Decreasing coverage of co-production based on maternal and child health services (Posyandu) during the COVID-19 pandemic in Indonesia

Abstract This study analyzes the declining coverage of the co-production system in Posyandu health services during the COVID-19 pandemic. This research utilized qualitative analysis approach. Based on data obtained from the Indonesian Ministry of Health’s official website (2019–2020), journal related to maternal and child health services during the COVID-19 pandemic (2019–2022). Data focused on themes related to co-production in healthcare during the COVID-19 pandemic. There were several sub-themes identified, including ANC, immunization, and monitoring toddler growth through weighing. Problems with implementing ANC at Posyandu during the pandemic occurred in several cities in Indonesia. While the coverage of some immunizations had decreased over the national scale. Furthermore, growth monitoring had decreased by up to 10% on a national scale. To prevent the recurrence of this condition, health service innovation is required. Posyandu has good principles to improve the health status of mothers and children, but the Government needs to support the quantity and quality of cadres so that this principle can be realized. Support from several community leaders also needs to be encouraged to facilitate Posyandu implementation.


Introduction
Service quality is a central element in the health sector (Helmi et al., 2021).One of the mechanisms adopted to improve service quality is to run a co-production system (Vennik et al., 2016).Co-production is the voluntary and involuntary involvement of service users in the design, management, and service delivery evaluation of public services (Osborne et al., 2018).Co-production emphasizes the broad role of citizens in designing and delivering public services (Loeffler & Bovaird, 2018).Co-production in health cares has several characteristics, including collaboration between patients, service users, patient families, and professional health workers in designing and delivering services (Batalden et al., 2016).Another study on co-production in health services discusses collaboration between professionals and volunteers (community) in providing public services (Helmi et al., 2021).
The wide spread of COVID-19 has a direct impact on health services, including co-productionbased services (Beresford et al., 2021;Rasmussen & Burau, 2022).Several factors contribute to the problem of co-production-based services.During the COVID-19 pandemic, the use of public health services was reduced by one-third globally (Moynihan et al., 2021).The impact of the pandemic has also been felt on the health of mothers and children, where parents, especially mothers, have experienced a decrease in their trust in government-owned health institutions (Heerman et al., 2020;Amin et al., 2022;Batool et al., 2023).Apart from that, during the pandemic there was also confusion about accessing valid information related to health.
During the COVID-19 pandemic, Indonesia experienced problems with co-production-based health services for mother and children.One of the health services that stopped during the pandemic was Integrated Health Service Post (Posyandu).Posyandu is a form of Community-Based Health Effort (UKBM) that is managed and organized by, for and with the community in implementing health development (Ministry of Health of the Republic of Indonesia, 2011).Since March 2020, the Government of Indonesia has advised stopping activities at Posyandu to reduce the transmission risk.More than 75% of Posyandu in Indonesia did not provide services and 41% of home visits stop (Ministry of Health Republic of Indonesia, 2020).Posyandu's demise has an impact on early detection and prevention efforts that are not functioning optimally (Ministry of Health Republic of Indonesia and UNICEF, 2020).When the government tried to reactivate services at Posyandu, the utilization was still not running optimally.The city of Palu illustrates an area with a minimal utilization rate of Posyandu services when COVID-19 subsides a little.This is due to people's fear of virus transmission (Wandira et al., 2022).
Health services are experiencing serious challenges due to the spread of COVID-19.The structure of health services experiences problems in terms of capacity, starting from the internal structure of the institution to the limitations of implementing actors.Studies show that co-production is a strategy pursued by health services during the COVID-19 era (Andersen et al., 2020;Turk et al., 2021).The co-production approach emphasizes the role of the community as the leading actor in providing health services during the spread of COVID-19 (Yeo & Lee, 2020).In its development, coproduction provides healthcare services during a pandemic (Marsilio et al., 2021;Pestoff & Saito, 2022).The trend of co-production studies during COVID-19 has shown innovation and success in providing health services, such as the involvement of street vendors to provide goods and basic needs for quarantine patients (Recio et al., 2021); changing perspectives from hospital-based to the community in preventing the spread of COVID-19 (Cepiku et al., 2021); integration of health services during COVID-19 by local authorities provides service effectiveness (Diba et al., 2023).
Meanwhile, several studies focus on children's health during a pandemic.Some research focusing on children's health includes health service innovations in online antenatal classes (Bonciani et al., 2022); co-production-based integrated care collaboration for child health (Gilmartin et al., 2022).Another research examines the co-production of health services as a solution for the health of children under 5 years due to a pandemic (Rosenthal et al., 2023).The development of coproduction studies in health services during the COVID-19 outbreak shows that no one has criticized failures or problems in implementation.Furthermore, there are no studies that discuss maternal and child health services at Posyandu during the COVID-19 pandemic in Indonesia.
Several studies that discuss maternal and child health services during the COVID-19 pandemic in Indonesia about monitoring continuity of maternal and child services during COVID-19 (Helmyati et al., 2022), experiences of midwives and mothers in the health service process during the COVID-19 pandemic (Herwansyah et al., 2023).The resolution of issues pertaining to mother and child health necessitates careful consideration, particularly due to the persistent nature of this unresolved problem.The prevalence of maternal mortality in Indonesia has been significantly higher before to the outbreak of the pandemic.Additionally, the issue of stunting in children remains unresolved (Indonesian Ministry of Health, 2020).The study of Posyandu's impact on maternal and child health throughout the COVID-19 pandemic is interesting given that the primary objective of establishing Posyandu is to mitigate maternal and child mortality (Ministry of Health of the Republic of Indonesia, 2011).This article analyzes the declining coverage of the co-production system in Posyandu health services during the COVID-19 pandemic.

