Surjaningrum et al. Int J Ment Health Syst (2018) 12:27
https://doi.org/10.1186/s13033-018-0208-0
International Journal of
Mental Health Systems
Open Access
RESEARCH
The feasibility of a role for community
health workers in integrated mental health care
for perinatal depression: a qualitative study
from Surabaya, Indonesia
Endang R. Surjaningrum1,2*, Harry Minas1, Anthony F. Jorm1 and Ritsuko Kakuma1
Abstract
Background: Indonesian maternal health policies state that community health workers (CHWs) are responsible for
detection and referral of pregnant women and postpartum mothers who might suffer from mental health problems
(task-sharing). The documents have been published for a while, however reports on the implementation are hardly
found which possibly resulted from feasibility issue within the health system.
Aims: To examine the feasibility of task-sharing in integrated mental health care to identify perinatal depression in
Surabaya, Indonesia.
Methods: Semi-structured interviews were conducted with 62 participants representing four stakeholder groups in
primary health care: program managers from the health office and the community, health workers and CHWs, mental
health specialists, and service users. Questions on the feasibility were supported by vignettes about perinatal depression. WHO’s health systems framework was applied to analyse the data using framework analysis.
Results: Findings indicated the policy initiative is feasible to the district health system. A strong basis within the
health system for task-sharing in maternal mental health rests on health leadership and governance that open an
opportunity for training and supervision, financing, and intersectoral collaboration. The infrastructure and resources
in the city provide potential for a continuity of care. Nevertheless, feasibility is challenged by gaps between policy and
practices, inadequate support system in technologies and information system, assigning the workforce and strategies
to be applied, and the lack of practical guidelines to guide the implementation.
Conclusion: The health system and resources in Surabaya provide opportunities for task-sharing to detect and refer
cases of perinatal depression in an integrated mental health care system. Participation of informal workforce might
facilitate in closing the gap in the provision of information on perinatal mental health.
Keywords: Community health workers, Integrated mental health, Perinatal depression, Health system framework,
Indonesia, Primary health care
*Correspondence: esurjaningru@student.unimelb.edu.au
1
Centre for Mental Health, Melbourne School of Population and Global
Health, The University of Melbourne, Melbourne, Australia
Full list of author information is available at the end of the article
© The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License
(http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium,
provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license,
and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/
publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Surjaningrum et al. Int J Ment Health Syst (2018) 12:27
Background
Community health workers (CHWs) in Indonesia are
encouraged to be able to examine mental health problems experienced by pregnant women and postpartum
mothers, which are stated in two policy documents: “the
Guidance of Integrated Antenatal Care” [1] and manual
for CHWs [2]. Nevertheless, despite policy and guidelines available, there is little data to indicate that this concept is being implemented.
The prevalence of maternal mental health problems
in Indonesia is under-recorded. Neither the national
health survey conducted regularly every 5 years nor
the annual Indonesia health profiles [3] present specific
information regarding maternal mental health. Only
a small number of epidemiologic studies on maternal mental health have been conducted, including one
in Surabaya [4], that found the prevalence of perinatal
Fig. 1 PHC system and networks
Page 2 of 16
depression was 22% [4, 5] (based on a cut-off point > 10
of Edinburgh Postnatal Depression Scale (EPDS), far
higher than the reported global prevalence of 12% [6,
7]. Both the lack of information regarding implementation of policies on maternal mental health and the high
prevalence of depression are reasons to initiate mental
health care as part of maternal care in Surabaya, particularly identification of perinatal depression. Under
the guidelines on integrated mental health in PHC
[8], integrated mental health care could be developed.
Within PHC system, there are integrated health service
posts (ISPs) where CHWs work for maternal care in the
community (see Fig. 1). A recent mental health policy
accommodates the role of CHWs in mental health areas
[9], even though not all administrative governments
have implemented the decree. This policy provides an
opportunity for task-sharing, i.e. CHWs to identify
Surjaningrum et al. Int J Ment Health Syst (2018) 12:27
mental health problems in women during pregnancy
and the postpartum period.
Task-sharing in general mental health care has been
reported in other district in Indonesia [10] and other
countries [11, 12]. This approach has also been applied
for maternal mental health care [13–15]. In Surabaya,
mental health care has been integrated into primary
health care (PHC) centres, for several years [16–18],
providing a basis for initiation of mental health care by
CHWs [15, 19, 20].
While task-sharing in maternal mental health care has
a legal policy foundation, annual reports indicated that
it has neither been implemented in Surabaya nor known
whether this is feasible and acceptable within this district
health system [21–23]. To fill this knowledge gap, a comprehensive qualitative study was conducted to examine
the feasibility and acceptability of task-sharing for perinatal depression, as well as the skills and competencies
of CHWs to carry out the role. This article reports on a
feasibility study based on perceptions of health system
stakeholders.
Page 3 of 16
child health [30, 31], but also in other health areas. The
relationship and roles of the PHC centre, FWM, and ISP
working group in relation to the ISP and CHWs are presented in Fig. 2.
In certain circumstances, the role of ISPs extends to
other health areas or areas other than health, such as
social services and family welfare [30, 32]. When there
are no people who have agreed to work voluntarily, a
CHWMCH may also be co-opted for this purpose, resulting in multiple roles for one CHW [32] including population and civil administration-related services [30].
Aim of the study
The current study aimed to examine the feasibility of
task-sharing of perinatal depression care in the health
system in Surabaya. The aim was achieved through interviews to obtain perspectives of four types of stakeholders
in the health system: (1) program managers, (2) health
workers, including CHWs, (3) mental health specialists,
and (4) service users.
Methods
Role of CHWs within health system
The health system in Indonesia is administered in line
with decentralization of the government system, such
that services are decentralized to provincial and district governments under the Ministry of Home Affairs
(MoHA) [24]. District governments operate health services provided through PHC centres called puskesmas,
which typically reside in a sub-district. These centres
supervise and support a wide network in the village level,
including integrated health service posts (ISPs) known as
posyandu, and village midwives (see Fig. 1).
