/A | N/A | N/A | 0 | |
| Existence of care pathways for tracer conditions | Tier 2 | N/A | N/A | N/A | 0 | |
| Subdomain: Organisation and facility management (n = 6) | ||||||
| Professionalisation of management | Tier 2 | Patients’ views on GPs’ professionalism attributes [33], GPs’ experiences with the implementation of medical practice standards implementation [34, 35] | Study-specific instrument [33–35] | Patients’ perspectives (in-depth interviews) [33], PHC providers'perspectives (in-depth interviews) [34, 35] | 3 | |
| Management capability and leadership | Tier 2 | Midwives’ self-reports regarding the ability of head of public PHC services in interpersonal, informational, and decisional roles [36] | Study-specific instrument [36] |
PHC providers'perspectives (self-administered survey) [36] |
1 | |
| Multidisciplinary team-based service delivery | Tier 2 | Physicians’, nurses’, midwives’, and pharmacists’ views on collaborative competencies at PHC [37] | Study-specific instrument [37] |
PHC providers'perspectives (in-depth interviews) [37] |
1 | |
| Existence of supportive supervision system | Tier 1 | N/A | N/A | N/A | 0 | |
| Existence of facility budgets and expenditures meeting criteria | Tier 2 | Health budget management review in the context of PHC [38] | Study-specific instrument [38] | Reviews of existing studies or documents [38] | 1 | |
| Subdomain: Community linkages and engagement (n = 2) | ||||||
| Collaboration between facility and community-based providers | Tier 2 | Community health workers’ perspectives on the influence of the governance of village heads and public PHC on community PHC performance [39] | Study-specific instrument [39] |
PHC providers'perspectives (community-based survey) [39] |
1 | |
| Community engagement in service planning and organization | Tier 2 | N/A | N/A | N/A | 0 | |
| Proactive population outreach | Tier 1 | Patients'and health workers'perspectives on population outreach on the basis of portable health clinics for NCD services: usefulness, ease of use, facility conditions, social influence, resistance to use, and perceived risk [40] | Study-specific instrument [40] | Both PHC providers'and patients'perspectives (in-depth interviews) [40] | 1 | |
| Service for self-care and health literacy in primary care | Tier 2 | N/A | N/A | N/A | 0 | |
| Domain: Systems for improving the quality of care |
n = 0 (0%) |
|||||
| Percentage of facilities with systems to support the improvement of quality of care and safety | Tier 1 | N/A | N/A | N/A | 0 | |
| Domain: Resilient health facilities and services |
n = 0 (0%) |
|||||
| Percentage of facilities meeting criteria for resilient health facilities and services | Tier 2 | N/A | N/A | N/A | 0 | |
| Domain: Access and availability | n = 13 (38%) | |||||
| Subdomain: Accessibility, affordability, acceptability (n = 4) | ||||||
| Geographical access to services | Tier 2 | Spatial accessibility of PHC services in light of the average distances travelled by land or sea to the nearest PHC providers, weighted by the availability of health workers [14] | Study-specific instrument [14] | Routine or administrative data [14] | 1 | |
| Perceived barriers to access (geographical, financial, sociocultural) | Tier 1 | Community’s perspectives on barriers to access PHC services [41]; patients’ perspectives on PHC access in terms of five aspects: availability, accessibility, affordability, acceptability, and adequacy [42]; PHC providers’ perspectives on barriers to access screening for hypertension risk factors in the context of PHC [43] | Study-specific instrument [41–43] |
Patients'perspectives (focus group discussions, in-depth interviews [41], community-based survey [42]), PHC providers'perspectives (focus group discussions) [43] |
3 | |
| Access to emergency surgery | Tier 2 | - | - | - | 0 | |
| Existence of a system of post-crash care | Tier 2 | - | - | - | 0 | |
| Subdomain: Service availability and readiness (n = 6) | ||||||
| Percentage of facilities offering core services according to national defined service package | Tier 1 | PHC general service readiness on the basis of WHO’s modified service availability and readiness assessment (SARA) [15]1) and the modified WHO-SARA with national guidelines [16]; PHC readiness for CVD services on the basis of the modified WHO-SARA with national guidelines [17]; PHC availability and readiness for HIV testing and counselling on the basis of the modified WHO-SARA [18] | Modified international instrument [15–18] | Direct investigation on the basis of facility visits [15–18]) | 4 | |