The concept of Posyandu in Indonesia
Long before the pandemic, Posyandu was one of the front lines in health.Posyandu has the same concept as Primary Health Care in the international world.Posyandu is a program intended to improve health status through community participation which began in the 1980s (Ministry of Health of the Republic of Indonesia, 2011).The primary goal of implementing Posyandu is to reduce maternal and child mortality, but there are several other goals that are being prioritized at the moment.There are at least five basic health programs in Posyandu, including maternal and child health, immunization, nutrition, contraception, and diarrhea management.The targets include infants, toddlers, pregnant women, postpartum mothers, breastfeeding mothers, and fertile-age couples (PUS) (Ministry of Health of the Republic of Indonesia, 2011).In addition, there are several other development goals, such as improving environmental health, controlling infectious diseases, and a variety of other village community development programs.
Posyandu is a coordinating organization for community service at the Puskesmas.The implementation of Posyandu is directly supervised by the Puskesmas (Figure 1).The Puskesmas (Public Health Center) provides training to Posyandu staff to improve their ability to run.In addition, the Puskesmas are also required to be involved in Posyandu activities with a role as supervisor and implementer of primary health services.The Puskesmas also has a function as an activity evaluator to plan and improve according to the needs of the Posyandu (Ministry of Health of the Republic of Indonesia, 2011).Posyandu is also a forum for community empowerment for villages and districts.Meanwhile, NGOs become partners for Posyandu in its implementation.The sub-district coordinated the NGOs and the Puskesmas in its implementation (Ministry of Health of the Republic of Indonesia, 2011).Furthermore, several stakeholders involved in this activity included the subdistrict head, village head, Posyandu Working Group (Pokja) (Ministry of Health of the Republic of Indonesia, 2011), Family Health Empowerment, community organizations, private organizations, and several related agencies.In practice, Posyandu implements the concept of co-production in health services (Vennik et al., 2016).This can be seen from the involvement of professionals such as workers at the Puskesmas and local government as well as non-professional multi-stakeholders such as Posyandu cadres and citizens who are involved in health services.
The organizational structure of Posyandu is determined by the community through deliberation.Posyandu's organizational structure is typically adaptable and can be created in accordance with needs, conditions, problems and existing resources.The minimum organizational structure consists of a chairman, secretary, treasurer, and Posyandu cadres who also serve as members.In one area, Posyandu is managed by a management unit or group that is chosen by the community (Ministry of Health of the Republic of Indonesia, 2011).Posyandu cadres are community members who are willing and able to organize Posyandu voluntarily; no financial rewards are given to cadres.Furthermore, cadres have an important role related to the preparation and implementation of Posyandu.Beyond that, cadres also have a role in-home visits to pregnant women, postpartum, and infants/toddlers.This is carried out for updating data, monitoring growth and development, and following up on the implementation of Posyandu (Ministry of Health of the Republic of Indonesia, 2011).