An ISP involves intersectoral cooperation between the
Ministry of Health and the MoHA at the village level
[25], through a body called ‘ISP working group’ [26]. This
working group coordinates with women’s agency of the
MoHA called the family welfare movement (FWM) to
run an ISP monthly activity [27] whose operationalization is managed by a PHC centre [28]. The FWM recruits
CHWs who are volunteers from local community and
allocate tasks for them. There are five main services of
maternal and child health care at an ISP [28–30], therefore the FWM should ensure that there are at least five
people to run an ISP. CHWs who specialize in this task
are called CHWsMCH in this article.
CHWs are responsible to assist health workers (e.g. village midwives) in maternal and child health care, nutrition advice and family planning during ISP activity;
assist them in antenatal care such as organizing maternal classes; and undertake home visits for perinatal care
[30]. Before taking the role, CHWs are trained in healthrelated areas by the health office, mainly in maternal and
Setting
The research took place at PHC centres in Surabaya that
provide a psychological service, several ISPs managed by
that PHC centre and a district hospital in Surabaya, and
the District Health Office. There are 62 PHC centres in
Surabaya and some of them provide psychological services. Three PHC centres were selected as the study sites:
Fig. 2 The relationship among ISP, CHWs, and PHC centre.
PHC centre is health service providers at sub-district; an ISP is a
community-based health care; CHWs are the community volunteers
running an ISP; IWG is a village agency that establishes ISPs; FWM is
women agency at the village that support ISPs
Surjaningrum et al. Int J Ment Health Syst (2018) 12:27
Centres A, B, and C, whereas Centre D was selected for a
pilot study. They have different numbers of ISPs and Centre C was selected as it has the highest number of pregnant women, ISPs, and CHWs. ISPs were selected based
on the centre’s advice.
Participants and inclusion criteria
Participants in the study were recruited from four groups
of stakeholders: program managers, health workers,
mental health specialists, and service users. Program
managers consisted of two participants from the health
office (district program managers) and three participants from three villages (community program managers). District program managers were the Head of the
section of primary care service delivery that is in charge
of maternal care and the head of the section of special
health care that is responsible for mental health care.
The three community program managers were members of an ISP working group from three villages which
are responsible for organizing CHWsMCH in the selected
ISPs, viz. an ISP from Centre C with a high population of
Madurese (ISP CM), one populated by Javanese (ISP CJ),
and one from a non-slum area (ISP CN). Health workers
comprised 12 formal health workers from three centres
and 12 CHWs. Health workers were the centre managers, (mental health) counsellors, midwives, and nurses.
CHWs were recruited from six ISPs, each of which typically has five CHWs and two of them were recruited: one
leader (CHW-manager) and one member (CHW-member). Mental health specialists were a psychologist and a
psychiatrist at the district hospital (Dr. Soewandhi Hospital). Two other psychologists and one psychiatrist were
recruited from other places. Service users were 15 pregnant women and 13 one-year postpartum mothers (they
will be called ‘women’ and/or ‘mothers’ interchangeably). Pregnant women were in their first pregnancy
(primigravida) or subsequent pregnancy (multigravida)
at any stage of pregnancy and had visited a health facility at least once. Postpartum mothers were mothers of a
first child (primipara) or mothers of subsequent children
(multipara). Two to three women were recruited from
each ISP based on the percentage of pregnancy among
women aged 15–49 [33]. The research setting and the
participants are summarized in Fig. 3.
Data collection
Semi-structured interviews were conducted individually by ES. The interviews consisted of questions on: (a)
demographic information; (b) knowledge and attitude
to mental health of mothers; (c) two vignettes about
perinatal depression cases; and (d) the feasibility. Four
different vignettes about perinatal depression cases
were developed, two of which were presented to each
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participant according to their stakeholder group. The
vignettes were presented before questions on whether
participants have experienced a similar situation (for
service users) or have dealt with similar clients (for
service providers and community program managers),
their perception of the importance of maternal mental
health, and their views on the feasibility of task-sharing. Data collection was pilot tested in Centre D. All
interviews were carried out in private settings, such as
at home (for CHWs, pregnant women and postpartum
mothers), or at their workplace (for health workers and
program managers) and transcribed in Indonesian.
Data analysis
Analysis of the data was carried out deductively with a
framework analysis (FA) approach in the local language
(Indonesian) using MS Word and the NVivo software
program. Framework analysis has five key steps [34,
35]: (1) coding (indexing), (2) developing a working
analytical framework, (3) applying the analytical framework, (4) charting data into the framework matrix, and
(5) mapping and interpreting the data. WHO’s health
systems framework was applied to direct the analysis.
This framework suggests that a health system consists
of six building blocks: health service delivery, leadership and governance, health workforce, health information system, medical products and technologies, and
a health financing system [36]. Using MS Word, the
researcher (ES) and an independent analyst, who is an
Indonesian researcher holding a Masters degree from
the University of Melbourne, read a set of transcripts
from pilot interviews to identify emerging themes and
to initiate the development of a thematic framework.
The framework, which was presented in English, was
then validated by the research team until a developing framework was agreed to be applied. The next step
was indexing, which applied the framework to all the
transcripts using NVivo 11. Frequent discussions with
the whole research team took place throughout the
data analysis phase, for which some transcripts were
translated into English and analysis was evaluated by
research team (RK), to ensure that interpretations were
credible, valid, and shared.
Ethics approval
Ethics approval for the study was obtained from the
University of Melbourne (No. 1543833). A research
permit was given by the Health Office of Surabaya.
Informed consent was obtained from all participants
prior to data collection.