| Provider availability (absence rate) | Tier 2 | Health workers’ nonattendance in public PHC, as verified by physical documents [44] | Study-specific instrument [44] | Direct investigation on the basis of facility visits [44] | 1 | |
| Percentage of facilities meeting minimum standards to deliver tracer services | Tier 1 | Essential medicines availability (60 essential medicines and 17 of the most essential medicines) in PHC facilities on the basis of physical verification [45] | Modified international instrument [45] | Direct investigation on the basis of facility visits [45] | 1 | |
| Percentage of facilities compliant with Infection Prevention and Control Assessment (IPC) measures | Tier 1 | - | - | - | 0 | |
| Subdomain: Utilisation of services (n = 3) | ||||||
| Outpatient visits | Tier 1 + Global | Self-reported PHC outpatient and inpatient visits [19, 20]; PHC utilisation index according to administrative reimbursement parameters for outpatient and inpatient visits [21] | Study-specific instrument [19–21] |
Patients’ perspectives (community-based survey) [19, 20], routine or administrative data [21] |
3 | |
| Emergency unit visits | Tier 2 | - | - | 0 | ||
| Domain: Quality care |
n = 10 (29%) |
|||||
| Subdomain: Core primary care functions (first-contact accessibility, continuity, comprehensiveness, coordination, and people-centredness) (n = 4) | ||||||
| Patient-reported experiences | Tier 1 | Patient-reported experiences in terms of access, trust, acceptability of PHC services [46]; efficiency, effectiveness, timeliness, patient-centred approach, equity, safety [47], and satisfaction with PHC quality services (effectiveness of medication received, personnel attitude, and cleanliness) [48] | Study-specific instrument [46–48] |
Patients’ perspectives (in-depth interview [46], self-administered survey [47], community-based survey [48]) |
3 | |
| People’s perceptions of health system and services | Tier 2 | Jakartans’ (Community Living in Jakarta) perceptions of PHC services, i.e., hospitality of personnel; quality of PHC facilities, medicines, and medical devices; service fee, opening hours and distance [49] | Study-specific instrument [49] |
Patients’ perspectives (focus group discussions) [49] |
1 | |
| Subdomain: Effectiveness (n = 2) | ||||||
| Diagnostic accuracy (provider knowledge) | Tier 2 | PHC providers’ knowledge scores, which are assessed via clinical vignettes on prenatal, respiratory infection, diarrhoea, vomiting [22] and cough and fever, diarrhoea, vomiting, antenatal [15]1) | Modified international instrument [15, 22] |
PHC providers’ perspectives |
2 | |
| Adherence to clinical standards for tracer conditions | Tier 2 | - | - | - | 0 | |
| Avoidable complications (lower limb amputation in diabetes) | Tier 2 | - | - | - | 0 | |
| Admissions for ambulatory care sensitive conditions (ACSC) | Tier 1 + Global | - | - | - | 0 | |
| Subdomain: Safety (n = 2) | ||||||
| Prescribing practices for antibiotics | Tier 1 | Antibiotic prescribing appropriateness for treatment or prophylaxis according to Giessen’s method or compliance with reference guidelines on the basis of a synthesis of relevant evidence [50] | Modified international instrument [50] | Reviews of existing studies or documents [50] | 1 | |
| Proportion of people 65 years and over prescribed antipsychotics | Tier 2 | Prevalence of potentially inappropriate medication (PIM) on the basis of medical prescriptions for patients aged ≥ 60 years, including antipsychotics, in light of the criteria proposed by Beers and McLeod [51] | Unmodified international instrument [51] | Routine or administrative data [51] | 1 | |
| Subdomain: Efficiency (n = 2) | ||||||
| Provider caseload | Tier 2 | - | - | 0 | ||
| Bed occupancy | Tier 2 | PHC bed occupancy rate [29] and number of PHC bed-days [30] on the basis of patient-level information | Study-specific instrument [29, 30] | Routine or administrative data, and community-based survey [29, 30] | 2 | |
| Subdomain: Timely access (n = 0) | ||||||
| Cancer stage at diagnosis (by cancer) | Tier 2 | - | - | 0 | ||
1)One publication [15] measured two indicators within the subdomain of service availability and readiness, and subdomain of effectiveness; this publication was included twice in this table
2)The health minimum service standard (HMSS) [31] in districts/cities is based on Minister of Health Decree No.741/Menkes/Per/VII/2008, which identifies 18 indicators. This HMSS has been updated on the basis of government regulation No.2/2018, which identifies 12 indicators
3)The performance-based capitation payment scheme, consists of 3 criteria [10]: the contact rate, the chronic disease contact rate, and the nonspecialist referral rate
Table 3.
