What factors do make quality improvement work in primary health care? Experiences of maternal health quality improvement teams in three Puskesmas in Indonesia

Autoři: Ralalicia Limato aff001;  Patricia Tumbelaka aff001;  Rukhsana Ahmed aff001;  Sudirman Nasir aff003;  Din Syafruddin aff001;  Hermen Ormel aff004;  Meghan Bruce Kumar aff005;  Miriam Taegtmeyer aff005;  Maryse Kok aff004
Působiště autorů: Malaria and Vector Resistance Laboratory, Eijkman Institute for Molecular Biology, Jakarta, Indonesia aff001;  Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom aff002;  School of Public Health, Hasanuddin University, Makassar, Indonesia aff003;  KIT Royal Tropical Institute, Amsterdam, The Netherlands aff004;  Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom aff005;  Emory University, Rollins School of Public Health, Center for Humanitarian Emergencies, Atlanta, Georgia, United States of America aff006;  Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, United Kingdom aff007
Vyšlo v časopise: PLoS ONE 14(12)
Kategorie: Research Article
doi: 10.1371/journal.pone.0226804



Indonesia has been shifting from ensuring access to health services towards improving service quality. Accreditation has been used as quality assurance (QA) mechanism, first in hospitals and subsequently in primary health care facilities, including Puskesmas (community health centres). QA provides measures of whether services meet quality targets, but quality improvement (QI) is needed to make change and achieve improvements. QI is a cyclical process with cycles of problem identification, solution testing and observation. We investigated the factors which influenced the process of QI based on experience of maternal health QI teams in three Puskesmas in Cianjur district, West Java province, Indonesia.


Qualitative data were collected using 28 in-depth interviews at two points of time: pre- (April 2016) and post- QI intervention (April 2017), involving national, provincial, district and Puskesmas managers; and Puskesmas QI team members. Thematic analysis of transcripts was conducted.


We found four main factors contributed to the process of QI: 1) leadership, including awareness and attitude of leader(s) towards QI, involvement of leader(s) in the QI process and decision-making in budget allocation for QI; 2) staff enthusiasm and multidisciplinary collaboration; 3) a culture where QI is integrated in existing responsibilities; and 4) the ongoing Puskesmas accreditation process, which increased the value of QI to the organisation.


Making QI a success in the decentralised Indonesian system requires action at four levels. At individual level, leadership attributes can create an internal quality environment and drive organisational cultural change. At team level, staff enthusiasm and collaboration can be triggered through engaging and tasking everyone in the QI process and having a shared vision of what quality should look like. At organisational level, QI should be integrated in planned activities, ensuring financial and human resources. Lastly, QI can be encouraged when it is implemented by the wider health system as part of national accreditation programmes.

Klíčová slova:

Antenatal care – Budgets – Decision making – Indonesia – Management of high-risk pregnancies – Maternal health – Midwives – Pregnancy


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