Surjaningrum et al. Int J Ment Health Syst (2018) 12:27
Page 5 of 16
Fig. 3 Research setting and the participants. PHC primary health care, ISP integrated health service post, CHW community health worker, FWM
family welfare movement (PKK), CM, CJ, and CN sites for majority groups of population within Centre C coverage: CM for Madurese, CJ for Javanese,
CN for non-slum area
Results
Participants
Recruitment of participants and interviews were carried
out simultaneously from June to August 2015. In total, 62
participants from four groups of stakeholders were interviewed. The distribution of participants was as planned,
but some adjustment was needed for the service users
group. There was one pregnant woman from village CM
who agreed to be interviewed but at the end refused to
do so, whereas another pregnant woman from the same
village agreed to participate in the study to enrich the
voices of Madurese.
The demographic composition of the participants is as
follow. Only four participants were male: three were specialists and the other one was a health worker. The ethnic
background of the majority of participants was Javanese,
with slightly more than ten percent being Madurese,
and other ethnic groups comprising less than two percent. The age of participants was varied, but was above
25 years of age for all groups other than service users.
Surjaningrum et al. Int J Ment Health Syst (2018) 12:27
All CHWs and community program managers were in
their 40 s or above, had finished high school (junior and
senior) but had no formal employment. Half of the service users were in their 20 s and only ten percent were
under 20 years. More than three-quarters of these users
had finished high school. Around 20% were primigravida,
almost 70% had one or two children, and about ten percent had three or more children.
Feasibility of extending CHWs’ role within the health
system
There were many shared views among stakeholders
on factors that enable or hinder feasibility, as shown in
Fig. 4.
Leadership and governance
Perceptions of feasibility based on leadership and governance factors were reported by program managers, a centre manager and a specialist. These participants described
feasibility in these areas as being related to the availability
Page 6 of 16
of strategic and technical policies at national and district
level, the intersectional collaboration between the general health service delivery sector and the special health
care sector, and the autonomy of PHC centres to design
context-specific programs.
The provision of national mental health policies
One factor that enables the feasibility of task-sharing in
perinatal depression is the availability of two national
policies on mental health. The first one is a national
policy that shifted mental health care from hospital to
community-based, called Community Mental Health
Action Team (also known as Tim Pelaksana Kesehatan Jiwa Masyarakat or TPKJM), adopted in 2002. The
second policy is the current national strategic policy
“Indonesia bebas Pasung (Indonesia Free from Shackles) by 2015”. A program manager stated that the latter
program has become the pivotal point and timeframe
for mental health actions, such as training on mental
health detection to general practitioners and nurses in
Fig. 4 Factors contributing to feasibility of CHWs taking role in integrated mental health care in Surabaya
Surjaningrum et al. Int J Ment Health Syst (2018) 12:27
the centres, and out-reach activity to find mental health
cases in the community. These policies do not refer to
maternal mental health directly; however, they have
brought about the establishment of mental health service units in several centres. The program manager for
specialist care described how the policies have guided
the formation of an out-reach team involving CHWs to
find out people with mental health problems who live
shackled. The significant number of cases found by the
team generated attention to the importance of mental
health issues and led to the establishment of mental
health service units in several centres. She said:
“Mental health is not a primary program, but an
extended program. It has not got attention until
during the outreach program–visiting patients
at their original places-we found a lot of cases.
Finally, the head office said ‘let’s develop your
mental health unit’…. Because it should be free
from pasung [shackle] by 2015, isn’t it?” (DPM 2)
The manager added that two centres have established
a mental health unit and another one is under preparation. Moreover, the community mental health action
team policy led to the formation of a collaborative team
across sectors to find and tackle mental health cases in
the community based on their needs. Subsequently, the
program manager explained that the team works regularly and is monitored directly by the Mayor.
“…Tim Pelaksana Kesehatan Jiwa Masyarakat
[Community Mental Health Action Team],
TPKJM. Yes, we haven’t formed the structure, but
I think… The team has not been structured, yet
coordination among sectors has worked. Structurally it has not formed yet but the coordination
has worked…. Usually each sector sends a letter
to the Mayor and then the Office of Human Welfare would organize a meeting. These are from the
Office of Social Affairs, of Health, of Housing…”
(DPM 2)
Health leader role
The involvement of the Mayor in coordinating the community mental health team was perceived as giving support and attention to mental health care in the city. A
specialist reported how he was impressed by the Mayor:
“The Mayor, indeed, believes in two principles, first
there is no child in Surabaya who does not go to
school, and second no sick people in Surabaya are
neglected, including people with mental health
problems….” (Sp 1)
Page 7 of 16
Coordination between sections in the district
Beside intersectoral collaboration conducted by the
community mental health team, coordination between
sections in the health office has worked well. The head
of the section of general service delivery that organises
maternal care felt sure that mental health care could be
facilitated within maternal care. She said that integrated
antenatal care is an obligation and the integrated care for
mental health has been implemented by referring pregnant/postpartum mothers to the psychologist in the centre. She described:
“It actually can be done, if the metal health [section] wants. Even though I am from maternal and
child health I facilitate this…Those are compulsory,
whether a mother is sick or not. An example of this
is HIV assessment, it is compulsory…like that. When
there is a complaint…yeah… it can be referred to the
expert. You may have known that there are psychologists in several centres, so when there is a complaint
or as a result of assessment by a GP or midwife, the
patient would be referred to the psychologist… if
there is no one in the centre, she may be referred to a
psychologist at the closest centre.” (DPM 1)
Policy on training of CHWs
Strategic policy at the district level on mental health
training for CHWs is another factor to enabling feasibility. The training program for CHWs has been placed into
the strategic planning for the following year, focusing on
early detection and referral. The training was designed as
an extension of the one provided for doctors and nurses.