Studied and unstudied indicators of PHC service delivery performance in Indonesia
| WHO/UNICEF Framework | Included studies | ||||
|---|---|---|---|---|---|
| Indicator’s Tiers2) | Domains | No. of indicators | Studied indicators1) | Unstudied indicators | |
| Tier 1 | Models-of-care | 4 | 2 | 2 | Roles and functions of service delivery platforms and settings defined |
| Existence of supportive supervision system | |||||
| Systems for improving quality | 1 | 0 | 1 | Percentage of facilities with systems to support the improvement of quality of care and safety | |
| Access and availability | 4 | 3 | 1 | Percentage of facilities compliant with Infection Prevention and Control Assessment (IPC) measures | |
| Quality care | 2 | 2 | 0 | - | |
| Sub total | 11 | 7 | 4 | ||
| Tier 1 Global | Models-of-care | 1 | 1 | 0 | - |
| Access and availability | 1 | 1 | 0 | - | |
| Quality care | 1 | 0 | 1 | Admissions for ambulatory care sensitive conditions (ACSC) | |
| Sub total | 3 | 2 | 1 | ||
| Tier 2 | Models-of-care | 10 | 5 | 5 | Existence of an empanelment system |
| Protocols for patient referral, counter-referral, and emergency transfer | |||||
| Existence of care pathways for tracer conditions | |||||
| Community engagement in service planning and organisation | |||||
| Service for self-care and health literacy in primary care | |||||
| Resilient health facilities and services | 1 | 0 | 1 | Percentage of facilities meeting criteria for resilient health facilities and services | |
| Access and availability | 5 | 2 | 3 | Access to emergency surgery | |
| Existence of a system of post-crash care | |||||
| Emergency unit visits | |||||
| Quality care | 8 | 4 | 4 | Adherence to clinical standards for tracer conditions | |
| Avoidable complications (lower limb amputation in diabetes) | |||||
| Provider caseload | |||||
| Cancer stage at diagnosis (by cancer) | |||||
| Sub total | 24 | 11 | 13 | ||
| Total | 38 | 20 | 18 | ||
1)One publication [15] measured two indicators in both domain of access and availability and domain of quality care, it was included twice in this Table
2)Indicators’ Tier: 1) Tier 1, indicators that could be measured in most contexts; 2) Tier 1 global, part of prioritised Tier 1 indicators which are identified as key indicators for monitoring globally; and 3) Tier 2, indicators that are challenging to measure in most contexts or requisite methodological development [12, 13]
Table 4.