Co-Production in health services during Covid-19
Co-production in health services emphasizes the active role of patients, communities, and multistakeholders in providing health services together with professional actors (Batalden et al., 2016).The co-production system in health services aims to make improvements and improvisations in the last few decades (Batalden et al., 2016).Efforts to improve and improvise health services are manifested in shaping behavior change by increasing the active role of patients and by making improvements or even creating new quality services (Robert et al., 2022).The government is required to mobilize civil society in handling public health during COVID-19 (Andersen et al., 2020;Pestoff & Saito, 2022).Health services must continue prioritizing patients, the community, and the patient's family in co-production schemes during a pandemic (Turk et al., 2021).The big challenge due to COVID-19 requires the government to involve a bigger role for citizens in realizing innovation for health services.One of the pressure points in voluntary co-production in health services is carried out by citizens and the community (Carpenter et al., 2022).
In the context of Posyandu for example, due to limited access, it is obligatory that examination services for pregnant women can be carried out using website facilities online (Bonciani et al., 2022).The use of telemedicine has proven to be effective in family medicine services during the COVID-19 pandemic (AlAhmad et al., 2022).To overcome the limitations of face-to-face interactions, it is necessary for professional workers to collaborate with the community in presenting online infographics of health service options for children and toddlers (AlAhmad et al., 2022).This approach enables the dissemination of important information and resources in a visually appealing and easily accessible format, ensuring that parents and caregivers have access to essential healthcare information for their children.By utilizing online platforms, professionals can reach a wider audience, provide valuable guidance, and promote the well-being of children and toddlers within the community (Zaguia, 2023).The purpose of this online infographic is to provide families with quick and accessible information regarding health service options for children and toddlers, especially during challenging circumstances and limitations.By utilizing information technology, such as the creation of innovative co-production-based health services, facilities can adapt and overcome the challenges posed by the COVID-19 pandemic.The infographic aims to highlight these innovative approaches, empowering families to make informed decisions about the health services available for their children, while also promoting collaboration between healthcare providers and families in the delivery of quality care (Marzi, 2021).

Methods
Data collection was carried out from the official website of the Indonesian Ministry of Health and related journals.Data taken from the Indonesian Ministry of Health's official website (https://www.kemkes.go.id/) from 2019 to 2020, for journals published between 2019 and 2023.This research used qualitative analysis with an inductive approach.Previously, the data obtained was organized thematically on data subsets.This research explored themes related to co-production in healthcare during the COVID-19 pandemic.The research focused on the health services provided by Posyandu.The research framework was divided into four stages:1) collecting secondary data from the official website of the Indonesian Ministry of Health and related journals, 2) selecting relevant data, 3) extracting the most relevant subset of data, 4) conducting a qualitative analysis of the data.

Results
There was one sub-theme in the context of maternal health services, namely Antenatal Care (ANC).ANC is a routine pregnancy check carried out by health workers.Two sub-themes related to child health services were analyzed (immunization and monitoring growth in toddlers through weighing).We compared the findings from the Ministry of Health's website with several related journals.We used 15 journals for this investigation.

Barriers to Posyandu implementation during the pandemic
To stop the spread of the COVID-19 case, the Indonesian government implemented a Large-Scale Social Restrictions (PSBB) policy at the start of the pandemic.This policy also has an impact on health services.All activities that are mass-gathering are stopped, including Posyandu (Ministry of Health of the Republic of Indonesia, 2020).Thus, several activities has been impacted because of this.Growth and development monitoring is carried out independently at home by utilizing the maternal and child health book (KIA).In addition, immunization and vitamin A services has to be done by appointment.Also, monitoring of at-risk toddlers must be carried out by teleconsultation/ appointment/home visit (Ministry of Health of the Republic of Indonesia, 2020).Even though the co-production scheme in public health services necessitates the active participation of the patient, the patient's family, and the community.However, the wide spread of COVID-19 has hampered non-professional actors' active participation in health services (Gilardi et al., 2016).Maternal and child health services provided at Posyandu also experience this problem.Table 1 illustrates several changes in the coverage of utilization of maternal and child health services at Posyandu which has decreased.Researchers highlight some of the changes that have occurred in ANC, immunization and monitoring of toddlers' growth through weighing.