The program manager explained:
“We have run training on early detection of mental
health cases for health workers, and we plan to do
so for CHWs this year….and in 2016 they will be
trained in the basic knowledge of early detection and
referral. That’s what we want to do.” (DPM2)
The training at district level is more likely to be followed by centres because they have the autonomy to set
up MCH-related training for CHWs in their area, allowing the inclusion of mental health in the program. Again,
the manager emphasized:
“It is the autonomy of the PHC to set up training
materials for CHWs, not only about the health of
children under five but anything that supports the
health of those children.” (DPM 1)
Surjaningrum et al. Int J Ment Health Syst (2018) 12:27
Challenges in implementation
In contrast to policy and planning that supports feasibility, several factors were viewed as challenges to feasibility. First, practical guidelines are required before
task-sharing can be implemented in the community. A
program manager made the point that even though a
guideline has been regulated in the policy document,
it may take several years until the guideline results in
direct action. Second, there are practical problems with
the shared responsibility between centres and the family
welfare movement (FWM) in the village. Recruitment of
CHWs is supposed to be a FWM task; however, a community program manager complained that in fact the
PHC centre took over the task. Third, a centre manager
was concerned about financial issues with the autonomy
of a centre to arrange particular training for CHWs. Running a local program, which is centre specific is allowed,
even though it is not part of a national or district priority, however the centre is responsible for the financial
arrangement and the justification. The centre should find
the money either from within its own or other funding
sources and be able to justify the spending.
Service delivery
Identification at an ISP is not feasible
This study was to assess the feasibility of task-sharing
to be carried out by CHWsMCH in their place of work,
which is in an ISP. Nevertheless, stakeholders perceived
that carrying out the task in an ISP is not feasible. Health
workers stated that there are a lot of tasks to be accomplished by CHWs and that they are unable to also carry
out task-sharing within the time available. In addition,
the ISP was seen by mothers as a place for the health of
children under five. Therefore, a lot of adults and children
are around, resulting in a lack of sufficient space for privacy. A mother said:
“Prefer during home visit. It is impossible to talk
about my personal situation because the ISP is for
children’s health…it’s better to visit home for that
issue.” (Ppt A3)
Service through home visit
In contrast to the ISP, carrying out task-sharing through
a home visit was viewed as feasible. Home visits were
expected, both culturally and officially. A CPM said that it
is culturally accepted in the community to visit a mother
who has just delivered a baby. She also stated that CHWs
must carry out home visits when required, as part of a
government program. A nurse emphasized that home
visits have been conducted by CHWsMCH to regularly
monitor all aspects of the health of mothers and during
these visits CHWs sometimes encountered women with
Page 8 of 16
mental health problems. For example, CHWs reported
typical behaviours suggestive of a mental health problem,
including isolation at home and missing check-ups during pregnancy.
Some CHWs viewed home visits as convenient, as
they live close to users and the cost of transportation is
minimal. Home visits also allow CHWs to gather more
information from mothers, and enable them to approach
women in more acceptable ways. A CHW explained:
“I usually spend time to visit occasionally, during a
spare time. So, it is not in a particular time, because
it would be seen as a serious matter. Just pop in,
have a chat, sharing as a neighbour friend.” (CHW
J4)
Referral
There are two types of referrals, internal and external,
and CHWs could be involved in the former. Internal
referrals are those that occur among professionals within
a PHC centre. These procedures were illustrated by all
program managers, some health workers, and by the
CHWs. They explained that CHWs could refer depression cases in three formats: a verbal report directly or
via telephone, a written report within a monthly report,
and a written note in a communication book that delivers
messages between CHWs and midwives at a PHC. The
basic pathway for either format is from CHWs to village
midwife to PHC centre midwife to counsellor at the centre (CHW → village midwife → centre midwife → counsellor). Sometimes a CHW and a village midwife go
together to report a case, as one CHW described:
“Two of us. Together. When we cannot handle it, we
have a midwife coordinator and the coordinator will
report to bu Nl [the centre manager]. If we cannot
handle it, for example [because of ] a psychological
thing or need for a mental health consultation, we
will go to Lk [the counsellor] ….” (Mw 3)
CHWs might accompany mothers to the PHC centre
when required. For other cases, the village or centre midwife and the counsellor come and visit the mother, either
with or without a CHW. However, a centre manager was
concerned about the lack of a referral book or note that
provide details of the problem. Other health workers perceived that referral guidelines which describe the pathways and tasks of each professional are also needed.
External referrals send patients from the PHC to
higher-level facilities. These referrals can occur when
professionals at the centre cannot handle a health issue
anymore, such as when a counsellor cannot handle a
mental health case. A specialist and program manager at
the health office explained that an external referral can
Surjaningrum et al. Int J Ment Health Syst (2018) 12:27
only be made by a doctor in the centre and is directed
to the district hospital. A specialist explained that even
though a patient was being handled by a counsellor, the
referral letter must be sent by a doctor.
Workforce
The study participants raised numerous issues related to
human resources. Concern was expressed about recruiting a CHW workforce of the quality required for work
on perinatal depression. However, participants also perceived that the health system has training and supervision programs which could enhance skills and minimize
such issues.
Availability and recruitment
The primary concern about workforce was the shortage
of existing CHWs who qualify as suitable for task-sharing. Even for the general/current role, CHWs’ performance was often seen as being inadequate, due to their
often being sick, being too old or their workload simply
being too high. Program managers and health workers
identified that most CHW-managers have multiple tasks
related to their role in health assistance, i.e. in MCH,
aged care, TB, dengue prevention, etc. A centre manager
stated:
“I have a lot of CHWs: CHWspalliative, I have a
CHWLKB who handles HIV and IMS [sexually transmitted disease], I have CHWsTB, leprosy and basically those for communicable diseases, and then
CHWsfor nutrition called CFC [Community Feeding
Centre] which are based at ISPs that handle malnourished-children. Sometimes only one person
handles all of these because it is hard to recruit. But
we think the person is able to handle all those roles.”
(GP 3)
Despite the recognition of high workload from multiple
tasks, some health workers perceived CHWs as having
the capability to handle those tasks. A program manager
in the community suggested that CHWs could carry on
several tasks in one go, referring to a strategy to manage tasks. This view underlined the feasibility in terms of
human resources.