Types of analyses used in PHC service delivery performance studies in the Indonesian context
| Domains | Authors/institutions (Year) | Determinant analysis | Geographic variations or spatial analysis | Time trend analysis | Policy analysis |
|---|---|---|---|---|---|
| Models of care | Hendarwan, H. et al. (2015) [31] | - | - | - | √ |
| Sambodo, N.P. et al. (2023) [10] | - | - | - | √ | |
| Mulyanto, J. et al. (2021) [32] | √ | - | - | - | |
| Sari, M. et al. (2016) [33] | √ | - | - | - | |
| Syah, N.A. et al. (2015) [34] | √ | - | - | √ | |
| Ekawati, F. M. & Claramita, M. (2021) [35] | √ | - | - | √ | |
| Dwi Wulandari, R. et al. (2020) [36] | √ | - | - | - | |
| Ernawati, D. K. (2020) [37] | √ | - | - | - | |
| Kompak (2017) [38] | - | - | - | √ | |
| Hasanbasri, M. et al. (2024) [39] | √ | √ | - | - | |
| Wulandari, H. et al. (2023) [40] | √ | - | - | - | |
| Access and availability | Leosari, Y. et al. (2023) [14] | - | √ | - | - |
| Megatsari, H. et al. (2019) [41] | √ | - | - | - | |
| Shresta, J. (2010) [42] | √ | √ | - | - | |
| Widyaningsih, V. et al. (2022) [43] | √ | √ | - | √ | |
| Haemmerli, M. et al. (2021)1)[15] | √ | √ | - | - | |
| Rajan V.S. et al. (2018) [16] | √ | √ | - | - | |
| Arsyad, D. S. et al. (2022) [17] | √ | √ | - | - | |
| Saptarini, I. et al. (2023) [18] | √ | √ | - | - | |
| Ramadhan, A. P. & Santoso, D. (2015) [44] | √ | - | - | - | |
| Fanda, R.B. et al. (2024) [45] | √ | √ | - | - | |
| Wulandari, R. D. et al. (2023) [19] | √ | √ | - | - | |
| Mulyanto, J. et al. (2020) [20] | √ | √ | - | - | |
| Wenang, S. et al. (2021) [21] | √ | √ | - | - | |
| Quality care | Ekawati, F. M. et al. (2017) [46] | √ | - | - | - |
| Nijyoti, N. et al. (2020) [47] | √ | - | - | √ | |
| Maeda, A. (1999) [48] | √ | - | - | √ | |
| Sokang, Y.A. et al. (2019) [49] | √ | - | - | - | |
| Diana, A. et al. (2015) [22] | √ | √ | √ | - | |
| Haemmerli, M. et al. (2021)1)[15] | √ | √ | - | - | |
| Limato, R. et al. (2022) [50] | √ | √ | - | - | |
| Abdullah, R. et al. (2018) [51] | √ | - | - | - | |
| Hafidz, F. et al. (2018) [29] | √ | - | - | - | |
| Hafidz, F. et al. (2017) [30] | √ | √ | - | - |
1)One publication [15] measured two indicators in both the domain of access and availability and the domain of quality care; this publication was included twice in this table
Characteristics of the included studies
The 33 studies included in this review (Table 1) were published from before 2010 until March 2024. Approximately half (55%, n = 18) of the included studies were published from 2020 to March 2024. In terms of study location, 55% of the studies (n = 18) were conducted in specific districts/cities, 9% (n = 3) were conducted in specific provinces, and 36% (n = 12) focused on the national level (including most or all provinces and districts/cities). The types of studies included in this review were as follows: 64% (n = 21) were quantitative, 27% (n = 9) were qualitative, 6% (n = 2) were review articles, and 3% (n = 1) were mixed methods. In terms of the types of PHC providers included, 20 studies (61%) were conducted in public PHC only, 13 studies (39%) involved both public and private PHC, and no studies were conducted exclusively in the context of private PHC.
Table 1.