Decreased Antenatal Care (ANC)
The PSBB policy has had an impact on reducing the utilization of health services and disrupting surveillance.Although data from the Indonesian Ministry of Health did not show a significant reduction in ANC (Table 1), but several other studies provide an overview of the obstacles that occur.Previously, most pregnant women had their pregnancies checked at primary health services, one of which was Posyandu.In Surabaya city, for example, the closure of the Posyandu prevented pregnant women from receiving early detection and preventive services.Likewise with what happened in Mataram city, even pregnant women did not get home visits, so there was no monitoring of blood pressure and abdominal examinations (Hazfiarini et al., 2022).The decline in ANC visits shows that the design of co-production in maternal and child health services cannot improvise and adapt during a pandemic.In actuality, co-production requires elements of improvisation and adaptation of health services (Marsilio et al., 2021;Robert et al., 2022).Co-production in ANC at Posyandu is described in supporting Posyandu cadres for pregnant women.This aims to increase the adherence of pregnant women to ANC in health workers.Some areas include several communities in the mentoring process, such as in Banyuwangi District which named it Sakina (Banyuwangi District Government Official Government Website, 2020).
The decline in the utilization of health services will have an impact on preventive services.ANC is an effort to prevent complications in pregnant women, so as not to lead to complications.According to a study, using ANC services can lower the risk of complications, including symptoms of near-misses.However, this utilization should be carried out continuously, so that it is not lost in the process of following up on the mother's condition (Kebede et al., 2021).In reality, the direct and indirect impacts of the COVID-19 pandemic in Indonesia are being felt on maternal health.The number of maternal deaths in 2018 was 4221, then decreased in 2019 to 4196, but this number increased during the COVID-19 period (2020) to 4614.Other data states that the number of maternal deaths from January to September 2020 was 3048, then increased to 3794 from January to September 2021.Furthermore, maternal deaths with positive PCR/antigen were only 1331 from January to September 2021.Of course, it can be concluded that deaths not directly caused by COVID-19 dominate (Directorate of Family Health, 2021).

Decreased utilization of immunization services
Utilization of immunization services for infants and toddlers has also decreased during the pandemic (Ullah et al., 2022;Zakaria, 2021).In Indonesia, immunization is mandatory for infants and children as an effort to prevent disease transmission.All infants, toddlers and children get this service for free.Some of these immunization programs include basic immunization for infants, advanced immunization for children under two years old, and school children.At Posyandu, the services provided are basic immunization for infants and toddlers The Table 1 explains that complete immunization coverage for infants and toddlers during the COVID-19 pandemic has decreased.This service was covered by 93.7% of the population in 2019, 83.3 percent in 2020 (Ministry of Health of the Republic of Indonesia, 2021a).Furthermore, the Indonesian Ministry of Health and UNICEF reported that during the COVID-19 pandemic, 84% of immunization services at Puskesmas and Posyandu were hampered.64% of these obstacles were caused by the closure of Posyandu during the pandemic.Whereas before the pandemic, 75% of infants and toddlers were immunized at Posyandu (Ministry of Health Republic of Indonesia and UNICEF, 2020).Limited places for immunization services at the Puskesmas and Posyandu during COVID-19 were the reason for the decrease in targeted visits to obtain immunization services (Ministry of Health of the Republic of Indonesia, 2021a).
Previously, it was explained that immunization is a program created by the Government of Indonesia to prevent disease in infants, toddlers, and children.At the end of November 2022, the Indonesian Ministry of Health announced that 415 districts/cities in 30 provinces were included in the high-risk category for polio due to low immunization during the COVID-19 pandemic (Ministry of Health of the Republic of Indonesia, 2022).This incident started with the discovery of a Polio case in Aceh.Under these conditions, the Indonesian government mandates Polio Extraordinary Events (KLB).Indonesia was declared Polio-free in 2014.In the effort to eradicate polio, Indonesia was hit by the COVID-19 pandemic (Azizatunnisa et al., 2022).