Having new recruits might be seen as an ideal solution
to ease the overburdened CHWs and overcome the quality issue. However, there were some issues involved in
getting new people. Firstly, because CHWs are lay community members volunteering their time to contribute to
their community, other commitments such as work and
domestic responsibilities were among the difficulties in
recruiting new CHWs, as was described by some CHWs.
A CPM listed social relationships as a second issue, when
existing CHWs were seen as an obstacle to attracting and
Page 9 of 16
keeping new and younger CHWs. She illustrated this
with the example of a potential woman who agreed to be
recruited only if a particular CHW was not active in the
taskforce anymore; and by another case in which a newlyrecruited CHW stopped the role because she was treated
badly by a current CHW. Additionally, cultural and
demographic issues, such as ethnicity and literacy, came
up when a CHW described a difficulty in engaging with
women from a particular ethnic background because of
their cultural beliefs and/or of low level of education.
Recently, a new group of CHWs, called CHWspregnancy,
was established to work for a PHC centre and the Family Welfare Movement (FWM) at the district level, which
could also be seen as supportive of the feasibility of tasksharing and as an enrichment of the workforce. These
particular CHWs have several tasks, including finding pregnant and postpartum women in the village and
monitoring their health status through home visits, taking their pictures regularly to be documented, and making health record on monthly basis. The existence of
CHWspregnancy and their tasks was described by a community manager:
“Now we have what we call CHWspregnancy. Here we
have Wi, while Wa is from the next neighbourhood.
One CHW would work for 2-3 neighbourhoods.
They record pregnant women: how is their health
status, the risks, including depression, and others.
The CHWs monitor them until they give birth. To
do so, the CHWs come to FWM representation at
‘dasawisma’ [smallest aggregate of neighbourhood]
to collect the data on pregnant women in the area
and then they visit the women at home. The community health centre also guides them. There are
some in every village, for example this village has 6
CHWspregnancy.” (CPM 1)
Training and supervision
Training and supervision were perceived as other solutions for quality improvement that were available in the
system. Counsellors from three centres reinforced the
previous statement from a program manager that mental health training for CHWs and health workers has
been carried out in the previous year. Unfortunately,
follow-up of the training was challenged by staff rotation
when the trained staff moved to a different centre, resulting in the program ceasing. While concerns were raised
regarding the adequacy of training, the current strategic
plan for training seems to be trying to address this issue.
A counsellor said: The health office has provided training for CHWmental health. But I think mere training is not
enough; it needs to be continued with follow-up programs”
(Cs 3). A district program manager expected that an
Surjaningrum et al. Int J Ment Health Syst (2018) 12:27
already- established strategic plan for future training for
CHWsmental health from all centres would allow continuous
training and sustainability of implementation.
“That will be for next year. We will train them. For
all centres. The previous one took only one day…
therefore we will run the socialization so [the implementation] will not ‘come and go’ anymore.” (DPM 2)
In addition, there is an opportunity for all centres to
support the program and to provide supervision sessions
for CHWs in the form of a monthly refresher program
between health workers and CHWs. As well as supervision, the session is in fact also used for professional development when new and high-priority material needs to be
introduced to the CHWs. Such a session could be used if
mental health needed to become a topic area. Even better for feasibility is the fact that these regular sessions are
financially supported by the health office.
Information
Information systems that generate data about perinatal
depression hardly exist, at either national, provincial or
district level. Midwives and a district manager clarified
that data on pregnancy and childbirth and mental health
together is available, but there is no option to include
information about mental health during pregnancy or
across age. A CHW explained that a special case would
be reported in a descriptive note within the regular
maternal and child health recording sheet. Health workers suggested several potential ways of producing data
on perinatal depression, basically through home visits or
approaching pregnant and postpartum mothers directly
and recording the information in a specific form. A nurse
strongly suggested that the psychology unit could develop
a form that could be completed by CHWspregnancy:
“…[CHWspregnancy] are still working right now and
they have to send a report, so it would be better if
psychology can provide the sheet. But we may not
find, I mean cases are not always found. So, when
there are no cases they cannot just leave it blank,
rather they still have to write a report, just write ‘nil’
for example.” (Nr 1)
Another way was suggested by a CPM and CHWsmanager from three ISPs. They recommended that
CHWspregnancy compile mental health information
qualitatively, together with other health data for which
they are responsible. Either way, the existence of
CHWspregnancy was considered an opportunity for data
collection on perinatal depression.
At present, a CHWpregnancy reports data to the centre through village midwives and to the FWM at District level. While PHC centres use the data to determine
Page 10 of 16
service delivery to a mother, most CHWs and nurses did
not know how the FWM uses this data.
“There are CHWs for high risk of pregnancy; there
are two of them: one is assigned by FWM at district
level, and the other is assigned by the centre. In fact,
they are similar in their role and responsibility… The
one assigned by the centre will provide a report to us
[village midwife] from which the report will be compiled into the MCH unit. The one assigned by FWM
will send the report to the FWM at district level.” (Nr
1)
Financing
The financial feasibility of task-sharing is indicated by
the availability of incentives for CHWs as compensation
for taking the voluntary tasks, the budgeting policy to
assign funding to support mental health screening during the pregnancy and 1-year postpartum period, and
the open possibility for other funding sources. Currently,
CHWs receive transport compensation for their role in
each area they undertake (e.g. MCH, elderly, dengue)
and, according to a district manager, they will also receive
funding from the mental health program when it is set
up. CHWspregnancy also receive incentives from the FWM
or health office, depending on whom they work with.