Characteristics of the included studies
| Characteristics | Studies, n (%) |
|---|---|
| Year of publication | |
| Before 2010 | 1 (3%) |
| 2010–2019 | 14 (42%) |
| 2020-March 2024 | 18 (55%) |
| Study location | |
| National (including most or all provinces and districts/cities) | 12 (36%) |
| Specific provinces | 3 (9%) |
| Specific districts/cities | 18 (55%) |
| Type of study | |
| Quantitative | 21 (64%) |
| Qualitative | 9 (27%) |
| Mixed-methods | 1 (3%) |
| Review | 2 (6%) |
| Type of PHC | |
| Public only | 20 (61%) |
| Private only | 0 (0%) |
| Both public and private | 13 (39%) |
Domains of PHC service delivery performance measurement
Regarding the five domains of PHC performance measurement considered in this review (Table 2), 38% (n = 13) of the 34 studies measured access and availability, 33% (n = 11) focused on models of care and 29% (n = 10) emphasised quality care. No studies addressed the domain of systems used to improve the quality or resilience of PHC facilities and services.
Most studies that were conducted in the models of care domain focused on organisation and facility management (n = 6), and fewer studies emphasised community linkages and engagement (n = 2), service design (n = 2), or the selection and planning of services (n = 1). In the access and availability domain, the primary focus was on service availability and readiness (n = 6), whereas other studies focused on accessibility, affordability, acceptability (n = 4) and the utilisation of services (n = 3). The quality care domain focused on core primary care functions (n = 4), and fewer studies addressed the subdomains of effectiveness, safety, and efficiency (n = 2 each); furthermore, no studies addressed timely access.
Indicators of PHC service delivery performance measurement
Among the 38 indicators included in the WHO/UNICEF framework, 20 indicators or their proxies were used in previous studies to measure PHC performance at the service delivery level in Indonesia. Notably, 20 indicators or their proxies were used in previous studies to measure PHC performance at the service delivery level in Indonesia. This revealed a total of 18 indicators that remain unstudied in the Indonesian context. Among these 18 unstudied indicators, four were Tier 1 indicators, which are considered to be important and feasible to measure in most contexts, and one was a global monitoring indicator in Tier 1, namely admissions for ambulatory care sensitive conditions (ACSC). The remaining 13 indicators were in the category of Tier 2 indicators, which are either difficult to measure in most contexts or require further assessment (Table 3).
With regard to the models of care domain, relevant indicators included the health minimum service standard (HMSS) [31]; the performance-based capitation payment scheme for public PHC providers [10]; the gatekeeper role of PHC [32]; the professionalism attributes of GPs [33]; medical practice standards and implementation [34, 35]; the ability of the head of public PHC in interpersonal, informational, and decisional roles [36]; collaborative competencies among physicians, nurses, midwives, and pharmacists in the context of PHC [37]; health budget management in the context of PHC [38]; the influence of the governance of village heads and public PHC on community-based PHC performance [39]; and population outreach on the basis of portable health clinics for NCDs services [40] (Table 2).
In terms of access and availability, the indicators covered the spatial accessibility of PHC services [14], communities’ perspectives on barriers to access PHC services [41], patients’ perspectives on PHC access [42], PHC providers’ perspectives on barriers to access screening for hypertension risk factors in the context of PHC [43], PHC readiness for general services [15, 16], PHC readiness for cardiovascular services [17], and PHC readiness for HIV testing and counselling services [18], health workers’ nonattendance in public PHC [44], the availability of essential medicine in PHC facilities [45], PHC outpatient and inpatient visits [19, 20], and the PHC utilisation index [21] (Table 2).
Quality care was assessed in terms of patient-reported experiences [46–48], community perceptions of PHC services [49], PHC providers'knowledge scores [15, 22], the appropriateness of antibiotic prescriptions [50], the prevalence of potentially inappropriate medication (PIM) among the geriatric population [51], the PHC bed occupancy rate [29], and the number of PHC bed-days [30] (Table 2).
How indicators have been measured and analysed
Most studies (n = 23) utilised instruments that were specifically designed for each study. Eight studies employed modified international instruments [15–18, 22, 45, 50] and one study used an unmodified international instrument [51]. Two studies used instruments that were designed for the entire country of Indonesia [10, 31] (Table 2).