Decreased monitoring of toddlers' growth through weighing
Because Posyandu activities are limited, surveillance activities are also hampered.Monitoring children's growth through weighing does not run optimally.By 2020, weigh-in coverage will drop to 10% (Ministry of Health of the Republic of Indonesia, 2021a).In fact, the coverage of infant and toddler weighing (D/S) is an indicator of monitored growth.Before the pandemic, Posyandu cadres played a big role in motivating mothers to have their children checked.However, this cannot be done due to the social distancing policy.Table 1 explains that toddler weight loss in Indonesia has decreased during the pandemic, weight measurements have decreased by around 5%.Some areas experience this condition, for example Purwakarta.The closure of Posyandu has an impact on reducing the coverage of weighing babies and toddlers by up to 12.67% in 2020 (Desty & Wahyono, 2021).The delay of the Posyandu at the beginning of the pandemic resulted in a decrease in monitoring toddlers' growth by 67.76%, which was also felt in East Jakarta and Bandung (Saputri et al., 2020).Monitoring of toddler nutrition has also decreased in Bangka Belitung during the pandemic, decreasing from 1.9% to 50% in April 2020 (Ministry of Health of the Republic of Indonesia, 2021d).
Monitoring of Toddlers' Growth Through Weighing is important to prevent the bad consequences of stunting.Before the pandemic, early detection was carried out by Posyandu through empowering cadres.Obstacles from the pandemic will undoubtedly present a challenge for Indonesia in eradicating cases of stunting.Stunting still affects 24% of toddlers in Indonesia, far higher than the target set, which is 14% in 2024 (Ministry of Health of the Republic of Indonesia, 2021c).The impact of the pandemic on reducing stunting cases was felt in Bangka Belitung, where there was an increase in toddlers at risk of stunting by 4.3% (Ministry of Health of the Republic of Indonesia, 2021d).

Lessons from the COVID-19 pandemic: Increased innovation
Given Posyandu's central role, innovation is required to improve service quality.Actually, several studies have provided suggestions regarding this matter.For example, one study proposed the iPosyandu application (app), which utilizes information technology to provide health promotion and early detection (Faza et al., 2022).The COVID-19 pandemic has become a lesson that Indonesian healthcare systems need to be ready for emergency situations.Moreover, Posyandu still faced several challenges in its implementation prior to the COVID-19 pandemic.One of the big obstacles in posyandu health services is face-to-face barriers between individuals.Digital-based technology is a solution for creating innovative Posyandu services (Gilmartin et al., 2022).Posyandu services by utilizing technology will encourage the realization of adaptive and flexible digital-based health services (Gilardi et al., 2016).
Lack of quantity and quality of cadres, low trust of the target group, and low support from religious figures and leaders have been obstacles to the implementation of Posyandu so far (Pratono & Maharani, 2018).Other literature also explains that there is a need for a top-down policy to realize innovation at Posyandu.Considering the many challenges faced in its implementation, including the lack of infrastructure and facilities, as well as human resources (Faza et al., 2022).Whereas aspects such as the capacity of the lay actor and the trust possessed by the patient determine the success of co-production in health services.On the other hand, values such as social values become a determining factor to support or hinder co-production in health services (Hyde & Davies, 2004).
Co-production, when applied correctly, can be a positive concept for providing health services during the COVID-19 outbreak.One of the outputs of the idea of government and community collaboration is local knowledge that can be utilized to produce policies and decision-making in the health context during a pandemic (Marten et al., 2021).Apart from that, the idea of co-producing can provide the innovation needed to minimize the negative impact of COVID-19 on vulnerable groups (Marzi, 2023).The implementation of co-production is the emergence of trust, collaboration, and social mobilization in response to the impact of the COVID-19 outbreak (Andersen et al., 2020).The idea of co-production between local government and communities can provide child health services through digital infographics (Gilmartin et al., 2022).Furthermore, online Antenatal Classes based on co-production can contribute to a type of service that is long-lasting and integrated so that it can be applied until the pandemic is over (Bonciani et al., 2022).

Figure
Figure 1.Posyandu coordination line.Source: (Ministry of Health of the Republic of Indonesia, 2011).