She emphasized that while the amount may be minimal,
it shows the recognition of their roles. The other manager described the financial system assigned for PHCs
through universal health coverage (the capitation fund)
which could potentially be allocated to support depression identification in maternal care:
“There is a solution to do so, using the capitation
fund from universal health coverage. Here in Surabaya, which may be different from other districts,
there is 60% from the operational budget to be
addressed to services’ fee and 40% for others. The
40% will be divided into 30% for medicine and 10%
for operational. One third of the 10% operational
budget is targeted for health promotion programs
which can be arranged for any required actions
such as a goodie bag, leaflet, and so on. So, if mental health…, would possibly be printing a screening
tool….” (DPM 1)
A similar approach has been adopted to support supervision during the monthly refresher session. The manager
added that funds from other sources are also accepted,
such as from NGOs or the community. For example,
there is an ISP in an exclusive residential area whose
activities are fully funded independently by community
members.
Surjaningrum et al. Int J Ment Health Syst (2018) 12:27
Medical products and technologies
Medical products and technologies needed for depression identification by CHWs are basically related to the
production of screening tools, and technologies for communication and transportation. CHWs currently detect
mothers’ mental health in a common way using observation and then record the case as a note in the regular
maternal and child health recording sheet.
“They [CHWs] detected them in a common way:
when a person isolates herself and never out from
home and do not go for pregnant examination.” (Nr
2)
There was a disagreement between two specialists on
how the identification should be acted upon. One suggested two steps, starting with an interview and then following up with a scale. The other completely disagreed
with CHWs identifying depression through an interview,
as he believed that this requires a high level of knowledge
and skill and therefore requires long-term training. He
thought that a simple scale was preferable and he highlighted that tools for assessment of depression already
exist and a simple one is quite easy to find.
“For identification, it must use a tool that is internationally recognized, so using a depression rating
scale is very simple…that is easy and the depression
tools are not only one [type], from the simplest to
the complex. It is so easy; indeed the tool to detect
depression is easy so that we can teach CHWs. Identification using interview is more difficult, it needs a
long time to educate CHWs.” (Sp 2)
Means of communication and transportation are not
necessary, as CHWs live close by the mothers and the
village midwife is not far away. However, health workers
and CHWs expressed concerns about the cost involved in
taking mothers to the centre or if mothers live far away.
“Because it is around the area, therefore transportation is not a problem. I would think twice if it is
far away because I cannot ride a motorcycle and
automatically I need to ask others to take me there.”
(CHW J4)
Discussion
This study aimed to examine the feasibility of task-sharing in the identification of perinatal depression within
the health system of the City of Surabaya, from the perspective of the health system’s stakeholders. Policy documents stated that CHWs can carry out this role [1, 2].
Results indicate that the proposed task is feasible to be
implemented within the health system of Surabaya, from
Page 11 of 16
the perspectives of leadership and governance, homebased service delivery and internal referrals, training and
supervision, financing, and technologies. Information
systems and other areas need to be improved somewhat,
including the ISP-based service, operational regulation,
and workload of the volunteers.
Leadership and governance is a strong support for the
involvement of CHWs in the identification of depression. The vision of both district government and the
province as seen in mental health policy clearly indicates
the potential for development of practice in this area.
Indeed, mental health policy at the national level has had
a significant development in the last two decades, and
the lessons learnt can be useful in thinking about mental health policy for women and children. Perinatal mental health is an important component of mental health
overall (with implications for both the mother and the
child) and must be in one of the priorities within mental health. The recent development of mental health policies such as the mental health law and the law of persons
with disability is progressive, which gives hope for the
development of policies on women and children. This
was seen when a new mental health law was approved by
the house of representatives in 2014 (law number 18 year
2014), replacing the previous one that had been used for
about five decades (the first mental health law was sanctioned in 1966). Not long after its release, another related
law, the law of persons with disability, was authorized in
2016 (law number 8 year 2016) as a result of the ratification of the United Nation convention on the rights of
persons with disabilities (UNCRPD). For a specific population, those affected by a disaster, the disaster mental
health policy was developed in 2003 [37], while for those
who have severe psychosocial disabilities living in physical restraint, an initiative from Aceh has been applied as
a national program [38, 39]. These other laws/policies/
initiatives can be used to advocate for high quality health
and mental health care during the perinatal period.
Regarding the role CHWs in mental health care, the
establishment of the TPKJM or community mental
health action team in the district, whose performance
is monitored by the Mayor, is another promising step
for implementation of policy documents in task-sharing for perinatal depression. The fact that East Java is
among the provinces that have established initiatives to
implement TPKJM [40] is a good support for districts
within the province such as Surabaya. The regulation is
also reinforced by the policy on “Indonesia Free from
Pasung (shackle)” launched in 2010, that was aimed to
be achieved by 2014 (it has since been extended to 2019)
[39]. These two national programs and the commitment
of the leaders to them are evidence of a good foundation of health leadership and governance, and are most
Surjaningrum et al. Int J Ment Health Syst (2018) 12:27
likely to support task-sharing in the mental health area.
In particular, policies with a timeline, such as the free
from shackle policy, seem to be having a greater impact,
because the government is putting in greater effort to
meet the goal within the schedule. This phenomenon
accentuates WHO’s suggestion that a policy maker
should have a timeline in mind when developing a mental
health policy [41].
The policy emphases that facilitate task-sharing were
also strengthened by organisational management in the
health office. The existence of mental health within the
special care section provides open opportunities for the
mobilization of more resources in the health system. This
can be seen from its roles in: facilitating the establishment of centres with mental health units; in putting in
place a strategic plan for mental health training, including the training of CHWs; assigning a source of funding
for depression identification; and organizing multisectoral collaboration that could support resource management, including the application of integrated antenatal
care. Not all these efforts are right now directed specifically to the mental health of mothers; however, there is
potential within the section for commencing subsequent
steps to realise the vision.
According to stakeholders, home visits are the possible answer for the service delivery model for CHWs
in carrying out the task of depression identification. As
a model of care, this approach is not a novel one within
the national health system, particularly for CHWsMCH.