Most indicators of PHC performance in Indonesia were measured from either PHC providers’ perspective [15, 22, 31, 32, 34–37, 39, 43] or patients’ perspective [19, 20, 33, 41, 42, 46–49], whereas only one study used both of these perspectives [40]. Other indicators relied on routine or administrative data [10, 14, 21, 29, 30, 51], and others used direct investigation on the basis of facility visits [15–18, 44, 45]; finally, two studies used policy document reviews [38] and systematic reviews [50] (Table 2).
In terms of analyses (Table 4), 19 studies used more than one type of analysis. There were 30 studies that featured determinant analysis, 16 that employed geographic variation or spatial analysis, 8 that used policy analysis, and 1 that focused on time-trend analysis.
Discussion
To our knowledge, this review is the first to provide structured analysis synthesising evidence of how PHC performance has been measured in the context of service delivery in Indonesia. Using the WHO/UNICEF framework, we identified gaps in the performance measurement of PHC at the service delivery level, including: 1) no measurement in the domains of “systems for improving the quality” and “resilience of PHC facilities and services”, 2) 18 unstudied indicators, comprising 1 Tier 1 global indicator to measure PHC quality (important for global monitoring), 4 Tier 1 indicators (feasible and crucial to measure in most contexts), and 13 Tier 2 indicators (require adaptation for use in the Indonesian context), 3) limited use of instruments that were designed for Indonesia-specific national reporting, and 4) only one study featuring time-trend analysis.
Our review revealed that most studies on PHC service delivery performance in Indonesia focused on three of the five domains: access and availability (38%), models of care (33%), and quality care (29%). These studies have provided insights into the current state of PHC performance in the respective domains and may help inform policy and PHC service delivery improvements. For example, studies on perceived access to care [41–43] have provided evidence supporting the need to expand PHC service coverage. Similarly, research on the health minimum service standard (HMSS) [31] has provided evidence for the importance of updating PHC service delivery standard. Additionally, a study evaluating performance-based capitation payment scheme [10] have informed stakeholders of the roles of financial arrangements in PHC service delivery.
Although studies of the quality care domain have been substantial, nearly half (5 out of 11) of the indicators included in the WHO/UNICEF framework for this domain have not yet been explored in Indonesian studies (Table 3). Notably, one of the 18 unmeasured indicators, namely admissions to ACSC which is a global Tier 1 indicator of quality care, has been widely used to assess the quality of PHC in developed countries such as the USA, the UK, and Australia [52–54], but has not been measured, despite the availability of social health insurance sample data in Indonesia [55]. Other LMICs, such as, Vietnam [56] and Brazil [57] have utilised a health insurance database to assess admission to the ACSC, demonstrating its feasibility for use in similar settings like Indonesia.
Based on our study, the domain of “systems for improving quality” and “resilient health facilities and services” as well as 4 of 11 Tier 1 indicators (measurable in most context) and the remaining 13 of 24 Tier 2 indicators (difficult to measure or requiring further assessment) have not been examined to date (Table 3). These gaps may reflect not only the technical complexity of measuring such domains and indicators, but also this is likely in part due to challenges in providing these metrics in current Indonesia’s PHC performance monitoring systems. In particular, the absence of a comprehensive PHC performance framework and technical guideline for measurement may limit data recording and reporting.
Routine PHC monitoring systems in Indonesia primarily rely on self-reported data from PHC facilities, which remains heavily centred on input-based measures (e.g. health workers, financing, and medicine availability) and program-based measures (e.g. surveillance and immunisation coverage). Service delivery level indicators, such as those related to “system for improving qualities” and “resilient health facilities and services”, have not been systematically collected and remains absent from the national PHC performance monitoring system. This is not unique to Indonesia. A scoping review that focused on LMICs found a lack of evidence on service delivery level, despite ample evidence concerning input level [5]. A systematic review conducted in the Asia–Pacific region also emphasised the need for more evidence in this regard, particularly to support organisation of PHC service delivery [58].
Ongoing reforms, such as the introduction of “Satu Sehat” platform or one health information system in 2022, aimed at integrating fragmented health information systems [59], and a technical guideline for improving PHC data quality issued in 2023 [60], represent important steps towards improving PHC performance monitoring system. However, implementation challenges persist. Full interoperability of digital health information system has not yet achieved, and PHC facilities continue to report issues related to data quality, including completeness, timeliness, and verification, which vary across subnational levels. These challenges are further compounded by disparities in internet access [61], availability of digital health information system infrastructure [62], as well as inadequacy and unequal distribution of PHC staffs [63].
While some studies have utilised national instruments, such as the health minimum service standard (HMSS) [31], this instrument remains limited in scope. HMSS primarily measures population coverage of essential services such as maternal care, but it does not capture the complexity of PHC performance measurement, such as quality of services being provided. Additionally, in this review of previous measurement in terms of the domains and indicators of PHC performance in Indonesia, the fact that only one study conducted a time-trend analysis of PHC providers’ knowledge scores is notable [22]. Evidence is therefore lacking policy impact on PHC performance over time.
Implications for policy, practice, and future research
The findings of this review highlight specific measurement gaps in PHC service delivery performance in Indonesia. These gaps may limit the availability of data and evidence on the state of PHC performance in the country. Indonesia’s National Medium-Term Plan (known as RPJMN) 2025–2029 has identified PHC investment as one of the key policy interventions to improve population health [64]. In light of this and the ongoing PHC transformation efforts, our study contributes by providing which domains and indicators of PHC service delivery performance have not been measured to date and suggests a more comprehensive approach to measuring PHC service delivery performance. It may contribute to the evidence base on the extent to which current investment and efforts to improve PHC capacity and capability are achieving intended goal, namely, improving equitable access to quality PHC across Indonesia.
In the Indonesian context, policymakers could consider enhancing current PHC performance monitoring efforts by developing a more comprehensive framework that incorporates key domains and indicators identified in this review, particularly the domain of “systems for improving quality” and “resilient health facilities and services” as well as Tier 1 indicators, which are considered measurable in most context. The WHO/UNICEF framework does not suggest the minimum or ideal number of indicators to be included in PHC service delivery performance measurement but instead encourages countries to prioritise a feasible set of domains and indicators based on their specific needs to improve PHC performance measurement [12]. Integrating the Tier 1 global indicator under the quality care domain, namely admission for ACSC, into Indonesia’s PHC monitoring system may offer additional insights into PHC quality in the country, as high rates of admissions for ACSC often reflect problem in access to timely and effective PHC. This could involve establishing a reporting system and guideline to enable reliable data collections that integrated within Satu Sehat platform.
Practically, PHC providers play a key role in PHC performance measurement by actively engaging in data collection and reporting. Strengthening their capacity to assess more comprehensive indicators and implement quality assurance measures, along with ensuring availability of dedicated and trained data officers, digital health infrastructure, and digitised reporting system, may help address the gaps in existing PHC performance measurement. These may serve as a foundation for continuous quality improvement in PHC service delivery across geographic settings in Indonesia.
Regarding future research, developing indicators to specifically measure the domain “resilient health facilities and services” in the Indonesian context, as well as other unmeasured Tier 2 indicators identified in this study warrants further exploration. These indicators remain underexplored, primarily due to methodological complexity and data limitations. These indicators could be piloted in selected settings to assess feasibility before considering broader implementation. Exploring relevant international measurement instruments and assessing their potential adaptation to Indonesian context would help ensure that key performance metrics are effectively assessed. Conducting time-trend studies remains an essential step in understanding the impacts of policy changes on PHC performance over time.