Several documents openly regulate this responsibility and provide structured guidance on what and how
to conduct home visits [2, 30], even though not specifically for mental health care. For example, home visits
are directed for mothers whose children under five did
not attend an ISP activity, and those of malnourished
children, among others. The home visit approach is also
used by CHWspregnancy, many of whom are also CHWMCH
(mostly the managers). At a practical level, there is agreement among stakeholders that a home-based approach
is the best option to overcome the space limitation issue,
the difficulties of accessing primigravida, and time constraints which resulted from many services being provided during an ISP activity and the unsuitability of this
schedule for working mothers. This approach allows for
flexible scheduling, as has been stated by CHWs and
users, and is consistent with findings from another study
[42].
Service delivery should also be connected to infrastructure and resources in the health system to make it feasible for task-sharing. Resources could provide a wider
opportunity to assure that users get continuity of care
after being identified by CHWs, e.g. infrastructure for
referrals. It means task-sharing is supported by relevant
Page 12 of 16
continuous care so that the care does not end with the
CHWs or village midwives. Continuity of care could
also be understood in terms of protecting the rights of
users to get treatment. The complete resources available for mental health care are: (1) the provision of mental health care by a counsellor in a PHC centre, (2) the
availability of two district hospitals that provide mental
health services by both psychiatrists and psychologists,
and (3) the provincial mental hospital that is located in
the city. With these resources, community-based mental
health care fits within the national health system. Lack
of continuous care was a concern for women who were
reluctant to disclose their feelings during a mental health
assessment [43]. Findings from another study have suggested that mental health screening as part of integrated
routine maternity care would be a possible intervention
pathway [44] which would involve less stigma. Participants in that study emphasized the unease and feeling of
shame from talking about their experience of depression
with multiple professionals in a fragmented care system,
something that is not required in integrated care. In addition, continuity of care is supported by the financing system of universal health coverage. The economic cost of
perinatal depression is high for both individuals (mothers
and the family) and the public sector [45], therefore the
health coverage scheme needs to make service delivery
and referral procedures easy and accessible. The connection with other health systems, such as the PHC and the
social welfare system, is also needed for well-functioning
mental health care.
The financial source and policy in financing both support task-sharing, congruent with the arguments related
to service delivery and continuity of care. How the capitation budget could be allocated so that a specific amount
could be used to establish a depression screening tool
was clearly explained by a district manager. This financial policy would open several possibilities for further
steps, for example to identify and validate a simple and
locally-acceptable screening tool. Studies from a variety of settings suggest several possible perinatal depression screening tools that can be accessed worldwide and
have good psychometric properties [46–48], however
adaptation in the new context is required. Several studies in Indonesia have reported the use of some of these
tools (e.g. the Edinburgh Postnatal Depression Scale) [4,
5, 49]), nevertheless there is a need to examine whether
similar tools can be administered by CHWs. Specialists
in this study also emphasized the use of simple tools and
believed that CHWs are able to administer them. Health
workers suggested using a symptom list which is simple to administer and quite similar to a pregnancy risk
scale with which CHWs are familiar. Another method is
using a structured interview, but this was debated among
Surjaningrum et al. Int J Ment Health Syst (2018) 12:27
specialists, since it requires a high level of competence.
Furthermore, a specialist strongly suggested not using
the word ‘depression’ to avoid stigma, with the term
‘mood changes’ being preferable instead. This suggestion
is in line with previous findings in which the experience
of depression was expressed in many forms and terms by
Javanese [50]. This means that an understanding of the
personal and cultural terms should also be considered in
choosing or adapting an identification tool. Possible bias
in interpreting a woman’s mental health state resulting
from unfamiliar terms requires attention, considering
the level of education, language and ethnicity of both the
CHWs and users.
In regard to human resources, the findings on workload, scarcity, and personal barriers are consistent with
feasibility issues reported by previous studies [51, 52].
These issues may result from the role of CHWs as the
frontline workforce for many governmental sectors, not
only health and home affairs, but also others such as education and social services [32]. At least 12 roles for CHWs
have been listed in health-related areas [30], not including others in civil services [53]. Management of CHWs by
the FWM is supposed to enable organization and monitoring of the availability, distribution, and performance
of CHWs. However, it seems that the FWM, even at the
national level, does not have a strong bargaining position in the governance of a village when a new task for
CHWs is released. In fact, the findings about social relationships as one recruitment issue suggest that the FWM
is the agency that best understands the social boundaries
and cultural life of the community and so is best placed
to map human resources in the area. Several concerns
should be addressed to improve workforce management
and quality, such as regulation of skills and characteristics required, the need for a working contract that regulates the length of employment and a procedure for
terminating the role, the training required, and a means
of distributing tasks. Well-distributed tasks may prevent
duplication, so that new and existing CHWspregnancy, for
instance, could monitor not only physical but also mental health efficiently. Even though CHWs are volunteers,
having professional management of their tasks would
maintain their participation sustainably.
There is promise for developing and improving CHWs’
skills and competencies in task-sharing. This could
be achieved through the availability of mental health
counsellors at centres and the health office, and mental health specialists at district hospital. Skills enhancement programs are an opportunity for quality assurance
in service delivery. Components of mental health training for CHWs are found in several studies [10, 40] that
could be a source to learn from, including those addressing perinatal mental health [54, 55]. Nevertheless, since
Page 13 of 16
task-sharing in maternal mental health care has not yet
started, the specific skills and competencies, as well as
training, that fit the local context need to be examined.
Challenges and recommendations
The findings indicated three main challenges to feasibility. These are: (1) inconsistency between policy and
practices, (2) an inadequate support system for data management and technologies, and (3) unsupported means
for implementation. Gaps between policy and action are
revealed from the shortcut practices in recruiting CHWs
by the centre instead of by the FWM. Several approaches
may alleviate these challenges, such us inviting all parties (FWM and PHC centres) to sit together and review
the policies, or hearing about the best possible strategies
for a collaboration process before a proposed program is
released. However, this study did not explore this possibility further. The fact that there were gaps between written regulations and the reality generates a concern: even
if stakeholders’ perceptions lead to the conclusion that
the health system can feasibly accommodate task-sharing
in integrated mental health, personal views on participation may be different. Buist, O’Mahen [56] reported a
mixed attitude to the acceptability of perinatal depression
detection among women and health providers. Therefore,
it is necessary to understand the personal views of stakeholders about the acceptability of their involvement in
task-sharing.