Study limitations
The application of the WHO/UNICEF framework in this context facilitated a structured approach that enabled us to systematically select and analyse studies related to PHC performance. Nevertheless, as not all of the PHC-oriented indicators included in this framework were directly measured in the available studies, we included conceptually related measures as proxy indicators. For example, the framework indicator “geographical access to services”, defined as “percentage of population living within 5 km (or 1 h) of a comprehensive primary care facility/provider and 2 h of an emergency care unit/provider” [12, 13], is not directly translatable to the Indonesian context given the population is distributed over thousands of islands with travel involving both land and sea routes (Table 2 and Supplementary material 2). Therefore, we included an alternative metric, i.e., “spatial accessibility of PHC services in light of the average distances travelled by land or sea to the nearest PHC providers, weighted by the availability of health workers” [14]. The proxy indicators used in this review helped link the indicators defined by the WHO/UNICEF framework with comparable indicators that are appropriate for the Indonesian context.
While our broad search terms or keywords could capture studies aligned with indicators in the WHO/UNICEF framework, this approach may have excluded studies using non-WHO/UNICEF indicators, as these were not systematically assessed due to our search strategy and inclusion criteria being based on this framework. We also excluded any studies that were published solely as abstracts, which may have contained additional evidence pertaining to PHC measurement. Furthermore, we excluded hospital-oriented indicators that were listed in the WHO/UNICEF framework to ensure that we could maintain a clear focus and provide direct evidence regarding PHC performance measurement. Consequently, hospital-oriented indicators, as recommended by the framework for broader PHC system monitoring, were not included.
Finally, while 36% of the studies reported indicators at the national level, the vast majority were conducted in more affluent settings, with higher levels of PHC resourcing (Supplementary material 2). As such, areas with limited PHC resources, such as remote areas, are underrepresented in our study.
Conclusions
This review identified gaps in PHC performance measurement in the context of service delivery in Indonesia, in alignment with the WHO/UNICEF framework. These gaps include the absence of studies on the domains “systems for improving quality” and “resilient health facilities and services”, 18 unmeasured indicators, few studies using nationally designed instruments, and limited time-trend analysis. As part of its ongoing PHC transformation agenda, Indonesia has outlined efforts to strengthen capacity and capability of PHC with the goal of improving equitable access to quality PHC across the country. A more structured and comprehensive PHC performance measurement in Indonesia may support the monitoring of progress and inform strategies to achieve this goal.
Supplementary Information
Supplementary Material 1. PRISMA-Scr checklist.
Supplementary Material 2. Data extracted from Indonesian studies on PHC service delivery performance (in line with the WHO/UNICEF framework).
Supplementary Material 3. Search terms and number of records.
Acknowledgements
The authors would like to thank I Nyoman Sutarsa for his input with regard to the formulation of the scoping review protocol as well as an ANU Hancock librarian for her input with regard to the process of refining search terms.
Abbreviations
- PHC
Primary health care
- UHC
Universal health coverage
- WHO
World Health Organisation
- UNICEF
United Nations Children’s Fund
- LMICs
Low- and middle-income countries
- JKN
Jaminan Kesehatan Nasional Or Social Health Insurance
- NCD
Noncommunicable disease
- ACSC
Ambulatory care sensitive conditions
Authors’ contributions
D.A.S. conceived the original idea for this review, designed the scoping review protocol, served as the primary reviewer in Covidence, and analysed, drafted and finalised the manuscript. D.C.B. supervised and reviewed the protocol and manuscript and served as a third reviewer in cases of disagreement between the two reviewers. E.S. contributed as a second reviewer in Covidence. R.J.K. supervised and reviewed the protocol and manuscript. M.K. supervised and reviewed protocol and manuscript and served as a third reviewer in cases of disagreement between the two reviewers. All the authors approved the final version of the manuscript.
Funding
The lead author, D.A.S., received support from an Australian Award Scholarship (G-20 Cohort) for her Ph.D. programme. No specific funding was used to conduct this scoping review.
Data availability
No datasets were generated or analysed during the current study.
Declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplementary Material 1. PRISMA-Scr checklist.
Supplementary Material 2. Data extracted from Indonesian studies on PHC service delivery performance (in line with the WHO/UNICEF framework).
Supplementary Material 3. Search terms and number of records.
Data Availability Statement
No datasets were generated or analysed during the current study.