Other issues are logistical support and an information
system on perinatal depression. While transportation is
not a significant barrier, because the task is within walking distance, the findings imply a need to use telecommunication devices in doing the job. Lack of financial
support for communication and transportation is an issue
for task-sharing in another area [10] and a similar problem is anticipated by CHWs in this study. In addition, the
lack of an adequate data reporting system on perinatal
depression could be solved through the use of qualitative
reports from CHWs to village midwives to the centre. In
an annual report, the health office presents data on mental health cases other than maternal ones [23], suggesting
an opportunity to do the same for maternal mental health
data. This possibility is suggested by the existence a mental health qualitative report shown by a district program
manager during an interview when describing how the
data were collected. Moreover, a study on maternal mortality calculation suggested the important role of village
midwives and local registers (volunteers) in gathering
and reporting valid data [57]. The study highlights the
opportunity to integrate mental health as a component of
health data collected by CHWspregnancy.
Finally, the lack of practical regulation for task-sharing
and the need for practical guidelines and pathways for
Surjaningrum et al. Int J Ment Health Syst (2018) 12:27
identification and referral were anticipated as potential
issues for implementing task-sharing. The health office
should prepare staff in order to manage practices and
roles of each actor. Another challenge for implementation is financial barriers faced by a centre if it has the
will to initiate a program. The centre needs to allocate a
budget or to find funding from other sources and justify
it in a way that is acceptable within the health financing
system. The procedure is perceived as a significant difficulty by centre managers. Figure 5 presents a summary of
challenges and recommendations.
Limitations
The current study has several limitations. First, the study
was purely dependant on the perceptions of participants,
which may not represent the mechanism and procedure
in the health system. Using this strategy can produce
Page 14 of 16
unrealistically sound findings that do not fully identify
challenges in the financial area, which is a typical obstacle in many reports. Second, the study was conducted in
one district under decentralized governance, therefore
extrapolation of the results to other contexts is limited.
Third, the participants are only from health system tiers
and do not extend more comprehensively to home affairs
sectors. This strategy leaves several unanswered questions, such as the management of data by the FWM.
Moreover, the number of areas sampled to represent
the PHC centres was quite small compared to the total
number of centres in Surabaya, even though it is quite
large in the context of a qualitative study using individual
interviews. This limitation has, however, been alleviated
through the recruitment strategy for the research sites
which took account of the socio-economic and cultural
diversity of the city.
Fig. 5 Challenges and recommendations of CHWs playing a role in task-sharing in mental heath care in Surabaya
Surjaningrum et al. Int J Ment Health Syst (2018) 12:27
Conclusion
It can be concluded from this study that the health system and resources in Surabaya are sufficient for the
feasibility of task-sharing in integrated maternal mental health to detect perinatal depression. Most health
system areas support or provide an opportunity for
this concept, with there being a strong basis in governance and resources. The decentralized governance of
the health system allows contextualization of a national
policy. The role of CHWs also demonstrates their
potential for filling the gap that exists in the data information system. Further studies are necessary before the
idea can be prepared for implementation, including,
but not limited to, exploring the acceptability of tasksharing and the characteristics of CHWs required for
this purpose.
Abbreviations
CHWs: community health workers; CHWsMCH: community health workers
working for maternal and child health; CHWspregnancy: community health
workers working for pregnant mothers; CM, CJ, and CN: sites for majority
population groups within Centre C, which CM for Madurese, CJ for Javanese,
CN for non-slum area; EPDS: Edinburgh Postnatal Depression Scale; FWM: family welfare movement; GP: general practitioner; HIV: human immunodeficiency
virus; ISPs: integrated health service posts; MCH: maternal and child health;
MoHA: Ministry of Home Affairs; NGO: non-governmental organization; PHC:
primary health care; TPKJM: community mental health action team; WHO:
World Health Organisation.
Authors’ contributions
ES conceived of the study, participated in its design and coordination, carried
out the interviews and drafted the manuscript. RK, HM, and AJ guided ES in
the conception and design of the study and supervised her work. RK also
provided guidance on analysis and interpretation of the material. All authors
read and approved the final manuscript.
Author details
Centre for Mental Health, Melbourne School of Population and Global
Health, The University of Melbourne, Melbourne, Australia. 2 Faculty of Psychology, Airlangga University, Surabaya, Indonesia.
1
Acknowledgements
We would like to thank to the Health Office of Surabaya and four PHC centres,
three villages in Surabaya, and the Director of Dr. Soewandhi Hospital for
providing permission and technical support; Ms. Putri Maharani and Erwin
Erianto for helping with communication, transportation, and permit documents; Ms. Alma Aletta MPH for helping in the early stage of analysis. Our
deepest gratitude goes to all participants whom we interviewed for this
study, particularly the CHWs-manager who distributed letters of invitation to
potential participants.
Declaration
The authors declare that the content of the manuscript has not been published, or submitted for publication elsewhere.
Competing interests
The authors declare that they have no competing interests.
Availability of data and materials
The datasets used and/or analysed during the current study are available from
the corresponding author on request.
Consent for publication
Not applicable.
Page 15 of 16
Ethics approval and consent to participate
Ethical approval for the study was obtained from the University of Melbourne
in the Document No. 1543833. A research permit was released by Health
Office of Surabaya. Informed consent was obtained from all participants prior
to data collection.
Funding
This study is part of the doctoral degree project conducted by the first author
under supervision of the co-authors. There is no external funding to support
the research.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Received: 9 November 2017 Accepted: 25 May 2018
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